Every finding on record at Centre Avenue Health and Rehab LLC

Based on record review and interviews, the facility failed to ensure two (#1 and #20) of six residents out of 20 sample residents were free from significant medication errors. Specifically, the facility failed to:-Prevent Resident #20 from a missed administration of a rapid-acting insulin dose; and,-Prevent Resident #1 from receiving the wrong dose of a long-acting insulin.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/20/26 to 5/21/26, resulting in the deficiency being cited as past noncompliance with a correction date of 4/27/26.I. Incidents of insulin administration failures for Resident #20 and Resident #1On 4/8/26 at 7:00 a.m. registered nurse (RN) #2 failed to check Resident #20's blood sugar before breakfast and did not administer three units of insulin aspart (a rapid acting insulin with a duration lasting three to five hours), as ordered by the physician. Due to RN #2's failure to monitor and administer the physician ordered insulin, Resident #20's blood glucose level (measure of the amount of sugar present in the blood) increased to 600 milligrams per deciliter (mg/dl) later that afternoon (4/8/26).On 4/24/26 at 7:40 p.m. RN #1 obtained Resident #1's blood sugar, which was 127 mg/dl, and administered the resident's scheduled dose of three units of insulin glargine (a long lasting insulin with a duration of 24 hours). However, RN #1 inadvertently administered 30 units of insulin glargine instead of the physician ordered dose of three units.Due to RN #1's failure to ensure the correct dose of insulin was administered to Resident #1, the resident's blood glucose level decreased to 60 mg/dl and the resident experienced lethargy and difficulty staying awake. II. Facility plan of correctionThe corrective action plan the facility implemented in response to the incidents of the missed insulin administration for Resident #20 on 4/8/26, and the administration of the wrong dose of insulin for Resident #1 on 4/24/26 was provided by the chief nursing officer on 5/21/26 at 10:37 a.m.The corrective action plan documented the following: A. Immediate action for affected residents included the following:RN #2 notified the provider Resident #20's missed administration of the resident's morning insulin dose on 4/8/26. RN #2 was educated on 4/9/26 to prioritize diabetic medications in the morning and to ask for assistance if running behind on work.On 4/24/26 the facility notified the provider, the resident's representative and the director of nursing (DON) regarding Resident #1 receiving the wrong dose of insulin on 4/24/26.Resident #1 was notified of the medication error on 4/24/26 and was educated on signs and symptoms of low blood sugar and the use of glucagon (an emergency treatment for low blood sugar). Resident #1 was given orange juice, peanut butter, crackers and candy in response to the incorrect insulin administration. Resident #1 was placed on alert charting highlighting blood glucose checks every three hours initially and then increased to every one hour blood glucose checks. Education in response to the insulin medication error was provided to RN #1 by the DON on 4/24/26. RN #1 was observed during insulin administration on 4/25/26 to ensure she followed safe practices. Education was provided to charge nurses on 4/25/26 which included reviewing insulin orders in detail prior to administration.The medical director was notified on 4/25/26 by the on-call nurse practitioner of the insulin overdose administered to Resident #1 (on 4/24/26). B. Identification of other residents having the potential to be affected by the deficient practiceThe facility documented 11 additional residents that required insulin for treatment of diabetes mellitus. C. Measures or systemic changes to ensure the deficient practice will not recurThe facility documented the completion of a house wide audit on 4/25/26, which included a review of all current residents' insulin orders to determine if insulin had been correctly administered. The facility documented nursing staff education was completed on 4/25/26. The education included the rights of medication administration and a review of critical medications and documentation of online training titled The Dangers of Medication Administration. The nursing staff education additionally included the implementation of the use of a second nurse for verification of insulin orders during medication administration. The facility documented completion of insulin administration audits and competencies on 4/25/26 for nursing staff who were at the facility at the time and who routinely administered insulin. The facility plan included audits of insulin orders, insulin administration documentation and second nurse verification of insulin administration documentation daily for twelve weeks. The facility documented an ad hoc (spontaneous discussion scheduled to address an unexpected concern) quality assurance and performance improvement (QAPI) meeting on 4/27/26 with the medical director (MD), the nursing home administrator (NHA), the DON, the social services director (SSD) and the clinical manager determined the necessary re-education of all nursing staff which included: -Education about critical medication and insulin dosing before administration and the10 Rights of Medication Administration; -The addition of supplemental documentation which included second nurse verification; -Staff education (Rights of Medication Administration, critical medications), and through the online education (The Dangers of Medication Administration); and,-Insulin administration audits and competencies were initiated for nursing staff who routinely administered insulin.D. Plan to monitor for sustained complianceThe facility documented nursing leadership would be auditing residents' insulin orders and administration documentation and second nurse verification of insulin administration daily for 12 weeks.Nurses would be observed administering insulin by the DON or the pharmacist or designee.The facility documented the initiation of a QAPI Performance Improvement Project (PIP) on 4/27/26 for monitoring corrective action and the facility's plan was to review findings at the monthly QAPI meeting for a minimum of three months. The facility documented adjustments would be made to the plan to ensure sustained compliance. E. The facility documented the date of compliance was 4/27/26. III. Facility policy and procedure The Medication Administration policy, revised 5/6/26, was provided by the chief nursing officer on 5/21/26 at 4:59 p.m. It read in pertinent part, Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation. Review medication administration records (MAR) to identify medication to be administered.The Medication Errors policy, implemented 4/11/26, was provided by the chief nursing officer on 5/12/26 at 4:59 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. The facility will ensure medications will be administered according to physician orders. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. IV. Resident #20 A. Resident statusResident #20, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included diabetes mellitus, long term use of insulin, glaucoma, scoliosis and chronic lower back pain. The 4/30/26 minimum data set (MDS) assessment identified Resident #20 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident used a wheelchair, and required assistance with transfers, bathing, dressing and her vision was highly impaired.The MDS assessment indicated the resident received insulin injections. B. Resident interviewResident #20 was interviewed on 5/21/26 at 2:00 p.m. Resident #20 said she had diabetes for many years and always wanted to know her blood glucose levels and insulin dosages so she could keep track of her diabetes. She said she sometimes had felt symptoms of high or low blood sugars and she would let the nurses know when she had felt symptoms. C. Record reviewThe diabetes care plan, initiated 11/24/25, revealed Resident #20's potential for complications, including hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus. Interventions included administering medications and blood sugar checks as ordered and as needed. A review of Resident #20's April 2026 CPO revealed revealed the following physician's orders: Blood glucose monitoring before meals and at bedtime related to type 1 diabetes. Call the provider if blood glucose is less than 70 mg/dl or greater than 400 mg/dl, ordered on 11/19/25.Inject three units of insulin aspart subcutaneously (under the skin) one time a day before breakfast for type 1 diabetes mellitus, ordered on 3/22/26. Review of Resident #20's April 2026 MAR revealed no blood glucose level was recorded and no insulin aspart was documented as being administered to the resident on 4/8/26 at 7:00 a.m.On 4/8/26 at 1:38 p.m. the April 2026 MAR revealed Resident #20's blood glucose level was 191.0 mg/dl. On 4/8/26 at 3:28 p.m. the April 2026 MAR revealed Resident #20's blood glucose level had increased to 600 mg/dl. A nursing progress note, dated 4/8/26 at 3:28 p.m. revealed the physician was notified about Resident #20's elevated blood glucose level. The note documented the physician ordered monitoring of Resident #20 for signs and symptoms of high blood glucose and checking Resident #20's blood glucose one hour later. The note documented a new physician's order to inject insulin aspart subcutaneously before meals per a sliding insulin scale in addition to the scheduled insulin aspart dose. On 4/8/26 at 6:27 p.m. the April 2026 MAR revealed Resident #20's blood glucose level was 352 mg/dl. On 4/9/26 at 7:14 a.m. the April 2026 MAR revealed Resident #20's blood glucose level was 162 mg/dl. A medication/treatment error incident investigation, signed by RN #2 on 4/9/24, documented RN #2 did not check Resident #20's blood sugar before breakfast and did not administer insulin aspart three units as ordered by the physician. D. Staff interviewRN #2 was interviewed on 5/21/26 at 2:14 p.m. RN #2 said she usually worked on the first floor of the facility, but on 4/8/26 she was scheduled to work on the second floor where Resident #20's room was located. RN #2 said on 4/8/26 she worked the 6:00 a.m. to 2:00 p.m. shift and there were a lot of residents to check for blood glucose levels on that morning. RN #2 said she got behind that morning and did not catch up in time for checking Resident #20's blood glucose level and administering the resident's morning insulin dose. RN #2 said she reported the missed blood glucose level check and missed morning insulin aspart dose to the DON on 4/8/26 at approximately 2:00 p.m. RN #2 said she additionally reported the missed administration to the oncoming nurse at the change of shift. RN #2 said she should have recognized earlier that she was getting behind with her medication administration and she should have notified the charge nurse at that time so Resident #20 would receive her scheduled insulin. V. Resident #1A. Resident Status Resident #1, age [AGE], was admitted on [DATE] and discharged to home on 5/11/26. According to the May 2026 CPO, diagnoses included diabetes, right sided weakness as result of a previous stroke and right hip and right knee pain after a recent fall at home. The 4/24/26 MDS assessment identified Resident #1 was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment revealed the resident was dependent for assistance with sitting to standing and transfers, and required substantial assistance with bathing, toileting, and lower body dressing.The MDS assessment indicated the resident received insulin injections. B. Record Review The diabetes care plan, initiated 4/21/26, revealed Resident #1 had a diagnosis of diabetes mellitus. Interventions included administering medications as ordered and monitoring for signs and symptoms of high blood sugar and low blood sugar. A review of Resident #1's April 2026 CPO revealed the following physician's order:Inject three units of insulin glargine subcutaneously one time a day for type 2 diabetes, ordered 4/21/26.Review of Resident #1's April 2026 MAR revealed RN #1 documented the administration of three units of insulin glargine to Resident #1 on 4/24/26 at 7:46 p.m. An on-call nurse practitioner's progress note, dated 4/24/26 at 9:11 p.m. revealed the nurse practitioner was notified about a medication error for Resident #1. The note documented Resident #1 had received 30 units of Lantus (insulin glargine) and the correct dose for administration was three units. The note documented the nurse practitioner was concerned for low blood sugars and blood glucose checks were ordered for 12:00 a.m., 3:00 a.m. and 6:00 a.m. A nursing progress note, dated 4/24/26 at 10:14 p.m., revealed Resident #1's blood sugar level at 7:40 p.m. was 127 mg/dl. After obtaining the resident's blood sugar, RN #1 later returned to the resident's room to administer the resident's insulin. After administering the resident's insulin, RN #1 returned to her medication cart to chart the insulin administration and realized the amount of insulin she administered was incorrect (RN #1 administered 30 units of glargine insulin instead of 3 units of insulin - see RN #1 interview below) RN #1 returned to Resident #1, explained the insulin overdose to Resident #1, provided orange juice to the resident and directed Resident #1 to call if he experienced signs or symptoms of low blood sugar. RN #1 continued to monitor Resident #1 and the resident's representative and the on-call nurse practitioner were notified. A nursing progress note, dated 4/25/26 at 2:50 a.m. revealed Resident #1's blood glucose level was 60 mg/dl on 4/24/26 at 11:30 p.m. and glucose and orange juice were provided to Resident #1. Resident #1's blood glucose level recheck 15 minutes later (11:45 p.m.) was 90 mg/dl. The note documented Resident #1 was lethargic and had a difficult time staying awake. The note documented the on-call nurse practitioner was notified again and ordered continued monitoring of Resident #1's blood glucose levels. Resident #1's blood glucose level at 2:30 a.m was 111 mg/dl and Resident #1 was provided protein snacks.A nursing progress note, dated 4/25/26 at 6:40 a.m., revealed Resident #1 was alert in bed and his blood glucose level was 60 mg/dl. The resident was given yogurt and 240 ml (milliliter) of orange juice with four sugars added. A nursing progress note, dated 4/25/26 at 7:00 a.m. revealed Resident #1 was alert and was transferred to the toilet and had a large loose bowel movement. The note documented Resident #1's blood glucose level was 65 mg/dl and an Ensure shake was administered to the resident.A nursing progress note, dated 4/25/26 at 7:24 a.m., revealed Resident #1 was awake and alert and his blood glucose level was 88 mg/dl. The resident's vital signs were stable. A call was placed to the DON to inform him of the medication error.A nursing progress note, dated 4/25/26 at 8:00 a.m., revealed Resident #1 was eating breakfast and his blood glucose level was 86 mg/dl. The RN charge nurse was made aware of the situation and the provider was notified with instructions to continue frequent monitoring of the resident.A nursing progress note, dated 4/25/26 at 10:32 a.m., revealed Resident #1 was checked on every 15 to 20 minutes and the resident's blood glucose levels were checked every 30 to 60 minutes. The note documented Resident #1's regular nurse practitioner was notified and a physician's order was received for monitoring blood glucose levels every hour, calling the nurse practitioner at 1:00 p.m for an update, and also to call the nurse practitioner and send the resident to the emergency room if Resident #1 was symptomatic. The resident's representative was called to update her on the resident's status.A nursing progress note, dated 4/25/26 at 11:06 a.m., revealed Resident #1's blood glucose level was 66 mg/dl and peanut butter and crackers were provided to the resident. A nursing progress note, dated 4/25/26 at 1:37 p.m, revealed Resident #1's blood glucose level at 1:00 p.m was 95 mg/dl. The note documented Resident #1's nurse practitioner was notified and orders were received to continue checking the resident's blood glucose levels every hour and place a call back to the nurse practitioner with a report of the resident's status at 5:00 p.m. A nursing progress note, dated 4/25/26 at 4:13 p.m., revealed Resident #1's blood glucose level was 70 mg/dl and glucose tabs were administered to the resident. A nursing progress note, dated 4/25/26 at 5:17 p.m., revealed Resident #1's blood glucose level was 75 mg/dl and the resident's dinner was being served.A nursing progress note, dated 4/25/26 at 5:18 p.m., revealed Resident #1 had multiple stools due to all of the food and juice. The note documented Resident #1 said he was not happy that he had been in bed most of the day because his blood glucose levels were not stable enough for him to get up. The resident verbalized understanding that it was for his safety.A nursing progress note, dated 4/25/26 at 5:25 p.m., revealed Resident #1's nurse practitioner was notified and orders were received for continuing the resident's blood glucose level checks every hour until 9:00 p.m., at which time the nurse practitioner was to be called with an update of resident status. The note documented Resident #1's insulin was to be held until 4/27/26. A nursing progress note, dated 4/25/26 at 6:01 p.m., revealed Resident #1's blood glucose level was 146 mg/dl and he was tired but alert.A nursing progress note, dated 4/25/26 at 11:29 p.m., revealed Resident #1's blood glucose level was stable, he had eaten a nutritious snack prior to going to sleep and he was resting comfortably in bed. The resident's blood glucose levels would continue to be monitored throughout the night.The facility's medication error report, dated 4/24/26, revealed RN #1 called Resident #1's representative on 4/24/26 at 9:08 p.m. and she notified the on-call nurse practitioner on 4/24/26 at 9:11 p.m.C. Frequent visitor interview A frequent visitor to the facility was interviewed on 5/20/26 at 10:43 a.m. The frequent visitor said she met with Resident #1 on 5/1/26. The frequent visitor said Resident #1 told her he felt awful the night of the insulin overdose and that staff kept waking him up, but he did not feel unsafe at the facility. The frequent visitor said the facility's prevention plan was to re-educate RN #1 and the facility had a plan to re-educate all nursing staff.D. Staff interviewsRN #1 was interviewed on 5/21/26 at 10:04 a.m. RN #1 said she did not usually work on the floor where Resident #1 resided. She said 4/24/26 was the first time she administered insulin to Resident #1. RN #1 said on 4/24/26 at 7:55 p.m. she looked at the physician's order for Resident #1 and dialed in 30 units on the Semglee (insulin glargine) insulin pen. RN #1 said she administered the 30 units of Semglee insulin with the insulin pen to Resident #1 on 4/24/26 at 7:55 p.m. RN #1 said when she went back to document the insulin dose, she realized the physician's order was for 3 units of Semglee insulin and not the 30 units of Semglee insulin she had administered. RN #1 said she immediately got orange juice and candy for Resident #1, told the resident what had happened and stayed with Resident #1 for 15 minutes. RN #1 said she checked the resident's blood glucose level and the resident said he was feeling okay. RN #1 said she contacted the nurse practitioner on call who gave orders to monitor Resident #1' s blood glucose levels and treat the resident for low blood glucose. RN #1 said she called the DON to inform him of the situation. RN #1 said she spoke with Resident #1's representative 30 minutes later, after Resident #1 had texted the representative about the insulin overdose. RN #1 said the resident's representative was upset and RN #1 said she understood this was upsetting to the family. RN #1 said she checked Resident #1's blood glucose level and gave him peanut butter and crackers before she left the facility at the end of her shift. RN #1 said Resident #1 was doing okay when she left.Certified nurse aide (CNA) #1 was interviewed on 5/21/26 at 11:14 a.m. CNA #1 said she worked the evening shift on 4/24/26 when the insulin overdose administration occurred with Resident #1. She said she was told by RN #1 that Resident #1 needed to be monitored for symptoms of low blood sugar every five minutes. CNA #1 said she observed Resident #1 for symptoms of a change in alertness during the evening. CNA #1 said Resident #1 did not report symptoms of low blood sugar to RN #1.VI. Additional staff interviews The DON was interviewed on 5/21/26 at 5:45 p.m. The DON said he became aware of Resident #20's missed insulin dose through a record review, as he was not the DON at the time of the incident. The DON said RN #2 should have recognized that she was getting behind on her medication administration and notified the charge nurse immediately, at the time Resident #20's insulin was not administered on time according to the physician's orders.The DON said RN #1 notified him of Resident #1's insulin overdose on 4/24/26 at about 9:00 p.m., after she had notified the on-call nurse practitioner and Resident #1's representative. The DON said RN #1 should have contacted him right away for a significant insulin medication administration error, where the physician's order was not followed and ten times the insulin dose was administered to the resident. The DON said the nursing staff provided updates on the resident's status to him during the night and the next day. He said Resident #1 was tired during the next day and returned to baseline later the following day (on 4/25/26). The DON said an insulin overdose of ten times the dose ordered could have caused hospitalization, organ failure and adverse outcomes. Resident #1's primary care physician was interviewed on 5/21/26 at 2:58 p.m. The primary care physician said he was in the facility on 4/9/26 and spoke to Resident #20 about her intake of candy during lunchtime on 4/8/26. PCP #1 said he monitored Resident #20's condition after the missed insulin dose and said Resident #20's diabetes was difficult to control. The primary care physician said he was notified the next day about the incident with Resident #1 by the on-call provider service. The primary care physician said it was within the possibility that there could likely be harm when someone received ten times the dose of 30 units of insulin when someone was used to receiving only three units of insulin. The primary care physician said prevention for recurrence of this type of incident included staff education and this was primarily the responsibility of the medical director (MD). The MD was interviewed on 5/21/26 at 03:35 p.m. The MD said she was notified of Resident #20's missed insulin dose and blood glucose check. She said Resident #20's diabetes was difficult to control. The MD said she was notified of Resident #1's insulin overdose on 4/25/26 by the nurse practitioner on call and she was aware of Resident #1's status through 4/27/26, when she checked in with Resident #1. The MD said she routinely reviewed the facility's medication errors and assisted in providing staff education. The MD said she participated in the 4/27/26 QAPI meeting to review Resident #1's insulin medication error and the facility's corrective action plan.

Based on interviews and record review, the facility failed to ensure three (#53, #16 and #33) of eight residents reviewed for accidents out of 32 sample residents received adequate supervision to prevent an accident/hazard. Resident #53 was known to be at risk for falls on admission as he had fallen at home. The facility failed to implement effective interventions. The resident fell two times on 2/17/23, with the first fall resulting in a head wound with active bleeding where the resident was sent to the emergency department for treatment and the head wound was glued. Observations revealed fall interventions were not implemented. In addition, the facility failed to: -Implement effective fall interventions for Resident #16; and, -Implement interventions when Resident #33 obtained a skin tear during a transfer to prevent it from occurring again. Findings include: I. Resident #53 A. Facility policy and procedure The Skilled Nursing Facility Fall Management policy and procedure, revised on 2/8/23, was received from the nursing home administrator (NHA) on 4/13/23 at 4:52 p.m. It read in pertinent part: Residents have a right to a safe environment, while maximizing their independence. Fall prevention seeks to balance resident's safety from falls while respecting individual rights and preservation of dignity. It is the facility's goal to reduce falls and injury related falls. Admitting Nurse will complete the Fall Risk Observation upon admission. Individualized interventions will be implemented to minimize potential fall occurrence dependent upon the resident's risk. Additional interventions for residents identified to be at greater risk: anticipate needs by observing normal routines and times of increased risk, obtain consults as appropriate, encourage adequate rest periods to prevent over tiring, and increase staff observation and avoid self isolation. Encourage inclusion in activities and social interaction. The Fall Prevention Philosophy, dated 2/1/23, was received by the clinical nurse consultant on 4/18/23 at 11:00 a.m. It read in pertinent part: Call lights: We strive to meet each resident's needs prior to them having to use their call light. If a call light is used, it will be answered promptly and courteously by the first available staff person. Purposeful rounding is rounding routinely to meet the resident's needs before they ask, is proactive rather than reactive, prevents falls and other injuries, takes less time than answering call lights, and is done by all nursing department staff. With each round offer toileting/check incontinence products, reposition for comfort, offer, encourage, and assist with fluids, ask about pain or discomfort, ask if there are any personal items they need or an activity they would like to participate in. Look at the environment: ensure call lights are in reach, ensure water is available and in reach, and ensure the room is free of clutter and a neat appearance. B. Resident status Resident #53, age 87, was admitted on [DATE]. According to the April 2023 computerized physician order (CPO), the diagnoses included atrial fibrillation, muscle weakness, repeated falls, unspecified dementia, traumatic subdural hemorrhage (bleeding inside the skull) with loss of consciousness, attention and concentration deficit, cognitive communication deficit and frontal lobe and executive function deficit. The 4/3/23 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status score (BIMS) of three out of 15. He required extensive assistance of two persons for dressing and toileting, extensive assistance of two persons with bed mobility and transfers, and extensive assistance of one for personal hygiene and the supervision of one person for eating. The resident was also identified to be at high risk for falls. C. Resident representative interview The resident was not interviewable due to his cognitive communication deficit. The resident's spouse was interviewed on 4/12/23 at 11:34 a.m. She said she was with the resident all the time because she was responsible for all choices/decisions regarding the resident's care. She stated the resident had problems understanding things. She said he fell at home in the bathroom and hit his head that caused his brain to bleed. She said after she was admitted to the facility. She said the resident had been different ever since the fall, he had a poor memory and could not carry a conversation. She said she encouraged the resident to press the call light but he did not remember and the call light was always within his reach when he was sitting in the wheelchair. She said she had concerns the resident had fallen out of his wheelchair during the night. She said the staff were not consistent with rounding, it depended who was working and varied everyday. D. Observations On 4/12/23 at 2:49 p.m. the resident was in his wheelchair in his room without the call light within reach. The resident was not wearing his prescribed glasses. The resident had heel protectors on his feet that were resting on foot rests with no non-skid footwear. On 4/13/23 at approximately 9:00 a.m. to 10:05 a.m. the resident was observed in his room sitting in a wheelchair, he was dozing and abruptly woke up and cried out for his wife to take him home. No staff member entered the resident's room during that time period. The resident was not wearing his prescribed glasses, or non-skid footwear on both feet. The call light was hanging over the right armrest of the wheelchair resting on the floor. On 4/18/23 at 8:22 a.m. to 8:32 a.m. the resident was not wearing his prescribed glasses. At 9:29 a.m. the resident was yelling for help. A certified nurse assistant (CNA) arrived and attempted to calm the resident. The resident was not wearing his prescribed glasses.The call light was on his bed and the CNA tucked the call light between the gel seat cushion and left side of the wheelchair before exiting the room. At 12:42 p.m. the resident was sitting in the wheelchair in his room without a call light within reach. -The resident was not able to consistently use the call light (see family interview) and it was not placed properly for use, did not have his glasses on and often did not wear non-skid footwear. E. Record review The resident was admitted to the hospital from 9/28/23 to 10/3/22 status post fall at home resulting in subdural hemorrhage (bleeding in the brain), an 8th left rib fracture, increase in impaired mobility and generalized weakness. Care plan The care plan, revised on 1/5/23, read in pertinent part: the resident was at risk for falls related to a history of falls, decreased mobility, decreased balance, advanced age, and weakness. Interventions start date 10/8/22 date included PT, OT consults, strength training, toning, positioning, transfer training, gait training, and mobility devices. The resident was not a candidate for rehabilitation service due to presenting symptoms and the resident's spouse opted for hospice care. The care plan dated 1/5/23 continued with: keep call light and personal items and frequently used items in reach. Provide the resident with an environment free of clutter. Orient resident when there has been new furniture placement or other changes in environment. If falls occur, analyze resident's falls to determine pattern/trend. Give resident verbal reminders not to ambulate/transfer without assistance, provide resident with proper well-maintained footwear. Encourage the resident to use environmental devices such as hand grips, handrails. Assure the floor is free of glare, liquids, and foreign objects. Assure the resident was wearing glasses and they were clean. Toileting program, 12/28/22, read as follows: assure the resident is sitting upright in his wheelchair. Interdisciplinary team to review medication regimen, padding to gap in bed and bed extenders, and included offer distraction measures updated on 1/31/23. Interdisciplinary team: ensure resident has proper footwear over heel protectors when up in wheelchair updated 2/21/23. Care plan after 2/21/23 included the interdisciplinary team (IDT) to complete root cause(s) of fall events and establish and recommend interventions. Falls Two fall events occurred on 2/17/23 at 7:15 p.m. and at 11:53 p.m. The fall at 7:15 p.m. was unwitnessed and occurred in the hallway as the resident stood upright from his unlocked wheelchair and fell backward hitting his posterior head against the floor. The resident reported he was trying to find his wife. The resident was last toileted at 5:30 p.m. and was incontinent of urine at the time of the fall. Neurological checks were completed on 2/17/23 from 7:15 p.m. through 9:00 p.m. The spouse and medical provider were notified of the fall. At approximately 9:55 p.m. the resident's head wound started to actively bleed and the provider ordered an emergency room evaluation and computed tomography (CT) scan which was negative. The head wound was glued closed and the resident was returned to the facility. The investigation of the fall revealed the resident was not wearing non-skid footwear. Purposeful rounding stopped at 6:45 p.m. (30 minutes before the first fall). Root cause per interdisciplinary team (IDT): Urine incontinence. Interventions: proper footwear, educate the resident on importance of using call light, rearrange room. -There was no documentation the second fall on 2/17/23 at 11:53 p.m. was investigated. A third unwitnessed fall occurred on 3/20/23 at 1:35 a.m. The resident was found on the floor at his bedside, stating he wanted to go out. No injury noted. Neurological checks were completed immediately after the fall through 3/22/23 on the evening shift (time not documented). The resident was incontinent of urine at the time of the fall. Last toileting/brief changed at 12:30 a.m. The spouse, hospice, and the medical provider were notified. Root cause per IDT: No root cause documented. Interventions: Staff implemented fall protocol, rearrange room, place bed against wall. A fourth unwitnessed fall occurred on 4/2/23 at 8:45 p.m. The resident was found on the floor leaning against his wheelchair facing the television. No injury noted. Neurological checks were completed immediately after fall through 4/5/23 on the evening shift (time not documented). The resident was not incontinent of urine at the time of the fall. Last toileting brief change at 5:45 p.m. Wife and medical provider were notified. Root cause per IDT: Believed to be agitation. Interventions: Post Void Residual Volume (no progress note related to post void residual volume output). An assisted fall occurred on 4/4/23 at 7:00 a.m. as a certified nurse assistant (CNA) was assisting the resident with a transfer from bed to wheelchair and the resident's knees buckled. The CNA lowered the resident to the floor. No injury noted. The resident was not incontinent at the time of the assisted fall. Last toileting/brief change at 5:30 a.m. Root cause per IDT: increased weakness. Interventions: Collaborate with hospice to request physical therapy for strengthening related to comfort/fall prevention (no progress note to support collaborative practice with hospice/physical therapy). F. Staff interviews CNA #2 was interviewed on 4/13/23 at 2:10 p.m. He said the toileting program was knowing the resident's bowel and bladder habits and taking the resident to the toilet before they were incontinent. He said he used the Kardex (an abbreviated directive) to make sure he knew when to toilet residents but said it was way too much when he was the only CNA on the unit. CNA #1 was interviewed on 4/18/23 at 9:46 a.m. She said purposeful rounding was checking on residents every two hours to make sure they were okay and respond to their needs in a timely manner. She further explained, she was assigned to 15 residents and many were dependent on her for transfers but if she could not find help then she could not always round. The NHA was interviewed on 4/18/23 at 10:15 a.m. The NHA said the toileting program was located on the Kardex. The Kardex was generated every morning/evening (if needed) for the CNAs to offer toileting to residents because continence was a priority. The clinical nurse consultant (CNC) was interviewed on 4/18/23 at 11:20 a.m. The CNC said purposeful rounding was focused on answering call lights. The CNC stated there was no mechanism in place to assure purposeful rounding was consistently done, and no documentation to support purposeful rounding was completed. The CNC said all nursing staff were educated on fall prevention and purposeful rounding on hire and annually. 48112 II. Resident #16 A. Resident status Resident #16, age 61, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the March 2023 CPO, the diagnoses include displaced fracture of left femur, subsequent closed fracture, unsteadiness on feet, pain in left hip and left knee, history of falling, end stage renal disease, dependence on renal dialysis, kidney transplant, history of infections of the central nervous system-cryptococcal meningitis, history of sepsis (infection) and bacteremia (bacteria in bloodstream), pseudomonas (infection), type two diabetes and encephalopathy (altered mental status). The 3/17/23 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 one person assistance with transfer, dressing, toileting and personal hygiene. He used a walker and a wheelchair. It indicated that he had a fracture related to a fall within the last six months. B. Record review The fall risk care plan, revised on 3/28/23, documented the resident was at risk for falling related to history of falls, decreased mobility, decreased balance and a hip fracture. The interventions included assure resident is wearing eyeglasses, assure eyeglasses are clean and in good repair, assure the floor is free of glare, liquids and foreign objects, encourage resident to use environmental devices such as hand grips, hand rails,etc, keep call light and personal items within reach, occupy resident with meaningful distractions, provide assistance as needed for ADLs and mobility, provide toileting assistance/toileting plan. The initial social services progress note on 3/13/23 at 5:07 p.m. indicated that the resident was independent with all ADLs with no need of mobility. -There was no intervention in his fall risk care plan related to residents identified to be at greater risk. The activities of daily living (ADL) function status/rehabilitation potential care plan, initiated on 3/12/23, documented the resident will attain and maintain the highest practicable functional level and complications will be minimized. The interventions included providing an occupational and physical therapy evaluation, enforce weight bearing restrictions as ordered, instruct in use of assistive device and monitor for correct use, provide assistance for ADL's and mobility as needed, and teach safety measures and monitor resident's safety. The 3/13/23 fall assessment documented at 9:08 p.m. the resident told the nurse he tried to roll in the bed and fell down on the floor. The nurse's progress note on 3/13/23 at 10:11 p.m. documented the CNA informed the nurse that they came in the patient's room to help him to bed. Patient told the CNA he can't sleep and he needs his wife or someone (sic) to sleep with (sic) him in the room. The nurse told the resident that no one can be (sic) in his room during the night. Later the resident pressed the call light many times and asked the CNA if she can stay with him. There was no documentation that the staff asked the resident if they should call his wife nor did they attempt to reach the resident's wife at nightime. The facility attempted to reach the wife on 3/14/23 at 8:55 a.m. to inform the wife of the fall at night. They were unsuccessful in reaching the wife. They notified the son about the fall and he said he would visit the morning of 3/14/23. -There were no additional interventions added to the actual fall care plan related to the resident's need for increased supervision. The nurse's progress note on 3/21/23 at 12:09 p.m. documented the resident was asking for percocet for his pain. He has confusion at times. The 3/21/23 fall assessment documented at 8:08 p.m. the resident told the nurse that he slid out of his wheelchair and was lying on the floor at the end of the hall in front of the wheelchair. The care plan revealed the following intervention was added: encourage resident to become more involved in facility activities. The 3/22/23 fall assessment documented at 5:45 p.m. the resident told the nurse that he was trying to go to the bathroom. The CNA found the resident in between the toilet and the wall. The care plan revealed the following intervention was added: continue with PT/OT, social work to speak with family about changing room closer to nurse's station and explore post dialysis activities during peak time of confusion. The nurse's progress note on 3/22/23 at 5:30 p.m. documented the resident told the CNA that he saw a woman with a dog and was going after the dog. When asked by the nurse, resident said he was trying to go up a three to four run ladder. The nurse's progress note on 3/22/23 at 11:59 p.m. documented the resident complained of pain to whole body. The interventions used were low bed, appropriate footwear or grippy socks. The nurse's note on 3/23/23 at 2:03 p.m. documented the night shift night nurse reported that resident complained of right lower extremity pain overnight after his fall. The nurse's progress note on 3/23/23 at 2:46 a.m. documented the interventions used were purposeful rounding, appropriate footwear or grippy socks and toileting programs. The resident was educated to not stand up by himself. Resident was upset with nurse stating he was not in a concentration camp. The nurse reminded the resident that he was in rehabilitation for his broken hip and the facility has safety regulations. The nurse reminded him about his falls. The 3/27/23 fall assessment documented at 8:56 p.m. documented the resident told the nurse he was trying to get to the wheelchair from his bed. He was found on his knees in his room. The nurse's progress note on 3/27/23 at 9:55 p.m. documented the resident sustained a skin tear to the left outer forearm. The nurse's progress note on 3/28/23 at 7:00 a.m. documented the resident was very confused throughout the night. He was alert and oriented to self only. Resident had three falls since 8:00 p.m. last evening. The resident vacillated from very agitated and lethargic. When awake and restless (sic) and agitated, he continues to take off his clothes and attempting to grab staff and get up. Temperature started at 99.8 degrees F and went up to 100.2 degrees F. Tylenol was provided. Resident assisted to chair and back to bed but has remained unsafe and closely monitory. Heart rate was tachycardia but regular. Provider was notified after first fall and again this morning with orders to send to emergency room to evaluate and treat. The nurse's progress note on 3/28/23 at 9:54 a.m. documented called hospital emergency room for resident's disposition. Resident is being admitted for altered mental status, generalized abdominal pain, urinary retention, blood in urine, urinary tract infection, elevated white blood cells, elevated potassium of 7. -The care plan revealed the following interventions were added: sent to ER for evaluation on 3/28/23, room rearranged related to falls and purposeful rounding. -The facility failed to put effective interventions into place to prevent Resident #16 from continued falls. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/17/23 at 11:53 a.m. He said purposeful rounding was to go to the resident's door say hello and seeing if the resident needed anything. The nurse would see if the resident was in distress or pain. LPN #1 was unable to answer how often purposeful rounding should be completed. CNA #3 was interviewed on 4/17/23 at 11:48 a.m. She said purposeful rounding was to check on all residents every 60-90 minutes. She said she did not know what purposeful rounding was if a resident had an intervention. She stated the toileting program was to check on the resident every two hours to see if they needed incontinence assistance. A copy of the facility's purposeful rounding policy was requested on 4/17/23. The clinical services manager (CSM) #1 did not have a policy. She provided a presentation on purposeful rounding. -The presentation did not state what the frequency of rounding should be when ordered. Admission coordinator (AC) #1 was interviewed on 4/18/23 at 11:58 a.m. She said she notified the nurse and therapists when a new resident was a high fall risk. She stated new residents identified as a fall risk should have maximum assistance, have a sling in the room and be close to the nurse's station. The fall risk was communicated through email to all disciplines and the admission coordinator would give a report in person. 19262 III. Resident #33 A. Resident observations On 4/12/23 at 1:24 p.m., the resident sat in a wheelchair in her room. She had a bandage on her left lower extremity (shin). The bandage was dated 4/12/23. B. Family interview An interview was conducted with the resident's daughter on 4/12/23 at 1:24 p.m. She said on 4/2/23, the resident hit her left shin on a metal part of her wheelchair while she was in the bathroom with a staff member. The resident received a skin tear to her left shin. C. Resident status Resident #33, age 92, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included need for assistance with personal care, muscle weakness, history of falling, lack of coordination, chronic kidney disease stage 3, malignant neoplasm (cancer) of the breast, history of sepsis, chronic obstructive pulmonary disease, lack of coordination, cognitive communication deficit, lack of coordination, frontal lobe and executive function deficit. The 1/23/23 minimum data set (MDS) assessment, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers (two plus staff physical assist), dressing, eating, toileting (two plus staff physical assist), and personal hygiene. The resident had functional limitations in range of motion impairment on both sides of her lower extremities (hip, knee, ankle, or foot). The resident had occasional moderate pain that did limit her day to day activities. D. Record review Care plan for a skin tear was started on 2/23/23. The pertinent interventions included for staff to apply dressings according to physician and wound care team orders. Staff were to consult with the facility wound care team to follow and guide the resident's treatment. Staff were to report signs of cellulitis (localized pain, redness/swelling/tenderness/drainage, fever); sepsis (fever/malaise/change in mental status, tachycardia/hypotension, nausea/vomiting); osteomyelitis (pain/redness/swelling, muscle spasms, fever). Wound care would be managed by a hospital wound clinic, facility wound care team and the resident's family. Event report by licensed practical nurse (LPN) #1 dated 2/20/23 at 8:45 a.m., revealed to monitor a skin tear to the resident's left lower extremity (shin) related to contact with her wheelchair footplates upon transferring. The skin tear was vertical measuring 2 centimeters (cm) on the left lower shin. There was no pain associated with the skin tear and no signs or symptoms of infection. Staff were to monitor the skin tear daily for any change in condition. -The resident's physician and family representative were not notified (cross-reference F580). Wound note dated 2/23/23 at 8:30 a.m., by a registered nurse (RN) revealed skin tear/laceration to the left shin. The wound bed had granulated and epithelial tissue with heavy sanguineous (blood) exudate. The surrounding skin was bruised. Resident reported no pain to the area. Resident was at baseline for movement, strength, sensation, temperature and edema (water retention) for the extremity wound. Physician order dated 2/23/23 revealed a skin tear to the left middle shin. Wound care team to cleanse with saline or wound cleanser, pat dry, apply xeroform (cut to fit) followed by foam dressing every other day and as needed. -After the resident obtained the skin tear on 2/20/23, there was no subsequent education with staff or preventative measures put in place to prevent recurrence. E. Staff interviews The assistant director or nursing (ADON) was interviewed on 4/18/23 at 8:40 a.m. He said the resident's lower extremity wound occurred when her left was bumped on her wheelchair during a transfer by staff. The wound nurse (WN) was interviewed on 4/18/23 at 12:10 p.m. She said on 2/20/23 from a skin tear that occurred during a transfer with staff. She said a staff member was transferring the resident and her shin came into contact with the wheelchair pedals that were folded up and to the sides of the wheelchair. She said she felt this was an accident and the transfer was completed according to facility policy. She acknowledged that there was no evidence the resident's family nor her physician were notified of the incident on 2/20/23 and they should have been notified. LPN #1 was interviewed on 4/18/23 at 2:46 p.m. He said he was told by a certified nurse aide (CNA) that the resident had hit her shin on the wheelchair foot pedals. He said the food pedals were flipped up and she nicked her shin on the metal. He said it was a small skin tear and she did have some edema at the time. He said it was bleeding a little at the time. He said he could not remember if he notified the resident's family or physician. He said for changes of condition, falls, head injuries and unwitnessed falls the family and physician should be notified.

Based on record review and interviews, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident's representative when there was a change of condition for three (#33, #59 and #64) of eight residents out of 32 sample residents. Specifically, the facility failed to notify the resident's physician and/or the resident's legal representative related to: -Resident #33's skin tear to the left lower extremity; -Resident #59's falls on 1/26/23 and 2/27/23; and, -Resident #64's falls on 2/20/23 and 3/9/23. Findings include: I. Facility policy and procedures The Change of Condition with Resident policy, revised on 7/7/22, was provided by the clinical services manager (CSM) #1 on 4/18/23 at 12:42 p.m. The policy revealed a change of condition with a resident was a multi-disciplinary approach and might be observed by any member of the team. The interdisciplinary team (IDT) reviewed residents routinely and might identify a change of condition. The IDT should monitor residents on-going, for a change of condition/change in status. Upon identification of a change of condition, an event will be opened in (charting program) and interventions implemented immediately. The registered nurse (RN) or the licensed practical nurse (LPN) was responsible for notifying the provider and the resident's power of attorney (POA) of a significant change of condition. Documentation of notification should be made in the medical record. Except in a medical emergency, a resident should not be transferred or discharged , or his/her treatment radically altered without consultation with the resident/POA and the provider. II. Resident #64 A. Resident status Resident #64, age 86, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (altered mental status), cognitive communication deficit, history of falling, permanent atrial fibrillation, muscle weakness, presence of cardiac pacemaker, frontal lobe and executive function deficit. The 4/1/23 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility and dressing. The resident required limited staff assistance for transfers, toileting and personal hygiene. B. Record review Care plan for falls related to the resident's history of falls, decreased mobility, decreased balance and lack of understanding of surroundings was initiated on 1/31/23. The pertinent interventions were staff to provide ongoing education to use call light for assistance prior to getting out of bed or off the toilet. Ensure the resident was wearing eyeglasses. Ensure the floor was free of glare, liquids, and foreign objects. Encourage the resident to use environmental devices such as hand grips and hand rails. Provide the resident verbal reminders not to ambulate/transfer without assistance and encourage the resident to assume a standing position slowly. Provide the resident with proper and well-maintained footwear. If falls occur, analyze the resident's falls to determine the pattern/trend. Ensure the call light, personal items and frequently used items were within reach. Provide the resident an environment free of clutter. Staff were to orient the resident when there has been new furniture placement or other changes in environment. Staff were to provide the resident with assistance as needed for activities of daily living and mobility. Staff were to provide toileting assistance. C. Fall on 2/20/23 Event report revealed an unwitnessed fall on 2/20/23 at 6:00 p.m., in his room. The resident did not exhibit or complain of pain related to the fall. There were no signs of injury. The resident was able to perform ranges of motion on all extremities without limitations or pain. There was no observed rotation, deformity or shortening of extremities. The resident was alert and oriented at times two. The resident had a history of falls, movement problems or unsteady gait and an orthopedic condition. -The resident's physician and legal representative were not notified. The post fall investigation revealed the resident had a fall on 2/20/23 at 6:00 p.m. The resident was found lying on the floor in front of his recliner and said he was trying to go to bed. There were no observed injuries. The wound nurse (WN) was interviewed on 4/18/23 at 10:40 a.m. She acknowledged the resident's family nor physician were notified of the resident's fall on 2/20/23. She said they both should have been notified about the fall. E. Fall on 3/9/23 The family interview was conducted on 4/12/23 at 2:23 p.m. The daughter of the resident said the resident fell while going to the bathroom during the night of 3/9/23 and the facility staff did not notify them. She said she learned about the fall from the resident's physician the next day on 3/10/23 at 9:30 a.m. She said the resident fell and hit his head on the corner of the in room sink. She said the resident had a contusion to the back of his head, a bruise on his forehead, a bruise on the back of his neck and his left knee was hurting. She said he was sent to the hospital emergency department according to their request. Event report dated 3/9/23 at 11:15 p.m., revealed the resident had an unwitnessed fall at 9:55 p.m., in his room. The resident did not exhibit or complain of pain related to the fall. The resident's ranges of motion for all extremities were without any limitations or pain. There was no rotation, deformity or shortening of the extremities. The resident was alert and oriented at times one. The resident had a history of falling. The safety measures at the time of the fall were to ensure the call light (paddle) was in reach, bed in lowest position, walker, wheelchair and non-slip socks. -The resident's physician and legal representative were not notified. Fall investigation revealed on 3/9/23 at 9:55 p.m., the resident had an unwitnessed fall. A certified nurse aide (CNA) heard the resident fall and found him on the floor in his room. The resident wore regular socks. The resident said he was leaving. The resident had a hematoma to the base of the skull, minor injury of a skin tear or major bruise depending on the hospital's evaluation. The resident was educated on the use of the all light. Nurse note dated 3/10/23 at 10:24 a.m., by a RN revealed the resident's physician was notified the resident had a fall overnight. The resident was unable to bear weight on his left knee and was walking yesterday. The resident had a hematoma to the base of his skull and was going to the hospital for evaluation. Hospital note dated 3/10/23 at 11:12 a.m., revealed no acute osseous abnormality or intracranial processes. There was ecchymosis (contusion or bruise) to the occiput. There was no discomfort elicited upon the range of motion of the left knee or hip. The resident reported tenderness on palpation to the proximal aspect of the left femur and the lateral aspect of the proximal portion of left tibia/fibula. The WN was interviewed on 4/18/23 at 10:40 a.m. She acknowledged the resident's family was not notified of the resident's fall on 3/9/23. She said the resident's family should have been notified immediately due to his head injury and subsequent delayed transportation to the hospital emergency department. She acknowledged the resident's physician was not notified until 3/10/23 at 10:24 a.m. She acknowledged the resident's physician should have been notified immediately due to the resident's head injury. III. Resident #33 A. Resident status Resident #33, age 92, was admitted on [DATE]. According to the April 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness, history of falling, lack of coordination, chronic kidney disease stage 3, malignant neoplasm of the breast, history of sepsis (infection), chronic obstructive pulmonary disease, lack of coordination, cognitive communication deficit, lack of coordination, frontal lobe and executive function deficit. The 1/23/23 minimum data set (MDS) assessment, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers (two plus staff physical assist), dressing, eating, toileting (two plus staff physical assist), and personal hygiene. The resident had functional limitations in range of motion impairment on both sides of her lower extremities (hip, knee, ankle, or foot). The resident had occasional moderate pain that did limit her day to day activities. B. Record review Event report by licensed practical nurse (LPN) #1 dated 2/20/23 at 8:45 a.m., revealed to monitor a skin tear to the resident's left lower extremity (shin) related to contact with her wheelchair footplates upon transferring. The skin tear was vertical measuring 2 centimeters (cm) on the left lower shin. There was no pain associated with the skin tear and no signs or symptoms of infection. Staff were to monitor the skin tear daily for any change in condition. -The resident's physician and family representative were not notified. Care plan for a skin tear was started on 2/23/23. The pertinent interventions included for staff to apply dressings according to physician and wound care team orders. Staff were to consult with the facility wound care team to follow and guide the resident's treatment. Staff were to report signs of cellulitis (localized pain, redness/swelling/tenderness/drainage, fever); sepsis (fever/malaise/change in mental status, tachycardia/hypotension, nausea/vomiting); osteomyelitis (pain/redness/swelling, muscle spasms, fever). Wound care would be managed by a hospital wound clinic, facility wound care team and the resident's family. C. Staff interview The WN was interviewed on 4/18/23 at 12:15 p.m. She acknowledged the resident's family nor physician were notified of the skin tear to the resident's left lower extremity on 2/20/23. She said they both should have been notified about the skin tear. IV. Resident #59 A. Resident status Resident #59, age 78, was admitted on [DATE]. According to the April 2023 CPO, diagnoses included dementia, depression, lack of coordination, attention/concentration deficit, symbolic dysfunctions, history of falling, muscle weakness, frontal lobe and executive function deficit. The 2/16/23 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 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. B. Record review Care Plan for falls related to the resident's history of falls, decreased mobility, decreased balance and poor decision making was revised on 2/20/23. The pertinent interventions were to ensure the resident wore the proper anti-slip footwear, educate the resident to call staff prior to getting up independently and for the maintenance staff to assess for anti-roll back mechanism on the wheel chair. Ensure the resident's bathroom was free of clutter, and the light in the bathroom was tested and worked appropriately. Keep the resident's bed in the lowest position. Ensure the resident was wearing glasses. Ensure the floor was free of glare, liquids, and foreign objects. Encourage the resident to use environmental devices such as hand grips, and handrails. Provide the resident with verbal reminders not to ambulate/transfer without assistance and encourage the resident to assume a standing position slowly. If falls occurred, analyze the resident's falls to determine pattern/trend. Ensure the call light, personal items and frequently used items were within reach. Staff were to provide the resident an environment free of clutter. Staff were to orient the resident when there has been new furniture placement or other changes in environment. Staff were to provide assistance as needed for activities of daily living and mobility. Staff were to provide toileting assistance. C. Fall on 1/6/23 Event report revealed on 1/6/23 at 6:45 p.m., the resident had a witnessed fall in their room. The resident said I fell backwards cause my legs got wobbly. The resident was being transferred with staff assistance. The resident was able to move all extremities without pain. There was no observed rotation, deformity of the extremities. The safety measures that were in use at time of fall were the resident's bed was in the lowest position, paddle call light in reach, gait belt, shoes, and wheelchair. -The resident's physician and family representative were not notified of the fall. The post fall investigation for the fall on 1/6/23 at 6:45 p.m., revealed the resident was assisted to the bathroom, the resident's legs became weak and gave out from under her. The fall was witnessed and the resident hit the back of her head during the fall. The resident had slight pain to the area, and no other injuries were noted. The WN was interviewed on 4/18/23 at 10:05 a.m. She acknowledged the resident's family nor physician were notified of the resident's fall on 1/6/23. She said they both should have been notified about the fall. D. Fall on 2/27/23 Event report revealed on 2/27/23 at 5:40 p.m., the resident had an unwitnessed fall with no injuries in the resident's room. The resident said I was trying to get in the wheelchair and slipped. Prior to fall, the resident was sleeping in bed. The resident did not exhibit or complain of pain related to the fall. The resident was able to move all extremities without pain. There was no observed rotation or deformity of the extremities. The resident had a history of falls. The safety measures that were in use at time of fall were the resident's bed was in the lowest position, paddle call light in reach, cane, gait belt, low bed, shoes, walker and wheelchair. -The resident's physician and family representative were not notified of the fall. The WN was interviewed on 4/18/23 at 10:05 a.m. She acknowledged the resident's family nor physician were notified of the resident's fall on 2/27/23. She said they both should have been notified about the fall. V. Administrative interview CSM #1 was interviewed on 4/18/23 at 12:40 p.m. She said a resident's family and physician should be notified if a resident experienced a change of condition, falls or pressure ulcers.

Based on record review and interviews, the facility failed to ensure two (#18 and #16) residents out of 32 sample residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. Specifically, the facility failed to ensure Resident #18 and Resident #16 were administered medications according to the physician's orders. Findings include: I. Facility policy The Medication and Treatment policy, revised 6/23/22, was provided by the clinical nurse consultant (CNC) #1 on 4/18/23 at 11:55 a.m. It revealed in pertinent part, all medications and treatments will be administered with a provider order in a timely manner. If an order cannot be followed, the provider will be notified and the situation will be documented in the resident order. Timely administration of medications/treatments means the medication/treatment is administered as close to the scheduled time as possible. One hour before or after the schedule time or range is acceptable. Ideally, medications are administered at the time scheduled; if unable, reasoning will be documented. Residents have the right to refuse medications/treatments. If a resident refuses a medication/treatment, the following will occur. After the nurse's assessment of refusal, if it is determined that the medication/treatment being refused has the ability to cause a significant adverse event, the provider will be notified by midnight of the next calendar day. If there is a pattern of refusal (three consecutive refusals) the provider and the responsible party shall be notified. The type and purpose of the medication/treatment shall be taken into consideration and nursing judgment shall be used. II. Resident #18 A. Resident status Resident #18, age 79, was admitted on [DATE]. According to the April 2023 computerized physician order (CPO), the diagnoses include Alzheimer's, type two diabetes, hypertensive chronic kidney disease with stage 5 chronic kidney disease, dependence on renal dialysis, congestive heart failure and syncope. The 1023/223 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required two person assistance with transfer, dressing, toileting and personal hygiene. B. Record review The April 2023 CPO physician orders revealed: - Cinacalcet 30mg (milgrams) once a day for hyperparathyroidism (parathyroid gland overactive) secondary to chronic renal failure with dialysis, start on 1/25/23. The November 2022 medication administration record (MAR) showed the following medications were not administered per physician orders: On 11/12/22 Cincalcet 30mg was not administered as resident refused. The December 2022 MAR showed the following medications were not administered per physician orders: On 12/17/22, 12/23/22 and 12/29/22, Cincalcet 30mg was not administered as resident refused. The January 2023 MAR showed the following medications were not administered per physician orders: On 1/2/23, 1/4/23, 1/6/23, 1/13/23 and 1/16/23, Cincalcet 30mg was not administered as resident refused. The February 2023 MAR showed the following medications were not administered per physician orders: On 2/1/23, 2/2/23, 2/8/23, 2/12/23, 2/20/23, 2/22/23 and 2/28/23 Cincalcet 30mg was not administered as resident refused. The March 2023 MAR showed the following medications were not administered per physician orders: On 3/8/23, 3/14/23, 3/15/23, 3/21/23, 3/24/23 and 3/31/23 Cincalcet 30mg was not administered as resident refused. The April 2023 MAR showed the following medications were not administered per physician orders: On 4/7/23, 4/8/23, 4/9/23 and 4/10/23 Cincalcet 30mg was not administered as resident refused. The progress notes revealed that on 4/7/23 the dialysis center notified the facility that there was a concern for intact parathyroid hormone levels. The resident's level was 2,819 with a goal range of 160 to 720. It documented the resident was on cinacalcet 30 mg. -The Cinacalcet medication was used to produce less parathyroid hormone. There was an event created on 4/11/23 to monitor for medication refusals, document interventions and effectiveness. There was no documentation under the notification section of the event that the provider was notified. III. Resident #16 A. Resident status Resident #16, age 61, was admitted on [DATE] and discharged on [DATE]. According to the March 2023 CPO, the diagnoses include end stage renal disease, dependence on renal dialysis, kidney transplant, history of infections of the central nervous system-cryptococcal meningitis, history of sepsis (infection) and bacteremia (bacteria in bloodstream), pseudomonas (infection), type two diabetes and encephalopathy (altered mental status). The 3/17/23 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 one person assistance with transfer, dressing, toileting and personal hygiene. B. Record review The March 2023 CPO physician orders: -Eliquis 5mg twice a day for deep vein thrombosis, start on 3/11/23. -Insulin glargine solution 100 unit/mL 10 units twice a day for type two diabetes, start on 3/11/23. -Prednisone 5mg once a day in the morning for kidney failure, start on 3/11/23. -Vancomycin 125 mg twice a day for c-difficile prophylaxis, start on 3/14/23. The March 2023 MAR showed the following medications were not administered per physician orders: -3/15/23 Eliquis 5mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis. -3/17/23 Eliquis 5mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis. -3/15/23 Insulin glargine solution 100 unit/mL was not administered as resident was unavailable. The progress note documented the resident was at dialysis. -3/17/23 Insulin glargine solution 100 unit/mL was not administered as resident was unavailable. The progress note documented the resident was at dialysis. -3/15/23 Prednisone 5mg was not administered as resident was unavailable. The progress note did not give any additional information. -3/17/23 Prednisone 5mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis. - 3/15/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis. - 3/17/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note did not give any additional information. -3/20/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note did not give any additional information. -3/22/23 Vancomycin 125mg was not administered as resident was unavailable. the progress note documented the resident was at dialysis. -3/24/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note did not give any additional information. -There was no documentation in the resident's medical record that indicates the physician was notified when the prescribed medications were not administered. IV. Interviews Licensed practical nurse (LPN) #1 for Resident #16 and #18 was interviewed on 4/18/223 at 10:35 a.m. He said that if a resident did not receive medication, the doctor should be notified. The charge nurse (CN) #2 was interviewed on 4/18/23 at 10:40 a.m. She stated that if a resident has dialysis, the time should be readjusted so the resident receives the medication before or after dialysis. If a resident refused, it was the resident's right to refuse. She would educate the resident and call the family. For Resident #18, she stated they would call the husband to help encourage the resident to take the medication and the charge nurse would review. The assistant director of nursing (ADON) was interviewed on 4/18/23 at 10:51 a.m. He said that if a medication was not administered, it should be noted in the chart and the charge nurse should be notified. If the resident was at dialysis, the timing should be readjusted so the resident gets the medication before leaving for dialysis. If the resident refused and there was a pattern, an event should be opened. When an event was opened, that would trigger notifying the provider.

Based on resident observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#16 and #18) of five residents out of 28 sample residents. The facility failed to identify and implement pressure relieving interventions in a timely manner for Resident #16 to prevent the development of two unstageable pressure injuries. The resident was known to be at risk for skin impairment, had recently experienced a significant decline in her overall health status, and was known to be non-accepting of interventions such as heel protector booties and offloading her heels with a pillow. The resident required extensive two person assistance from staff for bed mobility. The facility provided the resident with the standard pressure reducing mattress (rated to a stage 3 per the wound care nurse, see below) which was provided for all residents. The facility implemented blue heel protector booties for the resident, and the staff was to offload the resident's heels on a pillow if she declined to wear the heel protector booties. However, when Resident #16 also declined to offload her heels on a pillow, the facility failed to put a pressure relieving low air loss mattress in place as an intervention to avoid the development of pressure ulcers. When the resident experienced a decline in her overall health status on 1/13/22, she stopped eating and declined the offloading interventions more frequently than she previously had. The facility again failed to provide a low air loss mattress and the resident developed a stage 2 pressure ulcer to her right heel on 1/16/22. Despite the development of the right heel pressure ulcer and the continued decline of offloading interventions, a low air loss mattress was still not implemented by the facility. Resident #16 developed an unstageable pressure ulcer to her left heel on 1/25/22. In addition, the resident's right heel ulcer worsened and was reclassified as an unstageable pressure ulcer on 1/25/22. On 1/25/22, Resident #16's family chose to initiate hospice services for the resident. The family was informed by the facility that hospice would provide a low air loss mattress for the resident. Resident #16 was admitted on hospice care and services on 1/29/22. Despite her admission to hospice care and services, the low air loss mattress was not put into place as a wound intervention until 2/8/22, which was 10 days after the resident went on hospice. Due to the facility's failure to provide timely interventions in place prior to the development of her pressure ulcers and after she developed a Stage 2 pressure ulcer on 1/16/22, she developed avoidable unstageable pressure ulcers to her right and left heels. Resident #18 was identified as being high risk for developing pressure ulcers and required extensive staff assistance for bed mobility. The facility documentation of the resident's pressure ulcer to the sacral region was inconsistently documented when the pressure ulcer developed and to its specific location sacrum, coccyx, gluteal fold left buttock, right buttock or bilateral butticks. In addition, many of the treatments did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was readmitted on [DATE] from the hospital.The nursing assessment on 11/18/21 documented the resident had moist yellow slough with moderate slowly blanching discoloration to the coccyx and a moist open area to the sacrum. The wound care nurse documented subsequently that the resident had friction wounds to his buttocks with no consistent measurements or staging. Resident #18 had friction wounds to the buttock region at admission and was not seen by a wound physician for an initial wound evaluation until 12/17/21. The wound physician assessment documented a sacral wound full thickness measuring 5.0 centimeters (cm) by 4.7 cm by 0.2 cm with a surface area of 23.50 cm squared that had developed from moisture associated skin damage, friction and shearing with definite pressure component that had developed over the sacral area with some necrosis and slough in the wound bed. Subsequently, the resident was seen by a hospital wound clinic after the inhouse wound physician assessment. The hospital wound clinic assessed on 12/22/21 the sacral wound as concerning since the wound was close to bone and only covered with devitalized connective tissue. On 1/5/22, the hospital wound clinic measured and described the wound as a stage 4 pressure wound to the buttock. The wound care nurse in the facility described the wound to the buttocks as friction since his readmission from the hospital 11/18/21, due to inconsistent treatments, timely monitoring by the wound physician (or outside wound clinic), the sacral pressure wound worsened and developed into a Stage 4. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 2/10/22, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. *Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (2/10/22), Interventions for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nutrition for Pressure Ulcer Prevention and Treatment Multivariable analyses of epidemiological data indicate that a poor nutritional status, indicated by low body weight or poor dietary intake among other signs, is a factor that impacts upon pressure ulcer risk. All individuals at risk of pressure ulcers should have their nutritional status screened. A comprehensive assessment should be conducted where risk of malnutrition is identified, and in individuals with existing pressure ulcers. Repositioning and Early Mobilization Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Repositioning to Prevent and Treat Heel Pressure Ulcers Heel pressure ulcers are a challenge to prevent and manage. The small surface area of the heel is covered by a small volume of subcutaneous tissue that can be exposed to high mechanical load in individuals on bedrest. It is important to conduct regular inspection and correct positioning in order to relieve heel pressure while avoiding potential complications such as Achilles tendon damage, foot drop and deep vein [CONDITION(S)] (DVT). Support Surfaces Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Medical Device Related Pressure Ulcers Individuals with a medical device in situ are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local [CONDITION(S)], as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility policy and procedure The Skin Protection and Wound Prevention policy, last revised 12/9/21, was provided by the director of nursing (DON) on 2/9/22 at 10:47 a.m. It read in pertinent part, Most residents admitted to the facility are considered at risk for developing wounds, although the level of risk may vary. Interventions to prevent wounds and promote healing include use of pressure-relieving devices when a resident has a pressure injury or is at high risk for pressure injuries. Care of residents with decreased mobility shall include: off-loading heels with a pillow if the resident is unable to reposition their lower extremities, use of an off-loading device (as recommended by the therapist and/or facility wound care team) if the resident has an ulcer on the heel or the use of a pillow is ineffective in maintaining proper off-loading, turning/repositioning at least every two hours or more frequently if every two hours is determined to be ineffective. III. Resident #16 A. Resident status Resident #16, age greater than 90, was admitted on [DATE]. According to the February 2022 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/29/22 minimum data set (MDS) assessment revealed that the resident's cognitive skills for daily decision making were severely impaired. She required two-person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She was totally dependent on staff for transfers using a mechanical lift. She was at risk of developing pressure ulcers/injuries, and had two unstageable pressure ulcers. The resident was on hospice. B. Resident observations On 2/3/22 at 12:30 p.m., Resident #16 was sitting in her wheelchair in her room. A pair of blue heel protector booties were lying on the floor between the dresser and the closet. The mattress on the resident's bed was the facility's standard mattress, not a specialty low air loss mattress. On 2/7/22 at 8:39 a.m., the resident was lying in bed. She was not wearing the blue heel protector booties and her heels were resting directly on the mattress. There was a pillow under the covers on the left side of her legs, however her heels were not being offloaded by the pillow. The blue heel protector booties were on the floor between the dresser and the closet. On 2/7/22 at 11:54 a.m., Resident #16 was lying in bed with the head of the bed elevated. She had slid down in the bed toward the foot of the bed. Her heels were on the mattress and she kept bending her right leg so the heel of her right foot was rubbing back and forth on the mattress. She was not wearing the blue heel protector booties. The pair of booties remained on the floor between the dresser and the closet. The pillow continued to be under the covers and on the left side of the resident's legs. Her heels were not offloaded on the pillow. On 2/7/22 at 12:03 p.m., certified nurse aide (CNA) #1 and CNA #2 entered Resident #16's room and shut the door. On 2/7/22 at 12:08 p.m., CNA #1 opened the door to the resident's room. The resident was sitting up better in the bed after the two CNAs repositioned her higher in the bed so she was no longer slouched down. The pillow remained under the covers on the left side of the resident and was not under the resident's heels. The blue heel protector booties were still on the floor between the dresser and the closet. Resident #16's heels were resting directly on the mattress. C. Wound observation and interview On 2/8/22 at 8:23 a.m., Resident #16's right and left heel unstageable pressure ulcers were observed during the wound dressing changes performed by the wound care nurse (WCN). The staff development coordinator (SDC) was also present during the dressing change to assist the WCN with positioning the resident and dressing supplies. Resident #16 was lying on her back with a pillow positioned under her ankles, however her heels were resting directly on the bed. The WCN said the resident's heels should be offloaded by the pillow so her heels were not touching the mattress. The WCN said the resident was not very compliant with wearing the blue heel protector boots or letting staff offload her heels with a pillow. The WCN said she told the staff to do the best they could with offloading the resident's heels. She said the facility's standard mattresses, which all residents were provided, were rated for pressure reduction up to a stage 3 wound. She said she wanted to implement a low air loss mattress when Resident #16 sustained the skin break down on her left heel on 1/25/22. She said when she discussed the mattress with the family, the family was not willing to pay for the mattress rental (however, if the specialty mattress was necessary for the care of her pressure ulcer, the facility should have provided it, see additional interviews below). She said the family did not want aggressive wound treatment, but instead wanted the resident to receive hospice services and be comfortable with minimal wound treatment. The WCN said because the resident was receiving hospice services effective 1/29/22, the hospice company would pay for a low air loss mattress and the facility was working with them to obtain the mattress. She said they had been working on getting the mattress for a few days and she planned to follow up with them after she completed the resident's wound dressings to see where they were in the process. -However, it had been 10 days since the resident was admitted to hospice and the mattress was still not provided during the wound observation. The WCN proceeded to wash her hands with soap and water prior to beginning Resident #16's wound care. She donned a pair of gloves and then removed the resident's socks. The SDC assisted by positioning the resident's legs so the WCN could perform the wound care on each heel. The WCN removed the old dressings dated 2/7/22 from both of the resident's heels. After cutting off the old dressings, the WCN removed her gloves, sanitized her hands with alcohol based hand rub (ABHR) and put on a new pair of gloves. She proceeded to perform the wound care on the resident's right heel first. The WCN said the right heel wound was a large blister initially and was classified as a stage 2 pressure wound on 1/17/22. She said the wound then appeared infected and had worsened on 1/25/22, so it was reclassified as an unstageable pressure wound. The back of Resident #16's right heel had a silver dollar size dark purple/black area of eschar (dead tissue). The wound was not open and the depth of the wound was not discernible. The surrounding skin was intact with flaky skin on the edges of the wound. There was no redness present to the surrounding skin. The WCN cleansed the area with wound cleanser and proceeded to remove her gloves. She sanitized her hands with ABHR and reapplied gloves. The WCN applied crushed [MEDICATION(S)] (an antibiotic medication) to the wound before covering it with an abdominal (ABD) pad (a highly absorbent dressing that provides padding and protection for wounds). She secured the ABD pad with a gauze wrap, dated the dressing and removed her gloves. The WCN sanitized her hands with ABHR before putting on a new pair of gloves and proceeding to the wound care for the resident's left heel. The back of Resident #16's left heel also had a silver dollar size purple/black area of eschar. The wound was not open and the depth of the wound was not discernible. The surrounding skin was flaky and intact with no visible redness. There is no visible depth. The surrounding skin is flaky and intact, no redness. The WCN cleansed the area with wound cleanser and proceeded to remove her gloves. She sanitized her hands with ABHR and reapplied gloves. She applied [MEDICATION(S)] to the left heel, let it dry, covered the heel with a ABD pad, and then wrapped the heel with a gauze wrap. The WCN dated the dressing, removed her gloves and washed her hands with soap and water prior to cleaning up her wound dressing supplies and leaving the room. D. Record review The 1/27/21 Braden Skin Risk assessment (a guide utilized for assistance with predicting pressure ulcer risk) documented Resident #16 was at risk for developing pressure ulcers based on a score of 15 out of 23 (a lower score indicates higher risk of developing pressure ulcers). The assessment documented the resident had slightly limited sensory perception, her skin was occasionally moist, she was chairfast, had slightly limited mobility, her food intake was probably inadequate, and her potential for friction (the force of rubbing two surfaces against one another) and shear (gravity force pushing down on the resident's body with resistance between the resident and the chair or bed) was a problem. The resident had additional risk factors of advanced age, was taking drugs that impair wound healing, and refused some aspects of care and treatment. These additional risk factors gave the resident a final moderate risk level for the development of pressure ulcers. Review of Resident #16's comprehensive care plan, initiated 10/24/2020 and last revised 2/7/22 (during the survey), revealed the resident was at risk for skin breakdown, refused offloading/repositioning/turning often, and refused to offload heels with offloading boots intermittently. Pertinent interventions included providing education to the resident as tolerated on turning/repositioning and offloading, assessing and monitoring the resident for the presence of risk factors, treating, reducing, and eliminating risk factors to the extent possible, instructing and encouraging the resident to reposition herself when in bed or to offload her weight when sitting in a chair, encouraging adequate nutrition and fluids. Ensure availability of food and fluids of choice, using a pressure reduction mattress when the resident was in bed, and using pillows or other offloading devices to relieve pressure on heels. -The care plan did not include an intervention for a pressure relieving low air loss mattress. Further review of the comprehensive care plan revealed Resident #16 had unstageable pressure injuries to bilateral (both) heels. The resident had a noted recent decline in status and increased refusals for care such as offloading, turning and repositioning (added 1/7/22). The resident was unable to retain education related to her cognition and was on hospice services. Pertinent interventions included applying dressings per the physician and wound care team orders, assessing for pain related to pressure ulcers or treatment, assessing the pressure ulcers for stage, size (length, width, and depth), presence/absence of granulation (healthy) tissue and epithelialization (the process of covering denuded (loss of the outer layer of skin caused by prolonged moisture and/or friction) epithelium, which is the layers of cells that make up the outer surface of the body), and condition of surrounding skin. ensuring consistent implementation of skin protection/wound prevention protocol, considering additional, more aggressive interventions, such as pressure relieving mattress/wheelchair pad, and using pillows or heel bridges to relieve pressure on the heels. Review of the February 2022 CPO revealed the following physician orders: -Cleanse right heel wound gently. Pat dry. Crush 500 milligrams (mg) [MEDICATION(S)] and apply to the wound bed. Cover with an ABD pad and secure with kerlix(gauze wrap). Change daily and as needed (PRN). The order had a start date of 2/7/22. -Left heel cleanse and pat dry. Apply [MEDICATION(S)] to the wound bed, cover with an ABD pad and secure with kerlix. Change every other day and PRN. The order had a start date of 2/2/22. -Off loading boots to bilateral feet. Patient to wear off loading boots at all times when in bed. The order had a start date of 11/8/21. Resident #16's treatment administration record (TAR) was reviewed from 1/10/22 through the day shift documentation of 2/8/22. The TAR revealed the resident refused her off loading boots six times out of 91 opportunities. -The TAR documented the resident had her offloading booties on during the day shifts on 2/3/22, 2/7/22, and 2/8/22, however, observations made during the survey revealed the offloading boots were on the floor in the resident's room and not on the resident's feet (see observations above). Further review of the TAR between the dates of 1/10/22 through the day shift documentation of 2/8/22 revealed the following discrepancies between the TAR documentation and the documentation in the progress notes: 1/21/22: The TAR documented the resident's offloading boots were on during the night shift, however the night shift nurse documented a progress note on 1/22/22 at 6:37 a.m. indicating the resident refused the offloading boots (see progress notes below). 1/24/22: The TAR documented the resident's offloading boots were on during the night shift, however the night shift nurse documented a progress note on 1/25/22 at 6:40 a.m. indicating the resident refused the offloading boots (see progress notes below). 1/25/22: The TAR documented the resident's offloading boots were on during the day shift, however WCN documented a progress note on 1/25/22 at 12:09 p.m. indicating the resident refused the offloading boots (see progress notes below). 1/26/22: The TAR documented the resident's offloading boots were on during the night shift, however the night shift nurse documented a progress note on 1/27/22 at 6:49 a.m. indicating the resident refused the offloading boots (see progress notes below). 1/30/22: The TAR documented the resident's offloading boots were on during the night shift, however the night shift nurse documented a progress note on 1/31/22 at 3:43 a.m. indicating the resident refused the offloading boots (see progress notes below). A copy of an email correspondence dated 2/3/22 from the registered dietitian (RD) to the dietary manager (DM) was provided by the RD on 2/8/22 at 2:42 p.m. The email instructed the DM to add a nutritional supplement with all meals three times per day. -The RD said she overlooked adding the order into Resident #16's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's electronic medication record (EMAR) for the dates of 1/10/22 through 2/7/22 revealed nursing staff documented the resident refused the off loading boots Review of Resident #16's electronic medical record (EMR) revealed the following progress notes: 11/8/21: Evaluated patient at this time. Resident shoes fit appropriately, resident has chronic redness to toes. Skin prep order in place to sites of redness and to heels. Resident noted with frequent refusals for repositioning/offloading. Will order resident offloading boots in attempts to float heels. Barrier cream ordered for buttocks. Staff to cluster care at bedtime and provide offloading/repositioning as tolerated. 12/14/21: Wound orders reviewed and care plan for wound/refusals/skin. Resident intermittently refuses offloading, turning and repositioning. She also intermittently refuses her offloading boots. Treatments remain in place and appropriate. Care plan in place. 1/11/22: Wound care plan remains in place. Resident continues to have intermittent refusals for cares such as turning, offloading, repositioning and offloading heels. Will continue with the current plan at this time. 1/13/22: Weekly skin assessment performed, no new skin issues noted at this time. 1/16/22: Certified nurse aide (CNA) reported drainage to resident's right sock, Nursing staff investigated and noted skin tear to right heel, wound care provided per facility protocol. Charge nurse notified. Resident has no complaints of pain to right heel at this time. No obvious signs of distress or discomfort noted. 1/17/22: New wound noted to right heel. stage 2. Resident denies pain. See observation for details. Care plan updated. Orders written. Left voicemail for family and sent email securely. Notified providers. Will follow up weekly. Reviewed medications/dietary interventions and appear appropriate at this time. 1/17/22: Weights reviewed with weight loss of 4.7% in 32 days. Patient with recent weight loss of 7 pounds in two days. Updated weight vital taken 1/17/22: 154.1# pounds; body mass index (BMI): 27.29. Weight trends stable times four days. Patient continues to receive a regular diet with a regular food snack at 3:00 p.m. Intake at meals reviewed and appears excellent. Patient with new wound noted (stage 2 right heel). Updating orders to offer Juven two times daily for increased protein exposure related to wound healing and skin integrity. With adequate oral intake, will not open a nutrition concern event at this time. Will continue to monitor weight trends and revisit as appropriate. 1/18/22: Resident refused juven and morning meds. No obvious signs of distress or discomfort noted. dressing intact to the right heel. 1/20/22: Weekly skin assessment performed, scattered bruising to right shin and right forearm, redness to toes continues, dry red area to left heel, pressure injury continues to right heel. Mild redness to buttocks. 1/21/22: Dressing to right heel intact. Patient refused offloading boots but did allow pillow to be placed under bilateral lower extremities (BLE) to offload pressure to heels. 1/22/22: Dressing to right heel intact. Patient refused offloading boots and refused to allow heels to be floated. 1/24/22: Left heel with dark firm tissue on wound bed and mild redness on peri wound, skin prep applied. Right heel with open area, noted maceration and redness on peri wound, wound bed moist and red. Patient reports some discomfort with touch. Patient medicated with Tylenol and [MEDICATION(S)] for pain as scheduled. Dressing applied as ordered, patient refused juven supplement for wound healing, appetite poor. 1/25/22: Dressing intact to right heel. Patient refusing to wear waffle boots but allowed a pillow to be placed under BLE to off load pressure. 1/25/22: Hospice referral sent to [name of hospice provider]. Social services will continue to follow. 1/25/22: Staff report resident refuses to remove shoes. With encouragement the resident did allow me to remove her shoes. Noted new wound to left lower extremity (LLE) and worsening to the right lower extremity (RLE) - see wound observations for details. Resident has recently been removing offloading boots in bed. The resident complained of moderate pain to both heels. RLE heel appears infected. Cleaned sites and dressing applied to RLE. Resident did allow for me to place socks on versus shoes. Will write order to reflect this. Resident refusing medications, care and has had increased weakness. Now sling for transfers. Noted 10 pound weight loss in 30 days and poor intake. Resident refused breakfast and snacks this morning. Notified family and discussed options treatments versus comfort. Family would like hospice to consult and make the patient comfortable. Provider order obtained and social services notified. 1/25/22: Comfort the goal, not healing of wounds. Will update orders on this date and refer to wound observations for wound measurements and observations. Attempted boot placement three times today and the resident refused. 1/26/22: Dressing to right heel noted to be soiled with moderate amount of serosanguinous (fluid) drainage and was changed per PRN order. Patient with tenderness noted during care. She refused to allow off loading boots to be placed on and started yelling 'no, no' in a repetitive manner. She did allow heels to be off loaded using a pillow. 1/27/22: Dressings covered with kerlix intact to RLE. Patient refused waffle boots but allowed pillow under heels to off load pressure. 1/29/22: No obvious signs of distress or discomfort noted. Wound care completed to right heel, left heel, and right shin per order. Resident sling for transfers. Resident not eating well, took one bite from her lunch tray, refused snacks. Continuing to encourage snacks and fluids. Resident evaluated for hospice, accepted into hospice. 1[TRUNCATED]

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for one (#16) of three residents out of 28 sample residents. Specifically, the facility failed to provide the necessary assistance for Resident #16 who required physical assistance and encouragement with eating. Findings include: I. Facility policy and procedure The Activities of Daily Living policy, revised 2/9/22 (during the survey), was provided by the director of nursing (DON) on 2/9/22 at 1:57 p.m. It read in pertinent part, The facility will provide necessary care and services for residents based upon the comprehensive assessment of each resident and consistent with each resident's needs and choices to ensure that abilities in activities of daily living (ADLs) do not diminish unless the clinical condition demonstrates that a decline was unavoidable. Each resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out ADLs, including: bathing, dressing, grooming, oral care, transfer, ambulation, elimination, dining, and communication. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. An unavoidable decline in ADL ability is justified if a resident's clinical picture reflects normal progression of a disease or condition. The facility will implement interventions to assist the resident immediately when a decline is observed. II. Resident status Resident #16, age greater than 90, was admitted on [DATE]. According to the February 2022 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/29/22 minimum data set (MDS) assessment revealed that the resident's cognitive skills for daily decision making were severely impaired. She required two-person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She was totally dependent on staff for transfers using a mechanical lift. She required one-person physical assistance and supervision with eating. The resident was on hospice. III. Observations A continuous observation of Resident #16 was conducted on 2/3/22 from 11:59 a.m. until 12:30 p.m. The following observations were made: -At 11:59 a.m., dietary aide (DA) #1 delivered a room tray to Resident #16 for lunch. DA #1 uncovered the resident's tray and placed it on the bedside table. She had her head down sitting in her wheelchair and said she did not want the food. DA #1 told the resident lunch was good and she should try it. When she shook her head again, DA #1 asked the resident if she wanted him to make her a grilled cheese sandwich. The resident did not respond and DA #1 left the room. Resident #16 continued to sit with her head down and did not attempt to eat her meal. -At 12:30 p.m., there had been no staff members in Resident #16's room since DA #1 delivered the resident's meal tray, 31 minutes prior. The resident did not receive physical assistance or encouragement to eat her meal, and she had not attempted to eat her meal herself. On 2/7/22 at 8:39 a.m., Resident #16 was sitting in bed with her breakfast in front of her on the bedside table. There was no staff in the room to assist her. She had not taken any bites of her meal and her silverware was still on the tray beside her plate. A continuous observation of Resident #16 was conducted on 2/7/22 from 11:54 a.m. until 12:36 p.m. The following observations were made: -At 11:54 a.m., an unknown dietary aide delivered the resident's lunch tray to her room. The resident was lying in bed with the head of the bed elevated and she had slid down in the bed toward the foot of the bed. The dietary aide uncovered the resident's room tray and told her what was on the plate. The resident did not acknowledge what was told to her. The dietary aide left the room. The meal consisted of broccoli, chicken with gravy, rice, and ice cream. The resident did not make an attempt to feed herself. -At 12:03 p.m., 11 minutes after the resident's meal tray was delivered to her room, certified nurse aide (CNA) #1 entered the resident's room with CNA #2 and shut the door. -At 12:08 p.m., CNA #1 opened the door to the resident's room. The resident was sitting up better in the bed after the two CNAs repositioned her higher in the bed so she was no longer slouched down. CNA #2 left the room. CNA #1 put the resident's ice cream in a plastic tumbler with a lid and straw and added Coke to make a Coke float for the resident. CNA #1 told the resident to drink all of her float and left the room. She did not attempt to physically assist the resident with eating. -At 12:10 p.m., the resident picked up her spoon which was lying on her plate. The spoon had a little gravy on it. She licked the spoon and then set it back on the plate. She picked up the coke float and took a drink of it before setting it back down on her table. -At 12:15 p.m., the resident took another sip of the Coke float, but she did not attempt to eat any food from her plate. -At 12:21 p.m., CNA #1 returned to the room and gave the resident a bite of chicken, which she accepted, chewed and swallowed. CNA #1 then told the resident to eat up and left the room again. The resident took another drink from her float and set it back down. She did not attempt to eat another bite of food from her plate. -At 12:36 p.m., Resident #16 had finished her Coke float, however she had not taken any more bites of her lunch. No staff members had returned to the room to attempt to physically assist the resident or encourage her with eating. A continuous observation was conducted on 2/9/22 from 8:15 a.m. until 8:44 a.m. The following observations were made: -At 8:15 a.m., Resident #16 was sitting in the dining room. She had a plate full of waffles and bacon. Her silverware was still wrapped and resting on the left side of her plate. No staff were physically assisting or encouraging her to eat her breakfast. -At 8:25 a.m., registered nurse (RN) #1 walked into the dining room to pass medications to another resident. After she gave the other resident his medications, RN #1 stopped at Resident #16's table to say hello. RN #1 did not attempt to offer the resident any bites of food or encourage her to take a bite on her own. After greeting the resident briefly, RN #1 returned to her medication cart down the hall. -At 8:37 a.m., dietary aide (DA) #2 stopped at Resident #16's table because the resident gestured her over to the table. The resident asked DA #2 to take her back to her room. DA #2 told her someone would take her back in a little bit. DA #2 did not encourage the resident to take a bite of her breakfast. -At 8:44 a.m., there still had been no nursing staff member make an attempt to physically assist or encourage Resident #16 with eating. IV. Record review Review of Resident #16's assist to dine care plan, initiated 2/7/22 revealed the resident was on the program related to decline. Staff was to offer assistance as tolerated, and if the resident became agitated they were to re-approach. Pertinent interventions included monitoring the dining program for safety and progress, and monitoring for adequate fluid intake with meals, and offering and encouraging fluids between meals unless contraindicated. Review of the resident's nutrition care plan, initiated 10/26/2020 and revised 2/3/22, revealed the resident had a potential for nutrition concerns related to contributing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Pertinent interventions included providing adequate assistance with meals, monitoring nutrition parameters, including intake, weight variance, skin and labs, encouraging food/fluid intake during interactions, offering regular diet as ordered and adding very small portions effective 2/3/22, and adding Boost and ice cream with meals three times per day. -Despite the care plan documenting the resident was to receive adequate assistance with meals and the MDS assessment documenting she required one staff physical assistance with meals, observations conducted during the survey did not show that staff was providing consistent physical assistance or encouragement with eating for the resident (see observations above). Review of Resident #16's electronic medical record revealed the following progress notes: 1/23/22: No obvious signs of distress or discomfort noted. Dressing intact to the right heel. Resident required more assistance with transfers. Resident refused breakfast and lunch, stated she didn't know what it was and did not want it. Encouraging snacks and fluids. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. 1/26/22: No obvious signs of distress or discomfort noted. Dressing intact to the right heel. Resident required more assistance with transfers, sling for transfers. Resident not eating, refusing snacks, refused morning medications, took afternoon medications. Continuing to encourage snacks and fluids. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. 1/27/22: Poor food intake noted, patient refused breakfast, accepted 25% of lunch and one ice Cream. Fluids provided and encouraged throughout the shift. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. 1/28/22: Up in wheelchair during shift. Accepted all medications, but had poor oral intake, not eating much for breakfast and lunch. Fluids offered throughout shift and available at bedside. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. 1/29/22: No obvious signs of distress or discomfort noted. Wound care completed to right heel, left heel, and right shin per order. Resident sling for transfers. Resident not eating well, took one bite from lunch tray, refused snacks. Continuing to encourage snacks and fluids. Resident evaluated for hospice, accepted into hospice. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. 2/2/22: Up in wheelchair, but mostly sleeping, is more confused and not really eating anything. Snacks offered. Took medications crushed for breakfast. Refused to eat lunch and refused noon medications. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. 2/3/22: Patient up in wheelchair throughout shift, increased confusion noted, accepted all medications, poor food intake, patient accepted only a couple small bites for lunch and breakfast, accepted 75% of shake, fluids provided and encouraged throughout shift. -The progress note did not document that staff made attempts to physically assist or encourage the resident with eating during her meals. A progress note dated 2/4/22 was the only progress noted which documented physical assistance with eating was attempted with the resident. It read in pertinent part: Patient up in wheelchair throughout shift, refused medications whole, accepted medications crushed with pudding, continues with poor food intake, assistance with meals provided, patient accepted 25% of breakfast and 25% of lunch, and 100% of ice cream, fluids provided and encouraged throughout the shift. V. Interviews DA #2 was interviewed on 2/8/22 at 8:37 a.m. DA #2 said Resident #16 had just started on an assist to dine program on 2/7/22. She said the resident had not been eating well in her room, so the facility wanted to bring her to the dining room to see if providing her with more assistance would encourage her to eat. DA #2 said when residents were on an assist to dine program it meant that CNAs were supposed to help them to eat if possible. The wound care nurse (WCN) was interviewed on 2/8/22 at 11:29 a.m. The WCN said Resident #16 had a decline in eating around 1/6/22 and had been started on an assist to dine program on 2/7/22. She said CNAs received a list of residents who were on an assist to dine program and the amount of assistance each resident needed for eating. The WCN said Resident #16 did not often allow staff to physically assist her with eating, however she said staff were to encourage her with eating even if she did not allow them to physically assist her. She said if the resident became agitated during their attempts to assist or encourage her with eating, the CNA should return periodically throughout the meal and continue to attempt to assist the resident. The WCN said CNAs were instructed to attempt to assist residents at least two to three times during a meal. She said she encouraged staff to wait about 10 or 15 minutes and then re-approach the resident and attempt to assist her with eating again. She said Resident #16 did not accept physical eating assistance, however she would drink some fluids with encouragement and cueing from staff. -Although, the WCN said the resident did not accept physical eating assistance, the observations conducted during the survey showed that staff did not consistently make attempts to physically assist the resident with eating her meals. (see observations above). The RD was interviewed on 2/8/22 at 2:06 p.m. The RD said Resident #16 was maintaining a stable weight until her recent decline in January 2022. She said beginning about 1/16/22, the resident stopped eating much. The RD said the resident was placed on an assist to dine program on 2/7/22. She said the resident's program was set up for staff to provide her encouragement for eating or maximum physical assistance for eating if the resident would accept the physical assistance from the staff. -The RD indicated the resident had stopped eating much around 1/16/22, but the facility did not recommend the assist to dine program until 2/7/22, almost three weeks later. The DON was interviewed on 2/9/22 at 10:21 a.m. The DON said Resident #16 had not been eating well and had been started on an assist to dine program on 2/7/22. She said the program for the resident was probably still new to the staff. She said assist to dine meant that staff were to assist residents with eating. The DON said the level of assistance varied with each resident. She said some residents required extensive physical assistance while others required only cueing and encouragement. She said Resident #16 did not often accept physical assistance with eating, however staff should attempt to physically assist her. The DON said if the resident declined physical assistance with eating, staff should continue to check on the resident and offer encouragement several times throughout a meal. She said staff should not just check on the resident one time and then not check back to see if she was eating.

Based on observations, record review and interviews, the facility failed to provide care in manner which promoted dignity and respect for four residents (#22, #71, #41 and #42) out of 21 sample residents. Resident #22, who was cognitively intact and dependent on staff for incontinence care, said she had to wait long periods of time for staff to provide her timely toileting assistance. Due to the facility failures to answer her call light timely to provide her toileting assistance, she sustained psychosocial harm from being self-conscious about the smell, she missed activities which provided her enjoyment. She had to wait for them in her mess and worried about getting infections from not being toileted timely. Resident #71, who was cognitively intact and dependent on staff for incontinence care, said she waited long periods of time for her call light to be answered, sometimes over an hour. She said her [MEDICAL CONDITION] (an opening in the intestines) bag sometimes bursts and she would have to wait long periods of time in the stool. Due to the facility's failures to answer her call light timely, she sustained psychosocial harm, the resident felt irritated. Resident #41, who was cognitively intact and required limited physical assistance from one staff for toileting and extensive assistance from staff for dressing, said she had to wait long periods of time for staff assistance for her care needs. She said she felt disgusting and it bothered her to wait long periods of time in soiled clothing. On 1/26/21 at 9:46 a.m. the resident complained of pain in her legs from her pressure stockings, she pressed her call light but she waited for 31 minutes. At 10:22 a.m., she coped with the pain from the stocking then missing an activity that was important to her. Due to the facility's failures to answer her call light timely, she sustained psychosocial harm, the resident felt pain, disgust and bothered. Resident #42, who was cognitively intact and required extensive physical assistance from one staff for toileting, said she did not have her call light answered timely for her care needs. She said she often had to wait 30 minutes or more for staff to respond. She said she yelled out when her call light was not answered and felt her door was shut in response to her yelling (cross-reference F609 for reporting an allegation of abuse to the State Agency in a timely manner). Due to the facility's failures, she sustained psychosocial harm and felt she was not treated with dignity and the staff did not value her needs which ultimately caused her panic and anxiety. Findings include: I. Facility policy The Resident Rights policy, revised 4/11/2020, was provided by the nursing home administrator (NHA) on 2/3/21 at 2:55 p.m. The policy read in pertinent part: The facility and the staff shall observe these rights in the care, treatment, and supervision of the residents. According to the policy, the residents had: The right to receive adequate and appropriate health care consistent with established and recognized practice standards. The right to be treated courteously, fairly, and to the fullest measure of dignity. II. Resident #22 A. Resident status Resident #22, age 73, was admitted to the facility on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. According to the 11/12/21 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required total dependent assistance from staff to perform transfers and toilet use. B. Resident interview Resident #22 was interviewed on 2/3/21 at 1:38 p.m. She said that she had to wait for staff to answer her call light for long periods of time which would sometimes result in her having bowel incontinence and having to wait for them in my mess. She said that she would push her call light as soon as she had the urge to go to the bathroom but could only hold it for so long. She said that she missed activities because she would not be cleaned up in time to attend. She said, It's uncomfortable sitting on your own mess and after a bit I start to feel self conscious about how I smell; I also worry about getting an infection in other other places. III. Resident #71 A. Resident status Resident #71, age 87, was admitted to the facility on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. According to the 1/41/21 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required total dependent assistance from staff to perform transfers and extensive assistance for toilet use. B. Resident interview Resident #71 was interviewed on 2/3/21 at 3:10 p.m. She said that she frequently waited for long periods of time for her call light to be answered, sometimes over an hour. She said that her [MEDICAL CONDITION] bag had burst on a few occasions after she had pushed her call light to alert staff that it needed to be emptied and then had to wait to be cleaned up. She said she felt irritated when she had to wait for long periods of time to receive care. She said that she knew that staff were busy but certain types of care were harder to wait for than others. IV. Record review A log of call light wait times between 1/4/21 and 2/3/21 was provided by the NHA on 4/2/21 at 4:37 p.m. Review of the log revealed Resident #22 waited over 30 minutes on 12 occasions for her call light to be answered in that time frame. On numerous occasions she waited well beyond 30 minutes which included: -On 1/4/21 call light was initiated at 6:16 p.m. and was answered at 7:18 p.m. for a wait time of one hour and two minutes. -On 1/6/21 call light was initiated at 8:25 a.m. and was answered at 9:24 a.m. for a wait time of 59 minutes. -On 1/9/21 call light was initiated at 6:05 a.m. and was answered at 6:58 a.m. for a wait time of 53 minutes. -On 1/18//21 call light was initiated at 12:20 p.m. and was answered at 1:02 p.m. for a wait time of 42 minutes. -On 1/20/21 call light was initiated at 6:08 p.m. and was answered at 7:04 p.m. for a wait time of 56 minutes -On 1/20/21 call light was initiated at 8:58 p.m. and was answered at 9:49 p.m. for a wait time of 51 minutes. Review of the call light log also revealed Resident #71 had waited over 30 minutes on 21 occasions during that time frame which included: -On 1/6/21 call light was initiated at 11:03 a.m. and was answered at 11:47 for a wait time of 44 minutes. -On 1/7/21 call light was initiated at 9:09 a.m. and was answered at 10:01 for a wait time of 52 minutes. -On 1/17/21 call light was initiated at 8:57 a.m. and was answered at 9:47 a.m. for a wait time of 50 minutes. -On1 /22/21 call light was initiated at 7:59 a.m. and was answered at 8:40 a.m. for a wait time of 41 minutes. -On 1/25/21 call light was initiated at 3:30 p.m. and was answered at 4:44 p.m. for a wait time of one hour and 14 minutes. -On 1/25/21 call light was initiated at 7:08 p.m. and was answered at 10:19 p.m. for a wait time of three hours and 11 minutes. V. Staff interviews Certified nurse aide (CNA) #12 was interviewed on 4/3/21 at 2:24 p.m. He said that sanitizing shared equipment used to assist with transfers and having enough qualified staff to assist with transfers impacted call light wait times. He said that while the facility had staffed resident aides (RA) to assist with some resident care tasks, RAs were not permitted to help with hands on direct care such as providing incontinence care. He said he would try to check in with residents he knew were waiting to let them know when he was running behind. He said that the availability of shared resident equipment such as sit-to-stand lifts and the need for sanitizing this equipment between residents contributed to longer call light wait times. The director of nursing (DON) was interviewed on 4/3/21 at 4:24 p.m. She said the facility regularly reviewed resident rights and issues related to treating residents with dignity and respect. She said treating residents with respect is part of the facility culture. She said she had not performed regular audits of call light wait times. She said the facility would review resident needs in daily morning meetings and tried to gauge needs based on the reports of nursing staff, however, the facility did not have a system in place to schedule staff based on resident acuity. She said the facility had staffed RAs for additional resident support on the units, however, RAs could not perform continence care. She said regularly having long call light wait times could increase feelings of depression and anxiety for residents. VI. Resident #41 A. Resident status Resident #41, age 81, was admitted on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. The 12/15/2020 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. Resident #41 and did not present inattention or disorganized thinking. According to the MDS assessment, the resident required extensive physical assistance of one person with bed mobility and dressing. She required limited physical assistance with one person for transferring and toileting. B. Resident interview and observation Resident #41 was interviewed on 1/26/21 9:46 a.m. During this interview she reported she was having some pain in her legs and wanted staff to come remove her pressure stockings. At 9:51 a.m., she pushed her call light to request assistance. By 10:22 a.m. staff had still not arrived after she had waited 31 minutes. At 10:22 a.m. activities staff came to the room to ask her if she would like to attend Bingo. The resident chose to attend Bingo and cope with the pain rather than miss the activity while she continued to wait. She said she felt like the staff were caring people who did their best, but at times they did not have enough help to meet her needs. Resident #41 was interviewed a second time on 2/3/21 at 4:22 p.m. The resident said she tried not to use the call light too often because the staff were so busy, but there had been times where she felt undignified. She said it was disgusting when she has to wait for long periods at a time in soiled clothing from incontinence. Resident #41 said the staff could not always attend to her because they were short staffed. She said it bothered her to be in soiled clothes while she would have to wait for someone to assist her. She said she would rather do herself then the long wait, even though it was very difficult for her to dress and undress herself, but she said she would work hard at trying. C. Record review The psychological well-being care plan, last revised on 12/29/2020, identified Resident #41 required 24 hour, seven day a week nursing care and assistance with ADL's. Her short term goal read the resident would be comfortable and her needs met as appropriate. The activities of daily living (ADL) function care plan, last revised on 12/31/2020, identified the resident experienced a decline in function from her baseline, with increased weakness, deconditioning and/or functional limitations. According to the care plan, staff were to provide ADL assistance as needed. The call light time spreadsheet between 1/3/21 and 2/2/21 was provided by the NHA on 4/2/21 at 4:37 p.m. The audit identified the resident required staff assistance an average of 5 times a day, equally 144 calls in a month. According to the spreadsheet, 17 of the calls for staff assistance were a 15 to 30 minute wait. The spreadsheet identified 6 times the resident had to wait more than 30 minutes to receive staff assistance in a month. Resident #41 required ADL assistance from staff. The spreadsheet revealed staff could not get to the resident in always timely manner as she indicated. This increased the risk of multiple occasions where the resident felt undignified and chose to struggle to assist herself during long waits for staff. VII. Resident #42 A. Resident status Resident #42, age 79, was admitted on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. The 12/17/2020 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. Resident #42 had adequate short term and long term memory and did not present inattention or disorganized thinking. According to the MDS assessment, the resident required extensive physical assistance of one person with bed mobility, transferring and toileting. B. Resident interview Resident #42 was interviewed on 1/27/21 at 10:12 a.m. Resident #42 said staff do not answer call lights in a timely manner. She said she needs staff assistance for most of her care needs. She said she can not stand alone and can not see well. She said call light could take 30 minutes or more at times for staff to respond. She said she had an incident in the past where she was yelling out when her call light was not answered for 30 minutes. She said she believed her door was then shut. She said she felt she was not treated with dignity when that occured or when call lights were not answered quickly. She said she felt staff did not value her needs. Resident #42 was interviewed again on 2/2/21 at 2:01 p.m. She said the slow call lights caused her anxiety and she would cause her to panic. C. Record review The activities of daily living (ADL) function care plan, last revised on 12/31/2020, identified the resident experienced a decline in function from her baseline, with increased weakness, deconditioning and/or functional limitations. According to the care plan, staff were to provide ADL assistance as needed. The [MEDICAL CONDITION] drug use care plan, initiated 12/18/2020, identified the resident exhibited signs and symptoms of anxiety. The resident short goal read that her anxiety would be minimized. Interventions included to leave the door open per her preference and approach her in a calm manner. According to the care plan, staff should attempt to identify any situational causes for her anxiety. The call light time spreadsheet between 1/3/21 and 2/2/21 was provided by the NHA on 4/2/21 at 4:37 p.m. The audit identified the resident required staff assistance an average of 38 times a day, equally 1144 calls in a month. According to the spreadsheet, 134 of the calls for staff assistance were 15 to 30 minutes. The spreadsheet identified 43 times the resident had to wait more than 30 minutes to receive staff assistance in a month. The spreadsheet indicated the resident required much assistance throughout the day from staff. The spreadsheet revealed multiple times the staff could not get to the resident timely as she reported, increasing the resident's feelings of anxiety and not being treated in a dignified manner. VIII. Staff interviews CNA #13 was interviewed on 2/03/21 at 12:55 p.m. She said it was impossible to answer all the call lights in under 15 minutes. She said some residents take at least 10 to 15 minutes to assist in their room and restroom. She said she was responsible for helping all the residents in her hall. CNA #13 said she was the only CNA in the hall. She said there was a resident assistant (RA) that floats between the halls but the RA can not stay in just one hall nor help residents to the restroom. The CNA said often 10 residents need assistance at the same time, and some of residents requested assistance several times in an hour. She said it was very hard on staff to have to stay with a resident to assist with toileting needs while knowing there were four to five other lights going off requesting help with care. CNA #11 was interviewed on 2/3/21 at 2:25 p.m. The CNA said there were multiple times during the day when call lights turned on at the time, especially before and after meals. CNA #11 said she just had to go down the line determining who was most critical to assist first. She said there were many residents that she had to care for, that required much assistance and attention. She said if she had more time and assistance she could answer the call lights quicker, reducing residents' feelings of anxiety. RA #2 was interviewed on 2/3/21 at 2:37 p.m. The RA said she could help residents with some basic things but confirmed that she could not assist the residents to the restroom or assist with continence care. CNA #12 was interviewed on 2/3/21 at 2:04 p.m. He said the staff were reminded to treat residents with respect and dignity in the last couple of days. He said management also reminded staff not to shut doors without resident consent because it could make residents feel imprisoned.

Based on observation, record review and interviews the facility failed to follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the transmission of disease and infection in six of six neighborhoods during a Coronavirus (COVID-19) outbreak. Specifically the facility failed to: -Ensure social distancing was performed during the vaccination clinic; -Ensure proper infection control practices were followed during wound care; -Ensure the appropriate personal protective equipment (PPE) was worn during visitation in isolation rooms; and, -Ensure hand hygiene was provided to residents during meal time. Findings include I. Professional references The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 11/20/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html on 2/8/21 included additional the measure that facilities should remind residents to perform frequent hand hygiene. Facilities should educate residents and families on topics including information about COVID-19, emphasizing the importance of hand hygiene and source control. According to the Centers for Disease Control (CDC) website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (Retrieved 2/12/21), Health care professional (HCP) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE (personal protective equipment), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. .enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use of respirator, gown, gloves and eye protection. When available, respirators should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring airborne precautions. The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Put on an N95 respirator (or higher level of respirator) or facemask (if a respirator is not available) before entry into the patient room or care area. Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19). According to the CDC guidance Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs), last updated 11/20/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html Enforce social distancing among residents. Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others .This approach is recommended because of the high risk of unrecognized infection among residents. Recent experience suggests that a substantial proportion of residents could have COVID-19 without reporting symptoms or before symptoms develop. Retrieved on 2/16/21. II. Facility policy and procedure The Standard Precautions Policy, revised July 2020, was provided from the nursing home administrator (NHA) on 2/1/21 at 1:41 p.m., it read in pertinent part; Standard precautions represent the infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is being delivered. Standard precautions include hand hygiene, use of personal protective equipment (PPE). Standards precautions shall be used routinely during the care and interactions of all residents regardless of their [DIAGNOSES REDACTED]. Hand Hygiene: In order to perform hand hygiene appropriately, soap, water, alcohol based hand rub (ABHR), and a sink should be readily accessible in appropriate locations including but not limited to resident care areas, and food and medication preparation areas. Healthcare workers must perform hand hygiene (even if gloves are used): -Before and after direct contact with the resident; - Before performing an aseptic task; -After contact with blood, body fluids or secretions, mucous membranes, non-intact skin or wound dressings; -If hands will be moving from a contaminated body site to a clean body site during resident care; -After contact with inanimate objects in the resident's room, especially those in the immediate vicinity of the resident; -After removing gloves; -After using the restroom; and -Before meals. If residents need assistance with hand hygiene, staff should assist with washing hands after toileting, before meals, and use of ABHR or soap and water at other times when indicated. Gloves: -Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. -Wear gloves with fit and durability appropriate to the task: -Wear disposable medical examination gloves for providing direct patient care, and -Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment. -Remove gloves after contact with a resident and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. -Do not wear the same pair of gloves for the care of more than one patient. -Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens. -Change gloves (and perform hand hygiene) during resident care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face). The Transmission-based Precautions Policy, revised July 2020, was provided by the NHA on 2/1/21 at 1:14 p.m., it read in pertinent part; When a resident was placed on transmission-based precautions, the staff should implement the following: -Clearly identify the type of precautions and the appropriate PPE to be used; -Place signage in a conspicuous place outside the resident's room such as the door or on the wall next to the doorway identifying the Center of Disease Control (CDC) category of transmission-based precautions (contact, droplet, or airborne), instructions for use of PPE, and/or instructions to see the nurse before entering. Ensure that signage also complies with residents ' rights to confidentiality and privacy; -Make PPE readily available near the entrance to the resident's room; -Don appropriate PPE upon entry into the environment or the residents room on transmission-based precautions, and; -Provide education to residents (to the degree possible/consistent with the resident's capacity) and their representatives or visitors on the use of transmission-based precautions. III. Social distancing during vaccination clinic A. Observations Observations of the vaccination clinic were conducted on 1/28/21 between 9:00 a.m. and 9:40 a.m. The former residents of the facility participated in the clinic. The former residents, at the time of the vaccination clinic, were members of the outside community who did not reside in the facility. Throughout the observations, the community members continued to enter the facility to receive the vaccine. The available space was congested and small for the number of people observed in and around the constructed vaccination clinic. Outside community members were not screened and no hand hygiene was offered. The lack of hand hygiene, screening and social distancing, created the potential risk of the spread of COVID-19. -At 9:00 a.m., a large crowd was observed sitting and standing in the front lobby of the facility. The crowd consisted of staff members working the event, staff waiting to receive a vaccination, outside community members and contracted clinic workers. The lobby was composed of an open area in front of the reception desk, a small sitting area across from the elevator and a larger sitting area near the front entrance. Four community members sat less than six feet part in the small sitting area across from the elevator. One of the community members said she was waiting for transportation to pick her up. Two community members sitting next to or across from the reception desk, said they have been in the facility since 7:45 a.m. and were waiting to be cleared to leave. One community member sat next to the front entrance as she waited for her transportation to arrive. Inside the larger sitting room in the lobby a total of 10 people who all stood or sat in the area at one time. The room contained a combination of clinic workers, outside community members and staff. Six of the people inside the room sat or stood less than six feet apart as vaccinations were conducted. In the sitting room, there were three small tables. One of the tables had three pharmacy staff sitting together. The two other small tables consisted of vaccine administrators and those who were receiving the vaccination. -At 9:15 a.m., there were over 13 people in the front lobby at one time, not including the larger sitting room. The receptionist was observed to inconsistently screen those who entered the facility during the clinic. The receptionist thoroughly screened some of the visitors and staff with COVID-19 symptom questions. She also took their temperatures to ensure they did not have a fever. The receptionist directed a portion of the staff and observed outside community members to the vaccination clinic table without being screened for signs and symptoms of COVID-19. Observations at the vaccination table did not indicate they were screened by the clinic worker after bypassing the initial screener. Hand hygiene was not encouraged or offered to those who did not go through the facility screening process. -At 9:35 a.m., three staff members formed a line in front between the intake coordinator and the facility screener. An outside family member, transporting for a former resident, waited inside the front lobby. The lobby remained congested throughout the observation. C. Interviews The social services director (SSD) was interviewed on 1/28/21 at 9:27 a.m. The SSD said the vaccination clinic was offered to staff and former residents that have returned to the community. According to the SSD, twenty former residents attended the event. The director of nursing (DON) was interviewed on 1/28/21 at 9:40 a.m. The vaccination clinic was originally to be held outside while the former residents waited in vehicles to receive their vaccination, to avoid having the outside community enter the facility. The DON said the company they contracted with would only provide the vaccine inside the facility. She said the facility determined the best inside location was the front lobby to limit the community access to residential areas. -At 1:15 p.m., the DON acknowledged the observed lack of social distancing during the vaccination clinic. She reviewed a new plan to help mitigate the identified concerns for the next scheduled clinic. She said the pharmacy drove the decisions on the vaccine clinic for today but the facility made the decision for the next vaccine clinic to have more social distancing. She said t in order to provide social distancing the staff would sit in the dining room which was a bigger space and waited to get called for the vaccine. The dining room area was not near resident rooms. A staff member was assigned to monitor each person after the vaccine in the therapy department away from residents to continue to social distance. IV. Observations and interviews during wound care A. Resident #41 Registered nurse (RN) #12 was observed on 2/2/2020 at 10:14 a.m. providing wound care. The dressing was removed prior to the observation. Two wounds on the resident's left shin were observed. The surrounding area of the shin was red in color. The beds of wounds had depth and each were green in color. The RN described the condition of the wound as containing slough with serous drainage. The resident described the wounds as very tender. The RN placed a square of gauze over each wound and sprayed wound cleaner over each wound. She removed the gauze and doffed her gloves. She did not wash her hands or apply alcohol based hand rub (ABHR) after removing her gloves. RN #12 doffed new gloves. She applied alginate to the wounds and placed gauze over the top. She rubbed lotion on the surrounding areas on the shin, doffed her gloves and wrapped the shin in an ace bandage. She did not perform hand hygiene after removing her gloves before wrapping the shin with the bandage. Registered nurse (RN) #12 was interviewed at 10:25 a.m. RN #12 said gloves should be changed between cleaning the wound and applying the new dressing. She said hands should be washed every time gloves were changed. She said hand hygiene between glove changes prevents infection and keeps the wound clean. B. Resident #38 Registered nurse (RN) #10 was observed on 2/2/21 at 10:45 a.m. to perform wound care for Resident #38. RN #10 gathered her supplies, cleaned off the bedside table with a wet paper towel and sat the supplies on top. She washed her hands and donned gloves. She took the dirty dressing off Resident #38's left heel, changed her gloves without hand hygiene. She cleaned the wound with normal saline and gauze and used her same gloved hand to apply the sterile dressing over the wound. She took off the dirty dressing of the right heel. She doffed the gloves and donned new gloves without hand hygiene in between. She cleaned the right heel with normal saline and gauze and used the same gloves to apply the sterile dressing over the wound. She used the same gloves again to wash the second wound on the right upper heel with normal saline and gauze. Using the same gloved hand, she squirted antibiotic cream onto her gloved finger and put on the wound. She failed to change gloves and perform hand hygiene from dirty to clean processes. The wound nurse (WN) #1 was interviewed on 2/3/21 at 11:10 a.m. She said while performing wound care hand hygiene was performed before and after glove use and before and after dirty to clean processes. She said she used aseptic technique when puting the supplies on the table and during wound care to ensure no cross contamination occurred. V. Observation and interviews of PPE not worn appropriately Hospice certified nurses aide (HCNA) #1 was observed on 1/26/21 at 11:52 a.m., to enter a resident isolation room [ROOM NUMBER]. She wore an N95 mask and goggles and she donned a gown. No hand hygiene and no gloves were donned. She assisted the resident with a meal tray set up, touched utensils and dishes and sat next to the resident. She put her goggles on top of her head while she sat. She left the room, doffed the gown, put on her coat and failed to wash her hands. She was interviewed immediately after the observation and said her company's human resource department gave her direction on what PPE to wear when in an isolation room. She said she was not sure what to wear in the facility here as it was her first time there. The family member for resident isolation room [ROOM NUMBER] was observed on 1/26/21 12:12 p.m. to enter the room wearing a surgical mask and eye protection. No handwashing was completed before she entered the room and no gown or gloves were donned. She sat next to the resident and assisted to put hearing aids into the resident's ears. VI. Ensure hand hygiene was provided to residents during meal time On 1/26/21 dining service in the second floor dining room was observed from 11:45 a.m. until 12:40 p.m. Eight residents sat at individual tables and received assistance from staff for meal set up and supervision throughout the meal service. At no time throughout this observation were residents offered reminders or support with hand hygiene. VII. Administrative interviews The director of nurses (DON) was interviewed on 2/3/2021 at 4:33 p.m. She said during wound care proper use of gloves from dirty to clean were used. She said the staff should wash hands when donning and doffing gloves. She said cross contamination occurred when hands were not washed in between. She said PPE to be worn in an isolation room was a mask surgical or N95, eye protection, gloves and a gown. VII. Facility COVID-19 status As of 2/3/21, the facility was currently reporting no resident's positive for COVID-19, 24 presumptive positive resident cases of COVID-19 due to being new admissions, zero positive staff for COVID-19.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility kitchens. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service; -Kitchen work surfaces and equipment were cleaned and sanitized appropriately; and, -Prevent potential contamination of food and drink contact surfaces. Findings include: I. Professional references A. According to the Colorado Retail Food Establishment Rules and Regulations (CRFERR, effective January 1, 2019) pages 47-48, Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and after touching bare human body parts other than clean hands and clean, exposed portions of arms .after handling soiled equipment or utensils .during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands. According to the CRFERR (effective January 1, 2019) page 72, Food shall only contact surfaces that are clean .and sanitized . B. According to the Food Code 2017, Recommendations of the United States Public Health Service Food and Drug Administration, page 149: Non-food contact surfaces of equipment should be kept free of dirt, food residue and other debris. Food contact surfaces should be clean to sight and touch. II. Facility policy and procedure The General food preparation and handling policy was provided by the dietary director on 2/3/21 at 12:20 p.m. The policy was read in pertinent part: The kitchen surfaces and equipment will be cleaned and sanitized as appropriate .Cutting boards will be cleaned and sanitized after use .Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared food. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use. 1. Observations Observations were conducted on 1/28/21 between 11:05 a.m. and 12:50 p.m. Observations revealed cross-contamination of dirty non-food related items touched surface areas where ready-eat-food was prepared. Observations also revealed hand hygiene was not conducted after repeatedly handling a marker from inside a pant pocket, as well as a facemask, potentially contaminating ready-to-eat food. -At 11:23 a.m., cook #1 retrieved the temperature log book and placed it on the cutting board surface of the steam table. The log book was covered with unidentified debris across the top and back plastic surface of the book. The inside the plastic protective cover over the log book continued numerous crumbs and other unidentified substances. Cook #1 sanitize a food thermometer with an alcohol wipe. The cook removed a marker from his pants pocket and marked down the items he planned to obtain a temperature in the temperature log book. He wrote down the items and returned the marker to his pocket. The cook did not perform hand hygiene after handling the marker from his pocket. Cook #1 proceeded to take the temperatures of the ready-to-eat food, gripping the entirety of the thermometer handle with the same hand that touched the marker from his pocket. The cook took the temperatures of the steamed vegetables, the sliced turkey, gravy and stuffing, recording the temperatures after each use with the marker. After each item,he placed the marker back in his pocket or on the porous surface on the steam table cutting board. As the cook took the temperature of the stuffing, the bottom thermometer handle was set into the ready-to-eat item. He removed his hand from the handle and recorded the temperature with the marker. Cook #1 continued to record and take the temperatures of the remainder of ready-to-eat food using the same practices as described above, with the thermometer handle sinking into both the mashed potatoes and the cranberry sauce. No observations were made of the cook performing hand hygiene after touching the marker. No observations were made of the cook sanitizing the marker, temperature log book cover, or the handle of the thermometer. The cook removed the book from the cutting board surface, performed hand hygiene and began to plate the meal. Cook #1 did not sanitize the surface of the cutting board after the temperature log was placed on top of it to record. -At 12:02 p.m., a knife and a slice of turkey was placed on top of the same cutting surface the temperature log rested on. Cook #1 proceeded to chop the meat with the knife and plate to be served to a resident. -At 12:07 p.m., cook #1 touched the outside surface of his mask with his left hand. He then touched his left thumb on the rim of a plate as he dished the meal on to it. He did not perform hand hygiene after touching the outside of his mask. 2. Interviews On 1/28/21 at 12:28 p.m., cook #1 was interviewed. He said he received infection control training that included hand hygiene. On 2/3/21 at 1:05 p.m. The dietary manager (DM) and the chef were interviewed. The chef observed the temperature log in its current condition. He described the log as very dirty and should not have been placed on top of the porous surface of the cutting board steam table. The DM was made aware of the observations of lack of hand hygiene while touching non-food related items and ready-to eat food. Both DM and the chef agreed observed surfaces should have been sanitized and hand hygiene should have been conducted because of the potential for cross-contamination to the ready-to-eat food. 3. Record review On 2/3/21 at 12:20 p.m., the DM provided the following training records cook #1 attended regarding infection control: -The bare hand with food training on 3/6/2020. -Hand hygiene education on 8/26/2020. -Employee sanitary practices and general food prep on 1/28/21.

Based on record review and staff interview, the facility failed to report allegations of abuse to the State and certification agency in accordance with State law for one (#42) of two residents reviewed for reporting out of 21 sample residents. Specifically, the facility failed to report an allegation of abuse for Resident #42, to the State Agency within two hours after the allegation was reported to administration. Findings include: I. Facility policy The Abuse Prevention policy, revised March 2020, was provided by the facility on 2/1/21 at 4:03 p.m. via email. The policy read in pertinent part: Providing a safe environment for the residents is one of the most basic and essential duties of our facility The policy defined the different types of abuse to include involuntary seclusion and neglect. The policy definition for involuntary seclusion, read in part: Is defined as confinement to his room against the resident's will The policy definition for neglect, read in part: Means failure to provide goods and services to avoid physical harm, mental anguish According to the policy, all employees must immediately report any observed or reported incident of resident neglect, abuse or misappropriation of resident property to the administrator or supervisor in charge. The abuse policy listed a procedural quick reference time frame when allegation of abuse was reported. The policy identified immediate action of an internal investigation of the alleged incident, notification to the family or responsible party, notification of the State agency per occurrence reporting procedures when two hours for any abuse, 24 hours for non-abuse. The medical director, the licensure board and the local ombudsman needed to be contacted when in 24 hours of report. II. Resident #42's status Resident #42, age 79, was admitted on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. The 12/17/2020 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. Resident #42 had adequate short term and long term memory and did not present inattention or disorganized thinking. According to the MDS assessment, the resident required extensive assistance with one person physical assistance with bed mobility, transferring and toileting. II. Failure to report abuse 1. Resident interview Resident #42 was interviewed on 1/27/21 at 10:12 a.m. Resident #42 said an incident had a occured approximately two weeks prior to 1/27/21, late in the evening. Resident #42 said she was balled up in pain in her bed and placed her call light on. She said she became anxious and started yelling out for help. Resident #42 said she heard her door loudly shut. She could not see who closed her door. She said she felt her door was closed because she was yelling out. The resident said her call light went unanswered for approximately 30 minutes before her nurse entered her room. According to Resident #42, the nurse told her it was too bad the door was closed when she needed assistance but she was not aware who shut it. The resident said she had not heard follow up from the facility after she reported her concern to the nurse. -She did not know which evening it occurred. She said the incident upset her. The resident said she had not reported the incident to management but a nurse she felt comfortable with was made aware. Resident #42 did not want to reveal the name of the nurse who she said she originally reported her concern to because she did not want to get the nurse in trouble. Resident #42 was interviewed again on 2/2/21 at 2:01 p.m. Resident #42 recounted the incident two weeks prior to 1/27/21. According to the resident, she was yelling for help because she started to panic when the call light was not answered. The door was then shut. She said a fire alarm was not sounding when she was yelling to prompt the staff to close the door. 2. Record review Review of nursing notes between 1/1/21 and 1/27/21 revealed the resident's report of her door shut when she was yelling after her call light was not answered was not documented in the nursing notes. The investigation event report packet was provided by the DON on 2/1/21 at 4:03 p.m., via email. The packet included an event report for pain, resident and staff interviews, a call light audit, the residents care plan, the policy for abuse and reporting. The packet also included staff inservices for abuse prevention, reporting and care reminders. Resident #42 was interviewed on 1/27/21. Staff and other residents were interviewed between 1/28/21 and 1/30/21. According to documented interviews, residents did not feel that they had long waits in pain, had incidences where their door was closed when they needed assistance nor expressed feelings of neglect. Staff interviews and call light audits did not indicate a known report of concern from Resident #42 nor could reveal a timeline when the event could have occurred. Staff inservices were conducted between 1/28/21 and 2/1/21. The provided report was created on 1/29/21 at 6:22 a.m. and completed on 1/29/21 at 8:52 p.m. According to the report, the physician was contacted on 1/28/21 at 6:47 p.m. The packet did not include when the State Agency, the ombudsman, the resident's family was contacted. A final request was made to review the facility timeline of reporting the allegation of abuse and if the facility substantiated or unsubstantiated abuse towards Resident #42. An email was provided by the NHA on 2/9/21 at 4:58 p.m. According to the email, the investigation was complete and the facility did not substantiate abuse. An email was provided by the DON on 2/9/21 at 8:27 p.m. According to the email, the initial report was filed to the State Agency on 1/28/21 at 4:57 p.m. which was over the two hour threshold for initial reporting. Messages were left with the ombudsman and family when the initial report was filed on 1/28/21 and they returned the calls on 1/29/21. 3. Staff interview The allegation of abuse was reported to the NHA on 1/27/21 at 11:00 a.m. According the NHA, the director of nursing (DON) was the facility's abuse coordinator and he was not aware of any reports made by Resident #42 that her door was shut when she was yelling for assistance. He said he would follow up with the DON. The DON was interviewed with the NHA and the director of clinical services (DCS) on 1/28/21 at 4:30 p.m. The DON said the investigation was started after being notified on 1/27/21 where she interviewed the resident, staff and other residents after the allegation was reported. According to the DON, she did not report the allegation of abuse to the reporting agencies because the resident felt safe, so she did not initiate the action to report. The NHA said the resident could not recall exactly what evening the event occurred and which staff were involved in her concern. He said a fire drill was conducted near the time she estimated that her door was shut. He said staff could have shut the door at that time. The DON acknowledged abuse could have occurred even though the resident currently felt safe. The DCS said the facility needed to report the allegation of abuse within two hours of becoming aware of the allegation because the resident reported involuntary seclusion and potential neglect. -He recommended the NHA and the DON to immediately report to the State Agency. The DON was interviewed again on 2/1/21 at 1:30 p.m. According to the DON, she reported the allegation of potential abuse to the State Agency, the family, the physician and the ombudsman on the evening of the 1/28/21. She said she said she did not contact the police because the investigation was ongoing and the allegation was not substantiated yet. The NHA was interviewed with DCS on 2/3/21 at 12:33 p.m. The NHA said he would follow the regulatory guidelines when a staff member or a resident would inform him of a potential incident of abuse. He said he did not identify the need to immediately report the allegation of abuse when the surveyor reported the alleged incident. The DCS identified the NHA was new to the position moving forward the facility would report allegations timely The NHA was interviewed with the DCS on 2/3/21 at 2:59 p.m. According to NHA, the facility has identified that they may not have captured all the reportable facility occurrences. He said the facility followed the philosophy of ensuring resident safety through a safe plan, but realized that they needed to take additional actions. He said he now has a better understanding of the reporting process and would review past occurrences to determine if they were reportable.

Based on observation, record review and interviews, the facility failed to ensure two out of two nurses were able to demonstrate competencies in skills and techniques necessary to care for two (#71 and #137) out of seven residents medication needs. Specifically; Registered nurse (RN) #1 failed to follow the parameter orders for Carvedilol medication for Resident #137; and RN #2 failed to prime insulin pens for Resident #71. Cross-reference: F760 the facility failed to ensure Resident (#71 and #137) were free from significant medication errors. F759 the facility failed to ensure it was free of a medication error rate of five percent (%) or less. Findings included: I. Professional reference The Prescribers Digital reference (PDR) guide dated 2021, retrieved on 2/8/21 from: https://www.pdr.net/drug-summary/[MEDICATION NAME]-carvedilol-182.4241 read in pertinent part; Carvedilol oral dosage (regular-release tablets) for adults initially, 6.25mg by mouth twice daily. Evaluate tolerability by measuring the standing systolic pressure one hour after administration.The full antihypertensive effects are achieved within 7 to 14 days. Maximum recommended dose is 25 mg by mouth twice daily. If the pulse rate drops below 55 beats per minute (bpm), reduce the dose. Carvedilol plasma levels are about 50 % (percent) higher in the elderly as compared to younger patients. The PDR guide dated 2021 retrieved on 2/8/21 from: https://www.pdr.net/drug-summary/[MEDICATION NAME]-insulin-[MEDICATION NAME]-520.3961 read in pertinent part; All pens require a priming procedure prior to use. [MEDICATION NAME] Pen Priming: Always perform the safety test before any injection from the pen to ensure proper pen function and removal of air bubbles. II. Failure to ensure RN #1 administered medications according to standards of practice A. Record review The Medication Administration report for Resident #137 was provided by the director of nurses (DON) on 1/26/21 at 10:00 a.m., read in pertinent part: The medication order for Carvedilol tablets 25 milligram (mg) dated 10/3/2020 read, give one tablet twice a day and hold the medication when the heart rate was less than 50 beats per minute (bpm). The medication report showed RN #1 administered the Carvedilol to Resident #137 on 10/17/20 with a heart rate of 47. The Carvedilol order changed on 10/18/2021 to 25mg tablet, give half (½) a tablet twice a day and hold for medication when the heart rate was less than 50 bpm. RN #1 administered the medication on 10/18/20, and 10/19/2020 with a heart rate of 46, and 48. The Completed Training record for RN #1 was provided by the DON on 1/26/21 at 10:00 a.m., it read in pertinent part: RN #1 completed the reading material on the reduction of medications errors on 6/11/2020. The record did not show competencies for holding parameters of medication. No other competencies were provided. RN #1 was not available for interview (see interviews below). III. Failure to ensure RN #2 administered medications according to the standard of practice A. Observations Registered nurse (RN) #2 was observed on 1/27/21 at 9:13 a.m. to prepare medications for Resident #71. RN #2 used two [MEDICATION NAME]pens, she dialed one with 5 units of insulin and the other one with 18 units of insulin to equal 23 units total and administered it to Resident #71 subcutaneously. She failed to prime (1-2 drops of insulin pushed up to get the air out of the needle) both insulin pens prior to administering the medication to Resident #71. B. Record review According to the January 2021 Medication Administration Record [REDACTED] The Nurse Orientation checklist for RN #2 was provided by the DON on 2/2/2021 at 1:30 p.m., it read in pertinent part: Medication administration for safety needle instruction and competency for insulin injection was completed on 2/21/2020. Floor orientation for insulin administration was completed on 3/6/2020. No other competencies were provided. IV. Staff Interviews RN #10 was interviewed on 2/1/21 at 1:15 p.m., she said the parameters for the heart medications showed the heart rate and the blood pressure. When either of them were too low she knew to hold the medication. She said when it was given the resident would have problems. She said she learned about parameters in nursing school. RN #2 was interviewed on 2/4/21 at 10:15 a.m., she said she had no knowledge of how to prime an insulin pen. She said she would ask the charge nurse to show her. She said heart medications were administered or not, after she checked the heart rate of the resident to make sure it was not below 50. RN #11 was interviewed on 2/4/21 at 10:35 a.m., she said she was not taught how to prime an insulin pen at the facility. She was the charge nurse that day and said she would find out about the pens. She said the parameters for the heart medications were set in the computer system. The heart rate was documented and when it was below 50 the medication was held. Sometimes the physicians changed the parameter orders for specific residents. The DON was interviewed on 2/3/21 at 4:33 p.m. She said insulin pens were primed (1-2 drops of insulin pushed up to get the air out of the needle) before the correct dose of insulin was dialed into the pen for administration. When the nurse did not prime the pen the insulin dose would be incorrect and was a medication error. She said priming an insulin pen and checking a heart rate prior to administering a heart medication were standard nursing knowledge. She said heart medications had standard parameters to check the heart rate prior to administration. When the heart rate was under 50 bpm (beats per minute) the medication was held to ensure the safety of the resident so he did not have a decline in his medical condition. A medication error occurred when the heart medication was given under 50. She acknowledged there was no evidence RN #1 had been educated on medication errors specifically when to hold Carvedilol medication for heart rate under 50 bpm. She said competencies were completed for RN #2 and RN #1 when they worked on the floor with the nurse who trained them. However, this training did not include education about when to hold a medication and how to prime an insulin pen prior to administration, moving forward would ensure staff were aware of standard of practice.

Based on observation, record review and interviews the facility failed to ensure it was free of a medication error rate of five percent (%) or less. Specifically, the medication administration observation error rate was 7.69%, or three errors out of 39 opportunities for error. Registered nurse (RN) #2 failed to administer Resident #71's [MEDICATION NAME] timely and failed to prime Resident #71's insulin pens prior to administration. Cross reference: F760 the facility failed to ensure Resident (#71 and #137) were free from significant medication errors. F726 the facility failed to ensure two out of two nurses were able to demonstrate competencies in skills and techniques necessary to care for two out of seven residents (#71 and #137) needs. Findings include: I. Facility policies The Medication Administration Policy and Procedure revised on 12/15/2020, was provided by the director of nurses (DON) on 1/28/21 at 4:00 p.m. It read in pertinent part: All medications in the facility will be handled and administered by licensed nursing staff employed or contracted by the facility. Procedure A. All medications will only be administered with a medical doctor (MD) or nurse practitioner (NP) order. If the order cannot be followed, the MD/NP will be notified and the situation will be documented in the resident record. B.The vital signs associated with any hold parameter must be taken within a timely manner of medication administration. C.All aadministrered medications shall be recorded, in the resident's record, indication teh name, strength, dosage, and mode of administration of the medication D. Medications will be administered in the form most easily tolerated by the resident. Staff will not mask or alter the form if doing so would be hazardous or within first obtaining consent and MD/NP order. E.Nursing staff will report to the MD/NP any errors in medication administration or any adverse reactions. Reported medication errors will be reviewed by the Director of Nurses (DON) including any follow-up measures deemed appropriate. F.A consultant pharmacist will provide random observation of personnel responsible for medication administration. These observations include but are not inclusive to: 1.Observation of performance in actual preparation and administration of medications by licensed nurses. 2. review of medication records [REDACTED] and state/federal regulations. G.Educational programs will be offered throughout the year as deemed appropriate by nursing administration. The Safe Injection Practices Policy revised January 2021, provided by the nursing home administrator (NHA) on 2/3/21 at 3:15 p.m. read in pertinent part; Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices are designed to permit self-injection and are intended for single-person use, using a new needle for each injection. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Facility staff must follow the manufacturer instructions for administration, regurgitation of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one resident, even when the needle is changed.The FDA makes the following recommendations to prevent transmission of bloodborne infections in residents who require insulin pens: Insulin pens containing multiple doses of insulin are meant for single-resident use only, and must never be used for more than one person, even when the needle is changed; Insulin pens must clearly be labeled with the residents name and other identifiers to verify that the correct pen is used on the correct resident; and Facilities should review their policies and procedures and educate their staff regarding safe use of insulin pens. The manufacturer's guide on How to use the [MEDICATION NAME] Pen was provided by the NHA on 2/3/21 at 3:15 p.m. read in pertinent part; Step 1. Get ready -Remove the pen cap with clean hands. -Check the reservoir to make sure the insulin is clear and colorless and has no particles-if not, use another pen. Step 2. Attach the needle -Wipe the pen tip (rubber seal) with an alcohol swab. -Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on. -Do not make the needle too tight. If you have a push-on needle, keep it straight as you push it on. -After you have attached the needle, take off the outer needle cap and save it (you will need it to remove the needle after your injection). -Remove the inner needle cap and throw it away. Step 3. Perform a safety test -Dial a test dose of 2 Units. -Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. -Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. -If no insulin comes out, repeat the test 2 more times.If there is still no insulin coming out, use a needle and do the safety test again. Always perform the safety test before each injectionNever use the pen if no insulin comes out after using a second needle. Step 4. Select the dose -Make sure the window shows 0 and then select the dose. Otherwise you will inject more insulin than yoneed and that can affect your blood sugar level. -Dial back up or down if you dialed the wrong amount. -Check if you have enough insulin in the reservoir. If you cannot dial the dose you want, it may be because you don ' t have enough insulin left. -You cannot dial more than 80 Units because the pen has a safety stop. If your dose is more than 80 Units, you will need to redial the rest of your dose. If you don ' t have enough insulin for the rest of your dose, you will need to use a new pen. Step 5. Inject your dose -Clean site with an alcohol swab. Please see injection site options on page 2. -Keep the pen straight, insert the needle into your skin. -Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose. Release the button and remove the needle from your skin.`` II. Record review and observations Registered nurse (RN) #2 was observed on 1/27/2021 at 9:13 a.m. to prepare medications for Resident #71. She administered [MEDICATION NAME] 10 mg by mouth to the resident. -According to Resident #71's January 2021 Medication Administration Record [REDACTED]. The medication was due to be given at 8:00 a.m. RN #2 administered the medication 35 minutes late at 9:35 a.m. (there was one error observed). Registered nurse (RN) #2 was observed on 1/27/2021 at 9:13 a.m. to prepare medications for Resident #71. RN #2 used two [MEDICATION NAME]pens, she dialed one with 5 units of insulin and the other one with 18 units of insulin to equal 23 units total and administered it to Resident #71 subcutaneously. -She failed to prime (1-2 drops of insulin pushed up to get the air out of the needle) both insulin pens prior to administering the medication to Resident #71 (there were two errors observed). III. Staff interviews Registered nurse (RN) #3 was interviewed on 2/1/21 at 8:44 a.m. she said when medications were late in the computer system, a description as to why it was late was charted. Sometimes the resident was asleep or in the bathroom, sometimes there was a cluster of cares needed so the medication was late. She said there was a 30 minute time frame before or after the scheduled time of the medications to give the medication. RN #4 was interviewed on 2/1/21 at 8:52 a.m. She said the medications scheduled between the hours of 7:00 a.m. and 10:00 a.m. were given at that time. She said when a specific time such as the medication due at 8:00 a.m. then there was an hour before or after that time to administer the medications. RN #10 was interviewed on 2/1/21 at 1:15 p.m. She said there were multiple reasons why medications were late. She said the resident may not be in the room, they were asleep or when there was not enough staff to complete all the cares. She said the facility had a policy on the timeframe of when to give the medication. She was not sure if it was 30 minutes or one hour before or after the due time of the medication. The director of nurses (DON) was interviewed on 2/3/21 at 4:33 p.m. She said the leeway time for medications due at a specific time was one hour before the due time and one hour after. When a medication was administered late the nurse charted the reason and the physician was notified. She said when a pain medication was given late, the resident could have an increase in pain. She said the insulin pen was primed before the correct dose of insulin was dialed into the pen for administration. When the nurse did not prime the insulin pen the insulin dose would be incorrect for the resident. She said she planned to provide RN #2 with education on medication pass. RN #2 was interviewed on 2/4/21 at 10:15 a.m., she said she had no knowledge of how to prime an insulin pen.

Based on observation, record review and staff interviews, the facility failed to ensure two (#71 and #137) out of seven residents, medications were free from significant medication errors. Specifically, the facility failed to ensure: -Registered nurse (RN) #1 failed to follow the Carvedilol medication parameter orders for Resident #137; and, -Registered nurse (RN) #2 failed to prime insulin pens for Resident #71. Findings include: I. Facility policy The Medication Administration Policy and Procedure revised on 12/15/2020, was provided by the director of nurses (DON) on 1/28/21 at 4:00 p.m. It read in pertinent part: All medications in the facility will be handled and administered by licensed nursing staff employed or contracted by the facility. Procedure A. All medications will only be administered with a medical doctor (MD) or nurse practitioner (NP) order. If the order cannot be followed, the MD/NP will be notified and the situation will be documented in the resident record. B.The vital signs associated with any hold parameter must be taken within a timely manner of medication administration. C.Nursing staff will report to the MD/NP any errors in medication administration or any adverse reactions. Reported medication errors will be reviewed by the Director of Nurses (DON) including any follow-up measures deemed appropriate. D. A consultant pharmacist will provide random observation of personnel responsible for medication administration. These observations include but are not inclusive to: 1. review of medication records [REDACTED] and state/federal regulations. The PDR guide dated 2021 retrieved on 2/8/21 from: https://www.pdr.net/drug-summary/[MEDICATION NAME]-insulin-[MEDICATION NAME]-520.3961 read in pertinent part; All pens require a priming procedure prior to use. [MEDICATION NAME] Pen Priming: Always perform the safety test before any injection from the pen to ensure proper pen function and removal of air bubbles. II. Resident #137 A. Resident status Resident #137, age 80, was admitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 10/3/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. He required extensive assistance with two person care for bed mobility, transfers and toileting. He required limited assistance and one person care for dressing and hygiene. B. Record review A request was made to the nursing home administrator (NHA) on 1/26/21 at 3:30 p.m for the investigation report for Resident #137. The NHA provided the information on 1/27/21 at 9:30 a.m. The investigation packet included a medication error incident report, medication administration history for Resident #137, telephone orders, medication policy and staff interviews. The packet also included staff education for medication parameters dated on 10/19/21 which was unsigned, and past education on huddle discussions. An on-site review of the facility investigation on 1/27/21 revealed RN #1 administered Carvedilol medication to Resident #137 on 10/17, 10/18 and 10/19 when the heart rate was 47, 46 and 48. RN #1 failed to review and monitor the heartrate prior to administration of the medications. The Medication Administration report for Resident #137 was provided by the DON on 1/26/21 at 10:00 a.m., read in pertinent part; The medication order for Carvedilol tablets 25 milligram (mg) dated 10/3/2020 read, give one tablet twice a day and hold the medication when the heart rate was less than 50 beats per minute (bpm). The medication report showed RN #1 administered the Carvedilol to Resident #137 on 10/17/20 with a heart rate of 47. The Carvedilol order changed on 10/18/2021 to 25mg tablet, give half (½) a tablet twice a day and hold for medication when the heart rate was less than 50 bpm. RN #1 administered the medication on 10/18/20, and 10/19/2020 with a heart rate of 46, and 48. The [MEDICAL CONDITION] Care Plan for Resident #137 dated 10/4/2020 provided by the DON on 2/4/21 read in pertinent part; Goal was the resident tolerates increasing levels of activity without pain, dyspnea or [MEDICAL CONDITION]. The resident remains free of complications related to cardiac status. The resident will attain and maintain their highest possible functional level. Intervention was to administer antiarrhythmic and other cardiac medications as ordered; monitor response. The Hypertension Care Plan for Resident #137 dated 10/4/21 was provided by the DON on 2/4/21, read in pertinent part; Resident's blood pressure will be maintained within their own normal range and the president will be free of complications related to hypertension. Residents will maintain optimal cerebral perfusion, renal perfusion and cardiac output. Interventions are to administer antihypertensive medications as ordered. Evaluate, record, report effectiveness and adverse side effects. Assess for signs of decreased cardiac output: [MEDICAL CONDITION] dyspnea, cough, crackles, [MEDICAL CONDITIONS] and anxiety. A nurse note dated 10/17/2020 at 8:00 a.m., read in pertinent part; Nurse practitioner was aware of Resident #137 having [MEDICAL CONDITION] trends. -2:45 p.m. nurse note read, monitored apical heart rate in the 40's. Resident was asymptomatic. -10:13 p.m. nurse note read, apical pulse remains in high 40's with no signs or symptoms of [MEDICAL CONDITION]. A nurse note dated 10/18/2020 at 2:17 a.m., read in pertinent part; Resident #137 was bradycardic but all other vital signs were normal. -9:24 p.m. nurse note read apical pulse remains in the high 40s at 47. No symptoms of [MEDICAL CONDITION]. Nurse practitioner (NP) note dated 10/18/2020 at 8:56 a.m., read in pertinent part; [MEDICAL CONDITION] plan due to the heart rate persistently below 55 and as low as 40 on 10/17/20 was to reduce the medication Carvedilol by 50 perscent (%) to be 12.5 mg twice daily and continue hold parameters. Nurse note dated 10/19/2020 3:42 a.m., read in pertinent part; Resident #137 had [MEDICAL CONDITION] and a low temperature of 95 degrees fahrenheit, but all other vital signs were normal. The Residents remained alert and communicated all needs appropriately. Resident #137 was no longer in the facility and was unavailable for interview. RN #1 no longer worked at the facility and was unavailable for interview. RN #1 failed to follow the Carvedilol medication parameter orders for Resident #137 (see interviews below). III. Resident #71 A. Resident status Resident #71, age 87, was admitted on [DATE] According to the Janurary 2020 CPO, [DIAGNOSES REDACTED]. The 8/13/2020 MDS assessment revealed the resident was cognitively intact with a BIMS of 14 out of 15. She required extensive assistance with two person care for bed mobility, transfers and toileting. She required limited assistance from one person for dressing and hygiene. B. Obsrvations Registered nurse (RN) #2 was observed on 1/27/2021 at 9:13 a.m. to prepare medications for Resident #71. RN #2 used two insulin pens, she dialed one with 5 units of insulin and the other one with 18 units of insulin to equal 23 units total and administered it to Resident #71. She failed to prime (1-2 drops of insulin pushed up to get the air out of the needle) both insulin pens prior to administering the medication to Resident #71. C. Record review According to the January 2021 Medication Administration Record [REDACTED] The Diabetes Care plan for Resident #71 dated 8/7/2021 was provided by the director of nurses (DON) on 2/4/2021, it read in pertinent part; The goal was to have the residents blood glucose levels be within normal range. The resident will verbalize understanding of disease processes, medications and treatments. The resident will remain free of complicaionts related to Diabetes. The intervention was to adminster medications as orderd and montitor for side effects. D. Staff interviews RN #2 was interviewed on 2/4/2021 at 10:15 a.m., she said she had no knowledge of how to prime an insulin pen. Medical director (MD) was interviewed on 2/2/2021 at 2:55 p.m., she said residents had parameters for heart medications and the nurses notified her of any changes. She said she was not familiar with Resident #137, she did know the facility had concerns about his [MEDICAL CONDITION] from another provider, that provider was unavailable for an interview. The pharmacist was interviewed on 2/3/2021 at 11:30 a.m., he said he was at the facility two to three times a week. He said he reviewed medications but was not involved in medication errors. He said he did not train any nurses on insulin pens and was not too familiar with them. He said he would read up on them to help the facility in the future. He said the parameters for heart medications were set in the computer system and he was unfamiliar with the specifics of them. He said he would read up on those too to reeducate himself. The DON was interviewed on 2/3/2021 at 4:33 p.m. She said insulin pens were primed (1-2 drops of insulin pushed up to get the air out of the needle) before the correct dose of insulin was dialed into the pen for administration. When the nurse did not prime the pen the insulin dose would be incorrect and was a medication error. She said priming an insulin pen and checking a heart rate prior to administering a heart medication were standard nursing knowledge. She said heart medications had standard parameters to check the heart rate prior to administration. When the heart rate was under 50 bpm (beats per minute) the medication was held to ensure the safety of the resident so he did not have a decline in his medical condition. A medication error occurred when the heart medication was given under 50. She acknowledged there was no evidence RN #1 had been educated on medication errors specifically when to hold Carvedilol medication for heart rate under 50 bpm. She said competencies were completed for RN #2 and RN #1 when they worked on the floor with the nurse who trained them. However, this training did not include education about when to hold a medication and how to prime an insulin pen prior to administration, moving forward would ensure staff were aware of standard of practice.

Based on record review and interviews, the facility failed to ensure three of five residents (#1, #2 and #4) reviewed for respiratory services out of nine sample residents, received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, Resident #1, was admitted to the facility on [DATE] for rehabilitation services. He had a history of [REDACTED]. He was receiving continuous oxygen two liters per minute during the day. At night he was using a [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) machine in combination with oxygen as it was ordered by his physician. In addition, the facility failed to develop resident centered care plans for respiratory treatment for [REDACTED].#2 and #4. According to nursing progress notes, on 12/22/19 around 7:00 a.m. registered nurse (RN) #1 was stopped by the resident's wife in the hallway and asked for help. The wife stated she could not wake her husband and needed help. RN #1 responded to the room and found Resident #1's face, lips, and fingers bluish-purplish, and eyes closed. She documented wall (oxygen) noted to be running at 3 (liters per minute) via nasal cannula hanging on bed and not connected to [MEDICAL CONDITION]. Resident was unresponsive. Oxygen was immediately administered to the resident and emergency services contacted. Given the staff's knowledge of Resident #1's incident on 12/22/19 when his oxygen was not properly connected to the [MEDICAL CONDITION] machine, and the failure of the facility to implement immediate action to ensure other residents who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] (continuous positive airway pressure) machines were properly connected to the oxygen, a situation of immediate jeopardy was created with the likelihood of serious harm. Cross-reference to F600 (negligence), failure to administer oxygen by qualified staff member and provide adequate supervision to assure delegated task of oxygen administration was done correctly. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 12/22/19 at approximately 7:30 a.m., Resident #1 was found unresponsive. As it was noted in progress notes, resident oxygen was not connected to his [MEDICAL CONDITION] machine correctly which resulted in resident #1's unresponsiveness. Given the staff's knowledge of Resident #1's incident on 12/22/19 when his oxygen was not properly connected to the [MEDICAL CONDITION] machine, and the failure of the facility to implement immediate action to ensure other residents who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were properly connected to the oxygen, placing the well-being of other residents at risk for the likelihood of serious harm creating a situation of immediate jeopardy. On 1/23/2020 at 2:00 p.m., the nursing home administrator (NHA) was notified the facility's failure to implement immediate action to ensure other residents who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were properly connected to the oxygen, created a situation of immediate jeopardy. The NHA was notified of the immediate jeopardy situation on 1/23/2020 at 2:00 p.m. B. Facilities plan to correct and remove the immediate jeopardy situation On 1/23/2020 at 6:17 p.m., NHA submitted a second and final plan to remove the immediate jeopardy situation. It read as follows: 1. Facility amended [MEDICAL CONDITION]/[MEDICAL CONDITION] use policy 1/20/20. - All nursing staff currently in the facility will have education to the new policy immediately effective 1/23/20. Each shift going forward will review and sign off on new policy at the beginning of their shift to ensure understanding of policy. Training includes: - Nursing will enter orders in the MAR (medication administration record) related to [MEDICAL CONDITION]/[MEDICAL CONDITION] machines for nursing staff to check mask placement & seal, function of machine and verify proper liter flow is connected to the oxygen source. - Nursing staff will obtain oxygen saturation within 30-60 minutes after the unit is applied and Q shift while being worn. Results will be documented in the MAR. - Respiratory Therapist will conduct an additional training for nursing staff on 1/28/20. 2. Audit all residents immediately who have orders for [MEDICAL CONDITION]/[MEDICAL CONDITION] machines to ensure we have proper orders in the MAR indicated [REDACTED]. - Clinical Managers are conducting a room to room audit immediately 1/23/20 starting 3:00 p.m. to ensure all patients using a [MEDICAL CONDITION]/[MEDICAL CONDITION] are accounted for and all orders are in place in the MAR. 3. Will educate all nursing staff to new [MEDICAL CONDITION]/[MEDICAL CONDITION] policy at the beginning of each shift prior to working with patients until all staff has completed training. - Nursing will enter orders in the MAR (medication administration record) related to [MEDICAL CONDITION]/[MEDICAL CONDITION] machines for nursing to check mask placement & seal, function of machine and verify proper liter flow and that its connected to the oxygen source. - Respiratory Therapist consults will be obtained for new residents using [MEDICAL CONDITION]/[MEDICAL CONDITION] machines. 4. Charge Nurse will round and document on any shift when a [MEDICAL CONDITION]/[MEDICAL CONDITION] is applied and in use. Nurse will document using the audit form to verify that the machine is functioning properly, the mask has a good seal, oxygen is connected and pulse ox has been documented. C. Removal of immediate jeopardy On 1/23/2020 at 6:22 p.m., the NHA was notified the facility's plan to remove the immediate jeopardy situation had been accepted, and the situation of immediate jeopardy was lifted. However, deficient practice remained at a G level, the potential for harm. II. Facility policies and procedures on oxygen use The facility [MEDICAL CONDITION]/[MEDICAL CONDITION] use policy effective 4/15/18 and revised on 1/20/2020 was provided by the clinical nurse consultant (CNC) on 12/23/2020 at 9:05 a.m. The policy read, patients who have provider orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] will have nursing and respiratory therapy (RT) services to address and monitor [MEDICAL CONDITION]/[MEDICAL CONDITION] use. A nurse will verify that the unit is working and the mask has a good seal. The nurse will verify supplemental oxygen is hooked up to the flow meter and [MEDICAL CONDITION]/[MEDICAL CONDITION] unit if needed. III. Failure to ensure Resident #1's [MEDICAL CONDITION] machine was properly connected to the oxygen source A. Resident #1 1. Resident status Resident #1, age [AGE] years old, was admitted [DATE] for rehabilitation services and discharged on [DATE] to an acute care facility. According to the December 2019 computerized physician orders [REDACTED]. The 12/21/19 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with the brief interview for mental status score (BIMS) of 12 out of 15. The staff assessment indicated the resident had no symptoms of [MEDICAL CONDITION] or difficulty concentrating on activities, no disorganized thinking and rejected care. He required extensive assistance from one staff for transfers, dressing, and bed mobility; supervision and set up from one staff for eating. Resident was on oxygen therapy. The resident's care plan documented resident was admitted for short term rehab stay with the intention to discharge home. He enjoyed outdoor activities when he was not spending time with family. The respiratory care plan documented the resident was using oxygen and had potential for complications related to pleural effusion (the build-up of excess fluid between the layers of the pleura outside the lungs). Interventions included staff to administer oxygen as ordered, and to monitor and report signs of respiratory distress, such as restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, and decreased breath sounds. The care plan did not document the resident was using [MEDICAL CONDITION] at night. The physician order [REDACTED]. In addition, to the provision of two liters of continuous oxygen per minute during the day. The resident was a full code, meaning he wanted to receive full medical treatment in the event if his heart or respirations stopped. 2. Resident #1's functional status prior to the incident on 12/22/19 The nurses admission note on 12/15/19 revealed on the day of the admission resident was calm and cooperative, oriented to the facility, policy and procedure, staff roles, daily and medication routines. According to the physical therapy (PT) plan of care, dated 12/16/19, resident was admitted for improving core and peripheral strength, balance, endurance, safety with functional mobility. Resident actively participated in physical and occupational therapy every day except for the day when he had scheduled medical procedure on 12/20/19. The physician admission note, dated 12/18/19 read that resident was admitted after hospitalization for [MEDICAL CONDITION] that improved with initiation of [MEDICAL CONDITION]. Resident was stable at home on two liters of oxygen per minute. 3. Family interview Resident's ex-wife was interviewed on 1/21/2020 at 2:30 p.m. She said she usually visited her ex-husband in the morning and brought him some food for breakfast. She visited him every day in the morning since he was admitted to the facility. She said he usually got up early around 5:00 a.m. and by the time she would come with food he would be up in the chair. She said in the evening before the incident, 12/21/19 they had several family members who came for the visit and her ex-husband was joking and seemed to be having a good time. In the morning of 12/22/19, around 7:30 a.m., she said as usual, she walked into his room. His room was poorly lit and the blinds were still closed. She said she approached her ex-husband on the right side of the bed and called his name. He did not respond. She said she called his name two more times and shook him on the shoulder. He did not respond. She said she took his [MEDICAL CONDITION] mask off with the intention to wake him up but he was not responding. After she took the mask off she realized that he would need regular oxygen. She said she looked around the room and there were multiple hoses and tubings and she did not know which one was oxygen. She said she did not touch any tubings or hoses that were around, she ran outside the room and and asked the nurse who was passing by for help and told her she could not wake up her husband. She said the nurse said she was not assigned to this resident but she would come and check. 4. Record review The progress note documented by RN #1 on 12/22/19 at 7:45 a.m. read: At approximately 07:45(a.m.) this RN was walking down east hall to retrieve scale when spouse alerted this RN stating Can you switch his oxygen over for me? I took his [MEDICAL CONDITION] off but don't know how to switch the oxygen and I can't get him to wake up for me. This RN responded immediately to (the patient's) room with (his) wife following. Upon entering room (patients) face, lips, and fingers noted to be cyanotic, eyes closed, (pulse oximetry) 70 (percent), unresponsive to verbal or painful stimuli. Wall (oxygen) noted to be running at 3 (liter per minute) via nasal cannula hanging on bed and not connected to [MEDICAL CONDITION]. Emergency red light activated by this RN, CNA (certified nurse aide) responded immediately and went to find (another) RN. (Patient) placed on 5(liters) of (oxygen) via nasal cannula with (pulse oximetry) rising quickly, (patient) not responding to verbal stimuli but responded to painful stimuli at this time. (Nurse Practitioner) notified and immediately responded to assess (patient). Pupils sluggish but reactive. (Nurse Practitioner) ordered 1 (liter) of (normal saline) wide open (by gravity), and to send (patient) to (emergency room ) for eval(uation). The facility discharge summary on 12/22/19 by nurse practitioner (NP) #1 documented: today patient seen emergently . patient found to be unresponsive, does minimally respond to painful stimuli (sternal rub). Patient noted to be on his [MEDICAL CONDITION], oxygen not connected to (the) machine. His oxygen on my arrival was 70 (percent), reported by nursing initially as low as 50's (percent). The ambulance note dated 12/22/19 documented that call from the facility was received at 7:54 a.m. At 8:12 a.m. resident was assessed by first responders with (the) following findings: Upon making patient contact, the patient is lying supine in bed, responsive to pain only. The patient is usually able to speak in full sentences and ambulate on his own. Nursing staff informs, the patient was found in bed today, off his oxygen/[MEDICAL CONDITION], with oxygen saturation of 55 (percent) and unresponsive. According to the admission note dated 12/22/19 from the ER, resident was admitted on [DATE] with the following clinical impression: acute [MEDICAL CONDITIONS] and history of [MEDICAL CONDITION]. The emergency room admission note dated 12/22/19 read, (patient) presents to the (emergency department) via ambulance. Patient is unresponsive. He was found unresponsive, hypoxic, and hypotensive overnight. I was told that his oxygen saturations were in the 50s. I was also told that his blood pressure was in the 50s systolic. He arrives in the (emergency department with intermittent response to painful stimuli. He arrived with vomiting on his clothes an in his oropharynx. He has no other purposeful movement or function. He is a full code. Patient was vomiting prior to arrival. Due to his [MEDICAL CONDITION], the patient was intubated. emergency room [DIAGNOSES REDACTED]. Resident was admitted to the intensive care unit in critical condition where he was put on the mechanical ventilator. Five days later several attempts were made to remove the ventilator, but the resident was not able to breathe on his own. He did not gain his previous level of consciousness. The hospital discharge summary on 12/27/19 revealed, Attempts were made to liberate (patient) from ventilator. Multiple attempts at spontaneous breathing trials were unsuccessful. (Patient) had indicated to family during his last admission that he would not want prolonged ventilatory support or dependence. Given his expressed wishes in the setting of his severe restrictive disease and inability to ventilate properly on his own, decision was made to transition focus of care to comfort. He was [MEDICATION NAME] extubated (removed from artificial ventilation) on 12/27/19 and passed at (3:27 p.m.) 5. Staff interviews CNA #1 was interviewed on 1/23/20 at 6:10 p.m. She said she was working in the facility for over a year, and this was her first healthcare job. She said helping residents with [MEDICAL CONDITION] and [MEDICAL CONDITION] machines was a regular thing for CNAs since she started the position and until late December 2019. She said she did not receive any formal education in school or in the facility about [MEDICAL CONDITION]/[MEDICAL CONDITION] units but she was shown by other CNAs how to turn them on, refill humidifier and connect to oxygen if needed. She said some time in December 2019 all CNAs were told that they are no longer allowed to help with [MEDICAL CONDITION]/[MEDICAL CONDITION] machines and only nurses were allowed to do so. In the evening of 12/21/2020 she was assigned to work with Resident #1. She said he usually went to bed around eight or nine in the evening. She recalled helping him with the [MEDICAL CONDITION] mask and turning the unit. She said she did not recall checking oxygen tubing to see if it was connected to the [MEDICAL CONDITION] machine. She said after she helped the resident to bed he did not call for help on her shift. Licensed practical nurse (LPN) #1 was interviewed on 1/23/20 at 7:05 p.m. She said she was working in the facility for the last two years and prior to that she worked in the long term care for at least three years. On 12/21/19 she was assigned to work with Resident #1 during her six a.m. to six p.m. shift. She said typically CNAs were assisting residents with [MEDICAL CONDITION] and [MEDICAL CONDITION] units at bed time. She said most residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] units were alert and oriented and they knew how to start the unit and apply the mask. The assistance they needed was very minimal and most of them did it independently. She said on the evening of 12/21/19 the [MEDICAL CONDITION] machine for Resident #1 was started by CNA #1. She said after the resident was assisted to bed she did not walk in his room to check the [MEDICAL CONDITION] unit or oxygen tubing. She said the door to the resident's room was open during the entire shift and she observed the resident on several occasions from the hallway. She said the resident was asleep, he did not use his call light at night and he did not appear to be in distress. She said she was notified of the resident's condition in the morning of 12/22/19 after she left her work. She said after the incident on 12/22/19 she talked to the director of nursing on several occasions and was instructed not to delegate application of [MEDICAL CONDITION]/[MEDICAL CONDITION] units to CNAs. RN #1 was interviewed 1/23/20 at 1:10 p.m. She said she was working the morning shift on 12/22/19 when she was stopped in the hallway by a female visitor who asked her for help. She said the visitor said that she could not wake her husband up and needed help with his oxygen. RN #1 said that upon entering the room she observed that the resident in bed was purple-blue in color. The [MEDICAL CONDITION] machine was running on the table on the right side of the room. She said she went out and grabbed a vital sign machine. After she checked his vitals, his oxygen was in the low 70s setting and she reached to the oxygen tubing that was hanging from the wall. One end of the tubing was connected to the wall (supply of oxygen) and the second end was connected to the nasal cannula that was curled up next to the resident on the upper side of the bed. She applied the oxygen to the resident. She said at that time they both (female visitor and her) looked at the oxygen tubing that was coming out of the [MEDICAL CONDITION] machine. She said the female visitor stepped forward and picked up oxygen tubing that was connected to the [MEDICAL CONDITION] machine, the other end of the tubing was not connected to the wall, it was on the floor. RN #1 said that oxygen tubing from the [MEDICAL CONDITION] machine was not connected to the supply of oxygen on the wall. She said she called for assistance and the resident was assessed by NP who was in the facility at the time of the incident. She said the resident did not respond to the voice when she called him, and only responded to painful stimuli when the NP completed a sternal rub. She said she documented the details of this event under the progress notes. NP #1 was interviewed on 1/23/20 at 9:30 a.m. He said he was familiar with Resident#1 as he met him on several occasions. He said the most recent time was on 12/16/19 when he did his assessment. He said the resident was alert and oriented to himself, to the place where he was, time of the day and individuals around him. Resident communicated verbally and was able to express all of his needs. He also participated in daily therapy. His goals were to regain the strength, discharge home and continue his [MEDICAL CONDITION] for [MEDICAL CONDITION]. He said in the morning of 12/22/19 he was working around 7:40 a.m. when he was called in to the room for Resident #1. He said upon entering the room he observed two other nurses next to the resident. He said the resident was unresponsive with strong bounding pulse, fixed pupils, he had weak response to pain, the oxygen was set up to the maximum of 15 liters per minute and oxygen saturation went up 98 percent. He said it was initially reported to him that the resident's oxygen saturation at some point was in 50s and since then climbed to 98 percent. He said Resident #1 also experienced a dramatic drop in blood pressure at the time of the incident. The initial blood pressure that was reported to him was around 76/54. He was informed by staff that the resident's [MEDICAL CONDITION] machine was not working correctly. He said the decision was made to call for an ambulance as there is nothing more could have been done for the resident. He explained that to the (ex) wife of the resident and she agreed to transfer to the hospital. He said normal oxygen saturation in healthy individuals should be above 90 percent. When it drops below 90 percent, the brain and other parts of the body deprived of oxygen, no longer function properly and start to shut down. He said it was individual for every patient. Specific for Resident #1 he said the resident was dependent on supplemental oxygen and required continuous oxygen at the rate of two liters per minute to maintain his oxygen saturation above 90 percent. He explained that at the time of stress, when the body does not receive enough oxygen, it would try to compensate for the lack of oxygen by increasing heart rate and blood pressure to bring more blood to the brain and other vital organs such as lungs, heart and liver. He said the body can only compensate for a short period of time until it runs out of vital resources such as oxygen. Once the resources depleted, organs such as heart and lungs start to fail and it will be evidenced by a drop in blood pressure. The low blood pressure would indicate that a situation of stress occurred a while ago. Low oxygen saturation in blood would eventually lead to tissue damage in all organs including the brain. He said considering what he observed and what was reported to him, very low blood pressure, severely low oxygen concentration in 50s, fixed pupil, weak response to pain stimuli, it was safe to say that resident's change in condition was a result of insufficient amount of oxygen to the brain and other vital organs. RT #1 was interviewed on 1/23/2020 at 11:05 a.m. She said in healthy individuals oxygen saturation was above 90 percent. For some individuals oxygen saturation in the 80s could be normal when they have chronic lung condition over extended periods of time, otherwise oxygen saturation below 80s is not normal. When the body detects low oxygen saturation it compensates by increasing the heart rate. She said most individuals use [MEDICAL CONDITION]/[MEDICAL CONDITION] units during the night, because at night individuals take more shallow respirations at a slower rate, and lungs are not expanded as much as during the day. For residents whose respiratory system was compromised by other conditions such as sleep apnea, chronic [MEDICAL CONDITION], or [MEDICAL CONDITION] and others, it was important to receive sufficient amount of oxygen during the night for proper functioning of all body organs. The medical director (MD) was interviewed on 1/23/2020 at 10:35 a.m. She said she was informed about the incident on the same day it occurred. She said she was contacted by the NP who was present in the building and responded to the incident. She said after the incident policies and procedures for [MEDICAL CONDITION]/ [MEDICAL CONDITION] units were reviewed and changes were made. She said she did not meet Resident #1 in person and she did not participate in the investigation. She said the DON conducted the investigation reported to her that it was undetermined if oxygen was connected to the wall or not. She said the [MEDICAL CONDITION] unit functioned well at night and no alarms from [MEDICAL CONDITION] were noticed (the [MEDICAL CONDITION] unit would trigger an alarm if it was not operating properly). She said they identified that in the evening of 12/21/19, CNA#1 assisted resident with a [MEDICAL CONDITION] machine. She said it was above CNAs scope of practice and [MEDICAL CONDITION]/[MEDICAL CONDITION] units should only be set up by nurses. She said on the same day nursing staff were educated not to delegate [MEDICAL CONDITION]/[MEDICAL CONDITION] units to CNAs. Regarding Resident #1's change of condition in the morning on 12/22/19: She said she could not accurately answer if the resident's change in condition was a direct result of insufficient oxygenation. She said Resident #1 had multiple lung conditions such as stage [MEDICAL CONDITION], chronic [MEDICAL CONDITION], and recent placement of chest tube on 12/20/19. All of the above conditions could have potentially contributed to his physical state in the morning of 12/22/19. She said upon admission to the emergency department the resident was started on antibiotics for [MEDICAL CONDITION], and abnormal blood work. All of the above, including emesis that were observed on his clothes would be an indicator [MEDICAL CONDITION] as well. DON was interviewed on 1/27/20 at 4:30 p.m. She said she was informed in the morning of the incident. She conducted an investigation with the help of other nurse managers. She said the investigation revealed Resident #1 was assisted with [MEDICAL CONDITION] on the evening of 12/22/19 by CNA. It was determined that CNA did not recall checking oxygen connection to the [MEDICAL CONDITION] unit. LPN #1 who was assigned to Resident #1 did not check the [MEDICAL CONDITION] unit during her shift either. DON said it was above the CNA's scope of practice to help with [MEDICAL CONDITION]/[MEDICAL CONDITION] units, and that task should have not been delegated to CNA. In addition, the investigation determined it was a widespread practice in the facility for CNAs to assist residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] units. Education to nurses was provided on 12/23/19. They were instructed not to delegate [MEDICAL CONDITION]/[MEDICAL CONDITION] application to CNAs. DON said she followed LPN #1 for the next two nights to make sure she was appropriately assisting residents with [MEDICAL CONDITION]/[MEDICAL CONDITION]. She said she did not keep any logs of observations and there was no documentation. She said the staff development coordinator (SDC) was providing formal education for the rest of nurses and CNAs. IV. Failure to put the system in place after the incident on 12/22/19 to make sure oxygen was applied correctly and by trained staff for other residents in the facility who used [MEDICAL CONDITION] and [MEDICAL CONDITION] machines. A. Record review and SDC interview Records of education were requested from SDC on 1/23/2020. At 12:12 p.m. she provided the records of education and was interviewed in the presence of CNC. She said education was provided in two different forms. Initially, on 12/23/19 the information was communicated to staff in a form of notice/flyer. The note read, [MEDICAL CONDITION] and [MEDICAL CONDITION] mask placement and (oxygen) set up with the machine cannot be a delegated task to CNA. The nurse or the patient may place the mask, but it is the nurse's responsibility prior to charting it off in (electronic medical record) to confirm: -the machine is on and working . -if (oxygen) is required it is hooked to machine and wall regulator -mask if fitting properly without any major leaks . The notice was posted in the staff room and every staff member who came to work that day was expected to read the notice and sign the log that he/she read the notice. She said she did not know how many staff members read the notice. She said she had a log with signatures and she can count how many staff members read the flyer. The second form of education was started on 1/17/2020 and was conducted online. She said the facility was transitioning to an online form of education and all nurses and CNAs were assigned a unit on [MEDICAL CONDITION]/[MEDICAL CONDITION]. She said since it was initiated on 1/17/2020, only nine staff members had completed the unit. The CNC who was present in the room added in addition, on 1/20/2020, the facility implemented a new policy for [MEDICAL CONDITION]/[MEDICAL CONDITION] units.The biggest change was a requirement to check oxygen saturation within 30-60 minutes after initiation of [MEDICAL CONDITION]/[MEDICAL CONDITION] unit. As well, every running [MEDICAL CONDITION]/[MEDICAL CONDITION] unit should be checked by a nurse every shift. She said the policy just came out on the 30th and staff did not receive any education on it yet. SDC was interviewed for the second time on 1/23/20 at 14:31. She said currently 49 nurses and 73 CNAs were employed by facility, with a total of 122 staff members total. She said out of 122 clinical staff members only 61 had signed they read the notice on delegation of [MEDICAL CONDITION]/[MEDICAL CONDITION] machines. She said electronic training was still in progress and only nine staff members completed the training. B. Staff interviews CNA #2 was interviewed on 1/23/2020 at 11:30 a.m. She said CNAs were instructed not to touch [MEDICAL CONDITION] or [MEDICAL CONDITION] equipment and only nurses and independent residents were able to turn the equipment on and off. She said CNAs were only allowed to refill distilled water for humidifiers. CNA #3 was interviewed on 1/23/2020 at 1:19 p.m. She said CNAs were allowed to help residents to take [MEDICAL CONDITION]/[MEDICAL CONDITION] mask off and turn the machine off by pressing the off button. She said nurses were in charge of turning the equipment on. CNA #4 was interviewed on 1/23/2020 at 2:30 p.m. She said she was a CNA preceptor and provided training for the CNAs. She said CNAs were allowed to help residents to put [MEDICAL CONDITION]/[MEDICAL CONDITION] mask on and make sure oxygen was connected to the unit and the wall. She said it was the nurses responsibility to follow up after and make sure everything was working. RN #1 was interviewed 1/23/20 at 1:10 p.m. She said she did not worked with [MEDICAL CONDITION]/[MEDICAL CONDITION] machines recently because she was working the morning shift and no one usually used [MEDICAL CONDITION]/[MEDICAL CONDITION] in the morning or during the day. She said the last time she helped residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] machine was at least 2 years ago when she used to work in the hospital. RN #2 was interviewed on 1/23/20 at 1:25 pm. She said she was a charge nurse and she did not know how many residents were using [MEDICAL CONDITION]/[MEDICAL CONDITION] machines on the first floor unit. She said since she worked only in the morning she did not assist with [MEDICAL CONDITION]/[MEDICAL CONDITION] unit recently. The last time she was working with one was at least six months ago. RN #3 was interviewed on 1/23/20 at 12:03 pm. He said he was a charge nurse and he did not know how many residents were using [MEDICAL CONDITION]/[MEDICAL CONDITION] equipment. He said he did not operate/helped with [MEDICAL CONDITION]/[MEDICAL CONDITION] in years because he works the morning shift and no one used [MEDICAL CONDITION]/[MEDICAL CONDITION] in the morning or day time. He said in the last couple of months he received a flyed about [MEDICAL CONDITION]/[MEDICAL CONDITION] machines that talked about not delegating to CNAs any tasks related to respiratory equipment. RN #4 was interviewed on 1/23/20 at 6:15 pm. She said she was working an evening shift and she did not know if she had any residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] units. She said when she initially started working in the facility three months ago it was a common practice for CNAs to assist residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] machines. Recently, about a month ago, she said she received a notice not to delegate [MEDICAL CONDITION]/[MEDICAL CONDITION] placement to CNAs. She said it was not any form of training, it was a notice. She said she did not have any experience at all applying [MEDICAL CONDITION]/[MEDICAL CONDITION] machines, and it would be nice to have some training since there were so many different types of them. RN #5 was interviewed on 1/23/19 at 6:35 p.m. She said she was working evening shifts and

Based on record review and interviews, the facility failed to protect one (#1) resident, out of three residents reviewed in a sample of five residents, from abuse and neglect. Specifically, the facility failed to administer oxygen to Resident #1 by qualified staff member and provide adequate supervision to assure delegated task of oxygen administration was done correctly. Resident #1, was admitted to the facility on [DATE] for rehabilitation services. He had a history of [REDACTED]. At night he was using a [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) machine in combination with oxygen as it was ordered by his physician. In the evening of 12/21/19 residen't [MEDICAL CONDITION] machine was set up by a certified nurse aide (CNA) #1, who was not certified to work with [MEDICAL CONDITION] machines. In the morning of 12/22/19 around 7:30 a.m. Resident #1 was found unresponsive. Registered nurse (RN) #1, who was the first staff member to approach the resident in the morning, discovered the oxygen tubing was not properly connected between [MEDICAL CONDITION] machine and the source of oxygen on the wall. Cross-reference to F695 (respiratory care), failure to provide respiratory care consistent with professional standards of practice. Findings include: A. Facility policy and procedure A copy of the facility's policy and procedure on Abuse Prevention with no revision date was provided by the nursing home administrator (NHA) on 1/27/20 at 10:37 a.m. The policy read in part, Neglect means failure to provide goods and services necessary to avoid physical harm, or mental anguish. Investigation of abuse and neglect: The facility will conduct an internal investigation. Upon completion of the investigation, the Administrator or designee will prepare a written summary. B. Resident #1 1. Resident status Resident #1, age [AGE] years old, was admitted [DATE] for rehabilitation services and discharged on [DATE] to an acute care facility. According to the December 2019 computerized physician orders [REDACTED]. The 12/21/19 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with the brief interview for mental status score (BIMS) of 12 out of 15. The staff assessment indicated the resident had no symptoms of [MEDICAL CONDITION] or difficulty concentrating on activities, no disorganized thinking and rejected care. He required extensive assistance from one staff for transfers, dressing, and bed mobility; supervision and set up from one staff for eating. Resident was on oxygen therapy. The resident's care plan documented resident was admitted for short term rehab stay with the intention to discharge home. He enjoyed outdoor activities when he was not spending time with family. The respiratory care plan documented the resident was using oxygen and had potential for complications related to pleural effusion (the build-up of excess fluid between the layers of the pleura outside the lungs). Interventions included staff to administer oxygen as ordered, and to monitor and report signs of respiratory distress, such as restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, and decreased breath sounds. The care plan did not document the resident was using [MEDICAL CONDITION] at night. The physician order [REDACTED]. In addition, to the provision of two liters of continuous oxygen per minute during the day. The resident was a full code, meaning he wanted to receive full medical treatment in the event if his heart or respirations stopped. 2. Resident #1's functional status prior to the incident on 12/22/19 The nurses admission note on 12/15/19 revealed on the day of the admission resident was calm and cooperative, oriented to the facility, policy and procedure, staff roles, daily and medication routines. According to the physical therapy (PT) plan of care, dated 12/16/19, resident was admitted for improving core and peripheral strength, balance, endurance, safety with functional mobility. Resident actively participated in physical and occupational therapy every day except for the day when he had scheduled medical procedure on 12/20/19. The physician admission note, dated 12/18/19 read that resident was admitted after hospitalization for [MEDICAL CONDITION] that improved with initiation of [MEDICAL CONDITION]. Resident was stable at home on two liters of oxygen per minute. 3. Family interview Resident's ex-wife was interviewed on 1/21/2020 at 2:30 p.m. She said she usually visited her ex-husband in the morning and brought him some food for breakfast. She visited him every day in the morning since he was admitted to the facility. She said he usually got up early around 5:00 a.m. and by the time she would come with food he would be up in the chair. She said in the evening before the incident, 12/21/19 they had several family members who came for the visit and her ex-husband was joking and seemed to be having a good time. In the morning of 12/22/19, around 7:30 a.m., she said as usual, she walked into his room. His room was poorly lit and the blinds were still closed. She said she approached her ex-husband on the right side of the bed and called his name. He did not respond. She said she called his name two more times and shook him on the shoulder. He did not respond. She said she took his [MEDICAL CONDITION] mask off with the intention to wake him up but he was not responding. After she took the mask off she realized that he would need regular oxygen. She said she looked around the room and there were multiple houses and tubings and she did not know which one was oxygen. She said she did not touch any tubings or houses that were around, she ran outside the room and and asked the nurse who was passing by for help and told her she could not wake up her husband. She said the nurse said she was not assigned to this resident but she would come and check. 4. Record review The progress note documented by RN #1 on 12/22/19 at 7:45 a.m. read: At approximately 07:45(a.m.) this RN was walking down east hall to retrieve scale when spouse alerted this RN stating Can you switch his oxygen over for me? I took his [MEDICAL CONDITION] off but don't know how to switch the oxygen and I can't get him to wake up for me. This RN responded immediately to (the patient's) room with (his) wife following. Upon entering room (patients) face, lips, and fingers noted to be cyanotic, eyes closed, (pulse oximetry) 70 (percent), unresponsive to verbal or painful stimuli. Wall (oxygen) noted to be running at 3 (liter per minute) via nasal cannula hanging on bed and not connected to [MEDICAL CONDITION]. Emergency red light activated by this RN, CNA (certified nurse aide) responded immediately and went to find (another) RN. (Patient) placed on 5(liters) of (oxygen) via nasal cannula with (pulse oximetry) rising quickly, (patient) not responding to verbal stimuli but responded to painful stimuli at this time. (Nurse Practitioner) notified and immediately responded to assess (patient). Pupils sluggish but reactive. (Nurse Practitioner) ordered 1 (liter) of (normal saline) wide open (by gravity), and to send (patient) to (emergency room ) for eval(uation). The facility discharge summary on 12/22/19 by nurse practitioner (NP) #1documented: today patient seen emergently . patient found to be unresponsive, does minimally respond to painful stimuli (sternal rub). Patient noted to be on his [MEDICAL CONDITION], oxygen not connected to (the) machine. His oxygen on my arrival was 70 (percent), reported by nursing initially as low as 50's (percent). The ambulance note dated 12/22/19 documented that call from the facility was received at 7:54 a.m. At 8:12 a.m. resident was assessed by first responders with (the) following findings: Upon making patient contact, the patient is lying supine in bed, responsive to pain only. The patient is usually able to speak in full sentences and ambulate on his own. Nursing staff informs, the patient was found in bed today, off his oxygen/[MEDICAL CONDITION], with oxygen saturation of 55 (percent) and unresponsive. According to the admission note dated 12/22/19 from the ER, resident was admitted on [DATE] with the following clinical impression: acute [MEDICAL CONDITIONS] and history of [MEDICAL CONDITION]. The emergency room admission note dated 12/22/19 read, (patient) presents to the (emergency department) via ambulance. Patient is unresponsive. He was found unresponsive, hypoxic, and hypotensive overnight. I was told that his oxygen saturations were in the 50s. I was also told that his blood pressure was in the 50s systolic. He arrives in the (emergency department with intermittent response to painful stimuli. He arrived with vomiting on his clothes an in his oropharynx. He has no other purposeful movement or function. He is a full code. Patient was vomiting prior to arrival. Due to his [MEDICAL CONDITION], the patient was intubated. Resident was admitted to the intensive care unit in critical condition where he was put on the mechanical ventilator. Five days later several attempts were made to remove the ventilator, but the resident was not able to breathe on his own. He did not gain his previous level of consciousness. The hospital discharge summary on 12/27/19 revealed, Attempts were made to liberate (patient) from ventilator. Multiple attempts at spontaneous breathing trials were unsuccessful. (Patient) had indicated to family during his last admission that he would not want prolonged ventilatory support or dependence. Given his expressed wishes in the setting of his severe restrictive disease and inability to ventilate properly on his own, decision was made to transition focus of care to comfort. He was [MEDICATION NAME] extubated (removed from artificial ventilation) on 12/27/19 and passed at (3:27 p.m.) 6. Facility investigation On 1/23/2020 facility investigation provided by NHA. The investigation was completed on 1/4/2020 and read: Wife arrived to facility approximately 7:35 am on 12/22/19, went to (the) room, unable to talk with (the) resident. Removed [MEDICAL CONDITION] and staff related to (the) machine. Went to get (a) nurse to help to attach oxygen. Staff assessed him as catatonic state. Got assistance from several nurses. (oxygen) stats came back up. Sent to hospital (emergency room ). Summary of findings: Oxygen was not hooked to (the) wall when (the) wife came back into (the) room. Based on interviews, unable to validate when and if (oxygen) was attached to (the) wall and [MEDICAL CONDITION] machine. Follow up/Interventions/Training: Education and training for nurses and CNAs related to oxygen, machines and monitoring. Additional training to amended/updated policy. Closer monitoring of residents on machines. Met with (the) medical director and clinical team to review policy and procedures. Continue training. Add to skills fair, annual training for all nurses and staff. Review at (Quality Assurance). The investigation was signed by NHA 1/4/2020. 5. Staff interviews CNA #1 was interviewed on 1/23/20 at 6:10 p.m. She said she was working in the facility for over a year, and this was her first healthcare job. She said helping residents with [MEDICAL CONDITION] and [MEDICAL CONDITION] machines was a regular thing for CNAs since she started the position and until late December. She said she did not receive any formal education in school or in the facility about [MEDICAL CONDITION]/[MEDICAL CONDITION] units but she was shown by other CNAs how to turn them on, refill humidifier and connect to oxygen if needed. She said some time in December 2019 all CNAs were told that they are no longer allowed to help with [MEDICAL CONDITION]/[MEDICAL CONDITION] machines and only nurses were allowed to do so. In the evening of 12/21/2020 she was assigned to work with Resident #1. She said he usually went to bed around eight or nine in the evening. She recalled helping him with the [MEDICAL CONDITION] mask and turning the unit. She said she did not recall checking oxygen tubing to see if it was connected to the [MEDICAL CONDITION] machine. She said after she helped the resident to bed he did not call for help on her shift. Licensed practical nurse (LPN) #1 was interviewed on 1/23/20 at 7:05 p.m. She said she was working in the facility for the last two years and prior to that she worked in the long term care for at least three years. On 12/21/19 she was assigned to work with Resident #1 during her six a.m. to six p.m. shift. She said typically CNAs were assisting residents with [MEDICAL CONDITION] and [MEDICAL CONDITION] units at bed time. She said most residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] units were alert and oriented and they knew how to start the unit and apply the mask. The assistance they needed was very minimal and most of them did it independently. She said on the evening of 12/21/19 the [MEDICAL CONDITION] machine for Resident #1 was started by CNA #1. She said after the resident was assisted to bed she did not walk in his room to check the [MEDICAL CONDITION] unit or oxygen tubing. She said the door to the resident's room was open during the entire shift and she observed the resident on several occasions from the hallway. She said the resident was asleep, he did not use his call light at night and he did not appear to be in distress. She said she was notified of the resident's condition in the morning of 12/22/19 after she left her work. She said after the incident on 12/22/19 she talked to the director of nursing on several occasions and was instructed not to delegate application of [MEDICAL CONDITION]/[MEDICAL CONDITION] units to CNAs. RN #1 was interviewed 1/23/20 at 1:10 p.m. She said she was working the morning shift on 12/22/19 when she was stopped in the hallway by a female visitor who asked her for help. She said the visitor said that she could not wake her husband up and needed help with his oxygen. RN #1 said that upon entering the room she observed that the resident in bed was purple-blue in color. The [MEDICAL CONDITION] machine was running on the table on the right side of the room. She said she went out and grabbed a vital sign machine. After she checked his vitals, his oxygen was in the low 70s setting and she reached to the oxygen tubing that was hanging from the wall. One end of the tubing was connected to the wall (supply of oxygen) and the second end was connected to the nasal cannula that was curled up next to the resident on the upper side of the bed. She applied the oxygen to the resident. She said at that time they both (female visitor and her) looked at the oxygen tubing that was coming out of the [MEDICAL CONDITION] machine. She said the female visitor stepped forward and picked up oxygen tubing that was connected to the [MEDICAL CONDITION] machine, the other end of the tubing was not connected to the wall, it was on the floor. RN #1 said that oxygen tubing from the [MEDICAL CONDITION] machine was not connected to the supply of oxygen on the wall. She said she called for assistance and the resident was assessed by NP who was in the facility at the time of the incident. She said the resident did not respond to the voice when she called him, and only responded to painful stimuli when the NP completed a sternal rub. She said she documented the details of this event under the progress notes. NP #1 was interviewed on 1/23/20 at 9:30 a.m. He said he was familiar with Resident#1 as he met him on several occasions. He said the most recent time was on 12/16/19 when he did his assessment. He said the resident was alert and oriented to himself, to the place where he was, time of the day and individuals around him. Resident communicated verbally and was able to express all of his needs. He also participated in daily therapy. His goals were to regain the strength, discharge home and continue his [MEDICAL CONDITION] for [MEDICAL CONDITION]. He said in the morning of 12/22/19 he was working around 7:40 a.m. when he was called in to the room for Resident #1. He said upon entering the room he observed two other nurses next to the resident. He said the resident was unresponsive with strong bounding pulse, fixed pupils, he had weak response to pain, the oxygen was set up to the maximum of 15 liters per minute and oxygen saturation went up 98 percent. He said it was initially reported to him that the resident's oxygen saturation at some point was in 50s and since then climbed to 98 percent. He said Resident #1 also experienced a dramatic drop in blood pressure at the time of the incident. The initial blood pressure that was reported to him was around 76/54. He was informed by staff that the resident's [MEDICAL CONDITION] machine was not working correctly. He said the decision was made to call for an ambulance as there is nothing more could have been done for the resident. He explained that to the (ex) wife of the resident and she agreed to transfer to the hospital. He said normal oxygen saturation in healthy individuals should be above 90 percent. When it drops below 90 percent, the brain and other parts of the body deprived of oxygen, no longer function properly and start to shut down. He said it was individual for every patient. Specific for Resident #1 he said the resident was dependent on supplemental oxygen and required continuous oxygen at the rate of two liters per minute to maintain his oxygen saturation above 90 percent. He explained that at the time of stress, when the body does not receive enough oxygen, it would try to compensate for the lack of oxygen by increasing heart rate and blood pressure to bring more blood to the brain and other vital organs such as lungs, heart and liver. He said the body can only compensate for a short period of time until it runs out of vital resources such as oxygen. Once the resources depleted, organs such as heart and lungs start to fail and it will be evidenced by a drop in blood pressure. The low blood pressure would indicate that a situation of stress occurred a while ago. Low oxygen saturation in blood would eventually lead to tissue damage in all organs including the brain. He said considering what he observed and what was reported to him, very low blood pressure, severely low oxygen concentration in 50s, fixed pupil, weak response to pain stimuli, it was safe to say that resident's change in condition was a result of insufficient amount of oxygen to the brain and other vital organs. RT #1 was interviewed on 1/23/2020 at 11:05 a.m. She said in healthy individuals oxygen saturation was above 90 percent. For some individuals oxygen saturation in the 80s could be normal when they have chronic lung condition over extended periods of time, otherwise oxygen saturation below 80s is not normal. When the body detects low oxygen saturation it compensates by increasing the heart rate. She said most individuals use [MEDICAL CONDITION]/[MEDICAL CONDITION] units during the night, because at night individuals take more shallow respirations at a slower rate, and lungs are not expanded as much as during the day. For residents whose respiratory system was compromised by other conditions such as sleep apnea, chronic [MEDICAL CONDITION], or [MEDICAL CONDITION] and others, it was important to receive sufficient amount of oxygen during the night for proper functioning of all body organs. DON was interviewed on 1/27/20 at 4:30 p.m. She said she was informed in the morning of the incident. She conducted an investigation with the help of other nurse managers. She said the investigation revealed Resident #1 was assisted with [MEDICAL CONDITION] on the evening of 12/22/19 by CNA. It was determined that CNA did not recall checking oxygen connection to the [MEDICAL CONDITION] unit. LPN #1 who was assigned to Resident #1 did not check the [MEDICAL CONDITION] unit during her shift either. DON said it was above the CNA's scope of practice to help with [MEDICAL CONDITION]/[MEDICAL CONDITION] units, and that task should have not been delegated to CNA. In addition, the investigation determined it was a widespread practice in the facility for CNAs to assist residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] units. Education to nurses was provided on 12/23/19. They were instructed not to delegate [MEDICAL CONDITION]/[MEDICAL CONDITION] application to CNAs. DON said she followed LPN #1 for the next two nights to make sure she was appropriately assisting residents with [MEDICAL CONDITION]/[MEDICAL CONDITION]. She said she did not keep any logs of observations and there was no documentation. She said the staff development coordinator (SDC) was providing formal education for the rest of nurses and CNAs. NHA was interviewed on 1/27/2020 at 4:50 p.m. in the presence of CNC and DON. She said after conducting an investigation they were unable to conclude if oxygen was attached to the wall or not. The fact that the (ex)wife was in the room and she was touching the [MEDICAL CONDITION] machine made it difficult to determine if she removed any other parts of the [MEDICAL CONDITION] machine. She said (ex)wife was very upset and she did not ask her if she touched/removed oxygen tubing that was connected to the machine. She said the incident was discussed with the management team during the morning meeting, and the training was initiated the next day. As well, they initiated the review of current policies and procedures for [MEDICAL CONDITION] and [MEDICAL CONDITION] units.

Based on record review and interviews, the facility failed to ensure the comprehensive care plans for three (#1, #2 and #4) residents out of five sample residents were reviewed and revised by the interdisciplinary team. Specifically, the facility failed to develop comprehensive, person specific care plans for residents #1, #2 and #4 who used [MEDICAL CONDITION] and [MEDICAL CONDITION] machines in the building. Cross-reference to F695 (respiratory care), failure to provide respiratory care consistent with professional standards of practice. Findings include: [NAME] Resident #1 1. Resident status Resident #1, age [AGE] years old, was admitted [DATE] for rehabilitation services and discharged on [DATE] to an acute care facility. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 12/21/19 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with the brief interview for mental status score (BIMS) of 12 out of 15. The staff assessment indicated the resident had no symptoms of [MEDICAL CONDITION] or difficulty concentrating on activities, no disorganized thinking and rejected care. He required extensive assistance from one staff for transfers, dressing, and bed mobility; supervision and set up from one staff for eating. Resident was on oxygen therapy. The respiratory care plan documented the resident was using oxygen and had potential for complications related to pleural effusion (the build-up of excess fluid between the layers of the pleura outside the lungs). Interventions included staff to administer oxygen as ordered, and to monitor and report signs of respiratory distress, such as restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, and decreased breath sounds. The care plan did not document the resident was using [MEDICAL CONDITION] at night. B. Resident #2 1. Resident status Resident #2, age [AGE] years old, was admitted [DATE] for rehabilitation services. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. 2. Record review The resident's care plan documented resident had [MEDICAL CONDITION], interventions included to administer oxygen and respiratory treatments as ordered by physician and monitor for signs and symptoms of [MEDICAL CONDITION]. The care plan did not mention that the resident was using [MEDICAL CONDITION] at night. The physician order [REDACTED]. 3. Resident interview Resident was interviewed 12/23/2020 at 2:12 p.m. He said he was using a [MEDICAL CONDITION] machine every night and nurses helped him with it. He said he was on four liter per minute of oxygen during the day and night. C. Resident #4 1. Resident status Resident #4, age [AGE] years old, was admitted [DATE] for rehabilitation services. According to the (MONTH) 2020 CPOs, [DIAGNOSES REDACTED]. 2. Record review The resident's care plan for psychosocial well being documented resident wears oxygen at baseline. Resident ' s care plan did not include the reason the resident was using supplemental oxygen, or the rate it was used at. The care plan did not mention that the resident was using a [MEDICAL CONDITION] machine at night. The physician order [REDACTED]. Titrate oxygen to keep (saturation) above 90 (percent).Nurse to assist with [MEDICAL CONDITION] at (night , and three liters of oxygen to) bleed in (baseline) with [MEDICAL CONDITION]. 3. Resident interview Resident was interviewed on 1/23/2020 at 2:20 p.m. He said he used a [MEDICAL CONDITION] machine at night and nurses were helping him every night with settings. He said he was on three to four liters of oxygen per minute at night, and usually minus one liter during the day. He said he had to remind nurses to refill the humidifier for the [MEDICAL CONDITION] machine, because occasionally they forgot. D. Staff interviews RN #6 was interviewed on 1/23/2020 at 2:15 p.m. He said all residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] machines should have a care plan for that. He said it was important that nurses can be aware what settings they are using, the preference that the resident had and the level of assistance that resident would require with the unit. He said all care plans initiated on admission by admitting nurses and later changes made by charge nurses and unit managers. RN #7 was interviewed on 1/27/2020 at 6:15 p.m. She said the initial care plan was created by the admitting nurse on the day the resident was admitted . Any changes to care plan after that were done by floor nurses or unit managers if and when communicated to them. DON was interviewed on 1/27/20 at 4:30 p.m. She said her expectation was that such care plans could be incorporated with other area of concerns such as supporting [DIAGNOSES REDACTED]. She said it was not expected from nurses to create a separate care plan just for [MEDICAL CONDITION]/[MEDICAL CONDITION] units. She said moving forward they will review all residents with [MEDICAL CONDITION]/[MEDICAL CONDITION] units and make sure they had resident specific care plan that reflected oxygen needs and use of supporting equipment.

Based on observations, record review, and interviews the facility failed to ensure the residents had a comfortable and safe environment throughout the facility. Specifically, the facility failed to accommodate comfortable sound levels of the bathroom exhaust fan in all resident bathrooms that ran continuously. Findings include: I. Resident interviews and observations Resident #51 was interviewed on 11/6/19 at 3:08 p.m. He said the exhaust fan in the bathroom ran 24/7 causing negative pressure/ventilation in the room. The resident said the exhaust fan was loud and he had to keep the bathroom door closed when he wanted to watch television or converse with company, but this only muffled the sound of the exhaust fan. He said he had spoken with the staff, but was told that was just the way it was. The bathroom door was closed and the exhaust fan could be heard during the interview. Resident #226 was interviewed on 11/6/19 at 3:53 p.m. She said you could hear the fan in the bathroom, even with the door closed. The bathroom door was closed and the exhaust fan could be heard during the interview. Resident #25 was interviewed on 11/11/19 at 12:05 p.m. She said she had to leave the bathroom door closed because the fan ran constantly and was loud. The bathroom door was closed and the exhaust fan could be heard during the interview. Resident #233 was interviewed on 11/11/19 at 12:30 p.m. She said the fan did not shut off and it kept her awake at night. The bathroom door was closed and the exhaust fan could be heard during the interview. II. Record review The grievance binder provided by the director of nursing (DON) on 11/11/19 at approximately 2:00 p.m., revealed there had been no reported or written complaints about the noise level from the bathroom exhaust fans. III. Staff interviews The maintenance service director (MSD) was interviewed on 11/12/19 at 10:15 a.m. He said the building was designed so the bathroom exhaust fans ran continuously, as it pulled air from the hall into the residents room to aid in the circulation of the air in the room. He said he received complaints about the noise level of the exhaust fans, but he did not make a formal or written complaint on behalf of the residents. He said the resident concerns were presented to management, but he never heard what they were going to do to correct the issue. He said he explained to the residents the exhaust fans ran continuously because that was how the building was constructed. The MSD said an option would be to add an on/off switch or change the exhaust fans to motion activation. He said if the exhaust fans were unplugged, there could be inadequate air circulating within the building. The nursing home administrator (NHA) was interviewed on 11/12/19 at 11:53 a.m. She said the bathroom exhaust fans needed to run continuously, as the exhaust fan provided circulation in the residents room, even if the door to the room was closed. She said she knew of only one resident complaint about the exhaust fan in the bathroom being too loud, but thought it had been resolved with a verbal explanation. She said the facility would look into alternatives for a quieter exhaust fan.

Based on observations, interviews, and record review, the facility failed to ensure prompt efforts to resolve all resident grievances. Specifically, the facility failed to respond to resident call lights in a timely manner. Findings include: I. Facility policy 1. The Call Light policy, revised on 9/18/19 was provided by the nursing home administrator (NHA) on 11/12/19. It read, in pertinent part, Call lights are part of the resident communication system. All calls for assistance are to be answered as timely as possible by any available staff member. 2. The Resident Rights policy, revised on 4/11/19 was provided by the NHA on 11/12/19. It read, in pertinent part, The facility shall adopt a statement of the rights and responsibilities of their residents, post it conspicuously in a public place, and provide a copy to each resident or guardian before admission. The facility and staff shall observe these rights in the care, treatment, and supervision of the residents. The (resident) has the right to present grievances on behalf of him/her or others to the facility's staff or administrator, to governmental officials, or to any other person, without fear of reprisal, and to join with other patients or individuals within or outside of the facility to work for improvements in resident care. II. Observations On 11/6/19 at 1:55 p.m., the call light for Resident #39 was observed to be illuminated in the hall. The resident could be heard from the hall yelling for help. At 2:00 p.m., certified nurse aide (CNA) #9 walked past the room of Resident #39 and told the resident she would be back. The CNA did not acknowledge the residents need and the resident continued to yell for help. At 2:05 p.m., a nurse practitioner (NP) entered Resident #39's room, answered her call light and addressed her needs. On 11/6/19, Resident #18 said she needed to be changed as her brief was soiled and was observed to push the call light button at 1:33 p.m. At 1:54 p.m., 21 minutes later, the call light still had not been answered. The following staff either walk past or near the residents room: -Between 1:54 p.m. and 2:00 p.m. the maintenance service director (MSD) walked past the residents room three times. -At 1:55 p.m., CNA #13 walked in and out of the room adjacent to the residents room. -At 1:56 p.m., the activities assistant (AA) walked past Resident #18's room to the room next door to invite the resident to activities. At no time during the observation did staff acknowledge that the call light was activated or provide assistance to the resident. -At 2:00 p.m., 27 minutes after the resident pushed the call light, therapy was observed entering Resident #18's room. However, therapy did not ask the resident if she needed assistance, but rather to take the resident to her therapy session. -At 2:02 p.m., CNA #9 observed the call light, entered the room and turned off the call light and left the room. CNA #9 was interviewed after leaving the residents room. She said had provided toileting assistance an hour before, but would check to see if she needed to be changed. The CNA did not return to the residents room until 2:05 p.m. The therapist left the room as CNA #9 shut the resident's door to assist. Due to the untimely call light response, the resident waited in a soiled brief for a total of 32 minutes from the time the call light was activated until staff came to address the residents needs. On 11/7/19 at 3:37 p.m., the call light for Resident #178 was observed to be illuminated in the hall. The resident was heard from the hall to yell for help. At 3:42 p.m., CNA #2 was observed to walk past the room without addressing the residents needs. At 3:43 p.m., the family for Resident #178 entered the residents room, at which time CNA #2 was observed returning to the residents room and answered the call light. On 11/11/19 at 10:49 a.m., observed Resident #238's call light illuminated in the hall. It was not until 11:08 a.m., 19 minutes after the resident had activated the call light that CNA #10 entered the residents room to address his needs. Resident #238 was interviewed at 11:15 a.m. He said he pressed the call light because he needed to go to the bathroom and then wanted to lie down in bed. He said there have been times in the past when the CNA's took too long to answer the call light and he had an accident and needed to be changed. On 11/11/19 at 10:57 a.m., observed Resident #127's call light illuminated in the hall. It was not until 11:14 a.m., 16 minutes after the resident had activated the call light that CNA #10 entered the residents room to address his needs. Resident #127 was interviewed at 11:21 a.m. He said he pressed the call light because he wanted the urinal that had been on the bedside table emptied. Resident #127 said there were times when he had to wait 15 to 20 minutes for staff to assist him to the bathroom. III. Resident interviews Resident #42 was interviewed on 11/6/19 at 2:30 p.m. The resident said she has waited up to 40 minutes during shift change before staff answered the call light. Resident #175 was interviewed on 11/6/19 at 3:31 p.m. He said he had pressed his call light earlier this morning for assistance to go to the bathroom. He became very frustrated with the length of time he had to wait and the lack of assistance he received from CNA #1. He said he was told by the CNA that he had to continue to wait because she was the only CNA for 15 residents. Resident #175 said he was so upset with the response that he reported the concern to his nurse and thought about discharging. Resident #175 was interviewed on 11/6/19 at 4:43 p.m. The resident said there were times when it took over 10 minutes for the call light to be answered. Earlier this morning, a CNA told him someone else would help him in the bathroom. IV. Group Interview A group of four residents were interviewed on 11/8/19 at 3:00 p.m. The group of residents were concerned with the call light response time and said call lights were not answered in a timely manner. It could be as long as 20 to 40 minutes before the call light was answered. They said the facility staffed according to the number of residents in the facility. V. Record review The resident council minutes documented the following: -6/20/19: .Resident voiced that she would like more CNA's around . The resident was assured by the restorative supervisor (RS) that the facility staffed by the number of residents and that the facility was overstaffed according to that ratio. -8/15/19: .RS was starting a call light project in order to decrease call light times . The outcome of the call light project was not mentioned in subsequent resident council minutes. Call light record detail reports were reviewed for dates before and during the survey. The call light report tracked the date and time, the room number and the response time. Although, the call light report had the majority of the call lights answered within five to seven minutes, there were several call lights which were in excess of 15 minutes. Such as: -11/2/19: 28 minutes for room [ROOM NUMBER], 23 minutes for rooms #211 and #200, 20 minutes for room [ROOM NUMBER], 22 minutes for room [ROOM NUMBER], 25 minutes for rooms #220 and #224, 31 minutes for room [ROOM NUMBER], 32 minutes for room [ROOM NUMBER], and 22 minutes for room [ROOM NUMBER]. -11/3/19: 25 minutes for rooms #238 and #207, 45 minutes for room [ROOM NUMBER], 53 minutes for room [ROOM NUMBER], 20 minutes for room [ROOM NUMBER], #228, and #145, 56 minutes for room [ROOM NUMBER], 21 minutes for room [ROOM NUMBER], 28 minutes for rooms #223 and #245, 26 minutes for room [ROOM NUMBER], 22 minutes for rooms #218, #230, and #232, 37 minutes for room [ROOM NUMBER], and 23 minutes for room [ROOM NUMBER]. -11/6/19: 21 minutes for rooms #131, #214, and #138, 23 minutes for rooms #139 and #214, 20 minutes for rooms #209 and #143, 22 minutes for rooms #233 and #107, 29 minutes for rooms #240 and #223, and 24 minutes for rooms #138 and #230. -11/7/19: 25 minutesfor rooms #208, #226, and #200, 24 minutes for rooms #211 and #142, 23 minutes for room [ROOM NUMBER], 27 minutes for room [ROOM NUMBER], 21 minutes for rooms #121 and #138, 20 minutes for rooms #137 and #241, 35 minutes for room [ROOM NUMBER], 52 minutes for room [ROOM NUMBER], 34 minutes for room [ROOM NUMBER], and 30 minutes for room [ROOM NUMBER]. -11/11/19: 22 minutes for rooms #141 and #126, 21 minutes for rooms #218 and #210, 24 minutes for room [ROOM NUMBER], 25 minutes for room [ROOM NUMBER], and 34 minutes for room [ROOM NUMBER]. VI. Staff interviews CNA #11 was interviewed on 11/11/19 at 2:06 p.m. She said call lights should be answered in less than five minutes. CNA #4 was interviewed on 11/11/19 at 2:21 p.m. He said call lights should be answered as soon as possible, within three minutes. CNA #12 was interviewed on 11/11/19 at 2:31 p.m. She said call lights should be answered within five minutes. CNA #2 was interviewed on 11/11/19 at 2:38 p.m. She said she tried to answer call lights as soon as possible, usually no more than five minutes. Sometimes it was difficult, especially if she was the only CNA for that hall and it was during the rush hours of 6:00 p.m. to 8:00 p.m. CNA #1 was interviewed on 11/12/19 at 9:08 a.m. She said call lights should be answered as soon as possible, usually in 15 minutes or less but no more than 15 minutes. The director of nursing (DON) was interviewed on 11/12/19 at 11:28 a.m. She said the goal for call lights to be answered was less than five minutes. She said any staff, both clinical and non-clinical staff should answer a residents call light and address their need. She said during orientation, staff were educated to leave the call light on if resident care still needed to be completed. She said, at times, the staff forgot to turn the call light off when they left the residents room.

Based on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Prevent potential cross contamination during meal preparation and meal delivery; -Ensure ready-to-eat food preparation and holding surfaces, specifically cutting boards, were free of contamination; -Use proper hand hygiene when hands touch a contaminated surface; -Maintain kitchen equipment in good repair to limit the risk of bacteria exposure and growth; and, -Use safe food handling practices, specifically, the use of hairnets and beard guards. Findings include: I. Prevent potential cross contamination during meal preparation and meal delivery. [NAME] Facility policy The employee sanitary practices policy, revised 2019, was provided by the dietary manager (DM) on 11/12/19 at approximately 11:30 a.m. The policy read in pertinent part: All food and nutrition service employees will practice good personal hygiene and safe food handling procedures. All employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food Wash hands before handling food The hand washing policy, revised 2019 was provided on 11/12/19. The policy read in pertinent part: Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures after handling soiled equipment or utensils After engaging in other activities that contaminate the hands The facility ' s infection prevention in the food and nutrition department procedure and training guide was provided by the DM. The training guide read in pertinent part: CDC (center for disease control) clean hands campaign: Most germs that cause serious infections in healthcare are spread by people ' s actions Cross-contamination is the transfer of harmful bacteria to the food from other foods, cutting boards, utensils, ect., if they are not handled properly food poisoning, also called foodborne illness, is caused by eating contaminated food. Infectious organisms including bacteria, viruses and parasites, or their toxins, are the most common causes of food poisoning Infectious organisms or their toxins can contaminate food at any point of processing or production. The infection prevention section in the food and nutrition department procedure and training guide identified, under personal hygiene for food service, staff should be clean shaven or use a beard hair cover. The training guide also identified hairnets should be worn and cover the entire head of hair. II. Observations B. Cross contamination related to poor repair ready to eat food preparation surfaces, specifically cutting board surfaces, and improper hand hygiene. The lunch meal service was observed in the kitchen on 11/12/18 from 11:20 p.m. to 1:05 p.m. At 11:26 a.m. a white cutting board laid on a food preparation table in the back portion of the kitchen. A used knife rested on top of the board. The cutting board had deep cuts on its porous surface. Many of the cuts contained black debris and had brown stains covering the surface. A light blue cutting board, in a holding rack under the prep table, that was put up after cleaning, revealed deep cuts, black marks over the cutting surface of the board A long cutting board attached to the top surface of the refrigerated unit of the tray line revealed deep cuts, brown stained spots, and numerous black marks. Another long cutting board attached to the top surface of the tray line steam table also displayed brown stains, deep cuts, and some of the cuts were black in color. Both cutting surfaces attached to the tray line were in poor repair. Throughout the meal service, dietary staff including the DM, placed non-food items on the cutting board surface of the tray line. Potentially contaminated non-food items included resident meal tickets were in a line on the boards. -At 12:17 p.m. a meal ticket fell off the cutting surface of the tray line and landed on the floor. -At 12:18 p.m. The chef picked up the ticket from the floor and placed it back on the cutting board with his bare right hand, contaminating his hand and the porous cutting surface for ready-to-eat foods, and the entire tray line. The chef did not wash his hands after picking up the ticket. He did not sanitize the tray line after placing the fallen ticket back on the cutting surface. The chef proceeded to plate two lunch meals of sweet and sour chicken with rice and stir fried vegetables. The chef touched food service utensils, the door handle of a warming unit and the handle of a small refrigerator. He unwrapped plastic covering from a bowl of ready-to-eat salad, squeezed salad dressing from a bottle, unwrapped plastic covering from a ham and cheese sandwich, and placed it on the grill. -At 12:21p.m. the chef removed the contaminated meal ticket from the cutting surface and hung it above the steam line on a clip and washed his hands. -At 12:22 p.m. the chef placed a plastic container of spinach and two slices of ready-to-eat loaf bread on directly on top of the cutting surface where the contaminated meal ticket once rested. He cut the bread in half, assembled a bacon, tomato and spinach sandwich,and placed the sandwich on a plate that sat on top of the non-food, contaminated cutting board surface. -At 12:24 p.m. he placed two more slices of bread and plastic containers of jelly and peanut butter on the cutting surface. He assembled and plated the peanut butter and jelly sandwich. -At 12:40 p.m. the chef assembled a salad on top of the contaminated cutting board. He cut ready to eat bacon, sliced a hard boiled egg, and placed the items in a bowl of spinach. He then wiped the cutting surface of the tray line with a cloth from a bucket filled with water and sanitized solution. Between 11:57 p.m. and 12:51 p.m., the chef placed and cut grilled sandwiches of cheese and ham and cheese on the cutting board attached to the surface of the steam line. The grilled sandwiches left oil from the grill on top of the already compromised surface. Observations revealed meal tickets were also placed on the steamline cutting surface. C. Use safe food handling practices, specifically, the use of hairnets and beard covers. Dining service was observed in the first floor dining room on 11/6/18 between 11:30 p.m. and 12:55 p.m. During observations the dietary manager (DM), a dietary aide (DA) #3 and Cook #1 failed to use hair restraints to prevent the potential of hair contacting food during the meal service. DA #3 and Cook #1 had facial beards. DA #3 beard growth was trimmed close to his face, approximately less than one inch in length. Cook #1 beard growth was approximately two inches or less in length. They did not wear a beard guard. The DM had her hair tied back. She did not wear a hairnet. Between 11:56 a.m. and 12:53 p.m. DA #3 was observed 27 times taking resident meal orders, entering the kitchen, placing meal order tickets on the cold food preparation counter of the tray line and retrieved and ready to be served food. DA #3 did not wear a beard guard. -At 12:00 p.m. Cook#1 was observed entering and exiting the kitchen five times, he did not wear a beard guard to cover his beard. -At 12:19 p.m. Cook #1 was observed standing in the kitchen near the steam table holding plate next to the chef and ready to eat food. Throughout the lunch observation the DM walked in and out of the kitchen, at or passed the tray line a total of 14 times including retrieval of a resident ' s meal consisting of a salad. The DM wore a long ponytail without a hairnet. The lunch meal and preparation was observed in the kitchen on 11/12/18 from 11:20 p.m. to 1:05 p.m. During observations the DM, DA #3 and Cook #3 failed to use hair restraints to prevent the potential of hair contacting food during the meal service. DA #3 and Cook #1 donned a beard. They did not wear a beard guard. The DM had her hair tied back with loose hair around her face. She did not wear a hairnet. DA #1 -At 12:12 p.m. DA #1 entered the kitchen from the 2nd floor entrance, passed the stream line, retrieved items from the front of the steam table, and exited the kitchen. DA #1 donned a beard without a beard guard. -At 12:58 p.m. DA #1 entered the kitchen, placed items in the refrigerator next to the steam table and exited the kitchen. He did not wear a beard guard. DM The DM assisted her staff in serving resident meals. She did not wear a hairnet. The DM was observed from 11:44 p.m. to 12:41 p.m. placing meal tickets on the cold food preparation counter of the tray line and retrieving plated meals from the frontside of the steam table. Cook #1 Cook #1 was observed in and out of the kitchen, at streamline, grilling sandwiches and plating resident meals from 11:46 p.m. to 1:05 p.m. He donned a beard without a beard guard. -At 11:46 p.m. Cook #1 assembled and plated salad at the cold food preparation counter of the tray line. -At 12:24 p.m. Cook #1 entered the kitchen, and gathered supplies from the back food preprepartion station, and dishwasher station. -At 12:25 p.m. Cook #1 stood at the steam table and filled a blender with sweet and sour chicken and vegetables. He pureed the meal at the back food preprepartion station. -At 12:38 p.m. he exited the kitchen. -At 12:48 p.m. Cook #1 returned to the returned with a dish cart. -At 12:51 p.m. Cook #1 put away containers of peanut butter and spinach from the cold food preparation counter of the tray line. He removed tickets from the steam table surface and hung the tickets on clips above the food. -At 12:52 p.m. he grilled two cheese sandwiches at the grill behind the steam table. -At 1:00 p.m. Cook #1 wiped down the tray line of the steam table and cold food preparation counter. The cook did not wear a beard guard when working with or near ready to eat food. On 11/12/19 and 11:10 a.m., Cook #1 was observed collecting plates from the plate warmer between the steam table and cold food preparation counter. Cook #1 did not wear a beard guard. III. Staff interview The infection control nurse who also was the director of nursing (DON), was interviewed on 11/11/19 at 2:30 p.m. with the corporate infection control consultant. The DON said infection control is a building wide focus and departments such dietary are responsible for establishing and maintaining appropriate infection control practices. The DON said she puts monthly surveys for departments to do random audits to ensure safe practices. She said the (MONTH) 2019 survey audit indicated on 10/24/19, the dietary management focused on hand washing. DA #1 was interviewed on 11/12/19 at 10:50 a.m. She was observed to wear a hairnet. DA #1 said staff can not go past the front of the dishwashing station located at the front entrance of the kitchen station, without a hairnet. The dietary manager (DM) and the chef were interviewed on 11/12/19 at 12:00 p.m. The DM said she and the facility provide multiple trainings so her dietary staff understand how to prevent cross-contamination. Training included new hire job specific orientation, annual education through an online learning center and review and training during their evaluations. The chef said he was responsible for many of the day to day management responsibilities in the kitchen related to food. He said he continues to train staff on appropriate hand hygiene, and safe food handling and cooking procedures. He said he provides both on the spot education and regular monthly meetings. The DM said staff should practice good personal hygiene and safe food handling procedures. She said staff should wear hairnets and beard guards, should stay above the service line and should not pass or stand near ready to eat food stations, including the cold food preparation and steam table tray line. She said she would establish clear lines so staff know they can not cross without hair or beard coverings. The chef said he was responsible for ensuring kitchen equipment is in good repair and responsible for ordering new equipment as needed. The chef acknowledged the cutting boards and cutting board surfaces attached to the tray line were in poor condition with the potential to harbor bacteria. The chef stated he would replace those items. The DM cutting board surfaces used for food, should not have non-food items placed on top of food preparation surfaces. She said items that have touched the floor should never be put on surfaces meant to prep and hold food. The DM said she will continue to establish processes to prevent contamination of food workstations such as the cold food preparation and steam table tray line. The DM and chef said they would create systems within the kitchen and meal service process to ensure safe food handling practices and limit the risk of cross contamination.

Based on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchens, one of one kitchenettes and in two of two dining rooms. Specifically, the facility failed to: -Prevent potential cross contamination during meal preparation and meal delivery; -Place ready-to-eat food on a non-food contact surface, particularly, the kitchen floor; -Demonstrate appropriate use of gloves when handling ready-to-eat foods; -Sanitize and wash hands between meal delivery, and -Sanitize and clean ice makers (ice machines). Findings include: I. Prevent potential cross contamination during meal preparation and meal delivery A. Professional reference The Colorado Retail Food Establishment Rules and Regulations (effective 3/1/13) pg. 56, defined the term highly susceptible population (HSP) as persons who are more likely than other people in the general population to experience foodborne disease because they are immunocompromised, preschool age children, or older adults; and they obtain food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. The Colorado Department of Public Health and Environment (2013) The Colorado Retail Food Establishment Rules and Regulations, on 11/20/18, https://www.colorado.gov/pacific/sites/default/files/Reg_BOH_RetailFoodRegulations.pdf, in pertinent part; -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is reasonably expected to be consumed in that form. -Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. -Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. According to the Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 21, 2012, effective (MONTH) 1, 2013) pg. 25, in part: Food employees shall clean their hands and exposed portions of their arms for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, fingertips, area between the fingers, hands and arms for at least 15 seconds, followed by; thorough rinsing under clean, running, warm water; and immediately follow the cleaning procedure with thorough drying of cleaned hands and arms . Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles .after handling soiled equipment or utensils. 1. Observations The lunch meal was observed on 11/12/18 from 11:30 p.m. to 12:35 p.m. At 12:30 p.m. the chef was observed plating food for a resident, using utensils with his gloved hands. At 12:31 p.m. he opened the door of the heated holding cabinet for food trays transportation with his gloved hands, he placed the covered plate in the unit, and closed the door. He returned to the steam table, picked up a serving spoon, and plated another meal for dining room delivery. He did not change gloves or wash his hands. Lunch preparation and service in the main kitchen was observed on 11/13/18 from 10:55 a.m. to 12:30 p.m. On 11/13/18 the chef was observed continuously from 11:14 a.m. to 11:25 p.m. The following was observed: The chef washed his hands, put on new gloves and set up the serving utensils on the steam table. In the process he noticed a small object had fallen to the floor in front of the heated holding cabinet, he reached for a paper towel and picked up the fallen item off the floor with the paper towel and gloved hands. Then he opened the door of the dietary office with his gloved hands, stepped inside, returned to the back room of the kitchen and started to assemble the top of a food blender to the machine. While holding the blender lid in his left gloved hand, he opened the office door with his right gloved hand. He left the blender lid on the desk and returned to the kitchen. He did not change the gloves or washed his hands. The chef walked to the refrigerator and opened the door with his gloved hand. He pulled out a container of cottage cheese and placed it next to an opened can with fruit, on the prep counter. He opened the cottage cheese lid with his gloved hand. The chef picked up a set of dessert cups and placed on two serving trays. He picked up a large spoon off the counter with his gloved hand and proceeded to scoop the fruit and the cottage cheese into dessert cups. The chef removed his gloves, washed his hands, and put on new gloves. At 11:25 p.m. the chef picked up two trays with filled dessert (cottage cheese and fruit) cups from the preparation counter. He walked to the refrigerated unit attached to the steam table. He kneeled down, placed both trays with dessert cups on the floor with his gloved hands. He opened the small refrigerator, picked up one of the trays off the floor, and placed the entire tray in the refrigerator. He picked up the second tray off the floor with his gloved hands and placed the rest of the dessert cups on the first tray in the refrigerator. He stood up, set the empty dessert tray on the dishwashing counter, and removed his gloves. Ready-to-eat food was placed on a non-food contact surface, the kitchen floor. 2. Sanitize and wash hands between meal delivery a. Observations Dining service was observed in the first floor dining room on 11/12/18. -At 11:48 a.m. DA #3 placed her right thumb on the eating surface of plate twice, as she served a resident. -At 12:20 p.m. DA #3 served a plate to a resident, went back into the kitchen without sanitizing or washing her hands, picked up another plate of the serving line and delivered it to a resident. -From 12:12 p.m. to 12:33 p.m. the assistant dining room manager (ADRM) was observed placing her thumb on the eating surface of six plates before the plates reached the residents table. She did not sanitize or wash her hands prior to handling the plates. -At 12:34 p.m. ADRM washed her hands. DA #4 was observed on 11/14/18 at 12:12 p.m. She delivered a lunch plate to a resident. She touched the resident's table and moved a half drunk glass. DA #4 returned to the kitchen without sanitizing or washing her hands. -At 12:15 p.m. she picked up another plate from the serving line and delivered to the next resident. b. Staff Interview The dietary manager (DM) was interviewed on 11/15/18 at 1:15 p.m. The DM said staff should sanitize their hands after each meal delivery. Staff should wash their hands after every third time of delivery to prevent contamination. The DM said they do not keep clean gloves in the kitchen office. She said gloves are kept in the kitchen within easy access to staff. The DM said for proper glove use when working with food, hands should be washed before and after each use of gloves. Gloves should be changed when switching tasks or touching anything that could contaminate the gloves such as door, appliance handles or picking something off the floor. She said food should never be put on the floor and contaminated trays off the floor should not be put in a refrigerator. The infection control nurse who also was the assistant director of nursing (ADON), was interviewed on 11/15/18 at 2:38 p.m. The ADON said the staff should change gloves every time their gloves are visibly soiled or contaminated. The ADON said gloves are contaminated when they touch multiple surfaces. c. Record review The infection control nurse provided standard precaution guidelines from her infection prevention and control manual on 11/15/18 at approximately 4:30 p.m. The infection control nurse said the provided precaution guidelines were applicable for nursing and kitchen practices. The guidelines applied to hand hygiene and appropriate use of gloves. According to the guidelines in pertinent part; Standard precautions represent the infection prevention measures that apply to all resident care. These evidence-based practices are designed to protect health care staff and residents by preventing the spread of infections .ensuring staff do not carry infectious pathogens on their hands or via equipment. II. Ice machine sanitary condition A. Professional reference The Food and Drug Administration (2017) Food Code, https://www.fda.gov/downloads/food/guidanceregulation/retailfoodprotection/foodcode/ucm 0.pdf. Read in pertinent part; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. -Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. -In equipment such as ice makers, (a) a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. -In a clean, protected location, an ice scoop shall be maintained in a state of repair or condition. According to www.foodsafetysite.com, read in part: The food code requires that items must be allowed to air dry before being stacked or stored . Stacking wet items prevents drying and might allow an environment where microorganisms can grow. B. Manufacturer recommendations Hoshizaki America Inc. Instruction Manuel for KM-151 BAH, last revised on 9/30/13, retrieved from: http://www.hoshizaki.com/docs/manuals/http://www.hoshizaki.com/docs/manuals/KM-61_101_151B_H_serv_LTR.pdf. Read in pertinent part; -A plastic mesh air filter removes dirt or dust from the air and keeps the condenser from getting clogged. As the filter gets clogged, the icemaker's performance will be reduced. Check the filter at least twice a month. -Keep the scoop clean. Clean by using a neutral cleaner and rinse thoroughly. Scotsman Ice Systems Installation and User ' s Manual issued (MONTH) 2014, for Modular Cuber [MEDICATION NAME] Plus D Series Models C0322-C1030, pages nine through 20, retrieved from: https://www.scotsman-ice.com/service/User%20Manuals/ 501.pdf. Read in pertinent part; -Caution: Do not place anything on top of the ice machine, including the ice scoop. Debris and moisture from objects on top of the machine can work their way into the cabinet and cause serious damage. -Potential for airborne contamination installing an ice machine near a source of yeast or similar material can result in the need for more frequent sanitation cleanings due to the tendency of these materials to contaminate the machine. -Clean air filters when they become visibly dirty. They will need cleaning more often than the other items. C. Observations The main kitchen ice machine was observed on 11/12/18 at 8:00 a.m. The ice machine was located on the side wall directly across the food serving steam table. On the front surface of the ice machine was a vent. Inside the vent was a removable filter. The filter was covered with a thick, dark coating of dust and debris. The ice machine in the nourishment room on the first floor, was observed on 11/14/18 at 10:30 a.m. The top of the machine was covered with a layer of dust. The removable filter was coated in thick, dark dust across the entire surface. A clear plastic scoop in a metal scoop holder laid horizontally on top of the ice machine. The scoop laid flat in the metal holder. There was visible water in and under the scoop. The horizontal ice scoop holder did not allow water to drain. The clear scoop in the metal holder was the only scoop available for use. The metal holder was adhered to the top of the ice machine. Exposed adhesive striping was on the left side of the ice machine. Medical tape covered the seals on the top left corner and down the side of the machine. The tape had dark brown saturated marks on the surface. An unidentifiable yellow crusty substance, the size of a thumb print, was on the side of the machine directly below the medical tape. The ice machine in the nourishment room on the second floor, was observed on 11/14/18 at 10:40 a.m. The removable filter contained a layer of dust. The top of the ice machine was covered with dust. There were two ice trays set on top of the machine. The trays were covered with dust. A metal ice scoop holder was vertically attached to the left side of the ice machine. The scoop was clean and dry. The first floor nourishment room was observed on 11/14/18 at 1:50 p.m. The ice machine lid was open. A dietary aide was observed restocking nourishment room with resident snacks. The DA left the room at 2:01 p.m. The ice machine lid remained open. -At 2:04 p.m. a certified nurse aide (CNA) enter the nourishment room. She pulled the ice scoop from the dusty and wet holder and put ice into a cup. She closed the lid of the machine and left the room. D. Staff interviews The dietary manager (DM) was interviewed on 11/14/18 at 3:25 p.m. The DM said the facility had five ice machines. She said there was an ice machine in the main kitchen, one machine for each of the two dining rooms and ice machine in the first and second floor nourishment room. She said she was not sure why there was soiled medical tape glued on the corner seams on the ice machine in the first floor nourishment room. She said the maintenance director was responsible for ice machine service maintenance, cleaning and replacement of filters. The DM said all staff were responsible for keeping the ice machine lid closed after each use. She said failure to do so could containment the ice. The director of maintenance (DOM) was interviewed on 11/15/18 at 8:57 a.m. The DOM said the filters were last changed on 9/11/18 during his quarterly maintenance routine. He said he has vendor do a complete flushing and preventative maintenance every six months. -At 9:01 a.m. the DOM observed the ice machine in the first floor nourishment room. The DOM said the lid to the machine is broke and needed new clips. He said the machine is old and he no longer could order the parts. A new ice machine will be ordered once it was approved by the company distribution center. According to the DOM, the medical tape on the seams was a temporary solution to secure the lid. The DOM said the lid needed to remain secure and shut for proper ice machine performance and to prevent foreign matter from getting in to the ice. The DOM said the medical tape should not be soiled. The DOM said the filters had been cleaned quarterly. The filters are soaked in a descaler and then put in the dishwasher. He said that the nourishment ice machine filters should be changed once a month. The DOM said he spoke to the DM and she would clean the kitchen filters once a week. He said the kitchen ice machine filter is subjected to grease which attracted a lot of dust. The DOM said the scoop holder used to be attached vertically to the side of the machine, however it had been removed during the cabinet installation six months ago. The DOM said he never thought about the potential of dust and moisture collecting on and under the surface of the scoop and the holder, not allowing air flow and drainage horizontally placed. The housekeeping director (HKD) was interviewed on 11/15/18 at 1:35 p.m. She said her staff is responsible for cleaning the nourishment room. HKD said her staff should wipe down the surface of the ice machine daily. The HKD said they do not clean the scoops or the scoop holder. The housekeeping aide (HK)was interviewed on 11/15/18 at 1:45 p.m. The HK said she clean the outside of the ice machine with a stainless steel polish. She said she does not clean the ice scoop or the holder. She said she wipes the top surface of the ice machine, around the adhered holder. She said she does not use a sanitizer on any part of the ice machine, including the lid handle. She said she sometimes, had to close the lid when it was left open because residents have scooped their own ice out of the machine. The infection control nurse (ADON), was interviewed on 11/15/18 at 2:38 p.m. The ADON observed the ice machine and the ice scoop in the ice scoop holder. The ADON picked up the scoop. The scoop was slightly stuck to the surface of the holder from moisture. The ADON said a bacteria could grow in the holder. She said the scoop should be in an environment to be able to thoroughly dry. She said the holder should be cleaned and disinfected on a daily basis. E. Record review and facility follow up A quarterly maintenance schedule, an invoice of preventive maintenance for the two different types of machines serviced by a certified restaurant equipment repair vendor, a Scotsman preventive maintenance service aid and a memo from the nursing home administrator (NHA) was provided by the DOM on 11/15/18 at 11:21 p.m. According to the maintenance schedule, the last quarterly cleaning was completed on 9/11/18. The equipment vendor provided preventive maintenance on 8/7/18. The Scotsman preventive maintenance service aid read air filters needed to be changed every six months or more frequently as needed. The NHA memo dated 11/9/18, read a new ice machine was needed for the nourishment room. The dietary aide weekly cleaning list schedule was provided by the DM on 11/15/18 at 2:04 p.m. The list included what area and equipment was cleaned, who was responsible for the cleaning, cleaning due dates and cleaning guidance. The cleaning list revealed weekly cleaning of the nourishment rooms and the ice machines. According to the list, the nourishment room microwave and refrigerators were cleaned on a weekly basis. The nourishment guidance and the area to be cleaned, did not include the ice machine or the ice scoop holder. The kitchen and dining room ice machines were also cleaned on a weekly basis. The nourishment ice machines were not included in the weekly list. A responsibility check off list for daily evening side work and duties was also provided by the DM. The list revealed the ice scoops and holders should be washed through the dishwasher in the evenings. The list did not indicate if the nourishment room scoops and holders were included.