Every finding on record at Gardens, The

Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure dietary staff washed their hands and changed gloves appropriately; and,-Maintain the kitchen in a sanitary condition. Findings include:I. Hand hygiene failuresA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 12/15/25, read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves to initiate a task that involves working with food; after engaging in other activities that contaminate the hands. (2-301.14)B. ObservationsDuring a continuous observation of the lunch meal on 12/10/25, beginning at 11:25 a.m. and ending at 12:16 p.m., the following was observed in the kitchen:At 11:30 a.m. cook (CK) #1 began assembling meal plates for residents. At 11:45 a.m. while wearing gloves, CK #1 removed a slice of turkey from hot holding and placed the turkey on a cutting board. CK #1 cut the turkey with a knife held in her right hand and held the turkey with her left hand. CK #1 set the knife on the cutting board and used both gloved hands to pick up the turkey and placed the turkey on a plate to be served to a resident.At 11:47 a.m. CK #1 removed her gloves and donned (put on) a new pair of gloves without performing hand hygiene.At 11:49 a.m. CK #1 picked up a spoon that was hanging on the utensil rack by the stove with her gloved hand. CK #1 did not pick up the spoon by the handle but instead picked it up by the head of the spoon (part that holds the food). CK #1 walked to the stove and placed the head of the spoon into a pot on the stove and started to stir.At 11:55 a.m. while wearing the same pair of gloves, CK #1 placed a slice of turkey on the cutting board. CK #1 picked up the knife with her right hand, and holding the turkey with her left hand cut the turkey. CK #1 set down the knife, and used both gloved hands to pick up the diced turkey and placed it on a plate to be served to a resident. CK #1 then turned to pick up a pan of potatoes. CK #1 used her gloved hands to use a scoop to place potatoes from one pan into another. CK #1 took the empty pan to the dish area and removed her gloves. CK #1 then donned new gloves and did not perform hand hygiene. CK #1 placed her used gloves on the back preparation table instead of the trash can.At 12:00 p.m. CK #1 while wearing the same pair of gloves placed a slice of turkey on the cutting board. CK #1 picked up the knife with her right hand, and holding the turkey with her left hand cut the turkey. CK #1 set down the knife, and used both gloved hands to pick up the diced turkey and place it on a plate to be served to a resident.At 12:02 p.m. CK #1 picked up a cutting board on the back table while wearing gloves and brought it to the front prep table. Two sandwiches were on the cutting board. CK #1 picked up the sandwiches, cut the sandwiches in half while wearing the same gloves and placed them on a plate. CK #1 then placed an individual bag of potato chips onto the plate.At 12:04 p.m. CK #1 picked up a scoop and began placing mashed potatoes onto a plate with a sandwich. CK #1 placed the plate on a tray to be served to a resident. CK #1 then picked up the cutting board previously that had the sandwiches and took the cutting board to the dish area. CK #1 removed her gloves and did not wash her hands. C. Staff interviewsThe dietary manager (DM) and the nursing home administrator (NHA) were interviewed together on 12/11/25 at 3:15 p.m. The DM said she did not notice that CK #1 was touching ready to eat foods with contaminated gloves during meal service because the DM was also serving food. The DM said the dietary staff received in-services on hand hygiene. The DM said the facility provided hand hygiene training through the skilled nursing facility clinics, which is the online staff training platform, and during monthly staff meetings. The DM said she had recently spoken with the dietary team about hand hygiene. The DM said she did know that handwashing was required prior to donning a clean pair of gloves while working in the kitchen. The DM said touching ready to eat foods with contaminated gloves can contaminate the food because it was served and not cooked further.II. Ensure kitchen was maintained in a sanitary condition A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 12/15/25, read in pertinent part, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 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, and cleaning shall be done during periods when the least amount of food is exposed such as after closing. (4-601.11) The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (D) Eliminating harborage conditions. (6-501.111)B. ObservationsThe initial tour of the kitchen was completed on 12/8/25 at 9:40 a.m. and revealed the following:There were four bags of potato chips and other unidentifiable food debris on the floor of dry storage behind the deep freezer.There were multiple pieces of food debris underneath a dry storage shelf, including crackers, pieces of dried pasta, and other crumbs on the floor that extended the length of the shelf. A covered pest control bait station was under the shelf next to the wall.There were two slices of bread and crumbs on the floor behind a stainless steel table. A second observation of the kitchen was conducted on 12/10/25 at 10:28 a.m. Observations identified the same concerns as identified on 12/8/25 during the initial tour. C. Staff interviewsThe DM was interviewed on 12/11/25 at 3:15 p.m.The DM said she used a cleaning schedule to ensure kitchen cleaning tasks were completed. The DM said she reviewed the cleaning tasks to verify daily cleaning tasks were completed and said staff ensured the tasks were completed weekly.The DM said staff swept and mopped the kitchen daily. The DM said it was difficult to clean tight spaces and to clean under the shelf. The DM said staff tried to clean under the shelf as much as possible but it was hard to reach. The DM said that while sweeping under the shelf, staff often hit the broom on items in dry storage, which made it difficult to clean the entire area under the shelf. The DM said the freezer was difficult to move, which made it hard for staff to clean behind the freezer.

Based on observations, interviews, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the development and worsening of pressure injuries for one (#14) resident reviewed for pressure injuries out of 25 sample residents. Specifically, the facility failed to ensure interventions for Resident #14's pressure injury were consistently implemented. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/1/23. Pressure ulcer classification is as follows: Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover; and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Risk Factors and Risk Assessment -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries; -Consider individuals with a Category/Stage 1 pressure injury to be at risk of developing a Category/Stage 2 or greater pressure injury; -Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries; and, -When conducting a pressure injury risks assessment: Use a structured approach; Include a comprehensive skin assessment; Supplement use of a risk assessment tool with assessment of additional risk factors; Interpret the assessment outcomes using clinical judgment. Skin and Tissue assessment -Assess the pressure injury initially and as soon as possible after admission/transfer to the healthcare service; -Re-assess at least weekly to monitor progress toward healing; -Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment; and, -Monitor the pressure injury healing progress. Support Surfaces For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policy and procedures The Skin Management policy, dated June 2022, was provided by the director of nursing (DON) on 12/4/24 at 1:05 p.m. The policy read in pertinent part: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new pressure injuries from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. III. Resident #14 A. Resident status Resident #14, under the age of 65, was admitted on [DATE]. According to the computerized physician orders (CPO), the diagnoses included sepsis (infection) of right knee with unspecified organism, effusion (fluid accumulation) right knee, unilateral osteoarthritis right knee, unspecified severe protein calorie malnutrition and pressure induced deep tissue damage of left heel, right heel and right buttock. The 11/7/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of thirteen out of 15. The resident required partial/moderate assistance with activities of daily living (ADL) from staff members for bed mobility, positioning, and transfers (toileting not assessed due to medical condition). The resident was at risk for the development of pressure injuries and had two unstageable pressure injuries. B. Resident interview Resident #14 was interviewed on 11/29/23 at 4:38 p.m. The resident said he developed the wounds to his heels and buttock due to lying in bed too long. The resident said he was hospitalized prior to admission to the facility due to an infection in his right knee. The resident said the right knee was extremely painful and he could not roll left to right and could not extend or straighten his leg due to the pain. The resident said he could not walk, had trouble putting pressure on the right leg and tried to extend the knee but could not. The resident said the hospital doctors drained a lot of red/yellowish fluid from the knee and he had to take antibiotics for six weeks. The resident said staff come in to check on him but don't know how often, staff tried to reposition him but it was too painful. The heel protectors did not stay in place because he used his feet to raise himself in bed to eat and drink. C. Resident observations On 11/29/23 at 2:03 p.m. the resident was covered with a sheet with his lower extremities exposed. The resident has bilateral heel protectors on but both heel protectors were covering his calves, not his heels. On 11/30/23 at 8:04 a.m. the resident had the left heel protector on his left foot, the right heel protector was not positioned correctly on his foot and instead was covering his right calf. There was no pressure reducing or air mattress on the resident's bed. -At 9:40 a.m. registered nurse (RN) #1 entered the resident's room to perform wound care. RN #1 removed the resident s non-skid sock from the right foot and the right heel protector was on the resident's right calf. -At 11:00 a.m. both heel protectors were on the bed and not on his heels. -At 12:51 p.m. there was an air mattress inflating outside the resident's room to replace the resident's mattress. D. Record review The comprehensive care plan last revised on 11/3/23, revealed the resident had potential for skin breakdown and documented the resident admitted with right knee surgical site, open area to right buttocks and deep tissue injury to left heel, deep tissue injury to right heel (11/5/23). The primary goal was the skin will remain intact. Wounds will show signs/symptoms of healing through the next review. Target date 11/26/23. Interventions included applying skin moisturizer/barrier as needed. Check frequently for incontinent episodes and assist with wash, rinse and dry soiled areas and change clothes prn (as needed). CNA (certified nurse aide) to monitor skin daily and licensed nurse to check skin thoroughly on a weekly basis. Encourage adequate fluid and nutritional intake. Encourage/assist with turning and positioning frequently. Heel boot while in bed. Pressure reducing mattress on bed. Report any changes or abnormalities in skin to the charge nurse/MD (medical doctor) immediately. Treatment as ordered. Wound doctor to follow. The 11/1/23 Braden scale assessment (scale for predicting pressure injury risk) documented the resident was at mild risk (lower probability of developing a pressure injury, but needs to be managed with routine procedures as a preventative measure) for developing a pressure injury. The assessment revealed the resident had no sensory perception impairment, was rarely moist, his mobility was slightly limited and his nutrition was adequate. The resident required moderate to maximum assistance with repositioning, therefore, required a lift to avoid sliding against the bed sheets. Scoring: 17.0 or at lower risk for the development of pressure ulcers. Nursing note dated 11/4/23 During wound care intact deep tissue injury noted to the right heel. Skin prep applied, heel floated, and heel boot applied. Resident did not report pain during examination to right heel. Director of Nursing aware. Writer placed a call to the resident's power of attorney, unable to leave a message, voice messaging not set-up. The Head to Toe Skin Check dated 11/5/23 documented that the resident did not refuse a skin check. The resident had existing bruises, existing pressure ulcers to his upper buttocks, a left heel deep tissue injury, a right knee status post surgical incision that was well approximated a left knee abrasion, scabbed areas all over body in various stages of healing due to recent recovery from scabies and lice. Interdisciplinary team (IDT) note dated 11/7/23 documented the IDT met and reviewed new skin issues related to the right heel. Place heel boot to float right heel. On 11/7/23 at 3:32 p.m. a skin/wound note documented the resident refused to be seen by the wound care doctor. The wound care evaluation note dated 11/21/23 written by the wound care physician assistant documented the resident was seen as a new patient for an evaluation of pressure injuries and moisture associated skin damage of the sacrum. Patient had scabies several weeks ago and the hospital cleared him. Patient now states he's been having itching on the left buttock and hip recently. Recommended PCP (primary care physician) evaluation to assess possible Scabie recurrence. The patient is at high risk for new or worsening wounds, recommended continuing off loading measures and floating heels. Wound Assessment #1 documented : The right heel was a deep tissue injury, persistent non-blanchable deep red, maroon, or purple discoloration pressure ulcer and had received a status of non-healed. Initial wound encounter measurements are 5.0 centimeters in length, 2.5 centimeters in width with no measurable depth and an area of 25 square centimeters. There was no drainage noted. The periwound skin did not exhibit erythema, periwound skin did not exhibit signs or symptoms of infection. Wound Orders: Wound cleansing and dressing: Apply betadine and leave open. Float heels and reposition frequently. Wound Assessment #2: The left heel was a deep tissue injury, persistent non-blanchable deep red, maroon, or purple discoloration pressure ulcer and has received a status of non-healed. Initial wound encounter measurements are 2.5 centimeters in length x 2.0 centimeters in width, no measurable depth with an area of 5 square centimeters. There was no drainage noted. The periwound skin did not exhibit erythema, periwound skin did not exhibit signs or symptoms of infection. Wound Orders: Wound cleansing and dressing: Apply betadine and leave open. Float heels and reposition frequently. Wound Assessment #3: The right buttock wound is partial thickness moisture associated with skin damage and has received a status of non-healed. Initial wound encounter measurements are with no measurable depth. There is no drainage noted. The periwound skin exhibited maceration (the softening and breaking down skin resulting from prolonged exposure to moisture). The periwound skin did not exhibit erythema, periwound skin does not exhibit signs or symptoms of infection. Diffuse partial thickness breakdown and blanching erythema roughly 5% dermis. Wound Orders: Apply barrier cream every shift. Skin Injury Evaluation per Wound Care 11/28/23 at 12:38 p.m. Right heel unstageable wound, not classified as unavoidable, measures 4 (length) x 4 (width) centimeters, no tunneling, no exudate, no odor, 100% eschar, defined wound edges, surrounding skin normal, no pain, treatment betadine. Interventions: pressure reducing mattress, heel protectors. -However, observations (see above) the resident's heel protectors were not consistently positioned correctly or on the resident and the air mattress was not placed on the resident's bed until 11/30/23. The 11/20/23 CPO revealed to apply heel boots to both heels related to deep tissue injuries, ensure boots are on at all times, except during cares. IV. Staff Interviews Licensed practical nurse (LPN) #1 was interviewed on 11/28/23 at 4:06 p.m. LPN #1 said she was found the wound on the right heel as she was completing a head-to-toe skin assessment on 11/4/23. LPN #1 said the resident had two other wounds, one on his sacrum and the other on the left heel. LPN #1 said both the sacrum and left heel wounds occurred at the hospital and were pre-existing. The right heel wound developed at the facility because the resident could not straighten his right leg and pushed himself up in bed using his feet. LPN #1 said she immediately put heel protectors on the resident's feet. LPN#1 said she notified the director of nursing (DON) and reported the presence of the resident's wounds. Certified nurse aide (CNA) #1 was interviewed on 11/30/23 at 12:49 p.m. CNA #1 said the resident kept his right knee flexed and could not straighten it without extreme pain. The DON was interviewed on 11/28/23 at 3:35 p.m. The DON said the resident had two wounds. One on the right heel and one on the left heel. The DON said she was unaware of the right buttock wound. The DON said the right heel wound was found on 11/7/23 and heel protectors were recommended at that time. The DON said the left heel wound was pre-existing and occurred prior to his admission to the facility.

Based on interviews and record review, the facility failed to ensure two (#14 and #10) out of 19 sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent a resident-to-resident altercation between Resident #15 and #10; -Failed to prevent a resident-to-resident altercation between Resident #15 and #14; -Failed to care plan and address the altercations involving Resident #15; and, -Failed to educate and train staff on triggers and the potential for Resident #15's aggression. Findings include: I. Facility policy and procedure The Preventing Resident Abuse policy, dated 11/1/17, was provided by the nursing home administrator (NHA) on 8/15/22 at 8:30 a.m., included in part, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, training programs, systems, etc., to assist in preventing resident abuse. The facility's goal is to achieve and maintain an abuse-free environment. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. II. Altercation on 6/16/22 A. Investigation Resident #10 was observed giving Resident #15 a hard time in the dining room. Resident #10 stated, 'you're late, there is no food left for you.' Unsure if he was joking, Resident #15 became upset yelling at him 'to shut the (expletive) up.' Resident #10 stated, 'I want a new roommate, I don't want to live in the same room as this (expletive).' Resident #10 stated his roommate, Resident #15, came to dinner and asked Resident #10 what was for dinner. Resident #10 stated pulled pork. Resident #15 became upset asking again what was for dinner. Resident #10 stated pulled pork. Per Resident #10's report, Resident #15 became upset, yelling, and kicked Resident #10's left posterior leg with his right foot. Resident #10 stated he was not in pain. Resident #10 stated he was not afraid. Resident #10 was his own person (decision maker). Resident #10 was separated from Resident #15. All notifications (were) made. The resident was taken to (different room) for the evening per NHA. Resident #10's skin was intact, no discoloration noted at this time. Oncoming nurse aware, residents separated at this time. The conclusion of the internal investigation, Security video footage provided evidence that Resident #15 did kick Resident #10's left lower leg with his right foot while seated in the dining room. This was an isolated incident between these two roommates in the dining room. There is no pattern to physical abuse in this community. III. Altercation on 6/26/22 A. Investigation Dietary cook (DC) #1, heard Resident #15 in the dining room say, 'don't hit me' to Resident #14, who was seated next to Resident #15. DC #1 stated she then witnessed Resident #15 hit Resident #14's left forearm with his right hand. DC #1 immediately alerted the nurse and with the nurses assistance separated the two residents. The nurse then notified this administrator and nurse management. The nurse performed a nurse assessment on each resident and found no injury and both residents reported not being fearful from the incident. The conclusion of the internal investigation, The video evidence from the security cameras in the dining room supported the witness (DC #1) statement, the victim's statement, and the nurses assessment notes. The incident was isolated in our community and not indicative of widespread physical abuse occurring with our residents. -The facility indicated the altercation was isolated, however Resident #15 was the aggressor in the altercation that occurred on 6/16/22 (see above). IV. Resident #10 A. Resident status Resident #10, over the age of 90, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/23/22 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had no behaviors or rejections of care. V. Resident #14 A. Resident status Resident #14, age 89, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/2/22 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of six out of 15. She had no behaviors or rejections of care. VI. Resident #15 A. Resident status Resident #15, age 71, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/8/22 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had no behaviors or rejections of care. B. Record review -The resident did not have a care plan to address behaviors to include aggression toward other residents. -The facility failed to provide education and training to staff on Resident #15's altercations and potential triggers for aggression. VII. Interviews Certified nurse aide (CNA) #1 was interviewed on 8/16/22 at 2:23 p.m. She said Resident #15 had only had one incident with another resident that she was aware of. She said Resident #15 had not been aggressive toward another resident recently.She said Resident #15 was not aggressive. She said she had not received training on Resident #15's potential triggers and interventions for him. CNA #2 was interviewed on 8/16/22 at 2:31 p.m. She said she had not been in the facility long. She said she had not received training for Resident #15. She said she was not aware of any altercations involving Resident #15. Licensed practical nurse (LPN) #1 was interviewed on 8/16/22 at 2:33 p.m. She said she knew Resident #15 had been in an altercation with one resident. She said a resident (Resident #14) had tapped him on the arm, and Resident #15 hit her, the Resident #14 hit him again, and then Resident #15 hit her again before getting separated. -However, what LPN #1 said regarding the altercation that occurred on 6/26/22 did not match the facility ' s investigation of what happened (see investigation above). LPN #1 said she had not received training on Resident #15 to include interventions and triggers. The social services director (SSD) was interviewed on 8/16/22 at 2:39 p.m. He said Resident #15 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He said if staff were to see Resident #15 escalated, the staff were to move him to a different location. He said staff should have been educated on triggers and interventions to prevent possible further incidents. He said there should have been a person-centered individualized care plan in place to address the altercations Resident #15 had been involved in. He said he would write a care plan and educate staff to promote the highest practicable well being for Resident #15 and all the residents in the facility. The director of nursing (DON) was interviewed on 8/16/22 at 2:50 p.m. She said she was not aware of Resident #15 having any behaviors. She said she was not sure of the altercations. She said she was not sure if staff education had been provided. She said going forward to prevent future altercations she did not want Resident #15 to sit next to the two individuals Resident #15 had previously had altercations with. The nursing home administrator (NHA) was interviewed on 8/16/22 at 2:45 p.m. He said the incident on 6/16/22 had included review of video footage that revealed Resident #15 had indeed kicked Resident #10. He said review of the 6/26/22 video footage also revealed the altercation between Resident #14 and #15. He said the facility was aware Resident #15 had a quick temper. He said Resident #15 was easy to redirect. He said the team had strategized trying different seating locations in the dining room. He said the facility did not want any altercations between residents and was working diligently to prevent future altercations for all residents.

Based on observations, interviews, and record review, the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection in two of two neighborhoods. Specifically, the facility failed to perform proper hand hygiene: -Before donning and after doffing gloves; -During medication administration; and, -After touching potentially contaminated surfaces to prevent cross-contamination. Findings include: I. Professional standard According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/30/2020, accessed on 11/25/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Clinical indications for hand hygiene included: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. II. Facility policy The Hand Hygiene/Hand Washing policy, undated, was provided by the nursing home administrator (NHA) on 11/23/2020 at 3:38 p.m. According to the policy, the facility considered hand hygiene as the primary means to prevent the spread of infections. The policy stated staff were trained on the importance of and shall perform hand hygiene in preventing the transmission of healthcare-associated infections. The policy read in pertinent part: Hand hygiene is the final step after removing and disposing of personal protective equipment. The Personal Protective Equipment (PPE) for Droplet Precautions policy, reviewed May 2020, was provided by the NHA on 11/23/2020 at 3:38 p.m. According to the policy, staff are provided PPE to perform tasks that may involve possible exposure. III. Observations Observations revealed opportunities for cross-contamination without proper hand hygiene when touching high touch surfaces, medication administration and during donning and doffing of personal protective equipment (PPE). Observations included residents who were isolated on transmission based precautions routinely touched the door handles. On 11/23/2020, in room meal delivery and medication administration for residents in isolation with transmission based precautions for COVID-19 was observed between 11:50 a.m. and 12:10 p.m. Certified nurse aide (CNA) #2 donned personal protective equipment (PPE) of a gown and gloves. She wore eye protection and a N95 mask to enter resident isolation room [ROOM NUMBER]. CNA #2 delivered the meal tray, doffed her gown and gloves. She touched the high touch surface of the outside room door handle. CNA #2 closed the door with her potentially contaminated hands. She performed hand hygiene with an alcohol based hand rub (ABHR) after she exited the room. She did not perform hand hygiene before touching the door handle after doffing PPE used in a room with confirmed COVID-19, potentially cross-contaminating the door handle. CNA #2 continued the same practice of touching the door handle after doffing PPE in isolation rooms #6, #8, #10, without performing hand hygiene. -At 12:02 p.m., licenced practical nurse (LPN) #1 prepared medication for administration. She donned a gown, gloves to enter isolation room [ROOM NUMBER]. She collected three medication cups from her nursing cart. LPN #1 set one of the medication cups on the hand railing as her gloved hand knocked on and opened the door with her gloved hand touching the outside handle. LPN #1 then retrieved the third medication cup from the hand railing by pinching the lip of the cup used to administer the medication. As she pinched the lip of the medication cup, gloved the thumb went inside the cup and gloved indexed finger supporting the outside rim of the cup, with the same glove she used to touch the door handle. She did not change her gloves after touching the door handle. She did not properly hold the medication cup to prevent potential cross-contamination on the lip of the cup where the resident would place their mouth. -At 12:10 p.m., CNA #1 delivered a meal tray to isolation room [ROOM NUMBER], then doffed her gown and gloves. She touched the outside room door handle to close the door and performed hand hygiene with ABHR. She did not perform hand hygiene before touching the door handle after doffing PPE used in a room with confirmed COVID-19. -At 12:16 p.m., CNA #1 was observed in isolation room [ROOM NUMBER] assisting the resident in her wheelchair by touching the wheelchair handles to move the chair forward. The CNA then held the resident's hands with her gloved hands as she helped the resident in the wheelchair. CNA #1 doffed her gown and gloves, closed the door behind her, touching the room door handle without performing hand hygiene till after she exited the room. -At 12:27 p.m., a resident exited isolation room [ROOM NUMBER], touching her room door handle. The NHA assisted her back to her room. She was not offered hand hygiene after touching her door handle. -At 1:57 p.m., a resident returned to her isolation room [ROOM NUMBER]. She removed the face mask and nasal canula, touched the door handle and entered the room. On 11/23/2020 at 2:08 p.m., an unidentified staff member opened the each drawer of the PPE cart in front of resident room [ROOM NUMBER]. She did not perform hand hygiene before opening the drawers, touching the drawer handles with her bare hands. She quickly shut the high touch surfaces drawers and continued the same practice with PPE carts in front of isolation rooms #5 and #6. She did not perform hand hygiene between each PPE cart. -At 2:15 p.m., LPN #1 touched the opened the top drawer of the PPE cart outside room [ROOM NUMBER] and retrieved a PPE gown touching multiple surfaces of the gown as she held it in her hand. She then she applied ABHR, donned her gown and moved her cart in front of room [ROOM NUMBER]. As she prepared to administer medication, she donned her left glove, dropping the right glove on to the floor. LPN #1 picked up the glove from the floor with her bare hand and threw it in the waste bin and donned a new glove. She did not perform hand hygiene after picking up the glove from the floor. The LPN collected the medication cups with her gloved hands and entered the room. On 11/24/2020 at 9:13 a.m. LPN #1 touched the door handle to room [ROOM NUMBER] with her bare hands as she called out to the resident. With same hand she touched the door handle with, she opened the top drawer of the PPE cart outside room [ROOM NUMBER] and retrieved and doffed the gown without performing hand hygiene. After she doffed her gown, she applied ABHR. -At 9:15 a.m., a resident exited room [ROOM NUMBER], pulled the door shut behind her, touching the door handle with her bare hands. She was not offered hand hygiene after touching the door handle. On 11/24/2020 between 11:14 a.m. and 11:19 a.m. CNA #1 exited isolation rooms #4 and #5. She doffed her gown and gloves, touched the door handle to close. She did not perform hand hygiene between touching to doffing her PPE and touching the door handles. Disinfection of high touch surfaces of the resident door handles or PPE cart drawers was not observed during the observations above. IV. Staff interviews LPN #1 was interviewed on 11/23/2020 at 1:58 p.m. LPN #1 said she was trained on hand hygiene with monthly infection control training, meetings with the director of nursing (DON), and years of experience as a seasoned nurse. According to LPN #1, hand hygiene was crucial in preventing the spread of transmission [MEDICAL CONDITION] and infections. LPN #1 said hand hygiene should be performed in between resident rooms and during medication pass. The LPN demonstrated as she described the appropriate technique to handle a medication cup for administration. She held the cup in her fingers, only touching the bottom portion of the cup. She said the hand and fingers should never touch the rim of the cup. She said the improper practice could spread infectious diseases, viruses, and was unsanitary. CNA #1 was interviewed on 11/24/2020 at 9:20 a.m. CNA #1 said should not touch anything between doffing PPE and performing hand hygiene to prevent cross-contamination. The NHA was interviewed on 11/24/2020 at 10:15 p.m. with the infection control preventionist (ICP) and the DON. The DON participated in the interview by way of the phone. According to the NHA, high touch surfaces such as door handles were cleaned in morning and at the end of the day. He said the door handles were not cleaned throughout the day or after every use. He said proper hygiene should be practiced to prevent potential cross-contamination on high touch surfaces such as door handles and PPE drawers. Observations were shared with the management team. The NHA stated hand hygiene should have been performed before donning PPE, immediately after doffing and after touching potentially contaminated surfaces. The NHA acknowledged staff should have performed hand hygiene between doffing PPE and touching the resident room door handles to prevent cross-cotamination. The ICP acknowledged LPN #1 did not perform proper infection control medication administration technique when she used her gloves to open the resident room door then touch the lip surface of the medication cup. He said he would review appropriate practices with the nursing staff including LPN #1. The NHA said additional education was required to change the mind set of when hand hygiene was necessary to prevent potential cross-contamination. He would also improve audit processes to ensure staff practiced infection control prevention at every step. V. Record review Training and audit records were provided by the NHA on 11/24/2020. According to inservice records, CNA #2 and LPN #1 attended an infection control in-service on 11/18/2020. CNA #1 attended the in-service on 11/23/2020. The in-service included hand hygiene and donning and doffing PPE education. A staff audit was conducted on 11/18/2020 for CNA #2. According to the audit, CNA #2 appropriately donned and doffed PPE correctly and performed hand hygiene. The audit tool used to observe the CNA read in pertinent part: Wash hands or use alcohol-based hand sanitizer immediately after removing all PPE. A Hand Hygiene Competency Tool revealed LPN #1 completed the competency tool on 11/13/2020. According to the tool, hand hygiene should be performed: -Immediately before and after touching a resident or the resident ' s immediate environment; -After contact with contaminated surfaces; and, -Immediately after removal of gloves. The Common Area and Equipment Cleaning log was provided by the NHA on 11/25/2020 via email. According to the log, surface cleaning of the resident room handles was completed on 11/23/2020 at 7:00 a.m. and 7:40 p.m. The surface cleaning of the door handles on 11/24/2020 was last completed at 7:30 a.m. According to the log, the doors were not cleaned throughout the day. The log revealed the PPE carts were not included in the surface cleanings. VI. Facility COVID-19 status The NHA was interviewed on 11/23/2020. He said the facility had 22 COVID-19 positive residents and five COVID-19 positive staff. VII. Facility follow up The Medication Pass Administration for Quartine/Isolation Rooms record was provided by the NHA on 11/25/2020 via email. The record revealed LPN #1 educationed on 11/24/2020 on proper medication standards in isolation rooms to include the following step by step procedures: -Perform hand hygiene; -Open door; -Perform hand hygiene; -Don PPE; -Take medication (touching only the cups that have been previously prepared in the room; -Do not place medication on any intermediary surface (table outside resident room, hand rail); -Doff PPE; -Perform hand hygiene; -Close door; and, -Perform hand hygiene. The Hand Hygiene in-sevice provided on 11/24/2020 was provided by the NHA on 11/25/2020 via email revealed the facility was in process of reeducating all staff on appropriate hand hygiene practices after touching contaminated surfaces.

Based on observations, record review, and interviews, the facility failed to ensure the necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals and preferences was provided for three (#29, #3 and #15) of three residents reviewed for Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure ([MEDICAL CONDITION]/[MEDICAL CONDITION]) non-invasive ventilation therapy, of four residents received [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy, out of 24 sampled residents. Specifically, the facility failed to: - Assure the resident care policy and procedures for respiratory care and services included safe handling, cleaning, storage and staff training for [MEDICAL CONDITION]/[MEDICAL CONDITION] treatments, - Identify [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy in minimum data set (MDS) assessment, - Develop comprehensive person-centered care plan, including the residents goals and preferences for [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy, and - Address the respiratory services and monitoring in residents' records. Cross reference to F880 (Infection Prevention and Control); the facility failed to properly maintain, clean and store [MEDICAL CONDITION]/[MEDICAL CONDITION] equipment in a sanitary manner, per the manufacturer's recommendations. Findings include: I. Facility policy The (MONTH) 2010 [MEDICAL CONDITION]/[MEDICAL CONDITION] Support facility policy, provided by the director of nursing (DON) on 10/10/19 at 1:17 p.m., did not include maintenance, cleaning and storage of [MEDICAL CONDITION]/[MEDICAL CONDITION] masks. II.Professional reference According to Phillips (2019) Keeping it Clean: [MEDICAL CONDITION] Hygiene, retrieved from https://www.usa.philips.com/c-e/hs/better-sleep-breathing-blog/better-sleep/keeping-it-clean-[MEDICAL CONDITION].html , identified: -It was vitally important to keep everything as clean as possible, masks can be a prime breeding ground for bacteria and mold. -Daily clean the mask (including areas that come in contact with skin) using a damp towel with mild detergent and warm water then let the mask air-dry on a towel. -Wash the mask weekly, to keep it free of bacteria and germs, with warm water and a few drops of ammonia-free, mild dish detergent. Swirl it around for about five minutes, rinse it well then let it air dry during the day on a towel. III. Residents status [NAME] Resident #29 Resident #29, under the age of 60, was admitted on [DATE]. According to (MONTH) 2019 computerized physician orders [REDACTED]. The 8/23/19 minimum data set (MDS) assessment revealed the resident had no cognitive deficits with a brief interview for mental status (BIMS) score of 15 out of 15. She received oxygen therapy. The assessment did not include [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy. The (MONTH) 2019 physician order [REDACTED]. 1. Resident interview Resident #29 was interviewed on 10/09/19 at 9:24 a.m. She said she used her [MEDICAL CONDITION] every night. She said she did not observe or noticed the staff cleaned her [MEDICAL CONDITION] mask and respiratory equipment. She said once a month she was provided new respiratory mask and tubing. 2. Observations The following observations of Resident #29's [MEDICAL CONDITION] equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #29's respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 3. Record review The comprehensive care plan, dated 5/22/19, identified Resident #29 was at risk for impaired gas exchange related to [MEDICAL CONDITION]. Interventions included a [MEDICAL CONDITION] respiratory mask at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. Further record review revealed the facility failed to address the [MEDICAL CONDITION] respiratory therapy and monitoring in the resident's records. B. Resident #3 Resident #3, under age 65, was admitted [DATE]. According to (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 6/24/19 and 9/24/19 MDS assessments revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. She received oxygen therapy. The assessments did not include [MEDICAL CONDITION]/[MEDICAL CONDITION] treatment. The (MONTH) 2019 physician order [REDACTED]. 1. Resident interview Resident #3 was interviewed on 10/09/19 at 9:24 a.m. She said she used her [MEDICAL CONDITION] every night. 2. Record review According to the manufacturer's instructions for Resident #3 [MEDICAL CONDITION], provided by the clinical nurse consultant (CNC) on 10/10/18 at 3:00 p.m., identified: -To wash the water tub and air tubing, weekly, in warm water with a mild detergent, rinse them thoroughly and allow them to air dry. -To refer to the mask user guide for detailed instructions on cleaning the mask; the mask user guide was not provided by the facility with the manufacturer's instructions. The comprehensive care plan, initiated 3/21/18, identified Resident #3 was at risk for impaired gas exchange related to [MEDICAL CONDITION]. Interventions included [MEDICAL CONDITION] at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. Further record review revealed the facility failed to address the [MEDICAL CONDITION] respiratory therapy and monitoring in resident's records. 3. Observations The following observations of Resident #3 [MEDICAL CONDITION] equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #3 respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. C. Resident #15 Resident #15, age 71, was admitted on [DATE] and readmitted on [DATE]. According to (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 7/19/19 MDS assessment revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. He received oxygen therapy. The assessments did not include [MEDICAL CONDITION]/[MEDICAL CONDITION] treatment. The (MONTH) 2019 CPO documented [MEDICAL CONDITION] during the day, when sleeping, and to receive 3L of oxygen via [MEDICAL CONDITION] at bedtime. 1. Observations The following observations of Resident #3 [MEDICAL CONDITION] equipment were made on: - 10/9/19 at 5:25 p.m. - 10/10/19 at 10:59 a.m. - 10/11/19 at 9:55 a.m. All observations revealed Resident #15's respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 2. Record review The comprehensive care plan, initiated 10/12/18, documented the resident had impaired gas exchange related to [MEDICAL CONDITION], sleep apnea, and heart failure. Interventions included a [MEDICAL CONDITION] at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. Further record review revealed the facility failed to address the [MEDICAL CONDITION] respiratory therapy and monitoring in the resident's records. 3. Interviews The [MEDICAL CONDITION] manufacturer representative was interviewed on 10/17/19 at 11:31 a.m. She said all respiratory masks should be washed daily with warm water and a gentle detergent (like baby soap), and let to air dry; to prevent respiratory infections. Certified nurse aide (CNA) #4 was interviewed on 10/10/19 at 2:28 p.m. She said CNAs did not clean Resident #29's, Resident #3, and Resident #15's respiratory masks, nor their respiratory equipment and it was not a part of the residents' care. Registered nurse (RN) #1 and licensed practical nurse (LPN) #1 were interviewed on 10/10/19 at 3:29 p.m. They said [MEDICAL CONDITION] and [MEDICAL CONDITION] respiratory masks should be cleaned once a week to prevent respiratory infections. They said the respiratory masks were to be removed from the tubing, for cleaning, then were to be placed on a barrier (like a paper towel) to dry and were not to be placed directly on a table without a barrier. The DON was interviewed on 10/10/19 at 11:31 a.m. She said Resident #3 and Resident #15 used [MEDICAL CONDITION], and Resident #29 used a [MEDICAL CONDITION]. Once a month they received new respiratory masks and respiratory tubing from outside companies. She was not aware the respiratory equipment for the above residents was not maintained properly. She said she will research the manufacturers' instructions. She said she will educate the nursing staff to have [MEDICAL CONDITION] and [MEDICAL CONDITION] respiratory masks cleaned. She said the residents' records did not address appropriate maintenance of their [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment and masks. The clinical nurse consultant (CNC) was interviewed on 10/10/19 at 3:00 p.m. She said the facility used the manufacturer's instructions as a references for the [MEDICAL CONDITION]/[MEDICAL CONDITION] used by Resident #3, Resident #15, and Resident #29. Facility follow up On 10/11/19 at approximately 9:00 a.m. the DON provided the following: - Resident #29's, (MONTH) 2019 CPO, dated 10/10/19, physician's orders [REDACTED]. Empty the reservoir and let it air dry for daily maintenance of the [MEDICAL CONDITION] equipment. The comprehensive care plan, dated 10/10/19, included the following interventions: clean [MEDICAL CONDITION] on a weekly basis with warm soapy water and allow to air dry. The reservoir should be emptied and left to air dry. - Resident #3, (MONTH) 2019 CPO, dated 10/10/19, physician's orders [REDACTED]. Empty the reservoir and let it air dry; for daily maintenance of the [MEDICAL CONDITION] equipment. The comprehensive care plan, dated 10/10/19, included the following interventions: [MEDICAL CONDITION] machine should be cleaned weekly with warm soapy water and allowed to air dry. The reservoir should be emptied and left to air dry; for [MEDICAL CONDITION] daily maintenance. - Resident #15's, (MONTH) 2019 CPO, dated 10/11/19, physician's orders [REDACTED]. Empty the reservoir and let it air dry; for daily maintenance of his [MEDICAL CONDITION] equipment. The comprehensive care plan, dated 10/10/19, included the following interventions: clean respiratory mask on a weekly basis with warm soapy water and allow to air dry. The reservoir should be emptied and left to air dry for daily maintenance.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically the facility failed to: - develop and implement a cleaning schedule for the respiratory equipment ([MEDICAL CONDITION]/[MEDICAL CONDITION]) to prevent infections for residents #29, #3 and #15, - provide catheter care according to infection control standards for Resident #27, - maintain hand hygiene during wound care for Resident #27, - provide wound care treatment according to the infection control standards for Resident #27, and - ensure the oxygen equipment, including tubing and nasal cannulas, was stored in a sanitary manner for Residents #9, #30, #31 and #194 I. Facility policy According to the 11/1/17 Wound Care policy, provided by the director of nursing (DON) on 10/10/19 at 1:17 p.m., hand hygiene was to be performed between glove changes. The (MONTH) 2010 [MEDICAL CONDITION]/[MEDICAL CONDITION] Support facility policy, provided by the director of nursing (DON) on 10/10/19 at 1:17 p.m., did not include maintenance, cleaning and storage of [MEDICAL CONDITION]/[MEDICAL CONDITION] masks. According to the (MONTH) 2010 Catheter Care, Urinary policy, provided by the DON on 10/10/19 at 1:17 p.m., read, use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. According to the undated Hand Hygiene Program facility policy, provided by the DON on 10/10/19 at 1:17 p.m., hand hygiene was to be performed between glove changes. II. Professional references According to Phillips (2019) Keeping it Clean: Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Hygiene, retrieved from https://www.usa.philips.com/c-e/hs/better-sleep-breathing-blog/better-sleep/keeping-it-clean-[MEDICAL CONDITION].html , identified: -It was vitally important to keep everything as clean as possible, masks can be a prime breeding ground for bacteria and mold. -Daily clean the mask (including areas that come in contact with skin) using a damp towel with mild detergent and warm water then let the mask air-dry on a towel. -Wash the mask weekly, to keep it free of bacteria and germs, with warm water and a few drops of ammonia-free, mild dish detergent. Swirl it around for about five minutes, rinse it well then let it air dry during the day on a towel. According to the Centers for Disease Control and Prevention (CDC) (4/29/19) Hand Hygiene in Healthcare Settings, retrieved from https://www.cdc.gov/handhygiene/providers/index.html identified: -Cleaned hands protected patients from deadly germs. -Hand sanitizer was to be used after glove removal. -Gloves were not a substitute for hand hygiene. -Visibly soiled hands were to be washed with soap and water. III. Residents' status [NAME] Resident #29 Resident #29, under the age of 60, was admitted on [DATE]. According to (MONTH) 2019 computerized physician orders [REDACTED]. The 8/23/19 minimum data set (MDS) assessment revealed the resident had no cognitive deficits with a brief interview for mental status (BIMS) score of 15 out of 15. She received oxygen therapy. 1. Resident interview Resident #29 was interviewed on 10/09/19 at 9:24 a.m. She said she used her [MEDICAL CONDITION] every night. She said she did not observe or noticed the staff cleaned her [MEDICAL CONDITION] mask and respiratory equipment. She said once a month she was provided new respiratory mask and tubing. 2. Observations The following observations of Resident #29's [MEDICAL CONDITION] equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #29's respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 3. Record review The comprehensive care plan, dated 5/22/19, identified Resident #29 was at risk for impaired gas exchange related to [MEDICAL CONDITION]. Interventions included a [MEDICAL CONDITION] respiratory mask at night. The interventions did not include cleaning and maintenance of the resident's respiratory equipment. B. Resident #3 Resident #3, under the age of 65, was admitted [DATE]. According to (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 6/24/19 and 9/24/19 MDS assessments revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. She received oxygen therapy. 1. Resident interview Resident #3 was interviewed on 10/09/19 at 9:24 a.m. She said she used her [MEDICAL CONDITION] every night. 2. Record review According to the manufacturer's instructions for Resident #3 [MEDICAL CONDITION], provided by the clinical nurse consultant (CNC) on 10/10/18 at 3:00 p.m., identified: -To wash the water tub and air tubing, weekly, in warm water with a mild detergent, rinse them thoroughly and allow them to air dry. -To refer to the mask user guide for detailed instructions on cleaning the mask; the mask user guide was not provided by the facility with the manufacturer's instructions. The comprehensive care plan, initiated 3/21/18, identified Resident #3 was at risk for impaired gas exchange related to [MEDICAL CONDITION]. Interventions included [MEDICAL CONDITION] at night. The interventions did not include cleaning and maintenance of the resident's respiratory equipment. 3. Observations The following observations of Resident #3 [MEDICAL CONDITION] equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #3 respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. C. Resident #15 Resident #15, age 71, was admitted on [DATE] and readmitted on [DATE]. According to (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 7/19/19 MDS assessment revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. He received oxygen therapy. 1. Observations The following observations of Resident #3 [MEDICAL CONDITION] equipment were made on: - 10/9/19 at 5:25 p.m. - 10/10/19 at 10:59 a.m. - 10/11/19 at 9:55 a.m. All observations revealed Resident #15 respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 2. Record review The comprehensive care plan, initiated 10/12/18, documented the resident had impaired gas exchange related to [MEDICAL CONDITION], sleep apnea, and heart failure. Interventions included a [MEDICAL CONDITION] at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. 3. Interviews The [MEDICAL CONDITION] manufacturer representative was interviewed on 10/17/19 at 11:31 a.m. She said all respiratory masks should be washed daily with warm water and a gentle detergent (like baby soap), and let to air dry; to prevent respiratory infections. Certified nurse aide (CNA) #4 was interviewed on 10/10/19 at 2:28 p.m. She said CNAs did not clean Resident #29's, Resident #3, and Resident #15's respiratory masks, nor their respiratory equipment and it was not a part of the residents' care. Registered nurse (RN) #1 and licensed practical nurse (LPN) #1 were interviewed on 10/10/19 at 3:29 p.m. They said [MEDICAL CONDITION] and [MEDICAL CONDITION] respiratory masks should be cleaned once a week to prevent respiratory infections. They said the respiratory masks were to be removed from the tubing, for cleaning, then were to be placed on a barrier (like a paper towel) to dry and were not to be placed directly on a table without a barrier. The DON was interviewed on 10/10/19 at 11:31 a.m. She said Resident #3 and Resident #15 used [MEDICAL CONDITION], and Resident #29 used a [MEDICAL CONDITION]. Once a month they received new respiratory masks and respiratory tubing from outside companies. She was not aware the respiratory equipment for the above residents was not maintained properly. She said she will research the manufacturers' instructions. She said she will educate the nursing staff to have [MEDICAL CONDITION] and [MEDICAL CONDITION] respiratory masks cleaned. She said the residents' records did not address appropriate maintenance of their [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment and masks. The clinical nurse consultant (CNC) was interviewed on 10/10/19 at 3:00 p.m. She said the facility used the manufacturer's instructions as a references for the [MEDICAL CONDITION]/[MEDICAL CONDITION] used by Resident #3, Resident #15, and Resident #29. D. Resident #27 Resident #27, under the age of 65, was admitted on [DATE]. According to (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/21/19 MDS assessment revealed the resident had no cognitive deficit with a BIMS score 14 out of 15. She required extensive, two persons assistance with bed mobility and dressing, she was totally dependent on two staff with transfers and toilet use. She had indwelling urinary catheter. She had two, stage IV (four) pressure ulcers.She received oxygen therapy and was under hospice care. 1. Observations A catheter care was observed on 10/10/19 at 8:08 a.m. Certified nurse aide (CNA) #1 wiped back and forth (from the insertion site at the urethra and away from the urethra/insertion site) along Resident #27's Foley catheter using the same wipe and on the same side of the wipe. A stage IV pressure ulcer wound care was observed on 10/10/19 at 8:23 a.m. Registered nurse (RN) #1 used the same 4x4 gauze (sprayed with wound cleanser) and wiped the outside area of Resident #27's coccyx pressure wound then wiped inside the coccyx pressure wound; she did this twice with the same 4x4 gauze. After RN #1 cleaned the pressure wound she removed her gloves and donned another pair of gloves without performing hand hygiene. After these observations RN #1 identified she should have performed hand hygiene prior to donning the other set of gloves. 2. Record review The comprehensive care plan, initiated on 2/26/19 and revised on 6/20/18, identified Resident #27 had a potential for urinary tract infection [MEDICAL CONDITION] due to an indwelling catheter. Interventions included to assist with perineal care after each incontinent episode. There was no intervention addressing daily catheter care. According to the (MONTH) 2019 treatment administration record (TAR), Resident #27 received Foley catheter care every shift; two times a day. 3. Interviews CNA #1 was not available for an interview. CNA #5 was interviewed on 10/10/19 at 1:00 p.m. She said when staff provided catheter care they were to wipe catheters in one direction only, away from where the catheter was inserted; to prevent infections. Staff were to perform hand hygiene between glove changes. CNA #4 was interviewed on 10/10/19 at 2:00 p.m. She said when staff provided catheter care they were to wipe catheters in one direction only, away from where the catheter was inserted not back and forth; to prevent infections. Staff were to perform hand hygiene between glove changes. The licensed practical nurse (LPN) #1 was interviewed on 10/10/19 at 1:45 p.m. She said when staff provided catheter care they were to wipe catheters in one direction only, away from where the catheter was inserted not back and forth; to prevent infections. The DON was interviewed on 10/10/19 at 8:23 a.m. She said staff were to wipe in one direction when providing catheter care, from the insertion site of a catheter then away from the insertion site. Staff were to use only one wipe at a time when wiping a catheter. Staff were not to wipe back and forth along a catheter. She said staff were to perform hand hygiene in between glove changes to prevent infections. She said nurses were to clean inside a pressure wound with a different set of 4x4s then those used to clean around the pressure wound. The clinical nurse consultant (CNC) was interviewed on 10/10/19 at 3:00 p.m. She said the facility used the CDC as a reference for catheter care, hand hygiene, and glove changes. She said the facility used the manufacturer's instructions as a references for the [MEDICAL CONDITION]/[MEDICAL CONDITION] used by Resident #3, Resident #15, and Resident #29. She said the facility used the Utilization of the Wound Ostomy Continent Nurses Society (W[NAME]NS) website as a reference for pressure wound care. The W[NAME]NS website required a membership and could not be accessed for additional references. The Centers for Disease Control and Prevention (CDC) health care specialist was interviewed on 10/22/19 at 1:39 p.m. She said when performing urinary catheter care, one was to wipe away from the peri-urethral area along the catheter (in one direction, utilizing one wipe at a time) when providing catheter care and cleansing of the catheter insertion side. E. Resident #9 Resident #9, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/5/19 minimum data set (MDS) assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with all activities of daily living. The respiratory treatments included oxygen therapy. 1. Record review The (MONTH) 2019 CPOs, revealed continuous oxygen treatment at three liters per minute by nasal cannula to maintain oxygen saturation at or above 88 percent for [MEDICAL CONDITION]. The comprehensive care plan, initiated 3/29/18 and revised on 4/22/19, identified risk for impaired gas exchange related to [MEDICAL CONDITION]. Interventions included oxygen at three liters by nasal cannula. 2. Observation On 10/8/19 at 9:36 a.m., the oxygen concentrator in the resident's room, was infusing oxygen through a nasal cannula at 2.5 liters per minute (2.5LPM) and not connected to the resident. The nasal cannula tubing was hanging over the bed side rail, not bagged, and the nasal prongs touching a shirt that was on the bed. F. Resident #30 Resident #30, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. The 8/23/19 MDS assessment revealed the resident's cognition was intact with a BIMS score of 15 out of 15. The respiratory treatments included oxygen therapy. 1. Record review The (MONTH) 2019 CPO, revealed continuous oxygen at four liters per minute by nasal cannula to maintain oxygen saturation at or above 88 percent for [MEDICAL CONDITION]. The comprehensive care plan, initiated 8/14/19 did not address oxygen therapy. 2. Observation On 10/9/19 at 9:49 a.m., the resident's portable oxygen tank was observed on the back of the wheelchair, not in use, with nasal cannula tubing attached and draped over the back of wheelchair, with the nasal prongs not bagged and touching the seat. G. Resident #31 Resident #31, age 76 was admitted on [DATE]. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. The 8/28/19 MDS assessment revealed the resident's cognition was impaired with a BIMS score of five out of 15. The respiratory treatments included oxygen therapy. 1. Record review The (MONTH) 2019 CPO revealed, oxygen as needed during the day and night, at two liters per minute flow, to maintain oxygen saturations at or above 88 percent for chronic [MEDICAL CONDITION]. The comprehensive care plan, initiated 8/19/16 did not address oxygen therapy. 2. Observation On 10/9/19 at 3:36 p.m., Resident #31's oxygen concentrator was observed near the head of the bed, not in use, nasal cannula connected to the concentrator with the tubing draped over the bedside table, not bagged and the nasal prongs touching the bed side rail. H. Resident # 194 Resident #194, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. The 9/26/19 MDS assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 13 out of 15. The respiratory treatments included oxygen therapy. 1. Record review The comprehensive care plan, initiated on 9/17/19, revealed a risk for impaired gas exchange related to [MEDICAL CONDITION]. Interventions included oxygen as ordered, change oxygen tubing, nasal cannula, and humidifier as needed and according to the facility protocol. 2. Observation On 10/8/19 at 9:28 a.m. Resident #194's oxygen concentrator was observed with nasal cannula attached and not bagged, lying at the head of the bed with the nasal prongs touching the linens on the bed. 3. Staff interviews Registered nurse (RN) #2, was interviewed on 10/9/19 at 10:01 a.m. She said the oxygen tubing is to be stored in a bag when not in use. She said the night shift changes the tubing and oxygen bags weekly. She said a bacteria could get on the nasal cannula and can cause a resident to inhale dirt and dust when not properly stored. Certified nurse aide (CNA) #3 was interviewed on 10/9/19 at 1:53 p.m. She said the oxygen tubing is changed by the oxygen company weekly. She said when not in use the oxygen tubing should be stored inside a bag that is provided by the oxygen company. The director of nursing (DON) was interviewed on 10/10/19 at 1:33 p.m. She said the oxygen tubing should be stored off the floor. She said sometimes there is a bag for the tubing and sometimes there is no bag. She said a respiratory infection may result when tubing is not properly stored. She said the facility used the Center for Disease Control (CDC) website for reference on oxygen storage.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) for two (#42 and #41) of five residents reviewed for ADL decline out of 42 sample residents. Specifically, the facility failed to; -provide positioning device for dependent Resident #42 to prevent leaning while in wheelchair receiving care and; -provide positioning device for dependent Resident #41 with [MEDICAL CONDITION] to right arm while sitting in a wheelchair. Findings include: I. Facility policy and procedure The Request for Therapy Services policy and procedure, dated (MONTH) 2007, was provided by the director of nurses (DON) on 10/10/19 at 4:36 p.m. It read in part, a therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. Therapy is scheduled in coordination with nursing services and is documented in the resident's medical record. II. Residents status [NAME] Resident #42 Resident #42, age 71, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/18/19 minimum data set (MDS) assessment revealed the resident had short and long term memory problems, and severely impaired cognitive skills for daily decision making. He required extensive, two persons assistance with transfers, and extensive, one person assistance with dressing, eating, and personal hygiene. He required total assistance with toilet use and had no functional limitations in range of motion to upper and lower extremities. 1. Observations On 10/8/19, 10/9/19 and 10/10/19 at approximately 11:30 a.m., Resident #42 was observed in the dining room. He was leaning to the left side while sitting in his wheelchair. No positioning support or device was observed. On 10/9/19 at 8:06 a.m., Resident #42 was observed in the dining room, assisted by a nurse aide with breakfast meal. He was leaning to the left side while sitting in his wheelchair. No positioning support or device was utilized. During the observations, the resident was not reposition or encouraged to reposition self. 2. Record review The comprehensive care plan, revised 9/30/19, identified activities of daily living (ADL) self-care performance deficits. Interventions included: adjust the level of care according to his individual needs. The plan of care identified risk for falls related to impaired balance. Interventions included occupational therapy (OT) for evaluation and treatment for [REDACTED]. The CPOs, dated (MONTH) 2019, read in part, OT treatment to include therapeutic activities and adjustments to new environment. Resident to participate in the restorative program. The OT evaluation and plan of treatment, dated 9/5/19, was provided by the therapy director (TD) on 10/10/19 at 9:31 a.m. It read in pertinent part, Resident referred to OT services related to reports from staff, patient demonstrated decreased safety with performance transferring self from his wheelchair and leaning forward and or backwards while in wheelchair. OT identified functional limitations as a result of posture included sitting upright, functional mobility, repositioning self, skin integrity, and propelling wheelchair. OT recommended the use of anti-tilt bars on the back of wheelchair to prevent patient from tipping over and falling out of a wheelchair. 3. Staff interviews The TD was interviewed on 10/10/19 at 9:20 a.m. She said Resident #42 was able to position himself while sitting in a wheelchair. She said a rehab evaluation would be performed if a resident is referred by the nursing department. She said the resident was evaluated last month with recommendations for an anti-tipping device for the wheelchair. The DON was interviewed on 10/10/19 at 1:39 p.m. She said no device was used for positioning. She said Resident #42 is on the restorative program. B. Resident #41 Resident #41, age 53, was admitted on [DATE]. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. The 9/29/19 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use. He had functional limitations in range of motion with impairment on one side of the upper and lower extremities. 1. Observations On 10/8/19 at 10:33 a.m. Resident #41 was observed sitting in his room in his wheelchair with severe [MEDICAL CONDITION] to his right arm. The right upper extremity was resting on his lap with no arm support observed. On 10/10/19 at 8:35 a.m. the resident was observed during transfer to his wheelchair. He was assisted by two nurse aides. The resident was transported to a [MEDICAL TREATMENT] center. He did not have any upper extremity support and his right arm was resting on the arm of the wheelchair. 2. Record review The comprehensive care plan, dated 9/25/19, identified ADL self-care performance deficit related to [MEDICAL CONDITIONS] with right side effect. Intervention included arm board to the right side of his wheelchair. 3. Staff interviews The TD was interviewed on 10/10/19 at 3:14 p.m. She said due to Resident #41 having a right arm fistula, no intervention was put into place to reduce the [MEDICAL CONDITION]. She said the lap tray attached to the wheelchair should be utilized for arm support. The certified occupational therapy assistant (COTA) was interviewed on 10/11/19 at 10:51 a.m. She said she received recommendations for Resident #41 to apply a bandage called, [MEDICATION NAME]. She said she placed the bandage to his right extremity for a trial and error. She said the arm board should be in place at all times while Resident #41 was up in the wheelchair. The DON was interviewed on 10/10/19 at 1:39 p.m. She said Resident #41 received therapy for his right upper extremity. She said she was not familiar with the treatment and more information can be obtained from the rehab department.

Based on observations and staff interview, the facility failed to maintain a sanitary, orderly, and comfortable environment for its residents in 12 of 26 resident rooms and four of four hallways. Specifically the facility failed to ensure walls, ceilings and doors were repaired, painted and properly maintained. Findings include: I. Initial Observations Observations of the resident living environment conducted on 10/17/18 at 12:59 p.m., revealed: -Room # 22; the walls behind both beds had deep scratches and chipped sheetrock from the beds being lowered and lifted. Both beds had two large wheels, which would hit the wall as the bed was lifted and lowered. -Room # 23; the residents bed had deep scratches and peeling sheetrock from the bed being lifted and lowered. Both beds had two large wheels, which would hit the wall as the bed was lifted and lowered. The wall next to the bed had deep scratches the whole length of the bed. The bathroom had repaired patchwork next to the commode, which was unfinished in the restroom. The bottom half was green in color and the top half white. The baseboard cove approximately five inches by six inches was missing next to the restroom. -Room # 24; both beds damaged from the beds being lifted and lowered. Section was approximately two feet by three feet of damaged walls. -Room # 25; the wall in the middle of the two beds had an outline of shelves, which were removed with the glue outline still visible. -Room # 27 the wall behind the dresser had white patchwork, which had not been completed. -Room # 4 the wall behind the bed was damaged from the bed being lifted and lowered. There were three large holes approximately dime size behind the headboard. The door to the restroom was damaged from the wheelchair. The door had damage approximately 36 inches long by two inches wide with wood splinters and peeling paint. -Room # 3 the walls were damaged from the beds being lifted and lowered. The door had damage approximately 36 inches long by two inches wide with wood splinters and peeling paint. -Room # 2; the commode had a ½ of an inch gap where missing caulking all around the base of the commode. Rust was visible around the whole base of the commode. -Room # 1; the wall next to the residents bed had three large dime sized. The ceiling had tan colored paint with the white walls. The walls had been painted with ceiling unfinished. -Room# 9; the wall was damaged from the resident ' s gate being opened and closed. The wall had peeling and deep chips. -Room # 8 the walls behind both beds were damaged from the beds being lifted and lowered. -Room # 10 the wall behind the resident recliner had damaged approximately three feet wide and four feet wide from the recliner hitting the wall. II. Environmental Tour and Staff Interview The environmental tour was conducted with the maintenance supervisor (MS) on 10/18/18 at 10:51 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said staff filled out requisition requests in the facility computer system for repairs. The MS said he reviewed them on a daily basis and had a walk through with environmental consultant monthly. The MS provided a report of items, which had been observed during monthly audits with environmental consultant. The above damage reviewed during environmental tour were not noted on the audit form provided by MS. MS and this surveyor compared the 10/4/18 audit. Each room had areas of concerns but did not address the damage and areas listed above. MS said he had no work order for the above listed room damage. He said going forward from today he would be on top of all work needed in the facility and would repair it in a timely manner.

The facility failed to ensure one of one resident smoking areas remained free from accident hazards. Specifically, the facility failed to ensure the resident designated outdoor smoking area was lit appropriately for unsupervised resident smokers. Findings include: I. Facility policy According to the resident smoking policy, provided by the nursing home administrator on 10/15/18, revised 8/20/18, in pertinent part, Independent smokers may smoke at anytime in accordance to these policies. Smoking restrictions shall be strictly enforced in all non-smoking areas. Smoking was restricted to the back of the building, on the concrete pad furthest West. Smoking was discouraged anywhere else around the perimeter of the building. II. Resident #14 1. Resident status Resident #14, age 74, was originally admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 8/8/18 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS revealed the resident ' s ability to identify objects was in question but he appeared to be able to follow objects. The care plan, initiated 1/26/18 and revised 3/19/18, identified the resident had a vision impairment and was at risk for falls. Interventions included provision of adequate lighting. According to a facility provided list of resident smokers, Resident #14 was identified as an independent smoker. 2. Resident interview Resident #14 was interviewed on 10/15/18 at 1:13 p.m. The resident stated the smoking area was too dark at night and he had difficulty moving in and out of the smoking area safely. He said it had been a problem since he was admitted last January. The resident said he requested the maintenance supervisor (MS) to fix it, but was told the light had to be ordered. Resident #14 said there was a light outside over the main patio area, but not where the smokers are required to go to smoke. Resident #33, an independent smoker, was interviewed on 10/16/18 at approximately 3:00 p.m. She said the smoking area was too dark to see well at night. She said she had often heard Resident #14 mention it as a concern. On a follow up interview with resident #14 on 10/18/18 at 3:30 p.m, Resident #14 said the MS fixed light. The resident said he went outside to smoke with another resident that morning at 4:00 a.m., before the sun was up, and could see the tables and chairs. He said he felt much safer now. Resident #18 was interviewed during the resident exit group on 10/18/18 at approximately 7:00 p.m. Resident #18 identified herself as a smoker and expressed relief that the smoking was going to be lit at night for resident safety. 3. Resident interview and observation Resident #14 was observed on 10/17/18 at 7:01 p.m. Resident #14 went outside to the designated smoking area and sat at the provided table. A light was in the corner over the main patio. The patio was sectioned in multiple areas. The lighted portion of the patio was not the designated smoking area. The smoking area was a dark corner by the storage sheds, with a table and a few chairs. A shed blocked the light from the main patio. Two solar small lights were fixed to the fence. The lights only illuminated themselves. A small light was fixed to the post near the table and chairs. The light was not on. The resident sat in the dark. The nurse consultant (NC), MS and the director of nursing (DON), were also in the smoking area. Resident #14 said to the group, It ' s too dark for a blind person. The NC instructed MS to replace the light. The MS said he did not have a light to replace it. The NC instructed the MS to purchase a light immediately and she would stay with the resident. 4. Staff interviews On 10/18/18 at approximately 9:00 a.m.,the nursing home administrator (NHA) demonstrated two newly installed solar lights over the designated smoking area. The NC was interviewed on 10/18/18 at 3:27 p.m. The NC stated she thought the smoking area was an immediate jeopardy concern for resident safety. The MS was interviewed on 10/18/18 at 4:20 p.m.The MS said he purchased and installed two new lights for the smoking area. He stated he also purchased a headlight and a back up battery operated light to have on hand when needed. Facility follow-up On 10/19/18 the facility provided receipts of lights purchased, photos of installation, photo of the newly installed lights working at night and a witness statement signed by the regional nurse consultant (NC) indicating the smoking area had a light as of the evening of 10/16/18. The facility also provided a weekly audit tool implemented on 10/18/18, to monitor the lights to ensure they were in working order.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Specifically, the facility failed to ensure: -- The cutting boards were free from deep scratches and stains; and -- Beard restraints were worn in kitchen areas while preparing food. Findings include: 1. Cutting Boards A. Professional Standard According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated (MONTH) 1, 2013), page 55, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 10/15/18 at 8:30 a.m. revealed three cutting boards that were heavily scored and stained. On 10/17/18 at 10:00 a.m., kitchen staff were observed using cutting boards to cut vegetables, bread and chopped turkey. C. Staff Interview The dietary manager (DM) was interviewed on 10/18/18 at 9:17 a.m. The DM looked at the stains on all the cutting boards and said, I could see the deep scratches being a possible bacteria issue if not cleaned correctly. She said I will replace the cutting boards; they do need replacing. 2. Beard Restraints A. Professional Reference According to the Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 19, 2004, effective (MONTH) 30, 2004) pg. 14, .Except as provided under paragraph B of this section, employees engaged in food preparation shall wear hair restraints, such as hats, hair coverings, nets, or other effective means, to effectively keep hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service or single-use b. Observations and Interviews On 10/15/18 at 8:21 a.m., dietary aide (DA) #1 was observed in the kitchen area without wearing a beard restraint. DA #1 was observed preparing individual entrees for the residents. --At 11:38 a.m., DA #1 was observed in kitchen area not wearing a beard restraint. DA #1 was observed preparing and serving lunch meals On 10/17/18 at 10:00 a.m., DA #1 was observed in kitchen area not wearing a beard restraint. DA#1 was preparing pureed meals and preparing the lunch menu On 10/18/9/18 at 9:17 a.m., the DM stated all kitchen staff are required to wear hair restraint and should have all hair covered. The DM said they had a previous discussion in reference to beard guards in the kitchen. She said DA#1 had been covering several shifts as they had a staff member quit, which put the discussion back. She said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas. She said she would provide a copy of facility policy on hair restraints. At time of exit, no policy was provided.

Based on observations, interviews and record review, the facility failed to ensure one (#15) of 25 sample residents was treated with respect and dignity. Specifically, Resident #15 was being fed during meals when she was independent with eating. Findings include: I. Resident status Resident #15, age 91, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 8/9/18 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident required set up help only for eating with supervision, oversight, encouragement or cueing. The MDS identified her diet as mechanically altered. According to MDS, the resident did not have swallowing difficulty. The care plan, initiated 1/27/18 and revised 3/20/18, identified the resident had an activities of daily living (ADL) performance deficit. Inventions included to allow the resident sufficient time to perform the ADL task of eating and other ADL tasks and encourage the resident in optimal participation in ADL performance including eating. 2. Observations Resident #15 was observed on 10/15/18 from 11:55 a.m. to 12:24 p.m., observations included: - At 11:53 a.m. the resident picked up the fork and fed herself four bites of her mechanical soft meal which was enchiladas with refried beans. - At 11:58 a.m. she set her fork down while she chewed her food. - At 11:59 a.m. certified nurse aide (CNA) #2 picked up the fork and fed the resident while she fed another resident which was on her left side. - At 12:23 p.m. the resident indicated to the CNA #2 she was finished. The resident ate approximately 10% of her meal. Resident #15 was observed on 10/16/18 from 11:30 a.m. to 12:30 p.m., observations included: - At 11:40 a.m. the resident ' s meal was served and included meatloaf, potatoes and green beans. CNA #11 sat between Resident #15 and another resident. Without offering set up, cueing, or encouragement CNA#11 used the fork of Resident #15, and placed a bite of her meal in the resident ' s mouth. CNA #11 then focused on another resident who sat on the other side of the CNA, while Resident #15 chewed and drank her beverage independently. - At 11:55 a.m CNA #11 continued to assist the other resident. - At 12:01 p.m CNA #11 served a bite to Resident #15 as she still chewed the previous bite. - At 12:07 p.m. Resident #15 fed herself the next bite of food. - At 12:10 p.m CNA #11 removed herself from the table and assisted the other resident out of the dining room. -At 12:16 p.m CNA #6 came from assisting another resident at another table and offered Resident #15 a bite. Resident #15 refused the offered bite. CNA #6 encouraged her to take a drink, and returned to her other resident sitting next to the CNA. Resident #15 picked up her glass, took several sips of her beverage. She placed her glass down and picked up a fork and fed herself a bite of food. - At 12:19 p.m CNA #11 returned to the table and sat next to Resident #15. CNA #6 came back to the table and sat on the other side of Resident #15 who continued to drink her beverage. The social service director (SSD) came over to Resident #15 and encouraged her to eat. - At 12:26 p.m. the resident finished both her apple juice and her water and accepted a bite of her meal from CNA #6. Resident #15 was observed on 10/17/18 from 8:15 a.m. to 8:50 a.m., observations included: - At 8:16 a.m. to 8:30 a.m., the resident sat between the activity director (AD) and the assistant director of nursing (ADON). The resident was simultaneously fed by AD and ADON. The staff did not encourage Resident #15 to eat independently with setup cueing as needed. - At 8:31 a.m until 8:50 a.m., Resident #15 fed herself toast. Resident #15 was observed on 10/18/18 from 8:00 a.m. till 8:28 p.m as she ate her all of her toast and 10% of her eggs The resident fed herself breakfast independently. Observation and staff interview Resident #15 was observed on 10/17/18, observations included: -At 12:36 p.m. the resident was observed eating bread independently. CNA #2 said Resident #15 could feed herself finger foods but staff had to feed her the non-finger food portions. - At 5:00 p.m. the registered dietitian (RD) stood near Resident #15. The resident used her utensils, and fed herself . A CNA sat next to the resident and offered encouragement The CNA proved a one time adjustment with the resident ' s fork. -At 5:11 p.m., the RD said based on dinner observation, Resident #15 was still able to feed herself, make choices and decide what she wants to eat. The RD added times of the day may change her ability. - At 5:00 p.m. until 5:15 p.m., Resident #15 independently ate 14 bites of her food with minimum assistance with adjustment of the resident ' s fork and to hand her the glass of juice. 3. Interviews The RD was interviewed with the dietary manager (DM) on 10/17/18 at 2:29 p.m. The RD said she was in the facility weekly to every other week. She said Resident #15 had a stable weight. She said she was always part of the weekly nutrition at risk meeting through attendance and reports. The RD said based on her (MONTH) audit and observation, Resident #15 was able to feed herself if she was provided meal set up and assist with cutting food. The resident received a mechanically soft diet with a divided plate. She did not require finger foods, and was able to use utensils. The DM told the RD sometimes staff fed Resident #15. RD said if the resident has to be fed, then she would assume there has been a decline since (MONTH) but was not aware of, or received reports of decline. The DM said she has not seen a decline either. The RD said not promotion resident independence would be taking away dignity. CNA #8 was interviewed on 10/18/18 at approximately 3:15 p.m. CNA #8 said she had assisted Resident #15 since (MONTH) when she started. CNA #8 said the resident was at the dining table where residents sat who required assistance with meals. She said Resident #15 required total care but sometimes would feed herself. The regional nurse consultant (NC) was interviewed on 10/18/18 at 3:27 p.m. The NC said based on her recent meal observations, she provided education related to dignity at meals on 10/16/18. The training consisted of hand over hand cueing, and how to position themselves and the resident, so they could sit at eye level with the resident without having to stand over them. The NC said staff needed to offer cueing to promote independence and said too much assistance could make a resident dependant. The NC said CNA ' s had told her they were frequently in a hurry and did want residents to have to wait to eat. She added a resident right was to treat the resident with dignity during meals. She said without dignity, it could cause the resident to be fearful. 4. Record review The 8/10/18 dietary note was completed by the RD, read Resident #15 needed verbal cues to eat and had some difficulty chewing. The 9/13/18 dietary note was completed by the RD, read the resident was pleased with the divided plate to assist with self feeding and set up assistance as needed.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for one (#22) of 25 sample residents. Specifically the facility failed to ensure grievances reported by Resident #22 were addressed timely by the facility. Findings include: I. Facility Policy The undated grievance/complaint policy, provided by the social service director (SSD) on 10/17/18 documented, Our facility will help residents file grievances or complaints when such requests are made. II. Resident #22 1. Resident status Resident #22, age 69, was initially admitted on [DATE] and readmitted on [DATE],. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 8/28/18 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS revealed she required extensive one person physical assistance for dressing and toileting. Resident #22 had frequent urinary incontinence and was occasionally incontinent of bowel. According to the MDS, the resident did not reject care when receiving medications or activities of daily living (ADL) assistance. According to the 8/6/18 baseline care plan, the resident did not self-administer medications. A current medication list was not provided to resident or representative and the medication list was not reconciled with the resident or representative. 2. Resident interview Resident #22 was interviewed on 10/15/18 at 2:28 p.m. The resident said she was concerned there were three grievances she had addressed with the social service director (SSD) and the nursing home administrator (NHA), which were not resolved. Resident #22 stated that two certified nurse aides (CNA) refused to provide assistance in the restroom. She said the same staff had made comments towards her that made her feel bad. These comments included: -What do you need? - You can do it for yourself. - Not you again. -Resident #22 said she was also concerned that her number of pills would fluctuate daily. The quantity changes in medications made her anxious that staff tried to cause her harm. The NHA told her he monitored it, and the medication was correct. She did not know to what extent he reviewed her concern and felt her medication was still a problem. 3. Record review The grievance log was reviewed on 10/18/18 at approximately 3:00 p.m. The log did not show a grievances address by Resident #22. The 7/25/18 physician note read the resident informed the physician she did not like the facility and felt that she no longer belonged there. According to the note, she said she asked for help, and the staff occasionally told her to do it herself. The physician added it frustrated the resident. The resident said the concern was mostly with one CNA. The note indicated the resident said the staff does not help her change her brief after daily morning incontinence. According to the nursing note on 7/25/18, the resident felt nobody cared and she did not want to be here. 4. Staff interviews The SSD was interviewed on 10/16/18 at 3:25 p.m. He said that he was responsible for grievances and once an individual filed a grievance he would log the grievance into the logbook and identify which staff member would receive the grievance in order to address and resolve the grievance. Once the grievance had been addressed, he would give the grievance form to the NHA who would follow-up with the individual who filed the grievance. The SSD was interviewed on 10/18/18 at 1:51 p.m . The SSD said that he did not recall grievances made by Resident #22. He said that he did not have a record of her concerns upon review, in the grievance log book. The NHA was interviewed on 10/18/18 at 2:35 p.m. The NHA was aware of the medication concern. The NHA stated that he reviewed the medications and quantity of medications for two days but could not recall when. The NHA said he informed her the medication was correct during an observed medication pass. The NHA stated he did not recall the resident ' s concern regarding the lack of toilet assistance or comments directed to Resident #22. -At 3:55 p.m., the NHA said, after a conversation with the director of nursing (DON), he remembered the grievance.The NHA said education was provided to one CNA and removed from the resident ' s hall. The education and action was not documented. The NHA said the resident ' s allegations of two CNA ' s not providing care and making inappropriate comments and the steps the facility took to attempt to resolve were not documented through the grievance process. The concern, findings, resolution, and resident response of resolution attempt, was not documented to show the resident ' s grievances were addressed. He said he was not aware the resident felt the concerns were unresolved. He said he documented concerns that could not be addressed right away. He revealed that moving forward he would document concerns brought to his attention and the facility actions taken. The NHA said he would follow up with Resident #22.

Based on observations, interviews and record review, the facility failed to ensure a resident with an indwelling catheter, received the appropriate care and services to prevent urinary tract infections, to the extent possible, for one (#18) of one resident reviewed out of 25 sample residents. Specifically, the facility failed to, in a timely manner: -Change Resident #18's urine drainage system (which contained white, cloudy sediment throughout the tubing), which included the catheter tubing and the urine drainage bag; -Treat the urethral pain and burning at the insertion site of the indwelling catheter, Resident #18 had reported to CNA #8; -Change Resident #18's catheter due to the urethral pain and burning she had at the insertion site Due to this failure, Resident #18 sustained pain and burning in her urethra, and irritation in the surrounding tissue, for two weeks. Findings include: I. Professional reference According to WebMD, How Should I Take Care of My Indwelling Catheter? (YEAR), https://www.webmd.com/a-to-z-guides/indwelling-urinary-catheter#3 , (10/29/18), it identified to call the doctor if there was redness, pain, or burning at the catheter insertion site. II. Facility policy and procedure According to the Urinary Catheter Care policy, revised (MONTH) 2010 provided by the director of nursing (DON) on 10/19/18 at 4:53 p.m., it revealed: -The purpose of the procedure was to prevent catheter-associated urinary tract infections (UTIs). -The general guideline was to maintain a closed drainage system after the aseptic insertion of a urinary catheter. -It was suggested to change indwelling catheters and drainage bags when clinical indications existed, such as when the closed systems were compromised. III. Resident #18 status Resident #18, age 60, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 8/20/18 minimum data set (MDS) assessment revealed, she had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS indicated she was totally dependent for toileting and had an indwelling catheter. A. Resident interview Resident #18 was interviewed on 10/15/18 at 9:53 a.m. She said two weeks ago she complained that she had pain at the insertion site of the catheter and the surrounding tissue. She said it continued to burn and sting. Resident #18 was interviewed a second time on 10/16/18 at 3:42 p.m. She said the nurses knew she had pain at the insertion site of the catheter and the surrounding tissue. Resident #18 was interviewed a third time on 10/17/18 at 1:48 p.m. She said last week she told certified nurse aide (CNA) #8 that it hurt at the catheter insertion site and in the surrounding tissue. B. Family interview A family member was interviewed on 10/18/18 at 10:14 a.m. She said the inside of the tubing, which led from the catheter to the urine drainage bag, had been cloudy for a few weeks. C. Observation Several observations made of Resident #18's urine drainage system, while she was in her wheelchair, revealed the tubing, which led from the catheter to the urine drainage bag, contained a white, cloudy substance within it, on the following days and times: -10/15/18 at 9:53 a.m. -10/16/18 at 9:03 a.m. -10/16/18 at 1:05 p.m. -10/16/18 at 3:36 p.m. D. Record review The care plan, initiated on 3/12/18 and revised on 7/9/18, revealed she required a Foley catheter. Interventions included to change the catheter when needed, and to change the gravity bag if it was cloudy within the tubing (had visible sediment within it). Record review of the (MONTH) (YEAR) skin assessments revealed there was no documentation that the facility conducted an assessment regarding the pain and burning Resident #18 had at the insertion site of her urinary catheter, and the tissue surrounding her urethra. According to the (MONTH) (YEAR) nursing progress notes (from 10/1/18 to 10/16/18) there was no documentation which addressed the pain and burning Resident #18 had at the insertion site of her urinary catheter, and the tissue surrounding her urethra. There was no documentation the facility made attempts to contact the nurse practitioner or physician regarding it. E. Staff interviews CNA #5 was interviewed on 10/17/18 at 1:48 p.m. She said, during a shift change last week, she overheard Resident #18 tell CNA #8 that she had pain at the insertion site of the catheter and the surrounding tissue. Registered nurse (RN) #3 was interviewed on 10/17/18 at 1:34 p.m. She said if the catheter was causing pain or irritation to Resident #18 it should be changed. RN #3 was interviewed a second time on 10/17/18 at 1:53 p.m. While observing the tubing, which led from the catheter to the urine drainage bag, she said the tubing had sediment in it and needed to be changed. She said failure to change it could lead to an infection in her urinary system. She said she would change the tubing on this day. While observing the urethral tissue surrounding Resident #18's catheter, she considered the tissue to be reddened and irritated. She said no staff informed her of her urethral pain at the catheter insertion site. She said no staff informed her that her urethral tissue was reddened. She said her catheter needed to be changed due to the irritation she had. The director of nursing (DON) was interviewed on 10/17/18 at 2:04 p.m. As she observed the tubing, which led from the catheter to the urine drainage bag, she said the tubing needed to be changed because it was dirty inside it and it could cause a urinary tract infection. She said it would be changed on this day. As she observed the urethral tissue surrounding Resident #18's catheter, she said her perineal area looked irritated and the catheter should be changed as well. She said none of her staff had informed her of her urethral pain. CNA #5 was present during this observation and informed her that Resident #18 told CNA #8 last week about her urethral pain. The DON said she would have wanted CNA #8 to have informed a nurse last week about her urethral pain. She said she would have then wanted the nurse to have informed her and a hospice nurse about it last week. F. Hospice consultant (HC) interview The HC was interviewed on 10/18/18 at 10:29 a.m. She said resident #18 received nurse and aide hospice services with her company every week. She said the facility called the hospice nurse to insert a new catheter and received a new order from the hospice nurse practitioner for triple antibiotic ointment (TAO). She said if the hospice staff knew of a problem with her catheter they were to tell the facility, and vice versa. She said she received daily emails from hospice staff regarding resident care they provided, and had not received an email from the hospice staff regarding Resident #18's catheter concerns between 10/1/18 and 10/16/18. G. Follow-up 1. Observation An observation made on 10/18/18 at 10:10 a.m. revealed the tubing which led from the catheter to the urine drainage bag was new, and there was no cloudy substance in the urine that was contained within it. 2. Resident #18 interview Resident #18 was interviewed on 10/18/18 at 10:10 a.m. She said the hospice nurse put a new catheter in and she no longer had burning or pain at the catheter insertion site and in the surrounding tissue. 3. DON interview The DON was interviewed on 10/18/18 at 4:59 p.m. She said the tubing which led from the catheter to the urine drainage bag was changed yesterday. She said the facility received an order for [REDACTED]. She said she would ensure all of them were in-serviced regarding it. 4. Record review According to the 10/17/18 Foley Catheter Care In-Service, provided by the DON on 10/19/18 at 4:53 p.m., it revealed: -Nurses and CNAs were educated on performing catheter care in the evening and in the morning; and to document refusals. -The in-service topic did not list education on the present care concerns of: -How to maintain a closed, uncompromised urinary drainage system after a catheter was inserted, per facility policy -What to do if the urinary drainage system was potentially compromised, per facility policy According to the (MONTH) (YEAR) progress notes: -On 10/17/18 at 7:24 p.m. her urethral meatus was assessed at the catheter insertion site by RN #3 -Resident #18 cried out in pain when the area was cleaned and assessed by RN #3 -Her urethral meatus tissue was red -Resident #18 said the area at the catheter insertion site and surrounding tissue had been hurting for at least a week -The hospice nurse was contacted, new orders to apply triple antibiotic ointment for three days was obtained, and orders were received to change the catheter on this evening shift -On 10/18/18 at 1:12 a.m., RN #4 documented that Resident #18 reported,on 10/17/18 at 7:15 p.m., that it was hurting again down there, -Resident was medicated for discomfort, one hour prior to catheter change. There was no progress note documentation which addressed the removal of the catheter, condition of her urethra, condition of the catheter status [REDACTED]. According to the 10/18/18 at 1:45 a.m. Weekly Summary, RN #4 performed a skin assessment and did not document the condition of Resident #18's urethra nor her urethral tissue in the surrounding area. According to the (MONTH) (YEAR) progress notes: -On 10/18/18 at 2:28 a.m. Resident #18 yelled and called out Help me Jesus! during attempts to reinsert a new catheter -Multiple attempts to insert a new catheter were unsuccessful -Facility staff were unable to move her legs far enough apart to visualize her urethra -The hospice nurse was notified -There was no documentation which addressed the condition of her urethra According to the 10/18/18 hospice Progress Note, at 3:22 a.m. a new catheter was inserted for Resident #18, per the facility's nursing request.The previous catheter had been removed by a facility nurse. According to the (MONTH) (YEAR) CPOs, it revealed: -A 10/18/18 physician order [REDACTED]. According to the (MONTH) (YEAR) progress notes: -On 10/18/18 at 4:32 a.m. the hospice nurse inserted a new catheter -TAO was applied to her urethral meatus

Based on observations, record review and interviews, the facility failed to ensure one of one resident (#11) of 25 sample residents who required oxygen, received the proper oxygen care. Specifically the facility failed to ensure: While the resident received oxygen, her oxygen sats were monitored; The resident had a current physician's order [REDACTED]. The resident continued receiving oxygen, although the oxygen was discontinued; The resident ' s MDS was not accurate for the use of oxygen.; and The resident ' s care plan reflected inacurate current physician orders [REDACTED]. Findings include: I. Facility policy The facility ' s oxygen administration policy was provided by the by the health administration manager (HIM) on 10/18/18. According to the policy, its purpose was to provide guidelines for safe oxygen administration. The policy read in pertinent part: - Verify there was a physician's order [REDACTED]. - Review the resident ' s care plan to assess for any special needs of the resident. III. Resident #11 1. Resident status Resident #11, age 92, was admitted on [DATE] . According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 7/28/18 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS) due to severely impaired cognition. The staff interview documented the resident had both short and long term memory problems, had severely imparied decision making skills, disorganization and inattention. The resident required extensive assistance for transfers, locomotion, bed mobility, dressing and eating. On the 7/28/18 MDS, the resident was not marked for oxygen therapy. The resident was on oxygen therapy according to the 4/27/18 MDS. 2. Record review The (MONTH) (YEAR) CPO did not show Resident #11 had an order for [REDACTED].>The care plan, initiated 2/7/17 and revised 8/30/18, identified the resident was at risk for impaired gas exchange related to sleep apnea. Inventions included to apply oxygen at 3 liters per minute (LPM) per nasal cannula to maintain saturation (sats) at or above 88% and check sats every shift. 2. Observations The resident was observed in the TV lounge on 10/15/18 at 8:40 a.m. The resident had deep imprint lines on her cheeks, which appeared to be from oxygen tubing. She was not wearing oxygen. The resident was observed in bed sleeping on 10/16/18 at 8:43 a.m. The oxygen concentrator was on and resident wore oxygen via nasal cannula. -At 3:25 p.m., Resident #11 was awake in bed, she had oxygen via nasal cannula. -The resident was observed in bed sleeping on 10/17/18 at 9:29 a.m. Her oxygen was on via nasal cannula. 3. Record review Computerized physician orders The CPO dated 10/18/18, which included current and discontinued orders, revealed on 8/30/18, Resident #11 had orders for oxygen at 3 LPM per nasal cannula continuous to maintain sats at or above 88% two times a day was discontinued. The 10/2/18 CPO read to discontinue oxygen at 2 LPM per nasal cannula continuous to maintain sats at or above 88% two times a day related to obstructive sleep apnea, and dependence on supplemental oxygen. The 10/3/18 resident oxygen orders read 2 LPM per nasal cannula continuous at night to maintain at or above 90% every night shift, were discontinued. The 10/5/18 oxygen orders revealed the resident had an order to discontinue the oxygen at 2 LPM per nasal cannula continuously at night to maintain sats above 90% at bedtime for [MEDICAL CONDITION]. The resident did not have a current order for oxygen. A 10/17/18 nurse's note written at 10:08 a.m., documented Resident asleep in bed, removed oxygen, oxygen (O2) sats at 95% on room air (RA). A 10/17/18 nurse ' s note written at 10:38 a.m. documented The resident was asleep in her bed, O2 sats at 90% on RA, removed oxygen concentrator. The weights and vital summary showed Resident #11 sats were taken four times in (MONTH) and included: - On 10/1/18 91% on RA - On 10/3/18 at 89% on RA - On 10/5/18 at 93% on oxygen via nasal cannula. - On 10/17/18 at 10:11 a.m. her O2 sats were at 95% on RA. The 10/17/18 at 10:38 a.m. nursing note documented oxygen sats were at 90%, was not recorded on the weights and vital summary. The treatment administration record (TAR) for oxygen indicated the resident ' s oxygen saturation level with oxygen was 89% on 10/2/18 and 93% on 10/4/18. Based on the review of TARs and the weight and vitals summary, the resident ' s sats were read and recorded daily in September. The resident ' s oxygen saturation levels were not obtained 10/6/18 to 10/16/18, although the resident received oxygen therapy. Upon review of the most recent physician visit dated 9/13/18 there was no documentation related to the resident ' s use of oxygen. 4. Interviews The certified nurse aide (CNA) #6. was interviewed on 10/17/18 at 9:19 a.m. The CNA said Resident #11 was currently on two liters of oxygen but she thought they were trying to titrate her. The registered nurse (RN) #1 was interviewed on 10/17/18 at 9:47 a.m. She said Resident #11 used oxygen continuously in the past. She said her sats have been in the low 90s so O2 was not needed during the day. RN #1 reviewed her TARs and said there is nothing on the TARs right now for oxygen. RN #1 reviewed the CPO. She stated that she could not find a current order for oxygen and should have orders when oxygen is in place. CNA #2 was interviewed on 10/17/18 at 12:55 p.m. after she assisted Resident #11 to bed. She said Resident #11 continued to use oxygen when she was in bed because she had trouble breathing without it. The CNA said they had kept the oxygen at two liters. RN #2 was interviewed on 10/18/18 at 9:16 a.m. She said she believed Resident #11 ' s oxygen was discontinued recently. She reviewed the CPO for oxygen and said the most recent discontinue date was on 10/5/18 but there had been several orders that were edited and changed. RN #2 was interviewed a second time on 10/18/18 at 2:09 p.m. She said the lines on her cheeks was from recent use of oxygen. The RN said she observed the resident wearing oxygen a few days prior, even though she did not have orders. The director of nursing (DON) was interviewed on 10/18/18 at 4:35 p.m. The DON said Resident #11 ' s oxygen was removed earlier this week because she did not have a physician's order [REDACTED]. She said a nurse should not change a physician's order [REDACTED]. She confirmed there was not an immediate concern but said Resident #11 had remained on oxygen after it was discontinued because she had not removed it from the care plan or the CNA task guide.

Based on observations, record review and interviews, the facility failed to ensure one (#34) of one resident reviewed for dementia care of 25 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure: -The necessary care and services were person-centered and reflected the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety for resident #34. - Measures were implemented to anticipate needs and provide safety for resident #34 who was at a high risk for isolation. Findings include: I. Facility Policy The facility's Dementia Clinical Protocol (policy 11/1/17) read, As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia or otherwise irreversibility impaired cognition. -For the individual with confirmed dementia the staff and physician will identify a plan to maximize remaining function and quality of life. -The physician will help define potential benefits and risks of medical interventions, including [MEDICATION NAME] inhibitors and other medications used to enhance or stabilize cognition. -The physician will address conditions and factors that may be causing additional cognitive impairment or increasing risk in the individual with dementia; for example, by adjusting or discontinuing medications that adversely affect cognition or behavior, increase risk of fluid and electrolyte imbalance, cause anorexia or weight loss, etc. The physician and staff will identify and address ethical issues and related treatment options; for example management of continued functional decline or unplanned weight loss in someone with late stage dementia. The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia based on pertinent clinical guidelines and regulatory expectations. -Medications should be targeted to specific symptoms and should be used in the lowest possible dose for the shortest possible time, unless a clinical rationale for higher doe or longer-term use is documented. -If a psychiatrist consultant was called to help manage behavioral issues in the individual with dementia, the attending physician will retain an active role by reviewing the consultants recommendations, addressing medical issues that affect mood, cognition, and function; helping monitor for complications related to treatment and evaluating subsequent progress. -The physician should not simply defer the consultant for everything related to dementia and related behavior problems. The staff will monitor the individual with dementia for changes in condition and decline in function and report these findings to physician. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia development of new acute medical conditions or complications, changes in resident or family wishes etc. The physician and staff will review the effectiveness and complications of the long-term use of medications used to enhance cognition and of psychoactive medications used to manage behavioral and psychiatric symptoms related to dementia and will adjust stop, or change such medications appropriately. II. Resident Status Resident #34, age 70, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders, [DIAGNOSES REDACTED]. According to the 10/16/15 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The MDS documented the resident's cognitive skills for daily decision-making was severely impaired. The resident had no mood symptoms. The resident had verbal and other behaviors directed towards others. He required extensive assistance for bed mobility, transfers, grooming and toilet use. He was always incontinent of bladder and bowel. The MDS revealed no falls since admission. According to the 3/20/18 annual MDS assessment, the resident preference for customary routine activities revealed the resident enjoyed listening to music, doing things in groups, participating in favorite activities, spending time outdoors and attending religious activities. III. Observations The resident was continuously observed: - On 10/15/18 from 8:40 a.m., to 1:35 p.m. - On 10/16/18 from 8:23 a.m. to 1:32 p.m. - On 10/17/18 from 8 a.m. to 1:20 p.m. - On 10/18/18 at 9:30 a.m. During these observations, the resident was observed: - Spending most of his time in his room sitting on the floor on the mats or on the room floor. - Spending much of his time slumped over slapping the floor. -The resident would moan loudly screaming at times. -The resident would hit his head with the palm of his hand. He would hit the walls and the wooden gate with his hand. -The resident's wheelchair was observed in front of the resident's wooden gate with the wheels locked. -The resident was taken out of his room for meals only and assisted immediately back to his room after he was done with his meal. -The resident was observed with his name clearly written on his tennis shoes. -He would scoot on his buttocks and slap the mats on the wall and floor. 10/15/18 -At 8:55 a.m., the resident was sitting on the floor trying to feel around his room. The resident was observed to be slapping the floor with his hand and hitting the side of his head with the palm of his hand. The resident's w/c was in front of the wood gate and the brakes were locked. The resident was observed trying to move his w/c and would bang his hand on the side of the w/c. -At 10:30 a.m., the resident was sleeping on the floor wrapped in his blanket. He was lying partially on the mat and the floor. -At 11:30 a.m., the resident was in the dining room sitting at the assisted dining table. The resident was observed to be moaning loudly and hitting the side of his head with his palm of his hand. The certified nursing aide CNA, who was assisting the resident, would give the resident a spoonful of food as an attempt to stop resident from self-injurious behavior. The CNA did not attempt to redirect resident or try to deter the resident from hitting himself. -At 12:38 p.m., the resident was escorted back to his room. The CNA placed Resident #34 behind the gate and locked the brakes on his w/c. CNA exited the room. -At 1:08 p.m., the resident was observed sitting in his w/c hitting the walls with his hands and hitting the walls. The resident was yelling out with no staff responding. The resident was observed to be hitting the side of his head with his palm causing the head to snap to the side. No staff members were observed to intervene while the resident was yelling or hitting himself. -At 1:28 p.m., the resident was observed to stretch his legs out and slide out of his w/c. As he slid out of his w/c, he bumped his shoulders and his head bounced off the back of the seat. The w/c tipped a bit forward but did not flip over. The resident then was seated on the floor. The resident's w/c was still in front of the wooden gate. 10/16/18 --At 8:28 a.m., the resident was seated at the assisted dining room eating breakfast. He would moan and hit his head with the palm of his hand. -At 8:34 a.m., the resident was escorted to his room. The CNA placed the resident behind to wooden door and locked his breaks. Closed the door and exited the resident's room. -At 8:44 a.m., the resident was observed sitting in his w/c. He was moaning, which could be heard at the end of the hall. No staff were observed to engage the resident. -At 8:57 a.m., CNA entered resident's room to provide perineal (PERI) care. The CNA exited the resident's room. The resident was observed to be sitting on the floor. -At 9:16 a.m., the dietary manager (DM) was asking all residents' what their preference was for lunch. The DM looked in Resident #34's room and was observed not to engage resident or ask resident what he wanted for lunch. -At 9:41 a.m., licensed practical nurse (LPN) #2 entered Resident #34's room. She looked over the gate and exited the room within approximately 30 seconds. She did not engage resident or communicate with Resident #34. -At 9:45 a.m., maintenance staff entered resident's room and were discussing repairs in the restroom. Activities assistant entered the Resident #34's room. She talked to the maintenance worker for a short time. She exited the resident's room and was observed to not ask the resident if he wanted to participate in daily activities. -At 10:12 a.m., the hydration cart was being passed through the halls. The SNA was observed filling the resident's water. She did not, engage, or speak to Resident #34. -At 10:23 a.m., the shower aide was observed getting the resident ready for a shower. She was observed to assist resident to the shower chair. -At 12:13 p.m., Resident #34 was seated at the assisted dining table. He was observed moan loudly and was observed hitting the side of his head with the palm of his hand. CNA was observed trying to redirect resident behavior but was unsuccessful. -At 12:35 p.m., the resident was escorted to his room. The CNA placed the resident in his room, closed the wooden gate and exited the resident's room. -At 1:23 p.m., AA was observed looking into Resident #34's room. She was heard stating, Oh he was sleeping. She exited and did not return. -At 1:33 p.m., the resident was on the floor next to his w/c sleeping. The resident was tightly wrapped in his blanket next to his w/c. The resident was observed sleeping with half of his body on the mat and his trunk on the floor and the w/c next to his head. The resident's w/c was locked and in front of the wooden gate. 10/17/18 - At 8:31 a.m., the resident was observed sitting in his w/c in his room. The resident was hitting himself in the head with his palm of his hand. He was observed hitting the walls and the top of the gate with his hand. Resident #34 would yell out as he was hitting himself walls and the wooden gate. No staff were observed to engage or check on the resident. -At 8:51 a.m., a nurse was observed entering the resident's room. She exited the room at 8:52 a.m. She did not engage or speak to the resident. -At 8:57 a.m., the resident started yelling out with no staff members coming to his room to check on the resident. -At 9:10 a.m., the resident continued to yell out. The resident continued to hit himself, walls and the wooden gate. -At 9:23 a.m., CNA # 12 entered the resident's room. The resident continued to yell as the CNA tried to redirect him. The CNA tried to stop the resident from hitting himself but was unsuccessful. The CNA was observed trying to coax the resident get out of his w/c. The resident continued to yell out and became agitated. Resident #34 was observed to slide out of the w/c. He stretched his legs and proceeded to slide out of the chair. The resident was observed to sliding out of the w/c sideways and hit his shoulder and head on the w/c. The resident slide onto the floor. CNA #12 was heard telling the Resident #34, Man you scare every time you slide out of your chair. CNA #12 removed the resident's w/c and exited the resident room. -At 1:20 p.m., Resident #34 was observed on floor scooting himself along the floor from the inside of his room. He scooted himself outside of the gated door (which was open wide enough for him to get through). He was observed sitting outside of the gate and was making his way to the threshold of the doorway to the hallway. CNA #6 observed Resident #34 sitting in the doorway. She called Resident #34 by his name and stated, Let's get back into your room. She was observed motioning the resident back into his room. She was observed taking steps toward him (as in a shoeing motion) saying come on let us get you back into your room. She continued to take steps toward the resident and continued a shoeing motion. This continued until he was back behind the wooden gate in his room and then closed the wooden gate. IV. Facility failures A. Failure to treat Resident #34 in a dignified manner. Resident #34 was observed throughout the survey on 10/15/18 to 10/18/18. During this time, the resident wore a pair of tennis shoes, which had his name clearly written. The letters were approximately one inch and a half high. The facility failed to address the residents clothing needs. -Resident #34 was observed to be left in his room at all times and only taken out of his room for meal times. B. Record Review The care plan, initiated 11/15/10 and revised 9/18/18, identified the resident was at risk for isolation due to need for gated room as evidence by (AEB) danger to self-secondary to dx of MR and impaired vision. Interventions include take resident to the dining room or outside for meals (during nice weather). See his activity care plan for other interactions he enjoys. Observe resident for increased agitation while he was on the floor in his room. Open gate while providing care for resident as needed. Please allow resident to lower himself to floor from wheelchair or mattress with minimal assist at times. C. Staff interviews Laundry staff (LS) was interviewed on 10/18/18 at 10:23 a.m. She said the resident's should not have their names written on their clothes where others can see it. She said facility would tell the families during admission not write their names on their cloths as the facility will do it. She said it would be her expectation that the resident's name should not have been written on his shoes. The director of nurses (DON) was interviewed on 10/18/18 at 2:30 p.m. The DON was told of the observation above. She said, Staff should check on resident regularly. She said it was hit or miss with Resident #34. She said the resident has self-injurious behaviors, which we try to redirect. We have tried various interventions but it was difficult with Resident #34. She said the resident at times will strike out at staff and she showed her arms as she had been hit and scratched by resident # 34. She said the resident liked to stay in his room as he gets agitated when taken out which was why he was only taken to meals. She said the negative outcome would be dignity, which she said she would take care of immediately. The activity director (AD) was interviewed on 10/18/18 at 3:34 p.m. The AD was told of the observations above. She said we have offered various interventions such as aromatherapy a weighted blanket. She said the resident receives 1:1 five times a week. She said the resident was able to understand simple conversation. She said, No activities does not ask Resident #34 if he would like to participate in outside activities. CNA #13 was interviewed on 10/18/18 at 4:43 p.m. She said the resident was taken out of his room only for meals and then he was returned to his room. She said she had never seen the resident outside. CNA #14 was interviewed at 4:58 p.m. He said the resident was only taken out of his room for all meals. He did have behaviors, which did occur in the dining room. CNA # 8 was interviewed on 5:14 p.m. She said the resident was assisted from his room to meals and back to his meals. She said she had never seen him in activities or outside. She said she would turn the television on when she assisted him back to his room. V. Failure to provide an individualized program of meaningful activities for the resident A. Professional Reference According to the University of Rochester Medical Center, Older Adults and the Importance of Social Interaction, (YEAR), https://www.urmc.rochester.edu/encyclopedia/content.aspx (March (YEAR)), in pertinent part: Specific health benefits of social interaction in older adults include: Potentially reduced risk for cardiovascular problems, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] arthritis. Potentially reduced risk for [MEDICAL CONDITION]. Lower blood pressure. Reduced risk for mental health issues such as depression. Conversely, social isolation carries real risks. Some of these risks are feeling lonely and depressed. Being less physically active. Having a greater risk of death. Having high blood pressure. Social interaction helps keep your brain from getting rusty, but it's most effective when coupled with an overall healthy lifestyle, including a nutritious diet and physical activity . B. Record review The care plan, initiated 11/5/10 and revised 9/18/18, identified the resident liked to be softly spoken too, having his back/feet/arms/ rubbed, receiving special snacks, candy, cookies and going outside at times when the weather was nice. He has a TV with recorder he seem to be most comfortable by food network or quieter channels he usually does not engage in TV but at times it seem to calm him down. He prefers a quieter environment most of the time. He was most relaxed in his room, covered with his blanket from head to toe unless it was too warm. He was not generally interested in most tactile stimulation items such as items, which make noise. The resident responds better to staff he knows. He was dependent upon staff for cognitive stimulation and social interaction due to his diagnosis. The resident spends very little time in-group activities due to anxiety/agitation exhibited when environment was loud or busy unless he was eating. Interventions include assist him to schedule activities he likes as tolerated. Encourage and assist him to sensory stimulation group activities such as high five music, being outside and food activities. Provide soft sound stimulation, incorporate aromatherapy, taste stimulation, touch stimulation, and provide 1:1 activities. Have resident sit away from source as needed in-group activities to prevent over stimulation. When he yells out grunts or hits self-offer, him snacks. Remind resident yelling can be scary for other residents. Turn white noise on radio, start aromatherapy, take him outside or for strolls in hallway. If any of these interventions do not work, notify nurse. The activities quarterly assessment/progress note date 9/18/18 documented in part: resident participated in one to two group activities. Resident was passive in most activities, needs assistance to attend activities, needs a scheduled 1:1 program. His behavior in activities was disruptive and required maximum assistance during activities. Resident finds meaning in visiting staff, visiting with family and 1:1 program. 2. Staff interview The activities director (AD) was interviewed on 10/17/18 at 4:31 p.m. The AD was told of the observations of resident # 34. She said they did not provide specific special needs programing for residents with dementia. She said she provides a High Five activity that targets sensory stimulation. The activity is for all residents. The AD stated sensory stimulation provides the benefit of keeping the resident alert and involved with their surroundings. The AD said she does provide a meditation program that targets the behavior of agitation. The activity assistant was interviewed on 10/18/18 at 1:15 p.m. She said the resident was limited in scope of what to do. He enjoyed reading books and pictures and pictures on his wall. Whenever he gets tired , he puts a blanket over his head and sleeps. She said 1:1's after lunch when he returned to his room. She said that cannot do the things with the Resident #34 as I do with other residents. There's not much we can do other than the 1:1 with Resident #34 He needs a companion who can talk to him and respond to him. He will let you know if he does not want to. The resident was only invited to large groups or special activities. The AD was interviewed again on 10/18/18 at 3:34 p.m. She said she they have tried various activities with Resident #34 such as aromatherapy and giving him a weighted blanket but have not had any luck. She said everybody was afraid of trying something new for Resident #34. She said she has made suggestions to change it up but has not had any follow up or support. She said the resident should have been invited, encouraged to participate in all activities. CNA #13 was interviewed on 10/18/18 at 4:43 p.m. She said she has never seen the resident outside. CNA # 8 was interviewed on 5:14 p.m. She said she has never seen him in activities or outside. She said she would turn the television on when she takes him back to his room. VI. Failure to implement measures to anticipate needs and provide safety for Resident #34 who had self-injurious behaviors. 1. Record review The care plan, initiated 11/5/10 and revised 9/18/18, identified the resident required many interventions to keep self-safe related to (r/t) [DIAGNOSES REDACTED]. The resident was unable to use call light. Interventions include 8/8/18 self-inflicted red area to face / perineal care orbital area: Monitor, red direct, monitor pain, redirect with activity of choice. Allow the resident to rearrange his room to his preference. His room may look messy at times as he likes to scoot around and has a history of throwing and moving items. Staff to monitor for safety and wellbeing. Encourage time in-group activities (i.e. activity time outside, meals, and time in lobby. Ensure that padding on wall is in an appropriate place depending on where the resident washitting or banging head/foot. Frequent checks for safety due to inability to use call light. Nursing log note dated 9/9/18 at 10:47 a.m., documented in part: It was reported to this nurse resident had his right lower forearm/wrist in his mouth this a.m., now has a reddened mouth mark to the area but he does not have teeth so he did not break skin. Nurse aides reported when they went into care for him this a. m., he had his right lower forearm/wrist in his mouth. After they got resident to take his arm out of his mouth, he started slapping the floor and himself. This nurse did not note any other reddened marks from this morning. Resident was unable to say what happened. He was noted to be yelling this a.m. The nurses' aides did stop to report to this nurse the a.m., care issues when they started care as resident does have a new reddened area to the right forearm/wrist area in the shape of his mouth. After resident took his arm out of his mouth, this nurse did hear him yelling and moaning very loudly down the hall. The nurse's aide di report he started slapping the floor and himself. No other skin issues noted at this time. Residents brother who as power of attorney POA was in this am. In addition, this nurse did report the changes to him, the provide was update. Nurse log not dated 8/8/18 at 11:00 a.m., documented in part: late entry; noted at 11:00 a.m. CNA noted to this writer resident had a purplish-greenish discoloration around his right peri orbital area. Blanch able redness also noted to right cheek. Resident had been observed slapping and rubbing his right palm of hand against right cheek and right eye during this morning shift. Attempts redirection have been made and effective for short period. Resident would then begin yelling out again or hitting himself. Log note dated 8/9/18 at 10:19 a.m., documented in part: interdisciplinary team (IDT) met and reviewed incident of discoloration to right periorbital area. Self-inflicted. Daily behaviors are monitored. Medical doctor and POA notified. Log note dated 8/9/18 at 10:19 a.m., documented in part: IDT met and reviewed self-inflicted redness to right forearm. Nurse practitioner (NP) aware and was reviewing, medications changed. Care plan conference review dated 9/11/18 at 12:14 p.m., documented in part: attendee's assistant director of nursing (ADON, dietary, activities, SSD, NP and POA. Nursing care plan changed; No. activities care plan was changed with TV and cable in resident's room. Social care plan was not changed. Additional comments; resident refused to attend care plan. Copy of care plan and medication list given to POA. A written request was made for safety, behavior assessments and facility interventions for incidents dated 9/9/18 and 8/8/18. Written request form was returned on 10/18/18 at 2:22p.m., with no information requested. At time of exit, no further information was provided. 2. Staff interviews CNA #7 was interviewed on 10/16/18 at1:32 p.m. She said we would put him in his room after meals. We will leave him in his w/c lock his breaks and wait for him to get out of his w/c himself. She said he could become physically aggressive so I just leave him alone until he gets out of his w/c. It usually takes him anywhere from and half hour to an hour to get out of his w/c. Licensed practical nurse (LPN) #2 was interviewed on 10/16/18 at 1:43 p.m. LPN #2 said the resident was always yelling or moaning. She said the resident would get out of his w/c by himself. She said the CNA's were supposed to check on him regularly. CNA #12 was interviewed on 10/17/18 at 9:23 a.m. He said Resident #34 could get physically aggressive when providing care so I have to be careful. If he becomes aggressive, I will come back later and try. Resident #34 did better with staff who he was familiar with which was a problem with different staff providing care. CNA #13 was interviewed on 10/18/18 at 4:43 p.m. She said the resident was always yelling or moaning. She said he was always hitting himself in the head. She said she would try to redirect him but it usually got him more agitated. She said she would come back later to see if he would accept assitance. CNA #14 was interviewed at 4:58 p.m. He does have behaviors, which he takes into the dining room. He will hit himself in the head with his hand and would yell out. CNA # 8 was interviewed on 5:14 p.m. She said the resident always has behaviors. She said that they just got used to the behaviors. The social service director (SSD) was interviewed on 10/18/18 at 10:59 a.m. SSD was told of the observation listed above. He said we try to make Resident #34 as safe as we can possibly can without him injuring himself. He said the resident had several behaviors from hitting himself on the head, slapping the floor, walls and yells out daily. He said we discuss Resident #34 during morning meeting and discuss what changes need to be done. The SSD acknowledged the resident hitting his head, however he was not involved in any solution. As for his room, it was set up as was for quite some time. It was his understanding Resident #34 would throw furniture and tip furniture over. It would be the SSD's expectation we should have a quarterly assessment for behaviors, safety and interventions for Resident #34. The DON was interviewed on 10/18/18 at 2:30 p.m. The DON was told of the observation above. She said, Staff should check on resident regularly. She said it was hit or miss with Resident #34. She said the resident has self-injurious behaviors, which we try to redirect. We have tried various interventions but it was difficult with Resident #34. She said one intervention, which was used with the resident as giving him chocolate to redirect him. She said we have tried a lot of intervention with Resident #34 and make changes with IDT. Another intervention was a helmet but he kept taking it off.

Based on observation, record review and interviews, the facility failed to ensure that one (#5) out of four residents reviewed for oxygen out of eight sample residents, received necessary respiratory care and services. Specifically, the facility failed to ensure that resident #5, with a history of non-compliance and [MEDICAL CONDITION], was administered and monitored for oxygen as ordered by the physician Findings include: I. Professional Reference According to Christine McDonald (2014), Oxygen therapy for [MEDICAL CONDITION], Journal of [MEDICATION NAME] Disease, pp 6 (11). .[MEDICAL CONDITIONS] is a leading cause of disability and death globally, characterized by progressive breathlessness, loss of function and, in its later stages, chronic hypoxaemia. Long-term continuous oxygen therapy increases life expectancy in patients with severe resting hypoxaemia. It has been known for decades that patients with acute exacerbations of [MEDICAL CONDITION] may develop worsening hypercapnia with the application of supplemental oxygen, particularly at high concentrations. The mechanisms underlying this phenomenon relate to a combination of (I) worsening ventilation perfusion mismatch secondary to attenuation of hypoxic [MEDICAL CONDITION]; (II) the Haldane effect which involves displacement of carbon [MEDICATION NAME] bound to hemoglobin by increased oxygen concentration; and (III) hypoventilation. The adverse effects of high concentrations of supplemental oxygen were recently confirmed in a study by Austin et al. which reported an increase in mortality for patients randomized to receive high concentration oxygen versus those who received low concentration titrated oxygen to a target saturation range of 88-92% II. Facility Policy on Pulse Oximetry, last revised 10/10. In pertinent part. To assess arterial blood oxygenation toward evaluating respiratory status during ventilation, acute illness, activity, and sleep and to evaluate the effectiveness of therapeutic interventions. III. Resident #5 A. Resident status Resident #5, age 77, was admitted on [DATE], and readmitted on [DATE]. According to the face sheet, the [DIAGNOSES REDACTED]. The 2/16/18 minimum data set (MDS) assessment documented Resident #5 had moderate cognitive impairment as evidenced by a brief interview for mental status (BIMS) score of 11 out of 15. The resident was coded as extensive assist of one for activities of daily living. The resident was documented to be on oxygen. B. Observations On 2/14/18 at 11:38 a.m., the resident was asleep in his bed. The resident's room oxygen concentrator was turned on and set at 3 LPM (liters per minute), but the nasal cannula was observed laying on the floor. The resident ' s portable oxygen concentrator, attached to the back of his wheelchair, was still on and set to 4 LPM. Staff was observed entering the resident ' s room after the surveyor exited. On 2/14/18 at 11:45 a.m., the resident was observed asleep with his oxygen nasal cannula correctly placed, and the concentrator set at 3 LPM. On 2/21/18 at 12:43 p.m., the resident was observed sleeping in his bed with the nasal cannula correctly placed. The oxygen concentrator was set at 3.5 LPM. On 2/22/18 at 9:45 a.m., the resident was observed asleep in his bed, with the nasal cannula correctly placed. The oxygen concentrator was set at 3.5 LPM. C. Record Review The (MONTH) (YEAR) Medication Review Report revealed a 1/18/18 physician order for [REDACTED]. The (MONTH) (YEAR) Medication Review Report revealed a 1/17/18 physician order to monitor for increased shortness of breath every shift. The order specifically stated to document any behaviors in the resident's progress note, as it related to the resident ' s use of [MEDICATION NAME], not oxygen. The resident record did not have a physician order to monitor or document the resident ' s oxygen saturation level, as it pertains to shortness of breath. No baseline or parameter was established to ensure effective monitoring and assessments of the resident ' s oxygen usage. A progress note on 1/9/18 documented that the resident was found in his room with his oxygen off, and an oxygen saturation of 82%. The resident was replaced with oxygen, and his saturation level increased to greater than 90% after 3 minutes. The progress note indicated that 25 minutes later the resident was at 98% on 10 LPM, and was therefore decreased to 6 LPM. There was no physician order to adjust the resident ' s oxygen usage. A progress note on 2/10/18 documented that the resident displaces oxygen cannula while resting in bed, and his oxygen saturation was at 84%. After oxygen was provided, the oxygen saturation was at 96%. A progress note on 2/11/18 documented that the resident was resting without oxygen on, and his oxygen saturation was at 74%. Oxygen was placed at 5 LPM, and the saturation increased. There was no physician order to adjust the resident 's oxygen LPM. The (MONTH) (YEAR) vitals report revealed the resident's oxygen saturation level was checked only on 1/2/18 - 1/5/18 and 1/8/18 - 1/10/18. Although the resident had low oxygen saturation on 1/9/18 due to removal of his oxygen, the resident was only monitored until 1/10/18. The (MONTH) (YEAR) vitals report revealed the resident's oxygen saturation was checked only on 2/15/18 and 2/22/18, even though the resident was documented to have removed his oxygen on 2/10/18 and 2/11/18 and developed [MEDICAL CONDITION], requiring assistance. The care plan, last updated 5/16/17, failed to reference the resident's oxygen flow rate (LPM). It also failed to show how the resident's oxygen saturation level was to be checked, the resident's history of altering the LPM, and the resident ' s recent hypoxic events. A physician progress notes [REDACTED]. No change in physician orders for respiratory care were documented in the resident record. D. Interviews Certified nurse aide (CNA #1) was interviewed on 2/21/18 at 12:45 p.m. She said that the CNAs were responsible for refilling the oxygen tank. She said that they will fill them in the mornings, when they get the residents up, around 6:00 a.m. The CNA #1 said that she would look at the oxygen tank again after lunch, before many of the residents take a nap. The CNA said that she had not been informed of any established process to follow in regards to ensuring the tanks were full, or that the residents on oxygen were properly monitored. The CNA said she had never been asked to check a resident's oxygen saturation level. CNA #2 was interviewed on 2/22/18 at 9:52 a.m. The CNA said that the facility did not have a developed process to monitor oxygen. The aide said she filled oxygen tanks every few hours, depending on how many liters the resident was ordered. The aide said that most residents at the facility are on a specific liters per minute, according to the physician orders. The CNA said she would not change a resident's oxygen liters unless the nurse asked her to. The CNA said she did not check oxygen saturation levels on the residents. The CNA said the resident used to change his oxygen liters by himself, but he has declined recently, and was less capable. Registered nurse (RN #1) was interviewed on 2/22/18 at 12:05 p.m. The RN said that the CNAs filled the oxygen concentrators in the morning and at the end of their shifts. The nurse said she would check resident oxygen saturation levels only if there was a physician order. RN #2 was interviewed on 2/22/18 at 12:55 p.m. The RN said that she would monitor a resident's oxygen if there was a physician order. She said that Resident #5 often removed or adjusted his oxygen. The RN said she was not sure why the resident did not have a direct order to document his oxygen saturation levels. The RN confirmed that his oxygen saturation levels had been low recently. The nurse said that the resident ' s oxygen orders were written in the computer system in all caps, which made it look like a standing order. The nurse said that this might be a reason why oxygen saturations were not required in the computer. After reviewing the resident's record the RN confirmed that Resident #5's oxygen saturations were not consistently monitored or charted. The nurse said that even a resident on hospice or comfort care should have their oxygen monitored, as the use of oxygen assisted in keeping a resident comfortable. The nurse said that a parameter for a resident's oxygen would be helpful. CNA #3 was interviewed on 2/22/18 at 3:40 p.m. The CNA said that he tried to check the portable oxygen concentrators whenever he had the time.

Based on observations and staff interviews, the facility failed to maintain an infection control program designed to prevent the spread of disease and infection. Specifically, the facility failed to: -Ensure that oxygen/nebulizer equipment was cleaned and stored in a sanitary manner; and -Ensure personal use items were labeled and stored appropriately. The finding included: A. Oxygen Tubing Observations - On 4/10/17 at 12:48 p.m. in room [ROOM NUMBER] oxygen tubing was observed laying on the bed. - On 4/10/17 at 2:31 p.m. in room [ROOM NUMBER] oxygen tubing was observed laying on the bedside table. - On 4/10/17 at 2:32 p.m. in room [ROOM NUMBER] oxygen tubing was observed hanging over the arm of a wheelchair with the nasal cannula sitting on the wheelchair seat. - On 4/10/17 2:32 p.m. in room [ROOM NUMBER] oxygen tubing was observed laying across bed. - On 4/11/17 at 1:30 p.m. in room [ROOM NUMBER]A oxygen tubing was observed to be hanging on the side of the concentrator. - On 4/12/17 12:42 p.m. in room [ROOM NUMBER]A the cannula of oxygen tubing was hanging on the wheelchair handle. Staff Interview The assistant director of nursing and the director of nursing were interviewed on 4/12/17 at 2:00 p.m. They said when the oxygen was not being used the tubing should be kept off the floor in the plastic bag that was attached to the concentrator or portable canister. If the cannula touches an unclean surface then it would be replaced. B. Oxygen Tubing Observations: On 4/10/17 at 11:19 a.m., a portable oxygen tank was observed sitting on a side table outside the dietary office. The oxygen tubing was not bagged and dangled on the floor and table. - At 11:35 a.m., a female resident came in from the outside smoking area to the portable oxygen tank. She placed the tubing over her head and the nasal cannula into her nose. She walked away with the use of a walker. On 4/11/17 at 9:23 a.m., a resident removed her portable oxygen tank and tubing and placed them on the side table outside the dietary office. The tubing was not bagged or properly stored. On 4/12/17 at 8:28 a.m., a resident removed her portable oxygen tank and tubing and went outside with help from the activity staff member. The nasal tubing was placed on the table and not properly stored. - At 8:29 a.m., a separate resident removed her portable oxygen tank and tubing and went outside. Her tank was next to the tank previously removed and the tubing was not properly stored and lying on the side table. - At 8:30 a.m., another tank was placed at the table and tubing not properly stored. There were three separate tanks for three different residents with tubing all on the side table. - At 12:36 p.m., the oxygen tubing attached to the oxygen concentrator in room [ROOM NUMBER] was found on the floor and not properly stored. Interviews: The dietary manager (DM) was interviewed on 4/12/17 at 8:32 a.m. She said there were three separate portable oxygen tanks stored on a table near the exit door towards the smoking area. She stated the tubing was not stored properly and should be bagged to prevent any potential infection control issues. She stated she would work on ensuring tubing would be stored appropriately. The activity director (AD) was interviewed on 4/12/17 at 8:35 a.m. She confirmed there were three separate portable oxygen tanks with tubing at the door near the smoking area not properly stored. She stated the nasal cannulas left on the table could present a possible infection control issue. She stated she would continue to come up with ways to reduce any infection control issues with tubing storage. The maintenance supervisor (MS) and housekeeping supervisor (HS) were interviewed on 4/12/17 at 12:36 p.m. The MS and HS confirmed the resident's oxygen tubing was found on the floor in room [ROOM NUMBER]. They stated there was a bag on the concentrator and it should be used to store tubing to prevent any potential infection control issues. C. Personal-Use Items Observations: On 4/09/17 at 8:10 p.m., the bathroom on the Canyon unit was observed. In the cabinet, there were multiple unlabeled house stock combs and brushes stored in the same cup-like container. There were various hairs of different length and colors in the combs and brushes. On 4/11/17 at 4:20 p.m., the bathroom on the Canyon unit was observed. Approximately ten house stock combs and four brushes were stored in a cup-like container. They brushes and combs were not labeled with individual resident names. The brush had hairs of various length and color. There were four unlabeled black combs stored in the sink in the bathroom. Staff Interview: The director of nursing (DON) was interviewed on 4/11/17 at 5:44 p.m. The DON confirmed the combs and brushes were house stock and were not labeled for individual resident use. The DON said she was not aware that the bath aide had been storing combs and brushes in bathroom in the manner observed. The DON was not aware of the facility having an approved disinfectant for barber/cosmetology implements. The DON said that it looked to her like the bath aide might be cleaning the combs in the sink. DON agreed the combs and brushes were stored in the sink and together in a cup. The DON said the brushes and combs were not stored in a sanitary manner and were a source of possible cross contamination. The DON said personal use items should not be shared between residents. The DON removed the combs and brushes from the cabinet.

Based on observations, record reviews, and interviews, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (#56, #58, and #64) of four out of five residents identified with ancillary concerns. Specifically, the facility failed to assist resident #56, resident #58 and resident #64 with dental needs. The findings include: 1. Resident #56 Resident #56, age 91, admitted into the facility 1/26/17. The 4/17 computerized physician orders [REDACTED]. According to the 2/5/17 minimum data set (MDS) the brief interview for mental status (BIMS) was not performed because the resident was rarely or never understood. The staff assessment for mental status (SAMS) showed the resident had both short-term and long-term memory problems. Her ability to make decisions regarding daily life tasks was severely impaired. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. There were no identified oral/dental issues identified on the MDS. Observations: On 4/10/17 at 4:01 p.m., the resident was seated in her manual wheelchair near the main entrance. The resident was missing teeth. There was one natural tooth with some plaque buildup around the tooth and gum. On 4/11/17 at 8:24 a.m., the resident was in the dining with breakfast in front of her. She had a breakfast sandwich with egg and cheese and a small yogurt. There was one full quarter sandwich left untouched, another quarter piece partially touched. The resident did not have any partial dentures in place as she attempted to eat. The resident was missing teeth with some decayed teeth. -At 12:01 p.m., the resident was in the dining room. There was food in front of her but she was not eating her meal. When greeted, she smiled and missing teeth were observed. Record Review: A review of the 1/13/17 physician note performed by the nurse practitioner (NP) revealed the resident was negative for dentures but positive for poor dentition, gingivitis, and decayed teeth. The NP's physical exam revealed the resident had very poor dentition with rotting and decaying teeth. She was partially edentulous with gingivitis present. The health maintenance was ordered on [DATE] for a dental exam. A review of the 4/17 CPO revealed on 1/26/17, an order for [REDACTED]. A review of the 1/27/17 admission nursing assessment revealed the resident had her own teeth. There was no mention of broken or carious, missing teeth. A review of the 1/27/17 social services assessment revealed the resident had her own teeth with some missing and broken. The resident's daughter requested the resident be seen for routine cleanings. A review of progress notes from 1/26/17 through 4/12/17 failed to show any evidence dental services were setup for the resident to be seen although 1/13/17 and 1/26/17 showed orders for dental exam/evaluation. A review of the 1/27/17 activity of daily living (ADL) care plan showed the resident had ADL self-care deficits and dental assistance was needed. The 2/7/17 dental care plan revealed the resident had care deficits related to carious teeth. The facility was to provide oral hygiene, refer to dentist for an evaluation, alignment, fitting, extractions. Interviews: The licensed practical nurse (LPN) #1 familiar with the resident was interviewed on 4/11/17 at 3:23 p.m. The LPN said the resident had missing and decaying teeth. She stated issues with not having teeth could be appearance issues and problems with eating. The LPN stated she knew the resident did not eat well. The social worker (SW) was interviewed on 4/11/17 at 3:25 p.m. The SW stated her department was responsible for monitoring ancillary services including dental. The SW reviewed her notes and acknowledged she spoke with the resident's daughter and the daughter requested the resident receive routine dental cleanings. The SW stated the last visit from the dental vendor to the facility was 12/16 although in 1/17, the facility was aware of the resident's dental condition and order for dental exam by the physician and NP. The SW said the dental provider only visited the facility twice a year. She stated they came in June/July and December. She stated routine dental services were not made available to residents any other time. She said if she was made aware of pain, she could setup emergent dental services. 2. Resident #58 Resident 58, age 57, admitted into the facility on [DATE] and readmitted again on 12/21/15. The 4/17 CPO revealed [DIAGNOSES REDACTED]. According to the 2/9/17 MDS assessment, the resident's cognition was intact with a BIMS score 12 out of 15. The resident had mouth and facial pain, discomfort and difficulty with chewing during the review period. Observations: On 4/10/17 at 3:26 p.m., the resident was in her room rolling cigarettes on her side tray table. The resident opened her mouth to show her missing and decaying teeth. There were multiple upper and lower teeth missing. Record Review: A review of the 4/17 CPO revealed on 11/5/15, an order for [REDACTED]. A review of the 2/8/17 social service assessment revealed the resident was seen by a dentist and had some teeth extracted. There was no additional information about further oral care needs to address. A review of the progress notes from 2/6/16 through 4/12/17 revealed: -On 3/24/17, the resident reported to a registered nurse (RN) at 12:15 a.m., her two front crowns fell . She stated the front crown had been loose from three weeks. The resident stated her insurance would not cover another dental visit until July 2017 and could not afford to pay for a dentist out of pocket. The RN stated to the resident to notify dental and teeth issues to the facility staff. There was no follow-up or referral to social services after it was made known of the resident's dental issues. -On 4/3/17, LPN #1 documented a housekeeper observed two teeth on the resident's dresser on 4/2/17. The LPN noted the two front teeth were joined together on the resident's dresser. The LPN notified social services, the assistant director of nursing (ADON), and director of nursing (DON) on 4/3/17. -On 4/5/17, the SW noted the resident had missing and carious teeth. The SW contacted the dental provider and was told the resident had used her Medicaid allotted money and would have to wait until June 2017. A review of the 2/8/17 dental care plan revealed the resident had carious teeth causing self-care deficits. An intervention was to refer to dentist for evaluation and recommendations. Resident Interview: The resident was interviewed on 4/10/17 at 9:01 a.m. She said she had problems with her teeth. She said the facility was not taking care of her problems in a satisfactory manner. She said she had some teeth pulled out but her money ran out and was told she would have to wait until July 2017 for additional dental services. The resident stated the facility informed her if she moved to another location, she could have a cheaper dental plan and dental services provided before July 2017. The resident stated she still needed some teeth pulled and wanted to get dentures. Staff Interview: The SW was interviewed on 4/11/17 at 3:25 p.m. She stated in 2/17, the resident thought she cracked a tooth and the dental vendor was contacted. The SW stated she was told by the dental provider, the resident exhausted dental services and could not been seen unless the resident wanted to be liable for payment and restoration needs. The SW stated if a resident was a Medicaid recipient; it was the responsibility of the facility to ensure all dental needs were met. Facility Follow-up: The SW was interviewed on 4/11/17 at 5:50 p.m. She said she spoke with the resident and the resident would like to be seen by a dentist to discuss her dental issues. The SW stated she was working with the SW consultant to obtain services from a separate dental provider. 3. Resident #64 Resident 64, age 74, admitted into the facility on [DATE]. The 4/17 CPO revealed [DIAGNOSES REDACTED]. According to the 2/18/17 and 2/25/17 MDS assessments, the resident's cognition was intact. He had broken and/or loosely fitting full or partial dentures; mouth and/or facial pain with discomfort and difficulty chewing. Observations: On 4/10/17 at 3:30 p.m., the resident was lying in bed, he was edentulous. He motioned towards his mouth to show he had no teeth. On 4/11/17 at 3:00 p.m., the resident was observed in the presence of LPN #1. LPN #1 confirmed the resident did not have teeth. Record Review: A review of the 4/17 CPO revealed on 3/15/17, an order for [REDACTED]. A review of the progress notes from 3/13/17 through 4/10/17 revealed: -On 3/15/17, the resident informed the RD he had dentures and they made it difficult to eat tough meats. There was no notes related to social services discussing ancillary services with the resident although a consent for ancillary services was signed on 3/13/17. A review of the 3/14/17 admission nursing assessment revealed the resident had both full upper and lower dentures. His dentures did not fit but were to be worn when eating. He had chewing problems. A review of the 3/30/17 speech therapy plan of treatment revised on 4/5/17 revealed the resident had difficulty with chewing due to poorly fitting dentures. Resident Interview: The resident was interviewed on 4/10/17 at 9:44 a.m. He said he was having problems with his dentures. He said he spoke with a doctor about his dental issues but no one has followed up on his dental needs. He did not feel the facility was addressing his dental issues in a satisfactory manner. He said it would be nice for the facility to do something to get him off of puree foods. Staff Interviews: The LPN #1 was interviewed on 4/11/17 at 3:00 p.m. The LPN said the resident did not have any natural teeth. She said she thought he had dentures but did not know if they were fitting properly. She said if she were aware of any dental issues, she would report to social services to have the SW make a dental appointment. The SW was interviewed on 4/11/17 at 3:41 p.m. She said she was not aware of any dental needs for the resident. She said if social services was not notified or made aware of dental concerns for residents, ancillary services could not be addressed or setup timely. She stated she would follow-up with the resident. Facility Follow-up: A review of the progress notes revealed on 4/11/17, the SW spoke with the resident and he stated approximately two weeks ago, his dentures stopped fitting properly and he wasn't sure if it was due to gum recession. The SW asked the resident if he would like to be seen by a dentist and he was agreeable. Although the resident stated his dentures stopped fitting two weeks ago, his admission paperwork revealed the facility was aware of his ill-fitting dentures on admission and during the evaluation of speech therapy. Additional Follow-up: The SW was interviewed on 4/11/17 at 5:43 p.m. She said she spoke with her regional SW consultant and they are in the process of starting ancillary services with a new dental provider. The SW stated she could not locate the contract with the current dental provider. The SW acknowledged the issues with having a dental provider come out twice a year could delay preventative care and treatment, identify resident dental needs in a timely manner, and provide consultation and education in a reasonable amount of time for most residents in the facility.

Based on observations, record review and interviews, the facility failed to ensure that routine housekeeping and maintenance services were timely completed in seven of 13 sampled resident rooms. Specifically, the facility failed to ensure: -clean and sanitary building conditions; -residents were free from odors; and -room furnishings were in good repair. The findings included: Observations and Interviews: Room 6 On 4/10/17 at 9:22 a.m., brown fecal smears were observed on the wall near a colored picture located about two feet up from floor. The wall was an interior wall and to the right side of the egress door. There was wall damage behind resident's bed. Bed B had tobacco shavings spread all over the tray table beside the bed. The tobacco shavings were scattered on the floor. The housekeeping supervisor (HS) was interviewed on 4/12/17 at 12:23 p.m. The HS and maintenance supervisor (MS) confirmed the brown smears on the wall in room 6. The HS stated it was necessary to clean all bodily functions to prevent any infections from spreading, reduce odors and keep residents and others from getting sick. The MS confirmed the wall damage and stated ongoing education continued to be provided to nursing staff on raising and lowering resident beds. The HS and MS stated they continued to have ongoing problems with the housekeeping issues for the side of the room with the resident who rolled cigarettes with tobacco shavings. The HS and MS stated they would continue to come up with ways to ensure routine housekeeping was performed in the room while allowing the resident to remain in a homelike environment. Room 9 On 4/10/17 at 1:00 p.m., the wall above the toilet in the resident restroom shared by two residents had peeling paint. The bathroom sink was also stained blue. The HS and MS observed the room on 4/12/17 at 12:43 p.m. The MS confirmed wall damage after grab bars were affixed to the wall near the toilet. He stated having holes in the walls caused potential fire safety issues. The HS and MS also confirmed a strong odor coming from the resident's bed and linens. They stated the odor smelled of urine and needed replacement. Room 12 On 4/10/17 at 4:53 p.m., there was a strong odor of urine throughout the resident's room. The HS and MS confirmed resident's room had odor of urine on 4/12/17 at 12:50 p.m. The electrical faceplates did not cover wall damage and dry wall holes identified to cause concerns in the event of a fire. Room 19 On 4/10/17 at 3:21 p.m., a strong odor of urine observed in room. The HS and MS confirmed room was malodorous on 4/12/17 at 12:53 p.m. Room 22 On 4/10/17 at 1:51 p.m., the restroom had brown substance on the call light cord and on the wall near the toilet. The HS and MS confirmed on 4/12/17 at 12:58 p.m., the brown substance on the wall and cord. Room 26 On 4/10/17 at 10:41 a.m., the paint in the room was peeling in multiple areas throughout the room. The call light cord in the restroom was damaged and did not extend to the floor in the event of an accident. The HS and MS toured the room on 4/12/17 at 1:05 p.m. They confirmed the peeling paint and short call light cord. The MS acknowledged the problem a person could have if they fell in the restroom and needed to access the call light cord. Room 27 On 4/10/17 at 2:12 p.m., the light bulb covers were missing on the fixture in the restroom. The HS and MS confirmed on 4/12/17 at 1:07 p.m., the bulb fixtures were not repaired and remained missing. Additional Interview: The HS and MS were interviewed on 4/12/17 at 12:03 p.m. The MS said the facility recently transitioned to an online work order system. He said anyone with an account could place a work order. He said he was also informed of problems in the building through a stand up meeting and what was reported in person by staff. He stated preventative maintenance allowed to identify small things before they became bigger issues.

Based on observations, record review and interviews, the facility failed to ensure comfortable sound levels were maintained for residents down the Canyon hallway. Specifically, there was a resident who yelled and other noises which caused residents discomfort. The findings included: Resident Interviews: Resident #19 was interviewed on 4/10/17 at 9:28 a.m. She said there was a lot of noise in the mornings and during the evenings. She said the noise was a problem and affected her comfort. Resident #24 was interviewed on 4/10/17 at 3:39 p.m. He said there were residents who could be heard yelling down the hallway and it affected his comfort. Resident #68 was interviewed on 4/10/17 at 9:27 a.m. She said it was always noisy. The resident stated there was a gentleman in room [ROOM NUMBER] who screamed and yelled from his room. She stated it happened all day and into the night. Resident #64 was interviewed on 4/10/17 at 9:37 a.m. He said the noise levels affected his comfort. He stated it was a variety of noises that he could hear from staff talking, residents yelling, equipment banging. Observations: On 4/12/17 at 10:11 a.m., there was a person moaning loudly and could be heard down the Canyon hallway. There were five egress doors left open. - At 10:19 a.m., the loud moans continue to be heard down the hallway. The staff from medical records walked down the hallway to room [ROOM NUMBER]. She attempted to calm the resident and then exited the room. - At 12:16 p.m., the resident could be heard down the hallway in the presence of the housekeeper supervisor (HS) and maintenance supervisor (MS). The HS and MS verified the noise coming from the resident in room [ROOM NUMBER]. Record Review: A review of interdisciplinary progress notes for resident #1 living in room [ROOM NUMBER] revealed: - On 3/24/17, the resident had one episode of screaming and banging of hands on floor mat. Interventions attempted and the resident started to scream again. - On 4/7/17 during the overnight shift, the resident had one episode of loud moaning that lasted for about 7 minutes. -On 4/7/17 on the evening shift, the resident was heard from the hallway moaning loudly in his room. He was hitting his right hand against the floor. -On 4/11/17, the resident was hitting his wheelchair arm padding and grunting. Additional Interviews: The resident council president was interviewed on 4/12/17 at approximately 10:15 a.m. He stated he felt like he lived in a mental institution with the increase in yelling and screaming he could hear down his hallway. He stated there was a man in room [ROOM NUMBER] known to scream. The medical records clerk was interviewed on 4/12/17 at 10:19 a.m. She said in the last month or more resident #1's screaming and yelling had increased. She said the resident used to be calmed with chocolate and aroma therapy or going outside but the interventions have not been successful recently. The HS and MS were interviewed on 412/17 at 12:18 p.m. They confirmed resident #1 could be heard making noises in his room from down the far end of the hall. The HS said when the resident had behaviors of yelling or screaming, she tried to offer him chocolate. She said if it had not worked, she notified a certified nurse aide (CNA) or nurse. She said all residents should be allowed to have comfortable noise levels. She said earplugs, headphones, or closing the door could be used. The MS said he provided nursing with multiple earplugs to help residents with uncomfortable noise levels.