Every finding on record at Continuing Care at Wind Crest

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection on two of four halls.Specifically, the facility failed to:-Ensure staff performed hand hygiene during medication pass; -Ensure medications were administered in a sanitary manner;-Ensure vital signs equipment was sanitized between resident use;-Ensure respiratory equipment was stored in a sanitary manner; and,-Ensure infection control practices were followed during wound care.Findings include:I. Medication pass failuresA. Facility policy and procedureThe Medication Administration policy, revised October 2023, was provided by the nursing home administrator (NHA) on 6/16/26 at 11:48 a.m. It read in pertinent part, Medications are administered in accordance with nursing standards of practice and state law. Medication will be administered using appropriate infection control and prevention practices.B. ObservationsOn 6/15/26 at 8:30 a.m. licensed practical nurse (LPN) #1 was observed preparing medications to administer to Resident #44, who was seated at a dining room table. LPN #1 did not perform hand hygiene prior to preparing the medications. LPN #1 placed the medication cup containing several tablets on the dining room table then bumped the cup and caused it to spill two tablets onto the table. She started to pick the medications up with her hand but then used the plastic spoon she had used to administer the medications to the resident and scooped the tablets onto the spoon. LPN #1 placed the two medications back into the medication cup. She then used the same spoon and placed the medications into Resident #44's mouth. LPN #1 returned to her medication cart and began to prepare Resident #12's medications. -LPN #1 failed to perform hand hygiene after administering Resident #44's medications and prior to dispensing Resident #12's medications into a medication cup and administering them to the resident. C. Staff interviewsLPN #1 was interviewed on 6/15/26 at 9:00 a.m. LPN #1 said that when the medication tablets landed on the dining room table, she should have discarded them and dispensed new tablets. She said she was supposed to sanitize her hands between administering medications to multiple residents but failed to do so.The director of nursing (DON) was interviewed on 6/15/26 at 11:00 a.m. She said LPN #1 should have discarded the medications that landed on the dining room table and dispensed new medications. She said nurses were to sanitize their hands between residents when administering medications.D. Facility follow upOn 6/16/26 at 11:48 a.m. the NHA provided documentation of an inservice, started on 6/15/26 (during the survey) and completed on 6/16/26, with nursing staff on medication administration and infection control policy reminders. Seventeen staff members attended the inservice. The education read, Wash hands or use hand sanitizer before and after administration of medications. If a medication is dropped onto any surface during administration, that medication should be disposed of and a new medication pulled.-However, the education was not provided until the concern was brought to the facility's attention during the survey.II. Equipment failuresA. Facility policy and procedureThe Infection Prevention and Control Safe and Sanitary Environment policy, revised August 2025, was provided by the NHA on 6/16/26 at 11:48 a.m. It read in pertinent part, To maintain a safe and sanitary environment through the cleaning and disinfection of environmental surfaces as well as the equipment routinely used by residents. The type and frequency of cleaning required for a piece of equipment is dependent on the principles of cleaning and disinfecting surfaces and equipment and takes into account the intended use of the equipment in patient care and the potential of contamination. Non-critical items are those items that touch a resident's intact skin, (stethoscopes, blood pressure cuffs, pulse oximeters). Clean these items with a hospital grade disinfectant labeled as tuberculocidal (destroys tuberculosis bacteria).B. ObservationsOn 6/10/26 at 9:00 a.m. portable oxygen canisters were observed sitting on the floor outside of room [ROOM NUMBER] and room [ROOM NUMBER].On 6/15/26 at 7:15 a.m. portable oxygen canisters were observed sitting on the floor outside of room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. On 6/15/26 at 10:00 a.m. registered nurse (RN) #1 was observed obtaining blood pressures on two unidentified residents with the blood pressure cuff touching their bare arms. RN #1 placed a pulse oximeter on their fingers to obtain oxygen saturations and used a stethoscope that was hanging on the vital signs machine to listen to the residents' lung sounds. She did not sanitize the equipment in between the two residents, even though sanitizing wipes were readily available in the basket of the vital signs machine. On 6/15/26 at 10:15 a.m. a continuous positive air pressure (CPAP) mask was observed lying on top of Resident #43's bedside table behind the CPAP machine and between the telephone and a lamp base. It was not stored in a sanitary manner, even though a plastic storage bag for the mask was hanging from the top drawer pull of the bedside table.C. Staff interviewThe DON was interviewed on 6/16/26 at 11:48 a.m. The DON said CPAP masks were to be cleaned, air dried, and placed in a bag when not in use, and portable oxygen canisters were not to be placed on the ground. She said vital signs equipment was to be cleaned between resident use with the disinfecting wipes provided on the machines. She said the certified nurse aides (CNA) were interviewed and they said they placed the oxygen canisters on the floor as a reminder to refill them. D. Facility follow upOn 6/16/26 at 11:48 a.m. the NHA provided documentation of an inservice, started on 6/15/26 (during the survey) and completed on 6/16/26, with nursing staff on equipment cleaning and CPAP and oxygen. Seventeen staff members attended the inservice. The education read, CPAP tubing and masks should be rinsed using mild soap and water after use (in the morning) and allowed to air dry. Place mask and tubing in bag when dry and not in use. Portable oxygen tanks should not be placed on the ground. After use, vital signs equipment should be cleaned with Oxyvir (disinfectant), including the vital signs machine, the blood pressure cuff, and any probes.-However, the education was not provided until the concern was brought to the facility's attention during the survey.III. Wound care failureA. Facility policy and procedureThe Skin Integrity Program policy, revised November 2025, was provided by the NHA on 6/16/26 at 11:48 a.m. It read in pertinent part, When an alteration in skin integrity is present, an interdisciplinary and comprehensive approach will be taken to provide necessary care and treatment to promote healing and prevent infection. The approach to the management of skin injuries and preventions will be consistent with professional standards of practice to promote healing, prevent infection, and prevent new injuries from developing.B. ObservationsOn 6/15/26 at 1:30 p.m. LPN #1 was observed completing wound care for Resident #16. LPN #1 gathered the wound care supplies that were in a plastic container and placed them within easy reach. She donned (applied) the appropriate personal protective equipment (PPE), which included a gown, gloves, and eye protection. After removing the old dressing from the resident's wound, she removed her gloves, performed hand hygiene and donned clean gloves. She then cleaned the wound per the physician's order and placed the bottle of wound cleanser on the floor. After cleaning the wound, LPN #1 removed her gloves, performed hand hygiene, and donned clean gloves. She opened a package that contained a foam dressing that would cover the wound. She then opened a package of silver alginate (antimicrobial bandage), cut it to fit the wound, and wearing the same gloves, she reached under the gown she was wearing and retrieved a black marker from the pocket of her uniform top. LPN #1 used the marker and dated the foam dressing. She then used the same hand that she used to retrieve the marker with to place the piece of silver alginate into the wound bed and covered it with the foam dressing.-LPN #1 failed to change her gloves and perform hand hygiene after retrieving a marker from her uniform top prior to finishing Resident #16's wound dressing change. C. Staff interviewsLPN #1 was interviewed on 6/15/26 at 2:00 p.m. LPN #1 acknowledged that she should not have reached into her pocket to retrieve the marker and then continued to complete the wound care without removing those gloves, performing hand hygiene, and donning clean gloves. She agreed that no wound care supplies should be placed on the floor. She said normally she would have all the supplies she needed in place for the wound care prior to starting the dressing change. The DON was interviewed on 6/16/26 at 11:00 a.m. The DON said the nurse should gather all the wound care supplies needed prior to starting a wound treatment dressing change so there would not be any breaks in infection control during the wound treatment. The DON said if additional supplies were needed during the wound care, the nurse's PPE was to be changed. She said no wound care supplies should be placed on the floor.D. Facility follow up On 6/16/26 11:48 a.m. the NHA provided documentation of an inservice, completed on 6/15/26, with nursing staff on infection control and wound care. Seventeen nursing staff members attended the inservice. The education read, When providing wound care, ensure that all supplies are gathered prior to starting. If additional supplies are needed, PPE must be removed, hands washed, additional items gathered, hands washed, then PPE reapplied.-However, the education was not provided until the concern was brought to the facility's attention during the survey.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#3) of one resident reviewed for dialysis out of 25 sample residents. Specifically, the facility failed to:-Ensure thorough dialysis documentation was in place for Resident #3; and,-Ensure staff consistently and thoroughly completed the dialysis communication forms between the facility and the dialysis center for Resident #3.Findings include:I. Facility policy and procedureThe Dialysis policy, revised May 2021, was provided by the nursing home administrator (NHA) on 6/16/26 at 9:00 a.m. It read in pertinent part, The facility will establish a process for residents who require dialysis to receive services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. The facility will create a communication book for each resident who is receiving dialysis. The dialysis communication worksheet accompanies the resident during each dialysis visit to enhance communication. Prior to dialysis, the worksheet will be completed by the licensed nurse or designee of the community which will indicate the current status of the resident. The dialysis team will review the worksheet completed by the licensed nurse or designee prior to dialysis and record pertinent information on the worksheet at the end of the dialysis treatment. Upon return of the resident to the community, the licensed nurse or designee will review the worksheet and follow up on any concerns written by the dialysis team. Any identified concerns/changes in condition documented on the worksheet will be reported to the medical provider.II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included end stage renal disease and dependence on renal dialysis (process to filter wastes from the body). The 5/29/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with most activities of daily living (ADL). He had impairment of one lower extremity, he used a walker and wheelchair for mobility, and he required supervision and set up assistance for bathing.The MDS assessment indicated the resident received hemodialysis treatment. B. Record reviewReview of Resident #3's dialysis care plan, initiated 6/1/26, revealed the resident received dialysis three times weekly and had a right upper extremity fistula (surgically created dialysis access site). Interventions included avoiding performing procedures on the resident's right arm, coordinating medication administration, weights, and lab results with the dialysis center and monitoring the resident's dialysis access site for complications and signs of infection. -However, the care plan did not include the dialysis center's contact information, the resident's chair time (time spent at dialysis), the transportation company's contact information, or pre- and post-dialysis treatment instructions. -Review of Resident #3's June 2026 CPO revealed no physician's orders related to dialysis.Review of Resident #3's dialysis communication forms for the month of May 2026 and June 2026 revealed the following:-The 5/1/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/20/26, 5/22/26, 5/27/26, 6/3/26, 6/5/26, 6/8/26, and 6/10/26 dialysis communication forms were not signed by the nurse upon his return to the facility. -The resident's weight was marked as N/A (not applicable) on the 5/6/26 form. -No weight was documented in the pre-dialysis section on the 5/20/26 form. -The nurse that completed the pre-dialysis section on the 6/3/26 form did not sign it. -An undated dialysis communication form did not include pre-dialysis vital signs or a weight and was not signed by the nurse when the resident returned to the facility.-Review of the vital signs and nursing progress notes on Resident #3's dialysis days in May 2026 and June 2026 revealed no nursing progress notes were documented pre- or post-dialysis. Vital signs were documented pre-dialysis but no vital signs were documented post-dialysis. III. Staff interviews Registered nurse (RN) #2 was interviewed on 6/11/26 at 11:00 a.m. RN #2 said when a resident returned from dialysis, the nurse was to obtain a set of vital signs, assess the resident's fistula site for bleeding and check for adequate blood flow by listening and feeling the site. She said the nurse was to review the dialysis communication binder to see if the dialysis center documented any new orders or if anything pertinent happened during the resident's dialysis treatment.The NHA was interviewed on 6/11/26 at 3:00 p.m. The NHA acknowledged that the dialysis communication forms for Resident #3 lacked the needed documentation the facility nurse should complete when a resident returned from a dialysis appointment, such as vital signs, assessing the dialysis access site, and the overall condition of the resident. She said nursing pre- and post-dialysis progress notes were not being completed.Licensed practical nurse (LPN) #2 was interviewed on 6/16/26 at 8:30 a.m. LPN #2 said prior to a resident going to dialysis, the nurse was to complete the pre-dialysis section on the dialysis communication form. She said the nurse was to obtain the resident's weight and vital signs. She said any medications the resident took during the day while at dialysis were to be sent with the resident for dialysis staff to administer. She said if a resident was out of the facility through meal time, food was sent with them. She said Resident #3 would eat breakfast before he left the facility and snacks were sent with him. LPN #2 said Resident #3 would eat dinner upon returning to the facility. She said a pre-dialysis nursing note should be entered that documented the resident's condition prior to dialysis. She said upon the resident's return to the facility, the nurse was to check the dialysis communication form for any new orders or important information from dialysis, obtain vital signs, a weight, and check the fistula site to ensure adequate blood flow and document all findings in a post-dialysis progress note. RN #1 was interviewed on 6/16/26 at 8:37 a.m. RN #1 said prior to a resident going to dialysis, the nurse was to complete the pre-dialysis communication form that included the resident's weight, vital signs, any medications given, and the fistula site condition. She said the nurse was to document a pre-dialysis progress note that included the resident's condition information prior to dialysis. She said when the resident returned from the dialysis appointment, the nurse was to check the communication form for any new orders or pertinent information from the dialysis center, obtain vital signs, a weight, and assess the dialysis fistula site for bleeding and adequate blood flow and enter a post-dialysis progress note. She said there were no physician's orders for nursing to monitor the status of Resident #3's fistula site on a daily basis. The NHA and the director of nursing (DON) were interviewed together on 6/16/26 at 1:00 p.m. The NHA said Resident #3 was the first dialysis resident they had had in the facility in 10 years. She said he transferred to long-term care last year from assisted living and the dialysis orders were not adequate. She agreed the dialysis communication form the facility had been using did not include all the needed information, and nursing staff were not completing all required documentation pre- and post-dialysis. The DON said nursing staff had not been completing all the needed information on the post-dialysis communication form and they were not documenting progress notes before or after Resident #3's dialysis appointments. She said nursing staff had not been documenting their assessments of the resident's fistula sight for adequate blood flow on a daily basis. She agreed it was important for the fistula to be assessed every day and not just on dialysis days.IV. Facility follow upOn 6/16/26 at 9:00 a.m. the NHA provided the following:A copy of a new dialysis communication form that included the post-dialysis nursing documentation needed when a resident returned from a dialysis appointment, such as vital signs and instructions for the nurse to enter a post-dialysis progress note that included the resident's condition and assessment of the fistula site. A copy of dialysis care education provided to nursing staff that started on 6/12/26 (during the survey) and was completed on 6/16/26. The education included the new dialysis communication form with required information, fistula site assessment, and reporting any issues to dialysis. The education additionally included examples of how to write a pre- and post-dialysis progress note. Thirteen nursing staff attended the education. A copy of Resident #3's updated care plan that included the addition of the resident's chair time, and the dialysis center and the transportation company's contact information. Additional instructions added to the care plan included to complete the dialysis communication form to send with the resident and upon return review the form for any new orders from the dialysis center. Vital signs were to be obtained and the fistula site was to be assessed. An updated physician's order that indicated Resident #3's dialysis days, the pick up time, and the dialysis center's contact information, as well as copies of completed dialysis communications forms, dated 6/12/26 and 6/15/26, and the pre- and post-dialysis nursing progress notes on those dates.-However, above changes were not implemented until the concern was brought to the facility's attention during the survey.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were labeled and stored properly according to professional standards in two of five locked cabinets in resident rooms. Specifically, the facility failed to ensure medications were labeled with the date they were opened. Findings include: I. Professional reference According to the manufacturer Astra Zeneca, Symbicort Medication Guide (June 2024), retrieved on 8/19/24 from https://den8dhaj6zs0e.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/a4b62ab8-1314-4583-91b4-294ec239f790/a4b62ab8-1314-4583-91b4-294ec239f790_pi_med_guide_rendition__c.pdf, Throw away Symbicort when the counter reaches zero or three months after you take Symbicort out of its foil pouch, whichever comes first. According to the manufacturer NovoNordisk, Storage and Travel with Tresiba (June 2024), retrieved on 8/19/24 from https://www.mynovoinsulin.com/insulin-products/tresiba/how-to-take-tresiba/flextouch-storage.html, Storage after use - dispose after eight weeks, even if there is insulin left in the pen or vial and the expiration date has not passed. According to the manufacturer NovoNordisk, Taking Novolog-Insulin Aspart (March 2023), retrieved on 8/19/24 from https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, Storage after use - keep at room temperature or refrigerated up to 28 days. Dispose after 28 days, even if there is insulin left in the pen or vial. II. Facility policy and procedure The Storage and Expiration Dating of Medications and Biologicals policy, revised August 2024, was provided by the director of nursing (DON) on 8/15/24 at 2:45 p.m. The policy read in pertinent part, Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (example vial, bottle, inhaler) when the medication has a shortened expiration date once opened. III. Observations and interviews On 8/14/24 at 1:58 p.m., the medication storage cabinet in Resident #17's room was observed with licensed practical nurse (LPN) #2. The following was observed: -An opened Tresiba Flex Touch U-100 insulin pen was not labeled with the date it was opened for use. -An opened Novolog U-100 insulin pen was not labeled with the date it was opened for use. LPN #2 said the insulin pens should have been labeled when opened. LPN #2 said she did not know what the facility policy said about the storage of insulin pens. LPN #2 said she would check with the staff from the previous shift to find out if they knew when the insulin pens were opened. -LPN #2 did not remove the insulin pens from Resident #17's medication storage cabinet. On 8/15/24 at 10:27 a.m., the medication storage cabinet in Resident #4's room was observed with LPN #1. The following was observed: -An opened Symbicort 160 microgram (mcg)/4.5 mcg inhaler was not labeled with the date it was opened for use. LPN #1 said inhalers should be labeled with a date the medication was opened. LPN #1 said she did not know if inhalers could be used until the manufacturer expiration date after they were opened. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 8/13/24 at 2:00 p.m. RN #2 said the residents' medications were stored in the residents' rooms in locked cabinets. She said the facility did not have medication carts. The DON was interviewed on 8/14/24 at 2:15 p.m. The DON said insulin pens should be labeled with the date they were opened and staff should know how long the pens could be opened before they needed to be discarded. The DON said the Tresiba and Novolog insulin pens needed to be discarded and she would immediately discard the insulin pens and replace them with new pens which would be labeled with the date they were opened. The DON said she planned to check all staff competencies and confirm appropriate education had been provided. The DON said that insulin could be less effective if not discarded by the recommended disposal date. The DON was interviewed a second time on 8/15/24 at 11:04 a.m. She said inhalers should be labeled with the date they were opened. The DON said staff should check manufacturers' instructions for information about when inhalers needed to be discarded when opened. The DON said inhalers could be less effective if used beyond the recommended disposal date. V. Facility follow-up On 8/14/24 at 2:48 p.m, the DON provided a staff education document titled Insulin Pen Storage/Dating. The education contained three staff signatures and was dated 8/14/24 (during the survey). The education content included adding the date opened to medication vials when put in use and expiration dates of medications after opening. The document included reference to a second document provided without a title which described storage information specific to Tresiba and Novolog. The document revealed Tresiba should be discarded eight weeks after opening and Novolog Flex Pens should be discarded 28 days after opening. The DON said the information was posted in Resident #17's medication storage cabinet.

Based on observations, record review, and staff interviews, the facility failed to ensure food items were served, stored, and prepared under sanitary conditions, to prevent the potential cross contamination of food-borne illness to food served to residents, in one of two dining rooms and in one of one kitchen. Specifically, the facility failed to ensure: -The main kitchen and food preparation area were maintained in a sanitary manner; -Resident meals were served in a sanitary manner; -Ready to eat foods served to residents were not handled by staff with bare, unwashed, hands; and, -Staff preformed proper hand hygiene in-between assisting one resident to the other with eating, setting up residents meals, and performing other care tasks for residents. Findings include: I. Kitchen sanitation A. Professional Reference According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 3/23/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view 6-501.12 Cleaning, Frequency and Restrictions: Physical facilities shall be cleaned as often as necessary to keep them clean. Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. 6-201.16 Wall and Ceiling Coverings and Coatings: Wall and ceiling covering materials shall be attached so that they are easily cleanable except in areas used only for dry storage, concrete, porous blocks, or bricks used for indoor wall construction shall be finished and sealed to provide a smooth, nonabsorbent, easily cleanable surface. 5-502.12 Receptacles or Vehicles: Refuse, recyclables, and returnables shall be removed from the premises by way of portable receptacles that are constructed and maintained according to law; or a transport vehicle that is constructed, maintained,and operated according to law. 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered inside the food establishment if the receptacles and units contain food residue and are not in continuous use; or after they are filled; and with tight-fitting lids or doors if kept outside the food establishment. 5-501.15 Outside Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors,or covers. Receptacles and waste handling units for refuse and recyclables shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad under the unit. B. Facility policy The Redbook Sanitation Checklist policy, revised 10/18/18, was received from the nursing home administrator (NHA) on 3/16/23 at 5:30 p.m. It read in pertinent part: The purpose of this policy is to ensure assigned cleaning tasks are completed daily prior to the closing of each shift. A comprehensive closing and opening checklist to ensure all assigned cleaning duties are completed. The closing/opening manager will assign specific tasks to the relevant person in each area.The kitchen and services will be inspected and documented in the Kitchen Red Book. Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and medication will be provided on an as needed basis determined by the employees supervisor. C. Observations The initial kitchen walkthrough was conducted on 3/13/23 at 9:15 a.m. revealed: -The inside lid of the ice machine contained a white substance that was dried to the lid; -The floor in the walk-in freezer had a translucent yellowish slimy film on the floor; -The oil in the deep fryer contained burned floating particles and the oil was dark in color and had an odor; -The juice machine drip tray had fallen off the machine; the part of the machine that the drip connected to had a layer of deep blackened matter. Additionally, there was fresh bright red juice dried on the narrow ledge that was intended to be held in the drip tray; -The counter surface underneath the juice machine had spilled dried justice on the surface; -The surface under the coffee machine had a large amount of spilled, dried coffee, and an excess of coffee had spilled onto the floor in front of the coffee machine; -None of the trash cans in the kitchen were covered with lids; -The mop sink contained a blackish brown substance on the surface and cracked in the corners and the wall behind the sink had dried drips and splashes; -The walls throughout the kitchen had several dried brown drips of liquid on the surface; -The floors was heavily soiled with food debris (bread, lettuce and other unidentified food items) under cabinets and throughout the kitchen; and, -The outside dumpster lid was open and there was trash on the ground outside the dumpster. On 3/16/23 at 2:05 p.m., a second kitchen walkthrough revealed: -The walls throughout the kitchen were soiled with dried drips of a translucent brown substance; -The mop stationary sink was heavily soiled with a reddish brown substance particularly in the basin and along the top edge. The floor around the sink was soiled with black marks. The mop handle where the mop head connected was heavily soiled with a black substance. The inside of the yellow mop bucket was heavily soiled with a black film. The water pipe going into the sink was heavily soiled with a brownish black film; -The stainless steel dish counter next to the dishwasher was heavily soiled with dried white droplets and the wall behind the counter and beside the dishwasher was heavily soiled with dried splatters of food and other unidentified matter; -The recycle bin was full of large empty cans. The receptacle was overflowing and there were two empty cans and two empty gallon milk jugs that did not fit into the container on the floor beside the receptacle. Kitchen staff were working on preparing the dinner meal; -Unused coffee filters were observed out of their packaging in a box that also contained bananas. The coffee filters were soiled with brown colored dust and other substance particles. In addition, there was also an opened bag containing coffee filters that were also soiled with brown dust and debris; -All stainless steel appliances and cabinets were streaked with dried white smudges and splatters and dust in the cracks at the ledges and seams of the units; -A dietary aide (DA) entered the kitchen and entered the food preparation area without a hair net on. The dietary manager asked the DA a number of times to put a hair net on, the staff argued back that she was only passing through the kitchen. After several exchanges, the DA complained and put on a hairnet. In addition, the other conditions observed on 3/13/23 at 9:15 a.m. were not addressed and remained the same (see above). D. Staff interviews The assistant director of dining (ADD) was interviewed on 3/16/23 at 1:00 p.m. The ADD said management would hold an inservice with kitchen staff to discuss kitchen sanitation expectations. The ADD said he would stay in close contact with the dining service manager to assist with keeping the staff on track with kitchen sanitation. The sous chef (SC) was interviewed on 3/16/23 at 1:30 p.m. The SC said he would check the kitchen and dining area for sanitary conditions every shift every day; and initiate a new checklist for sanitation procedures in the kitchen and dining areas. The SC said the fryer was cleaned weekly or as needed. E. Facility follow-up On 3/16/23 at 3:00 p.m., observations of the kitchen revealed: -The facility called the vendor and requested a new juice machine; the machine was replaced; and, -The stainless steel tables and refrigerator doors were wiped down, the deep fryer had been cleaned out. The rest of the observed sanitation concerns had not yet been addressed. 41032 II. Resident dining services A. Professional reference According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 3/23/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view \ Persons who are more likely than other people in the general population to experience foodborne disease because they are .older adults; and they obtain food at a facility that provides services such as nursing home. -Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: Poor personal hygiene. -The Food Code addresses controls for risk factors and further establishes five (5) key public health interventions to protect consumer health. Specifically, these interventions are: demonstration of knowledge, employee health controls, controlling hands as a vehicle of contamination. B. Facility policy and procedure The Food Handling policy, revised May 2012, was provided by the nursing home administration (NHA) on 3/16/23 at 5:30 p.m., it read in pertinent part: Purpose: To ensure the prevention of food borne illness. Policy: High standards of sanitation will be maintained and practiced in all community food preparation and service areas. - Continuing care staff are trained regarding general sanitation theory, use and cleaning of equipment, personal hygiene. C. Observations On 3/13/23 from 12:00 p.m. to 1:05 p.m., lunch service was observed: -At 12:05 p.m., certified nurse aide (CNA) preformed hand hygiene and assisted Resident #14 with lunch. CNA #9 handed Resident #7 the silverware from the resident plate. Resident #7 took the spoon and ate the food off the spoon. CNA #9 then handed the resident her cup to drink. -CNA #9 then walked over to Resident #7 and without performing hand hygiene CNA #9 started assisting Resident #7 with eating. -At 12:24 p.m., CNA #9 stood by Resident #39 and without any hand hygiene picked up Resident #39's spoon and assisted the resident with a couple bits of soup; then picked up the resident's cup and prompted the resident to drink. The resident took the cup and drank some liquid and handed it back to CNA #9. CNA #9 set the cup on the table and walked back to Resident #7 and without hand hygiene, CNA #9 assisted Resident #7 eat some soup with a spoon. -At 12:11 p.m. CNA #8 sat down to assist Resident #16 and #31. CNA #8 was assisting both residents simultaneously; one bite to Resident #16 then one bite to Resident #31 and so on. CNA #8 used the same hand to hold the spoons for each resident with the same hand and did not perform hand hygiene in-between assisting each resident with eating. -At 12:40 p.m. CNA #2 approached the resident eating lunch at the table; CNA #2 reached behind Resident #16 and grasped the resident pants waistband and assisted the resident to reposition in the chair. -CNA #2 then without performing hand hygiene assisted CNA #9 to reposition Resident #31. -CNA #9 stopped assisting Resident #31 and #16 to assist CNA #9 in repositioning Resident #31. The CNAs grasped Resident #31's pants at the waistband to reposition the resident. CNA #9 went back to assisting Resident #31 and Resident #16 without performing hand hygiene. -CNA #2 walked over to the other end of the table to prompt the resident to eat and rearranged the resident's dishes closer to their reach. The CNA did not perform hand hygiene between assisting Resident #16 and #31 and helping other residents with their meals. -CNA # 2 then sat next to Resident #7 to assist the resident with eating via a spoon. CNA #2 still had not performed any hand hygiene. On 3/15/23 from 11:58 a.m. to 1:07 p.m., lunch service was observed: -At 12:08 p.m. activities assistant (AA) brought two bananas to the table and offered one banana to a resident. When the resident accepted the AA opened the banana and with bare unwashed hands, the AA broke the banana into small manageable pieces and set the banana pieces on the resident's plate. The resident ate the broken up banana. -The AA then peeled the second banana and with bare unwashed hands broke it in half and walked around the table offering it to residents. Two residents accepted each of the halves of the peeled banana. -At 12:22 p.m., after assisting a different resident to eat her meal, CNA # 3 sat next to Resident #16 to feed the resident a couple spoons of soup. In-between the spoons of soup CNA #3 stopped assisting Resident #16 to assist Resident #31's clothing protector, then went back to assisting Resident #16 with her soup. The CNA did not perform hand hygiene in-between assisting the three different residents. -At 12:24 p.m., CNA #1 assisted Resident #39 lunch, then with bare unwashed hands cut up Resident #30's sandwich. The CNA used an unwashed bare hand to hold the sandwich while cutting it up. On 3/16/23 from 11:56 a.m. to 1:05 p.m., lunch service was observed: -At 12:28 p.m., CNA #3 was assisting Resident #39 with lunch via spoon and assisting the resident hold a cup while the resident drank. CNA #3 stopped assisting Resident #39 to help another resident rearrange plates of food for better reach and get a better grasp on her silverware. CNA #3 then retried to assist Resident #39 to eat. CNA #3 did not perform any hand hygiene between assisting the two residents. -At 12:32 p.m., CNA #5 was holding Resident #39's hands, when another resident asked for hot coffee. The resident still had some coffee in her cup; CNA #5 left Resident #39 to pick up the other resident's coffee mug and reheated it in the microwave. CNA #5 then took the cup back to the resident. CNA #5 did not perform hand hygiene in between holding Resident #39's hands and touching the other residents. D. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 2:55 p.m. RN #2 said staff should wash their hands prior to providing eating assistance to a resident. If the staff was transitioning to assisting a different resident with their meal, the staff should perform hand hygiene between working with one resident to another. CNA #3 was interviewed on 3/16/23 at 4:22 p.m. CNA #3 said when assisting a resident with eating finger foods or ready to eat foods, staff should perform hand hygiene before handling the resident food and perform hand hygiene after assisting the resident before assisting another resident. When assisting two residents at once staff needed to perform hand hygiene before sitting down to assist the residents. It was ok to give one resident a bite using their utensils and then give the other resident a bite using that resident's utensils. Once staff were done assisting both residents the staff needed to perform hand hygiene. CNA #5 was interviewed on 3/16/23 at 4:35 p.m. CNA #5 said when assisting a resident with finger foods or ready to eat foods, staff should put on gloves or cut up the food so the resident could feed themselves. Staff should perform hand hygiene prior to assisting a resident with their meal and before handling resident dishes and utensils. The director of nursing (DON) was interviewed on 3/16/23 at 5:06 p.m. The DON said staff should wash their hands prior to assisting a resident and in between assisting two residents with any care including eating assistance. If staff need to touch ready to eat foods, staff should wash their hands first and put on gloves; the preferred method would be for staff to use a utensil to hold the food while cutting and fork the food pieces to assist the resident with eating.

Based on observation, record review and interviews, the facility failed to accommodate the needs of one (#22) of three residents reviewed for dining services, out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #22 had a table that was adjusted to a height and distance from the resident's person that accommodated positioning and range of motion needs in order to be able to see drinks and food on the plate and in the bowls; and to be able to reach and eat the food served without additional struggle and fatigue; and, -Resident #22 had accessible dishes such as a mug with a handle that accommodated the resident being able to self-feed food items such as soup, as recommended by speech, occupational and physical therapy assessment (see therapy recommendations below). Findings include: I. Facility policy A request was made, during the survey on 3/16/23, for the facility's policy on accommodation of needs and feeding assistance for a dependent resident. The nursing home administrator (NHA) said the facility did not have a specific policy for incontinence care; in lieu of a dedicated policy, the facility used Lippincott nursing procedures as a guide for care. The NHA provided copies of pages from the Lippincott manual. The resource was undated, and documented in pertinent part: There is growing evidence that a balanced diet along with either health promoting behavior contributes to longevity . -Position food on the plate so that if there is visual neglect or impairment, the patient is best able to see the food served. II. Resident #22 A. Resident status Resident #22, age 89, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified protein calorie malnutrition, dementia, contractures (a permanent tightening/stiffness of the muscles) of the left hand, dysphagia (swallowing difficulties) and muscle weakness. The 2/28/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15 and no psychosis or aggressive behaviors. The resident was totally dependent on staff for bed mobility/positioning, and extensive assistance with eating. The resident had functional limitations of the upper extremities (shoulder, elbow, wrist, hand) on one side and required the use of a specialized wheelchair for mobility and positioning. The resident was able to eat independently if set up appropriately but was dependent on staff to perform oral hygiene. The resident had no dental concern. B. Observations On 3/13/23, Resident #22 was observed from 12:00 p.m. to 1:05 p.m., during the lunchtime meal; observations as follows: -At 12:00 p.m. staff delivered Resident #22's lunch. The resident was served a turkey sandwich, French fries, peaches, a carton of milk, a can of cola, and a juice or ice tea drink. The staff set the resident's food on a bedside table that was already in place in front of the resident then opened the drinks and uncovered the food. Staff did not announce the food items served to the resident, but did tell the resident lunch was served. The resident nodded and the staff walked away. Resident #22 was seated in a specialized manual wheelchair in front of a rolling bedside table tray. The resident was seated up right but was unable to sit up straight. The resident head was tilted forward with the chin bent downward towards the chest. The resident was unable to lift her head up straight and had limited range of mention to move her head (see therapy notes below). The height of the table tray was even with the resident's eyes and the resident was unable to look down on the dishes/food on the table. The resident was unable to lift her head any higher and once the food was set in front of the resident on the table the resident remained still and continued looking downwards. The resident made no effort to eat. -From 12:02 p.m., until 12:25 p.m., no staff approached Resident #22 to encourage or assist the resident with the meal. The resident made no attempts to eat any of the meal. The resident did reach up and over the table to reach a can of coke and took a few sips. The can was placed directly in front of the meal and was directly in front of the resident. -At 12:26 p.m., a staff approached Resident #22 to ask if the resident was done with the meal. The resident shook her head no. The staff offered to cut up the sandwich the resident declined and acknowledged she was still hungry. Staff did not rearrange the resident did her or adjust or lower the height of the table and walked away after earning the resident was hungry. -At 12:47 p.m., a staff approached Resident #22 to ask how the meal was and lowered the bedside table to its lowest possible height and moved the table closer to the resident. Once the table was repositioned Resident #22 immediately reached out to pick up the turkey sandwich and started to eat. The resident still had a bit of a struggle to lift her arm up and over the table to reach food but ate all of the sandwich and fries on the plate without needing assistance or prompting. Although the resident at a slow pace; engagement with food and eating progressed at a steady pace. On 3/15/23, Resident #22 was observed from 11:58 p.m. to 1:07 p.m., during the lunchtime meal; observations as follows: -At 12:02 p.m., staff delivered a lunch tray to Resident #22. Staff uncovered the resident food and set the plates on the table but did not tell the resident what was served; did not adjust the table height; or move the table close to the resident. Resident #22 was seated in front of a rolling bedside table; the table was positioned at the resident's nose level and approximately 10 inches above the resident's lap and was approximately six inches from the resident. This enabled the resident to see food on the flat plates on the table but not the food inside of the bowls. The resident was served a tuna salad sandwich, a bowl of soup, a bowl of Jell-O, a carton of milk, a can of cola and a glass of juice or ice tea. The resident was able to reach the sandwich, as it was on the plate directly in front of her. The resident ate the entire sandwich. The resident had to extend the reach of the right arm, up and over the table, to reach the bowl of Jell-O that was off to the left side of the table on the far left of the plate. The resident ate a few bites of Jell-O then stopped. The resident did not eat any of the soup that was out of vision, because the resident was positioned towards the left side of the table and was not able to turn her head far enough to see the right side of the table. The bowl of soup was off to the right side of the table placed at the back of the table. -During the observation, staff did not offer to adjust the resident plates or the height or distance of the resident table to facilitate eating. Staff did not check to see if the resident liked the Jell-O and soup or if the resident wanted alternative food items when she did not eat the soup or Jell-O. -At 12:29 p.m., after eating the entire sandwich Resident #22 stopped eating. -At 12:59 p.m., staff approached Resident #22 and removed the plates for the table in front of the resident. Staff did not inquire when the resident had not eaten all of the food; attempt to move uneaten foods closer to the resident; or to see if the resident wanted an alternative option for uneaten food. On 3/16/23, Resident #22 was observed from 11:56 p.m. to 1:05 p.m., during the lunchtime meal; observations as follows: -Resident #22 was observed sitting in front of the bedside table. The table was lowered to a level even to the tip of the resident's nose. The resident's head was tilted forward with her chin angled down toward her chest. The resident did not (or could not) raise her head up to look at the food that was served. -The resident was served a sandwich and soup. Staff set up the resident meal, told the resident what each plate and bowl contained and moved the table close to the resident. The resident was able to reach and eat the entire sandwich but struggled with eating soup due to the height of the table and the resident's ability to reach up to the table and spoon up the soup. The resident only ate a couple of spoons of soup. -No staff offered the resident assistance to adjust the table position, to rearrange the resident's dishes or asked if the resident wanted an alternative for the uneaten soup. C. Resident interview Resident #22 was interviewed on 3/16/23 at 2:10 p.m. Resident #22 was interested in eating but acknowledged she could not always see the food on the table and sometimes could not reach food easily. D. Record review Speech language discharge summary-treatment plan goals and progress notes documented Resident #22 required physical assistance with proper/safe positioning in bed or wheelchair for meals. -Staff educated for proper position and safe swallow strategies. -Self-feeding with moderate assistance. Resident was able to take bites without assistance but fatigued quickly. Forward flexion of head and neck may have been a limiting factor in self- feeding. -Resident demonstrated selective intake behaviors if not encouraged to eat a variety of foods served -Resident #22 tended to eat sweets, fruits and soup (clear broth). -Staff educated (including floor clinical manager, nurses and certified nurse aids) regarding the importance of the resident being out of bed for meals at least on time a day for cueing for self-feeding in order to minimize risk of malnutrition as well as to maximize safety with oral intake due to the resident being diagnosed with mild oral pharyngeal dysphagia. Functional Status: The resident requires a straw for functional oral hydration intake due to being unable to lilt her head backwards because of a severe stiff neck. The resident's general head and neck position is hanging down forward. The Resident tolerated a mechanical soft chopped diet with only selective dishes such as a half inch cut up cucumbers and cantaloupe. Food avoidance noted when served food larger than one half inch in diameter the resident complained they were too big. Resident #22 needed food cut into manageable size pieces because the resident was unable to use the left hand for cutting food due to severe contracture. -Resident #22 required dining modification to promote a program that manages contractures in the left hand and maximizes ability for self-feeding. Occupational therapy progress note documented: -Resident dines in the main dining room for lunch. Occupational therapist noted the height of the table is restrictive for the resident's comfort with self-feeding. Resident agreeable to trial bedside adjustable table for meal. Resident reports improved ability to reach food and utensils with modification. Resident #22 primarily ate finger food items but was able to hold a cup to drink soup. -Functional maintenance program completed and restorative aid verbalizes understanding of modifications made (for resident dining). Continue to recommend lower table surface for increased accessibility to food and drink items. Bedside table available dining room and executive team was looking into long term options to provide optimal dining experience. The comprehensive care plan, dated 8/22/22, last reviewed 2/22/23, revealed the resident had specialized care needs for dining, eating and swallowing. The care plan documented in pertinent part: -Resident #22 needed limited assistance, defined as a meal set up only and in another section, the care plan documented the resident needing assistance eating. -Nutritional approaches included encouragement to consume the meal. -The comprehensive care plan did not include speech and occupational assessment that the resident did better with finger hand held foods or with the recommendations to provide a table at the appropriate height or to provide the resident with a cup to drink rather than spoon in food items such as soup. III. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 2:55 p.m. RN #2 said there was a list posted at the nurses station listing all resident nutritional and feeding assistance needs. Nursing staff should make sure the resident was positioned correctly to facilitate swallowing and ability to reach and eat food without risk of choking. If the resident's table was not accommodating the resident's ability to eat independently. Staff could provide an adjustable bedside table for the resident to be able to reach and eat their food. Certified nurse aide (CNA) #3 was interviewed on 3/16/23 at 4:22 p.m. CNA #3 said there was a listing of residents who needed feeding assistance and the type of assistance needed. The nurse would provide a report if any resident needs changed and give instruction of the changes. If a resident was not positioned properly to facilitate eating, staff were expected to reposition the resident so the resident was sitting up as straight as possible and close enough to the table to see and reach food items. If the resident had an adjustable table, the table could be moved closer to the resident and adjusted downward so the resident was able to reach their food. CNA #5 was interviewed on 3/16/23 at 4:35 p.m. CNA #5 was familiar with the resident's eating needs due to regularly wiring with the residents. If there were any new residents, the nurse and the registered dietitian would hold a staff huddle (meeting) and give report on the new resident's needs. If a resident was too far from the table or the table was too high for the resident to reach the food staff should position the resident to make sure they were squared up close to the table. For residents with a specialized wheelchair staff would need to adjust the chair down so that they could fit under the table and be able to reach their food. The director of nursing (DON) was interviewed on 3/16/23 at 5:06 p.m. The DON said staff should offer meal assistance and or encourage eating to any resident who required assistance or was not eating. The DON said each resident had a care plan for nutrition and eating where eating and nutritional needs were documented. Care plans were maintained in a resident specific binder in the nurses station and all nursing staff had access to the care plan. The DON said Resident #22 ate in the dining room at an adjustable table. Staff should adjust the table in the low position and close enough to the resident so the Resident #22 could reach and eat all served foods. Staff should continually round during the meal, identify resident struggles while eating and offer assistance as needed to facilitate successful eating. The DON said Resident #22 was unable to reposition to sit up straight due to limited range of motion with her upper extremities-arms, hands and shoulder; as well as with the head and neck. The DON said the CNAs and nursing staff had been using the adjustable bedside table for the resident's meals and was unaware of any challenges the resident may have had with the table height; but would look into it.

Based on observations, record review and staff interviews the facility failed to provide services for one (#36) of four residents reviewed out of 25 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #36's vital signs, specifically the resident's blood pressure, was monitored prior to the administration of a blood pressure medication. Finding include: I. Professional reference According to Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from:https://www.ncbi.nlm.nih.gov/books/NBK532906 on 3/20/2023. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. According to Kizior, R. J., Hodgson, K. J. (2023). Metoprolol. Saunders Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. II. Resident #36 A. Resident status Resident #36, age 81, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included atherosclerotic heart disease (plaque formation in the arteries that supply the heart) and atrial fibrillation. The 2/23/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. The resident required limited assistance of one person for transfers, dressing, personal hygiene, toileting and was independent with bed mobility and eating. B. Observations On 3/15/23 at 9:00 a.m. registered nurse (RN ) #1 was observed dispensing and administering Metoprolol 25 milligrams (mg) toResident #36. RN #1 did not assess the resident vital signs including the resident's blood pressure; check the order for blood pressure parameters; or review the resident's record for the resident's most recent vital signs prior toadministering the Metoprolol medication to Resident #36. C. Record review The March 2023 CPO documented a physician order of Metoprolol tartrate 25 mg, give twice a day for paroxysmal atrial fibrillation ordered on 2/28/2023. The CPO did not document any vital signs parameters for when to hold the Metoprolol medication or when to notify the physician of irregular vital sign results. The March 2023 medication and treatment administration record (MAR/TAR) did not document how often the resident's vital signs should be checked. The February 2023 and March 2023 vital signs summary revealed Resident #36's blood pressure and pulse were only assessed on 2/17/23, 2/21/23, 2/23/23, 3/3/23, 3/8/23 and 3/12/23 and not daily at the time the resident was given the prescribed Metoprolol tablets. III. Staff interviews RN #1 was interviewed on 3/15/23 at 9:05 a.m. She reviewed the Metoprolol physician's order and said there were no parameters ordered. She confirmed she did not obtain the resident's vital signs prior to administering the Metoprolol medication. She said she did not know when the resident's vital signs were last taken. She said the residents vital signs were taken once a week and up to once a month. RN #2 was interviewed on 3/16/23 at 10:00 a.m. She said for residents that were on a blood pressure medication that blood pressure should be taken once a shift prior to administration. She said they would follow the physician ordered parameters. If there were no ordered parameters and the systolic was less than 100 or if the blood pressure was trending downward, they would hold the medication and notify the physician and obtain parameters. The director of nursing (DON) was interviewed on 3/16/23 at 5:05 p.m. She said when a resident was on a blood pressure medication they would follow the physician ordered parameters. She said when there were no parameters the nurse would document and monitor for signs of hypotension and notify the physician if there was a concern. She said that vital signs should be taken prior to the administration of a blood pressure medication.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#34) of one sample residents for incontinence care and one (#16) of five sample residents for eating assistance out of 25 sample residents. Specifically, the facility failed to ensure -Resident #34 was provided incontinence care in a timely manner; and, -Resident #16 was provided eating assistance in a timely and consistent manner. Findings include: I. Incontinent care A. Professional reference According to [NAME] C., Ratnana I., [NAME] S., et al. (July 12, 2020). Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve. Cureus: 12(7): e9161. National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7419143/ on 3/20/23. Besides the financial ramifications, urinary incontinence (UI) increases the risk for physical problems such as skin breakdown, for example, perineal dermatitis, skin maceration and pressure ulcers. Residents who are incontinent are also at risk for developing urinary tract infections (UTI's ) that not only exacerbate incontinence but also represent a major source of sepsis in the elderly. Incontinent elderly persons are more likely to fall, either because of the sense of urgency to reach the toilet or because of slipping on a floor wet with urine. B. Facility policy A request was made for the facility's policy on incontinence care for dependent residents. The nursing home administrator (NHA) said the facility did not have a specific policy for incontinence care; in lieu of a dedicated policy, the facility used Lippincott procedures as a guide for care. The NHA provided copies of pages from the Lippincott manual; the resource was undated, and documented in pertinent part: Institute other interventions such as: a. Bladder retraining-progressive lengthening or shortening of voiding intervals to restore the normal patterns of voiding after a period of immobility or catheterization. b. Scheduled toileting-using a fixed toileting schedule to prevent episodes for patients with urge or functional incontinence, c. Habit training-involves using a viable toileting schedule based on the patient's pattern of voiding, also incorporates positive reinforcement, d. Prompted voiding-includes regular prompts to void every 1 to 2 hours with positive reinforcement. C. Resident #34 1. Resident status Resident #34, age 91, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included syncope (fainting) with collapse, multiple left side rib fractures, liver laceration and cognitive communication deficit. The 2/9/23 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance of one person with bed mobility, transfers, dressing, toileting, personal hygiene and supervision with set up for eating. The MDS indicated the resident was continent of bowel but had frequent urinary incontinence. A toileting program trial was not attempted during this assessment. 2. Observations On 3/13/23 at 12:00 p.m. Resident #34 was observed sitting in the dining room seated at a table with other residents. Three staff were present delivering and assisting the resident in the dining room with the meal. Resident #34 smelled strongly of urine during lunch time observation. Resident was not checked or changed during the meal. During a continuous observation on 3/15/23 beginning at 10:00 a.m. and ending at 2:40 p.m., Resident #34 was observed. At 10:00 a.m., Resident #34 was observed sitting at a table in the dining room eating breakfast. At 11:25 a.m., certified nursing assistant (CNA) #1 was observed giving Resident #34 a glass of water and after the CNA transferred the resident from the dining room chair into a wheelchair. CNA #1 then transported Resident #34 to her room and transferred the resident in a recliner. -The resident was not checked for incontinence or provided incontinent care. At 12:05 p.m., CNA #1 transferred the resident from the recliner to a wheelchair and transported the resident to the dining area for lunch. -The resident was not checked for incontinence or provided incontinent care At 1:15 p.m., an unidentified activity staff person wheeled the resident from the dining room to the common area where music was being played. At 2:40 p.m., CNA #2 wheeled Resident #34 to the bathroom. CNA #2 removed the brief from the resident. The resident's incontinence brief was wet and soiled with urine slightly yellow in color and had a mild odor of urine. The incontinence brief when held was moderately heavy but not completely saturated. -Resident #34 had not been changed or toileted in over four hours. C. Record review The continence care plan, initiated on 2/6/23, documented the resident needed the assistance of nursing staff for toileting. The interventions included assisting resident to pull up or down garments, cleansing the perineal area properly and managing protective garments and continence products. The fall care plan, initiated on 2/6/23, documented the resident needed the assistance of nursing staff to help maintain and improve current level of self performance with ADL's . The interventions included anticipating and checking frequently for resident's need to use the bathroom. A review of Resident #34's comprehensive care plan did not reveal person centered approaches to incontinence care. Personalized interventions, such as habit retraining and an individualized toileting schedule, were not identified. D. Staff interviews Certified nurse assistant (CNA) #3 was interviewed on 3/15/23 at 9:15 a.m. CNA #3 said residents were checked for incontinence every two hours and offered toileting at that time.The nursing staff would toilet or change residents when the residents got up in the morning and after meals. When the resident smelled of urine, the nursing staff changed and offered the residents toileting in the moment. The director of nursing (DON) was interviewed on 3/15/23 at 5:10 p.m. The DON said the nursing staff would identify the residents voiding patterns and then develop an individualized toileting schedule for the resident. The individualized toileting program was care planned. If voiding patterns were not identified, the routine schedule was to check and change the resident every two hours while awake. Residents that smelled strongly of urine were to be checked and changed. The DON acknowledged that a resident who presented with the smell of urine should be taken to the bathroom and not left to eat their meal while soiled with bodily fluid and smelling of urine. 41032 II. Eating assistance A. Facility policy On 3/16/23, a request was made for the facility's policy on eating assistance for dependent residents. The nursing home administrator (NHA) said the facility did not have a specific policy for eating assistance; in lieu of a dedicated policy, the facility used Lippincott procedures as a guide for care. The NHA provided pages from the Lippincott manual. The resource was undated, and documented in pertinent part: There is growing evidence that a balanced diet along with either health promoting behavior contributes to longevity . In large facility settings, environment factors may influence food enjoyment. Encourage socialization when eating . If possible, encourage five to six small meals per day rather than three large meals. B. Resident #16 1. Resident status Resident #16, over the age 90, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), Alzheimer's disease, vascular dementia, dysphagia (difficulty swallowing), and major depression. The 1/7/23 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had unclear speech; was usually able to make self-understand; and sometimes understood others in conversation if communication was simple and direct. The resident needed limited assistance from one staff member to eat meals; where the staff member provided guided maneuvering of limbs or other non-weight bearing assistance. Additionally the resident needed supervision throughout the meal where the helper was to provide verbal cues or touching/steading assistance while the resident ate. 2. Observations On 3/13/23 from 12:00 p.m. to 1:05 p.m., Resident #16 was observed sitting at a large dining room table with several other residents. Staff delivered Resident #16's meal uncovered the food and walked away to deliver other resident meal trays. Resident #16 sat looking at the food for approximately five minutes but did to eat any of the meal. -At 12:07 p.m., certified nurse aide (CNA) #8 sat between Resident #16 and Resident #31. The CNA said facing forward and not facing either resident. The CNA spooned food to each resident extending reach across the resident's torso with a backwards wrist movement. The staff did not communicate with either resident during the meal. -CNA #8 did not socialize with Resident #16 during the meal and did not tell the resident what she was eating. On 3/15/23 from 11:58 p.m. to 1:07 p.m., Resident #16 was observed sitting at a large dining room table with several other residents. -At 12:08 p.m., staff delivered Resident #16's meal and walked away. Resident #16 said at the table looking at her food but did not eat any of the meal. -At 12:17 p.m., Resident #16 still had not made any attempt to eat her meal and no staff sat with the resident to assist with eating. -At 12:22 p.m., CNA #3 sat with Resident #16 to assist the resident to eat but kept stopping to assist other residents with their meals. The resident spooned up three spoons of soup. -At 12:25 p.m., CNA #3 left the table to assist another resident with their meal. As soon at the CNA left the resident, Resident #16 stopped eating. -At 12:36 p.m., CNA #1 approached Resident #16 and asked the resident how the tuna sandwich was; Resident #16 said I don't like it. The CNA said you should eat your sandwich. Then the CNA offered Resident #16 a spoon of soup; Resident #16 said I don't think I like it. CNA #1 said the soup is a nice color, you like orange, eat your soup. The CNA walked away. The resident did not eat any more of the meal. -At 12:55 p.m., a CNA approved Resident #16's table; the CNA did not ask the resident about the meal or if Resident #16 had enough to eat. No staff offered Resident #16 and alternate meal option when the resident said she did not like the meal and did not eat any more than three bites of soup. On 3/16/23, from 11:56 p.m. to 1:05 p.m., Resident #16 was observed sitting at a large dining room table with several other residents. -At 12:03 p.m., the lunch meal was set out in front of Resident #16. No staff sat to assist the resident with the meal and the resident did not initiate eating. The resident sat rocking back and forth in a manual wheelchair. -At 12:50 p.m., a staff member handed the resident a drink; the resident took a sip and placed the cup back on the table. The resident then closed her eyes and appeared to be dozing. -At 1:05 p.m., a staff approached Resident #16 and picked up the lunch plates. No staff assisted Resident #16 to each lunch. 3. Record review The comprehensive care plan documented a care focus for dining and eating assistance, initiated on 1/11/23. The care focus documented the resident needed daily eating assistance where staff were to provide standby assistance and encouragement to improve dining self-performance. The interventions included providing the resident set up assistance and supervision throughout the meal. -The resident comprehensive care plan and MDS assessment did not match in reflecting the type of assistance the resident needed to consume a meal. The MDS assessment indicated the resident needed guided maneuvering of limbs or other non-weight bearing assistance; the care plan did not document staff providing eating assistance. 4. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 2:55 p.m. RN #2 said there was a list posted at the nurses station listing all resident nutritional and eating assistance needs. RN #2 said staff should follow the resident's care plan and provide eating assistance as written in the care plan. CNA #3 was interviewed on 3/16/23 at 9:15 a.m. CNA #3 said the facility posted the names of residents who needed eating assistance at the nurses station. The posting also documents the type of assistance each resident on the list needed. CNA #3 said Resident #16 could eat foods on her own but usually needed prompting to eat meals. Sometimes staff had to assist Resident #16 in order to get her to eat the meal. CNA #5 was interviewed on 3/16/23 at 4:35 p.m. CNA #5 said she had worked for the facility for several years and knew the resident's needs; including eating needs. The registered dietitian would notify the nursing staff of any changes in the resident's assistance needs. If a resident needed eating assistance staff were to sit with the resident and assist one resident at a time. The director of nursing (DON) was interviewed on 3/16/23 at 5:06 p.m. The DON said staff should offer meal assistance and or encourage eating to any resident who required assistance or was not eating. The DON said each resident had a care plan for nutrition and eating where eating and nutritional needs were documented. Care plans were maintained in a resident specific binder in the nurses station and all nursing staff had access to the care plan.

Based on record review and interviews, the facility failed to to keep residents safe from accident hazards related to safe transfers for one (#24) of two residents reviewed out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #24 receive safe transfer assistance from staff during transfers from wheelchair to the bed; -Staff used the recommended gait belt while assisting Resident #24 to make a safe transfer; and, -Update the Resident #24's care plan after the resident was reassessed following a fall during a staff assisted transfer. Findings include: I. Facility policies: The Lifting,Transfer and Bed Mobility policy originated in November 2012 was received from the nursing home administrator (NHA) on 3/16/23 at 5:53 p.m. a.m. It read in pertinent part:The purpose of this policy is to identify and assess the guests/ residents in the (Continuing Care) program that require mobility assistance to eliminate unnecessary manual repositioning and lifting resulting in potential injury or increased pain/discomfort to guest/resident. Each resident will be assessed by a nurse upon admission and readmission to determine the need for continuing services and change of condition. The gait belt will be used for residents who can contribute a moderate effort (50%) or more to the transfer and can follow simple commands in the transfer process but still requires physical guidance or support by the direct care giver. Refer to the policy Gait Belt for Transfers for specific procedures pertaining to use of the gait belt (see below). -Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and education will be provided on an as needed basis. The Gait Belts for Transfers and Ambulation policy originated in November 2012 was received from the NHA on 3/16/23 at 5:53 p.m. It read in pertinent part: Purpose/scope:To provide staff with detailed information regarding safe and proper usage of the gait belt during recent transfers and ambulation. Procedure: Gait belts are used by staff to improve the safety and decrease the risk of injury to residents and staff while assisting the residents with transfers or ambulation. -The gait belt will be utilized for guests/residents who can contribute at least 50 percent or more to the transfer effort and can follow simple commands but still requires physical guidance or support from the direct care staff. The need for a gait belt will be documented on a resident's care plan. II. Resident #24 A. Resident Status Resident #24 age 83, was admitted to the facility on [DATE]. According to the March 2023 computerized physicians orders (CPO) diagnosis included a personal history of stroke, type two diabetes, muscle weakness, and abnormalities of gait and mobility. The 1/3/23 minimum data set (MDS) indicated the resident had intact cognition evidenced by a brief interview of mental status score (BIMS) of 12 out of 15. The resident required two person weight bearing assistance with transfers and bed mobility. The resident did not walk around his room or the unit; and had no history of walking since he had been at the facility. The resident manipulated his wheelchair adequately around the unit. B. Resident interview Resident #24 was interviewed on 3/13/23 at 10:30 a.m. Resident #24 said he had a stroke that affected his left arm causing constant pain. Resident #24 said CNA #4 caused his fall because the CNA did not use a gait belt when assisting him with a transfer. Resident #24 said that was the first time he fell since he was admitted to the facility. Resident #24 was interviewed on 3/15/23 at 11:09 a.m. Resident #24 said he experienced a fall on 3/8/23 and was sent out to hospital per his wife's request. Resident #24 said he did not have any major injuries from the fall, but did have some bruises and head pain. Resident #24 said he remembered that he did not have the gait belt on and he bumped his head against the wall when he fell but was unable to remember any details of the fall. The resident was most concerned that CNA #4 did not place the gait belt on him during the transfer. The resident said he knew how to use the transfer pole and felt confident using it because he had one when he lived at home; no one from the facility trained him how to use it. The resident said he felt confident using the grab bar. He said he had no training from the staff on how to do this. Resident #24 said he was agreeable using the gait belt during a transfer, however not all of the staff would put the gait belt on him. Resident #24 said he needed staff to put a gait belt on him for transfers so they could help him be safe in case his leg buckled or in case he lost his balance. C. Record review The comprehensive care plan initiated on 1/3/23, revealed the resident was at risk for falls and needed extensive assistance from staff when transferring from surface to surface. -The transfer functional status care focus initiated 1/3/23, documented the resident required one staff to assist with transfers. Staff were to stand on the resident's left side; the transfer pole was to be on the right side of the resident and the surface he resident was transferring during the procedure. The assisting staff was to remind Resident #24 to move slowly through the transfer. Additionally, because resident #24 was unable to use the right arm, staff was to provide the resident under arm support and use a gait belt on the resident while assisting the resident to transfer. -The falls care focus initiated 1/3/23 documented the resident wanted to maintain current level of self-performance of activities of daily living and not experience decline in functional abilities due to fall risk. Care plan approaches included: staff to assist with re-positioning; therapy to educate staff on the correct way to complete transfer and provide instruction in room for reference. Physical therapy progress notes-dated 2/7/2023; documented: Resident #24 presented for skilled physical therapy for transfer training after admission. The resident had by this date participated in 11 physical therapy sessions with a plan of care focused on transfer training (training for both patient and staff) and endurance exercises. The resident's transfers fluctuated in technique from staff member to staff member. The physical therapist (PT) educated the staff on a consistent transfer method for bed mobility, sit to stand and stand pivot transfers. The PT discharged the resident from therapy once safe transfer training had been accomplished. Therapy goal: Resident will perform supine to sit transfer using transfer pole and minimal assist to demonstrate improved independence with function mobility. A nurse's note dated 3/8/23 documented the resident injuries following the 3/8/23 fall included two bruises to the back of the right shoulder and an abrasion to the resident's left pinky finger. The hospital visit report dated 3/8/23, documented that the resident received a computerized tomography (CT) scan of the head and cervical spine. The findings of the test revealed no hemorrhage or mass of the brain. There was no acute fracture of any bones in the brain and no brain bleed. Staff education for resident transfers provided to staff during a staff huddle (shift report update) on 3/8/23, read in part: Falls/change of condition: director of nursing (DON) reviewed all fall interventions with staff on shift. Fall interventions for Resident #24, read in pertinent part: -Bed mobility and morning transfers: Put gait belt on, have one staff member support under Resident #24's left arm ( after asking permission, put your forearm under [the resident ' s] armpit) and have other [NAME] member support at the gait belt. Resident #24 reaches to the transfer pole with his right hand. Resident #24 counts to three, then both staff members work with Resident #24 while he stands up. One staff member removes old brief and shorts, other staff members supports Resident #24 while he stands. Assist Resident #24 with pivoting into the wheelchair. -Evening transfers: Bring wheelchair alongside bed so Resistant #24 can reach the transfer pole. Put a gait belt on Resident #24. Have one staff member support under Resident #24's left arm . and have OTHER staff member support at the gait belt. Resident #24 reaches to the transfer pole with his right hand. Resident #24 counts to three, then both staff members work with Resident #24 while he stands up. Support Resident #24 while he pivots to the edge of the bed. Assist with bringing his legs up and into bed while he lays down. Physician's note dated 3/10/23 documented the resident was seen for follow up after a visit to the emergency room . Assessment: Fall subsequent encounter. Treatment: Fall while being transferred into bed; hit head; patient without evidence of injury other than two abrasions on the posterior left shoulder. Incident report form dated 3/15/23 revealed the resident fell during a staff assisted transfer. The note read in pertinent part: On 3/8/23 at 6:10 a.m. Resident #24 had a witnessed fall during a staff assisted transfer into bed. The CNA (CNA#4) who had been assisting the resident with transferring notified the floor nurse to report the fall. The resident was found laying on the floor, at bedside on his left arm with his head turned sideways against the wall and feet under the bed without shorts or brief pulled up. The resident had sandals and socks on; the resident's oxygen (nasal cannula tubing) was not on. The resident was screaming at the CNA that she dropped him and he hated the facility . -Upon assessment the resident complained of neck; back; left hip and (left) arm pain. The resident was very upset, and unable to calm. The fire department emergency medical services (EMS) arrived to assess Resident #24. The EMS applied a cervical collar to Resident #24 and transported the resident to the hospital for further assessment due hitting his head in the fall. -Conclusion of the investigation: the resident fell in a staff assisted transfer when the resident's leg buckled and the resident let go of the transfer pole; the resident fell forward and hit his head on the floor. -Steps taken to prevent recurrence (actions): All current interventions are active and in place. Additional interventions include non-skid strips added by transfer pole. Therapy order obtained to re-evaluate the transfer pole and to provide staff training. The investigation revealed the fall, during a staff assisted transfer, involved an assistive device handrail/grab bar but not the use of a gait belt assistive device (see above). -The care plan was not updated to include new interventions. Fall Reassessment dated [DATE] revealed Resident #24 had one fall prior to 3/8/23, on 10/22/22. Root cause of falls was related to a history of Falls unsteady gait, use of assistive devices, loss of limb movement, unsafe transfers, use of opioids, partial and full dependence on activities of daily living (ADL), performance, pain and medical diagnosis. -Care plan approaches: No self transfer attempts. Staff will assist the resident with repositioning. Therapy to educate the staff on the correct way to complete transfers and provide instructions in room for transfers. -Assistive devices: low bed, call pendant, wheelchair, and gait belt. -New care plan approaches: Restorative program for maintaining function; personal trainer; physical therapy to complete direct training to staff for proper transfer pole and transfers; non-skid strips placed by recliner and by resident's bed; wearing proper footwear for transfers (not described). The resident's care plan was not updated with all newly implemented care approaches/ interventions. IV. Staff interviews CNA #6 was interviewed on 3/15/23 at 11:14 a.m. CNA #6 said she had worked with Resident #24 and was familiar with the resident. CNA #6 said Resident #24's left arm was weak so the CNAs needed to provide extra support while assisting the resident to get the resident up. Sometimes it took one CNA and sometimes it took two CNAs to help the resident out of bed; a gait belt should always be used to help steady the resident. CNA #6 did not know the resident had any memory issues. The physical therapist (PT) was interviewed on 3/16/23 at 10:30 a.m. The PT said transfer training for Resident #24 and the staff was ongoing. The PT said Resident #24 did not like the gait belt, however, the staff should try their best to encourage the resident to wear the gait belt when transferring. The director of nursing (DON) was interviewed on 3/16/23 at 10:30 a.m. the DON said the CNA who was assisting the resident on 3/8/23 when he fell should have asked for help from the nurse on duty to persuade the resident to wear the gait belt since he had been refusing. The DON acknowledge that Resident #24 had a physician's orders indicated Resident #24 should be wearing the gait belt for all transfers and the gait belt should be applied before the resident stood up from the bed; and there should be two staff available to help the resident transfer. This would increase the resident's safety when transferring. CNA #7 was interviewed on 3/16/23 at 10:55 a.m. CNA #7 said it usually took two staff to transfer Resident #24 with a gait belt. CNA #7 said some days the resident was able to transfer with one staff person and the gait belt. CNA #7 said she did not know that the resident had memory loss. CNA # 5 was interviewed on 3/16/23 at 4:14 p.m. CNA #5 said Resident #24 agreed to use the gait belt to transfer if staff approached him politely and used manners. CNA #5 said most of the time it just took one CNA with the gait belt to assist the resident with a transfer. CNA #5 said it took two staff to get him out of bed this morning but she gave him a shower today and his wife was in the room as a standby assistant. CNA#5 said the proper way to use a gait belt was to make sure it was snug but not tight and not too loose; staff should be able to get only two fingers in between the resident's body and the gait belt. The restorative aide (RA) #1 was interviewed on 3/16/23 at 4:55 p.m. The RT said all residents had to be evaluated to use the transfer pole and had to demonstrate safe use of the transfer pole while in the therapy room before the pole could be installed in the resident's room. The RT said Resident #24 had a transfer pole in his room since she could remember. The RT said she was not sure if Resident #24 had been evaluated prior to the transfer pole being installed.

Based on observations, record review and interviews, the facility failed to develop and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Encourage and/or provide residents with protective masks when in common areas to prevent the spread of COVID-19 on two of two units; -Ensure proper hand hygiene after glove use; -Ensure bedpan equipment was properly contained; and, -Ensure proper handling of linen. Findings include: I. Facility policies The Infection Prevention and Control policy, revised May 2021, was provided by the director of nursing (DON) on 12/14/21 at 3:28 p.m. It read, in pertinent part, The infection preventionist will collaborate with members of the campus infection prevention committee/subcommittee members to .Monitor to ensure established infection prevention and control standards, policies and practices are consistently executed by staff and residents/patients. -Provide education and training, such as, preventing the transmission of infectious diseases, hazardous material management, food safety & sanitation, blood borne and water borne pathogens, emerging infectious diseases, and emergency preparedness program and other education and training as needed. The Hand Hygiene policy, revised March 2020, was provided by the DON on 12/15/21 at 4:54 p.m. It read, in pertinent part, When to perform some form of hand hygiene (at a minimum) .Before putting on (donning) and after removing (taking off) PPE (personal protective equipment), including gloves. II. Failure to encourage and provide residents with protective masks A. Observations and interviews On 12/8/21 at 9:15 a.m. several residents were observed in the dining room having breakfast. Staff were observed bringing residents to the dining area, the residents did not have masks on. -At 10:00 a.m. staff were observed providing activities to several residents who stayed in the dining room. Staff did not offer resident protective masks during the activity. -At 12:27 p.m. Resident #20 was assisted by staff from the main hallway into the dining room, after a couple of minutes he asked a staff member to take him to his room. Resident #20 did not have on a protective mask. -At 12:29 p.m. Resident #20 was interviewed. He said he came from the salon and just received a haircut and the staff member assisted him in the dining room because it was time to have lunch. On 12/13/21 at 8:35 a.m. staff were observed transporting Resident #4 and #19 to the dining room without protective masks on. -At 8:58 a.m. certified nurse assistant (CNA) #1 assisted Resident #5 out of bed and to the dining room. CNA #1 did not encourage Resident #5 to wear a protective mask. There was signage posted in the resident's room which read, Are you leaving your room? You must wear a mask. -At 9:19 a.m. the hospice CNA was observed assisting a resident down the hallway without a protective mask. -At 10:10 a.m. CNA #1 assisted Resident #33 out of her room to the dining room. Resident #33 did not have a protective mask on. -At 10:12 a.m. CNA #1 was interviewed. She said she was supposed to offer Resident #33 to wear a mask, but she often refused and would remove it. She said she was nervous and forgot to offer Resident #5 a protective mask before she brought her out of her room to the dining room. On 12/14/21 at 9:06 a.m. Resident #3 was observed in a common area in her wheelchair. She was not wearing a protective mask. She said she was confused and needed help to make a phone call. An unidentified housekeeper asked if she needed help. She did not offer a protective mask to the resident. -At 9:06 a.m. Resident # 23 was assisted by physical therapy to walk in the hallway near the dining room. She was not wearing a protective mask. The therapist did not offer the resident a protective mask. B. Staff interviews The nursing home administrator (NHA) and DON were interviewed on 12/9/21 at 5:29 p.m. They said they were tracking their COVID-19 outbreak (only staff no residents) and it was from the outside community. The NHA said the staff had continued to follow guidance to ensure they did not spread COVID-19 to the residents by wearing N95 masks and protective eyewear. They said the outbreak initially started with only one resident who was found positive for COVID-19 on 11/4/21 which they believe was contracted from a compassionate visit as the resident was on hospice, and the first positive staff member was on 11/4/21; however they were not connected because the staff member did not work with that resident. They said several residents had refused to wear protective masks, they would remove them and leave them hanging around and several did not know how to apply them or remove them. They acknowledged protective masks were beneficial to prevent the spread of COVID-19. They said to ensure resident safety they should have continued to encourage residents to wear protective masks and planned to re-educate staff to offer and encourage masks. III. Failure to ensure proper hand hygiene after glove use A. Observation and interview On 12/13/21 at 8:38 a.m. CNA #1 was observed providing care to Resident #5. She performed hand hygiene and donned gloves. After she unfastened the residents brief she wiped the resident's peri-area (in the front area) with a wet wipe then she doffed her gloves and donned new gloves. She did not perform hand hygiene. She rolled the resident on her right side and then wiped her buttocks with a wet wipe and placed a clean brief under the resident's buttocks. She doffed her gloves and donned new gloves. She did not perform hand hygiene. She fastened the resident's brief and rolled the resident to either side to pull up the resident's pants. She doffed her gloves and performed hand hygiene. -At 8:59 a.m. CNA #1 was interviewed. She said she knew she was supposed to perform hand hygiene after she removed her gloves, but she was nervous and forgot. B. Staff interviews The NHA and DON were interviewed on 12/13/21 at 4:38 p.m. The DON said staff were trained on when to perform hand hygiene, including after glove use. She said they planned to re-educate staff. IV. Failure to ensure bedpan equipment was properly contained and proper handling of linen A. Observation and interview Housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER] on 12/13/21 at 10:15 a.m. There were three used bedpans (they had white film surrounding the pan) on the floor. After she cleaned the bathroom and the toilet from top to bottom, she placed the bedpans on top of the toilet. She then swept and mopped the resident's bathroom floor. She doffed her gloves, performed hand hygiene and donned clean gloves and continued to clean the rest of the resident's room. After she was finished, she placed the bedpans back on the bathroom floor. She doffed her gloves, performed hand hygiene, went to the laundry closet and grabbed clean towels (face towel and hand towel). She placed them under her arm and carried them to the room and placed them in the resident's bathroom. She exited the room, performed hand hygiene and moved to the next room. -At 10:52 a.m. HSK #1 was interviewed, she said she did not know where the bed pans belonged or if they needed to be placed in a bag. She said she just left them on the floor for the CNAs to take care of. She said she did know she should not place linen up against her clothing. -At 11:45 a.m. during wound observation the bedpans were still observed on the bathroom floor. -At 4:28 p.m. the bedpans were observed on the resident's bathroom floor with CNA #2. He said the bedpans should be placed in a plastic bag after use. He said he was going to throw them away and obtain a clean bedpan for the resident and place in a bag in the resident's bathroom. B. Staff interviews The NHA and DON were interviewed on 12/13/21 at 4:38 p.m. The DON said she expected all staff to ensure bedpans were bagged. She said bedpans could be easily rinsed/wiped and placed in a bag after use. She said typically all staff were instructed on how to transport linen and they should not hold them against their body or under their arm next to their clothing. She said she would provide education. V. Staff interviews The staff development coordinator (SDC) was interviewed on 12/13/21 at 12:53 p.m. She said she provided orientation education related to infection control as well as education regarding hand hygiene (spot check) with return demonstration. She provided documentation of hand hygiene and returned demonstration. Two to five staff completed the training monthly from January 2021 to December 2021. In addition, education included proper use of PPE, peri-care, catheter care and droplet precautions. The NHA and DON were interviewed a second time on 12/13/21 at 4:50 p.m. The NHA and DON said they had previously offered and encouraged residents to wear their masks when they were under quarantine or isolation; they had more luck getting residents to comply with the regulation when they were on quarantine. They said staff were encouraged to offer residents protective masks and signage and masks were in resident rooms and at the nurse's station as a reminder. They acknowledged all breaks in infection control identified above and would re-educate. VI. Facility COVID-19 status The director of nurses (DON) was interviewed on 12/8/21 at 9:30 a.m. She said they had zero COVID-19 positive residents and three COVID-19 positive staff who had not returned to work. She said there were no presumptive positive COVID-19 residents and all staff and resident tests from 12/7/21 were pending for COVID-19. On 12/14/21 all staff and all residents test results for 12/7/21 and 12/10/21 were negative for COVID-19.

Based on observations and interviews, the facility failed to prepare and serve food in accordance with professional standards for food safety. Specifically, the facility failed to follow proper hand hygiene procedures in the kitchen. Findings include: I. Policy and procedure The Food Handlers Employee Health policy, revised 1/2020, was provided by the nursing home administrator (NHA) on 10/15/2020 at 8:30 a.m. It read, in pertinent part, staff washes hands and exposed arm areas thoroughly with soap and warm water: before handling exposed foods and food-contact surfaces; before starting work; as often as required to remove soil and contamination; after using toilet facilities; and before and between glove use. Staff use gloves or utensils to protect exposed food: uses gloves for one task; does not use the same gloves while working with read-to-eat food and raw food; and discards gloves when damages or soiled, and interruption occurs in the operation, or after two hours of continuous use. II. Observations A. Cook #1 The lunch dining service was observed on 10/14/2020 starting at 11:23 a.m. The following observations were made: -At 11:23 a.m., cook (CK) #1 was observed cutting fruit with gloves on. She used the same gloves to then mix the fruit with her hands. She removed her gloves and did not perform hand hygiene. -At 11:45 a.m., CK #1 was observed making grilled cheese sandwiches on the stove. She put gloves on, touched the stove temperature knobs, then the bread packaging, then reached into the package to grab bread slices with her gloved hands. She made the sandwiches then grabbed serving containers. She took the sandwiches off the stove top and put them on the serving line cutting board. She cut the sandwiches, then picked them up with the same gloved hands to put them in the serving containers. She failed to change her gloves and perform hand hygiene after she touched contaminated surfaces. B. Cook #2 -At 11:38 a.m., CK #2 arrived in the kitchen. He changed his cloth mask to a surgical mask upon arrival then did not perform hand hygiene. He then put on gloves, grabbed multiple pots and pans in the preparation area, went into the walk-in to get butter and brought it back to the preparation area. He then went to the dishwashing area, pulled out multiple dirty pans to wash then went back to the preparation area. He grabbed the butter with his same gloved hands and put it into a pan on the stove top. He then went back to the dirty dishes area to sort dirty pans. He then went to grab a recipe notebook and brought it back to the food preparation area. He then got a cup and put ice and water in it for himself, took a drink and set the cup down. He then went back to the dirty dishes area to get additional pans and brought them back to the preparation area. He failed to change his gloves and perform hand hygiene after touching contaminated surfaces. -At 11:53 a.m., CK #2 was observed wearing the same gloves since 11:38 a.m. He walked into the walk-in refrigerator to get a box of carrots and touched multiple surfaces throughout the kitchen. He then grabbed a clean scoop, touched the serving side of the scoop then used it to scoop carrots into a pan. He then left the scoop in the box of carrots with the handle inside the container and went back into the walk-in refrigerator for additional food items. -At 12:06 p.m., CK #2 was observed with the same gloves on his hands. He touched his pants to pull them up, then touched butter and took it back to the preparation area. -At 12:09 p.m., CK #2 was observed with the same gloves on his hands. He was cutting onions and touching the onions with his gloved hands. -At 12:29 p.m., CK #2 was observed with the same gloves since initial observations at 11:38 a.m. He touched multiple surfaces around the stove, then put an oven mitt over his gloves to move a hot pan. He took the mit off his hand, but did not remove his gloves. He then grabbed a serving spoon, touched the serving side of the spoon with his gloved hands, then used the spoon for his meal preparation. -At 12:40 p.m., CK #2 was observed cutting pies, he put a cut resistant glove over his gloved hand and covered that with another glove. He cut several pies into pieces and touched the crust of the pie with the contaminated glove to help stabilize his cutting. C. Dietary Aide #1 -At 11:36 a.m., DA #1 was observed preparing salads and dressings on the serving line. Her bangs were outside of her hair net. This observation continued throughout the whole dining service. D. Dietary Aide #2 -At 11:27 a.m., dietary aide (DA) #2 put gloves on to move lettuce from a serving container to a storage container. She then removed her gloves and did not perform hand hygiene. -At 12:00 p.m. DA #2 touched peanut butter and jelly sandwiches with her gloved hands. She picked up a knife to cut the sandwiches in half. Then picked up the sandwiches, with the same gloved hand that touched the knife, and put them into the serving container to take to residents. -At 12:07 p.m. DA #2 put gloves on, grabbed a storage container filled with potato chips. She opened the container and used her same gloved hands to put chips in containers served to the residents. -At 12:19 p.m., DA #2 was observed cutting up shrimp then using her gloved hands to put the shrimp in resident serving containers. She then got a second glove to put over the one she just used to touch shrimp and continued to serve food into resident containers. She failed to change gloves and perform hand hygiene after her gloves were contaminated. -At 12:29 p.m. DA #2 put gloves on, then cut sandwiches. She used the same gloved hand that touched the knife to move the sandwiches into the resident ' s meal containers. -At 12:47 p.m. DA #2 was observed touching serving utensils, then putting sandwiches into resident meal containers with the same gloved hands. III. Interview The dietary manager (DM) was interviewed on 10/14/2020 at 4:00 p.m. He said he noticed staff throughout the lunch service did not perform proper hand hygiene. He said they should remove their gloves and perform hand hygiene after their glove touches any surface throughout the kitchen. He said in the future he would educate staff to use tongs for all bread and sandwiches to prevent contamination and touching the food with gloves that had touched contaminated surfaces. He said he watches dining services regularly to watch for hand hygiene practices and the staffing development coordinator (SDC) also provided training to dietary staff on proper hand hygiene practices. The DM said all staff should have their hair fully tucked into their hair net, and he did not know why DA #1 did not have all her hair tucked into her hair net. He said he would provide immediate education for her.

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, such as coronavirus (COVID-19), in two of four halls observed for infection control practices. Specifically, the facility failed to: -Ensure proper hand hygiene was performed during medication administration and when donning/doffing personal protective equipment (PPE), -Ensure proper cleaning of shared medical equipment, and; -Ensure proper isolation gown storage and resident mask use when staff provided care. Findings include: I. Hand hygiene, cleaning of shared equipment, and resident mask use A. The Centers for Disease Control (CDC) references The CDC (2020) Hand Hygiene, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. [MEDICATION NAME] hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. Accessed on 10/20/2020. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [DIAGNOSES REDACTED]-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% [MEDICATION NAME] or 70% [MEDICATION NAME] in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. The Center for Disease Control (2019) Guideline and Recommendations for Disinfection in Healthcare Facilities, retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection. It read in pertinent part; -Disinfect non-critical medical devices (like blood pressure cuffs) with an EPA-registered disinfectant using the label ' s safety precautions and use directions. Most EPA-registered disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of disinfectants against pathogens with a contact time of at least 1 minute. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient). -If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient (who is in isolation) before using this equipment on another patient. Accessed on 10/20/2020. According to the Centers for Disease Control (CDC) website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes last updated 5/7/2020, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others enter their room. 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, updated 4/13/2020, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, read in pertinent part, Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. Accessed on 10/20/2020. B. Facility policies The Infection Prevention and Control Preventing Transmission of Infectious Agents policy, dated 6/2019 and revised 8/2020, provided by the director of nursing (DON) on 6/15/2020 at 10:00 a.m., read in pertinent part: Hand hygiene, also known as hand washing, is the act of cleaning hands for the purpose of removing soil, dirt, and microorganisms. Hand washing with soap consistently at certain critical moments during the day prevents the spread of many diseases. If water and soap are not available, hand sanitizer can be used when not working dining areas. -Hand hygiene can keep residents and staff healthy and prevent the spread of respiratory and diarrheal infections from one person to the next. -Key times to wash hands include: after providing activities of daily living (ADL) care, before and after providing resident care, and between each resident during medication administration. -If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. The Infectious Disease Management Guidelines policy and the Applying and Removing PPE policy, dated 8/20/2020, provided by the DON on 10/15/2020 at 10:00 a.m., read in pertinent part: -Hand hygiene is to be performed prior to donning PPE. -Goggles or face shields that are reusable are to be placed in a designated receptacle for reprocessing otherwise they are to be discarded in a waste container in the resident room. -When doffing the isolation gown, do not touch the front of the gown. -Fold or roll the gown into a bundle and discard in a waste container. -Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. -Staff will wipe down all medical equipment post use. C. Manufacturer ' s instructions Review of the manufacturer's instructions for the Oxivir Tb Wipes read in pertinent part: Oxivir Tb Wipes are intended for the cleaning and disinfecting of healthcare environmental surfaces. Kills bacteria [MEDICAL CONDITION] in one minute including the COVID-19 virus. -Disposable latex or vinyl gloves must be worn during cleaning and decontamination procedures. -Wipe hard, non-porous environmental surfaces allowing the surface to remain wet for one minute. D. Observations On 10/12/2020 at 9:05 a.m. the door to quarantine room [ROOM NUMBER] had a stop sign that read to see the nurse before entering, but did not indicate the reason. There was no isolation cart in the hall and an isolation gown was seen draped over the back of a chair in the hallway. An unknown certified nurse aide (CNA) was seen outside the room preparing to enter. She was wearing a surgical mask. She picked up the gown lying on the chair outside the room, donned it, then retrieved gloves from under the gown in a pocket of her uniform. She applied the gloves without performing hand hygiene, then entered the room. On 10/13/2020 at 12:10 p.m. There was an isolation gown draped across the back of a chair between quarantine rooms [ROOM NUMBERS]. -At 12:14 p.m., an unknown CNA exited quarantine room [ROOM NUMBER] wearing gloves. She proceeded down the hall pushing a grey trash receptacle with her hands over the edges of the bin. She stopped at the CNA charting alcove, picked up the trash can there and emptied it into the large bin. Wearing the same gloves she then obtained an Oxivir Wipe and cleaned the counter tops in the alcove, picking up different items on the counter to wipe underneath them with the contaminated gloves. Still wearing the gloves, she pushed the trash bin down the hall to the soiled linen room with her hands over the edges. With her gloved hand, she grabbed the door handle and opened the door. She then removed the gloves, dropped them in the trash bin and grabbed the bin with her bare hands over the top edges and pushed it inside. She did not perform hand hygiene and walked to the resident laundry room, touching the door handle, and entered the room. -At 10/13/2020 at 12:21 p.m., the facility ' s physician assistant (PA) was seen outside quarantine room [ROOM NUMBER] wearing a gown and an N95 mask. She did not perform hand hygiene and removed a pair of gloves from a pocket of her uniform, under the gown, and applied them, then entered the resident room. -At 12:27 p.m. the PA exited quarantine room [ROOM NUMBER] wearing the gown and N95 mask, walked down the hall and entered an office. -At 12:38 p.m. an unknown CNA was seen in the west hall dining room assisting a resident to apply a mask. She used her bare hands, touching the resident ' s face and hair. She did not perform hand hygiene and exited the building onto a courtyard. -At 12:39 p.m. the unknown CNA re-entered the west hall dining room. She did not perform hand hygiene and proceeded down the hall to assist with passing lunch trays. She touched the tops of resident drink containers moving them around on the cart, then entered a resident room with a meal. -At 1:42 p.m., during observation of wound care on the resident in room [ROOM NUMBER], registered nurse (RN) #2 did not have the resident apply a mask while the wound care was being performed. On 10/14/2020 at 8:32 a.m., licensed practical nurse (LPN) #1 was seen in the east dining room preparing to administer medications to a resident. She was wearing a surgical mask and safety glasses. She did not perform hand hygiene. She retrieved a pulse oximeter (pulse ox) from the basket of the vital signs machine. She did not apply gloves or clean the pulse ox and applied it to a resident's finger, touching her hand and fingers. Once the reading was obtained she did not clean it and placed it back into the vital signs machine basket. She retrieved a temporal thermometer from a pocket of her uniform, she did not sanitize it or her hands before obtaining the reading. After obtaining the resident's temperature she placed the thermometer back in her pocket. She readjusted her safety glasses then assisted another resident with applying a mask, touching the resident's hair and face. She then returned to the medication cart, touching the pill crushing tool, the computer mouse, and her ink pen. She then administered medications to the resident. She did not sanitize her hands and grasped the handles of a resident's wheelchair to assist her in going forward then touched another resident's wheelchair handles. She did not sanitize her hands then donned gloves to administer a gel medication to a resident's face. -At 8:42 a.m., LPN #1exited the east dining room to obtain a mask for a resident and with her bare hands, assisted the resident with applying it, touching her hair and face. She did not sanitize her hands and entered room [ROOM NUMBER]. She retrieved the thermometer from a pocket of her uniform, did not sanitize it, and obtained the resident ' s temperature. She then placed the thermometer back in the pocket without sanitizing it. She then assisted the resident with removing her sweater, to obtain her blood pressure, touching her hands and arms. She removed the pulse ox from the basket of the vital signs machine, did not clean it, and placed it on the resident's finger. After the reading was obtained, she did not clean it, placed it back in the vital signs machine basket and assisted the resident to reapply her sweater. She did not sanitize her hands and exited the room to obtain pudding from the kitchen. She touched the door handle of the refrigerator and retrieved the pudding from inside. After she administered the resident's medications she did not sanitize her hands and exited the room. -At 9:26 a.m. LPN #1 was preparing to administer medication to the resident in quarantine room [ROOM NUMBER]. At the same time an unknown CNA had the resident's breakfast to deliver. The CNA was wearing a gown and a surgical mask. She did not perform hand hygiene nor don gloves and picked up the disposable containers of food and entered the room. She placed the items on the resident's table then exited the room. LPN #1 knocked on the door and entered the room with the vital signs machine. She was wearing a surgical mask and safety glasses. She did not perform hand hygiene or don PPE prior to entering the room. She walked to the other side of the room next to the resident and realized she was not wearing the required PPE. She said, Oh no! I forgot! She exited the room, walked down the hall and entered a supply room to retrieve a gown and an N95 mask. She returned to the med cart, donned the gown, removed her surgical mask and placed it on the unprotected surface of the med cart and applied the N95 mask. She did not perform hand hygiene and donned gloves. She entered the room, removed the thermometer from a pocket of her uniform under the gown. She did not sanitize the thermometer and obtained the resident's temperature, then placed it back in her pocket. She obtained a pair of scissors from a pocket of her uniform to open a medication packet. She did not sanitize the scissors and once the medication packet was open, replaced the scissors in her pocket. She exited the room with the vital signs machine. She removed the gloves, did not perform hand hygiene before applying another pair of gloves to clean the pulse ox. She did not clean the entire vital signs machine after she exited the room. She removed the gloves, did not perform hand hygiene, and picked up her ink pen to document on a piece of paper, then put the pen in her pocket. She proceeded down the carpeted hall with the vital signs machine. -At 9:51 a.m. LPN #1 prepared to enter a quarantine room to administer medications. She did not perform hand hygiene before donning PPE. She applied a gown, removed her surgical mask and placed it on the unprotected surface of the med cart. She then applied an N95 mask and gloves and entered the room. She reached under her gown to retrieve keys from a pocket of her uniform, to unlock the medication cabinet in the resident room. Prior to exiting the room she removed the gloves, used hand sanitizer then removed the gown by pulling it off by the front of the material. She hung the gown on the back of the door and exited the room. She did not sanitize her hands after she removed the gown. On 10/15/2020 at 8:40 a.m. RN #1 was seen in the east dining room obtaining a resident's vital signs. She did not don gloves and cleaned the equipment with an Oxivir Wipe. E. Interviews The DON was interviewed on 10/15/2020 at 9:50 a.m. She said staff should perform hand hygiene before and after contact with a resident, before and after donning and doffing PPE and anytime their hands become soiled. She said staff were to clean resident shared equipment before and after use and they should wear gloves when using the bleach or peroxide wipes. She said isolation gowns were to be hung inside quarantine rooms on hooks, on the back of the doors, and not draped across a chair in the hallway. LPN #1 was interviewed on 10/15/2020 at 10:40 a.m. She said hand hygiene should be performed before and after resident contact. She said equipment shared among residents should be cleaned with disinfecting wipes after use. She said she would clean the pulse oximeter after use on the quarantine residents and it's probably cleaned throughout the day as well. She said she had her own temporal thermometer so she did not have to use the oral thermometer on the vital signs machine. She said the quarantine residents did not have disposable vital signs equipment so she left the blood pressure cuff from the machine in the quarantine room. She said she would take the vital signs machine into every resident room whether they were in quarantine or not. She said she did not clean the entire machine, just the pulse oximeter. II. Failure to ensure staff had masks on at all times in resident room A. Observations On 10/13/2020 from 2:00 p.m. to 2:36 p.m. Resident #31, a quarantined resident, was observed with an agency companion in her room. The companion was observed sitting at a table with the resident in her room doing activities. The companion had a surgical mask pulled down under her chin and had no face covering over her mouth and nose. B. Interviews The nursing home administrator (NHA) was interviewed on 10/13/2020 at 3:00 p.m. He said Resident #31 ' s companion was expected to wear a mask at all times in the resident ' s room. He said he would re-educate her on proper personal protective equipment (PPE) use in the facility and in quarantine rooms. C. Failure to ensure proper hand hygiene followed RN #1 was observed exiting room [ROOM NUMBER], a quarantine room, on 10/15/2020 at 9:06 a.m. She took her gown off, then her gloves, then exited the room. She then grabbed a wipe to clean the multi use vital signs equipment. She failed to perform hand hygiene prior to exiting the room and wear gloves to clean the multi use equipment.

Based on observations, record review, and interviews, the facility failed to ensure one (Resident #4) of one resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, out of 16 sample residents reviewed for skin alteration. Specifically, the facility failed to identify, monitor, and document two bruises on Resident #4s left hand and left forearm (see observations below) during routine cares. Findings include: I. Facility policy The Skin Integrity Program policy, dated 5/2003 and revised 2/2019, provided by the director of nurses (DON) on 10/14/2020 at 2:00 p.m., read in pertinent part: The prevention and management of alterations in skin integrity is a priority for the community. When an alteration in skin integrity is present, an interdisciplinary and comprehensive approach will be taken to provide necessary care and treatment to promote healing and prevent infection. -Clinical care teams will observe/assess skin at a minimum weekly. The skin assessment will be documented in the electronic medical record. -If a new wound is identified during skin checks, wound documentation is completed. -The wound is assessed weekly and documented on the wound assessment form in the electronic medical record. -When the wound is healed, the medical record will reflect the status of the wound and the care/service plan is updated. II. Resident #4 A. Resident status Resident #4, age 86, was admitted [DATE] and readmitted [DATE]. According to the 10/2020 computerized physician orders (CPO) [DIAGNOSES REDACTED]. The 10/7/2020 minimum data set (MDS) assessment indicated Resident #4 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She had mood symptoms, did not have behavior symptoms, and no skin issues were documented. She did not walk and required extensive assistance of two staff members with bed mobility, transfers, and toilet use. B. Observation On 10/12/2020 at 2:51 p.m. Resident #4 was seen sitting in a wheelchair in her room. There was a circular purple area on top of her left hand near the thumb and oval shaped reddish purple area to her left forearm. C. Record review The 10/2020 CPO included orders: -[MEDICATION NAME] 200 milligram (mg) orally two times daily for [MEDICAL CONDITION] arthritis. -[MEDICATION NAME] 150 mg orally one time daily at 9:00 a.m. for [DIAGNOSES REDACTED]. -[MEDICATION NAME] 50 mg orally at hour of sleep at 9:00 p.m. for [DIAGNOSES REDACTED]. Review of the 7/29/2020 care plan revealed Resident #4 required extensive assistance of two staff members for bed mobility, transfers, and toileting. Interventions included: -Nursing staff will assist me with bed mobility such as repositioning frequently while I am in bed. -Nursing staff will use a sit-to-stand to help with all transfers and remind me to hold the handles. -I am unable to walk and will need assistance with mobility using my wheelchair. -Nursing staff will provide two person extensive assistance to transfer me on and off the commode and to and from the shower, using the sit-to- stand. -Nursing staff will use proper lifting protocols to properly and safely transfer me. -Nursing staff will assess my skin weekly and as needed for any impaired skin. Review of the 10/8/2020 certified nurse aide (CNA) shower documentation sheet revealed no skin issues were documented and the sheet was not signed by a nurse. The 10/11/2020 CNA shower documentation sheet was signed by registered nurse (RN) #3 and revealed no skin issues. The 10/11/2020 nursing note documented by RN#3 at 1:12 p.m. revealed no documentation of skin alterations to the resident ' s left hand/arm. Review of the electronic medical record revealed no physician order for [REDACTED]. III. Interviews Resident #4 was interviewed on 10/12/2020 at 2:51 p.m. She said she bumped her left arm a few days ago going through the doorway into the bathroom. The clinical nurse manager (CNM) was interviewed on 10/13/2020 at 3:30 p.m. She was unaware of the bruises to Resident #4s left hand and arm. She said the facility did not enter orders for weekly skin assessments. She said the nurses were supposed to do skin assessments on the resident's shower day but the assessment was not documented on the TAR as being completed. She said she could find only one nursing note dated 10/11/2020 documented by RN #3, and it did not contain any documentation of bruising. She said there was no way of knowing if the skin assessments were actually being completed as they were not documented in the medical record by the nurse, and that was a problem. The DON was interviewed on 10/14/2020 at 1:00 p.m. She said when a new skin issue was identified, the nurse was to fill out an incident report form so an investigation can be started to identify the cause. The interdisciplinary team (IDT) was then alerted so a follow up can be done. Areas were to be monitored until they were healed. IV. Facility follow up On 10/14/20 at 10:22 a.m. the CNM provided documentation of the incident report and investigation she completed on 10/13/2020 at 7:00 p.m., after she was made aware of the bruising to Resident #4s left hand/arm. The resident stated she bumped her left arm and denied any staff abuse. The staff were to monitor the areas until healed.

Based on observations, record review, and interviews, the facility failed to ensure three (Residents #2, #4, and #8) of four residents, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, out of 16 sample residents reviewed, for respiratory care. Specifically, the facility failed to: -Ensure a physician's order for oxygen administration, that included the flow rate and parameters, was in place for Residents #2, #4, and #8. Findings include: I. Facility policy and procedure The Oxygen Therapy policy, dated 6/2019, provided by the director of nursing (DON) on 10/15/2020 at 10:00 a.m., read in pertinent part: -Oxygen is administered by the licensed nursing staff -Oxygen administration requires a medical provider order. II. Resident #4 A. Resident status Resident #4, age 86, was admitted [DATE] and readmitted [DATE]. According to the 10/2020 computerized physician orders (CPO) [DIAGNOSES REDACTED]. The 10/7/2020 minimum data set (MDS) assessment indicated Resident #4 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She had mood symptoms, did not have behavior symptoms, and required oxygen therapy. She did not walk and required extensive assistance of two staff members with bed mobility, transfers, and toilet use. B. Observations On 10/12/2020 at 2:53 p.m. Resident #4 was seen seated in a wheelchair in her room. She was wearing oxygen through a nasal cannula and the oxygen concentrator was set on 3 liters per minute (LPM). She said she thought it was supposed to be set on 2 LPM. Throughout the day on 10/13 and 10/14/2020, Resident #4s oxygen concentrator was set on 3 LPM. C. Record review The 10/2020 CPO included orders dated 6/27/2020: -Breo Ellipta 200 microgram (mcg)/dose powder for inhalation (1puff) one time daily. -Change all oxygen tubing every Sunday and label with date changed. Despite having an order to change oxygen tubing, there was no order for oxygen administration, LPM, or parameters. The 7/29/2020 care plan revealed Resident #4 needed assistance in keeping her oxygen (O2) on and maintain prescribed liters of administration at all times daily. Interventions included: -Oxygen therapy at 3-4 LPM per nasal cannula. -Nursing staff will ensure I am wearing my supplemental O2 and that my O2 saturations are greater than 90% at all times. Review of the September and October 2020 nursing notes revealed no documentation of oxygen use for Resident #4. The 9/28/2020 physician progress notes [REDACTED]. Review of the 10/2020 Medication Administration Record [REDACTED]. D. Interviews Registered nurse (RN) #2 was interviewed on 10/13/2020 at 4:10 p.m. She said Resident #4 was on oxygen continuously so it was set on 2 LPM. She said in order for her to know what LPM the oxygen was to be set on, she went by the nurse report sheet at the beginning of her shift. She said the nurses would titrate the LPM by a half liter or so to keep her oxygen saturation above 90%, then notify the doctor. She said, When a resident was admitted from the hospital they reviewed the hospital record and set the resident's oxygen at the LPM it was on when she was hospitalized , even if there was no physician order for [REDACTED].>III. Resident #2 A. Resident status Resident #2, age above 80, was admitted on [DATE]. According to the October 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 6/28/2020 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment and a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive one person assistance for activities of daily living (ADLs). She received oxygen therapy while she was a resident in the facility. B. Observations The resident was observed on 10/12/2020 at 11:21 a.m. She was in bed and received oxygen from a concentrator via nasal cannula. C. Record review The October 2020 CPO revealed the resident had an order to change oxygen tubing every week and label with the date. -The facility failed to obtain an order for [REDACTED].>The comprehensive care plan, revised 12/21/19, revealed the resident had no history of respiratory concerns. It read, the resident had shortness of breath when transferring and performing ADLs. She also experienced increased anxiety with shortness of breath. D. Interviews Registered nurse (RN) #1 was interviewed on 10/15/2020 at 9:19 a.m. She said Resident #1 was always on oxygen therapy at 3LPM (liters per minute) via nasal cannula. She said if her oxygen saturation dropped below 90% she would contact the physician to titrate her oxygen. She said she did not look at the order because she knew this resident well and she always received oxygen therapy at 3LPM. IV. Resident #8 A. Resident status Resident #8, age below 80, was admitted on [DATE]. According to the October 2020 CPO, [DIAGNOSES REDACTED]. The 7/16/2020 MDS assessment revealed the resident had severe cognitive impairment and a BIMS score was unable to be obtained. She required extensive two person assistance with ADLs. Oxygen therapy was not identified on the MDS assessment. B. Record review The October 2020 CPO revealed the resident was ordered supplemental oxygen therapy at night due to [MEDICAL CONDITION] and titrate to maintain oxygen saturations greater than or equal to 90%. -The order failed to identify a liter flow for the resident. The comprehensive care plan, revised 11/26/19, revealed the resident had hypertension and the nurse may initiate oxygen at 2LPM via nasal cannula, and titrate as needed to keep oxygen saturations above 90%. C. Interviews Licensed practical nurse (LPN) #2 was interviewed on 10/13/2020 at 4:06 p.m. She said Resident #8 received 2LPM oxygen via nasal cannula at night due to sleep apnea. She said the resident ' s oxygen saturations were checked throughout the night to determine liter flow rate. The DON was interviewed on 10/15/2020 at 9:50 a.m. She said since oxygen was a medication it required a physician's order for the administration. The order should include the LPM, and if the physician wanted titration to maintain an oxygen saturation above 90%, there should be parameters.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable dseases and infections such as COVID-19 for four of four halls and two of two dining rooms. Specifically, the facility failed to ensure adequate hand hygiene during meals, ensure resident mask usage and ensure quarantine isolation measures were followed. Findings include: I. Facility policy: Review of the Coronavirus COVID-19 information and updates policy (pages two and three), dated 4/8/2020, provided by the director of nurses (DON) on 5/4/2020 at 10:05 a.m. revealed in part Resident will remain in isolation/quarantine until provider discontinues recommendation. II. Reference Review of the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html, updated 4/15/2020, revealed in part, Key strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs) .Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others .Assess supply of personal protective equipment (PPE) and initiate measures to optimize current supply. Review of the CDC website: 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, updated 4/13/2020, revealed in part Standard Precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting . Patients and visitors should, ideally, be wearing their own cloth face covering upon arrival to the facility. If not, they should be offered a facemask or cloth face covering as supplies allow, which should be worn while they are in the facility .Patients and visitors should, ideally, be wearing their own cloth face covering upon arrival to the facility. If not, they should be offered a facemask or cloth face covering as supplies allow, which should be worn while they are in the facility .Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. III. Observations, record review and interviews Interview with the assistant director of nursing (ADON) on 5/4/2020 at 8:55 a.m. revealed the following resident rooms were under quarantine related to new admission status/asymptomatic: 1104, 1105, 1107, 1109, 1119, 1129, 1133 and 1124. The Bistro dining room was observed on 5/4/2020 at 9:00 a.m. There were four residents in the dining room eating breakfast. They did not have any facemasks near them. Resident #8 was observed going down the hallway in a wheelchair. He was initially assisted by a staff member and then continued by himself. The DON was observed talking to him. The resident was not wearing a mask and staff did not encourage use of a facemask. The main dining room was observed on 5/4/2020 at 9:18 a.m. There were seven residents eating breakfast and did not have any facemasks nearby. The staff did not offer/encourage use of facemasks with the residents, after the completion of breakfast. The DON was interviewed on 5/4/2020 at 9:18 a.m. She said they placed residents newly admitted or readmitted into a 14 day quarantine. She said the residents wore masks only during cares. The hallways were observed at 10:10 a.m. with the following: -Rooms 1123-1133: There were two hallway sanitizer dispensers. -Rooms 1134-1144: There were two hallway sanitizer dispensers. -Rooms 1112-1122: There were three hallway dispensers. -Rooms 1101-1111: There were two hallways sanitizer dispensers. Sanitizer dispensers were not readily accessible throughout the facility. At 10:17 a.m, Resident #1 was observed walking down the hallway with use of a walker. She was not wearing a mask. Another resident was watching TV in a common area around rooms 1112-1122 and not wearing a mask. The main dining room was observed on 5/4/2020 at 10:17 a.m. One resident was sitting at a table, without a mask. Resident #1 was observed walking down the hallway into the dining room area, without a mask. This resident was noted to be in quarantine. Another resident was observed in a small TV area without a mask. The DON and the Assistant director of nurses (ADON) (IC-infection control) were interviewed on 5/4/2020 at 9:18 a.m. The DON said that residents with high cognition ate in their rooms. She said the residents requiring assistance and cueing ate in the dining room. She said the residents used masks with cares only. She said the residents did not have the retention to wear the masks. They said they had been short on personal protective equipment (PPE). They said the normal gel sanitizer was backordered. The ADON said they did not have enough sanitizer supply for the residents to have sanitizer in their rooms. She said they had enough stock for the sanitizer wall units and they had just gotten some supply for the medication pass. They said they did not have enough surgical masks. They said they did not have any cloth masks for the residents. They said they kept some masks up front in case the residents needed to leave the facility, but the residents did not have them when they left their rooms.

Based on record review and interviews, the facility failed to ensure services provided to one (#3) of 3 sampled residents met professional standards of quality. Specifically, the facility failed to ensure an assessment of Resident #3 was completed by a registered nurse (RN) following an unwitnessed fall Findings include: I. Resident #1 status Resident #3, age 87, was admitted on [DATE] and readmitted to the facility on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 2/18/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. She required limited assistance of one person with bed mobility and personal hygiene. She required extensive assistance of one person with transfers and toileting. She required total assistance of one person with dressing. It indicated the resident had one fall since her admission to the facility. [NAME] Record review The fall risk care plan, reviewed 2/19/2020, revealed the resident required assistance to maintain safety in the room and the facility. The interventions included: bed in the low position with the fall mats in place, staff to ensure the resident laid in the middle of the bed, bed bolsters, frequent safety checks, the bedroom door to be kept open while the resident was in bed, and encourage the resident to eat meals in the dining room. The 1/23/2020 nursing progress notes revealed the resident was assisted to bed for a nap after lunch. The certified nurse aide (CNA) found the resident sitting up at 2:30 p.m., with her legs in the prone position, on the fall mat next to the bed. It indicated the resident complained of pain and stated her back hurt. The nursing progress notes stated, This nurse and the CNA assisted the resident to the wheelchair, to a seated position. It indicated the nurse gave the resident pain medication of [MEDICATION NAME]. The nurse notified the physician and the resident ' s responsible party. It did not indicate an RN performed an assessment of the resident to determine if an injury was sustained, prior to the resident being moved off the ground and to a seated position in the wheelchair. The nursing progress note was completed by licensed practical nurse (LPN) #1. The 1/23/2020 resident accident report form revealed the resident was found, sitting on the fall mat next to the bed. It indicated the resident did not sustain an injury from the fall. It indicated LPN #1 completed the incident report form. The form was not cosigned by an RN. The supervisor signature indicated the report had been reviewed by the director of nursing (DON) on 2/13/2020 (21 days post-fall) and the nursing home administrator (NHA) on 2/19/2020 (27 days post fall and during the survey process). B. Staff interviews LPN #1 was interviewed on 2/19/2020 at 3:30 p.m. She said if the resident sustained [REDACTED]. She said the physician and the resident ' s family should be notified. She said the nurse should complete the incident report form, identify the root cause of the fall and put new interventions in place. She said all nurses could perform an assessment. She said she did not feel a RN assessment of the resident was a must. She said she would not call an RN to conduct an assessment of the resident. She said she was the nurse on duty when Resident #3 fell on [DATE]. She said the resident was found seated, with her legs in the prone position, on the fall mat next to the bed. She said she performed an assessment on the resident, and then instructed the CNA to assist her in moving the resident off the floor and into a seated position in the wheelchair. She confirmed the resident complained of pain to her back. She said she did not call an RN to conduct an assessment of the resident post-fall. She said she did not feel the need to have an RN conduct an assessment. She said she was a very capable nurse and did not feel an RN would provide any other knowledge or insight to a resident ' s potential sustained injury post-fall. The DON was interviewed on 2/19/2020 at 4:28 p.m. She said an RN assessment should be completed after a resident sustained [REDACTED]. She said the RN assessment should always be documented in the resident ' s medical record. She said each fall incident report should be reviewed by nursing management and the NH[NAME] She said she could not recall how many days the incident should be reviewed. She said 21 and 27 days were too long for the fall to be reviewed.

Based on observations and interviews; the facility failed to prepare food in accordance with professional standards for food service in one of one production kitchen. Specifically, the facility failed to ensure the proper cutting board was used for raw food preparation. Findings include: I. Facility policy and procedure The Food Handling Sanitation policy, dated 5/2012, provided by the sous chef (SC) on 4/8/19 at 2:44 p.m. revealed, in part, To ensure the prevention of food borne illness .Separate cutting boards are labeled for use in the preparation of raw food products, and are stored separately from other cutting boards. Separate cutting boards are provided for meat, poultry, fish, raw fruits and vegetables. II. Standards of reference According to the Food Code (2017) by the U.S. Food and Drug Administration, retrieved from: https://www.fda.gov/downloads/food/guidanceregulation/retailfoodprotection/foodcode/ucm 0.pdf, page 618, revealed Simple control measures integrated into recipes and processes can improve management control over foodborne illness risk factors. For example: Process instructions that specify using color-coded cutting boards for separating raw animal foods from ready-to-eat products are developed to control the potential for cross contamination. According to the Cutting Board Company, retrieved from: https://www.cuttingboardcompany.com/cutting-board-sets/ the following color coding for cutting boards: Red: raw meat; Tan: cooked meat; Yellow: raw poultry; Black: breads and grains; Blue- raw fish, seafood; Green- fruits and vegetables; and White- dairy and cheese. III. Observation and interview On 4/8/19 at 12:15 p.m. a cook/dietary staff member was cutting cantaloupe on a white cutting board. On another prep station, a cook/dietary staff member was cutting raw chicken fillets on a white cutting board. Near the steam table, other staff members were cutting bread and sandwiches on a white cutting board. There were several color-coded cutting boards (blue, red, green, tan and white) underneath one of the prep stations. The SC was interviewed on 4/8/19 at 12:20 p.m. He said he was told he did not have to use the different cutting boards. He had always used the different colored cutting boards in the past. He then informed the cook to stop using the white cutting board for the chicken. -The SC, general manager (GM) and the registered dietitian (RD) were interviewed at 2:58 p.m. The SC said they were unable to find the yellow cutting board. He acknowledged the importance of the different cutting boards to help with the prevention of food borne illness.

Based on record review and interviews the facility failed to immediately notify the physician and resident representative of an accident for one (#6) of one resident out of 26 sample residents reviewed for notification of change. Specifically, the facility failed to immediately notify Resident #6's physician and representative of an accident that resulted in injury and required physician interventions. Findings include: I. Facility fall policy The Fall Management policy, provided by the assistant director of nursing (ADON) on 4/8/19 at 2:30 p.m., read in pertinent part: -If a fall occurs, the following steps will be taken; -Notify provider and family/responsible party (if appropriate) -Any resident with a fall resulting in a suspected serious injury (e.g. a fracture), any hip pain, head injury, or more than minor pain elsewhere will include notification of the medical provider as soon as possible. II. Resident status Resident #6,[AGE], was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/16/19 minimum data set (MDS) assessment revealed Resident #6 had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She required extensive assistance of one staff member with bed mobility, transfers, dressing, toileting, and personal hygiene. She was not steady and was only able to stabilize with assistance. She had balance difficulties when moving from a seated position to standing, moving on/off the toilet, transferring between bed and chair or wheelchair, and she had impairment in both lower extremities. II. Record review The 1/5/19 incident report written at 5:30 p.m., revealed the resident was ambulating in her room with one of her daughters present, when she fell injuring her right leg. She rated her pain level at a seven out of ten indicating very severe pain, she was unable to bear weight on her right leg and had a change in range of motion of that leg. According to her daughter, who witnessed the fall, the resident was walking in her room independently, went over by her bed, bent to grab something, lost her balance and fell backwards hitting her head on the wall. She said, she laid on the floor and grabbed her right leg. Her level of supervision at the time of the fall was stand by assistance with cueing for safe mobility. Review of the 1/5/19 nursing note written at 7:42 p.m., documented by LPN #1, revealed after the fall the resident is able to move both legs up and down but right knee is tender and sore and has a hard time bearing weight on right leg. Resident took to the bathroom and went to bed. Call placed to medical doctor (MD) to inform. Will continue to monitor. Licensed practical nurse (LPN) #1 documented on the incident report that the medical provider was notified of the fall at 7:46 p.m. -This notification to the residents medical provider was done over two hours after the incident occurred with the resident suffering an injury. Review of the 1/5/19 telephone physician order [REDACTED]. -The resident chart revealed no documentation the residents POA was notified at this time regarding these orders. Review of the nurses note written at 11:21 p.m. by the night shift registered nurse (RN) #1 documented the following information, the resident had an x-ray of her right femur and a fracture was confirmed. She notified the physician on call that the resident was being sent to the hospital. She then called the resident's daughter who was her power of attorney (POA). The radiology report of 1/5/19 at 11:41 p.m. revealed an acute distal femur fracture. III. Staff and family interviews The assistant director of nursing (ADON) was interviewed on 4/8/19 at 12:07 p.m. She acknowledged the delay in notifying the resident's POA, the medical provider, and not getting the order for the x-ray timely, caused a delay in treatment, and was not acceptable practice. She said they should be notified immediately. The medical director (MD) was interviewed on 4/8/19 at 1:17 p.m. He said if a resident had a fall with an injury, experiencing pain, and was unable to stand, the physician should be notified immediately because that would require an immediate order for an x-ray. The resident's POA was interviewed on 4/8/19 at 2:46 p.m. She said the facility did not notify her until after 11 p.m., the day of the fall, when the resident was being sent to the hospital. She said she did not understand why it took so long for her mother to be sent to the hospital when she had fallen at 5:30 p.m. earlier that day.

Based on observations, record review and staff interviews, the facility failed to follow physician orders [REDACTED].#7) of two residents out of 26 sample residents. Specifically the facility failed to follow physician's orders [REDACTED]. Findings include: I. Professional references Citation for Geri Sleeves (aka protective sleeves and shin guards; please search for the term protective sleeve in the document): Davis, J. [MI] (2018). STAMP out skin tears: Skin tear assessment, management, and prevention: A complete skin tear program benefits patients, staff, and organizations. American Nurse Today, 13(6), 37+. Retrieved from http://link.galegroup.com.ezproxy.denverlibrary.org/apps/doc/A 4029/HRCA?u=denver&sid=HRCA&xid=1748c177 (4/19) Citation for TED hose (aka Compression Stockings; please search for the term compression stocking in the document): Nettina, S.M. (2019). Lippincott Manual of Nursing Practice, (11th Ed). Philadelphia, PA. Lippincott[NAME] & Wilkins. STAT!Ref Online Electronic Medical Library. Retrieved from: https://online.statref.com/Document.aspx?docAddress=WAOfHh5RTsOlVVqQsUA6Kw!!. (4/19) II. Resident #7 A. Resident status Resident #7, age of 80, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/19/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) exam score of five out of 15. The resident had significant functional limitations in range of motion was not walking and needed extensive assistance with all activities of daily living from at least one staff. She was not physically, verbally or otherwise aggressive towards herself or others and had not been rejecting care. B. Observations On 4/3/19 at 11:17 a.m. Resident #7 was sitting in the bistro listing to music therapy. Her left hand was swollen at the wrist and fingers; she did not have her prescribed Geri sleeves on nor did she have on the prescribed compression socks. The resident was wearing white ankle socks. On 4/3/19 at 4:00 p.m. Resident #7 was observed and she was not wearing compression socks or Geri sleeves as prescribed. On 4/4/19 10:42 a.m. Resident #7 was being escorted from her room by the hospice provider certified nursing aide (CNA), to the dining room bistro area after the completion of the residents morning care. The resident did not have on prescribed compression socks or Geri sleeves. Resident was wearing three quarter length sleeves with her hands and arms clearly exposed, and she was wearing white sports socks. C. Record review The resident ' s (MONTH) 2019 CPO documented: an order for [REDACTED]. an order for [REDACTED]. An order to monitor skin tear to left forearm until healed start date of 1/25/19. The resident ' s comprehensive care plan was provided by the director of nursing (DON) on 4/4/19 at 3:00 pm. The plan revealed Resident #7 had a history of [REDACTED]. Care plan interventions included an intervention for skin integrity, due to limited moisture, and impaired mobility. Care plan approaches revealed, Resident #7 was to wear Geri sleeves, on both arms, to be worn at all times, for the protection of resident's skin. Resident was also wearing knee high compression stockings on both legs, during the day time. The resident ' s hospice care plan revealed resident started with hospice services on 12/10/18. The hospice provider developed a separate care plan dated 3/13/19. The plan included weekly registered nurse visits; CNA services for hygiene and personal care assistance two times a week. The plan included morning hygiene, grooming assistance, oral care and dressing with the application of compression socks. The (MONTH) 2019 treatment administration record (TAR) documented electronic signature for 8:00 a.m. administration of the compression socks and Geri sleeves by licensed practical nurse (LPN) #4 on 4/3/19 and by LPN #3 on 4/4/19, however, observation as written above revealing the resident was not wearing the compression socks or Geri sleeves to both extremities on either of those days. D. Interviews On 4/4/19 at 10:42 a.m., the hospice providers CNA was interviewed. The CNA said when she first started working with Resident #7 she knew the resident needed compression socks and was applying the resident ' s compression socks as a part of morning care. The CNA said since the resident no longer had the compression socks available in her room, she thought the resident no longer need the compression socks. The CNA said she had not discussed the need for resident to stop or continue wearing the compression socks with any of the facility staff, and did not know the status of the orders. On 4/8/19 at 12:00 a.m. LPN #3 was interviewed. LPN #3 reviewed the resident ' s electronic record and confirmed Resident #7 had an order for [REDACTED]. LPN #3 said she was unaware if the resident had the stockings on at the time of this interview. The LPN checked the resident for compression socks and Geri sleeves and upon discoing the resident was without the compression socks or Geri sleeves, LPN #3 took the resident to her room to apply the Geri sleeves and compression socks to resident ' s arms and legs, as ordered. On 4/4/19 at 4:33 p.m., the assistant director of nursing (ADON) was interviewed. The ADON said it was the CNAs responsibility to apply the physician ordered compression socks and Geri sleeves to the resident during the course of providing morning care. She said the licensed nurses were responsible to make sure the task was completed by the CNAs.

Based on observations, record review and staff interviews, the facility failed to follow infection control and hygienic practices to prevent cross contamination for two (#7 and #19) of two out of 26 sample residents. Specifically, the facility failed to properly maintain, clean, and store respiratory tubing, reusable oxygen humidifier equipment in a sanitary manner. Findings include: I. Professional reference Fauci, V.L., et. al. (2017) Humidifiers for Oxygen Therapy: What Risk for Reusable and Disposable Devices?, Journal of Preventive Medicine and Hygiene, 58(2), ppE161-E165. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 85/. It read, Reusable oxygen humidifiers may be easily contaminated, and that they may play a role in the transmission of potential nosocomial pathogens, especially in those units that provide assistance and care to patients in critical clinical conditions (e.g. immunocompromised individuals, patients with chronic diseases, etc.). Aerosol particles that generate when small water particles mix with oxygen may serve as excellent vehicles in the transmission of microorganisms, for they reach the deep lung immediately after inhalation. Conversely, all sterile disposable oxygen humidifier samples, which were collected in the second stage of the research, confirm that these devices are safe for patients and that it is necessary to substitute reusable oxygen humidifiers with disposable ones. This could be a preventive way to reduce the risk of transmission of potentially pathogenic microorganisms and to minimize the possible development of nosocomial pneumonia. 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 (including oxygen tubing) have been identified as the potential vehicles which cause major nosocomial infections if they are colonized (germs in significant quantity) by fungi or bacteria. II. Facility policy and procedure A request was made for the facility's policy and procedures for oxygen administration for care and sanitation of oxygen equipment, on 4/8/19. The facility was unable to provide a formal policy or procedure that included protocol for care and sanitation of respiratory equipment and supplies. The director of nursing (DON) provided a portion of the facility contact with a local oxygen provider, on 4/8/19 at 1:00 p.m. The contract read in pertinent part: the company shall be responsible to provide maintenance service for its products and equipment in use at the community. The DON said the facility did not have a policy to address responsibility and technique for changing oxygen tubing, or maintaining, cleaning, and changing the oxygen humidifying canisters. The facility provided two procedural guidance documents for handling used resident care equipment and dental hygiene on 4/8/19 at 1:00 p.m. The document titled Preventing Illness Caused by Infectious Organisms, last updated 5/10/18, it read in pertinent part: used resident care equipment is a major source for spreading infections organisms. Clean and disinfect all multi-use devices with a germicidal disinfectant solution according to manufacturer's direction. III. Resident #19 status Resident #19, age 88, was admitted on [DATE]. According to the (MONTH) 2019 CPO [DIAGNOSES REDACTED]. The 2/21/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) exam score of five out of 15. The resident had significant functional limitations in range of motion and needed extensive assistance with all activities of daily living from at least one staff. The resident was diagnosed with [REDACTED]. The resident was receiving hospice services. A. Observation On 4/8/19 at 9:45 a.m. the resident's oxygen concentrator and equipment was observed. The concentrator was connected to a reusable oxygen humidifier canister and the oxygen tubing to the humidifier; so when operational the oxygen gas circulated through the humidifier canister. The oxygen tubing had an open on date of 4/7/19 the humidifier canister was not dated. The reusable humidifier canister was dry with no sign of moisture inside and the inside of the humidifier container was crusted over with a dry white flaky film. B. Staff interview On 4/8/19 at 10:38 a.m., licensed practical nurse (LPN) #4 was interviewed. LPN #4 said she was not sure how often the humidifier was changed or what the requirements for cleaning and sanitizing the reusable canister, but she would find out. LPN #4 was interviewed a second time on 4/8/19 at 10:50 a.m. LPN #4 said she talked with the minimum data set coordinator and the humidifiers should be changed weekly. LPN #4 said the resident's hospice provider managed the resident's oxygen equipment, so the hospice provider was responsible to check, fill, and change the reusable humidifier as needed. The DON was interviewed on 4/8/19 at 11:44 p.m. The DON said the expectation was for the floor nurse to monitor and check resident oxygen equipment and for the oxygen tubing and humidifier to be changed weekly by the night nurse. She said she would have to check to see who was changing resident #19's humidifier, because the resident received hospice services. The assistant director of nursing (ADON) was interviewed on 4/8/19 at 11:57 p.m. The ADON said her expectation was for oxygen humidifier canister to be changed weekly. She said Resident #19s oxygen was managed by her hospice provider. The hospice company provided the oxygen equipment, so the provider maintained the equipment and would change the humidifier canisters. If the resident did not have hospice the facility nurse would be responsible for changing the humidifier canister and they would only be using the disposable type humidifier canisters. The ADON said because hospice was not with the resident 24 hours a day seven days a week the facility nurse would have been responsible for monitoring the oxygen humidifier and refilling the container as needed, between hospice visits. The DON was interviewed a second time on 4/8/19 at 1:09 p.m. The DON said the facility nurses were responsible to monitor Resident #19's oxygen humidifier and to change the humidifier container as needed. The timeframe for changing canisters can vary depending on oxygen liter flow and frequency of use. The medical director (MD) was interviewed on 4/8/19 at 1:16 p.m. The MD expressed concern and said it would depend on how long the resident had been breathing oxygen through the dried humidifier container. He would be concerned about a humidifier that was empty and had dried, it could cause drying of the nasal passages and possible nose bleeds. He would be more concerned about the contents of the dried sediment and what the sediment contained. He said the sediment was probably salt residue from the saline that was in the humidifier, but bottom line there should be saline in the canister to bubble thought the system and oxygen to prevent drying of the nasal passages. C. Record review The care plan not dated, revealed Resident #19 was on oxygen at two liters per minute by nasal cannula. Resident needed assistance from staff to maintain prescribed liters of administration and follow oxygen safety, and needed assistance by staff to place the nasal cannula back on if it fell off during the night. IV. Resident #7's status Resident #7, age of 80, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/19/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) exam score of five out of 15. The resident had significant functional limitations in range of motion and needed extensive assistance with all activities of daily living from at least one staff. A. Resident observations and interview On 4/3/19 at 8:55 a.m., the resident was sleeping in bed with her oxygen by nasal cannula at two liter per minute, the tubing was dated 3/31/19; there was no storage bag for the tubing. On 4/3/19 at 12:30 p.m., the resident was not in her room, the oxygen concentrator was off and her oxygen tubing was draped over the concentrator not stored in any type of protective packaging/bag. The oxygen tubing was dated 3/31/19. On 4/4/19 at 8:48 a.m., Resident #7 was observed sleeping in bed her oxygen concentrator was on set at two liters per minute, the oxygen was not applied to her nose. Instead, the nasal cannula oxygen tubing was running across the floor under the fall mat and the nasal cannula was directly on the floor next to her bed. On 4/4/19 at 12:42 p.m., the resident was not in her room the bed was made, trash was removed, and the oxygen tubing in a neat pile stored directly on the floor next to the bed, the nasal cannula was touching the floor the tubing had was dated 3/31/19. On 4/4/19 at 4:30 p.m., in the presence of the assistant director of nursing (ADON), we observed the oxygen tubing in a neat pile stored directly on the floor next to the bed, the nasal cannula was touching the floor the tubing had was dated 3/31/19. Resident #7 was unable to participate in an interview due to significant cognitive deficits. B. Staff interview On 4/4/19 at 10:21 a.m., certified nursing aide CNA) was interviewed. The CNA said that oxygen tubing was changed every four to six days by the facility nurse. She was not sure of further details. On 4/4/19 at 11:28 a.m., LPN #3 was interviewed. LPN #3 said the oxygen tubing was changed every Sunday by the night nurse and the tubing was dated the day of change. She said the tubing should be stored at the machine in a bag in the resident's room when not in use. On 4/4/19 at 4:30 a.m., the ADON was interviewed. The ADON said the oxygen tubing was not to be stored on the floor. She said the tubing should be stored in a plastic bag that was attached to the oxygen concentrator and the tubing is to be labeled with the date the tubing was opened. All oxygen tubing was scheduled to be changed every Sunday by the night nurse. The ADON said the resident's oxygen tubing should have been thrown out when it was found on the floor and replaced. The ADON tossed out the tubing following the interview. C. Record review The resident's comprehensive care plan was provided by the director of nursing (DON) on 4/4/19 at 3:00 pm. The plan revealed Resident #7 was on oxygen at two liters per minute by nasal cannula. Resident needed assistance from staff to maintain prescribed liters of administration and follow oxygen safety, and resident needed extensive assistance to complete oral care. The hospice care plan revealed resident started with hospice services on 11/16/18. The hospice provider developed a separate care plan. The plan included weekly registered nursing visits; certified nursing aide services for hygiene and personal care assistance three times a week.The plan included morning hygiene, grooming assistance and dressing.

Based on observations, record view and interview, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facilities most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically the facility failed to provide three years worth of survey and investigation findings in a prominent location for public viewing. Findings include: I. Observations On 4/4/19 at 3:46 p.m. the facility's survey results binder, located in the front lobby was examined and found to contain only the most recent survey results (10/19/17), there was no other notice of availability of federal survey information in any prominent location. The survey results binder failed to include the following surveys: 8/8/16. II. Interviews On 4/4/19 at 1:30 pm the four participants of the resident group interview (Resident's #4, #10, #26, and #32) said they were not aware of the results of past surveys, and did not know the facility was responsible to provide copies of the last three year of complaint investigations, survey findings and actions taken to correct any cited deficiencies. The residents had numerous questions about the of past findings and wanted to better understand the facilities responsibility to correct deficiencies. On 4/4/19 at 5:11 p.m. the administrator in training (AIT) was interviewed. The AIT said she had a responsibility to keep the survey findings binder updated. She said she was not familiar with federal requirements regarding the contents of the survey results binder. When informed the regulation she said she will fix the past survey to bring the binder up to date.

Based on record review and staff interviews, the facility failed to ensure two (#87 and #14) of five residents reviewed of 23 sample residents remained free from accidents and hazards. Specifically, the facility failed to develop and implement individualized interventions to address resident #87's risk factors for falls although the resident's risk factors were documented in assessments, progress notes and incident report. Resident #87 fell sustaining a head laceration and intracranial bleeding. The facility also failed to determine the root cause of resident #14's repeat falls and develop and implement individualized safety interventions that minimize her fall risk. The findings included: A. Facility policy and procedure The fall management policy, developed June 2013, was provided by the nursing home administrator (NHA) on 10/18/17 at 4:35 p.m. It revealed, in pertinent part: Each guest/resident will be assessed for potential risk for falls on admission, re-admission, significant change of condition, post falls, monthly for post-acute guest, and quarterly for continuing services. Care/services plan will be developed using individualized approaches identified during assessment process. If a fall occurs the following steps will be taken: .review care/services plan for appropriateness of approaches and/or modify/add approaches if necessary . Director of nursing (DON) and/or designee will review 24 hour report and audit falls documentation to ensure it is complete and accurate, to include completion of investigative protocols, review of care plan and updating of holistic assessment. B. Resident #87 1. Resident status Resident #87, age 89, was admitted on [DATE] and re-admitted on [DATE]. According to the June 2017 computerized physician orders [REDACTED]. According to the 5/25/17 minimum data set (MDS) assessment, the resident had short-term and long-term memory impairment. He was moderately impaired in decision making regarding tasks of daily life. He required limited assistance of one person with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit and toileting. He required extensive assistance of one person with dressing. -The assessment indicated the resident was not steady with moving from a seated to a standing position, walking with an assistive device, moving on and off the toilet, and surface to surface transfers. He used a walker and a wheelchair for mobility. -It further revealed the resident had a fall in the last month prior to admission with a sustained fracture. It indicated the resident had a fall since admission with no sustained injury. 2. Record review revealed the facility had knowledge of the resident's behaviors (impulsivity, transfers without assist) and of functional limitations (unsteady gait, unsafe transfers, poor balance) which placed him at risk for falls and which increased his need for care and supervision to prevent falls. The resident fell [DATE] and sustained significant injuries. a. Events 5/16/17 to 5/30/17 - risk factors documented in assessments and nursing progress notes. The 5/16/17 holistic assessment revealed the resident was admitted to the facility due to pneumonia and a C1 vertebral fracture. It indicated the resident had sustained a fall on 5/9/17, had poor balance and was working with physical therapy to increase strength and endurance. It also indicated the resident was deconditioned due to his recent hospitalization s. The resident was considered a fall risk due to a history of falls, syncope, unsteady gait, unsafe transfers and impaired hearing and cognition. The 5/18/17 nursing progress note revealed the resident had episodes of agitation and was difficult to re-direct. The 5/19/17 nursing progress note revealed the resident was impulsive and required a sitter during the nocturnal shift. The sitter was provided by the resident's family. The 5/20/17 nursing progress note revealed the resident was impulsive. It indicated the resident would ambulate and transfer himself without staff assistance. The 5/22/17 nursing progress note revealed the resident was non-compliant in using the call light and call pendant. It indicated the resident exhibited impulsive behavior. The nurse documented the resident's non-compliance and impulsivity caused the resident to be at an increased risk for falls. The 5/22/17 social services progress note revealed the one to one sitter was no longer scheduled. The note read the resident's family, who was financially responsible for the sitter, determined they no longer were able to continue providing the sitter. The social worker documented she had informed the family member the facility did not provide one to one supervision and support for the resident and could not guarantee the resident would not fall again. The 5/23/17 nursing progress note revealed the resident continued to have impulsive behavior. b. Events 5/30/17 and 5/31/17 - additional risk factors documented in incident report and progress notes. A 5/30/17 resident fall incident report form revealed the resident sustained [REDACTED]. It indicated the resident was using a front wheel walker with the occupational therapist (OT) when he lost color in his face and started to fall. The OT assisted the resident to the floor. The report read the resident did not sustain an injury. -The report revealed a certified nurse aide (CNA) had reported to the registered nurse (RN) she had witnessed the resident's face go white and the resident swaying earlier that day. The CNA reported she had to steady the resident on his feet. -The conclusion of the investigation revealed the nurse notified the physician to re-evaluate the resident's medications or arrange for a consult due to these orthostatic episodes. -The report indicated the steps taken to prevent recurrence was staff would need to provide contact guard assistance (hands on assistance) when the resident was ambulating with his walker. The 5/31/17 physician follow-up progress note revealed the physician identified the resident had essential hypertension. It indicated the resident was stable and should continue with his current prescription. The physician did not specifically relate the resident's hypertension to the events on 5/30/17 or suggest any change in the resident's care and services. A 5/31/17 nursing progress note revealed the resident had two episodes of feeling lightheaded during the day. The note read the resident was assisted to the floor during one incident without injury. During the second incident, the resident was rescued and assisted into a wheelchair by two staff members. There was no documentation the resident's vital signs were taken or the physician notified of these episodes. c. Event 6/1/17 - fall with significant injuries documented in nursing progress note and hospital report. The 6/1/17 nursing progress note revealed the resident had an unwitnessed fall in his room and sustained a head laceration. The resident reported he hit his head but he was unable to recall how he hit his head. It was believed he hit his head on the table he was found lying beside. The progress note read the resident's wound was approximately six to eight centimeters in length and 0.5 centimeters wide. The physician's assistant assessed the resident and ordered the resident sent to the hospital for further evaluation. The 6/6/17 hospital discharge summary indicated the resident sustained [REDACTED]. 3. Failure to implement individualized fall interventions including adequate supervision to address resident #87's known fall risk factors. The fall care plan (undated, although the other care plans included the admitted ) revealed the resident needed encouragement to use adaptive equipment. The approaches included the resident would participate in therapy services every day to increase strength and coordination and the staff would remind the resident to wear his hearing aids daily. -It indicated the resident was on a low bed with a fall mat. -It did not document the resident's falls on 5/30/17 or 5/31/17 or provide updated fall interventions. Specifically, the facility failed to implement any fall interventions related to the resident's impulsive behavior and orthostatic episodes in the facility. The care plan failed to address the level of supervision the resident required, in particular, after one to one caretaker support ended. 4. Staff interviews Staff interviews revealed, consistent with facility policy above, that a resident's fall risk was evaluated on admission using a holistic assessment and that care plan review and updates were expected following a resident's fall. Staff confirmed updates and revised interventions for resident #87's care had not been completed since admission. The nursing home administrator (NHA), the director of nursing (DON), clinical manager (CM), assistant director of nursing (ADON) and medical director were interviewed on 10/18/17 at 2:00 p.m. The DON said the facility determined if a resident was a fall risk based on the discharge paperwork from the hospital and assessments completed by the interdisciplinary team (IDT) upon admission to the facility. The CM said an interim care plan was developed after the holistic assessment had been completed. She said the care plan was based on the results of the holistic assessment. She said she or the nurse assigned to the resident was responsible for ensuring the care plan was created and placed into the care plan binder at the nurses' station. -She said each care plan should be individualized for each resident. -She said the care plan should be updated with any change of condition with new approaches and interventions. She said the care plan should be updated after each sustained fall with new approaches and interventions. The DON said when a resident sustained [REDACTED]. The ADON said following a fall, the IDT, including the floor staff, was involved in developing and implementing new fall interventions. Thereafter, the DON and NHA reviewed each fall along with the added approaches and interventions. The DON said the facility did not provide updated approaches and interventions on the fall care plan for resident #87. She said the care plan had remained unchanged since the resident's admission to the facility. The NHA said there were no other interventions documented on the care plan other than the low bed, strengthening with physical therapy and reminding the resident to wear hearing aids. He said those were interventions put into place upon admission. -He said the care plan had not been updated after each fall with new approaches or interventions. -He said the facility had not implemented any other interventions following each fall or addressed the resident's impulsive behavior. The NHA was interviewed again on 10/19/17 at 5:30 p.m. He said the quality assurance (QA) committee had been reviewing all falls in the facility as the facility had been cited in the same quality of care area during the previous year's survey. -He said the facility had not identified barriers contributing to the facility's high number of falls. -He said the facility had not identified the lack of interventions and lack of monitoring as a concern through the QA process. -He confirmed the facility's lack of interventions and approaches could be a facility barrier to reducing the number of falls residents sustained while at the facility. He said he had made a push with the corporation for increased staffing to assist in addressing the facility's fall rate. C. Resident #14 1. Resident status Resident #14, age 79, was admitted [DATE]. According to the October 2017 CPO, [DIAGNOSES REDACTED]. According to the last completed holistic assessment dated [DATE], the resident was a high fall risk related to history of falling, unsteady gait, unsafe transfers or poor cognition/memory. She had fallen in the last 30 days with her last fall being 7/4/17, related to poor balance. Her new approaches were to check on the resident frequently especially around her routine bedtime and make sure her walker was nearby when she got out of her bed or chair. The resident was occasionally incontinent of urine and a three day bladder diary was initiated. (This bladder diary was not found in the resident's record). According to the 8/1/17 MDS assessment, the resident had moderately impaired cognitive function with a BIMS score of 11 out of 15. She required extensive assistance of one person for most of her ADL's, including transferring and toileting. She had two or more falls since the last assessment. The care plan, undated except for an admitted , indicated the resident required extensive assistance of one person for transferring and toileting and was at risk for falls related to a history of falls, unsteady gait requiring the use of a front wheeled walker (FWW) or wheelchair, unsafe transfers and pain. Approaches included: -Calling for help with transfers, staff to help with transferring and toileting and will provide the needed equipment to perform the task safely; -Using wheelchair and FWW for transfers and mobility; -Not walking alone; -Physical therapy/occupational therapy (PT/OT) on strengthening; -Keep room free of clutter and have proper lighting; -Check on the resident frequently to make sure her needs are met; -Keep her things within reach; -Always wear proper footwear; -Remind her to go slow and call for help when needed; and -Monitor medications for risk of falls. 2. Observation On 10/16/17 at 4:24 p.m. the resident was observed sitting in her wheelchair in her room. She had a large black hematoma on the right side of her forehead with black/yellow bruising under both of her eyes. The hematoma was approximately two centimeters in diameter and raised approximately one centimeter. The resident said she got it when she fell and that she still gets occasional headaches requiring medication. 3. Falls 7/4/17, 8/3/17 and 9/24/17 Record review revealed the resident fell ,[DATE], 8/3 and 9/24/17. Record review revealed the facility failed to take steps to comprehensively investigate the cause of the resident's falls in relation to her known fall risk factors, including unsteady gait, unsafe transfers or poor cognition/memory as well as her incontinence, and failed to develop, communicate and implement effective, resident specific interventions to keep her from repeatedly falling. a. Fall 7/4/17 According to a 7/5/17 clinical note written at 5:07 a.m., the resident was found by the CNAs in the bathroom in her wheelchair attempting to stand and toilet herself. Her wheelchair wheels were unlocked and as she stood up, she slipped and fell . According to the resident incident report, the fall occurred on 7/4/17 at 9:00 p.m. The report concluded the resident was trying to toilet herself, did not lock the wheels on her wheelchair and slipped as she was trying to stand. -An addendum was added on 7/6/17 at 3:18 p.m. indicating a huddle with the nurses and care staff was held to determine what needed to be done to avoid the resident falling again. It was agreed the resident needed to be assisted to the toilet after meals and around bedtime to reduce her needing to try to toilet independently. The staff was educated that after the resident was toileted, she needed to be encouraged either to go out to the common area to engage in socialization or activities or to assist the resident to a comfortable position in her recliner or bed. The resident only propelled herself to her room if she needed to toilet, so if the task was completed with assist, she would likely be content in social areas. -These interventions were included in the resident's care plan. According to the ADL verification worksheet, the resident was taken to the toilet once on 7/4/17 at 1:08 a.m.There was no documentation of the resident being toileted on 7/5/17. Moreover, there was no documentation in the resident's record that a voiding pattern assessment was completed to determine if the resident would benefit from a toileting program. b. Fall 8/3/17 According to an 8/3/17 clinical note written at 3:40 a.m., the resident was placed on the toilet at 10:30 p.m. on 8/2/17. She was left unattended on the toilet and attempted to transfer off the toilet to her wheelchair without assistance. The resident was assisted to the floor and during the process she hit her head on the wall. According to the 8/2/17 resident incident report form, the report concluded the resident was placed on the toilet and instructed to call and wait for assistance upon completion of her bowel movement. However, the resident attempted to self-transfer without assistance, resulting in her fall. Steps taken to prevent recurrence were for staff to perform frequent, unrequested toilet checks to diminish impulsive actions following the completion of toileting. A fall reassessment was completed on 8/3/17. New approaches to prevent falls included: frequent toilet checks were to be performed to aid in staff transferring the resident before the resident was compelled to self-transfer. And, with each toileting episode and with each toilet check, the resident was to be reoriented to use the pull cord next to the toilet to ask for assistance. However, the above new approaches were not included on the resident's permanent care plan kept at the nurse's station. In addition, there was no documentation in the resident's record that a voiding pattern assessment was considered to determine if the resident would benefit from a toileting program. c. Fall 9/24/17 According to a 9/24/17 clinical note written at 3:50 p.m., the resident was found on the floor in her room by the CNA at around 8:00 a.m. The nurse arrived to find the resident laying on the floor on her left side with her head to the foot of the bed, parallel to the bed. The resident had a very large hematoma to her forehead and an abrasion to her nose and left knee. The resident was alert; however, she appeared confused and was answering questions very slowly. The resident stated she was trying to go to the bathroom. The resident was transferred to the emergency room at 8:30 a.m. to be evaluated for a head injury. The resident returned to the facility at 2:00 p.m. The resident was reminded to use her call light system and the CNAs were instructed to check on the resident frequently. According to the 9/24/17 resident incident report form, the resident had a change in level of orientation from baseline for resident, although there was no evidence, however, neurological checks were initiated by the nursing staff after the fall with a head injury. -The report concluded the resident had tried to ambulate on her own. The nurse had observed the resident on occasion try to attempt to get out of bed for the day or use the toilet around 8:00 a.m. that morning. The resident was unaware of physical decline and inability to transfer self and walk. -Steps taken to prevent a recurrence were to have the morning CNAs go to the resident's room first in the morning to either offer toileting or to get her up and ready for the day. According to the ADL verification worksheet, the resident had not been offered or assisted with toileting in the morning on 9/24/17 prior to her fall. According to the notes from the hospital emergency room dated 9/24/17 at 8:58 a.m., the resident was currently on anticoagulation and presented to the emergency department as a coagulation alert for a mechanical fall when she fell out of bed that morning. She had a large hematoma above the right eye with a small abrasion to the bridge of her nose. Imaging results revealed no acute fracture. According to the physician progress notes [REDACTED]. The note read that there may be a need to evaluate the room and look to see if the fall could be prevented. It further read, the resident could have an occupational therapy (OT) evaluation. However, review of the resident's medical record revealed [REDACTED]. Moreover, record review revealed no evidence in the resident's record that an order for [REDACTED]. 4. Staff Interviews CNA #2 was interviewed on 10/19/17 at 2:08 p.m. She said the resident had several interventions in place to help prevent her from falling, including rounding on her every two hours to check on her, a hospital bed kept in the low position, and a fall mat on the left side of the bed. She said the resident was incontinent of bowel and bladder on occasion and she required extensive assistance of one person to transfer and toilet. She agreed it was not always safe to leave the resident alone in the bathroom unattended because she would try and transfer herself. LPN #3 was interviewed on 10/19/17 at 2:37 p.m. She said some of the fall interventions in place for the resident were a low bed, a call light pendant, frequent checks and to try to engage her in activities. She said she considered frequent checks to be every two hours. She said the resident was not on a scheduled toileting program. She said staff toilet the resident when she gets up and they offer to take her to the toilet after meals. She said the resident could tell the staff when she needed to go to the bathroom. The clinical manager was interviewed on 10/19/17 at 3:34 p.m. She said they had not done any three day bladder studies on the resident. She said they found a flaw in their computer system and when they thought they were doing bladder diaries, they weren't actually being done. She said they had an in-service on this on 8/1/17. She said the resident should have had a bladder study done and possibly been put on a bowel and bladder program. 5. Facility Follow up The facility completed a fall reassessment on 10/18/17 at 6:02 p.m. (during survey) and updated the resident's care plan with interventions documented in the incident reports above.