Every finding on record at Clear Creek Care Center

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen, dining room, dry storage room, nutrition rooms and dishroom. Specifically, the facility failed to ensure:-Food was held at a safe temperature;-The kitchen was maintained, in good repair to be able to have a cleanable surface; -Food was labeled with an expiration date and removed when expired; and-Ensure the dishwasher was working effectively. Findings include: I. Failure to hold food at the correct temperatureA. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 7/22/26. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower. (Chapter 3)B. Facility policy and procedureThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, dated January 2024, was received from regional clinical resource #1 on 7/22/26 at 6:42 p.m. It read in pertinent part, Store, prepare, distribute, and serve food under sanitary conditions: Food safety requirements. The facility must: Procure food from sources approved or considered satisfactory by federal, state or local authorities. Foods are prepared with minimal handling at room temperature. Cold foods are kept between 34 to 41 degrees before serving and frozen foods are kept at 0 degrees or below.C. ObservationsDuring a continuous observations on 7/20/26, beginning at 4:00 p.m. and ending at 5:49 p.m. the following was observed during meal service in the kitchen:The temperatures were taken after the last person was served at 5:40 p.m. There was an area where the dining staff prepared special orders. There were several containers with food in them that were sitting on ice. The ice did not surround the containers that had the food in it. The ice was below the food level. The containers had shredded cheeses, sliced cheese, sliced tomatoes and lettuce. The following temperatures were out of the range:-The cheese was 47 degrees F-The lettuce was 63.6 degrees F-The sliced tomatoes were 44 degrees F-The sliced onions were 44 degrees F-The pickles were 46.2 degrees FD. Staff interviewsThe dietary manager (DM) and the registered dietitian consultant were interviewed on 7/20/26 at 5:40 p.m. The DM said cold foods needed to be held at 41 degrees F and below. The registered dietitian consultant told the cook to use a different container, so he could put more ice to encase the food containers. She said this would help keep the food at the correct temperature. II. Failed to ensure the kitchen was maintained, in good repair to be able to have a cleanable surface. A. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 7/22/26. It revealed in pertinent part, Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4, 5 and 6) Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. (4-501.12)B. Facility policy and procedureThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, dated January 2024, was received from regional clinical resource #1 on 7/22/26 at 6:42 p.m. It read in pertinent part, Foods are stored under cleanable conditions. This includes all areas in the facility. A regular cleaning schedule is maintained and initiated when used. Food service management checks the schedule regularly.C. Observations During the initial kitchen tour on 7/16/26 at 8:40 a.m. the following observations were made:-In the dish washing room there was a dirty wet blanket under the dishwasher machine. There was an open area under the dish washing station that had a piece of wood lying on the floor. The wood was soiled with stains and unknown residue. -The ceiling over a preparation table in the middle of the kitchen and a dish sink had yellow splatter over areas of non painted ceiling. There were approximately two missing tiles under the food preparation sink. There was brown debris caked on the floor under sinks. -The flour and sugar bin container handles felt greasy to the touch and had dark residue on the handles.-The can opener had a dirty blade and insertion site. The base where it was attached to the preparation table had black residue.-The dry storage area in the basement had one open glue trap for mice and insect control. The shelves and floors throughout the dry storage had dust settled on the surfaces. On 7/20/26 at 4:10 p.m. the following was observed in the main kitchen: -The can opener at the base where it attaches to a prep table was noted to still have black residue.-There was a green cutting board on the preparation table ready to be used. The curing board had visible scores on it and the center was no longer green. The bottom left corner of the cutting board was also warped and curved upwards. On 7/20/26 at 6:50 p.m. A kitchen tour was conducted with the DM, the registered dietitian consultant and the nursing home administrator (NHA). The following observations were reviewed: -The greasy handles for the flour and sugar bins -The food debris splatter on the ceiling and lack of painted surfaces on the ceiling in several locations within the kitchen.-The open mouse trap in the dry food storage in the basement.-The base of the can opener attached to the preparation table still had black debris.-There were five other cutting boards stored on a shelf with multiple visible scores on them.During the observation, the NHA removed the trap and said she would talk to the pest control provider regarding acceptable traps within the facility.D. Staff interviewsThe DM was interviewed on 7/20/26 at 4:10 p.m. She said the can opener was washed daily in the dishwasher and the base was removed from the preparation table every two weeks but needed to be unscrewed to be cleaned. She said she needed maintenance to assist with this because it was screwed onto the preparation preparation table. The DM said the green cutting board that was wrapped had been thrown out.The DM did not know what the wood structure under the dish rack was for. The registered dietitian consultant did not know what the wood construction under the dish rack was for. III. Failed to ensure food was labeled with expiration date and removed when expiredA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 6/9/26, read in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location and, where it is not exposed to splash, dust, or other contamination. (3-305.11) Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food. (3-302.12) Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. (3-501.17) A food specified in 3-501.17(A) or (B) shall be discarded if it exceeds the temperature and time combination specified, is in a container or package that does not bear a date or day, or is inappropriately marked with a date or day that exceeds the temperature and time combination. (3-501.18)B. Observations During the initial walkthrough on 7/16/26 at approximately 9:00 a.m. the facility nutrition rooms were observed to have eight strawberry health shakes with 7/15 written on them. Observations of the nutrition rooms with the DM on 7/20/26 at approximately 6:50 p.m. the DM was observed to throw out eight strawberry health drink cartons with the 7/15 date on them.C. Staff interviewsThe DM was interviewed on 7/20/26 at 6:50 p.m. The DM said there were eight strawberry health shakes found in the refrigerator that were dated 7/15. The DM said the dates on the health shakes was the date they needed to be removed from circulation. The DM said when the health shakes were pulled from the freezer they count 14 days and mark the carton with that date. She said the dietary staff should be going through the refrigerators every other day to check for dates and spoiled foods. The DM said she removed the eight cartons of the expired health shakes and threw them into the trash. -The health shakes were four days past the 14 day recommendations. IV. Ensure the dishwasher is working effectivelyA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised March 2024, retrieved on 7/22/26, read in pertinent part,A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. (4-302.14)A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified in accordance with the EPA- registered label use instructions A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart: The concentration range minimum temperature chart indicated if the MG/L was 25 to 49 and the PH (potential of hydrogen) was 10 or less or the PH was eight or less the temperature of the water needed to be 120 degree F. If the MG/L was 50 to 99 and the PH was 10 or less or eight or less the water needed to be 100 degree F. If the MG/L was 100 and the PH was 10 or less or eight or less the water needed to be 55 degree F. The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 degrees F. (4-501.114)B. Observations and interviewsOn 7/20/26 at approximately 6:10 p.m. after the dinner service the dishwashing machine was reviewed with the DM, the registered dietitian consultant and the NHA. The registered dietitian consultant said the dishwashing machine was a low temperature and chemical sanitization machine and needed to meet the following temperatures of 120 degrees fahrenheit and 50 parts per million (PPM). The registered dietician consultant tested the dish machine and the test strip indicated 10 PPM. -The dishwasher PPM was tested and measured at 10 PPM, 40 PPM below the recommendation. The registered dietitian consultant tested the dish machine four more times and the same results occurred. The machine did not meet the 50 PPM of the chlorine for sanitizations. The registered dietitian consultant told the DM they needed to get the sink compartment ready for sanitizing the dishes as the dishwasher was not working appropriately. The dish machine had a plastic spatula pushed into the dish machine and was taped with blue painters tape to hold it in place. The machine had a large black container under the area of the dishwasher machine that had the spatula inserted as the machine was leaking. The DM said the staff had put the spatulas in place and had noticed it decreased the amount of leaking the machine was having. C. Record reviewThe DM provided the July 2026 (7/1/26 to 7/20/26) dish machine sanitization concentration log on 7/20/26 at 7:10 p.m. The log revealed instructions on the process for chlorine sanitization, including the level of chlorine should be 50 PPM at a minimum and if the minimum was not met the DM or the dietitian needed to be contacted. The dish machine sanitizer concentration documented the following:-The morning PPM was out of range 14 times at 45 PPM;-The afternoon PPM was out of range 12 times at 45 PPM and one of 10 PPM; and,-The evening PPM had 45 PPM documents twice. The log also revealed that on 7/4/26 the machine was not working for the morning and afternoon PPM readings and the evening PPM was 45 PPM.The log also had missing documentation on 7/2/26, 7/5/26, 7/7/26, 7/9/26, 7/12/26, 7/16/26 and 7/19/26.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two of two units.Specifically, the facility failed to:-Ensure resident rooms were cleaned in a hygienic manner; and,-Ensure staff wore appropriate personal protective equipment (PPE) when providing care to residents who were on enhanced barrier precautions (EBP). Findings include: I. Failure to ensure cleaning of resident rooms in a hygienic manner. A. Professional references According to the United States Environmental Protection Agency, dated 5/3/21, retrieved on 7/23/26 from https://www3.epa.gov/pesticides/chem_search/ppls/070627-00074-20210503.pdf The Oxivir 1 product label revealed, One Minute bactericidal, virucidal, and fungicidal A disinfectant and cleaner (that cleans, disinfects and deodorizes in one labor saving step) when used according to disinfection directions for use. According to the Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, revised July 2021, retrieved on 7/23/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) retrieved on 7/23//26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It revealed in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. B. Facility policy and procedure The Cleaning and Disinfecting Resident's Rooms policy and procedure, revised August 2013, was provided by the clinical resource #1 on 7/21/26 at 5:34 p.m. It documented in pertinent part, The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled. Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products including: recommended use-dilution; material compatibility; storage; shelf-life; and safe use and disposal. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solutions frequently. The environmental services director and administrator, in conjunction with the infection preventionist, will select appropriate facility disinfectants. Steps In the Procedure: Resident Room Cleaning -Prepare disinfectant according to manufacturer's recommendations. -Change mop solution water at least every three rooms, or as necessary. -Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. -Clean personal use items (lights, phones, call bells, bed rails, etc.) with disinfectant solution at least twice weekly. -When cleaning rooms of residents on isolation precautions, use personal protective equipment as indicated. B. Observations On 7/16/26 at 1:50 p.m. HK#1 was cleaning resident room [ROOM NUMBER] a double occupancy room. HK #1 applied gloves, entered the resident room and went to the sink counter with a wet rag from her cleaning cart. She began wiping down the sink bowl rim then the bowl then wiped the rim of the sink again. She then splashed water in the sink bowl and onto the mirror. HK #1 then took a dry paper towel to the mirror. Using the same rang she cleared the sink bowl with she then wiped down the mirror anchors that held the mirror on to the wall. -HK #1 failed to clean the sink from the cleanest to dirtiest areas. HK #1 failed to use a clean rag on areas outside of the sink bowl. HK #1 returned to her housekeeping cart and collected a spray bottle labeled Oxivir and a container labeled cottage cheese with a toilet bowl brush in it. HK #1 entered the bathroom, placed the container with the toilet bowl brush on the floor and then began to spray the toilet riser bowl with Oxivir. HK #1 then wiped areas down with a rag immediately after spraying them. -HK #1 failed to adhere to the one minute dwell time for Oxivir. HK# 1 then scrubbed the toilet bowl with the brush, also scrubbing the inside of the riser shoot. She wiped the rim of the riser and then pulled the riser off the toilet. Using the same rag to wipe the rim of the outer toilet she then wiped the toilet seat. She then wiped the rim again off the toilet. Went to the cart, placed the dirty rag into a bag containing dirty rags, removed her gloves, performed hand hygiene with alcohol based hand rub and then applied new gloves. -HK #1 failed to clean the toilet from the cleanest area to the dirtiest area. HK #1 began collecting trash from the room from the sink then bed B and lastly bed A. HK #1 noticed a urinal hanging on the trash can rim for bed A. She then took the urinal with yellow urine to the bathroom where she then dumped the urine in the toilet. HK #1 then flush the toilet and then dipped the urinal into the toilet water and swished it around and dumped it back in the toilet. HK #1 then returned the urinal to hang on the trash can on bed A. -HK #1 contaminated the urinal by washing it out with toilet water. HK #1 then went to her cart, collected the broom and began sweeping the room starting on the bed B side then to bed A and lastly to the door. As HK #1 swept the residents room while sweeping she touched personal items. -HK#1 failed to change her gloves after touching and rinsing the urinal. SHe touched resident personal items with soiled gloves. HK #1 then collected three mop pads from the clean section of her cart and added them to the mop bucket. HK #1 then reached into the bucket to retrieve the mop pads one at a time, ringing them out and tossing them at the entrance of the room on the floor. HK #1 used one mop pad for the bathroom, a second mop pad was used for bed B side of the room and the third mop pad was for bed A and the entryway to the room. HK #1 failed to change her gloves after touching the urinal and contaminated her mop bucket solution with soiled gloves. HK #1 placed all the dirty mop pads into the soiled bag on her cart. HK #1 removed her gloves and stated the room was done. -HK #1 failed to clean the high touch area in the room for both residents in room [ROOM NUMBER] such as door knobs, drawer handles, cal lights, remotes, bed controls, and light switches. III. Staff interviews HK #1 was interviewed on 7/17/26 at 2:38 p.m. HK #1 said she was assigned to clean rooms daily on two wings in the building. HK #1 said she needed to change her gloves after cleaning the sink and the bathroom. She said she did not need to change her gloves between resident bed A and bed B sides of the room. HK #1 said she wiped everything down with the wet rag from her cart. She said the chemical she used was Comet Disinfectant Cleaner with Bleach. HK #1 said the Comet was in her mop bucket, rag bucket and in her toilet bowl brush container. HK #1 said she did not know if the Comet had a dwell time. HK #1 said she filled the containers with water and added the chemical directly to the containers by eyeballing how much chemical she thought it needed. HK #1 said she changed the mop bucket solution between each wing. HK #1 said she was unsure what high touch areas were. HK #1 said the call lights, bed control, bedside tables were done only during deep cleanings of the resident's room per the schedule. She said the deep cleaning schedule was one room every Thursday. HK #1 said it was important to clean the residents' rooms daily to prevent smells, pests from evading resident rooms and so the resident room was clean. HK #1 said she normally did not touch resident urinals as it was not her job, but she did today because the urinal was almost full and was afraid it would spill. She said if she had not emptied it most likely she would be called back later in the day to clean up a spill. HK #1 said she had not been trained on how to clean the urinal. HK #2 was interviewed on 7/20/26 at 11:35 a.m. HK #2 said she had worked in housekeeping less than a month and had some training with the housekeeping manager when she started this position, and she has not had training yet with the new environmental service manager. She said she mixed her cleaning solution with water and a little Clorox bleach, and she changed the cleaning solution in the mop bucket when it got dirty and about after finishing every hall. The infection preventionist (IP) was interviewed on 7/21/26 at 11:00 a.m. The IP said she had involvement with housekeeping staff training, and talking them through the cleaning process, and completed quarterly room cleaning observations. She said she was not sure what solutions are used for housekeeping and disinfecting. The IP said only the certified nurse aides (CNA) or nurses should empty urinals and then bag the urinal for cleaning or replacement with a new urinal. The IP said the housekeeping staff should not empty urinals and should not clean a urinal in the toilet. The maintenance director and regional clinical resource #1 were interviewed together on 7/21/26 at 1:48 p.m. The maintenance director said cleaning solutions used by housekeeping staff should be measured according to the manufacturer guidelines for safety, and to provide for sanitary cleaning. The maintenance director said the Spic and Span automated dispensing unit in the janitor closet should be used for floor cleaning. He said Clorox and water would not be a solution he recommended for the cleaning of floors or rooms. The maintenance director said the housekeeping staff should use proper hand hygiene and glove changes when moving from clean to dirty areas to prevent the spread of illness. The maintenance director said high touch areas like door handles, light switches, sink cabinet handles, dresser handles, counter tops, and faucet handles should be cleaned every day because they are touched the most throughout the day. The maintenance director said housekeeping staff should clean areas from top to bottom, clean to dirty areas, as a best practice to avoid the spreading of germs. II. Failure to follow EBP A. Professional reference The Centers for Disease Control and Prevention (CDC), Frequently Asked Questions About Enhanced Barrier Precautions in Nursing Homes (revised 6/28/24) was retrieved on 7/23/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html. It revealed in pertinent part, Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). B. Facility policy and procedure The EBP policy and procedure, dated 9/11/15, was received from the regional clinical resource on 7/21/26 at 5:34 p.m. It documented in pertinent part, Initiate EBP for residents with wounds or indwelling medical devices, regardless of MDRO status. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing high-contact resident care activity (as opposed to before entering the room). Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator); and any wound requiring a dressing. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk, the wound is resolved, or the indwelling medical device that poses an increased risk is discontinued, as they can still serve as a source of transmission even after the infection has resolved. Staff to gown and glove up prior to providing direct care. The gown and gloves used for each resident during high-contact resident care activities should be removed and discarded after each resident care encounter. C. Observations On 7/20/26 at 4:00 p.m. Resident #7 was lying on his side in bed, with his left heel exposed for the dressing change. There was an EBP precaution sign on the resident's door and on the wall above the resident's bed. The wound care nurse entered the resident's room with dressing change supplies. She performed hand hygiene and put on gloves prior to providing wound care. -The wound care nurse failed to put on a gown prior to providing wound care to Resident #7 who was on EBP. D. Staff interviews The wound care nurse was interviewed on 7/21/26 at 4:00 p.m. The wound care nurse said she knew she forgot to put on a gown before Resident #7's dressing change. The wound care nurse said Resident #7 was on EBP. She said it was important to wear a gown and gloves with the dressing change to prevent the transmission of infection between residents. The IP was interviewed on 7/21/26 at 11:00 a.m. The IP said staff should follow EBP guidelines. She said the staff needed to wear a gown and gloves when completing midline catheter care and dressing changes e. She said wearing PPE was important to prevent the transmission of MDRO infections, and cross contamination. E. Additional observations During a continuous observation on 7/16/26, beginning at 12:16 p.m. and ending at 12:30 p.m., licensed practical nurse (LPN) #2 was observed administering medications to residents. LPN #2 gathered supplies, completed hand hygiene and donned (put on) clean gloves. LPN #1 mixed the IV antibiotic medication and primed the IV tubing (let the medication flush through the tubing). LPN #2 cleaned Resident #64's midline IV with an alcohol wipe. LPN #2 flushed the midline with IV heparin (blood thinning medication), followed by IV normal saline and hooked up the IV antibiotic to Resident t#64's midline. LPN #2 removed her gloves and washed her hands. LPN #2 said she would be back when the antibiotic was completed. -LPN #2 did not wear a gown when caring for Resident #64's midline. During a continuous observation on 7/16/26, beginning at 1:28 p.m. and ending at 1:35 p.m., LPN walked into Resident #64's room to check on the medication. LPN #2 completed hand hygiene and donned clean gloves. LPN #2 unhooked the IV tubing from Resident #64's midline. LPN #2 flushed the midline with IV heparin followed by IV normal saline. LPN #2 disposed of the used medications. LPN #2 removed her gloves and washed her hands. -LPN #2 did not wear a gown when caring for Resident #64's midline. F. Additional staff interviews LPN #2 was interviewed on 7/16/26 at 3:46 p.m. She said the purpose of EBP is to prevent the spread of infections. She said any resident with clostridium difficile (infectious diarrhea) or a respiratory disease should be on EBP. She said residents with central lines or midlines do not require any additional personal protective equipment for staff when caring for them. The DON, the NHA and regional clinical resource #1 were interviewed on 7/21/26 at 10:18 a.m. The DON said residents with pressure or surgical wounds or any indwelling medical device including central lines, midlines, foley catheters and gastrostomy tubes were placed on EBP. The DON said a gown and gloves were required for these residents when staff was performing any direct contact care or device care with the resident. The DON said the purpose of EBP was to prevent the transmission of bugs from resident to resident. The DON said the nurses should be wearing a gown and gloves when administering medication through a midline. The DON said education was provided to nursing staff on 7/20/26 (during the survey).

Based on observations, record review and interviews, the facility failed to follow physician orders and appropriately administer medication for one (#64) of one resident out of 35 total sample residents. Specifically, the facility failed to follow the Resident #64's physician's order for the correct order of administering heparin (anticoagulant), saline flush and intravenous (IV) antibiotics.Findings include: I. Facility policy and procedure The Central Venous Catheter Flushing and Locking policy, revised March 2022, was received by regional clinical resource #1 on 7/21/26 at 6:42 p.m. It documented in pertinent part, The purposes of this procedure are to maintain patency of central venous catheters (CVADS); to prevent mixing of incompatible medications and solutions; and to ensure the entire dose of solution or medication is administered into the venous system. Perform hand antisepsis. [NAME] non-sterile gloves. Disinfect needleless access device with alcohol wipe. Attach prefilled saline syringe to needleless access device. Unclamp catheter or lumen. Aspirate slowly for blood return to ensure patency of catheter. Flush with 0.9% sodium chloride using the push-pause technique. Disconnect syringe from needleless access device. Attach a syringe with locking solution and lock with saline or heparin, as ordered. Repeat the process on each lumen of a multi-lumen catheter.II. Professional referenceAccording to [NAME], Godelieve [NAME]. (2015) Flushing and Locking of Venous Catheters: Available Evidence and Evidence Deficit, Nursing Research and Practice. Retrieved on 7/23/26 from https://doi.org/10.1155/2015/985686, Flushing the catheter is the most important factor in preventing malfunction by maintaining catheter patency. The fact that fibrin and other deposits are impeded in attaching to the intraluminal catheter wall is paramount. Therefore a major recommendation is to flush before and after administration of medication, also known as the SAS acronym. The order of IV injections is as follows: a normal saline flush (S), followed by the administration (A) of drugs or fluids, followed by a normal saline flush (S). If the procedure ends with a heparin (H) lock the acronym is SASH.III. Resident #64A. Resident status Resident #64, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (chronic disease process of the airway), bipolar disorder, and chronic sinusitis (inflammation of the nasal passages and sinuses). The 3/31/26 minimum data set (MDS) assessment revealed Resident 64 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #64 was independent with mobility and required supervision with dressing and toileting. B. Observations During a continuous observation on 7/16/26, beginning at 12:16 p.m. and ending at 12:30 p.m., licensed practical nurse (LPN) #2 was administering medications to Resident #64. LPN #2 gathered supplies, completed hand hygiene and donned (put on) clean gloves. LPN #1 mixed the IV antibiotic medication and primed the IV tubing (let the medication flush through the tubing). LPN #2 cleaned Resident #64's midline IV with an alcohol wipe. LPN #2 flushed the midline with 5 milliliters (ml) of IV heparin (blood thinning medication), followed by 10 ml of IV 0.9% normal saline and hooked up the IV antibiotic to Resident #64's midline. LPN #2 removed her gloves and washed her hands. LPN #2 said she would be back when the antibiotic was completed. -LPN #2 gave an additional dose of IV heparin During a continuous observation, beginning at 1:28 p.m. and ending at 1:35 p.m. LPN #2 walked into Resident #64's room to check on the medication. LPN #2 completed hand hygiene and donned clean gloves. LPN #2 unhooked the IV tubing from Resident #64's midline. LPN #2 flushed the midline with 5 ml IV heparin followed by 10 ml 0.9% IV normal saline. LPN #2 disposed of the used medications. LPN #2 removed her gloves and washed her hands.-LPN #2 gave IV heparin before the normal saline flush instead of after the normal saline flushC. Record reviewA review of Resident #64's CPO revealed the following orders: -SASH flush the midline with 10 ml before the administration of the antibiotic, then flush with 10 ml of normal saline after the antibiotic and then 5 ml of heparin flush. Every eight hours for SASH for seven days, ordered on 7/15/26. D. Staff interviews LPN #2 was interviewed on 7/16/26 at 1:28 p.m. She said the purpose of IV heparin was to break up any blood clots in the midline before administering the antibiotic, so the IV medication flowed through it without getting stuck. She said whoever entered the order for the heparin and saline flush entered it wrong and she was going to clarify with the director of nursing (DON). -However, the heparin flush should have been administered last (see DON and pharmacy consultant interview below).The director of nursing (DON), the nursing home administrator (NHA) and regional clinical resource #1 were interviewed on 7/21/26 at 10:18 a.m. The DON said Resident #64 had a physician's order to utilize the SASH method for her IV medications. The DON said the order of this was to administer the saline flush, antibiotic medication, saline flush and the heparin flush. The DON said the importance of administering the heparin flush last was to keep the midline free of blood clots. The pharmacy consultant was interviewed on 7/21/26 at 3:00 p.m. She said that if the SASH method was ordered by the provider, the order was to administer IV saline flush, the IV medication, an IV saline flush and the IV heparin flush.

Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#8) of five residents reviewed for unnecessary medications out of 35 sample residents.Specifically, the facility failed to ensure Resident #8 was provided with the risks and benefits and provided consent prior to the administration of psychotropic medications.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/26 to 7/21/26, resulting in the deficiency being cited as past noncompliance with a correction date of 5/11/26.II. Facility plan of correctionOn 7/22/26 at 3:13 p.m. the nursing home administrator (NHA) provided documentation indicating in May 2026 the facility identified informed consents that were missing or incomplete for residents receiving psychotropic medications. The facility initiated a whole house audit in May 2026 of all residents receiving psychotropic medications. The audit included review of psychotropic medication orders, diagnoses, authorized decision makers, existing informed consent documentation, medication initiation dates, dosage changes, and medication increases. The facility states compliance was achieved on 5/11/26. Based on their completion of the audit and any identified missing informed consents had been obtained.The facility also reviewed their medication management process to ensure informed consent was obtained and documented prior to new medication initiation, changes in existing medications. III. Facility policy and procedureThe Psychopharmacological policy, dated 3/10/23, was received from regional clinical resource #1 on 7/21/26 at 6:42 p.m. it revealed in pertinent part, The facility supports the appropriate use of psychopharmacological drugs that are therapeutic for residents suffering from mental illness. The licensed nurse will complete the psychotropic informed consent with the resident or responsible party. This will be completed at admission or as needed.II. Resident #8A. Resident statusResident #8, age greater than 65, was admitted to the facility on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included bipolar disorder (mental health conditions with extreme shifts in mood and energy) with episodes of manic with severe psychotic features, anxiety (emotions of tension, worried thoughts), post-traumatic stress disorder mental health condition triggered by a terrifying event), and type 2 diabetes. The 5/21/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The assessment revealed the resident had little interest in doing things, was feeling down and depressed or hopeless, trouble concentrating, and moving or speaking slowly. There were no rejections of care documented. B. Record reviewReview of Resident #8's July 2026 CPO revealed the following physician's orders:Abilify (antipsychotic medication) 5 milligram (mg) tablet for bipolar disorder, ordered on 3/3/26.Buspirone (antianxiety) 5 mg by mouth three times a day for anxiety, ordered on 2/24/26. Review of Resident #8's electronic medical record (EMR) revealed the resident signed an informed consent for Buspirone and Abilify on 5/11/26.-However, the Buspirone had been administered to Resident #8 for 75 days prior to informed consent being obtained from the resident and the Abilify had been administered to Resident #8 for 69 days prior to informed consent being obtained. The antipsychotic medication for bipolar disorder care plan, revised on 6/8/26, revealed Resident #8 was at risk from drug related complications. Pertinent interventions included administering medications as ordered by physician for effectiveness and side effects; monitoring behaviors like agitation and irritability by offering redirection, activities, low stimulating environment, toileting, snacks, offer fluids and assessing for pain; conducting medication reductions as indicated; and consulting with the pharmacists and physicians quarterly.The antianxiety medication care plan, revised 6/8/26, revealed Resident #8 received an antianxiety medication. Pertinent interventions included administering medications as ordered; monitoring for effectiveness and side effects; educating the resident/family/caregiver about risk, benefits and side effects and/or toxic symptoms of Buspirone; monitoring the resident for safety due to increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looked like dementia and increased risk of falls, broken hips and legs and offering the resident non-pharmacological interventions, such as cold, relaxation breathing exercises, massage repositioning, aromatherapy, and therapeutic touch. An email from the director of nursing (DON) was received on 7/21/26 at 5:02 p.m. The email documented that during her audit in May 2026, it was identified that informed consents were missing from Resident #8's chart. The DON said at that time, she spoke with Resident #8 and obtained her consent for Buspirone and Abilify. IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 7/21/26 at 9:50 a.m. LPN #3 said residents had the right to know what medications they were being administered. LPN #3 said psychotropic medications required a consent signed by the resident or the resident's responsible party to ensure they were aware of the black box warnings. The DON was interviewed on 7/21/26 at 6:00 p.m. The DON said informed consent should be obtained prior to the start of a psychotropic medication. The DON said informed consents were important to ensure residents were aware of the black box warnings and side effects of medications. The DON said the facility held monthly psychological pharmacology meetings where residents and psychotropic medications were discussed and they ensured things, such as the informed consent, were in place. The DON said she was not sure how Resident #8's consents were missed, but during her monthly audit in May 2026, she discovered they were not present and corrected the issue at that time.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#10) of four residents reviewed for accidents out of seven sample residents.Resident #10 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #10 was determined to be a high fall risk. On 8/30/25 Resident #10 sustained an unwitnessed fall. The facility updated the resident's care plan to indicate he needed a one-to-one caregiver. However, on 9/3/25 Resident #10 sustained an unwitnessed fall when he was found on the floor in his room with a laceration to his head. Resident #10 was transported to the hospital for further evaluation. Resident #10 sustained a three to four millimeter left tentorial subdural hematoma (brain bleed) and posterior left tenth and eleventh rib fractures. The facility failed to ensure the person-centered interventions were consistently in place. After the fall on 9/325, it was implemented that the one-to-one caregiver needed to be within an arms length of the resident. Observations revealed the facility failed to consistently implement the one-to-one fall interventions on the resident's care plan by leaving the resident unattended, where he rolled out of bed onto his knees. Specifically, the facility failed to ensure fall interventions were consistently implemented for Resident #10. Findings include:I. Facility policy and procedureThe Accident and Supervision policy, implemented 2/29/24, was provided by the nursing home administrator (NHA) on 10/20/25 at 3:50 p.m. It read in pertinent part,The purpose this fall management policy was to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program. Risk factors that were internal to the resident include the resident's physical health and functional status. External risk factors include medication side effects, the use of appliances, and environmental conditions Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. A baseline plan of care will be initiated for residents determined to be at risk.A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), the diagnoses included dementia, repeated falls, muscle weakness, cognitive communication deficit and a history of falls prior to admission. The 9/5/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of two out of 15. He required touch assistance with bathing and substantial/maximal assistance with bed to chair transfers, toileting transfers and sit to stand. The MDS indicated Resident #10 had a recent fall at the facility. B. ObservationsDuring a continuous observation on 10/20/25, beginning at 11:30 p.m. and ending at 2:30 p.m., the following was observed:At 12:10 p.m. certified nurse aide (CNA) #1 was at the nurses' station and was overheard telling an unidentified staff member that she was assigned as the one-to-one caregiver for Resident #10.At 12:45 p.m. Resident #10 was lying in his bed on his back. He sat up and rolled over onto his knees on his floor mat and looked under his bed. There were no staff in his room at this time. There was not a pressure sensitive bed alarm in place. At 12:58 p.m. CNA #1 returned to Resident #10's room. At 1:02 p.m. CNA #1 assisted Resident #10 out of bed and assisted him down the hall in his wheelchair. At 1:10 p.m. CNA #1 returned to the unit while assisting Resident #10 in his wheelchair. CNA #1 positioned Resident #10 in the television room that was next to the nurses' station, with two unidentified residents to watch television. At 1:15 p.m. CNA #1 was sitting at the nurses' station documenting on the computer. CNA #1 was not facing the resident and her back was turned towards the resident, while she faced the computer. The resident was left in the television room and was not within an arms length of the one-to-one care giver. At 1:122 p.m. CNA #1 left the nurses station and returned to the TV room with Resident #10C. Resident #10's representatives interviewResident #10's representative was interviewed on 10/20/25 at 3:55 p.m. She said Resident #10 had a few falls shortly after admission, but had not had any recently. The representative said Resident #10 was provided a one-to-one caregiver for the last month. The representative said the resident had a fall and was sent to the hospital because he sustained a cut. She said after he returned, he was placed on a one-to-one caregiver.D. Record reviewResident #10's fall care plan, revised 9/15/24, revealed the resident was at a high fall risk due to dementia, history of frequent falls, new environment, weakness, gait imbalance, poor impulse control, decreased safety awareness and use of psychotropic medications. Interventions included one-to-one observation at arm's length (initiated 8/30/25), assessing Resident #10's need for adaptive devices as indicated (initiated 8/26/25), ensuring Resident #10's call light was within reach and encouraging him to use it for assistance as needed, providing prompt response to all requests for assistance (initiated 8/26/25), placing the fall mat next to the bed, bed in lowest position and pancake light(flat round call bell) (initiated 8/28/25), offered padded cap for safety (initiated 9/3/25), placing the bed bed in low position while resident was in bed (initiated 8/26/25), pressure sensitive alarm pad on bed (initiated 8/28/25), physical therapy to evaluate and treat as ordered or as needed (initiated 8/26/25) educating the staff that if the resident was was in wheelchair, he needed to be at nurse's station, therapy, or activity for closer observation and cannot be in wheelchair alone in room (initiated 8/28/25) and toileting the resident before and after meals (initiated 8/29/25).-However, observations revealed the staff failed to ensure the resident was appropriately monitored by his assigned one-to-one caregivers within arm's length and the pressure sensitive pad was not on the bed. (see observations above).The 8/30/25 facility investigation for Resident #10's fall was received from the NHA on 10/20/25 at 1:30 p.m. The investigation documented that on 8/30/25 Resident #10 was reported to have an unwitnessed fall. Nursing staff reported seeing Resident #10's call light illuminated indicating the need for assistance. When the nursing staff entered Resident #10's room, they observed him lying on his floor mat with his head touching the nightstand. Resident #10 was noted to have a small hematoma to his right side of his head. The resident was not bleeding, however bruising was indicated with nursing staff attempting to apply an ice pack.An IDT nursing progress note, dated 9/3/25 at 12:17 p.m., revealed Resident #10 had an unwitnessed fall with a hematoma to his head on 8/30/25. The root cause was identified as impulsive, gait imbalance, and decreased safety awareness. Immediate treatment was noted as nursing staff attempting to apply ice to his head but refused by the resident. Interventions put into place included offering a padded baseball cap for safety and re-educating staff to respond promptly to resident call light. -According to the resident's fall care plan, the resident was placed on a one-to-one caregiver after the fall on 8/30/25. The 9/3/25 facility investigation for Resident #10's fall was received from the NHA on 10/20/25 at 1:30 p.m. The investigation documented on 9/3/25 Resident #10 was reported to have an unwitnessed fall. Resident #10 was sitting at the nurses' station in his wheelchair when the nursing staff walked away down the hall to assist another resident, when Resident #10 fell out of his wheelchair and was noted to have bleeding coming from his head. Nursing staff pressure to Resident #10's head to stop the bleeding. The resident was noted to have complaints of back pain. Nursing staff contacted the on-call physician and received instructions to send Resident #10 to the hospital for further evaluation and treatment. -However, according to the resident's care plan, the resident was supposed to be on a one-to-one caregiver, when he sustained an unwitnessed fall.The 9/3/25 hospital documentation indicated Resident #10 had diagnostic imaging that included CT (computed tomography imaging) of the head, CT of the spine and CT of the chest abdomen and pelvis. The resident sustained a three to four millimeter left tentorial subdural hematoma without mass and a fracture of the tenth and eleventh posterior ribs. The documentation indicated the resident was not on blood thinners. A nursing progress note, dated 9/3/25 at 1:42 p.m., revealed nursing staff were walking down the hallway to assist another resident when Resident #10 was sitting on the floor with head bleeding. The nursing staff applied pressure to the resident's head. Resident #10 was sent to the hospital due to him needing further assessment. The resident was assisted from the floor by two staff members in a wheelchair. An IDT nursing progress note, dated 9/4/25 at 10:00 a.m., revealed Resident #10 had an unwitnessed fall with injury on 9/3/25. The note documented the root cause was identified as impulsive, gait imbalance and decreased safety awareness. The registered nurse (RN) assessed the resident, cleansed the head laceration with saline and the resident was sent to hospital for further evaluation and treatment. Interventions put into place upon readmission was the one-to-one caregiver needed to be within an arm's length of the resident.-However, observations revealed CNA #1 was assigned as Resident #10's one-to-one caregiver. CNA #1 was not within an arms length per the care plan and left the resident alone in his room when he rolled out of bed (see observations above).The 9/5/25 fall risk assessment revealed the resident's fall risk score was a 15, indicating he was a high fall risk. III. Staff interviewsCNA #1 was interviewed on 10/20/25 at 12:58 p.m. CNA #1 said she was assigned as Resident #10's one-to-one caregiver. She said as his one-to-one caregiver. She said she was responsible for monitoring Resident #10 because he had a history of falls. She said was not in Resident #10's room because she needed a restroom break and was trying to be quick to return to the resident's room. She said she knew that was not a good idea because the resident could fall and injure himself. She said typically, if she needed a break she would press the call button for another staff member to relieve her. She said at that time, there were only two CNAs on the unit and she knew they were busy so she did not want to bother them. She said Resident #10 had had a one-to-one care giver for more than a month because of his constant falls. She said it was important to watch the resident at all times because he had so many falls. She said the resident had sustained falls after the one-to-one intervention was put in place.CNA #2 was interviewed on 10/20/25 at 1:50 p.m. CNA #2 said she checked her report sheet at the beginning of the shift to see which residents were at risk for falls She said she only worked with Resident #10 on a few occasions. She said she knew Resident #10 was a fall risk because he had fallen at the facility multiple times. CNA #2 said Resident #10 was very quick when he wanted to get out of his bed or out of his chair. She said it was important to keep a close eye on him. Registered nurse (RN) #1 was interviewed on 10/20/25 at 2:00 p.m. RN #1 said she knew Resident #10 was a fall risk because she had worked with Resident #10 many times. RN #1 said Resident #10 had a one-to-one care giver to prevent him from having any additional falls. RN #1 said the one-to-one sitter should never leave the resident alone and should always be within arms reach of the resident. She said it was important for the one-to-one care giver to be very close to the resident in order to be able to react quickly and prevent falls or injuries. She said the residents' care plan had information regarding fall interventions. CNA #4 was interviewed on 10/20/25 at 3:35 p.m. She said she had taken over for evening shift as the one-to-one care giver for Resident #10 today. She said as the one-to-one care giver it was her responsibility to monitor the resident at all times and assist him with transfers and toileting hygiene. She said she should never leave the resident unattended as the one-to-one care giver. The director of nursing (DON), the NHA and the regional nursing consultant were interviewed together on 10/20/25 at 4:26 p.m. The DON said Resident #10 was admitted to the facility on [DATE] due to his multiple falls at home. She said residents were assessed for their fall risk upon admission, quarterly and as changes dictate. She said resident care was resident specific to the resident behavior. She said it was important to ensure Resident #10 was monitored consistently because he could not be trusted to be left alone. She said Resident #10 had poor safety awareness and would fall and injure himself if left alone. She said the one-to-one caregiver started after Resident #10 had seven falls within the first six days of admission.The DON said the one-to-one caregiver for Resident#10 was initiated as a fall intervention on 8/30/25 after the resident had a fall with a minor head injury. She said the resident sustained another fall on 9/3/25. She said she believed the nursing staff was not watching the resident close enough. She said the fall intervention was changed from one-to-one observation, to one-to-one arm's length. She said the on-to-one arm's length was put in place to be more specific for the staff to understand the need to be close to the resident. She said this intervention was added to the resident's care plan for the nurses and on the Kardex (staff directive tool) for the CNAs. The DON said the facility did not provide any specific training for one-to-one caregivers, but the expectation was for the one-to-one caregiver to visually monitor the resident to prevent any falls or injuries. The DON said CNA #1 should always be able to see the resident and should not turn her back on the resident. The DON said she would talk to CNA #1 regarding the lack of monitoring of Resident #10. The NHA said it was very concerning to find out that the one-to-one caregiver assigned to Resident #10 left him unattended. She said the resident had a history of falls and if the caregiver left the resident unattended, he could sustain another fall with injury. The NHA said CNA #1 should know the potential risk of leaving him alone. The NHA said it was not a good idea for CNA #1 to turn her back on the resident while she was documenting at the nurses' station. the NHA said CNA #1 could have brought the resident behind the nurses' station with her while she did her documentation. The regional nurse consultant said she would initiate training for all nursing staff to start immediately regarding the requirements and importance of one-to-one care givers responsibilities. She said she would include the importance of being within arm's length of the resident while being a one-to-one caregiver.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#2 and #1) of three residents reviewed for bathing out of three sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #1, who were dependent on staff for bathing, received their scheduled showers. Findings include: I. Facility policy and procedure The Bathing/Shower policy, revised February 2018, was provided by the regional clinical resource (RCR) on 1/21/25 at 4:24 p.m. It read in pertinent part, The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The documentation includes the date and time the shower/bath was performed, the name and title of the individual who assisted the resident with the shower, all the assessment data obtained during the shower, how the resident tolerated the shower, if the resident refused the shower, the reason why, the intervention taken and report the refusal to the supervisor. The Activity of Daily Living policy, revised March 2018, was provided by the RCR on 1/21/25 at 4:20 p.m. It read in pertinent part, Residents who are unable to carry out activities of daily living (ADL) independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene and oral hygiene. Care and services will be provided for the following activities: -Bathing, dressing, grooming and oral care; -Transfer and ambulation; -Toileting; -Dining to include meals and snacks; and -Using speech, language or other functional communication systems. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included end stage renal failure, dependence on dialysis, cognitive communication deficit, limitations of activities due to disability, sacral pressure injury and depression. The 12/30/24 MDS assessment revealed she had modified independence with cognitive skills for daily decision making. She used a wheelchair and was dependent on staff for bathing. B. Resident interview and observation Resident #2 was interviewed on 1/21/25 at 3:32 p.m. She said she was not receiving two showers weekly as scheduled. She was lying in bed in a hospital gown with her hair disheveled. C. Record review The ADL care plan, revised on 10/12/23, revealed Resident #69 had an ADL self-care performance deficit related to impaired mobility and end stage renal disease. Interventions included providing two staff members with extensive assistance for transfers and ADL care. -Review of the comprehensive care plan did not reveal documentation indicating the resident's shower preferences. Review of the October 2024 through January 2025 shower logs revealed the following: The October 2024 (10/1/24 to 10/31/24) shower documentation revealed Resident #2 was provided bathing on two out of nine opportunities. The November 2024 (11/1/24 to 11/31/24) shower documentation revealed Resident #2 was provided bathing on two out of eight opportunities. The December 2024 (12/1/24 to 12/31/24) shower documentation revealed Resident #2 was provided bathing on seven out of nine opportunities. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included complete rotator cuff tear of the right shoulder, dependence on a wheelchair, pressure ulcer to the right buttocks, pressure induced deep tissue damage of the left heel and acute respiratory failure. The 11/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He had impairment to one side of his upper and lower extremities. He used a wheelchair and was dependent on staff for bathing. B. Record review The ADL care plan, revised 12/30/24, revealed Resident #1 had an ADL self-care performance deficit related to recent hospital stay for urinary tract infection and right shoulder pain which was found to be caused by complete tearing of three rotator cuff muscles. Interventions included providing two staff maximal assistance with bathing. -Review of the comprehensive care plan did not reveal documentation that indicated the resident's shower preferences. Review of the October 2024 through January 2025 shower logs revealed the following: The October 2024 (10/1/24 to 10/31/24) shower documentation revealed Resident #1 was provided bathing zero out of four opportunities. The November 2024 (11/1/24 to 11/30/24) shower documentation revealed Resident #1 was provided bathing on one out of nine opportunities. The December 2024 (12/1/24 to 12/31/24) shower documentation revealed Resident #1 was provided bathing on one out of five opportunities. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/21/25 at 3:38 p.m. CNA #1 said the shower aide was responsible for giving the residents their showers. CNA #2 was interviewed on 1/21/25 at 3:50 p.m. CNA #2 said she was the shower aide and was responsible for giving the residents their showers. She said all of the showers were documented on a shower sheet including bed baths and refusals. She said if the resident did not have a shower sheet completed, the shower was not given. She said when the floor staff was short staffed, she was pulled to work the floor and the showers did not get done. She said she was pulled to work the floors a lot of times. Licensed practical nurse (LPN) #1 was interviewed on 1/21/25 at 3:53 p.m. LPN #1 said the shower aide was responsible for completing the residents showers. She said all showers should be documented on a shower sheet indicating g if the shower was completed or refused. She said the CNA would turn in the shower sheet for the nurse to sign. The director of nursing (DON) was interviewed on 1/21/25 at 3:57 p.m. The DON said she had only been employed at the facility for two days. She said the facility had staffing challenges and the shower aide was often pulled to work the floor. She said the CNA assigned to the resident with a scheduled shower was responsible for giving the shower if the shower aide was unavailable. She said she was not aware how many shower aides were scheduled daily. She said she did not like using shower sheets because they could get lost. She said the showers should be documented in the medical record.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen; and, -Ensure the two facility ice machines were properly cleaned and sanitized according to the manufacturer's instructions. Findings include: I. Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen A. Facility policy and procedure The Cleaning and Disinfection of Environmental Surfaces policy, revised August 2019, was provided by quality mentor (QM) #1 on 3/20/24 at 5:43 p.m. It documented in pertinent part: Environmental surfaces will be disinfected (or cleaned) on a regular basis daily and when surfaces are visibly soiled. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Horizontal surfaces will be wet dusted regularly using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer. B. Observations During a continuous observation of the kitchen on 3/18/24, beginning at 2:00 p.m. and ending at 2:15 p.m., the following was observed: Main Kitchen: -Unfinished drywall and chipped paint to the left of the big sinks; -Dust buildup on pipes and emergency lights above prep tables and food storage areas in the kitchen; -Chipped paint on the runners along the floor and chipped paint above the hand washing sink; and, -Dirt and grime was built up under the hand washing sink. Chemical storage area: -Air vent was hanging open and light covers were missing. Dish room: -Large rodent hole under the dishwashing machine leading to the outside of the building; -Chipped tiles and dark substance build up under the sink; and, -Broken fan in the dish room was hanging from the ceiling. Main Dining Room: -All three doors leading to the kitchen had chipped paint and a dark substance was built up around the bottoms of the door frames. C. Staff interviews The dietary manager (DM) was interviewed on 3/21/24 at 11:16 a.m. The DM said she was not sure how often the kitchen was supposed to be deep cleaned to include the walls, floors and ceilings but said it had been a while since it was deep cleaned. She said she had not reached out to maintenance for the repairs to the broken tiles and holes but would reach out as soon as she could. The DM said without a clean and sanitary kitchen environment, the facility was at risk for contamination of food and food preparation surfaces. II. Ensure ice machines were properly cleaned and sanitized according to manufacturer's instructions A. Facility policy and procedure The Manitowoc Ice Machine Technician's Handbook was provided by the nursing home administrator (NHA) on 3/18.24 at 4:40 p.m. It read in pertinent part, Cleaning/ Sanitizing Procedure: Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. Use 1/2 (half) of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all surfaces of the removed parts or soak the removed parts in the sanitizer/water solution. Do not rinse parts after sanitizing. Use half of the sanitizer/water solution to sanitize all food zone surfaces of the ice machine and bin (or dispenser). Use a spray bottle to liberally apply the solution. When sanitizing, pay particular attention to the following areas: side walls, base (area above water trough), evaporator plastic parts - including top, bottom and sides and bin or dispenser. Do not rinse the sanitized areas. Replace all removed components. Wait 20 minutes. Reapply power to the ice machine and press the clean button. C. Observations During the initial kitchen tour on 03/17/24 at 1:19 p.m. it was observed that the facility had two ice machines, one on the first floor and one on second floor. No cleaning schedule logs were seen on or around the machine. The kitchen staff said maintenance was responsible for cleaning the ice machines. D. Record review The ice machine cleaning schedule was provided by NHA on 3/18/24 at 3:55 p.m. It read in pertinent part, The maintenance department is responsible for the cleaning and disinfecting of both facility ice machines. This will be done every 6 (six) months and documented as such. Procedure: All ice will be removed from the bin and thrown away, bleach will be sprayed on all areas inside the unit, all bleached areas will then be rinsed at least three times using hot water. Units are now ready to be turned back on, let both units make at least three dumps of ice cubes, throw all away and the fourth dump can then be used. -The facility provided records which indicated the ice machines had been cleaned, however, the chemical the facility used for the process did not contain a sanitizer (see record review and interview below). -The instructions on the cleaning schedule did not document the appropriate cleaning procedure per the manufacturer's instructions (see manufacturer's instructions above). The solution the facility used to clean the ice machines was identified as H.B. (Hydro-Balance) 30 Ice Machine Cleaner. -The product was identified as a commercial ice machine cleaner, however, the product did not include a sanitizing component. E. Staff interviews The maintenance assistant (MA) was interviewed on 3/21/24 at 10:19 a.m. The MA said he was responsible for cleaning the ice machines. The MA said he had been in the facility about a year. He said he had never cleaned ice machines before this position and said he had not been trained on how to clean the ice machines located in the facility. He said he learned how to clean the ice machines by watching a YouTube video. The MA said since he had been responsible for the ice machines he had not sanitized them due to lack of training and fear of using too much disinfectant. He said no one had trained him how to sanitize the ice machines and said the facility had not ever sanitized the ice machines to his knowledge. The MA said no specific parts of the ice machines should be removed to clean and sanitize the machines except for the ice tray. -However, the manufacturer's instructions documented that parts of the ice machine were to be removed during the cleaning and sanitizing process (see manufacturer's instructions above). F. Facility Follow-up The facility provided a receipt of service form on 3/20/24 at 8:45 a.m. It showed the facility hired a contract service to clean and sanitize the two facility ice machines on 3/19/24 at 8:45 a.m. The facility said they would continue to use the contract service provider every time the ice machines need to be cleaned and sanitized in the future.

Based on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to: -Ensure menu extensions were followed; and, -Ensure residents were provided with all menu options and substitutions were offered when appropriate. Findings include: I. Facility policy and procedure The Menus and Nutrition Adequacy policy and procedure, revised January 2024, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: Menus must meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance, be followed, be updated periodically and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. The US Foods Detailed Menu Cycle Nutritional Analysis was provided by the facility on 3/21/24 at 9:03 a.m. It read in pertinent part: The facility offered a total of 2,000 Kcal (calorie) daily nutritional intake across all meals. Milk was to be offered at every meal, offering 118 Kcal per each meal, 354 Kcal per day and 2,478 Kcal per week. II. Lunch meal observation Certified nursing aide (CNA) #8 was observed on 3/20/24 at 11:30 a.m. passing drinks to residents in the main dining room. She was observed to walk up to the table and ask what the residents would like to drink. -CNA #8 did not offer residents milk or an alternative if the resident declined milk. CNA #8 informed residents their drink choices were lemonade, iced tea or water. III. Menu and extensions The menu extensions read in part: Lunch 3/19/24: Regular diet: three individual Cheese Manicotti, 0.5 cup of green beans, 0.5 cup of butterscotch pudding, one slice of garlic parmesan bread, 8 fluid ounces of milk, 8 fluid ounces of beverage of choice. -However, milk was not offered to the residents even though it was included as part of the menu (see observation above). Liberal renal diet: two ounce beef patty and 0.5 cup of noodles, 0.5 cup of green beans, cookie, one slice of garlic parmesan bread, 8 fluid ounces of fruit punch, 8 fluid ounces of beverage of choice. -The kitchen staff did not prepare the renal substitute of beef patty and noodles. IV. Staff interviews CNA #8 was interviewed on 3/20/24 at 11:48 a.m. CNA #8 said the residents could get anything they wanted to drink. She said there was no mandatory drink such as milk that the residents had to have. She said staff offered the residents any drinks they would like and the facility served what was requested. The dietary manager (DM) was interviewed on 3/21/24 at 11:16 a.m. The DM said the kitchen staff who cooked the meals were trained on the facility's different menus and diets but the servers were not trained. She said everything listed on the menu extensions was to be offered to every resident and included on meal trays. She said if any item was omitted it was the facility's responsibility to provide a substitute of comparable nutritional value. The DM said residents needed to receive all items on the menu to meet the 2000 calorie daily requirement. The registered dietician (RD) was interviewed on 3/20/24 at 5:07 p.m. The RD said all items on the menu extensions were to be offered and provided to all residents unless special dietary constraints were in place. She said the extensions provided a nutrition meal and daily meal totals were at 2000 calories per day. She said any menu item excluded from being served could cause residents to have a daily calorie deficit.

Based on record review and interviews the facility failed to ensure residents were kept free from unnecessary medications for four (#15, #16, #33 and #76) of five residents reviewed for unnecessary medications out of 47 sample residents. Specifically, the facility failed to ensure informed consents were signed prior to the administration of psychotropic medications for Residents #15, #16, #33 and #76. Findings include: I. Facility policy and procedures The Psychopharmacological Policy, dated 3/10/23, was provided by quality mentor (QM) #1 on 3/20/24 at 12:42 pm. The policy revealed the community (facility) supported the appropriate use of psychopharmacological drugs that were therapeutic for residents suffering from mental illness. If a resident was admitted with orders for psychopharmacological drug use, the following would occur: a licensed nurse would review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician, the licensed nurse would complete the PCC Psychotropic Informed Consent with the resident or responsible party. This would be completed at admission and as needed. If the information was not obtained prior to admission, the licensed nurse and/or social service director (SSD) would make every effort to determine if there were any potential behavior symptoms that might require special monitoring and/or care planning. Possible sources of this information include, but were not limited to, physician, family, pre-admission screening & resident review program (PASRR), mental health clinician/developmentally disabled specialist (DDS), prior placement, or resident history. The licensed nurse or designee would document any known targeted behaviors and potential interventions on the Kardex (nurse worksheet that included a summary of a resident's information, such as medications, clinical follow-ups and daily care schedules). This would help to assure certified nursing assistants received communication related to the initial plan of care as appropriate. The licensed nurse would complete a baseline Abnormal Involuntary Movement Scale (AIMS) on admission, quarterly and as needed if the resident had orders for antipsychotic medications and/or as ordered by the primary care physician or psychiatrist (if applicable). The admission record would be reviewed within 72-hours (weekdays) of a resident's admission by the interdisciplinary team (IDT) to assure admission orders, applicable policy and procedures had been initiated. This review would include the use of psychopharmacological drugs, appropriate diagnosis, behavioral symptom(s) and the initial plan of care. The interdisciplinary team (IDT) would proceed to care planning for the use of psychopharmacological drugs, and the care plan for psychopharmacological medications would be implemented. The care plan would include the resident's focus and target behaviors for the medication. Realistic and measurable goals would be utilized and approaches would include alternatives to psychopharmacological drug use. The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate. Consideration should be given to potential underlying causes of the behavior symptoms to assure appropriate treatment. II. Resident #15 A. Resident status Resident #15, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, diabetes mellitus, chronic pain, dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/22/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15 with no behaviors. The resident had additional diagnoses of depression, renal insufficiency, and non-Alzheimer's dementia. During the seven-day assessment period the resident was administered antipsychotics, antidepressants, opioids, and hypoglycemic medications. B. Record review A physician's order dated 2/16/24 at 3:26 p.m. revealed Trazodone hydrochloride (HCL) 100 milligrams (mg) give one tablet by mouth at bedtime for insomnia. A physician's order dated 2/16/24 at 3:26 p.m. revealed Quetiapine Fumarate (Seroquel) 50 mg give one tablet by mouth once a day for insomnia. A physician's order dated 2/16/24 at 4:26 p.m. revealed Zyprexa 2.5 mg give one tablet by mouth for insomnia. A physician's order dated 2/16/24 at 3:26 p.m. revealed Sertraline HCL 25 mg give one tablet by mouth once a day for depression. A care plan for the use of an antidepressant medication related to depression and sleep was initiated on 2/16/24 and revised on 2/27/24. The interventions were for staff to monitor behaviors for the use of an antidepressant medication. Staff were to monitor/document/report, as needed any adverse reactions to antidepressant therapy. Staff were to observe for changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living, continence, lack of voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and/or dry eyes. Staff were to complete the patient health questionnaire-9 (PHQ-9) assessment on admission, quarterly, annually, and with a change of condition. The resident's medications would be reviewed with the interdisciplinary team quarterly and as needed and attempt gradual dose reduction when clinically indicated. A care plan for the use of an anti-psychotic medication for insomnia was initiated on 3/9/24. The interventions were for staff to administer psychotropic medications as the physician ordered. Staff were to monitor for side effects and effectiveness of the medications. Staff were to complete the abnormal involuntary movement scale (AIMS) assessment quarterly or as needed. Staff were to consult with the pharmacy and a physician to consider a dose reduction, when clinically appropriate at least quarterly. Staff were to discuss with a physician, power of attorney (POA) or the family regarding the ongoing need for the use of the medication. Staff were to review the behaviors/interventions, alternate therapies attempted and their effectiveness according to the facility policy. Staff were to educate and inform the resident of the current medication regimen and change recommendations. Staff were to educate the resident, POA (power of attorney), family and caregivers about the risks, benefits and the side effects and/or toxic symptoms of the psychotropic medication drugs being given. Staff were to attempt medication reductions and/or risk benefit assessments as indicated. Staff were to monitor, document, report, as needed any adverse reactions of the use of psychotropic medications. Staff were to observe for unsteady gait, tardive dyskinesia, extrapyramidal side effects (RPS) such as shuffling gait rigid muscles or shaking. Staff were also to observe for frequent falls, refusal to eat, sedation, difficulty swallowing, dry mouth, depression, extrapyramidal reaction, weight gain, edema, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, constipation, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Staff were to review the resident's medications with the interdisciplinary team quarterly and as indicated and attempt gradual dose reductions when clinically indicated. The medication administration record (MAR) for February 2024 revealed the resident was administered Quetiapine Fumarate 14 times, Sertraline HCL 13 times, Trazodone HCL 14 times and Zyprexa 13 times. The medication administration record (MAR) for March 2024 revealed the resident was administered Quetiapine Fumarate 13 times, Sertraline HCL 15 times, Trazodone HCL 13 times, and Zyprexa 11 times. -The resident signed the Informed Consent for Psychoactive Medications forms for the use of Sertraline, Trazodone, and Seroquel on 3/19/24 at 5:44 p.m., after the survey started. The Zyprexa was discontinued on 3/18/24. C. Staff interviews The director of nursing (DON), QM #1, QM #2 and the pharmacist (PH) were interviewed on 3/20/24 at 11:35 a.m. They agreed on the psychotropic medications the resident was administered. The PH said the resident's physician wanted the resident on multiple medications for his insomnia. The PH said the resident was admitted from the hospital with the same medications for a diagnosis of insomnia. The PH said there was some off-labeling (use of a medication that was not approved to treat a specific condition/diagnosis) of some of the medications for the resident's insomnia. The PH said the facility kept the same diagnosis for medications when the medications arrived and the facility would make changes as they could. The PH said the staff had not observed the resident being over sedated and the Zyprexa was discontinued on 3/18/24, after the survey started. The Quetiapine Fumarate was still at 50 mg with a diagnosis of dementia with behaviors. This diagnosis was changed on 3/18/24, after the survey started. The PH said the facility would continue to discontinue other medications. The facility had to wait at least a week for the Zyprexa to get out of his system. The DON, QM #1, QM #2 and the pharmacist (PH) were interviewed again on 3/20/24 at 11:48 a.m. They agreed the resident had been administered the above psychotropic medications. QM #2 said the consents for the use of psychotropic medications were not obtained prior to the administration of the medications. The consents were obtained on 3/19/24, after the survey started. III. Resident #76 A. Resident status Resident #76, age 56, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included anxiety, essential hypertension, fluid overload, lumbar region spondylolisthesis diabetes mellitus and chronic kidney disease stage 5. The 3/20/24 minimum data set (MDS) assessment revealed the resident had intact cognitive ability with a BIMS score of 14 out of 15 with no behaviors. B. Record review A physician's order dated 3/14/24 at 4:20 p.m. revealed Sertraline HCL 100 mg give two tablets by mouth at bedtime for anxiety with depression. A care plan for the use of an antidepressant medication related to depression was initiated on 3/18/24. The interventions were for staff to monitor behaviors for the use of an antidepressant medication. Staff were to monitor/document/report, as needed any adverse reactions to antidepressant therapy. Staff were to observe for changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living ability, continence, lack of voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and/or dry eyes. Staff were to complete the patient health questionnaire-9 (PHQ-9) assessment on admission, quarterly, annually, and with a change of condition. The resident's medications would be reviewed with the interdisciplinary team quarterly, as needed, and attempt gradual dose reduction when clinically indicated. A care plan for the use of an anti-anxiety medication related to an anxiety disorder was initiated on 3/18/24. The pertinent interventions were to administer the medication as physician ordered. Staff were to monitor for side effects and effectiveness. Staff were to monitor, document, report as needed any adverse reactions to the anti-anxiety therapy. The adverse reactions might include drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking/judgment, memory loss, forgetfulness, nausea, stomach upset, blurred and/or double vision. The staff were also to observe or unexpected side effects such as; mania, hostility, rage, aggressive or impulsive behavior, and/or hallucinations. The resident's medications would be reviewed with the interdisciplinary team quarterly, as needed, and attempt gradual dose reduction when clinically indicated. The MAR for March 2024 revealed the resident was administered Sertraline HCL 4 times. -The resident signed the Informed Consent for Psychoactive Medications form for the use of Sertraline on 3/20/24 at 10:56 a.m., after the survey started. C. Staff interviews The DON, QM #1, QM #2 and the pharmacist (PH) were interviewed on 3/20/24 at 11:48 a.m. They agreed the resident was administered the above psychotropic medication. The consent for the medication was obtained on 3/18/24, after the survey started. They agreed a consent should have been obtained before the medication was given. 47422 IV. Resident #33 A. Resident status Resident #33, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease, severe dementia with agitation and history of falls. The 1/12/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of three out of 15. The assessment did not identify the resident had any behaviors during the assessment period. The assessment did not identify the resident's functional abilities and goals at the time of the assessment. B. Record review A physician's order dated 2/20/24 at 3:05 p.m. revealed Zyprexa 10 mg, give 10mg by mouth in the afternoon for dementia with agitation. The antipsychotic medication use care plan, initiated on 8/1/23, revealed Resident #33 had symptoms and behaviors associated with the diagnosis of dementia Relevant interventions included staff to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness,staff to perform behavior monitoring for anti-psychotic medication,staff considered medication reductions and or risk benefit assessments as indicated,staff to review medications with the interdisciplinary team (IDT) quarterly and as indicated and attempt gradual dose reduction when clinically indicated and staff were to utilize the following non pharmacological interventions: cold, range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, repositioning, aromatherapy and therapeutic touch and massage. A review of Resident #33's MAR from 3/1/24 - 3/21/24 revealed the resident received 21 doses of Zyprexa during the reviewed timeframe. -Review of Resident #33's electronic medical record (EMR) failed to reveal a signed informed consent form for Zyprexa. C. Staff interviews Registered nurse (RN) #4 was interviewed on 3/21/24 at 1:24 p.m. RN #4 said all psychotropic medications needed a consent signed by the resident or resident's representative before being administered any psychotropic medications. He said he was not sure who was responsible for obtaining the informed consents. 48458 V. Resident #16 A. Resident status Resident #16, age greater than 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included heart disease, chronic obstructive pulmonary (lung) disease, major depressive disorder and post traumatic stress disorder. The 1/26/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15 with no behaviors. B. Record review A physician's order dated 7/8/23 at 8:00 p.m. revealed Mirtazapine 15 mg give one tablet at bedtime for depression and insomnia. A physician's order dated 7/12/23 at 5:00 p.m. revealed Venlafaxine 100 mg give 100 mg twice daily for depression. A care plan for the use of an antidepressant medication related to major depressive disorder and post traumatic stress disorder (PTSD) was initiated on 7/8/23. The interventions were for staff to educate the resident/family/caregivers about risks, benefits and the side effects or toxic symptoms of antidepressant for depression with insomnia. Staff were to monitor, document and report adverse reactions to antidepressant therapy, change in behavior, mood and cognition, hallucinations, delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living (ADLs), continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness, vertigo, fatigue, insomnia, appetite loss, weight loss, dry mouth and dry eyes. The March 2024 MAR revealed the resident was administered Mirtazapine 20 times and Venlafaxine 41 times. -Review of Resident #16's EMR failed to reveal a signed informed consent form for Mirtazapine or Venlafaxine. C. Staff interviews The pharmacist (PH) was interviewed on 3/20/24 at 1:00 p.m. The PH said the informed consents for psychotropic medications were to be completed by the nurses or the physician and signed by the resident/resident representative prior to the medication being administered.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control practices; -Ensure high touch areas were cleaned; -Ensure staff followed proper hand hygiene practices; -Ensure hand hygiene was offered to residents prior to meals; and, -Ensure Foley catheter bags were hung in a sanitary manner. Findings include: I. Failure to ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (2021) Jul;113:104-114, retrieved on 3/31/24 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The CDC Environment Cleaning Procedures (5/4/23), retrieved on 3/31/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs. B. Observations On 3/20/24 at 10:00 a.m., housekeeper (HSK) #1 cleaned room [ROOM NUMBER]. -HSK #1 failed to clean the door knobs to the resident room entrance, pull cords and light switches in the room. HSK #1 was observed to spray the door knobs of the bathroom with the disinfectant. -However, she then cleaned the toilet and with the same gloved hands she touched the door knobs of the bathroom as the door began to close. She did not go back and disinfect the door knob after the contamination. C. Interview The housekeeping supervisor (HSKS) was interviewed on 3/20/24 at approximately 4:00 p.m. The HSKS said that the high touch areas such as door knobs, call lights and light switches needed to be cleaned with a disinfectant as part of the room cleaning. He said that HSK #1 should have not touched the bathroom door knobs with contaminated gloves. The infection preventionist (IP) was interviewed on 3/21/24 at 9:38 a.m. The IP said she had not completed a start to finish observation of the housekeepers during cleaning of rooms. She said high touch areas (frequently touched surfaces) should be cleaned daily. The IP said the residents' call lights and door knobs should be cleaned daily. II. Failed to ensure staff performed hand hygiene A. Facility policy The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; Before and after direct contact with residents; Before preparing or handling medications; Before performing any non-surgical invasive procedures; Before and after handling an invasive device (e.g., urinary catheters, IV access sites); Before donning sterile gloves; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Before and after entering isolation precaution settings; Before and after eating or handling food; Before and after assisting a resident with meals; and After personal use of the toilet or conducting your personal hygiene. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Infection Control and Surveillance policy, revised July 2023, was provided by the nursing home administrator (NHA) on 3/17/24 at 5:10 p.m. It read in pertinent part: Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures. B. Observations 3/17/24 -At 4:51 p.m., kitchen staff were delivering room trays to room [ROOM NUMBER], #22 and #23. The kitchen staff failed to perform hand hygiene after delivering the room trays. -At 4:54 p.m., oom trays were delivered to rooms # 4, #6, #7, #8, #11 and #16. The unidentified kitchen staff member failed to perform hand hygiene prior to entering or after exiting each room. -At 5:05 p.m., room trays were served to resident room # 27, #28, #31, 37, #39 and #45. The unidentified staff failed to perform hand hygiene after exiting and entering the next room. 3/19/24 -At 4:15 p.m., CNA #7 took the vitals of Resident #13. After CNA #7 finished taking the resident's vital signs, he failed to perform hand hygiene. -At 4:23 p.m., registered nurse (RN) #5 was observed during the medication pass. RN #5 used hand sanitizer on both hands while wearing cloth hand and wrist braces on both hands. RN #5 prepared the medications and applied gloves. She wore gloves in Resident #18's room, administered the medications to the resident and then used hand sanitizer. -At 4:37 p.m., CNA #7 entered room [ROOM NUMBER] and pushed a resident out of the room to the dining room. CNA #7 assisted the resident with oxygen. CNA #7 failed to perform hand hygiene after adjusting the resident's oxygen. CNA #7 went into another room to assist another resident without performing hand hygiene. -At 4:38 p.m., RN #5 continued to wear the cloth wrist braces. She prepared medications without gloves and administered the medications to Resident #32 without gloves. RN #5 rinsed her hands under water for five seconds in the resident's room. RN #5 did not sanitize with soap. After rinsing her hands with water, RN #5 used hand sanitizer with the wrist braces on. -At 4:43 p.m., CNA #7 assisted a resident to the dining room by pushing his wheelchair. CNA #7 left the resident in the dining room and went to help another resident with another task. CNA #7 failed to perform hand hygiene between residents and tasks. -At 4:50 p.m., RN #5 prepared and administered medications to Resident #17 while still wearing her wrist braces. She rinsed her hands under water in the resident's room for five seconds and did not perform appropriate hand hygiene by removing the braces or using soap or hand sanitizer. C. Resident and staff interviews CNA #6 was interviewed on 3/17/24 at 5:24 p.m. CNA #6 said he was trained to sanitize his hands and hand sanitizer should be used after caring for every resident to ensure germs would not spread. The infection preventionist (IP) was interviewed on 3/21/24 at 9:38 a.m. The IP said staff was required to do hand hygiene between delivery of each meal tray and after any contact with a resident. The IP said RN #5 should not wear the wrist braces during medication passes. She said she provided education to RN #5 on 3/20/24 (during the survey) and RN #5 agreed not to wear the braces during medication administrations. The IP said all staff should perform hand hygiene between residents. She said gloves should not replace hand hygiene. III. Failed to offer hand hygiene to residents prior to meals A. Professional reference The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/30/2020), retrieved on 3/31/24 from https://www.cdc.gov/handhygiene/providers/guideline.html, included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Observations The dinner meal was observed on 3/17/24 starting at 5:20 p.m. The observations were as follows: -At 5:28 p.m., Resident #2 was served dinner, however, the resident was not offered hand hygiene prior to meal delivery. -At 5:36 p.m., Resident #55 was served his meal from CNA #5, however, he was not offered hand hygiene prior to eating his meal. -At 5:39 p.m,. Resident #16 and #22 were served their meals in the dining room. They were not offered hand hygiene prior to meal delivery. -At 5:44 p.m., Resident #23, #29, #35, and #47 were served their meals in the dining room. They were not offered hand hygiene prior to meal delivery. The lunch meal was observed on 3/19/24 starting at 11:50 a.m. The observations were as follows: -At 12:00 p.m., the residents sitting at the restorative table did not get offered hand hygiene prior to their meal being served. The lunch meal was observed in the dining room on 3/20/24 starting at 11:54 p.m. The meal was fried chicken. The observations were as follows: -At 11:54 a.m., some of the tables had wrapped hand wipes. However, not every table had them. -Resident #123 received his meal, however, the resident was not offered hand hygiene prior to eating. -Resident #64 received his meal and was not offered hand hygiene prior to eating. -Resident #15 was not offered hand hygiene prior to eating. C. Resident and staff interviews Resident #66 was interviewed on 3/17/24 at 5:34 p.m. Resident #66 said hand hygiene was not offered or encouraged to residents. Resident #73 was interviewed on 3/17/24 at 5:36 p.m. Resident #73 said hand hygiene was not offered or encouraged to residents. Resident #51 was interviewed on 3/17/24 at 5:41 p.m. Resident #51 said hand hygiene was not offered or encouraged to residents. CNA #5 was interviewed on 3/17/24 at 5:48 p.m. CNA #5 said she did not offer hand sanitizer to residents prior to serving the residents' meals. Registered nurse (RN) #1 was interviewed on 3/17/24 at 5:50 p.m. RN #1 said she did not offer or see anyone offer hand sanitizer to residents in the dining room prior to serving the residents' meals. The infection preventionist (IP) was interviewed on 3/21/24 at 9:38 a.m. The IP said residents should be offered hand hygiene prior to their meal being served. The IP said residents should be offered a hand sanitizing wipe or bottled hand sanitizer. IV. Failed to ensure Foley catheter bag was hung in a sanitary manner A. Observation On 3/20/24 at 11:10 a.m., Resident #51's Foley catheter bag was observed hooked to a trash can with trash in it next to the resident's bed. The catheter was hanging down inside the trash can. B. Interview CNA #8 was interviewed on 3/20/24 at 11:15 a.m. CNA #8 said the catheter bag should not be hung in the trash can. She said it should be hung on the side of the bed. She said the night shift staff probably hung it in the trash can. She confirmed there was trash present in the trash can. The IP was interviewed on 3/21/24 at 9:38 a.m. The IP said Resident #51's Foley catheter should never be hung on or in the garbage can. The IP said the catheter should be hanging from the bedrail, lower than the level of Resident #51's bladder. V. Facility follow-up The IP provided documentation of staff in-service education completed on 3/21/24 (during the survey) which included the following: -Gloves must be changed between each task when cleaning resident rooms. -Hand hygiene must be performed prior to glove application. -Gloves do not replace hand hygiene. -The education failed to include education regarding offering residents hand hygiene prior to meals, how to hang Foley catheter bags or appropriate processes for cleaning resident rooms. 20287

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards on two of four medication carts. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; -Expired and discontinued medications were removed from the medication cart; and, -Labeled medications were legible. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised [DATE], was provided by quality mentor (QM) #1 on [DATE] at 12:42 p.m. The policy read in pertinent part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Professional references According to the manufacturer [NAME] Lilly and Company, Basaglar Insulin Glargine 100 units/milliliter (ml), (February 2024), retrieved on [DATE] from https://www.basaglar.com/how-to-use-basaglar, After insulin use, store your opened pen at room temperature and throw it away after 28 days. According to the manufacturer [NAME] Lilly and Company, Humalog Insulin Lispro U-100 Insulin (February 2024), retrieved on [DATE] from https://www.humalog.com/u100, Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. According to the manufacturer Sanofi-Aventis US, Lantus Insulin Glargine Injection 100 units/ml- How to Use Your Lantus Solostar Pen, ([DATE]), retrieved on [DATE] from https://www.lantus.com/dam/jcr:817aed9c-a,d+[DATE]cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf, Your opened Lantus Solostar pen - After 28 days, throw your Lantus pen away, even if it still has insulin in it. III. Observations and interviews On [DATE] at 2:51 p.m., the Alpine Back medication cart was observed with licensed practical nurse (LPN) #1. The following item was found: An opened Insulin Glargine (Basaglar) 100 units/ml (milliliter) pen was not labeled with the date it was opened. LPN #1 said he expected to see a date opened label so he would know when the insulin pen should be discarded. On [DATE] at 3:37 p.m., the Challenger Back medication cart was observed with registered nurse (RN) #1. The following items were found: An Insulin Lispro (Humalog) 100 units/ml pen was dated as opened on [DATE]. -The insulin pen should have been discarded on [DATE], 28 days after it was opened. An Insulin Glargine (Lantus) 100 units/ml pen was dated as opened on [DATE]. -The insulin pen should have been discarded on [DATE], 28 days after it was opened. An opened Insulin Glargine (Lantus) 100 units/ml pen had a label on it, however, the writing on the label was illegible and the date it was opened was unable to be determined. RN #1 said the insulin pens should be discarded 28 days after opening and she proceeded to remove them from the medication cart. She said the insulin pen with illegible writing should be discarded. IV. Staff interviews The director of nursing (DON) and quality mentor (QM) #2 were interviewed on [DATE] at 10:13 a.m. The DON said the undated opened insulin pen should have been labeled, and if it was not labeled, it needed to be discarded. The DON said the insulin pen with the illegible label should be discarded. He said the insulin pens opened on [DATE] and [DATE] should have been discarded 28 days after opening. The pharmacist (PH) was interviewed on [DATE] at 11:33 a.m. The PH said insulin pens needed to be dated upon opening. She said Lantus and Lispro insulins should be discarded 28 days after opening. She said staff should discard any pens with illegible labels.

Based on observations, record review and interviews, the facility failed to ensure residents received food prepared in a form designed to meet their needs for two (#15 and #39) of four residents reviewed for therapeutic diets out of 47 sample residents. Specifically, the facility failed to provide meals prepared according to the prescribed food orders for Resident #15 and Resident #39. Findings include: I. Facility policy and procedure The Menus and Nutrition Adequacy policy, revised January 2024, was received from quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: Menus must meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance be followed, reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups, be updated periodically and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy II. Resident #15 A. Resident status Resident #15, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included diabetes mellitus with diabetic neuropathy, anemia, stage 4 kidney disease, essential hypertension and chronic pain. The 2/22/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15 with no behaviors. The resident required staff supervision for eating. The resident received six insulin injections during the seven-day review assessment. B. Resident interview and observations The resident was interviewed on 3/18/24 at 9:02 a.m. He said he wanted to be on a diabetic diet and he was not. He said he was served foods that were not on his prescribed diet. The resident was interviewed again on 3/20/24 at 3:00 p.m. He said he was served the main entree for each meal. He said each of the meals contained lots of carbohydrates and he always ate what they placed in front of him. He said he knew better than to eat the carbohydrates but he ate them anyway. He said staff had not talked with him regarding the foods that he should/should not eat and he felt someone should have discussed this with him. He said he had gained approximately 15 pounds and he did not want to gain weight. The resident's plate was observed on 3/20/24 at 5:40 p.m. and there were two slices of tomato on the plate. The resident said, because he was on a renal diet, he should not have been served the tomatoes. C. Record review A physician's order started on 2/16/24 at 6:25 p.m. revealed a controlled carbohydrate (CCHO) regular diet with a level 7 texture and a thin level 0 consistency. A care plan for diabetes mellitus was initiated on 2/16/24. The pertinent interventions were for a dietary consult for nutritional regimen and ongoing monitoring. Discuss with the resident his meal times, portion sizes, dietary restrictions, snacks that were allowed in his nutritional plan and his compliance with the nutritional regimen initiated on 3/10/24. A care plan for nutritional problems or potential nutritional problems related to diabetes, hypertension, depression, anemia, chronic kidney disease, depression and dementia, weakness, skin breakdown, and diet restrictions was initiated on 2/21/24. The pertinent interventions were to provide and serve the diet as ordered. Monitor the resident's meal intakes and record for each meal. The resident's meal card, dated 3/20/24, revealed a regular CCHO diet with thin liquids. III. Resident #39 A. Resident status Resident #39, age greater than 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease and anxiety. The 1/23/24 MDS assessment showed the resident had severe cognitive impairments with a BIMS score of five out of 15. B. Record review The 1/27/24 CPO showed an order which read regular diet, level seven please cut up patient's food into bite size pieces. The nutrition care plan, revised 1/31/24 showed the resident was at risk for nutritional problems related to Alzheimer's disease. The pertinent intervention was to provide and serve diet as ordered. The resident's meal ticket read cut up food into bite size pieces. C. Observations On 3/19/24 at 12:15 p.m. the Resident #39 received a peanut butter and jelly sandwich for lunch. When the sandwich left the kitchen it was cut in half. When it was served the activity director (AD) served the meal to the resident. The sandwich was cut one more time into fourths. D. Interview The registered dietitian (RD) was interviewed on 3/20/24 at 5:07 p.m. The RD said the peanut butter and jelly sandwich for Resident #39 should have been cut into bite size pieces. She said cutting the sandwich into four pieces was not sufficient. IV. Additional interviews The dietary manager (DM) was interviewed on 3/21/24 at 11:16 a.m. The DM said the facility had been using the International Dysphagia Diet Standardization Initiative (IDDSI) program for therapeutic diets since February 2023. She said when the training was initiated, staff were trained about the new program. She said since the first training was completed the facility had not trained on the IDDSI, however, she said there had been a lot of staff turnover since then and not all staff was trained. She said she personally trained all the kitchen staff that prepared and cooked the food but had not trained any of the serving staff. The speech therapist (ST) was interviewed on 3/21/24 at 1:42 p.m. The ST said, although residents were on therapeutic diets, the facility could issue waivers to allow the residents to liberalize their own diets. She said residents who did not follow their IDDSI plan were at risk for choking or unplanned nutritional deficits due to increased difficulty to chew. 20287 19262

Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#54) of one resident out of 47 sample residents. Specifically, the facility failed to ensure trauma assessments were conducted to determine the residents history of post-traumatic stress disorder (PTSD) and/or trauma, identify triggers and develop person centered interventions within the comprehensive care plan for Resident #54. Findings include: I. Facility policy The Trauma Informed Care policy and procedure, revised August 2022, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, Resident Assessment: Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. Use assessment tools that are facility-approved and specific to the resident population. Resident Care Planning: Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression). Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. For example: food preparation and choices; clothing preferences such as covering hair or exposed skin; physical contact or provision of care by a person of the opposite sex; or cultural etiquette, such as avoiding eye contact or not raising the voice. II. Resident #54 A. Resident status Resident #54, age 82, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included respiratory disease, limitations of activity due to disability, insomnia and PTSD. The 1/30/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance of two staff members with transfers, dressing, toilet use and personal hygiene. He displayed no behavioral symptoms. B. Record review A Resident Trauma interview, dated 3/21/24 at 2:08 p.m. (during the survey) revealed Resident #54 had a history of PTSD due to exposure to active duty combat while serving in the Vietnam War. He experienced the following symptoms related to his trauma: nightmares, flashbacks, intrusive images, sleep disturbance and irritation. He was not using any methods to cope with his trauma but said he wouldn't mind talking to someone about his experiences because talking about it helps take the trauma away. The interview revealed the residents were a good fit for a trauma informed care plan. The interview determined the follow parameters for a care plan for resident #54. The trauma related care plan, initiated 3/21/24 (during the survey), revealed Resident #54 had a past history of trauma related to active duty combat in Vietnam. He had a history of trauma that resulted in difficulty connecting and trusting others. Behaviors the resident might exhibit included being resistive to care and poor interpersonal interactions. The resident would communicate needs and preferences to staff in order to help accept recommended care and would verbalize feelings and identify ways staff could support feelings of safety. Interventions recommended included involving family and other supports in resident care whenever possible to maintain/develop connections and personal interests as well as providing consistent care providers whenever possible. -The social services director (SSD) who completed the interview, did not select interventions related to limiting triggering stimulus, assessment for further therapeutic services/specialists and interventions directing staff to approach directly and speak to the resident in a calm manner. -Review of Resident #54's electronic medical record (EMR) did not reveal documentation to indicate the facility had conducted a screening assessment specific to trauma or initiated a care plan related to the resident's PTSD to include personalized triggers, person-centered individualized interventions or personalized signs and symptoms of retraumatization completed when the resident admitted to the facility on [DATE]. C. Staff interviews Registered nurse (RN) #4 was interviewed on 03/21/24 at 1:24 p.m. RN #4 said the facility did not do any training based on trauma informed care. He said the facility did not provide any training for residents with mental health diagnoses. He said being trained to better understand residents with PTSD, to include what things could trigger them, would greatly increase the quality of care he provided to the residents. The SSD was interviewed on 3/21/24 at 12:12 p.m. The SSD said the facility did not generate care plans for residents with a PTSD diagnosis. He said the facility was aware of common PTSD triggers to look out for to include loud noises and bright lights so there was no reason to know individual resident triggers. He said he was aware of Resident #54's PTSD diagnosis but did not know any history or triggers associated with the resident specifically because the facility had not completed any assessments or interviews to determine any individualized care the resident would need. The SSD said to accurately care for the residents that had PTSD diagnoses, the facility should have created care plans specific to each resident's trauma and triggers. He said not knowing a resident's triggers or being knowledgeable about every resident's individualized trauma and needs could put the resident or other residents and staff in danger. The SSD said without proper psychosocial care training the staff could misinterpret the residents' behaviors and responses to certain things and do more harm than good when caring for the residents.

Based on observations, record review and interviews the facility failed to ensure residents with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM for one (#36) of one resident reviewed for limited ROM out of 47 sample residents. Specifically, the facility failed to ensure Resident #36 was provided with restorative services to maintain or prevent worsening of her right hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff). Findings include: I. Facility policy and procedures The Restorative Nursing Services policy, revised March 2018, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and the plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and participating in the development and implementation of his/her plan of care. II. Resident #36 A. Resident status Resident #36, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included Cerebral palsy, limitation of activities due to disability, history of traumatic fracture and contracture. The 12/11/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. According to the assessment, the resident did not exhibit behaviors or refuse care. The resident was totally dependent on staff for toileting, dressing and bed mobility. She required maximum assistance for personal hygiene. She required supervision for oral hygiene and was independant with eating. The assessment documented the resident did not receive any therapy services during the seven-day review period. B. Resident interview and observations On 3/17/24 at 5:24 p.m. Resident #36 was seated at the dining room table and eating with her left hand. She had a right arm/wrist/hand contracture. -She did not have any splint in place on her right hand to help prevent her contracture from worsening. On 3/18/24 at 2:08 p.m., the resident was seated in a chair next to the nurses station. She had a right arm/wrist/hand contracture. -She did not have any splint in place on her right hand to help prevent her contracture from worsening. On 3/19/24 at 3:04 p.m., Resident #36 was seated in a chair next to the nurses station. She had a right arm/wrist/hand contracture. She was holding a coloring book with her left hand. -She did not have any splint in place on her right hand to help prevent her contracture from worsening. On 3/20/24 at 10:14 a.m., the resident was seated in a chair next to the nurses station. She had a right arm/wrist/hand contracture. -She did not have any splint in place on her right hand to help prevent her contracture from worsening C. Record review An activities of daily living (ADL) care plan, initiated 10/22/22 and revised 7/5/23, revealed Resident #36 had ADL deficits related to cerebral palsy, right ankle fracture and right arm contracture. Pertinent interventions included the resident required the use of a wheelchair for mobility, staff were to assist the resident with eating and the resident required extensive assistance by one staff member for bed mobility and transfers. -The care plan failed to have any interventions related Resident #36's right hand contracture. A limited physical mobility care plan, initiated 10/22/22 and revised 7/5/23, revealed Resident #36 had limited physical ability related to cerebral palsy, right ankle fracture and right arm contracture. Pertinent interventions included the resident required assistance by one staff to move between surfaces, staff were to provide supportive care and assistance with mobility as needed, physical therapy (PT) and occupational therapy (OT) referrals as needed, and restorative nursing staff was to provide an active range of motion program to include exercises of the resident's choice to the upper and lower extremities as tolerated. -On 3/20/24, during the survey, an additional intervention was added to Resident #36's limited mobility care plan. The new intervention documented restorative nursing would provide passive range of motion to the right upper extremity by providing the resident with gentle stretch extension to the right elbow/shoulder/wrist. The staff were to provide gentle extension as tolerated. The staff were to provide extension with gentle pressure for a 10 to 15 second count as tolerated, monitor facial grimace and provide three to five repetitions per joint as tolerated for contracture prevention. An alteration of musculoskeletal status care plan, initiated on 11/1/22, revealed Resident #36 had altered musculoskeletal status related to cerebral palsy, right ankle fracture and right arm contracture. The relevant interventions were for the staff to anticipate and meet needs and ensure the resident's call light was within reach and response was prompt for all calls for assistance. A therapy progress note, documented by physical therapy on 10/29/23 at 4:28 p.m., revealed the resident was screened for therapy services to address contracture management. The resident was not interested in contracture management focused therapy. Resident #36 had several comorbidities impacting the resident's ability to tolerate interventions. Nursing also reported no known changes in contracture status. No skilled therapy services to address contracture management were recommended. A restorative progress note written on 3/20/24 at 5:14 p.m., during the survey, documented the resident was to begin a restorative passive range of motion (PROM) program to the right upper extremity for contracture prevention. The goal was to increase/maintain ROM to assist the resident to maintain/increase her ADLs. III. Staff interviews Licenced practical nurse (LPN) #4, who was also in charge of the facility's restorative nursing program, was interviewed on 3/20/24 at 3:32 p.m. LPN #4 said Resident #36 was not currently on a restorative nursing ROM or splinting program. He said he trained a few certified nursing aides (CNA) to help perform passive range of motion for residents enrolled in the restorative program. He said only the CNAs trained by him were permitted to document PROM in residents' electronic medical records (EMR). Registered nurse (RN) #4 was interviewed on 3/21/24 at 1:24 p.m. RN #4 said any resident with a contracture was supposed to be managed by restorative nursing in addition to having evaluations with PT/OT if the resident was eligible for therapy services. He said splints were not used for every resident with contractures but it was a common practice to help prevent worsening contractures. RN #4 said Resident #36 did have a diagnosis of a contracture but was not enrolled in the restorative program for the contracture specifically, but because of her posture. He said he would have Resident #36 evaluated for her right hand contracture as soon as possible. V. Facility follow up On 3/25/24 at 12:56 p.m., after the survey exit, an occupational therapy evaluation, completed on 3/22/24 was provided by the NHA via email. The evaluation identified new goals for Resident #36 to include that the resident would increase active range of motion (AROM) in her right elbow/forearm extension in order to facilitate optimal pain-free performance during ADLs for short term and would participate in the right upper extremity PROM to decrease risk of further musculoskeletal deficits. -The occupational therapy evaluation was not completed until after the survey exit on 3/21/24.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#17 and #19) of two residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to ensure Resident #17 and #19 received showers as scheduled. Findings include: I. Facility policy and procedure The Bathing policy was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: The facility will try to bathe residents in their preferred way at their preferred times. II. Resident #17 A. Resident status Resident #17, age 86, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease, hemiplegia (one sided paralysis), diabetes and neuromuscular dysfunction of the bladder. The 2/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with eating and oral hygiene, dependent for toileting hygiene and required substantial assistance with dressing. The assessment documented tub and shower transfers were not attempted during the seven day MDS assessment look back period due to the resident's medical condition. The 11/14/23 MDS assessment revealed Resident #17 found it was very important to choose between tub bath, shower and bed bath. B. Resident interview and observation Resident #17 was interviewed on 3/18/24 at 11:45 a.m. Resident #17's hair appeared disheveled. Resident #17 said he had missed showers approximately once per week during the past month because the facility did not have someone available to assist him. He said he enjoyed his showers and feeling clean afterward. He said the staff did not notify him when they were unable to offer a shower on his scheduled shower dates. C. Record review Resident #17's care plan, revised 12/6/23, revealed his bathing preference was three times per week. He required extensive assistance of one staff member for transfer between surfaces for bathing. The facility Bath and Skin Report for 1/23/24 through 3/19/24 was provided by QM #1 on 3/20/24 at 5:00 p.m. It revealed the following shower documentation for Resident #17: During a four week period from 1/23/24 to 2/20/24, the resident received showers on 1/23/24, 1/28/24, 2/1/24, 2/6/24, 2/8/24, 2/11/24, 2/13/24, 2/15/24, 2/18/24 and 2/20/24. Resident #17 refused to shower on 2/4/24. -There were 12 scheduled opportunities for showers during this period and Resident #17 received 10 showers (and refused one shower). During a four week period from 2/21/24 to 3/19/24, the resident received showers on 2/22/24, 2/27/24, 2/29/24, 3/5/24, 3/7/24, 3/12/24, 3/17/24 and 3/19/24. Resident #17 refused to shower on 2/25/24. -There were 12 scheduled opportunities for showers during this period and Resident #17 received eight showers. A shower log note documented on 2/25/24 revealed Resident #17 refused his shower on 2/25/24 but requested the shower be given on 2/26/24. -There was no documentation that the resident received a shower on 2/26/24. D. Staff Interviews Licensed practical nurse (LPN) #5, who was the unit manager, was interviewed on 3/20/24 at 2:09 p.m. LPN #5 said she expected Resident #17 to receive at least 12 showers over four weeks based upon his preference of three showers per week. She said Resident #17 should have received three additional showers over the past four weeks. Registered nurse (RN) #5 was interviewed on 3/20/24 at 3:53 p.m. RN #5 said Resident #17 had not told her he was not showering enough, however, she said he told her when he received his showers because the resident said he liked his showers. RN #4 was interviewed on 3/21/24 at 9:15 a.m. RN #4 said Resident #17 told him one week ago he was not getting his showers as scheduled. III. Resident #19 A. Resident status Resident #19, age 75, was admitted on [DATE]. According to the March 2024 CPO,diagnoses included kidney disease, heart disease, diabetes and depression. The 1/2/24 MDS assessment revealed Resident #19 was cognitively intact with a BIMS score of 15 out of 15. Resident #19 was independent with eating, hygiene and transferring self from bed to wheelchair. The assessment revealed it was very important for Resident #19 to choose between tub bath, shower and bed bath. B. Resident interview Resident #19 was interviewed on 3/18/24 at 2:00 p.m. Resident #19 said the facility was understaffed and often reassigned the certified nurses aide (CNA) who was assigned to shower duty which caused residents to miss showers. Resident #19 said if a shower day was missed the residents often had to wait until the next scheduled shower day. She said there were at least two days per month she was not getting showers as planned. C. Record review Resident #19's care plan, revised 12/8/23, revealed her bathing preference was two times per week and she required set-up assistance with bathing. The facility Bath and Skin Report for the 1/23/24 through 3/19/24 was provided by QM #1 on 3/20/24 at 5:00 p.m. It revealed the following shower documentation for Resident #19: During a four week period from 1/23/24 to 2/20/24, the resident received at least two showers per week. During a four week period from 2/21/24 to 3/19/24, the resident received showers on 2/25/24, 2/28/24, 3/6/24, 3/13/24, 3/17/24 and 3/20/24. -There were eight scheduled opportunities for showers during this period and Resident #19 received six showers. There were no documented refusals during this period. D. Staff interviews CNA #1 was interviewed on 3/20/24 at 2:02 p.m. CNA #1 said the facility sometimes would pull the shower aide off bath duties to the floor due to staffing. CNA #1 said when the shower aide was pulled to the floor residents would not receive a shower on their scheduled day or the next day if she was not working. LPN #5 was interviewed on 3/20/24 at 2:09 p.m. LPN #5 said she expected Resident #19 to receive at least eight showers in four weeks based upon her preference of two showers per week. She said Resident #19 should have received two additional showers over the past four weeks.

Based on interviews and record review, the facility failed to ensure one (#29) of two residents reviewed for abuse out of 47 sample residents was kept free from abuse. Specifically, the facility failed to ensure Resident #29 was kept free from physical abuse by Resident #27. Findings include: I. Facility policy and procedure The Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 3/17/24 at 5:13 p.m. It read in pertinent part: -Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. -Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Willful - means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. -Each facility assesses each potential resident prior to admission. This assessment includes a behavior history. Persons with a significant history or high risk of violent behavior are carefully screened and assessed for appropriateness of admission. II. Incident of physical abuse by Resident #27 toward Resident #29 The investigation was provided by the quality mentor (QM) #1 on 3/19/24 at 12:10 p.m. The investigation, dated 3/14/24, documented Resident #29 reported Resident #27 struck her with a closed fist in the right shoulder/back of the head area after Bingo. Resident #29 reported Resident #27 was upset that other residents were winning at Bingo. The residents were separated and frequent checks were initiated. Assessments were performed with no evidence of injury per report. According to the abuse investigation report, current status of the victim: Resident #29 returned to baseline shortly after the incident. The resident was tearful in the dining room but did not wish to eat lunch elsewhere and stated she was okay if the alleged assailant was seen/came down to the dining room for lunch. The investigation revealed staff and resident witnesses who confirmed Resident #27 made contact and hit Resident #29. The investigation included an interview with Resident #27 who indicated she did not remember what happened. The facility substantiated the physical abuse. III. Resident #27 A. Resident status Resident #27, age under 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included leukemia (cancer), diabetes, depression and cognitive communication deficit. The 2/22/24 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She was independent with hygiene, dressing and transferring herself. Resident #27 exhibited behavioral symptoms not directed toward others one to three days in the past seven days (examples of physical symptoms such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming). B. Record review The delusions/paranoia behavior care plan, revised 3/5/24, documented Resident #27 had a history of confusion and agitation with aggressive behaviors. The interventions included medications per order and pain assessment every shift when agitated, ascertaining causes of symptoms, conducting interventions matching causes of symptoms including resident habits, preferences, current ability and notifying the physician of behaviors. On 3/15/24 at 7:53 a.m., provider documentation included the following progress note: Per staff report and documentation, the patient has been having increasing behaviors over the last several weeks, especially in the evenings, including verbal aggression toward staff and other residents, paranoid delusions with racial fixation and even struck another resident. IV. Resident #29 A. Resident status Resident #29, age 75, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included diabetes, hemiplegia (paralysis on one side), respiratory failure and chronic kidney disease. The 1/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident had not exhibited any behavioral symptoms. B. Resident interview Resident #29 was interviewed on 3/18/24 at 3:00 p.m. Resident #29 said she was hit by Resident #27 four days earlier (3/14/24). She said Resident #27 hit her on the right side of her shoulder with her fist. She said it hurt when it happened but felt better after. Resident #29 said Resident #27 was mad that other residents won at Bingo. She said Resident #27 got mad at Resident #29 for saying it was a game. Resident #29 said there were witnesses to the incident. Resident #29 said the social service director (SSD) told her the police were going to come talk to her and they had not done so yet. She said she wanted to press charges. Resident #29 said the SSD said he would be back the next day to meet about what happened but he had not returned to see her. Resident #29 was interviewed again on 3/21/24 at 9:05 a.m. She said she had not had further issues with Resident #27. She said the facility had moved Resident #27 to a different table (apart from Resident #29) and staff supervision was provided. She said she felt safe and was not fearful. C. Record review Resident #29 had a behavioral care plan, revised 12/8/23, which addressed her potential to make false allegations and display misperception of reality. Interventions included anticipating needs, reassurance staff were there to assist, provide opportunity for positive interaction, stopping to talk with Resident #29 when walking by and monitoring behavior episodes to determine underlying cause. A nursing progress note on 3/13/24 at 11:00 a.m. documented in pertinent part: Resident (#29) reported to nurse that resident (#27) hit me in the right arm. Skin warm, dry and intact. Skin color within normal limits for the resident, denies pain/discomfort. Provider notified. A nursing skin assessment on 3/14/24 at 8:48 p.m. documented in pertinent part: Skin intact, no new skin conditions noted. Continuing on every 15 minute checks related to altercation with another resident. V. Staff interviews Registered nurse (RN) #5 was interviewed on 3/20/24 at 3:56 p.m. RN #5 said Resident #29 told her she was punched by another resident at Bingo a few days ago. She said Resident #29 did not indicate any further concerns. RN #4 was interviewed on 3/21/24 at 9:19 a.m. RN #4 said he was aware Resident #29 was hit by another resident. He said Resident #29 did not seem fearful and she had not indicated she was in pain. The SSD was interviewed on 3/21/24 at 10:23 a.m. The SSD said he was in the dining room when a nurse told him Resident #27 had hit Resident #29. He said the activities assistant separated the residents with assistance from the activity director. The SSD said he asked Resident #29 if she felt safe and she responded that she was okay. The SSD said he told Resident #29 the police might come to talk with her. The SSD said he contacted Resident #29's representative and provided the police case number. The SSD said the resident did not tell him she wanted to press charges against Resident #27. The SSD said he had not yet spoken with Resident #29 about the results of the investigation conducted by the facility. The NHA was interviewed on 3/21/24 at 1:55 p.m. The NHA said she was not aware Resident #29 wanted to press charges against Resident #27 until 3/21/24. The NHA said she spoke with the investigating officer who had spoken with Resident #29 on 3/21/24, during the survey. The NHA said according to witnesses, Resident #27 hit Resident #29 with a closed fist and the physical contact was substantiated. The NHA said Resident #29 had not indicated that she was fearful of Resident #27. The NHA said the facility had put interventions in place to prevent physical altercation from Resident #27 during Bingo. The NHA was interviewed again on 3/21/24 at 2:35 p.m. The NHA said the facility was going to utilize a sitter for Resident #27 until a plan was in place to prevent further abuse. Resident #23 was interviewed on 3/21/24 at 6:15 p.m. She said she was sitting next to Resident #29 when the incident occurred. She said the residents had just finished playing Bingo when Resident #27 became angry. Resident #23 said Resident #27 was sitting at a table behind Resident #29. She said Resident #27 turned toward Resident #29 and hit her. Resident #23 did not remember the location of impact or if Resident #27's fist was closed when she hit Resident #29. Resident #23 said she was not fearful of Resident #27.

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for two (#72 and #14) of four residents reviewed for notifications out of 47 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #72 and Resident #14 and/or their representatives. Findings include: I. Facility policy and procedure The Room Change and Room Change Notices policy, dated 11/4/23, was provided by quality mentor (QM) #1 on 3/21/24 at approximately 2:00 p.m. The policy read in pertinent part To ensure that residents are afforded their right to prior notification of room or roommate changes and the right to appeal these changes. Residents will be notified in advance of room or roommate changes and of their right to appeal these changes. The SSD/RSD (social service director/ resident service director) or designee will meet with the resident to explain the purpose of the room/roommate change and to provide an opportunity for the resident to express any concerns and ask questions as a result of the change(s). The resident/legal representative will be asked to review and sign the five days notice of the room change, prior to the change occurring. The resident will be advised of the right to waive the notice and/or to appeal the change within those five days. II. Resident #72 A. Resident status Resident #72, age 77, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease and hypertension. The 3/11/24 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was dependent on staff for activities of daily living. B. Resident interview Resident #72 was interviewed on 3/21/24 at 10:50 p.m. Resident #72 said he received a new roommate a few weeks ago. He said he was not provided anything in writing or provided any verbal notice before he got his new roommate. C. Record review -Review of Residents #72's electronic medical record (EMR) revealed no documentation to indicate the resident was informed he would be getting a new roommate. III. Resident #14 Resident #14, age 73, was admitted on [DATE]. According to the March CPO, diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease and end stage kidney disease. The 2/20/24 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a BIMS score of seven out of 1. The resident was dependent on staff for activities of daily living. B. Resident interview Resident #14 was interviewed on 3/19/23 at 3:39 p.m. Resident #14 said she did not like her roommate because she talked too much. She said she was not asked or told anything by the facility when the roommate moved in. She said she was at dialysis and when she returned to her room, the new roommate had moved in. Resident #14 was not informed and was not provided anything in writing regarding getting a new roommate. C. Record review -Review of Residents #14's EMR revealed no documentation to indicate the resident was informed she would be getting a new roommate. III. Interview The social services director (SSD) was interviewed on 3/21/24 at 12:25 p.m. The SSD said a room change authorization form should be filled out for each resident room change or when a resident got a new roommate. He said the form included a five day notice of the change. He said residents were informed verbally of any new roommate. He said the licensed nurses on the floor were responsible for completing room change forms when a new resident was admitted . The SSD said that there were no written room change or new roommate authorization forms completed for either Resident #72 or Resident #14. Registered nurse (RN) #8 was interviewed on 3/21/24 at 2:20 p.m. RN #8 said room change or room mate change forms were not her responsibility and she did not complete any forms. She said the social services department was responsible for completing the forms and informing residents of new roommates

Based on interviews and record review, the facility failed to ensure an effective quality assurance improvement program (QAPI) to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to resident rights, quality of care, pharmacy services, and infection control. The facility failed to identify quality deficiencies and develop effective action plans to ensure systemic and lasting change and improvements in these areas. Specifically, the QAPI committee failed to identify and address concerns related to resident rights, quality of care, pharmacy services and infection control. Findings include: I. Cross-referenced citations Cross-reference F561: the facility failed to ensure one resident received showers according to their preference. Cross-reference F695: the facility failed to ensure physician orders documented the appropriate care and settings of a continuous positive airway pressure (CPAP) machine; failed to follow manufacturer's recommendations for cleaning the CPAP machine; failed to store the CPAP machine properly; failed to identify the CPAP machine on the resident's minimum data set (MDS); and failed to develop a care plan for the use of a CPAP machine. The facility also failed to obtain physician orders for the use, cleaning and storage of a resident's nebulizer machine. Cross-reference F761: the facility failed to properly label and store medications in medication rooms and ensure medications were stored appropriately in medication carts. Cross reference F880: the facility failed to ensure proper hand hygiene occurred during peri care, clean supplies were not stored in the soiled utility room, air vents were cleaned in the laundry room, high touch areas were cleaned in a resident's room, and scissors were cleaned/sanitized prior to use in wound care. II. Facility policy and procedures The Quality Management Plan/Quality Assurance and Performance Improvement Plan policy, reviewed 11/19/18, was provided by the nursing home administration (NHA) on 11/28/22 at 4:07 p.m. The policy revealed this program was designed to objectively, systematically monitor and evaluate the residents' care and health care services. This comprehensive program was designed to provide care that was optimal within available resources and was consistent with achievable goals. Objectives: To ensure that monitoring quality of residents' care was performed systematically and continuously. To identify the organizational components responsible for Quality Management and QAPI Program functions and to delineate the components which included the line of authority, responsibility and accountability. To assure communication among all departments for the improvement of resident care and identifying problems through the use of on-going monitoring by focusing on identification, analysis, and resolution of problems. To evaluate the results of actions taken by each department and to maximize the use of resources available within the facility. The governing body was responsible for oversight and direction of the quality management program (QMP)/QAPI program. The governing body would be responsible for establishing and approving policies to sustain the facility's QMP/QAPI program and would set expectations around resident safety, rights, choice and respect. The Administrator, or designated chairperson, assumed the responsibility for the program and for assuring that the quality of residents' care was the highest possible by demonstrating performance consistent with established standards and enhancing standards through increasing knowledge, commitment, and improvement of care in a cost-effective manner. The QMP/QAPI committee may include but was not limited to medical director, nursing home administrator, director of nursing, department supervisors, pharmacy consultant, and charge nurses. The committee would meet at least quarterly. The department supervisors would report pertinent information for their departments based on data collected from the various systems and committee meetings. It was the goal of the facility to integrate QMP/QAPI into all care and service areas of the organization. The following will be key areas of focus of the facility: clinical care, quality of life, resident choices and care transitions. Effective performance improvement efforts would focus on the development, maintenance and periodic improvement of systems that influenced organizational outcomes. Systems would be designed and modified to achieve reliable, efficient outcomes. III. Repeat deficiencies F561 for resident self-determination During a recertification survey on 8/12/21, resident self-determination was cited at a E level. During the recertification survey on 12/1/22, resident self-determination was cited at an D level. F695 for resident respiratory/tracheostomy care and suctioning During a recertification survey on 8/12/21, resident respiratory/tracheostomy care and suctioning was cited at a E level. During the recertification survey on 12/1/22, resident respiratory/tracheostomy care and suctioning was cited at a D level. F761 for facility labeling and storage of drugs and biologicals During a recertification survey on 8/12/21, facility labeling and storage of drugs and biologicals was cited at a E level. During the recertification survey on 12/1/22, facility labeling and storage of drugs and biologicals was cited at a E level. F880 infection control During a recertification survey on 8/12/21, infection control was cited at a F level. During the recertification on 12/1/22, infection control was cited at an E level. III. Staff interviews The NHA and the director of nursing (DON) was interviewed on 12/1/22 at 4:00 p.m. The NHA said the QAPI committee met on a monthly basis, on the third Wednesday of the month. The NHA said the attendees to the meeting were the NHA, DON, medical director, pharmacist consultant, activity director, dietary manager, health information manager, staff development coordinator, registered dietitian, social services director, business office manager, director of rehabilitation, medical records staff and a restorative nurse. The NHA said the facility gathered information form grievance forms, committee weekly meetings, resident council meetings, huddles (interdisciplinary team meets with floor staff each morning), 24-hour reports, [NAME] reports (a report of clinical indicators), past hospitalization s, satisfaction survey with residents and families, a weekly clinical report that was sent to the corporate office, clinical quality improvement staff review ten random residents' clinical records each month, mock pre-surveys, and the review of past survey results. They conduct audits to find things that they are not doing well. Any staff member or resident can bring a concern to the QAPI committee. The NHA said the committee analyzed the root cause of the concern by using the 5 Whys ( problem solving methodology that explored the underlying cause and effect of a specified concern) approach. The committee then developed an action plan or a performance improvement plan (PIP) to address the concern. The committee developed specific goals for the PIP. The committee developed interventions to achieve the desired goals for the identified concern. The length of the PIP depended on the goals that were developed and how effective the interventions were working. The NHA said the interventions were effective by conducting a lot of audits and measuring the audits with the established goals. She said once the goals had been met, the audits were spaced further apart to make sure the goals continued to be sustained. The NHA said if the audits demonstrated the goals were not being met, the committee reviewed the action plan and determined new interventions to achieve the desired goals. She said the committee could meet as needed to make any necessary changes to the interventions. She said the PIP was a working document. The NHA said for F561 for resident self-determination for showers. On the last survey dated 8/12/21 the facility was missing the resident's shower preference on admission. She said at this time the facility had a good plan to capture the resident's shower preferences and at times they were not able to provide showers according to their preferences. She said currently some of the issues related to this concern were, at times the bath aides did not show up for work and the facility had to use floor certified nurse aides (CNAs) to provide showers. She said the facility also had shower documentation concerns in the resident's clinical record. She said the staff should document that a shower had been given or refused by the end of their shift. The NHA said for F695, the facility previously had missing physician orders and/or they were not following the physician orders that they received. She said upon admission the facility needed to audit all of the physician orders to ensure they were in place. The NHA said for F761 the facility did audits for a long time and felt that this deficiency was corrected. She said the facility needed to make regular audits to ensure this deficiency was still corrected. The NHA said for F880, the facility had completed audits on infection control. She said she did not remember any of the current concerns with infection control had been identified in the audits.

Based on record review and interviews, the facility failed to ensure five out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct annual nursing competencies. I. Facility policy and procedure The Competency of Nursing Staff policy, revised May 2019, was provided by the infection preventionist (IP) on 12/1/22 at 3:11 p.m. It documented in pertinent part, All nursing staff must meet the specific competency requirements of their respective licensure and certification. In addition, nurse assistants will participate in a facility-specific competencies-based staff development and training program, and demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents as identified through resident assessments and described in the plans of care. The facility assessment included an evaluation of the staff competencies that were necessary to provide the level and types of care specific to the resident population. Facility and resident-specific competency evaluations would be conducted upon hire, annually and as deemed necessary based on the facility assessment. II. Record review The employee files for five CNAs (certified nurse aides), were reviewed on 12/1/22 at 12:27 p.m. and did not contain a skills competency checklist. CNA #8's last competency was completed on 8/27/19, CNA #9's last competency was completed on 4/28/2020, CNAs #5, #6, and #7 had no competencies on file. III. Staff interviews The director of nursing (DON) was interviewed on 12/1/22 at 1:50 p.m. He said the staff development coordinator (SDC) was hired in August 2022, but had been out related to health issues. He said at that time the two unit managers stepped in to help. He said the previous week he had asked human resources (HR) for a list of CNAs whose competencies were due. He said the five CNAs missing their competencies must not have been on the list. He said they had an annual skills fair and that was when the competencies were completed. He said the facility did not perform individualized training for the CNAs. He said moving forward he would work with HR to provide accurate lists of annual competencies needed. The nursing home administrator (NHA) was interviewed on 12/1/22 at 3:13 p.m. She said the facility had a turn over of SDCs and HR staff. She said the facility held an annual skills fair in April 2022 to make sure staff was getting their training. She said the training was not individualized but rather a mass training. She said the facility had a new SDC and would work with corporate on a tracking process for annual evaluations and competencies.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of four medication carts and one of two storage rooms. Specifically the facility failed to: -Ensure loose medications in cart were properly disposed of; -Ensure temperature of refrigerators were kept within a safe range; and, -Ensure medications were labeled with open dates. Findings include: I. Manufacturer's recommendations According to the Tubersol package insert, retrieved 12/7/22 from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. II. Facility policy and procedure The Storage of medications policy, undated, received from the infection preventionist (IP) on 12/1/22 at 12:45 p.m. revealed in pertinent part, The facility stores all drugs and biologics in a safe, secure and orderly manner. Drugs and biologics used in the facility are stored under proper temperatures. Medications requiring refrigeration are stored in a refrigerator located in the drug room at nurses station or other secured location. Medications are labeled accordingly. The nursing staff are responsible for maintaining medications storage, and preparation areas in clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy. III. Observations and interviews On 12/1/22 at 11:25 a.m. Cart one on the Challenger hallway assigned to registered nurse (RN) #1. The cart contained 21 whole tablets and one half tablet loose in the cart. The nurse was unable to identify any of the loose medications. She did not know who was responsible for maintaining the cleanliness of the medication carts. She said medications needed to be disposed of immediately into a drug buster to prevent medications from harming a resident if they were able to get a hold of it. At 11:30 a.m. Cart two on Alpine hallway assigned to RN #2 revealed three whole tablets and one half tablet loose in the cart. The nurse was unable to identify medications. One Lantus insulin (medication for diabetes) pen was found to be open with no open date. She said the insulin pen should have been dated on opening to ensure staff know when it expires. She said she opened it with this morning dose. She then labeled the insulin pen with an open date of 12/1/22. She said she did not know by who or when the medication carts were cleaned. She disposed of loose pills into drug busters and said medications should be disposed of into drug busters to prevent residents getting wrong medication. The Alpine medication room was reviewed with the IP at 11:45 a.m. Upon opening the medication room a beeping noise was heard. The medication refrigerator was open, the temperature reading was 75 degrees fahrenheit, which was verified by IP. She was unable to determine how long the refrigerator was left open for. The refrigerator contained the following medications: a lock box with Ativan (anti-anxiety medication); emergency kit with Humalog, Humulin R and Lantus insulins (all used to treat diabetes); 30 acetaminophen 650 mg suppositories (fever and pain reducer); two Lantus insulin pens; one Humalog insulin pen; two vials of Humalog insulin; two vials of Turbersol (used to test for tuberculosis); and three bottles of Brimonidine tartrate (eye drops). The IP said all medications need to be evaluated to see if they could be used or if they need to be replaced. She said she would call the pharmacy and determine what needed to be done with variation in temperature. One vial of Tubersol was found opened and undated. The IP said it should have been dated with an open date to ensure it is not used past its expiration date. She said the TB medication needed to be destroyed as the staff are unable to determine when the vial was first accessed. The director of nursing (DON) was interviewed at 12:06 p.m. He said the nurses were responsible for maintaining the cleanliness of the medication carts. The duty of cleaning the cart was not assigned to any specific shift nor did he have any way of ensuring that the carts were maintained clean. He said loose medications in carts should be disposed of into the drug buster as soon as they were not used or found to prevent a resident from getting the wrong medication which could be harmful to their health. He said a vial/pen of insulin should be dated with the open date when first accessed, to ensure staff know when to use the medication by. Insulins should be discarded 28 days after the open date. Tubersol vials also need an open date applied when the initial access occurred to prevent the medication from being used past the expiration date. He said he did not know the expiration date of the Tubersol once opened. He said the unit nurse manager had the responsibility of removing expired medications from circulation on the carts and the medications rooms. The IP was interviewed a second time at 12:40 p.m. She said she called the pharmacy to discuss medications found in the open refrigerator. The pharmacist instructed her that the eye drops medications did not need to be stored in the refrigerator. The emergency kits containing insulin were safe for 24 hours at room temperature. All other insulin medications will be put into circulation today with an expiration date 28 days from 12/1/22. The Ativan was okay to be stored at room temperature for 60 days. The Tubersol would be discarded due to no date and temperature fluctuations.

Based on resident, staff interviews and record review, the facility failed to ensure a dignified existence was provided for one (#40) of three residents reviewed out of 37 sample residents. Specifically, the facility failed to respond in a timely manner to Resident #40's requests for assistance after incontinence episodes and did not honor her request for a specific agency staff member to not work with her. Due to the agency staff member not providing timely incontinence care on one occasion in June 2021, the resident reported she felt embarrassed, that her health was being jeopardized and that her blood pressure increased. After the resident requested that agency staff member not work with her again, the agency staff member did work with the resident in July 2021. The resident requested to be changed by the agency staff member in July 2021 due to her skin becoming irritated. The agency staff member left the resident's room without providing care which made the resident feel like a second class citizen. Findings include: I. Facility policies and procedures The Statement of Resident Rights section of the facility admissions paperwork, undated, was provided by the nursing home administrator (NHA) on 8/10/21 at 11:00 a.m. It read in pertinent part, You have the right to a dignified existence, self-determination, communication with, and access to, persons and services inside and outside of our facility. You have the right to be treated with respect and dignity in an environment that promotes maintenance or enhancement of your quality of life in a manner that recognizes your individuality. II. Resident #40 A. Resident status Resident #40, age 73, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/8/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 14 out of 15. She required limited assistance with one person physical assistance for bed mobility, transfers, and dressing. She required extensive assistance and one person physical assistance for toileting and personal hygiene. The assessment revealed the resident had no behavioral concerns and did not reject care during the assessment period. B. Resident interview Resident #40 was interviewed on 8/9/21 at 12:45 p.m. and again at 5:07 p.m. Resident #40 said she had concerns about the way she was treated by agency certified nurse aide (ACNA) #3. She said there was a day in June 2021 where ACNA #3 did not assist her with changing her briefs after a bowel movement for over an hour and a half. She said ACNA #3 would not answer her call light. She said she told the previous director of nursing (DON) that she did not want ACNA #3 to work with her again, but the same issue happened again in July 2021. She said in July 2021, ACNA #3 came into her room to take her vitals and when she asked ACNA #3 to provide incontinence care due to her skin becoming irritated, ACNA #3 said she had to go do something else for the nurse and left the room without providing care and did not return. The resident said that made her feel like a second-class citizen. The resident said she told her nurse and the previous DON about her concerns with ACNA #3 back in June 2021 and they assured her that ACNA #3 would not work with her anymore. However, ACNA #3 did work with the resident again in July 2021 according to the resident, ACNA #3, and the NHA (see below). The resident said she was not afraid of ACNA #3, but did not want to have her provide care again. III. Grievance report The NHA provided the 6/18/21 grievance filed by Resident #40 on 8/9/21 at 2:03 p.m. The grievance form documented that on the afternoon of 6/16/21, Resident #40 was left sitting in soiled briefs for an hour because her call light was not answered timely by ACNA #3. The resident was embarrassed because the wound doctor saw her while she was sitting in feces. When ACNA #3 did check on the resident, the resident asked ACNA #3 where she had been, and ACNA #3 told the resident they were short staffed. The resident said she felt her health was jeopardized and that her blood pressure was up. ACNA #3 said she would tell the nurse but the nurse did not come until it was time for her regular medications. The resident denied being afraid of ACNA #3. The follow-up action section of the grievance form documented that ACNA #3 would not be scheduled to work with Resident #40 again. -However, Resident #40, who had no cognitive impairments, said ACNA #3 did work with her again in July 2021 when she came to take her vital signs and refused to provide her incontinence care. -A grievance report was not completed with regards to the July 2021 concern. IV. Call light times The quality improvement specialist (QIS) provided the call light logs for Resident #40 on 8/10/21 at 3:18 p.m. Review of Resident #40's call light logs revealed the following information: -6/16/21 at 2:43 p.m. the call light was not answered for 34 minutes. -6/16/21 at 5:51 p.m. the call light was not answered for 43 minutes. -6/16/21 at 7:23 p.m. the call light was not answered for 38 minutes. V. Care plan The resident's comprehensive care plan, last revised 8/9/21, revealed the resident had a behavior problem related to refusal of care/staff assistance and paranoia. The resident at times would refuse to engage in her plan of care and would engage in staff splitting behavior as evidenced by being very kind to staff and then talking about them to other staff in an unkind way. Pertinent interventions included: -Administer medications as ordered. Monitor/document for side effects and effectiveness (initiated 1/7/21); -Anticipate and meet the resident's needs (initiated 1/7/21); -Caregivers to provide opportunities for positive interaction and attention. Stop and talk to resident when passing by (initiated 1/7/21); -Explain all procedures to the resident before starting and allow the resident time to adjust to changes (initiated 1/7/21); and, -Provide a program of activities that is of interest and accommodates resident status (initiated 1/7/21). VI. Staff interviews The NHA and the QIS were interviewed on 8/9/21 at 3:44 p.m. The QIS said ACNA #3 was taken off the schedule to assist Resident #40 in June 2021 but was somehow reassigned to help Resident #40 again in July 2021. The QIS said she did not know how ACNA #3 got assigned to work with Resident #40 again. ACNA #3 was interviewed on 8/11/21 at 9:39 a.m. ACNA #3 said she worked with Resident #40 twice. She said the first time she worked with Resident #40, the resident was very disrespectful to her and she asked her manager to make sure she was not assigned to that hallway again. ACNA #3 said she did not recall any specific incident the first time she worked with Resident #40, but that the resident would say things that get under your skin and was a negative person. ACNA #3 said the second time she worked with Resident #40 was in July 2021 and when she went to check on the resident the resident said she had been sitting in feces for 45 minutes. ACNA #3 said the resident was disrespectful and rude so she walked out of the room and told the nurse manager. ACNA #3 said she had not returned to the facility in several weeks but if she did go back she would not work with Resident #40 again. The NHA and QIS were interviewed again on 8/11/21 at 1:07 p.m. The NHA said ACNA #3 should not have been providing care to Resident #40 in July 2021 due to the prior grievance from June 2021. The NHA said after being made aware of the grievances against ACNA #3, the facility was now having two staff members provide cares for Resident #40. -However, Resident #40 did not have two staff members providing her cares until her grievances with ACNA #3 were identified during the survey. The QIS said she started providing re-education on abuse to the facility staff and was doing an audit throughout the facility to ensure there were no other resident grievances or concerns.