Every finding on record at Columbine Commons Health and Rehab LLC

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two out of two kitchenettes. Specifically, the facility failed to ensure: -Refrigerators were maintained at the correct temperature; -Food was properly stored after being opened; -Staff wore beard nets in the kitchen; -Staff did not have fake nails; and, -Staff did not wear a watch on their wrist while serving food. Findings include: I. Failure to ensure refrigerator temperatures were maintained appropriately A. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. It revealed in pertinent part, Time or temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. (Chapter 3) B. Facility policy and procedure The Kitchen Sanitation policy, revised 2023, was provided by the nursing home administrator (NHA) on 4/21/25 at 11:03 a.m. It read in pertinent part, Refrigerated food should be stored at or below 41 degrees Fahrenheit (F). C. Observations On 4/15/25 at 9:20 a.m. a tour of the kitchenette in the Lakes building revealed the bottom left refrigerator had an internal thermometer that read 46 degrees F. The refrigerator contained sodas, milk and yogurt. C. Staff interviews The dietary manager (DM), the registered dietitian (RD) and assistant dietary manager (ADM) were interviewed together on 4/16/25 at 2:15 p.m. The DM said he was unaware the refrigerator temperature was above 41 degrees F. He said he was going to have maintenance look at the refrigerator and provide education to the staff about notifying him if a refrigerator was at the wrong temperature. II. Failure to ensure food was properly stored A. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. It revealed in pertinent part, Food shall be discarded if it is in a container or package that does not bear a date. (Chapter 3) B. Facility policy and procedure The Kitchen Sanitation policy, revised 2023, was provided by the NHA on 4/21/25 at 11:03 a.m. It read in pertinent part, All time and temperature control for safety (including leftovers) should be labeled, covered and dated when stored. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. C. Observations On 4/15/25 at 9:20 a.m. a tour of the kitchenette in the Lakes building revealed a bag of French fries in the freezer that were not sealed shut or labeled with an open date. There was a bag of cheesecake mix in the dry storage area that was not sealed or labeled with an open date. On 4/15/25 at 11:15 a.m. a tour of the kitchenette in the Mountains buildings revealed a box of barley that was not sealed or labeled with an open date. D. Staff interviews The DM, the RD and the ADM were interviewed together on 4/16/25 at 2:15 p.m. The DM said once food was opened from its original packaging, it needed to be sealed and labeled with an open date and a use-by date. III. Failure to ensure beard nets were worn A. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. It revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens and unwrapped sing-service and single-use articles. (Chapter 2) B. Facility policy and procedure The Kitchen Sanitation policy, revised 2023, was provided by the NHA on 4/21/25 at 11:03 a.m. It read in pertinent part: Beard nets are required when facial hair is visible. C. Observations On 4/15/25 at 11:15 a.m. a tour of the kitchenette in the Mountains buildings revealed cook (CK) #2 wore a surgical mask due to COVID-19 in the building. CK #2 was not wearing a beard net, he wore a surgical mask and his beard was sticking out from under the mask. D. Staff interviews The DM, the RD and the ADM were interviewed together on 4/16/25 at 2:15 p.m. The DM said a surgical mask did not count as a beard net and that beard nets needed to be worn when the staff had a five o ' clock shadow or longer beard hair. He said CK #2 should have worn a beard net with his surgical mask. IV. Failure to ensure staff did not wear fake nails when handling food A. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. It revealed in pertinent part, Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. (Chapter 2) B. Facility policy and procedure The Kitchen Sanitation policy, revised 2023, was provided by the NHA on 4/21/25 at 11:03 a.m. It read in pertinent part, Keep fingernails clean and neat. Acrylic or painted nails must be covered when handling or serving food. C. Observations During a continuous observation on 4/16/25, beginning at 11:00 a.m. and ending at 12:30 p.m., CK #1 was wearing fake nails that were painted a beige color and approximately half an inch long while she served lunch without gloves on. D. Staff interviews The DM, the RD and the ADM were interviewed together on 4/16/25 at 2:15 p.m. The DM and the RD said the staff were not allowed to wear fake nails. The DM and the RD said CK #1 needed to have gloves on while serving lunch because she had artificial fingernails. V. Failure to ensure staff did not wear watches while preparing food A. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. It revealed in pertinent part, Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. (Chapter 2) B. Observations During a continuous observation on 4/16/25, beginning at 11:20 a.m. and ending at 12:30 p.m. CK #1 was wearing a smart watch while she served lunch. C. Staff interviews The DM, the RD and the ADM were interviewed together on 4/16/25 at 2:15 p.m. The RD said the facility ' s policy allowed watches to be worn, but that she was going to get the policy updated to match the regulations.

Based on 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 grooming and personal hygiene for one (#8) of four residents reviewed out of 17 sample residents. Specifically, the facility failed to provide Resident #8 with timely bathroom assistance. Findings include: I. Facility policy and procedure The Resident Rights policy, revised on 2/26/25, was provided by the nursing home administrator (NHA) on 4/18/25 at 4:14 p.m. It read in pertinent part, The resident has the right to be treated courteously, fairly and with the fullest measure of dignity, and to be cared for in a manner and environment that promotes maintenance or enhancement of his or her quality of life. II. Resident #8 A. Resident status Resident #8, age greater than 65, was admitted [DATE]. According to the April 2025 computerized physician order (CPO), diagnoses included atrial fibrillation (heart condition), chronic diastolic (congestive) heart failure, anxiety disorder and unspecified pain. The 3/20/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. She required substantial to maximum assistance with toileting hygiene and toilet transfers. Resident #8 was interviewed on 4/16/25 at 1:00 p.m. Resident #8 said she had to wait 40 minutes sitting on the toilet until she received assistance (the morning of 4/16/25). She had to scream and bang on the wall. B. Resident interview Resident #8 was interviewed again 4/16/25 at 2:45 p.m She said she was assisted to the bathroom and when finished she pushed the call box (a device used to signal for help) in her bathroom. She said she waited a long time and pushed the call box again and then her personal pendant for help. She said she sat on the toilet for 40 minutes and then started to scream and bang on the wall for help. Resident #8 said she did not want that to happen again. C. Record review The activities of daily living (ADL) functional care plan initiated 3/13/24 and revised on 4/1/25, indicated Resident #8 had experienced a decline in function with increased weakness. Pertinent interventions included provide assistance for ADLs and mobility as needed, provide moderate assistance with toileting. The cognitive loss care plan initiated 3/14/24 and revised on 3/20/25, indicated that Resident #8 has short term and long term memory loss. Pertinent interventions included anticipate and assist with needs and ADL's as appropriate and monitor every one to two hours and as needed (PRN) for safety or needs The 4/16/25 computerized response time log for Resident #8 was provided by the director of nursing (DON) on 4/16/25 at 1:58 p.m. It indicated the following: Resident #8 activated her personal pendant at 6:35 a.m. and it was deactivated nine minutes later. Resident #8 activated the bathroom call box at 6:57 a.m., which was on the wall located next to the toilet. The call box was deactivated at 7:09 a.m., 12 minutes later. Resident #8's personal pendant was activated at 7:09 a.m. Resident #8's personal pendant was deactivated at 7:24 a.m., 15 minutes after the personal pendant was activated. -Resident #8 initially activated her bathroom call box at 6:57 a.m., the call box was deactivated at 7:09 a.m., then her personal pendant was activated at 7:09 a.m. Resident #8 did not receive assistance for 27 minutes after she initially activated her call box, leaving her on the toilet for approximately 40 minutes. D. Staff interviews The DON and the social services director (SSD) were interviewed together on 4/16/25 at 1:58 p.m. The DON said the residents had two ways to notify staff that they needed assistance, the call box and their personal pendants. The DON said the call box could be deactivated in the room by a button and the personal pendant had to be deactivated by a staff member. The SSD said Resident #8's statement on the wait time was valid. The DON said Resident #8 may have deactivated the bathroom call box by pushing the deactivation button, which was located under the activation button on the call box. She said this would have sent an automated message that the light has been cleared. Certified nursing aide (CNA) #1 was interviewed on 4/16/25 at 2:25. CNA #1 said that CNAs were assigned to a hall and not specific rooms. She said the CNAs were responsible for answering all call notifications in their assigned hall. She said after the call box or personal pendant was deactivated a message was sent over the walkie talkie as cleared. CNA #1 said that she did not check on residents after the call notification had been cleared. CNA #2 was interviewed on 4/17/25 at 10:45 a.m. CNA #2 said she answered the call notification that morning and assisted Resident #8 to the toilet on 4/16/25 (at 6:44 a.m.) CNA #2 said she had told Resident #8 to call when she was finished. CNA #2 said she heard Resident #8's call notification, then heard the clear signal several minutes later. She said she heard Resident #8's call notification again and was going to assist her when she finished with another resident. She said she then heard Resident #8 screaming and banging on the wall. She said she entered the bathroom to assist the resident off the toilet.

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. Specifically, the facility failed to: -Ensure glucometers were disinfected per manufacturer's recommendations and ensure that individual glucometers were labeled on three of four medication carts reviewed; -Follow infection control practices when administering medications via gastrostomy (G-tube) tube; and, -Follow infection control practices when entering the room of a resident on contact precautions. Findings include: I. Standard precautions for resident equipment-disinfection and labeling of glucometers A. Professional reference Centers for Disease Control and Prevention. (2019). Part III: Precautions to Prevent Transmission of Infectious Agents. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 10/16/23. Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions, except sweat, non- intact skin and mucous membranes may contain transmissible infectious agents. These include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluid must be handled in a manner to prevent transmission of infectious agents (wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). B. Manufacturer recommendations Harmony Blood Glucose Monitoring System (2017). https://www.medline.com/media/catalog/Docs/MKT/MAN_MPH6540_APB.pdf, retrieved on 10/10/23, included the following recommendations: Cleaning and disinfecting are different and both should be performed. Cleaning can remove visible soil, blood and oily substances prior to disinfecting, but does not kill germs effectively. Disinfecting can destroy most recognized pathogenic microorganisms to reduce your exposure to disease. The following products have been validated for cleaning and disinfecting the meter: -Dispatch Hospital Cleaner Disinfectant Towels with Bleach -Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol -Clorox Healthcare Bleach Germicidal and Disinfectant Wipes -Medline Micro-Kill Bleach Germicidal Bleach Wipes Only the above wipes have been validated for use in cleaning and disinfecting. Cleaning and disinfecting frequency: The device must be cleaned before every disinfection step and should be cleaned and disinfected after each test. 1. Wash hands with soap and water and dry thoroughly. Put on single-use medical protective gloves. 2. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. 3. To clean the meter, blood/body fluids must be thoroughly cleaned from surface and objects before disinfecting. Wipe surface with one of the four validated disinfecting wipes until completely wet. Wipe all external areas of the meter using the same validated wipes for cleaning and for disinfection. Avoid wetting the test strip holder and data port. Discard used towel. 4. To disinfect the meter, dispense a wipe from the canister. Oily substances must be removed prior to disinfection. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Use the same validated wipes for cleaning and for disinfection. Avoid wetting the test strip holder and data port. Allow the surface of the meter to remain wet at room temperature for: -At least 30 seconds for Medline Micro-Kill Bleach -At least 1 minute for Dispatch and Clorox Healthcare -At least 2 minutes for Medline Micro-Kill 5. Allow to air dry. 6. Remove gloves, wash hands with soap and water, and dry thoroughly. C. Observations On 10/10/23 at 12:35 p.m. the Lakes unit east medication cart was reviewed with registered nurse (RN) #3. Harmony brand glucometers were present in at least two of the residents' bins. The glucometers did not have resident names on them. Medication cart #2 on the Mountain unit was inspected on 10/10/23 at 1:35 p.m with licensed practical nurse (LPN) #1. The medication cart contained three glucometers: an unlabeled glucometer in the top drawer, an unlabeled glucometer in a yellow basket labeled with room [ROOM NUMBER] and a glucometer labeled with room [ROOM NUMBER] in a yellow basket labeled with room [ROOM NUMBER]. D. Staff interviews RN #3 was interviewed on 10/10/23 at 12:35 p.m. RN #3 said each resident had their own glucometer, which was stored in the corresponding room in the medication cart. The RN said she used alcohol wipes to clean the glucometer, wiped the meter after leaving the room, and put it back into the drawer. RN #3 said she uses whatever is closest, purple top or alcohol wipes to clean the glucometer. She said she wiped a couple of times and puts the glucometer back in the drawer. RN #3 said she thought the policy said to use alcohol wipes to clean the glucometers, but she was not sure what it said. LPN #4 was interviewed on 10/10/23 at 1:10 p.m. LPN #4 said that she used a paper towel with water or alcohol wipes to clean the glucometer. At 1:30 p.m. LPN #4 said that she misspoke earlier, as she had been told at another employer to clean the glucometer with paper towel and water. She clarified she always cleaned glucometers at this facility with alcohol wipes. LPN #1 was interviewed on 10/10/23 at 1:35 p.m. She said that she did not know why the glucometer labeled with room [ROOM NUMBER] was in a basket labeled with room [ROOM NUMBER]. She said they must have mixed them up. She said she cleaned glucometers once after her shift with disinfectant wipes. The director of nursing (DON) was interviewed on 10/10/23 at 1:51 p.m. The DON was informed that nurses indicated they were cleaning glucometers with alcohol wipes. She said that the policy said to clean the glucometers between uses with alcohol wipes for 30 seconds or to use purple top wipes. Manufacturer's recommendations for cleaning were requested. The DON said the facility did not label the glucometers. The DON said the facility would provide the manufacturer's recommendations for cleaning and would have staff clean all glucometers per the manufacturer's recommendations. E. Facility follow-up On 10/10/23 at 4:46 p.m. the nursing home administrator (NHA) provided the following: Immediate interventions 1. Every medication cart was audited for resident specific glucometer immediately. Relabeling of glucometer and test strips and proper cleaning of all glucometers was completed. Every medication cart was stocked with the correct cleaning solution. We reviewed manufacturer guidelines and clarified proper disinfectant use. This was updated in skill validation and company policy. 2. Staff Development Coordinator (SDC) created in-service training education on proper use of glucometer and return demonstration was started for every floor nurse. 3. Additional glucometers that were stored in the top of the medication cart were removed and discarded. 4. DON and SDC have developed a schedule for education to ensure all floor staff sign off on the training before they start the shift. 5. There will be a complete medication cart audit daily on all carts through the period of re-education. 6. Updated resident discharge checklists and admission packets to indicate proper assigning, labeling, and disinfecting of glucometers and test strips. 37166 II. Infection control failures with medication administration A. Observations LPN #2 was observed administering medications to Resident #109 on 10/9/23 at 12:17 p.m. All medications were administered via G-tube. Resident #109 was on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in the wound on her hip. LPN #2 donned gown, gloves and surgical mask before entering the room. She brought with her to the room a yellow box with medication, and a bottle of Gabapentin solution. She placed it next to the sink area in the resident's room. She approached the resident and placed a clean white towel under the G-tube. As she was administering Tylenol, the towel that was under the G-tube fell on the floor. She picked up a towel off the floor, wiped the leaking Tylenol solution off the G- tube with the towel and tucked it back under the resident. When LPN #2 was done with medication administration, she took the bottle of Gabapentin and yellow box with medications out of the room. She did not sanitize items that she brought to the room before placing Gabapentin back to the refrigerator in the medication room and yellow box with medications to the medication cart. B. Staff interviews The DON was interviewed on 10/11/23 at 5:50 p.m. She said the number of items that were brought to the resident's room on isolation precaution should be minimized. Specifically, only medications that were administered should be taken to the room. However, if it was necessary to bring additional medications, containers that came in contact with the surface in the resident's room should be disinfected after removal from the room. Regarding the towel she said since the towel came in contact with the floor it should have been replaced with a clean one.

Based on record review and interviews, the facility failed to have a process in place to ensure one (#48) resident reviewed for cardiopulmonary resuscitation (CPR) out of 28 sample residents choices regarding CPR were honored and physician orders in place to support the choices. Specifically, the facility failed to ensure the physician orders were updated after admission to do not resuscitate (DNR) status in order to align with the Resident #48's documented choices. Findings include: I. Facility policy The Advance Directives and Resident Contacts policy, revised [DATE], was provided by the director of clinical services (DCS) on [DATE] at 10:45 p.m. The policy documented in pertinent part: All residents have the right to request, refuse, and/or discontinue treatment. The CPR directive is also a medical order, and it instructs providers not to resuscitate if a person's heart or breathing stops. This type of advance directive is typically for people who are frail or seriously ill and for whom CPR may do more harm than good. The doctor and patient must sign this form. II. Resident status Resident #48, age 81, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), her diagnoses included fractured left femur (upper leg), diabetes, heart disease and hypertension (high blood pressure). The [DATE] 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. III. Record review The resident's face (information) sheet, physician orders and care plan were reviewed. The face sheet revealed that the resident was a DNR (do not resuscitate, no CPR) status, however, the most recent physician order from [DATE] directed a full code status for the resident. The care plan, revised [DATE], revealed that the resident had an advanced directive on file and the copy was in the chart. The care plan documented the resident wishes will be honored and reviewed as needed. The Directive to Withhold CPR form, dated [DATE] (two days after the resident was admitted ) was reviewed. The form was signed by both Resident #48 and the medical provider and it directed health care providers to withhold CPR in the event that the resident's heart or breathing stopped. IV. Staff Interviews The staff development coordinator (SDC) was interviewed on [DATE] at 10:16 a.m. The SDC reviewed the CPR form, orders and face sheet and said the resident's order should have been changed to DNR on [DATE]. She said she would follow up with the provider immediately to change the order. The social services director (SSD) was interviewed on [DATE] at 10:20 a.m. She said every resident should have a physician order for their code status and she would expect the resident's order to match the face sheet and any directives the resident had. Registered nurse (RN) #3 was interviewed on [DATE] at 2:55 p.m. She said if a resident had a medical emergency she would look in the banner on the electronic medical record to know if the resident wanted CPR. The RN said she could refer to the shift report sheet for this information. The director of nursing (DON) was interviewed on [DATE] at approximately 3:00 p.m. She said that when staff are looking for the resident's code status, they could look in the banner in the computerized resident record, in the facility activity report, in the resident document under advanced directives and in the physician orders.

Based on observations, record review and interviews, the facility failed to ensure proper storage and disposal of medications in two of three medication carts. Specifically, the facility failed to discard prepared and contaminated medications that had not been administered to residents. Findings include: I. Facility policy and procedure The Medication Receiving, Storage, and Destruction policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE]. It read in pertinent part, Expired, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. II. Observations On [DATE] at 12:23 p.m. the medication cart of the east hallway of the Lakes building was reviewed with registered nurse (RN) #3. Approximately 15 pills were in a medication (30 milliliter) plastic cup in the top drawer of the cart. At 1:10 p.m., licensed practical nurse (LPN) #4 opened the top drawer of the Lakes building west medication cart. There were eight pills in an unlabeled medication cup. III. Staff interviews RN #3 was interviewed on [DATE] at 12:25 p.m. She said that she collected pills during the day from medications that were not given and from loose pills and old (expired) medications in the cart. She said she combined the pills into a cup and was waiting to put them in a medication disposal container. RN #3 then took the pills to the medication storage room and discarded the pills into the medication disposal container. LPN #4 was interviewed on [DATE] at 1:15 p.m. She said that the eight pills in the unlabeled medication cup were a combination of ones that were refused and medications found on the floor. She said that when she finished with her lunch pass of medications she planned to destroy the medications in the medication disposal container in the medication storage room. She said that she followed the same process for evening medications. The director of nursing was interviewed on [DATE] at 3:02 p.m. She said that the nurse could store non-narcotic pills that were intended to be wasted in a pill cup in the top drawer of the cart. She said that it was acceptable to store these medications in the cart and to dispose of the unused medications at the end of the nurse's shift. RN #4 was interviewed on [DATE] at 9:38 a.m. She said that when she found a need to dispose of non-narcotic pills during her medication pass, she put them in a pill container in the top drawer of the medication cart and disposed of them in the medication room when her medication pass was done. She said she typically did not immediately take individual medications which needed disposal to the medication room.

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#159) of three residents reviewed for hospice services out of 28 sample residents. Specifically, for Resident #159 the facility failed: -To have a hospice plan of care in order to maintain the resident's highest practicable physical, mental and psychosocial well-being; -To identify the responsibilities of the hospice provider and the facility to include frequency of visits; and, -To have consistent documentation of hospice care visits and updates in the resident's record. I. Facility policy The Palliative and hospice Services policy, updated on 5/18/23, was provided by the nursing home administrator (NHA) on 10/12/23 at 2:47 p.m. it revealed in pertinent part; The facility and palliative/hospice provider will work together to address the needs of the resident. The contract between (corporation) and the palliative/hospice providers will outline the specific details regarding services, including but not limited to: coordination of care, delineation of services, and communication. The palliative/hospice provider will obtain access to the resident's medical record. Documents from palliative/hospice will be obtained to place in the resident's medical record, including but not limited to certifications, advance directives, plan of care and updates, and orders. The resident, family, facility, and palliative/hospice provider will be involved in the development and changes to the plan of care. II. Resident #159 A. Resident status Resident #159, age 93, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease (narrowing of the arteries), acute cystitis without hematuria (bladder infection) and polyneuropathy (nerve damage). The 10/1/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of eight out of 15. He had no behaviors or rejections of care. The MDS assessment identified hospice care. B. Resident family interview The resident's wife and daughter were interviewed on 10/10/23 at 4:10 p.m. They said the resident received hospice care about once a week. The resident's wife and daughter said he was seen by a certified nurse aide (CNA) on Wednesdays but was not sure when he was seen by the nurse. The resident's wife and daughter said they had not talked with the hospice nurse recently and would like to have a schedule in order to be there when she visits for an update. C. Record review The October 2023 CPO revealed the resident was admitted to hospice services on 9/26/23 for heart disease. The facility's hospice care plan initiated on 9/26/23 revealed Resident #159 had a long term goal of Resident #159 would have his needs met by facility and hospice staff. Resident #159's medications and treatments would be provided as ordered, ensuring the resident had an optimal comfort level and time with family and friends. The care plan interventions revealed the facility would consult with the hospice nurse about Resident #159's medications, concerns, monitoring for pain level, comfort level, and would respond promptly to needs. The facility and hospice would coordinate care that would anticipate and meet all of the resident needs, would monitor for changes and coordinate care planning. The family and friends were to be involved in care decisions and hospice was to educate family on services provided and liaison as needed for communication. The hospice progress notes dated 9/26/23 revealed a visit from the hospice nurse. The hospice nurse completed assessment, reviewed, ordered bolster sheets and noted Resident #159 had no concerns. The hospice progress notes dated 10/9/23 revealed a visit from the hospice nurse. The nurse ordered a gel wheelchair cushion and noted the resident denied any concerns. The hospice progress notes dated 10/12/23 revealed a visit from the hospice nurse. The hospice nurse completed assessment, added a new order for Tylenol and provided education to the resident. -There were no other hospice progress notes in Resident #159's record from admission on 9/26/23 to 10/9/23. The record did not include consistent communication between the hospice provider and the facility. The hospice progress notes dated 10/9/23 and 10/12/23 were completed after the start of the recertification process. -The resident did not have a plan of care from the hospice provider in the record that identified the responsibilities of the hospice provider to include frequency of visits and schedule. III. Staff Interviews Registered nurse (RN) #2 was interviewed on 10/10/23 at 3:08 p.m. RN #2 said the hospice provider had their own computer program to record resident information. The hospice nurses would input the resident care and updates into the program and their medical records department would send the information to the facility. RN #2 said it could take up to two weeks to receive the information. RN #2 said the hospice nurse usually updated the unit nurse upon arrival and departure to give a verbal update. RN #2 said if there were updates she would input the information into the resident's record. RN #2 said the hospice plan of care should be located in the resident's record at the facility. The director of nursing (DON) was interviewed on 10/12/23 at 1:56 p.m. The DON said the hospice nurses would talk with the charge nurse upon arrival and departure and would give a verbal update of the residents. The DON said the hospice provider had their own computer program which they would add the resident information to then had their records department forward the progress notes to the facility. The DON said the facility recently requested more detailed and timely updates from the hospice provider. The DON said the hospice nurses had access to their program to update the resident's records but they did not consistently. The DON said she was not clear if the hospice provider had a schedule for services for each resident. The DON said the hospice plan of care should be located in the facility record.

Based on interviews and record review, the facility failed to ensure one (#24) of one resident reviewed for respiratory care of 20 sample residents were provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to ensure physician orders and a care plan were in place for Resident #24, who required a continuous positive airway pressure ([CONDITION(S)]) unit/machine. Findings include: I. Facility policy and procedure The [CONDITION(S)]/[CONDITION(S)] use policy, revised on 1/23/2020, was provided by the director of nursing (DON) on 7/12/22 at 1:14 p.m. The policy revealed a [CONDITION(S)] was a non-invasive form of therapy for residents with obstructive sleep apnea. The unit supplied pressurized air into the resident's airways called positive airway pressure. This positive pressure aided in keeping the resident's airway from obstructing or closing during sleep. With a [CONDITION(S)], the resident received one continuous set pressure with inhalation and exhalation. The purpose was to provide a [CONDITION(S)] unit, for residents with conditions that included but were not limited to obstructive sleep apnea (OSA), hypoventilation syndrome, chronic obstructive pulmonary disease ([CONDITION(S)]), [CONDITION(S)] (CHF), and neuromuscular disorders. Residents who had provider orders for a [CONDITION(S)], would have nursing and respiratory therapies (RT) services to address and monitor the use of the [CONDITION(S)] unit. The resident would have a RT consult, that was ordered for all residents with a [CONDITION(S)]. A nurse, RT, resident and/or a family member would set up the resident's [CONDITION(S)] unit per their home settings. The set up should include the use of distilled water for the humidifier chamber, oxygen port for supplemental oxygen if needed, and the confirmation that the unit was plugged into a generator backup outlet (typically a red electrical wall outlet). an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff would verify that the unit was working and that the mask had a good seal. The nurse would verify supplemental oxygen was hooked up to the flow meter and the [CONDITION(S)] machine if needed. An oxygen saturation level would be obtained and documented in the EMR every 30-60 minutes after the unit was applied to the resident, each time it was removed and reapplied, and every shift while the patient wore the unit. If the [CONDITION(S)] unit appeared not to be functioning properly, a nurse might attempt to troubleshoot the unit. If the nurse was unsuccessful in trouble shooting the unit, the nurse would contact RT during business hours or the provider on call after business hours. RT would evaluate the patient's settings and document in the observation section of resident's EMR. Nursing would create a care plan addressing the need for the [CONDITION(S)] with applicable device information. The cleaning of the device and accessories would be completed as instructed by RT or according to the manufacturer's recommendations. RT would provide ongoing training and education to facility staff and residents and/or families related to [CONDITION(S)] usage as needed. II. Resident #24 A. Resident status Resident #24, age 77, was admitted on [DATE]. According to the July 2022 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/26/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. The resident did not have any behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident received oxygen therapy. The MDS did not indicate the resident utilized a non-invasive mechanical ventilator [CONDITION(S)] unit. B. Resident interview and observations Resident #24 was interviewed on 7/11/22 at 1:48 p.m. She said she brought the [CONDITION(S)] machine from home and to her knowledge the staff had not cleaned the machine. The [CONDITION(S)] machine sat on a small dresser beside her bed. Resident #24 was interviewed on 7/13/22 at 8:40 a.m. She again reiterated she brought the [CONDITION(S)] machine from home and to her knowledge the staff had not cleaned the machine. She said her husband cleaned the machine and she had plenty of supplies located in the dresser drawer. C. Record review The July 2022 physician orders did not include any orders related to [CONDITION(S)] settings, care, or cleaning. The care plan for at risk for shortness of breath or reduced oxygen levels related to restrictive lung disease, initiated on 6/22/22, did not include a [CONDITION(S)] as an approach. D. Staff interviews The assistant director of nursing (ADON) was interviewed on 7/13/22 at 3:13 p.m. She acknowledged there were no physician orders for the use of a [CONDITION(S)] machine and therefore it was not encoded in the MDS dated [DATE]. She said the physician orders and care plan were developed on 7/12/22 (during the survey process). The DON was interviewed on 7/13/22 at 3:14 p.m. She said she first learned the resident had a [CONDITION(S)] on 7/12/22 (during the survey). She said the resident did not have physician orders for the use of a [CONDITION(S)] upon admission. She said the resident's family brought the [CONDITION(S)] from home during the resident's first week at the facility and did not inform the staff. She said the staff were aware of the [CONDITION(S)] after it was brought into the facility. She said they received physician orders for the use of the [CONDITION(S)] machine on 7/12/22 (during the survey). The resident's respiratory care plan was updated on 7/12/22 to reflect the use of a [CONDITION(S)]. She said a medical supply company employee came to the facility on [DATE] to ensure the [CONDITION(S)] was clean. The employee also checked the oxygen settings on the machine, checked the filters, tubing and the mask for cleanliness. The DON said the nurses were educated to obtain physician orders for a [CONDITION(S)] and to update the care plan, if a resident/family brought a machine into the facility. She said obtaining physician orders and updating a care plan would prompt the correct coding on the resident's MDS. She said the physician orders would be reflected on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Registered nurse (RN) #1 was interviewed on 7/14/22 at 9:36 a.m. She said she knew the resident had a [CONDITION(S)] machine. She said she had never cleaned the machine or changed any of its components. She said there was no electronic MAR (physician order) to direct her to clean or change out any of its parts or tubing on the machine. The ADON was interviewed again on 7/14/22 at 11:00 a.m. She said the [CONDITION(S)] machine needed to be cleaned to reduce the bacteria in the machine and to help keep the resident from getting sick. She said bacteria could be in the tubing or in the water reservoir. She said as of 7/12/22, the facility had all the necessary physician orders for the use of the [CONDITION(S)] machine. She said nursing staff received education on [CONDITION(S)] machines and to obtain physician orders when they observed a machine in a resident's room. The DON was interviewed again on 7/14/22 at 11:23 a.m. She said the necessity of cleaning a [CONDITION(S)] machine was to prevent pneumonia/respiratory infections from the moist air that might contain bacteria during the use of the machine. E. Facility follow-up (during the survey) A physician order revealed a [CONDITION(S)]/[CONDITION(S)] unit was to be placed by a nurse per orders (home settings). The nurse would verify the unit was working and the mask had a good seal. The nurse would bleed in (administer) the specified liters of oxygen (O2). The nurse would follow up oxygen saturation (SpO2) levels every 30-60 minutes after the unit was applied. The special instructions revealed, each time the mask was removed and reapplied; a nurse would recheck SpO2 and document in vital signs. This order was to be performed twice a day at 7:00 p.m .- 10:00 p.m., and 10:00 p.m. - 2:00 a.m. This order was started on 7/12/22. A physician order revealed a [CONDITION(S)]/[CONDITION(S)] unit was to be placed by a nurse per orders (home settings). The nurse would verify the unit was working and the mask had a good seal. The nurse would bleed in the specified liters of oxygen (O2). The nurse would follow up oxygen saturation (SpO2) levels every 30-60 minutes after the unit was applied. The special instructions revealed, each time the mask was removed and reapplied; a nurse would recheck SpO2 and document in vital signs. This order was to be performed once a day as needed (PRN). This order was started on 7/12/22. A physician order revealed a [CONDITION(S)]/[CONDITION(S)] unit was to be checked each shift. The nurse must check SpO2 levels each shift while [CONDITION(S)]/[CONDITION(S)] was in use. The special instructions revealed that each time the device was removed and reapplied; a nurse would check SpO2 and document in vital signs. This order was to be completed one a day at night. This order was started on 7/12/22. A physician order revealed weekly [CONDITION(S)]/[CONDITION(S)] cleaning special instructions were to be performed according to RT guidelines/manufacturer's instructions once a day on Sunday mornings between 6:00 a.m., and 2:00 p.m. This order was started on 7/12/22. A PO revealed a [CONDITION(S)]/[CONDITION(S)] unit was to be checked each shift. The nurse must check SpO2 levels each shift while [CONDITION(S)]/[CONDITION(S)] was in use. The special instructions revealed that each time the device was removed and reapplied; a nurse would check SpO2 and document in vital signs. This order was to be completed twice a day PRN one and PRN two. This order was started on 7/12/22. In addition, the resident's care plan for potential complications related to restrictive lung disease/chronic respiratory failure with [CONDITION(S)] was developed on 7/12/22 and included multiple approaches related to the use of a [CONDITION(S)].

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the development and spread of communicable and infectious diseases in two of two units. Specifically, the facility failed to: -Designate a representative to screen their employees for COVID-19 prior to entering the facility. -Provide, assist, and encourage residents to perform hand hygiene (either with alcohol based hand rub (ABHR) or soap and water, for at least 20 seconds) when they served them their meal. -Follow manufacturer directions to allow for a 10 minute dwell time for disinfection and perform hand hygiene. Findings include: I. Failure to screen employees for COVID-19 A. Facility policy According to the Preventing of Spreading COVID-19 policy, developed on 3/11/2020 and provided by the nursing home administrator (NHA) on 5/22/2020 at 11:34 a.m., it required: -Residents were educated on proper hand hygiene which is required before and after eating. -Alcohol-based hand sanitizer was made available to all residents. -Facility would monitor and track all staff for respiratory illnesses on a daily basis. -Any staff member who had signs and symptoms of respiratory illness would not be allowed to work. -Symptoms they would be monitored for included: fever > 100F, cough, shortness of breath or difficulty breathing, sputum production, sore throat, or rhinorrhea. The facility would consider chills, myalgia, fatigue, anorexia, headache, diarrhea, nausea or vomiting, or loss of taste or smell as other subjective symptoms to consider when staff were monitored. B. Observations On 5/20/2020 at 11:05 a.m. revealed the NHA and receptionist (REC) remained inside the facility as they directed surveyors to screen themselves for COVID-19 prior to entering the facility. Surveyors were told to take their own temperatures and document it as well as answers to a few questions listed on a sheet of paper. C. Staff interviews LPN #1 and LPN #2 were interviewed on 5/20/2020 at 11:24 a.m. They said when they came to work they screened themselves for COVID-19 before they entered the facility. They filled out a questionnaire sheet, took their own temperature, and recorded their own temperature. Then they entered the facility, donned on a mask, clocked in, and started working their shift. The facility did not screen them prior to them starting her shift. Registered nurse (RN) #1 was interviewed on 5/20/2020 at 11:31 a.m. She said when she came to work she screened herself for COVID-19 before she entered the facility. She filled out a questionnaire sheet, took her own temperature, and recorded her own temperature. Then she entered the facility, donned on a mask, clocked in, and started working her shift. The facility did not screen her prior to her starting her shift. CNA #1 was interviewed on 5/20/2020 at 11:37 a.m. She said when she came to work she screened herself for COVID-19 before she entered the facility. She filled out a questionnaire sheet, took her own temperature, and recorded her own temperature. Then she entered the facility, donned on a mask, clocked in, and started working her shift. The facility did not screen her prior to her starting her shift. CNA #2 was interviewed on 5/20/2020 at 11:45 a.m. She said when she came to work she screened herself for COVID-19 before she entered the facility. She filled out a questionnaire sheet, took her own temperature, and recorded her own temperature. Then she entered the facility, donned on a mask, clocked in, and started working her shift. The facility did not screen her prior to her starting her shift. The receptionist was interviewed on 5/20/2020 at approximately 1:00 p.m. She said the doors to the building were locked, and no one was allowed into the building without being screened. She said that she has the visitor/staff screen themselves, by answering the questions on the questionnaire, and taking their own temperature. She said before she let's them in the building, she will look at the temperature written down, however did not look at the thermometer or ask the screening questions to the visitor/staff. II. Failure to provide, assist, encourage hand hygiene before meals A. Professional reference According to the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance April 2, 2020, it recommended all staff should be screened at the beginning of their shift for fever (take temperature) or symptoms (cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new olfactory [smell] and taste disorder(s). According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from: https://www.cdc.gov/handhygiene/providers/index.html, it recommended hand hygiene helped prevent the spread of viruses, and when ABHR was used, put the product on hands and rub hands together, cover all surfaces until hands feel dry; this should take around 20 seconds. A. Observation On 5/20/2020 at 11:48 a.m. revealed the dietary aide (DA) brought Resident #1's lunch to him and set it up for him. She did not provide, assist, and encourage him to perform hand hygiene (either with alcohol based hand rub (ABHR) or soap and water, for at least 20 seconds) after she brought it to him nor before she left his room. On 5/20/2020 at 11:52 a.m. certified nurse aide (CNA) #1 brought Resident #2's lunch to her and set it up for her. She did not provide, assist, and encourage her to perform hand hygiene (either with ABHR or soap and water, for at least 20 seconds) after she brought it to her nor before she left her room. On 5/20/2020 at 12:40 p.m. LPN #1 brought Resident #3's lunch to her and set it up for her. She did not provide, assist, and encourage her to perform hand hygiene (either with ABHR or soap and water, for at least 20 seconds) after she brought it to her nor before she left her room. The DA brought Resident #4's lunch to him and set it up for him. She did not provide, assist, and encourage him to perform hand hygiene (either with ABHR or soap and water, for at least 20 seconds) after she brought it to him nor before she left his room. B. Staff interviews LPN #2 was interviewed on 5/20/2020 at 12:45 p.m. She said Resident #3 was cognitively intact and Resident #4 had dementia. She said staff were to offer ABHR or assist all residents with handwashing when they served them their meals. RN #1 was interviewed on 5/20/2020 at 12:55 p.m. She said Resident #1's and Resident #2's levels of cognition change daily. She said staff were to offer ABHR or assist all residents with handwashing when they served them their meals. The director of nursing (DON) was interviewed on 5/20/20 at 1:00 p.m. She said staff were to offer or assist all residents with hand hygiene when they served them their meals to maintain infection control. She planned to reeducate all her staff today on providing residents hand hygiene when they served them their meals. III. Houskeeping A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (Update April 12, 2020), retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html#infection_control, Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product ' s label) are appropriate for [CONDITION(S)]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. B. Chemical The HP202 chemical directions documented the following, 10 minute contact time, unless otherwise noted, this product kills a wide variety of pathogens on hard, non-porous surfaces. C. Observations On 5/20/2020 at 11:35 a.m., Housekeeper #1 (HK #1) was observed to enter Resident #5's room. She entered the room with gloved hands and two spray bottles. She proceeded to spray the sink at 11:35 a.m., with the chemical HP202. She then proceeded to touch the toilet and the high riser with her gloved hands as she sprayed the toilet with comet on the inside and HP202 on the outside of the toilet. She left the bathroom and went to her cart which was parked outside of the room. She reached into her pocket with the same dirty gloves and retrieved keys to open the cart. She put the bottles back into the cart, and then removed the dirty gloves. She immediately placed a new pair of gloves on and began the next task. She failed to provide hand hygiene before donning a new pair of gloves. After she dusted, she removed the gloves, and used the alcohol based hand rub (ABHR), however, she rubbed the ABHR on the palms of her hands only. She failed to ensure her entire hands were cleaned with the ABHR. At 11:43 a.m., HK #1 cleaned the sink and the toilet with a new clean towel. The disinfectant was on the sink and toilet for eight minutes, rather than the 10 minutes required as a dwell time. At 11:45 a.m., she doffed the dirty gloves, and immediately placed a new pair of gloves on, with no hand hygiene. She cleaned the door knob of the room with a cloth. D. Interviews: The HK #1 was interviewed on 5/20/2020 at 12:02 p.m. The HK #1 said she was newly hired. She said she had training on COVID 19 and infection control. She said the chemical HP202 had a dwell time of two minutes. She said when she cleaned the frequently touched items, like the door knobs, she would spray the cloth with the HP202 and then wipe the surface. She confirmed that she did not always perform hand hygiene after each glove change. The HK supervisor was interviewed on 5/20/2020 at 12:02 p.m. The HK supervisor said the dwell time for the HP202 chemical was 10 minutes. She said gloves needed to be changed in between tasks and hand hygiene performed in between. She said the door knobs and the heavy touched surfaces needed to be sprayed with the HP202 directly and let it sit for 10 minutes and then wiped. The HK supervisor said she would provide additional training to the HK #1.

Based on observations and interviews the facility failed to prepare, distribute, and serve food in a safe and sanitary manner, to prevent cross contamination, in one of one satellite kitchen reviewed for food service safety. Specifically, the facility failed to prevent the potential for cross-contamination of food from occurring by staff for the following: -Improper glove use, touching multiple surfaces and then touching ready-to-eat foods, while preparing, distributing, and serving residents' meals from the satellite kitchen. Findings include: I. Facility policy and procedure The Bare Hand Contact with Food and Use of Plastic Gloves policy and procedure, provided by the registered dietician (RD) on 6/6/19 at 10:20 a.m., read in pertinent part: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. -Staff will use clean barriers such as single-use gloves, tongs,deli paper and spatulas when handling food. -Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single-use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. -Clean barriers such as single-use gloves are to be used when handling ready-to-eat foods, handling raw meat, poultry, raw eggs, fish, and shellfish. -Gloves are just like hands, they get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. -Also,during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and anytime a contaminated surface is touched. II. Observations On 6/4/19 at 11:52 a.m., Cook #1 was preparing the lunch meal in the satellite kitchen wearing blue disposable gloves. She turned to the flat-top, used a spatula to remove the hamburger, she was cooking and turned and placed it on a light blue cutting board. She placed her gloved hand (that touched the spatula handle) on the hamburger, picked up a knife, cut it in two, then opened a plastic bag and reached into it to obtain a bun (ready-to -eat food). She then picked up a plate touching the eating surface and placed the hamburger on the resident ' s plate. She removed her gloves and donned a new pair. -She did not wash her hands. She repeated the procedure while preparing a hot dog on a bun, turning away from the counter to the flat top and back to the counter without changing gloves after touching a knife handle, plates, menu cards, hamburger and hot dog buns. She also leaned over the serving area with her clothing touching the counter where ready-to-eat food was placed. -At 11:54 a.m., while wearing a pair of blue disposable gloves, Cook #1 picked up a package of potato chips, opened it, then picked up a plate, touching the eating surface, poured the chips onto the plate, then picked up a cold sandwich and placed it on the plate and sent it out to a resident. Wearing the same gloves, she took the lid off a steam table compartment, retrieved an unknown meat with her hand, placed it on the same cutting board, sliced it, placed it on a plate touching the eating surface, then the menu cards. She turned to the flat top, used a spatula that was laying next to the flat top to remove the hamburger, placed it on a cutting board, cut it up and placed it on another plate, touching the eating surface of the plate, and sent it out to a resident. During the meal she was observed to remove her gloves, and reapply disposable gloves many times, but continued to touch multiple surfaces with the newly applied gloves, turning away from the prep area and back, then touching ready-to-eat foods that were served to resident's. -At 12:07 p.m., Cook #1, wore blue disposable gloves, picked up a plastic bag that contained ham, she reached in the bag and removed the ham and placed it on the flat top. She then used a spatula to remove the ham, turned and placed it on the cutting board, touching the ham with her gloved hand, sliced it, and scooped it into a bowl using both hands, wiping the excess ham off the knife with the gloved hand. On 6/5/19 at 8:30 a.m., Cook #1 was in the satellite kitchen preparing and serving breakfast. She was wearing blue disposable gloves. She touched multiple plates on the eating surfaces, the menu cards, the counter in front of her, and opened plastic fruit bowls. She turned to the flat top, used a spatula laying next to the flat top to retrieve food, turned to the counter, touched the food and placed it on a resident's plate. She did not change her gloves or perform hand hygiene. -At 12:30 p.m., Cook #1 prepared and served the lunch meal from the satellite kitchen. She was wearing blue disposable gloves. She touched a plate on the eating surface, picked up a sandwich, placed it on the plate, held it down with her gloved hand, picked up a knife, cut the sandwich in two, layed the knife down on the counter and picked the sandwich up and placed it on the resident's plate. She picked up a lettuce leaf with her gloved hand, used a scoop to place noodles on the lettuce then used the same gloved hand to pick up bacon crumbles and place them on top of the noodles then the plate went out to a resident. She then turned and obtained an uncooked hamburger patty with the same gloved hand and placed it on the flat top, she turned to pick up a bowl and a ladle to place soup into the bowl, she then turned and picked up a spatula laying next to the flat top to flip the hamburger. Wearing the same gloves, she walked to the refrigerator,opened the door, obtained a milk carton, poured milk into a bowl, opened the microwave door and placed the bowl inside. She closed the microwave door and pushed buttons to set the timer. She walked back to the refrigerator and placed the milk carton inside. She walked to the flat top, used a spatula to remove the hamburger and placed it on the cutting board. She turned to the side, removed a plastic lid from a container, used a small scoop to place a powder into a bowl, obtained a knife, cut the hamburger into pieces while holding the meat down with her gloved hand, then scooped the pieces up with both hands and placed the pieces on a plate and sent it out to a resident. Only at this point did she change her gloves, proper hand hygiene was not performed. III. Staff interviews The Chef and the registered dietician (RD) were interviewed on 6/6/19 at 8:44 a.m. They said the dietary staff that prepares and serves meals are to wear gloves if they are touching ready-to-eat foods. Any time they walk away (turn their back) from the serving line, they are to change their gloves and wash their hands after coming in contact with any ready-to-eat food, before moving to another item. They should not touch potentially contaminated surfaces such as: door or cabinet handles or utensils that have touched counter tops with their gloved hands and then touch ready-to-eat food. They should not wear gloves the entire time it takes to prepare and serve the meals. The chef said he would complete education for his staff regarding the proper use of gloves during meal service. IV. Facility follow-up after the Chef and the RD were made aware of the above observations for breaks in infection control during meal service. A copy of the inservice, The Food and Nutrition Services Training, dated 6/6/19 was provided on 6/6/19 at 1:07 p.m. It documented the following topics were covered: Hand washing, glove use, and the use of hand sanitizer, presented by the Chef and the RD with five dietary staff members in attendance so far.

Based on observations, record review and staff and resident interviews, the facility failed to ensure services provided met professional standards of quality for one (#19) of 17 sample residents. Specifically, the facility failed to ensure Resident #19 was properly assessed and had a physician's orders [REDACTED]. Findings include: I. Professional reference According to Clinical Nursing Skills & Techniques, by Perry & Potter, 8th Edition, (2014) page 488, Stay with the patient until the medication is taken. Provide assistance as necessary. Do not leave medication at the bedside without a prescriber order. According to the Lippincott Manual of Nursing Practice, by Lipincott,[NAME] & Wilkins, 10th Edition (copyright 2014), page 16: Standards of Practice: General Principals: 1) The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events. Common departures from the standards of nursing care: failure to assess the patient properly or in a timely fashion, follow physician orders. II. Facility policy and procedure The Medication Administration policy was provided by the director of nursing (DON) on 6/5/19 at 1:20 p.m. The policy read in pertinent part: Although the prescriber of medication is responsible for the order, the nurse has the responsibility to review order to ensure they are safe and appropriate for the patient. Medication management within the realm of the nurse, includes: Assessing the patient. Reviewing current medication and adherence to them. Evaluating for adverse reactions to medications. Educating in proper medication administration and contacting the prescriber regarding tolerance or adherence to the medication regimen. The Self Administration of medication policy was provided by the DON on 6/5/19 at 1:20 p.m. The policy read in pertinent part: Each resident who desires to self- administer medications is permitted to do so if the facility's interdisciplinary team (IDT) has determined the practice would be safe for the resident and other residents of the facility. An assessment is conducted to determine the resident's cognitive, physical and visual ability to carry out this responsibility. Self-administration of medication may apply to all of the resident's medications or just selected medication as requested by the resident. Self- administration of medications may also apply if the nurse dispenses the medications and the resident self-administers them at their own leisure without the nurse being present. If the IDT approves the resident for self-administration of medications, the following will occur: A physician's orders [REDACTED]. A list of the medication and dispensing instructions, written in a language understandable by the resident, shall be explained to the resident and provided to the resident to refer to when they administer their medications. The resident's care plan will indicate self-administration of medications. III. Resident status A. Resident #19 Resident #19, age 77, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician's orders [REDACTED]. The 5/14/19 minimum data set (MDS) assessment revealed the resident had intact cognition with a score of 15 out of 15 on the brief interview for mental status (BIMS). B. Resident observation and interview Resident #19 was observed on 6/4/19 at 9:44 a.m. She was sitting up in her bed and had recently finished breakfast. A 30 milliliter (ml) medication cup, full to the top of pills was observed on her bedside table. Resident #19 was interviewed on 6/4/19 at 9:44 a.m. The resident said the nurses bring my morning pills before breakfast and I cannot take them that early. Because there are so many pills to take, about 20 or so, they make me nauseous if I take them before I eat or if I take them too fast. Rather than the nurse wait for me to take the pills, she leaves the pills. I take the pills at my own pace; taking my time swallowing them. I have a hard time swallowing some of the pills, especially the salt pills so the nurse gives me applesauce to make taking the pill easier. Later in the morning I let the nurse know the number of pills I've taken. I know most of the pills by name because I took them at home prior to coming here. Resident #19 was observed on 6/6/19 at 8:07 at a.m. She was sitting up in bed, eating breakfast and her pills were placed on her bedside table in a 30 ml medication cup. The cup was full to the top. The resident confirmed she had been getting her pills in this manner. C. Staff interviews Registered nurse (RN#3) was interviewed on 6/6/19 at 8:10 a.m. RN #3 said she pours Resident #19s pills into a medication cup and leaves them at the bedside, within reach so the resident can take her time swallowing them. The RN said there should be a physician's orders [REDACTED]. The DON was interviewed on 6/6/19 at 9:10 a.m. The DON said she was not aware the nurses were leaving the Resident #19's pills in her room without watching her take the pills. The DON said the nurses should not be leaving the resident's pills for her to take unsupervised unless the resident was assessed by the IDT and had a physician's orders [REDACTED]. D. Record review: The (MONTH) 2019 CPO revealed in part the following order: - General Complete self-administration observations for: [MEDICATION NAME] mouthwash, electrolyte tabs and throat [MEDICATION NAME], order date 6/4/19 - Resident may self-administer electrolytes tabs, [MEDICATION NAME], and throat [MEDICATION NAME], medication to be stored in the resident's room, order date 6/4/19. Further review of the CPO and resident's medical record failed to show Resident #19 was assessed or had a physician's orders [REDACTED]. The care plan failed to document the resident's desire to self-administer medications, list medications resident was approved to self-administer or provide instructions and methods for resident's medication self-administration. review of the resident's medical record revealed [REDACTED]. The assessment read in part: Observation detail completed 6/4/19 at 10:14 p.m. Resident #19 wanted to self-administer some medications. The assessment determines it was appropriate for the resident to self-administer Nunn electrolytes tabs, [MEDICATION NAME] and throat [MEDICATION NAME], and store the medications in her room.

Based on observations, record review and interviews, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for one (#21) of two residents reviewed for accident hazards, out of 17 sample residents. Specifically, the facility failed to appropriately assess the use of an electric heating pad for cognitively impaired resident. Findings include: I. Professional reference Wiggens, B. (2018), Heating Pads Can Cause Second-Degree Burns, retrieved from, https://healthcare.utah.edu/the-scope/, read in part: Health information from expects, from the University of Utah Health, report that heating pads pose a big risk to the elderly geriatric population. A heating pad will only get to about 120 degrees, but when it's in a confined space or on the same location of a person's skin it can cause a second degree burn. This is most dangerous to individuals with decreased mobility and impaired physical sensation. The danger is that when left in the same place, a serious burn from a heating pad can develop within a few hours of exposure. Heating pads pose a risk of developing severe blistering, broken skin and even a risk of death. Having a significant burn injury, for those with thinner skin and poor circulation puts them at a higher risk because their skin doesn't heal as well. II. Faculty policy and procedure The Safe Environmental Control policy was provided by the director of nursing (DON) on 6/6/19 at 12:52 p.m. The policy read in pertinent part: Environmental control: Temperature in patient care areas shall be kept at a level that is conducive to the maintenance and promotion of good health. Safety: The use of electric blankets and electric heating pads is not permitted at any time. III. Resident status A. Resident #21 Resident #21, age 92, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, [DIAGNOSES REDACTED]. The 5/21/19 minimum data set assessment revealed the resident had severe cognitive impairment with a score of six out of 15 on the brief interview for mental status (BIMS). She required extensive assistance with activities of daily living. B. Resident interview and observation Resident #21 was interviewed on 6/5/19 at 12:30 p.m. She said she used her heating pad to get warm. On 6/4/19 at 9:08 a.m. Resident #21 room was observed. The resident was not in her room at the time of the observation. An electric heating pad was observed on the foot of the resident's bed. The heating pad appeared worn and the cover was faded. The heating pad was plugged into the power outlet but not turned on. The temperature setting in the resident's room was set to 80 degrees and it was very warm in her room. On 6/5/19 at 12:22 p.m. Resident #21 was observed in bed, sleeping. The heating pad was on her recliner. The heating pad was plugged into the wall electric outlet but was not turned on. C. Staff interviews Registered nurse (RN) #1 was interviewed on 6/5/19 at 4:15 p.m. RN #1 said Resident #21 had progressed in her dementia. The RN said the resident was more confused in the evening and at night. Certified nurse aide (CNA) #2 was interviewed on 6/5/19 at 4:30 p.m. CNA #2 said the resident used the heating pad mostly at bedtime. She said Resident #21 complained of cold feet and wanted her feet to be warm. CNA #2 said the resident would hold the controller in her hand throughout the night turning it on and off and could raise the temperature controller setting. RN #3 was interviewed on 6/6/19 at 8:10 a.m. RN #3 said she was aware that Resident #21 used the heating pad on her stomach while sitting up in her recliner. She said the resident knew how to turn it on, but would not necessarily know if she turn it up too high. CNA #1 was interviewed on 6/6/19 at 8:20 a.m. CNA #1 said he was aware that Resident #21 had a heating pad but had not observed the resident using the heating pad in bed. He had observed the resident using the heating pad over her lap while lounging in her recliner during the day. He said she can turn it on, but he did not know if she used the temperature settings appropriately. He said he was not sure where the heating pad came from and there were no instructions for its use on the CNA task sheet. He did not know if the use of the heating pad was on the resident's care plan. The DON was interviewed On 6/6/19 at 9:10 a.m. The DON said she was not aware that Resident #21 was using an electric heating pad. She said the resident should not have the electric heating pad. She said the facility does not permit residents in the facility to have or use electric heating pads, for their own safety. D. Record review Review of Resident #21's medical record did not reveal a physician orders [REDACTED].

Based on observations, record review and staff interviews, the facility failed to follow infection control practices related to maintenance of respiratory equipment, to prevent cross contamination for three (#6, #181, and #10) of three out of 17 sample residents. Specifically, the facility failed to properly maintain, clean, and store nebulizer equipment. Findings include: I. Professional reference Nitin, K., and Hassani, U.S. (June 2013). Microbial colonization profile of respiratory devices and the significance of the role of disinsertion: a blind study, National Journal of Medical Research doi: 10.7860/JCDR/2013/5681.3086, retrieved from https://www.ncbi.nlm.nih.gov/pubmed/ 094. It read, Approximately 10-40% of all nosocomial infections (an infection spread to susceptible patients in a healthcare facility) are [MEDICAL CONDITION] (related to the respiratory system), which lead to serious complications. Elderly, debilitated or critically ill patients are at a high risk. Respiratory care equipment which includes ventilators, humidifiers and nebulizers have been identified as the potential vehicles which cause major nosocomial infections if they are colonized (germs in significant quantity) by fungi or bacteria. The Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). (2016). How Infections Spread, retrieved from, https://wwwnc.cdc.gov/eid/article/8/9/02-0063_article. It read in pertinent part: Germs (virus, bacteria, or other microbes) are found in the healthcare environment. Examples of environmental sources of germs include: Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables). Wet surfaces, moist environments, and biofilms (slimy buildup of microorganisms that stick to various surfaces including wet surfaces and is not easily washed away (e.g., cooling towers, faucets and sinks, and equipment such as respiratory equipment). Indwelling medical devices (e.g., catheters and IV lines). Dust or decaying debris (e.g., construction dust or wet materials from water leaks). Germs depend on people, the environment, and/or medical equipment to move and cause and infection in healthcare settings. There are a few general ways that germs travel in healthcare settings: Through contact by hands and contaminated surfaces. By sprays and splashes, creating partial droplets which carry germs short distances (within approximately 6 feet). Close range inhalation, occurring when a droplet containing germs is small enough to breathe in but not durable over distance. Airborne transmission can occur when infected patients cough, talk, or sneeze germs into the air or when germs are aerosolized by medical equipment. The Centers for Disease Control and Prevention (2017), Nosocomial Infections Linked to Contaminated Sinks, retrieved from, https://wwwnc.cdc.gov/eid/article/23/2/16-0649_article, it read in pertinent part: Transfer of pathogens from sinks to patients might occur in several ways. Water from faucets is directed straight into the drain, resulting in splashing that can lead to contamination of an area less than 3 feet from the sink. Therefore, patients and items can be contaminated when they brush their teeth, wash their hands, or take a shower. II. Manufacturer's recommendations Medline Industries, Inc.(2007), Medline Aeromist Plus Evaluation Compressor Nebulizer User ' s Manual, Compressor Nebulizer User ' s Manual, retrieved from: http://pulmonaryprovidersgroup.com/yahoo_site_admin/assets/docs/Aeromist_Plus_HCS _HCS RD_USER_MANUAL 4859XXX 948.pdf, it read in pertinent part, Cleaning the nebulizer components and accessories: To clean: remove the tubing from the air inlet. Disassemble mouthpiece/mask, t-piece, nebulizer cap, chamber/baffle, and wash these items except the tubing in hot water with dish-washing detergent. Rinse these items thoroughly to remove the detergent. To disinfect: mix one part of white vinegar with three part of hot distilled water, and use a clean container to carry this disinfectant solution. Submerging mouthpiece/mask, t-piece, nebulizer cap, chamber/baffle for one hour. Remove these cleaned units from container and let them dry in the air. There is no need to clean the tubing if necessary wipe the surface of it regularly. The filter of air compressor should be replaced when it turns gray. III. Facility policy and procedure The Aerosol Drug Administration policy, undated, was provided by the director of nursing (DON) on 6/6/19 at 12:52 p.m. It read in pertinent part, There is no specific pretreatment procedures, except for the set-up of equipment used for the procedure. The mouthpiece and the nebulizer cup should be rinsed with tap water after each use. The policy and procedure failed to mention the need to follow manufacturer recommendations for proper sanitation and storage of nebulizer equipment to prevent transmission of a potential infection to the resident. IV. Resident status A. Resident #6 Resident #6, age 80, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 3/29/19 MDS assessment revealed, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She had hallucinations and delusional behaviors. a. Observations The condition of Resident #6 nebulizer machine and equipment was observed on 6/4/19 at 8:32 a.m. The resident's nebulizer medication set (mask and medication cup) was disconnected from the machine, was disassembled on a wet paper towel on the resident's nightstand. The medication set was not covered or in any type of protective container. The medication set was not labeled or dated with an open date. On 6/5/19 at 12:27 p.m., the resident's nebulizer medication set was observed on a damp paper towel on the side of the sink, in her room, directly next to her hair dryer and other hygiene products. The medication set was not covered or in any type of protective container. There was no open/first used date label on the nebulizer medication set or tubing. On 6/6/19 at 10:40 a.m., the resident's nebulizer medication set was observed lying on a damp paper towel on the side of the sink, in her room, directly next to her hair dryer and other hygiene products. The medication set was not covered or in any type of protective container. There was no open/first used date label on the nebulizer medication set or tubing. b. Record review The (MONTH) 2019 CPO revealed the following orders: - [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-3.0 (2.5 mg base) two and one half (2.5) milligrams (mg)/three (3) milliliters (ml), one vial inhaled orally three times a day, for wheezing (order date 5/30/19). - [MEDICATION NAME] solution for nebulization; two and one half (2.5) milligrams (mg)/three (3) milliliters (ml), administer one vial by inhalation, as needed for shortness of breath and wheezing. Monitor lung sounds before and after treatment, document results (order date 5/30/19). - Change denture cup, tooth brush, kidney basin, graduated cylinder, urinal, neb(ulizer) tubing, oxygen tubing. Initial and date. Disciplines: Nursing, document in point of care charting category. Frequency: once on the first Sunday of every month, night shift (order date 4/1/18). The resident's comprehensive care plan, dated 3/29/19, did not document resident's respiratory care needs/interventions related to her medical [DIAGNOSES REDACTED]. B. Resident #181 Resident #181, age 82, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 4/4/19 MDS assessment revealed, the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident experienced shortness of breath with exertion and was on oxygen. a. Observations The condition of the resident's nebulizer machine was observed on 6/4/19 at 8:22 a.m. The nebulizer medication set (medication cup, inhalation pipe and a mask) were observed on the resident's sink, directly on top of the nebulizer machine. The medication set was not on or in any type of protective covering or container. There was no open/first used date label on the nebulizer medication set or tubing. The resident's nebulizer machine and equipment were observed on 6/6/19 at 8:24 a.m. The nebulizer machine and nebulizer medication set were on the side of his sink. The medication set was attached to the nebulizer machine and was not on or in any type of portative covering or container. The medication cup had clear liquid inside. The machine was not on. No staff was in the resident's room. There was no open/first used date label on the nebulizer medication set or tubing. c. Record review The (MONTH) 2019 CPO revealed the following orders: - [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-3 three (3) milligrams (mg)/three (3) milliliters (ml), administer one vial, inhale orally every six hours, as needed for [MEDICAL CONDITION] (3/27/19). - Change Denture cup, Tooth brush, Kidney basin, Graduated cylinder, Urinal, Neb tubing, Oxygen tubing. Initial and date. Disciplines: Nursing, document in point of care charting category. Frequency: once on the first Sunday of every month, night shift (3/27/19). This order did not mention frequency to change the nebulizer medication set. C. Resident #10 Resident #10, age 74, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 4/24/19 MDS assessment revealed, the resident had moderate cognitive impairments with a BIMS score of nine out of 15. a. Resident interview and observations Resident #10 was interviewed on 6/4/19 at 8:45 a.m. The resident said he was on oxygen and received nebulizer treatments due to pneumonia. He was feeling better now and the pneumonia was gone, so he was no longer on oxygen. He said he still had occasional nebulizer treatment. He said the nurse rinsed the mask and nebulizer cup with water after his treatments, and the machine and nebulizer equipment were stored on his table by the door. He was not sure when the mask or medication cup were last replaced. The condition of Resident #10 nebulizer machine and equipment was observed on 6/4/19 at 8:45 a.m. The resident's nebulizer medication set (mask and medication cup) was observed next to the nebulizer machine lying directly on the resident's nightstand next to other personal hygiene products. The mask and medication cup was disconnected from the nebulizer machine, the equipment was uncovered and was not in any type of protective container. The medication set was not labeled or dated with an open date. On 6/4/19 at 12:31 p.m. and 6/5/19 at 8:05 a.m., the resident's nebulizer medication set was observed lying directly on top of the nebulizer machine on a table just inside the room in the path of visitors and staff going in and out of the resident's room. The nebulizer mask and medication cup were not covered or in any type of protective container. There was no open/first used date label on the nebulizer medication set or tubing. b. Record review The (MONTH) 2019 CPO revealed the following orders: - [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-3.0 (2.5 mg base) two and one half (2.5) milligrams (mg)/three (3) milliliters (ml), one vial inhaled orally every four hours, as needed, for congestion (9/16/17). - Change Denture cup, Tooth brush, Kidney basin, Graduated cylinder, Urinal, Neb tubing, Oxygen tubing. Initial and date. Disciplines: Nursing, document in point of care charting category. Frequency: once on the first Sunday of every month, night shift (9/16/17). This order did not mention frequency to change the nebulizer medication set. The resident's care plan dated 3/29/19 failed to document resident's respiratory care needs/interventions related to the medical [DIAGNOSES REDACTED]. IV. Staff interviews Registered Nurse (RN) #3 was interviewed on 6/6/19 at 8:10 a.m. RN#3 said once the resident's nebulizer treatment was complete she rinsed the medication cup and mask with water and the equipment was left on a clean paper towel on the residents sink, to dry until the next scheduled treatment. The RN said the certified nurse aides (CNA) change the respiratory equipment monthly on the night shift but she did not know the exact timing of the equipment change. RN #3 acknowledged the equipment she had used with the residents on her assignment did not have dated equipment and she was not sure when the tubing and nebulizer sets were last changed. The DON was interviewed on 6/6/19 at 9:10 a.m. The DON said the nebulizer masks/pipe and med sets were to be rinsed with water after each use and left to dry on the resident's sink and the CNA should change the equipment monthly.

Based on observations, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Monitor the temperatures of foods reheated in the microwave before serving the residents; -Ensure the hydration cups were dry before storing for resident use; and -Clean the main kitchen grill after cooking pork chops. The findings included: I. Monitoring food temperatures after use of a microwave. A. Food Temperature Policies The dietary manager (DM) provided undated copies of the following food temperature policies: -The Food Temperature policy revealed in pertinent part, All hot food items will be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (though 140 degrees Fahrenheit is recommended.) .Food temperatures will be measured often to monitor for safe holding temperature ranges of above 135 degrees for hot foods . -The Proper Cooking Temperatures policy revealed in pertinent part, Foods should be cooked to the proper internal temperatures . Proper Minimum Internal Cooking Temperatures . Ready to eat food taken from commercially processed, sealed containers or intact packages: 165 degrees Fahrenheit. -The Reheating Food policy revealed, Food reheated in a microwave should be covered, rotated, and stirred throughout the cooking process. The food should be heated to a uniform internal temperature of 165 degrees Fahrenheit . The final cooking temperature of all foods should be measured with a calibrated thermometer . B. Observations An observation through the satellite kitchen window in the main dining room on 12/12/16 at 5:34 p.m. revealed the DM pouring broccoli into a small white bowl and inserting it into the stainless steel microwave. The DM removed the bowl from the microwave and poured out the green broccoli florets on to a white dinner plate. The dietary aide (DA) #3 was holding the white dinner plate above the steam table as the DM was pouring. The DA #3 then set the plate on the serving counter. The staff member took the plate and served the resident. The broccoli was not temped with a thermometer to check internal temperatures before it was served. An observation through the satellite kitchen window on 12/13/16 from 5:00 p.m. through 5:35 p.m. revealed several microwave uses to reheat foods without checking internal core temperatures of the food. -At 5:20 p.m. the DA #3 opened a can of tomato soup and poured it into a maroon cup. She put the cup into the microwave and turned it on. When the tomato soup was done reheating, the DA took the maroon cup and placed it on a white dinner plate with a grilled cheese sandwich. She put the plate on the serving counter and the staff member served the resident in the dining room. Neither DA #3 or the DM tested the internal temperature of the food before serving it. -At 5:23 p.m. a resident requested broccoli with their dinner. The DM pulled a bag of broccoli out of the reach-in refrigerator. He poured some broccoli into a small white bowl and placed the bowl in the microwave to heat. The DA #3 pulled the bowl out of the microwave and poured the broccoli onto the resident's plate while spilling a few green crowns on the floor. The plate was set on the serving counter and the staff carried the plate to the resident. Neither the DA or the DM tested the internal temperature of the food before serving it. -At 5:25 p.m. a resident requested mashed potatoes. The DM was overheard saying he was going to the main kitchen to get some instant mashed potatoes. He brought back a container of instant mashed potatoes. He mixed the dry mashed potatoes with liquid and handed it to the DA #3. She wrapped the bowl with clear plastic wrap and let it sit. She then put the bowl in the microwave. She pulled the mashed potatoes out of the microwave and removed the plastic wrap. She stirred the mashed potatoes and then placed the bowl back in the microwave. She removed the bowl and set it on a plate. The plate with the mashed potatoes was set on the serving counter. The staff picked up the plate, and carried it to the resident. Neither the DA or the DM tested the internal temperature of the food before serving it. -At 5:30 p.m. a resident had requested macaroni and cheese. The cook pulled a small frozen package of single serving size macaroni and cheese from the reach-in freezer. She slit the bag open and put it in the microwave. She pulled the macaroni and cheese from the microwave after it was cooked. She poured them from the bag into the small white bowl. She stirred them and returned them to the microwave to cook some more. She pulled the bowl from the microwave and put it on the plate. She set the plate on the serving counter. Neither the DA or the DM tested the internal temperature of the food before serving it. C. Staff Interviews DA #4 was interviewed on 12/14/16 at 7:55 a.m. in the satellite kitchen. She said she would check internal food temperatures and would like 165 degrees (Fahrenheit) before serving to the resident. The safe zone for food would be no less than 140 or 145 degrees. She said any food that was microwaved for the residents should be checked with a thermometer for internal core temperatures. She did not want the food to be served too hot or too cold. The DM was interviewed on 12/14/16 at 7:58 a.m. He said any food items that came out of the microwave should be checked for internal core temperatures. The food temperatures should reach 145-155 degrees. If it did not have this temperature, the food should be returned to the microwave for continued cooking. He was not aware the food microwaved on the evening of 12/13/16 had not been monitored. II. Dry Storage of Resident Hydration Cups A. Colorado Retail Food Establishment Rules and Regulations. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13), page 69, section 4-601-part C, Equipment and Utensil Handling and Storage, includes, Utensils shall be air-dried . before being stored or shall be stored in a self-draining position. B. Facility Policy The DM provided an undated copy of the facility's policy for Dishwashing. This policy included, Do not stack dishes until they are dried completely. Dishes may be stored on a clean dish rack in a manner to continue air drying as needed. C. Observations On 12/07/16 at 11:48 a.m., the clear colored hydration cups with blue writing were observed stacked on a side table on the south wall of the main dining room. There were six to seven cups stacked on top of each other. There was a total of five stacks grouped together. There was an estimated count of 35 cups on the table. The cups had water droplets/condensation inside of them. The cups were not positioned to air dry. There was a brown rolling cart next to the table. On top of the cart was a red cooler with a white lid filled with ice. The cart had a side storage bin. It was stacked with clear hydration cups. These cups had water condensation. The cups were inverted upside down on top of each other. There were four stacks of at least 12 cups. There was no air flow to these stacked cups to allow them to dry. On 12/ at 9:06 a.m. there were 12 stacks of clear hydration cups. In each stack were five cups. Inside of each cup there was water condensation. There was no air movement to dry the cups. On 12/12/16 at 2:51 p.m., there was a brown rolling cart with a red cooler and white lid parked by the nurses' station. The attached side bin had stacks of hydration cups with water condensation. On 12/12/16 at 5:14 p.m., there was a brown rolling hydration cart on the 350-360 rehabilitation hallway. It was parked between room #352 and #354. The side bin had stacked clear colored hydration cups for the resident's water. The cups were inverted. There were water droplets inside of the cups. On 12/13/16 at 9:59 a.m. there were eight stacks of clear blue hydration cups on the side table in the main dining room against the south wall. The stacks were two cups and four cups high. The cups had visible water droplets. The cups were not open to air flow. D. Staff Interviews/Observations DA #2 was interviewed on 12/13/16 at 2:19 p.m. in the kitchen. She was not sure why it was important to make sure all dishes were dry before stacking and storing them. She summoned the DM over to the conversation and asked him about the importance of making sure all dishes were dry. She then summoned the DM over and asked him about the importance of making sure all dishes were dry without water condensation. He responded it was to make sure they do not cross contaminate dishes. If there was moisture on the dishes, it may have germs. They did not want mold to grow with the moisture. DA #2 said they do not want the residents to get sick. During this interview, the main dining room was observed, where there were eight stacks of clear hydration cups with blue writing on the side table. The DM confirmed there were water droplets inside the cups. Across the other side of the dining room next to the nurses' station were the brown hydration carts. The hydration cups were stacked inside of the side bin. The DM confirmed there was water in the hydration cups. He said he was not aware there was condensation in the cups. He said, That is a problem. He said he would talk to the dietary aid. He would look into the drying process for the hydration cups. They would get them washed and dried properly. He confirmed the water condensation could lead to residents potentially getting sick. On 12/13/16 at 7:58 a.m. the DM was in the main kitchen cooking scrambled eggs. He said they washed all of the hydration cups. There were eight cups on the four tier metal rack upside down. He also pointed out four tan dish racks in the corner of the room filled with hydration cups upside down to dry. He said they washed the cups 12 hours ago and the cups had retained moisture. There were still visible water droplets. He did not know if it was the type of plastic that did not allow the cups to dry sufficiently. He spoke with the registered dietitian regarding this concern. He would have to talk with management to problem solve further. III. Cleaning the main kitchen grill A. Colorado Retail Food Establishment Rules and Regulations. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations, page 68, section 4-407-part D-4, The food-contact surfaces of cooking and baking utensils and equipment, such as grills, woks, hot sandwich presses, waffle irons, as well as baking equipment and the cavities and door seals of microwave ovens shall be cleaned at least every 24 hours and shall be kept free of encrusted grease deposits and other accumulated soil. B. Observations/Staff Interviews On 12/13/16 at 4:00 p.m. DA # 1 was observed cooking the dinner time meal in the main kitchen. During dinner preparations, the grill with slats was observed to be unclean, with crumbs and crispy food particles in the reservoir of the grill. The slats had visible black charred grease buildup. The DA said they rarely used the grill. It was used about once a month to cook pork chops. They did not use this grill for any other purpose. When they cleaned the grill, they soaked the slats in degreaser overnight. Then they rinsed them off and ran them through the dishwasher a couple of times. She agreed the grill was dirty with food particles. The DM entered the kitchen on 12/13/16 at 4:45 p.m. and he looked at the grill. He said it was pretty grungy. The grill had food particles and black charred grease buildup on the slats. He said they only used the grill to cook pork chops. This was about once a month. He said the grill was on the cleaning list. The cleaning list was observed during the interview. The grill was not listed on the cleaning duties. The cleaning duty list included tasks for daily, weekly, monthly, quarterly and six months. C. Record Review The DM provided a copy of the nutrition and dining services cleaning list on 12/14/16 at 8:08 a.m. This list did not include cleaning the main kitchen grill with slats. The DM provided copies of the weekly special menus on 12/14/16 at 8:08 a.m. The menus were from 11/20 through 12/17/16. The last time the facility served pork chops was Sunday, 11/20/16. D. Staff Interview The DM was interviewed again on 12/13/16 at 7:58 a.m. He was standing next to the grill. The grill slats had been removed for cleaning. The reservoir was free from food crumbs and food debris. He said there were food particles and debris in the grill yesterday. They did clean it. He said it was not on his cleaning schedule as it should have been. He said the grill should be cleaned after each use.

Based on observation, record review, and interviews, the facility failed to ensure the assessments accurately reflected the residents' status for five (#21, #75, #71, #96, and #53) of 24 sample residents. Specifically, the facility failed to: -Ensure resident #21 was accurately coded for the use of an anticoagulant medication; -Ensure resident #75 was accurately coded for hospice services; -Ensure resident #71 was accurately coded for having significant weight loss; and -Ensure residents #96 and #53 were accurately coded for having pressure ulcers. The findings included: I. Facility's Policy On 12/14/16 at 12:15 p.m. the director of nursing (DON) provided a copy of the facility's undated policy titled Resident Assessment. The policy documented in pertinent part, The assessment shall include at least the following: Identification and demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychological well-being, physical functioning and structural problems, continence, disease [DIAGNOSES REDACTED]. II. Anticoagulants A. Resident #21 Status Resident #21, age 92, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/25/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Mild depressive symptoms and no behaviors were noted. The resident required extensive one-person physical assistance for bed mobility, transfers, walking and locomotion, dressing, toilet use, personal hygiene, and bathing; and limited one-person physical assistance for eating. For the seven-day look back period prior to the completion of the MDS assessment, the resident was coded as receiving an anticoagulant medication zero of seven days. B. Record Review The physician's orders [REDACTED]. The care plan dated 7/19/16 documented the resident received an anticoagulant medication for the treatment of [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]. C. Staff Interviews Nurse manager (NM) #1 was interviewed on 12/14/16 at 2:16 p.m. She said her role as nurse manager included completing MDS assessments for residents in the facility. She said rivaroxaban was a medication that should have been coded as an anticoagulant on the MDS assessment. NM #1 was interviewed a second time on 12/14/16 at 3:15 p.m. She provided a corrected copy of the resident's MDS assessment and said the anticoagulant not being marked was a coding error. The DON was interviewed on 12/14/16 at 3:27 p.m. She said that the facility had undergone some changes in the management department and they had found several errors in MDS assessments and were submitting a lot of corrections. She said she felt the facility's internal process of monitoring for MDS accuracy was working, but agreed the rivaroxaban not coded was an error. She said MDS accuracy was important for monitoring quality measures within the facility. III. Hospice Services A. Resident #75 Status Resident #75, age 92, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/29/16 MDS assessment, the resident was rarely/never understood and was severely impaired for daily decision making. The resident exhibited mild depressive symptoms and no behavior symptoms were noted. The resident required extensive two-person physical assistance for bed mobility, transfers, and toilet use; one-person physical assistance for locomotion on and off unit, dressing, eating, personal hygiene, and bathing. The resident had a condition or chronic disease that may result in a life expectancy of less than six months. Hospice care was not indicated. B. Record Review A physician's orders [REDACTED]. The physician's progress note dated 10/22/16 documented, (Resident #75) is hospice eligible with recent stroke and resulting dysphagia . She has previous history of dementia of unknown cause and appears to suffered a stroke on October 19. She now has left-sided [MEDICAL CONDITION], difficulty eating and difficulty speaking. She also has difficulty following commands and is eating only tiny bites. Family did not want workup nor did they want enteral feedings to be undertaken. They only want comfort care for her. Past history includes chronic pai[DIAGNOSES REDACTED], hypertension, recurrent UTIs (urinary tract infections) and falls. Her charting notes weight loss, however I do not have numbers to report. Given the severity of her deficits, she is likely to decline persistently and pass away in the next 6 months. The care plan dated 10/23/16 documented, Problem: (resident #75) is a hospice client. Goal: (resident #75) will have needs met by facility and hospice staff, all medications and treatments as ordered, optimal comfort level and time with family and friends during the next 90 days or as dying process progresses to a natural end. Appropriate interventions were listed on the care plan. C. Staff Interviews NM #1 was interviewed on 12/14/16 at 2:16 p.m. She said the information for the special services section of the MDS was gathered from the resident's medical record. She said hospice services should be marked on the MDS for any resident receiving such services. NM #2 was interviewed a second time on 12/14/16 at 3:15 p.m. She provided a copy of a corrected MDS assessment for resident #75 with hospice services indicated on the MDS. The DON was interviewed on 12/14/16 at 3:27 p.m. She said residents who have been admitted to a hospice should have that service indicated on the MDS assessment for quality monitoring purposes. IV. Weight Loss A. Resident #71 Status Resident #71, age 84, was admitted on [DATE] and discharged on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/5/16 MDS assessment, the resident had moderate cognitive impairment with a BIMS of eight out of 15. She required extensive one-person physical assistance for all ADLs except eating, for which she required limited one-person physical assistance. According to the MDS, she did not have significant weight loss. B. Record Review Resident #71 experienced weight loss during her stay at the facility. Her weights were documented as follows: 9/30/16: 118.2 pounds (admission) 10/1/16: 115.2 pounds 10/2/16: 109.3 pounds (7.5% loss) 10/11/16: 109 pounds 10/18/16: 109 pounds 10/19/16: 120.4 pounds The care plan dated 9/30/16 documented the resident was at risk for weight loss due to acute illness and decreased mobility. Approaches included monitoring the resident's weight, monitoring food intake, providing nutritional supplements as ordered, and notifying the physician as needed. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The registered dietitian (RD) note dated 10/14/16 at 2:52 p.m. documented the resident's significant weight loss had been discussed at a care conference and it was determined that her intake during meals was adequate, so a supplement was to be added during medication administration to provide extra calories and protein. C. Staff Interviews The RD was interviewed on 12/13/16 at 1:54 p.m. She said the significant loss was not coded on the 10/5/16 MDS because as a new resident, there was not a lot of information available and she did not know if the resident had truly experienced weight loss. She said when the resident's next assessment was done on 10/14/16, she coded the weight loss because the 109 weight had been identified as accurate at that time. For the resident's 10/24/16 discharge MDS, she did not code significant weight loss because the last weight recorded on 10/19/16 was 120 pounds, which would actually be an increase over the admission weight of 118 pounds. She said looking back, the 120-pound weight was probably inaccurate and should not have been used for the MDS assessment. She said she could submit a correction for the 10/5/16 and 10/24/16 MDS assessments. The DON was interviewed on 12/14/16 at 3:27 p.m. She said the resident's significant weight loss should have been coded on the MDS to accurately reflect the resident's status. She said MDS accuracy was important for monitoring quality measures. V. Pressure Ulcers A. Professional Reference - MDS Resident Assessment Instrument (RAI) The MDS 3.0 RAI Manual volume 1.14 dated October 2016 revealed in Chapter three, Section M pages 1-20, the resident should be coded in part M-100 section A, if the resident has a Stage one or greater pressure ulcer, a scar over bony prominence, or a non-removable dressing/device. The resident should be coded in part M-300-part G, Enter the number of unstageable pressure ulcers related to suspected deep tissue injury. This information can be viewed at the following website: https://downloads.cms.gov/files/MDS-30-RAI-Manual-V114-October-2016.pdf B. Resident #53 1. Resident Status Resident #53, age 91, was admitted on [DATE] and readmitted on [DATE]. According to the 12/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 12/6/16 MDS assessment, the resident had severe cognitive impairment with a BIMS score of six out of 15. The resident had mild depression symptoms with a score of five out of 27. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She required limited assistance with locomotion on/off the unit, and eating. The resident was documented as at risk for developing a pressure ulcer. The assessment indicated the resident did not have an unhealed pressure ulcer at a stage one or higher. The care plan, initiated on 11/21/16 and revised 12/13/16, identified the resident had a suspected deep tissue injury (SDTI) to the left medial heel. Intervention was to encourage resident to wear open heel shoes/sandals. Resident has gel padded heel protectors. She occasionally prefers to wear the gel padded heel protectors over her socks. Another intervention was documented on 12/13/16, the resident may wear gel padded heel socks at all times with no shoes per resident's preference. It also included assessing the pressure ulcer for stage, size and condition of surrounding skin weekly. 2. Record Review The following documents were provided by the director of nursing on 12/13/16 at 1:30 p.m.: a. Wound Team Progress Notes (WTPN) The WTPN dated 11/21/16 revealed the wound team had, Assessed L(left)heel due to report of purple area. Resident has a SDTI to L medial heel that measures 0.3 cm x 0.3 cm. Wound has intact skin but the skin is dark purple in color, non-blanchable. No odor or drainage noted as skin is intact. Remainder of L heel is red, blanchable, boggy, dry, but otherwise intact. The WTPN dated 11/27/16 revealed the wound team had, Assessed SDTI to L medial heel, which measures 0.5 cm x 0.4 cm. L heel is soft, boggy, dry, but otherwise intact. SDTI is purple in color. Upon palpation of heel wound resident noted to move heel as if in pain, tender area noted to wound and immediately surrounding wound measures 2.0 cm x 1.8 cm. The WTPN dated 12/4/16 revealed the wound team had, Assessed SDTI to L medial heel . Wound measures 0.6 cm x 0.7 cm, skin remains intact, wound is dark purple in color. There is a hard area immediately surrounding and including wound that measures 1.2 cm x 1.4 cm, callous-like. Resident has tenderness to wound and area surrounding wound, tender area measures 3.0 cm x 3.0 cm. b. Minimum Data Set (MDS) Assessment The 12/6/16 quarterly MDS assessment was reviewed. The assessment revealed the resident was at risk for developing a pressure injury. The assessment did not document in section M-100 part A as having a pressure injury stage one or greater. The assessment did not document in section M-300-part G as having one suspected deep tissue injury. Per the wound team progress notes, the resident was assessed on 11/21/16; 11/27/16 and 12/4/16 as having a suspected deep tissue injury. 3. Staff Interviews The nurse managers (NM) #1 and #2 were interviewed together on 12/14/16 at 2:18 p.m. They were responsible for completing the MDS assessments for the facility. NM #2 said the MDS assessments were completed using information such as therapy notes, progress notes, medical charts, and open events. When completing the skin section, they would look at any open skin events and/or progress notes. NM #2 said she would have to look at resident #53's assessment but agreed that if the resident had a SDTI then section M-100 part A and section M-300-part G should have indicated a skin issue. NM #1 and #2 on 12/14/16 at 3:14 p.m. upon review of the 12/6/16 MDS assessment, agreed the coding for resident #53's skin assessment included errors. The errors were corrected as of this date and sent to CMS (Centers for Medicare and Medicaid Services). The DON and the assistant director of clinical services (ADCS) were interviewed on 12/14/16 at 3:26 p.m. The DON said she expected her nurse managers to code the skin assessments accurately based on events in the medical record system. The importance of accurate assessments was for quality measures and correct reimbursement rates. C. Resident #96 1. Resident Status Resident #96, age 83, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 11/15/16 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS section M determination of pressure ulcer risk noted the resident had a completed formal assessment instrument/tool and a completed clinical assessment. The MDS did not note the resident had a stage one or greater pressure ulcer. The care plan, initiated on 11/30/16, identified risk for impaired skin integrity related to hydration status, admitted with a stage II pressure ulcer to the left buttock, a red blanchable area to the left outer buttock, fragile skin, admitted with scattered scabs to bilateral forearms and hands. Approaches included to handle skin and extremities with special care, wash and dry carefully, report breaks in skin or bruising to charge nurse. Protective or long sleeves as appropriate. Medications and treatments as ordered. Document responses, adverse effects and notify physician, nurse practitioner and wound care team as appropriate. Monitor for incontinence, assist with toileting and personal hygiene as needed. Apply barrier cream as needed. Monitor for irritation and notify charge nurse as needed. Monitor for signs and symptoms of breakdown with activities of daily living and during baths and/or cares such as redness or other discolorations; open, bleeding, weeping areas or other concerns. Notify charge nurse promptly. Pressure reducing mattress, wheelchair cushion, heel protection, use of pillow as appropriate for pressure reduction to bony prominences. Document refusals and non-compliance. Repositioning every one to three hours and as needed. Assist, remind, and provide total care as needed by staff. 2. Record Review The nursing note (wound team) dated 11/8/16 at 12:22 p.m., noted the floor nurse reported the resident arrived at the facility with a foam dressing to his left buttock. This nurse removed the foam dressing. The resident was noted to have a stage II to his left inner buttock that was consistent with pressure. The wound measured 1.4 centimeters (cm) by 1.5 cm by 0.1 cm. The wound bed had red granulation tissue. The wound edges were well defined and attached. There was a red area to the left outer buttock that was red, blanchable and intact. The red areas measured 2.3 cm by 3.5 cm. There was scant sanguineous drainage noted to the previous dressing. The resident drove to the facility from out of state with his family and reported that he sat on his buttocks for hours. The resident said it was not a pressure ulcer and he was not sure what was back there. The nurse discussed with the resident he had an open wound consistent with pressure and it was a stage II. New order to cleanse open area with normal saline or wound cleanser, pat dry, apply skin prep to the peri wound and cover with adhesive [MEDICATION NAME]. Change every other day and as needed. Occupational therapy would evaluate the resident for a wheel chair cushion. A specialty mattress (named) would be placed on his bed. An order would be placed in the electronic Medication Administration Record [REDACTED]. The wound team would assess weekly and as needed. A care plan had been developed. According to the nursing note dated 12/9/16 at 11:34 a.m., the resident was discharged from the facility with his medications and belongings at 11:35 a.m. to an assisted living facility. He was accompanied by his family. 3. Staff Interviews The director of nursing (DON) was interviewed on 12/13/16 at 8:35 a.m. The DON said the MDS dated [DATE] was coded incorrectly for this resident. The DON said the MDS should have noted in section M that the resident had a stage one or greater pressure ulcer. The nurse manager (NM) #1 who was also one of the MDS coordinators said the MDS dated [DATE] was not coded correctly for this resident. She said the resident should have been coded as having a stage one or greater pressure ulcer. She said she thought she had checked all of the appropriate boxes.

Based on observations, record review and staff interviews, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (#53) of three sample residents. Specifically, the facility failed to implement timely interventions to protect resident #53's suspected deep tissue injury to the left heel, while sitting in a wheelchair. The findings included: I. Professional Reference According to the NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Dr. Mikel Gray, 8 Apr. 2016. Web. 15 Dec. 2016, (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) the following is the definition of a pressure injury and proper staging. -A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . -Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration . Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. II. Facility Policy The director of nursing (DON) provided undated copies of the following policies on 12/13/16 at 1:30 p.m. -The Pressure Sore Prevention and Care policy revealed all residents who have pressure injuries would have active treatment plans to improve skin conditions. -The Skin at Risk/Wound Prevention Protocol policy revealed the facility took an aggressive approach to wound prevention. This included care of residents with decreased mobility. Examples given in the policy were the use of pillows or other positioning devices as necessary to prevent pressure on bony prominences. III. Resident #53's Status Resident #53, age 91, was admitted on [DATE] and readmitted on [DATE]. According to the 12/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 12/6/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had mild depression symptoms with a score of five out of 27. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She required limited assistance with locomotion on/off the unit, and with eating. The resident was documented as at risk for developing a pressure injury. The assessment indicated the resident did not have an unhealed pressure ulcer at a stage one or higher. (Cross Reference F278, failure to ensure MDS accuracy.) The care plan, initiated on 11/21/16 and revised on 12/13/16, identified the resident had a suspected deep tissue injury (SDTI) to the left medial heel. Interventions included: -Encourage resident to wear open heel shoes/sandals; resident has gel padded heel protectors; she occasionally prefers to wear the gel padded heel protectors over her socks. -An intervention documented on 12/13/16 read, The resident may wear gel padded heel socks at all times with no shoes per resident's preference. -Interventions also included assessing the pressure ulcer for stage, size and condition of surrounding skin weekly. IV. Observations The resident was observed in the dining room on 12/7/16 at 11:43 a.m. She was seated at the dining room table with another resident. She had a nonskid sock on her left foot. There was no gel padded heel protector visible. The resident was observed pushing off her left foot to roll her wheelchair away from the table. The resident's right foot was resting on a foot pedal. The resident was observed on 12/12/16 at 5:21 p.m. in the dining room for dinner. She was seated at the table with her meal and drinks. She was wearing nonskid red slipper socks. On top of the slipper socks, the resident had beige colored gel heel protectors. The resident was observed receiving wound care to her left medial heel on 12/13/16 at 9:37 a.m. The nurse manager (NM) #1 was providing the wound care treatment. She was responsible for all weekly wound care assessments in the facility. The resident was lying in bed looking out the window when she was approached by the NM. The NM informed the resident about skin treatment procedures that were going to be provided. The NM took off the resident's left gel heel protector and then her red nonskid sock. The NM said the resident had a stroke and the right side does not move and there was no range of motion. The resident can use her left leg/foot. She can propel her chair with the left foot. The wheelchair was in the room and it had a pressure reducing cushion seat. There was one leg rest pedal for the right side. -The NM questioned the resident throughout the wound care regarding pain. The resident denied any pain but said it was uncomfortable. The NM followed appropriate infection control procedures with washing her hands and donning protective gloves throughout the care being provided. The bandage was removed from the left medial heel. -The resident had a small discolored purple area. This area was approximated in size as smaller than a dime. As the NM palpated the heel, she was overheard saying it was hard and calloused. She said the initial suspected deep tissue injury (SDTI) was a flat purple area. She said the resident would often scratch her left heel against her right leg or she would rest the left heel against the paralyzed right leg. Where the left heel rested on the right leg, the pressure point developed for the SDTI. The wound was acquired in the facility. -The resident received her physician ordered treatment which included skin prep and two layers of foam protection (name brand). The NM covered the bandages with tape dated it 12/13/16. The NM said she completed the resident's wound care every other day. -She said the resident did have blue padded booties to protect her heels but she could not sleep at night. The facility tried the blue booties for two nights and the resident was agitated and not sleeping well. They switched to the gel padded heel socks which they had in the supply closet. However see physician orders [REDACTED]. -The NM placed the red nonskid sock back on the resident's left foot, and placed the gel padded heel protector over the red nonskid sock. The NM said the measurements of the wound on 12/11/16 were 1.2 cm (centimeters) by 1.1 cm with no depth. The NM said the facility had a new contract with a wound physician. This physician would be starting wound rounds next week. The NM said the resident's wound was improving. She said the wound was a suspected deep tissue injury. V. Record Review The following documents were provided by the DON on 12/13/16 at 1:30 p.m. A. Resident Profile The resident profile was documented in reference to ambulation as using her left leg to scoot around for short distances in her wheelchair. There was no left foot pedal to use, so resident was able to self-propel. The right foot pedal was to be used at all times due to weakness. B. Wound Team Progress Notes (WTPN) The WTPN dated 11/21/16 revealed the wound team had, Assessed L(left)heel due to report of purple area. Resident has a SDTI to L medial heel that measures 0.3 cm x 0.3 cm. Wound has intact skin but the skin is dark purple in color, non-blanchable. No odor or drainage noted as skin is intact. Remainder of L heel is red, blanchable, boggy, dry, but otherwise intact. Resident denies any discomfort to any areas on heel other than the area of the SDTI where she reports pain. When asked if pain is always there, she states 'not particularly.' She reported pain with palpation only. Current order in place to apply skin prep BID. New order to apply skin prep, non-adhesive foam (brand name), and secure with tape (brand name) (entire heel is to be covered with foam (brand name)). Floor nurse to apply dressing per new orders. Staff have been using pillows to offload L heel due to bogginess. Continue to off load bilateral heels with pillows while in bed . Blue booties placed in resident's room and to be in place at all times while in bed, floor nurse updated. Staff to assist with turning, repositioning, and off loading every 2 hours. Resident is wearing open heel sandals at time of assessment. Staff to encourage resident to wear open heel sandals/shoes due to wound. Resident self propels in room and on unit in wheelchair using L foot due to history [MEDICAL CONDITION] with R sided weakness . The WTPN dated 11/27/16 revealed the wound team had, Assessed SDTI to L medial heel, which measures 0.5 cm x 0.4 cm. L heel is soft, boggy, dry, but otherwise intact. SDTI is purple in color. Upon palpation of heel wound resident noted to move heel as if in pain, tender area noted to wound and immediately surrounding wound measures 2.0 cm x 1.8 cm. When asked resident if she is having pain to the heel she stated 'a little bit but not a disastrous thing.' Dressing not in place at time of assessment. Resident is wearing socks with open heel sandals. Treatment applied per orders with non-adhesive foam (brand name) covering much of the left heel. Resident has declined to wear blue booties and became quite agitated with them. Edge defying mattress in place to bed for resident's safety. Bilateral heels are to be off loaded at all times while in bed, using extra pillows to off load left heel. Order placed in eMar (electronic medication administration record) for nursing to check placement of dressing Q(every) shift and to replace as needed. Resident self propels in wheelchair using her left foot due to history [MEDICAL CONDITION] right sided weakness. She is frequently observed resting her left foot on her right foot when not propelling in wheelchair. Wound team will continue to assess weekly and PRN . The WTPN dated 12/4/16 revealed the wound team had, Assessed SDTI to L medial heel while resident was still in bed this morning. There was a pillow in place that resident seemed to have kicked away. Gel padded heel sock in place to L heel, gel padded heel sock to R heel was noted to be on her shin. Resident frequently removes the R heel one using her L foot. She is not able to remove the L heel sock due to hx (history) [MEDICAL CONDITION] R sided weakness. Previous dressing removed and resident had quite a bit of discomfort with the removal of the dressing. Wound measures 0.6 cm x 0.7 cm, skin remains intact, wound is dark purple in color. There is a hard area immediately surrounding and including wound that measures 1.2 cm x 1.4 cm, callous-like. Resident has tenderness to wound and area surrounding wound, tender area measures 3.0 cm x 3.0 cm. Skin prep applied, allowed to dry, non-adhesive foam (brand name) applied, secured with tape (brand name). When asked resident if she is having pain she states 'every time you touch that I about go through the ceiling.' This nurse asked resident if she has pain to the heel all the time and she stated 'no, only when you touch it.' This nurse asked resident several hours later when she was self propelling in the hallway using her left foot if she has any pain. Reports some discomfort to her hands but states she is not having any pain to her feet or heels when propelling. Open heel sandals are in place. Staff are using pillows to off load heels, extra pillows placed in room . The WTPN dated 12/11/16 revealed the wound team had, Assessed SDTI to L medial heel. Previous dressing removed with no odor or drainage noted, skin remains intact to site. Resident not reporting as much pain to site in comparison to previous assessment by this nurse. Wound measures 1.2 cm x 1.1 cm, hard area immediately surrounding and including wound measures 2.2 cm x 1.5 cm. When asked resident if she is having pain to site during assessment, she stated, 'It's sensitive.' Apply to measure, apply skin, and a new dressing with no signs of discomfort. SDTI is purple in color. Surrounding skin is dry but otherwise intact. L heel is soft, pink, blanchable. New dressing orders received to double non-adhesive foam (brand name) for further padding, applied new dressing . Upon entering room, resident's heels were off loaded of a pillow and she had bilateral gel padded heel socks on. She was observed to be moving her left leg up and down in bed with heel rubbing against bed. She has been compliant with wearing gel padded heel socks, has been wearing open heel shoes when she wears shoes . C. physician progress notes [REDACTED]. The ulcer did not have any obvious infections and recommendations was for continued wound care. The physician would continue to evaluate patient. D. Activities of Daily Living Administration History (ADLAH) 1. The ADLAH records dated 11/1 through 11/30/16 revealed the following: -The resident had an order for [REDACTED]. -The resident had an order to, Encourage resident to wear open heel shoes/sandals due to wound to heel. This order started on 11/21 and was open ended. -The resident had an order for [REDACTED]. There were no orders that revealed interventions for heel protection while up in the wheelchair. 2. The ADLAH records dated 12/1 through 12/13/16 revealed the following: -The resident had an order for [REDACTED]. -The resident had an order for [REDACTED]. VI. Observations/Staff Interviews The certified nurse aide (CNA) #1 was interviewed on 12/13/16 at 3:32 p.m. She said she was familiar with resident #53. The resident had blue padded booties to protect her heels. She kept kicking them off and they were not effective. She was off work for a few days and when she came back, the resident had gel padded heel protectors. Prior to each shift, she would look at the electronic medical record system to see what each resident's specific care needs were. This was how she knew the resident was now wearing gel heel protectors. The registered nurse (RN) #1 was interviewed on 12/14/16 at 11:19 a.m. She said the resident disliked her blue booties and said they were very uncomfortable. She would kick them off. She had a physician's orders [REDACTED]. Prior to the SDTI, when the resident was up and moving around in her wheelchair she would wear sandals or tennis shoes. She would also wear her regular nonskid socks. The resident was paralyzed on the right side and she would use her left heel to scoot around in her wheelchair. She was applying direct pressure to the heel. Once the SDTI had developed, they kept her out of her shoes. They would put on double layer of foam dressing and a nonskid sock over this while she was up in the wheelchair. Once they discovered the resident did not like the blue booties in bed, they implemented the gel padded heel socks. The NM #1 was interviewed on 12/14/16 at 1:50 p.m. She said the left heel was observed by the night nurse on 11/13/16. The heel was boggy, pink and blanchable. When she was notified by the night nurse, she completed an assessment. The resident had been wearing an open heel sandal with a strap across the back of the heel. The open area of the sandal did not touch the SDTI area. The NM received an order for [REDACTED]. The left heel was assessed on 11/21/16 and the NM determined it was an SDTI. They began the blue padded booties on 11/21/16 while resident was in bed. The following two days the resident was agitated and not sleeping well. She had been kicking the booties off. They discontinued the blue booties on 11/23/16 and added more pillows. The heel was assessed again on 11/27/16 and the area was slightly bigger. The NM was looking through the supply closet and discovered the gel heel cups sleeves on 11/28/16. She requested an order from the physician to begin this treatment option. (This treatment option was implemented five days after the blue booties were discontinued.) She did not know about gel heel protectors or that they even existed. If she had not seen them in the supply closet, she would not have implemented them. The resident continued wearing the open toe shoe sandals until it became too painful to put them on. The back strap was elastic and could not be unfastened. It hurt the resident too much to slip these on over the SDTI and she requested to wear nonskid socks. The resident did not have any supports to off load the heel when in a resting motion in her wheelchair. The resident was known to rest her left heel on the right leg. She also would scratch her right leg with the left heel. The resident could not wear the heel gel cups with her sandals. She would either wear her sandals with nonskid socks or just the socks with the gel heel cups. The SDTI on the heel would rest on the right leg even with sandals on. When the resident was discontinued for the blue booties while in bed, she ordered more pillows for her room. They would check her more frequently because she would kick off the pillows. She said the SDTI got progressively bigger each week. (See Wound Team Progress Notes above for measurements.) The double layer of foam was physician ordered on [DATE] and this was because the resident was moving around less and was self-reporting the area was more sensitive. The foam was helping with comfort. The NM could not say if the SDTI was avoidable. She was not sure if the SDTI would have stabilized and improved quicker had she implemented the gel heel protectors earlier. The NM #1 on 12/14/16 at 3:10 p.m. provided an observation of the resident's sandals. The sandals were in the bottom of the resident's closet. The sandals were dark brown in color. There was an elastic fastener for the back of the heel. It was visible the sandals could not have applied pressure to the left medial heel wound. When the resident self-propelled her wheelchair with her foot, the wound would not touch the floor. The NM demonstrated with her own left leg, how the resident would often lie in bed and kick her leg back and forth. She would also rub her right leg with the left heel which was what caused the SDTI. When she was up in the wheelchair, she would often rest her left heel on the right leg which caused pressure to the heel. The sandal would not prevent pressure to the SDTI area. The SDTI would still receive pressure when the resident rested her left heel on her right leg while wearing the sandals. The resident would kick off her pillows in bed. When she did not have the blue booties on, the resident was often seen rubbing the affected area. The DON and the assistance director of clinical services (ADCS) were interviewed together on 12/14/16 at 3:26 p.m. The DON said, she did not think the delay in implementing the gel heel protectors were a factor in the SDTI wound progressively getting larger in size. She said the resident refused the blue booties. They tried offloading the heels with the pillows while in bed. The resident was able to propel her wheelchair with her left foot. This was an area of independence with the resident. They tried to offload the heel while in the wheelchair with towels/pillows. The resident did not like this because it impeded her mobility. They did not try a podus boot (protective orthosis with a heel cavity to protect heels) with traction to protect the resident's heel because the DON thought it would be too heavy. It was not a good choice. They did not add a left wheelchair pedal to support left heel with pillows because it would impede the resident's independence for mobility. They were challenged in trying to protect the heel when resident was up in the wheelchair. The DON did not elaborate on any other interventions that were implemented prior to the NM discovering the gel heel protectors in the supply closet. She said the resident had been in the facility for the past three years. The resident had always rested her left heel on her right leg. She could not say why the SDTI got worse other than general decline in health.

Based on observation, record review, and staff interviews, the facility failed to ensure one (#21) of five sample residents was free from unnecessary medications. Specifically, the facility failed to ensure the administration of an as needed (PRN) anti-anxiety medication was for an appropriate reason; and that non-pharmacological approaches were attempted and documented prior to the administration of the PRN anti-anxiety medication. The findings included: I. Facility's Policy On 12/14/16 at 12:27 p.m. the director of nursing (DON) provided a copy of the facility's undated Policy and procedure for use and monitoring of psychopharmacological medications. The policy documented in pertinent part, An unnecessary drug is any drug when used: .(iii) Without adequate monitoring and, b) In conjunction with the PRN medications, non-pharmacological interventions are documented on the MARs (medication administration records) and e) If behavior monitoring is necessary, social services or nursing opens an event to monitor for current mood and behaviors. Additional documentation should be written in the progress notes. II. Resident #21 Resident #21, age 92, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/25/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Mild depressive symptoms and no behaviors were noted. The resident required extensive one-person physical assistance for bed mobility, transfers, walking and locomotion, dressing, toilet use, personal hygiene, and bathing; and limited one-person physical assistance for eating. During the seven-day look-back period for the 10/25/16 MDS assessment, the resident used an anti-anxiety medication two days. A. Record Review A physician's orders [REDACTED]. Diagnosis (dx): anxiety. Monitor for side effects/behaviors. Non-pharmacological approaches: 1) Distraction, 2) Redirection, 3) Offering a calm environment, 4) companionship, 5) Contacting/reassurance from family, 6) Reassurance of concerns, 7) Snack, 8) Warm blanket, 9) Activity of choice. A review of the resident's 10/16, 11/16, and 12/16 MAR and progress notes revealed the resident experienced frequent episodes of anxiety and had been given the PRN [MEDICATION NAME] on multiple occasions. 1. October 2016 During October 2016, resident #21's PRN [MEDICATION NAME] was administered 23 times. Of those 23 administrations, only three instances had documented non-pharmacological interventions. Multiple administrations had a code noted on the MAR for the reason, such as behavior issue but there was little documentation on the actual behaviors or symptoms of anxiety exhibited. On 10/30/16 at 12:11 p.m. the medication was administered to the resident prior to the development of symptoms of anxiety. The progress note dated 10/30/16 at 1:18 p.m. documented, No tearfulness this shift. Gave resident PRN [MEDICATION NAME] ([MEDICATION NAME]) at noon to help prevent agitation, had good effect. This nurse wrote note in NP (nurse practitioner) book for possible scheduled [MEDICATION NAME] in afternoon. According to the note, the resident was not experiencing symptoms of anxiety and no non-pharmacological interventions were documented. 2. November 2016 During November 2016, resident #21's PRN [MEDICATION NAME] was administered 13 times. Of those 13 administrations, eight were coded on the MAR as being given for sleep with no progress note explaining symptoms of anxiety. Five instances were noted on the MAR as being given for behavioral issue or agitation with no associated progress note explaining actual anxiety symptoms. There was no documented non-pharmacological intervention to reduce anxiety symptoms during the month of November at the times when the PRN [MEDICATION NAME] was administered. 3. December 2016 During December 2016 by the end of the survey on 12/14/16, resident #21's PRN [MEDICATION NAME] had been administered twice (12/5/16 and 12/11/16) for the reason, tearful/agitated. The nurse's note dated 12/5/16 at 10:54 p.m. documented, Resident was tearful at the beginning of this shift (1400-1500). Resident had a glass of wine with son while they reminisced over memories. Resident agreed to take [MEDICATION NAME] at 1530. Resident noted to have positive attitude for the remainder of the shift. There were no documented non-pharmacological interventions at the time of administration. According to the MAR, the [MEDICATION NAME] was administered on 12/11/16 at 7:24 p.m., after dinner. The nurse's note dated 12/11/16 at 10:57 p.m. documented, Resident was tearful after dinner, this nurse and CNA (certified nurse aide) attempted at redirection and were successful. Resident worried about keys being locked in car and how she was going to get back to California, nurse reassured resident it was taken care of. The progress note documented the non-pharmacological interventions were effective and did not document the medication was given; it is unclear why the medication was administered after dinner. B. Observations Resident #21 was observed multiple times throughout the four-day survey. No signs of anxiety were observed. The resident was observed on 12/14/16 at 5:45 p.m. She was sitting in her recliner in her room and appeared calm and in no distress. At that time, the resident complained of a headache but did not want the nursing staff to be alerted. Throughout the conversation, she became slightly tearful when discussing her son that had passed away, but was easily redirected through changing the subject. C. Staff Interviews Nurse manager (NM) #1 was interviewed on 12/14/16 at 10:25 a.m. She said she was familiar with resident #21's care needs. She said when a nurse is going to administer a PRN medication, non-pharmacological interventions should be attempted first. She said this would be documented in the progress notes. She said resident #21's anxiety often presented as fidgeting or picking at her dressings, tearfulness, or wanting to leave the building. She said resident #21 is sometimes redirectable, and enjoyed activities such as playing the piano, and that was often an effective method of reducing her anxiety. She said that the medication would only be administered if the resident was experiencing actual symptoms, and should not be used to prevent agitation. Registered nurse (RN) #1 was interviewed on 12/14/16 at 1:41 p.m. She said resident #21 experienced anxiety at times and staff would try to redirect her through activities such as playing the piano if she was upset. She said that many times, the distraction method was effective, but other times it did not work and the resident would be given [MEDICATION NAME] to help her anxiety. She said resident #21 also was given medication for pain routinely and that pain was assessed when the resident was exhibiting behavior symptoms. She said the resident had not been given a PRN pain medication in the previous two months but said she thought the resident was experiencing increased pain recently due to swelling in her lower extremities. She said behaviors should be documented in the progress notes, and that the resident currently had an open charting event for tearfulness or anxiety. The DON was interviewed on 12/14/16 at 12:10 p.m. She said the resident had anxiety that presented as behaviors such as sitting up on the side of the bed at night, pulling at her dressings, making repetitive statements, and wanting to go home. She said she assumed the nurses who marked sleep as the reason for using the PRN [MEDICATION NAME] had documented that because the resident was having anxiety that prevented sleep at those times. She said the resident enjoyed playing the piano and companionship, and said she was aware of nursing staff spending a great deal of time with the resident to try to calm her anxiety. She agreed this was not documented and speculated the task function of the electronic medical record system had not been updated to include a prompt for nurses to document the non-pharmacological interventions attempted. She also said the resident had difficulty sleeping and noted that after her hypnotic medication was increased on 12/9/16, she had fewer uses of the PRN [MEDICATION NAME]. She said pain should always be considered when a resident with dementia is having behaviors, but said this resident was not known to complain of pain. D. Facility Follow-up On 12/14/16 at 2:10 p.m. the DON provided a copy of the updated physician's orders [REDACTED].

Based on record review and staff and resident interviews the facility failed to provide two residents (#1, and #5) out of three sample residents, the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility; and make choices about aspects of his or her life in the facility that are significant to the resident. Specifically the facility failed to: - Allow the resident to make choices about family involvement and healthcare; and - Invite the resident to participate in her care conference. 1. Facility Policy and Procedure (P&P) The facility Care Conference P&P stated, .Residents and their representatives shall be invited to participate in care planning. Refusal to participate shall be documented. 2. Facility Job Description The facility Social Services Director (SSD) position description, dated [DATE] documented The SSD serves as a resident rights advocate in all manner of speaking. Other duties for the SSD included communicating the needs of residents to the appropriate persons and documents with consistency and accuracy specific goals, objectives and progress information for each resident as needed regarding social services issues. 3. Resident #1 Resident #1, age 87 admitted to the facility most recently [DATE]. Her prior admission was [DATE]. According to her face sheet she had [DIAGNOSES REDACTED]. The resident expired at the facility on [DATE]. The most recent minimum data set ((MDS) dated [DATE] documented the resident scored an eight out of 15 on the brief interview for mental status (BIMS) which indicated she had moderate cognitive impairment. A. Interviews On [DATE] at 12:41 p.m. the SSD was interviewed. She reported the resident had many family dynamics that were complicated and hard to explain. She reported the resident's son was her court appointed guardian. She had another son who she used to live with, who would frequently visit her. She stated, according to the guardian his brother did not take care of her while she was living with him. When asked about whether she would ask the resident if she wanted her son to visit she stated, We didn't talk about her family dynamics, it wasn't in her best interest. Additionally, she reported if her guardian (son) had asked to speak with his mother about whether she wanted her other son to visit or ask her about her health status we would have discussed it with her. She reported Hospice had never started; however, the conversation had been discussed with her guardian but the resident was never asked. She reported the conversation did not go much further out of respect. On [DATE] at 2:15 p.m. the director of nursing (DON), nursing home administrator (NHA) and the SSD were interviewed. When asked about whether the resident had been deemed incompetent they reported if one has a guardian one would be incompetent. The DON stated the resident had a difficult time when the resident lived with her son who was not her guardian. She reported this was part of the reason the facility did not discuss her son with her. On [DATE] at 3:35 p.m. the registered nurse (RN) #2 was interviewed. She reported the resident was very aware of her diet, her fluctuating blood sugar and the requirement for insulin. She stated the resident appeared to enjoy her visits with her son who used to care for her. She reported she was able to make her needs known and tell you what she liked and did not like. On [DATE] at 4:12 p.m. a frequent facility visitor was interviewed. She reported she had been notified about the situation with the resident and was familiar with the son who was the resident's guardian and the son who would frequently visit. She reported she had told the facility frequently even though the resident had a guardian the facility must talk to the resident and ask about her preferences. She stated even though a resident may not make good decisions the resident should always be included. On [DATE] at 5:35 p.m. the DON and NHA were interviewed. The NHA reported residents have the right to be included in decisions about their care. He then stated unless they have a guardian. B. Record review The Well Being care plan (CP) updated [DATE] revealed the resident had the potential for disruption to the resident's well being due to family dynamics. The goal for the resident was to not show signs and symptoms of distress to her well being by maintaining her sleep pattern over the next 90 days. The approach for the resident from the facility was to allow the resident's son to speak to the resident but not release any medical information to the son. The Cognition CP dated [DATE] revealed the resident had memory loss at times. The approach included assistance with needs and activities of daily living (ADL) as needed. The face sheet revealed, under alerts Do not have conversations r/t (related to) (resident's name) health with (resident's son's name). (Resident's son's name) is also not to interfere with any care being provided to (resident's name). Nor is he to stay in her room past 10pm per the Court Appointed Guardians (guardian/son's name). A review of the progress notes revealed the SSD met with or spoke to the resident's guardian on the following dates: - [DATE] at 5:32 p.m. in person; - [DATE] at 10:25 a.m. via the telephone; - [DATE] at 4:49 p.m. in person; and - [DATE] at 10:30 a.m. it was not clear if the conversation was in person or via the telephone. A review of the progress notes documented the SSD talked with the resident on [DATE] and had a care conference on [DATE]. The documentation did not reveal whether the SSD asked the resident if she was satisfied with the involvement of her son, if she was interested in Hospice involvement, and whether she minded if her son was made aware of her medical status. 3. Resident #5 A. Resident status: Resident #5, age 89 was admitted to the facility on [DATE]. According to her face sheet her [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed a score of nine out of 15 on the brief interview for mental status (BIMS) which indicated the resident had moderate cognitive impairment. B. Record review: The social services (SS) progress note for the care conference dated [DATE], documented the resident was not listed as attending and it was not documented the resident had refused to go to the care conference. The SS noted did reveal the resident's daughter in law (DIL) attended by phone. C. Resident interview: On [DATE] at approximately 3:15 p.m., the resident stated that she was not invited to her care conference. She stated, I don't think I have had a care conference, and if I was asked to attend, I would. D. Staff interview: On [DATE] at 4:30 p.m. and 4:50 p.m. the SSD was interviewed. She reported that per nursing home policy all residents should be invited to their care conferences and if the resident refused to attend, the SSD would document the refusal.

Based on observations, interviews and record review, the facility failed to prepare and distribute food under sanitary conditions. Specifically, the facility failed to ensure that staff members with significant beard growth were wearing beard protection. Additionally, the facility failed to ensure that food remained in temperature control until just prior to service. Observations On 12/1/14, from 11:50 p.m. to 12:30 p.m., an initial meal service was observed. There was one dietary aide serving the food, and a cook in the kitchen. Plates of food were observed sitting on the counter waiting for service for up to fifteen minutes as the dietary aide took orders and checked in with residents. At 12:05 p.m., a plate of fried chicken and mashed potatoes was placed on the counter by the cook, (Cook #3), followed immediately by two grilled chicken filets. At 12:13 p.m., the aide came to the counter and took the plate of fried chicken to take to a resident. The aide did not initiate a temperature, and when asked if she knew the temperature of the food, stated that she did not know. The temperature of the meat was taken and confirmed to be 113 degrees Fahrenheit. The temperature of one of the pieces of grilled chicken was measured at 100.9 degrees Fahrenheit. On 12/2/14 from 4:30 p.m. to 6:30 p.m., dinner preparation and service were observed. While in the kitchen, Cook #4 was observed unloading food and placing it into the facility ' s refrigeration units and deep freeze. The cook was observed to have approximately a centimeter of growth of beard. A second kitchen staff, Cook #2, was observed loading dishes of food into two insulated carts for distribution. The cook had a goatee greater than a centimeter in length. A third kitchen staff, Cook #1, confirmed that one of the two carts was headed to the SNF. At 4:35 p.m., Cook #1 initiated a pre-service temperature of the food and determined that the special, a creamy chicken and vegetables, was below the minimum holding temperature. She took the chicken back to the kitchen to Cook #2 to be reheated. The cook was still not wearing a beard cover over his beard. The cook took the food from the dish and placed it in a pot to be reheated. Interviews: On 12/2/14 at approximately 5:30 p.m., Cook #1 was interviewed. The cook confirmed that neither of the two male staff in the kitchen had been wearing beard covers, and stated that she had never seen any of the cooks in the facility use them. On 12/3/14 at 2:30 p.m., the dietary manager was interviewed. The DM stated that the facility ' s policy indicated that a beard cover was not required for less than an inch of facial hair, but agreed that less than an inch of facial hair would still have the potential to fall out and into food. The DM stated that she would order beard covers immediately, and in the meantime, would have the staff wear hairnets over their beards. The DM also acknowledged concerns about the amount of time plates were left sitting on the counter. The DM stated that it was the facility ' s expectation that food should be held in temperature control until the time of service, and that food should be served immediately after being plated. The DM stated that the facility could use additional staff in the dining room to serve food and take orders, but agreed that if the service was going slowly, the second cook in the kitchen should step up to assist in service rather than plating food.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent development and transmission of disease and infection. Specifically, the facility failed to implement appropriate isolation protocols in a room with contact precautions for an active[DIAGNOSES REDACTED] infection. Additionally, the facility failed to follow appropriate disinfection and cross contamination procedures during room cleanings, and failed to ensure that soiled linens were handled in a way that would prevent cross contamination. I. Professional Standards: a. Contact Isolation Precautions according to, "The Centers for Disease Control and Management, "Guidelines for Isolation Precautions," (2007), http://www.cdc.gov.hicpac/pdf/isolation/Isolation2007.pdf (December 8, 2014);The Centers for Disease Control and Management (CDC) current standards for Isolation Precautions, indicated in pertinent part: -- Contributing factors to transmission of[DIAGNOSES REDACTED] between residents in long term care facilities included the formation of spores that were resistant to routinely used disinfectants and hand carriage from staff to residents. -- Prevention of transmission was focused on contact precautions for infected residents, environmental measures, and consistent hand hygiene. -- Appropriate contact precautions included using a gown and gloves when interacting with the resident or his/her environment. b.Disinfection The current CDC standards for disinfection in health care facilities indicated, in pertinent part, that: -- The effective use of disinfectants is an important part of a multi-disciplinary infection control program. -- Environmental surfaces (e.g. a sink, toilet, items in the resident's room) potentially contribute to cross-contamination through contact of health care personnel with the infected surfaces. -- In regards to EPA (environmental protection agency) registered disinfectants, instructions listed on the label must be followed to assure efficacy of the product. II. Facility Policies and Record Review a.Contact Isolation Precautions The facility's policies for isolation and contact precautions, as provided by the director of nursing (DON) on 12/3/14, indicated the following: -- When a resident displayed a gastrointestinal illness, isolation was to be implemented immediately. -- The staff was to ensure that a stocked isolation cart was at the room, as well as an isolation sign on the resident's door indicating the type of isolation. The cart was to contain protective equipment (gown, gloves and mask) a laminated isolation sheet, and Clorox germicidal wipes. -- The intent of implementing contact precautions was to prevent the transmission of an infection from a resident with a serious illness to other residents. -- Transmission could occur either by direct person to person contact, or through contact with a resident's environment or another person who had been in contact with the infected resident. -- Gloves should be worn when entering the room. -- Health care personnel should wear gowns in any interaction that may involve contact with the resident or contaminate surfaces in the room. -- Contact precautions were indicated for residents with an active[DIAGNOSES REDACTED] infection b.Room Cleaning Policies The facility's housekeeping policies, as provided by the DON at 8:00 a.m. on 12/3/14, indicated that when cleaning resident rooms, the floor, all surfaces in the resident's room, including doors and windows, trash cans, and all bathroom surfaces were to be sanitized with a germicidal agent to kill pathogens. c.Use of Disinfectant -- Instructions for the use of HDQC2, as viewed on 12/3/14 at 11:30 a.m., indicated that in order to disinfect a surface, the product should be sprayed onto the surface and allowed to remain wet for ten minutes. -- The efficacy information listed for the HDQC2 product did not indicate efficacy against [DIAGNOSES REDACTED]. d.Resident in room [ROOM NUMBER] -- A nurse's note, dated 12/1/14 at 3:44 a.m. indicated that the resident had been placed on contact precautions following loose stools. III. Observations a.Isolation Precautions -- During the initial tour conducted on 12/1/14 at 10:45 a.m., a resident's room was observed. The room was not noted to have an isolation cart present. -- On 12/1/14, at 2:49 p.m., Certified Nurse Aide (CNA) #1 was observed inside the same resident's room. An isolation cart was present outside the door to the room; however, there were no signs on the door indicating that isolation precautions were in place. The CNA had a blanket draped over his right arm. The CNA was not wearing either gloves or a gown. At 2:50 p.m., the CNA reached outside of the resident's room and took gloves from the cart and then closed the resident's door. -- On 12/1/14 at 2:55 p.m., the isolation cart was observed to contain gowns, and gloves; however, there was no visible sign in the cart regarding what type of precautions were to be implemented or what the active infection in the room was. b.Room Cleanings 1. room [ROOM NUMBER] -- On 12/3/14 at 9:07 a.m., Housekeeper #2 was observed cleaning room [ROOM NUMBER]. The cart contained a clean linen bag with dry blue cloths, Pledge, 409 glass cleaner, and a spray bottle with a pink chemical. The housekeeper stated that this was HDQC2, the facility's disinfectant, and that it was used for the toilets, shower, and sinks with the intent to disinfect the surface as well as clean it, and that it was also used to clean and disinfect the floors. The housekeeper stated that the mixture was diluted to the concentration specified in the instructions by machine. The housekeeper put on gloves and entered the room. -At 9:08 a.m. the housekeeper sprayed Pledge onto a dry blue cloth and wiping of the surfaces in the resident's room. -At 9:15 a.m., the housekeeper handled items on her cart without changing her gloves. -At 9:17 a.m., the housekeeper took the spray bottle of disinfectant from the cart, and sprayed the resident's sink. She immediately wiped the sink with a dry blue cloth, and the surface was dry within one minute. The housekeeper handled items on the sink, including a cup for the resident's dentures, with the same gloved hands. -At 9:19 a.m., the housekeeper sprayed the other side of the sink and counter, and wiped the surface down. The surface was dry within one minute. -At 9:20 a.m., the housekeeper sprayed the surfaces in the shower, including the walls and grab bars, with the disinfectant, and immediately began wiping them down. The surfaces were dry within two minutes. -At 9:22 a.m., the housekeeper sprayed the shower chair with the disinfectant and wiped it down, then sprayed the toilet seat and the outside of the toilet bowl. The housekeeper wiped the toilet with a dry blue rag, and then reached into the toilet and cleaned the inside of the toilet bowl with the blue rag, rather than a toilet brush. The housekeeper used the same blue rag to wipe down the commode. All surfaces were dry by 9:23 a.m. 2. room [ROOM NUMBER] -- On 12/3/14 at 9:34 a.m., Housekeeper #2 was observed cleaning room [ROOM NUMBER]. The resident in the room was confirmed to be on isolation precautions for an active [DIAGNOSES REDACTED] infection. The housekeeper stated prior to entry that the room was on isolation precautions, but that she did not know what the active infection in the room was. The housekeeper asked a CNA who was in the room providing care, and the CNA answered that the resident had [DIAGNOSES REDACTED]. -At 9:38 a.m., the housekeeper sprayed a pink chemical onto a dry blue rag, and began to wipe down the surfaces in the resident's room with it. Surfaces were observed to be dry immediately. The housekeeper stated that the chemical was the same HDQ disinfectant she had used in the previous room. -At 9:43 a.m., the housekeeper sprayed the resident's sink with the disinfectant and immediately wiped it down. The sink was dry within one minute. -At 9:45 a.m., the housekeeper sprayed down the surfaces in the bathroom, including grab bars, a commode, and the toilet. Droplets of stool were observed on the interior rim of the toilet bowl. A drop of feces was also present on the commode. The housekeeper immediately began to wipe down the surfaces, which were dry by 9:47 a.m. -At 9:47 a.m., the housekeeper sprayed the disinfectant into the bowl of the toilet, and then reached into the toilet with a blue rag and wiped the interior of the bowl by hand. The housekeeper then flushed the toilet with the same gloved hand and cleaned the commode with the same rag. 3. Rm #352 -- On 12/3/14 at 1:30 p.m., Housekeeper #1 was observed finishing a cleaning in room [ROOM NUMBER]. The housekeeper was observed to begin mopping room [ROOM NUMBER] immediately following, without changing gloves. 4. room [ROOM NUMBER] -At 1:45 p.m., the housekeeper was observed cleaning room [ROOM NUMBER]. The housekeeper began by spraying the bleach into the inside of the toilet at 1:46 p.m. The housekeeper sprayed the sink and countertops with the disinfectant at 1:47 p.m., and wiped it off with a dry blue rag. The sink and counter were both dry within three minutes. The housekeeper sprayed the disinfectant on the blue cloth, and wiped down the furniture, walls, and grab bars in the room. The surfaces were dry immediately. -At 1:58 p.m., the housekeeper took new blue rags from the clean linen bag on the cart with the same gloves. -At 1:59 p.m., the housekeeper sprayed the surfaces in the bathroom with a disinfectant, and immediately wiped the outside of the toilet and grab bars. The surfaces were immediately dry. A smear of dried feces was observed on the floor to the right of the toilet. The housekeeper confirmed that it was feces and sprayed it with the disinfectant and immediately began scrubbing it with a blue rag. -At 2:00 p.m., the housekeeper retrieved the bleach and toilet brush, and a clean blue rag, from the cart without changing her gloves, and then sprayed the bleach onto the feces and scrubbed with the clean blue rag until 2:02 p.m. The housekeeper sprayed a new blue rag with the disinfectant, and wiped down the floor where the feces had been. -At 2:03 p.m., the housekeeper sprayed the shower with the disinfectant, rinsed the surfaces with water from the shower hose, and then dried with a clean blue rag. The surfaces were dry by 2:05 p.m. After cleaning up the feces smear in the bathroom of room [ROOM NUMBER], the housekeeper was observed to handle the following items without changing her gloves: -- At 2:03 p.m., a blue rag from the clean rags in her cart. -- At 2:05 p.m., the door to the housekeeping cart, and the Windex. -- At 2:06 p.m., the mop. -- At 2:08 p.m., the resident's armchair, and a jacket on the chair. -- At 2:09 p.m., a second jacket and a magazine that were sitting on a chest next to the resident's door. -- At 2:10 p.m., a small chair, then the handle of the mop wringer, the outside door handle on the door to the resident's room. -- At 2:11 p.m., the trashcan in the resident's room and the door handle on the outside of the bathroom door. -- At 2:12 p.m., the broom and dustpan, the door to her cart, and the cloths in the clean cloth bag. -- At 2:13 p.m., the door and door handle to room [ROOM NUMBER], and the trash cans inside room [ROOM NUMBER]. c. Laundry -- On 12/3/14 at approximately 9:30 a.m., the laundry facility was observed. A trash can for waste was observed to be sitting between the washing machines and the dryers. Housekeeper #3 stated that this was the trash can where the facility disposed of the yellow bags that soiled linens were enclosed in. Interviews -- On 12/1/14 at 2:58 p.m., RN #4 was interviewed. The RN confirmed that the resident in room [ROOM NUMBER] was on isolation and stated that it was contact isolation for [DIAGNOSES REDACTED]. The RN stated that the facility policy was for staff to use gloves and gowns for any interactions where staff would come into contact with the resident or his environment. -- On 12/1/14 at 3:05 p.m., RN #2 was interviewed. The RN confirmed that the resident in room [ROOM NUMBER] was currently symptomatic for [DIAGNOSES REDACTED], and had a loose stool that morning. -- On 12/4/14 at approximately 9:00 a.m., the Director of Nursing (DON) and Housekeeping Manager (HM) were interviewed. The DON stated that she was responsible for the infection control program in the facility, including isolation precautions, gloves, and hand washing procedures. The HM stated that he was responsible for oversight of room cleanings and laundry. The DON stated that she was disappointed to hear that CNA #1 had handled items inside of a room on isolation precautions without having a gown or gloves on, and that it was facility policy, as well as her expectation, that protective gear be worn for any contact with surfaces in a room on contact precautions. The DON also stated that the expectation was for all items needed on an isolation cart to be in place immediately following the imposition of isolation precautions, and that the delayed placement of the isolation cart, as well as the staggered additions of the disinfectant wipes and warning signs on the door, were not consistent with the intent of the isolation protocols. The DON stated that she communicated any current isolation precautions every morning during an interdisciplinary meeting. The HM confirmed this, and stated that housekeepers should already be aware of current isolation precautions, including the infection in the room, before beginning cleanings. In regards to the room cleaning, the HM stated that the intent on cleaning the room was not only to clean the surfaces, but to disinfect them to reduce transmission of pathogens from resident to resident, even when there was no active infection in the room. The HM stated that the facility used a quaternary ammonium agent, HDQC2, for everyday room cleanings, but that for some infections, including [DIAGNOSES REDACTED], it was necessary to use bleach. The HM stated that everything in the room should be cleaned and disinfected with the HDQC2, but especially the sinks and toilets. The housekeeper confirmed by observation that the directions of use for the HDQC2 indicated that in order to have the intended effect, it should be sprayed on and left to sit wet on the surface for ten minutes. In regards to the observed cleanings, the HM agreed that the housekeepers had not followed the instructions for the use of the disinfectant. The HM also agreed that the lack of glove changing by Housekeeper #1 had the potential to cross contaminate surfaces not only in that resident's room, but to the other residents as well. The HM also stated that the use of the quaternary ammonium agent in a room with an active [DIAGNOSES REDACTED] infection was not consistent with his expectations, and that he had instructed the housekeeping staff to use bleach against [DIAGNOSES REDACTED]. On 12/4/14 at 9:30 a.m., Housekeeper #3 stated that the facility used yellow bags for linens/garments that were soiled with bodily fluids, such as urine or feces. When asked whether the facility had the garments double bagged, the housekeeper stated that the facility did not use sugar bags and the garments were loaded directly into the washing machine from the yellow bags. She stated that she then took the bags to the trash can. The housekeeper confirmed that the yellow bags would be in direct contact with the bodily fluids. On 12/4/14 at approximately 9:45 a.m., the HM was interviewed regarding the laundry procedures. The HM stated that he was not familiar with the process of double bagging, and stated that the washing machine should kill all the pathogens on the garments. However, he acknowledged that because the yellow bags were in direct contact with bodily fluids, they also would be considered contaminated.

Based on record review and staff interviews the facility failed to develop a comprehensive care plan for one (#47) out of 25 sampled residents for care plans reviewed that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically the facility failed to implement an [MEDICAL CONDITION] care plan. The findings include: 1. Resident #47 a. Resident Status According to the admission record the resident was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly minimum data set ((MDS) dated [DATE] the resident's cognition was severely impaired. She was noted as needing extensive assistance on staff for bed mobility, transfers, dressing, toileting and personal hygiene. The resident's comprehensive care plan was reviewed and a care plan addressing the resident's [MEDICAL CONDITION] was not located. b. Record Review A review of the current physician's orders [REDACTED]. --[MEDICATION NAME] 3 milligrams (mg) by mouth at bedtime for [MEDICAL CONDITION] c. Interview --On 12/03/14 at 10:53 a.m., the Director of Nursing (DON) was interviewed and stated that her expectation was that the facility create a care plan for [MEDICAL CONDITION] for a resident prescribed [MEDICATION NAME] for [MEDICAL CONDITION]. She agreed that resident #47 did not have the care plan that reflected her [MEDICATION NAME] use or [MEDICAL CONDITION].