Every finding on record at Neurorestorative Colorado

Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen and nourishment refrigerator/freezer. Specifically, the facility failed to ensure time and temperature control food was labeled, dated and disposed of timely. Findings include: I. Professional reference The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/6/25 read in pertinent part, Commercially processed food: open and hold cold, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, the day the original container is opened in the food establishment shall be counted as day one and the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17) II. Record review The refrigerated storage chart, undated, was provided by the nursing home administrator on 5/1/25 at 5:12 p.m. The chart recommended the maximum storage period for unopened ham and unopened luncheon meats was five days. -The chart did not include a recommended maximum storage period for opened product or soft cheeses (see below). III. Observations The initial main kitchen tour was conducted on 4/28/25 at 9:15 a.m. The following was observed: -A clear plastic container with a lid that contained broccoli and carrots in liquid was not marked with a label or date. -A clear plastic bag that contained an opened package of sliced deli turkey had a written date in black marker of 4/10/25 on the bag. No expiration date was written on the bag. A freeze by date of 4/13/25 was printed on the package of turkey. -A clear plastic bag that contained an opened package of sliced deli honey ham that had a written date in black marker of 3/20/25. No expiration date was written on the bag. -A commercially processed raw turkey breast in the original wrapper with a date of 4/21 written in black marker on the wrapper. The instructions were to thaw in the refrigerator for one and a half to two days. -A clear plastic bag that contained an open package of sliced american swiss cheese. No date was written on the bag. On 5/1/25 at 10:25 a.m. the following items were observed in the nourishment refrigerator: 13 vanilla magic cups with use by date of 2/6/25 and 13 chocolate magic cups with a use by date of 4/10/25. On 4/30/25 at 11:35 a.m. the following was observed in the main kitchen: -A clear plastic bag that contained an opened package of sliced deli turkey had a written date in black marker of 4/10/25 on the bag. No expiration date was written on the bag. A freeze by date of 4/13/25 was printed on the package of turkey. -A clear plastic bag that contained an opened package of sliced deli honey ham that had a written date in black marker of 3/20/25. No expiration date was written on the bag. -A commercially processed raw turkey breast in the original wrapper with a date of 4/21 written in black marker on the wrapper. The instructions were to thaw in the refrigerator for one and a half to two days. -A clear plastic bag that contained an open package of sliced american swiss cheese; No date was written on the bag. IV. Staff interviews Cook (CK) #1 was interviewed on 5/1/25 at 12:45 p.m He said he did not know there were expiration dates on the bottom of the magic cups. CK #1 said he was not sure what expiration date to use for the opened sliced cheese and was unsure how long the turkey breast had been thawing in the refrigerator. CK #1 said the kitchen staff put a date on the original package of deli meat when it was received or frozen in the kitchen and an open date on the clear bag once the product was opened. CK #1 said he was unsure what expiration date to use. The quality director (QD) was interviewed on 5/1/25 at 5:00 p.m. The QD said the kitchen had a food storage guideline chart they should use for dating and labeling refrigerated food items.

Based on observations, record review and interviews, the facility failed to ensure accurate assessments, informed risks, and ongoing monitoring was in place for three (#1, #13 and #6) of six residents with bed rails out of 20 sample residents. Specifically, the facility failed to: -Ensure risks of bed rails were explained to Resident #1 or the resident' s representatives prior to the initiation of the bed rails; -Ensure bed rail assessments were accurately completed for Resident #1, Resident #6 and Resident #13; -Ensure consent was obtained for the use of a bed rail from Resident #1; and, -Ensure ongoing monitoring of bed rails in use was completed for Resident #1, Resident #6 and Resident #13. Findings include: I. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included surgical aftercare on the skin, pressure ulcers, traumatic subdural hemorrhage (brain injury where blood accumulates between the brain and its outermost covering) and emphysema (lung disease causing difficulty breathing). The 4/25/25 minimum data set (MDS) assessment revealed Resident #1 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He was dependent on staff for assistance with toileting, transfers and bathing, and needed supervision with upper body dressing and set up at mealtime. The MDS assessment documented bed rails were not used. -However, observations revealed bed rails were being used (see observations below). B. Observations and resident interview Resident #1 was interviewed on 4/28/25 at 10:38 a.m. Resident #1 said he used the bed rails to pull himself up but did not use them to turn to his side. He demonstrated how he used the bed rails to reposition himself and pulled himself toward the head of the bed. There was a quarter length bed rail on each side of Resident #1' s bed. C. Record review Resident #1' s 11/8/24 admission bed rail assessment and 2/9/25 quarterly bed rail assessment documented that side rails or bed rails would not be used or considered for this resident. -However, Resident #1 had a quarter length bed rail on each side of his bed and stated he used the bed rails to reposition himself in bed. A review of Resident #1' s record did not include a consent for the use of a bed rail. Resident #1' s care plan, initiated 11/20/24, documented the resident was at high risk for falls due to an above the knee amputation, traumatic brain injury, weakness and paralysis. Pertinent interventions included to use side rails as ordered. -However, Resident #1 did not have a physician' s order or assessment for bed rail use (see observations above). II. Resident #13 A. Resident status Resident #13, age less than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included quadriplegia (a loss of function of the arms and legs), hypotension (low blood pressure), neuromuscular (system of nerves and muscles that enables voluntary movement) spinal cord injury, anxiety and major depressive disorder. The 2/21/25 MDS assessment revealed Resident #13 was cognitively intact with a BIMS score of 15 out of 15. He was dependent on assistance for all activities of daily living (ADL). The MDS assessment documented bed rails were not used. -However, observations revealed bed rails were being used (see observations below). B. Observations and resident interview Resident #13 was interviewed on 4/28/25 at 11:07 a.m. Resident #13 said he wanted the bed rail to support his water bottle and devices but did not use the bed rails to reposition himself. There was a quarter length bed rail on one side of Resident #13' s bed. C. Record review Resident #13' s 4/20/23 admission side rail assessment documented side rails bed rails would be considered for the resident and the rails were requested for attaching personal devices and were requested by the resident. -However, the remainder of the assessment was not completed to indicate if the resident was assessed for the use of the bed rails and the section that included risk factors was not completed. Resident #13' s 12/5/24 quarterly side rail assessment documented side rails or bed rails would be used or considered for this resident for access to water. Risk factors were documented on the assessment. Resident #13' s 3/6/25 quarterly side rail assessment documented side rails or bed rails would not be used or considered for this resident. -However, a quarter length bed rail was on Resident #13' s bed and used for water bottle support and personal devices (see observations above). Resident #13' s skin care plan, revised 12/2/24, documented Resident #13 had potential/actual impairment to skin integrity due to his immobility, healed skin graft and surgical wound. Pertinent interventions, initiated 5/2/23 and revised 7/19/24, included to pad bed rails, wheelchair arms or any other source of potential injury if possible. III. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included amyotrophic lateral sclerosis (ALS-a neurodegenerative disease), hand contractures (tightening of the hands), major depressive disorder, anxiety and high blood pressure. The 3/21/25 MDS assessment revealed Resident #6 was cognitively intact with a BIMS score of 15 out of 15. He was dependent on staff for assistance for bathing, and needed substantial assistance dressing and set up assistance only with bed mobility. The MDS assessment documented bed rails were not used. -However, observations revealed bed rails were being used (see observations below). B. Observations and resident interview Resident #6 was interviewed on 4/28/25 at 2:54 p.m. Resident #6 said he wanted the side rails on his bed to support his pillows. Resident #6 said he did not use the side rails to reposition himself. There was a quarter length bed rail on each side on Resident #6' s bed. C. Record review Resident #6' s 7/14/22 admission side rail assessment documented side rails bed rails were for increased mobility and the residents request. Resident #6' s 3/7/25 quarterly side rail assessment documented side rails or bed rails would not be used or considered for this resident. -However, Resident #6' s a quarter length bed rail was on Resident #6' s bed and used to support his pillows (see observations above). The remainder of the assessment was not completed and the section that included risk factors was not completed. V. Staff interviews Registered nurse (RN) #1 was interviewed on 4/30/25 at 1:55 p.m. RN #1 said nurses and certified nurse aides (CNA) did visual checks on the residents rooms but was not sure who checked the bed rails for functionality. The director of nursing (DON) was interviewed on 5/1/25 at 3:30 p.m. The DON said the facility contracted a vendor to check the beds at least annually but he was unsure if there was documentation that the bed rails were checked monthly or more frequently. The DON said the risks of the bed rails were communicated to the residents but he was not sure where that documentation was. The DON said that he and the assistant director of nursing (ADON) would manage the bed rail consents in the future and the director of rehabilitation (DOR) would also be involved. The DON said every resident was assessed for bed rails when they were admitted to the facility. The DON said that the assessment for Resident #1 should have had more information included on the assessment and that Resident #6 used his bed rails to prop his pillows and Resident #13 used the bed rail for his devices and water. VI. Facility follow up The nursing home administrator (NHA) provided a performance improvement plan (PIP) for bed rail use on 4/30/25 at 4:36 p.m. The documented issues included in the plan were side rail assessments were to be completed per policy and accurately on admission and quarterly, and bed rail consents would be in place and signed. The steps to be implemented and completed were: a complete audit of all residents was to be conducted for the side rail assessments to determine their accuracy; training provide to staff to ensure the assessment process was followed and accurate; a risk vs benefit documented signed by the resident and reviewed quarterly; the outside vendor bed evaluations will be documented when completed.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for each resident. Specifically, the facility failed to: -Provide a balanced menu for residents; -Ensure Resident #5 received a variety of pureed dessert options; -Ensure international dysphagia diet standardization initiative (IDDSI) standards were utilized for production of IDDSI modified texture diet orders; and, -Ensure Resident #18 received a minced and moist level five texture diet instead of a pureed diet. Findings include: I. Professional reference The International Dysphagia Diet Standardization Initiative (IDDSI) minced and moist level five patient handout (2019) and retrieved 5/8/25, read in pertinent part, Meat is served finely minced or chopped to 4 millimeter (mm) lump size served in a thick, smooth, non-pouring sauce or gravy. Vegetables are cooked, finely mashed or use a blender to finely chop it into to 4 mm lump size pieces (drain any excess liquid). [NAME] requires a sauce to moisten it and hold it together. [NAME] should not be sticky or gluey and should not separate into individual grains when cooked and served; it may require a thick, smooth, non-pouring sauce to moisten and hold the rice together. II. Resident interviews Resident #1 was interviewed on 4/28/25 at 10:38 a.m. Resident #1 said he did not like the majority of the menu items offered and he did not always get what he had ordered. Resident #15 was interviewed on 4/28/25 at 11:36 a.m.Resident #15 said the menu primarily had chicken and hamburgers and he did not eat chicken so he ordered food from outside sources out a lot. Resident #13 was interviewed on 4/28/25 at 12:44 p.m. Resident #13 said the menu was too repetitive, the food was cooked poorly and did not look good. Resident #6 was interviewed on 4/28/25 at 2:54 p.m. Resident #6 said the menu was too repetitive from one week to the next. III. Resident group interview The resident group interview was conducted on 4/29/25 at 1:00 p.m. The group consisted of four residents (#13, #15, #4 and #18) who were interviewable based on assessment and the facility. The residents said they continued to have concerns about the food. Resident #1 said the menu was repetitive and he ate food from outside the facility frequently. Resident #4 said the menu was repetitive. IV. Resident council minutes The resident council minutes were provided by the nursing home administrator (NHA) on 4/29/25 at 2:30 p.m. The February 2025 minutes documented the residents would like more menu variety. The April 2025 minutes documented the residents would like to see less chicken. -Review of the February 2025 and April 2025 minutes did not reveal documentation indicating the facility had addressed the residents' concerns. V. Record review The weekly menu served from 4/27/25 to 5/3/25 (during the survey) was provided by the nursing home administrator (NHA) on 4/29/25 at 3:46 p.m. A review of the menu revealed the following: -Chicken was served as the entree for dinner on 4/28/25 and again for lunch on 4/29/25; -Rice was served as a side for dinner on 4/28/25, as a side and part of the entree for lunch on 4/29/25 and as a side for dinner on 5/2/25. The recipes for the 4/30/25 noon meal were provided by the NHA 4/30/25 at 6:12 p.m. The lunch meal on 4/30/25 was lazy stuffed peppers, spring fruit cup, green salad and mushroom rice. The recipes documented the following texture modifications: -Spring fruit cup puree diet: replace with mandarin oranges and process until smooth. Food should be smooth with no lumps and cohesive enough to hold its shape. -Lazy stuffed pepper dysphagia special diet instructions - puree to a smooth texture that holds shape with no lumps. The recipes failed to include diet modification for the minced and moist level five IDDSI diet prescribed to Resident #18 (see meal service observations below). VI. Dining observations 1. Resident #5 On 4/29/25 at 12:02 p.m Resident #5 received a pureed lunch that included a pureed entree, side dish, apple sauce and chocolate pudding. On 4/30/25 at 12:20 p.m. Resident #5 received a pureed lunch that consisted of pureed stuffed peppers, pureed green vegetable, apple sauce and vanilla pudding. On 4/30/25 at 5:12 p.m. Resident #5's received his dinner, which consisted of pureed pork roast, pureed vegetable medley, pureed au gratin potatoes, apple sauce and chocolate pudding. -A review of Resident #5's April 2025 CPO revealed a physician's order for a pureed diet. Resident #5 received applesauce and pudding at all three meals instead of a variety of desserts, including the pureed mandarin oranges in the puree diet modification for the lunch meal on 4/30/25 (see recipes above). 2. Meal service observation During a continuous observation on 4/30/25, beginning at 11:55 a.m. and ending at 12:18 p.m., the following was observed during meal preparation and service in the kitchen: At 11:58 a.m. Resident #18's lunch plate was assembled by cook (CK) #2 with pureed lazy stuffed peppers and pureed vegetables, applesauce and pudding. The meal ticket on the tray documented a minced and moist level five diet order and the tray was placed on the cart for delivery. -Resident #18's lunch on 4/30/35 was pureed using the instructions from the recipe and not prepared utilizing the standards of the IDDSI (see professional reference above) that included minced food items instead of pureed items. On 4/30/25 at 5:15 p.m. Resident #18 was eating dinner in his room. Resident #18's dinner consisted of ground pork roast without a sauce or gravy and chopped vegetables (see professional reference above). Resident #18 was interviewed on 4/30/25 at 5:15 p.m. Resident #18 said his food was pureed at lunch and used to have his food more blended. VII. Staff interviews CK #1 and CK #2 were interviewed on 5/1/25 at 12:45 a.m. CK #1 said he had been trained on modified textures. CK #1 said he was provided verbal training that included instructions on what residents could or could not have based on their diet order. CK #1 and CK #2 said they did not have diet spreadsheets or recipes that included IDDSI minced and moist level five modifications or puree specification. The director of nursing (DON) was interviewed on 5/1/25 at 4:30 p.m. The DON said the facility utilized IDDSI diets. The DON said a floor nurse would enter a prescribed diet and a registered dietitian would do an initial nutrition assessment upon admission. The NHA was interviewed on 5/1/25 at 4:30 p.m. The NHA said the staff had dysphagia training as part of the facility's online training but was unsure if IDDSI was included in the training. The quality director (QD) was interviewed on 5/1/25 at 5:00 p.m. The QD said the facility used a menu program but was unsure if all the IDDSI resources were included in the menu program. The QD said the facility had used IDDSI diets for approximately a year. 50690

Based on observations, record review and interviews, the facility failed to implement their policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to: -Implement the facility policy for food brought by visitors and ensure food that was kept in resident's refrigerators had safe and sanitary storage; and, -Ensure the residents personal refrigerator temperatures were monitored correctly for appropriate temperatures. Findings include: I. Professional reference The Colorado Retail Food Regulations, ([DATE]) were retrieved on [DATE]. It read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. (,d+[DATE].16) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (,d+[DATE].17) The Food and Drug Administration (FDA) food code ([DATE]) were retrieved on [DATE] from https://www.fda.gov/food/fda-food-code/food-code-2022 revealed in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. II. Facility policy and procedure The Food Brought Into Facility By Visitors policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:30 p.m. It read in pertinent part, All food brought to the facility residents by visitors will be checked by dietary or licensed personnel. Label food items brought in by visitor with resident's name, food content, date visitor brought item in and a use by' UB' date of one day out. Education on safe handling will be provided by trained dietary personnel or trained nursing staff to all family, residents, visitors and community groups who may provide foods or fluids to residents of the facility. This education will include at a minimum proper food handling to prevent foodborne illness, requirements for covered containers or secure wrapping, leftover foods will be discarded, method for checking proper food temperature (staff only). Perishable foods requiring refrigeration brought into the facility by a visitor for a resident, must be stored in a designated refrigerator and will be separate from the main facility kitchen storage area. The food must be stored in a container and labeled with the resident's name, content, date brought into the facility and UB date. The resident refrigerator agreement form was received from the DON on [DATE] at approximately 11:30 a.m. It revealed the following: The expectations of the facility regarding upkeep of personal refrigerators, are understood; Education was provided on appropriate food storage temperatures for personal refrigerators; It is understood that patients and families are responsible for ensuring that food is kept at the appropriate temperature; and, Patients and families are responsible for cleaning their personal refrigerators on a regular basis or asking for assistance. III. Observations On [DATE] at 10:45 a.m., the inside of Resident #8's personal refrigerator had a large, light brown, dried liquid spill on the left side of the refrigerator shelves. There were two opened, half eaten four ounce (oz). containers of chocolate pudding were in the resident's refrigerator. The pudding was not labeled. On [DATE] at 2:54 p.m. a four oz container of commercially packaged yogurt was in Resident #6's personal refrigerator. The yogurt had a use by date of February 2025. On [DATE] at 12:10 p.m. Resident #8's personal refrigerator still contained two opened, half eaten four oz. containers of chocolate pudding. The items were not labeled. On [DATE] at 12:14 p.m. there were two containers, one of commercially packaged vanilla pudding and one yogurt in Resident #12's personal refrigerator. The vanilla pudding had an expiration date of [DATE]. The yogurt had an expiration date of [DATE]. IV. Resident interviews Resident #6 was interviewed on [DATE] at 2:54 p.m. Resident #6 said the facility staff would rotate the food in his personal refrigerator and tried to discard the food if it was old or expired. V. Staff interviews Certified nurse aide (CNA) #1 and was interviewed on [DATE] at 10:30 a.m. CNA #1 said there were no temperature logs at the nurses'station for the residents personal refrigerator. CNA #1 said the maintenance director checked the residents personal refrigerators. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 11:54 a.m. LPN #1 said that if a resident's personal refrigerator looked dirty on the inside, she went through the contents and cleaned it. She said she thought that housekeeping staff checked and cleaned the personal refrigerators every so often. She thought that the maintenance department kept track of the refrigerator temperatures. LPN #2 was interviewed on [DATE] at 2:54 p.m. LPN #2 said that staff members kept track of what was in the residents' personal refrigerators. She said she had never seen families maintain the refrigerators, just stock them. She said that the food/personal refrigerator policy was signed by the resident's family upon admission. The director of nursing (DON) was interviewed on [DATE] at 3:30 p.m. The DON said staff were to assist the residents in getting food products from their personal refrigerators if the resident needed assistance getting the product. The DON said he was unsure if a formal process was in place to check the resident's refrigerators. The nursing home administrator (NHA) was interviewed on [DATE] at 5:00 p.m. The NHA said the facility's process was that the resident was responsible for their personal refrigerator but housekeeping staff also checked the refrigerators. 50690

Based on observations, record review and interviews, the facility failed to ensure residents on a pureed diet out of 20 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed pureed texture diets were served food that was prepared according to their diet order as indicated on their meal tray cards. Findings include: I. Professional reference The International Dysphagia Diet Standardization Initiative (IDDSI) Pureed Audit Tool (September 2020) retrieved 5/6/25 read in pertinent part, Critical appearance of pureed food: no lumps, food slides smoothly and easily between fingers. A puree needs to be able to be put in the mouth and swallowed whole. No chewing and no bolus (a soft mass of chewed food) formation skills should be needed to eat this. II. Meal observation During a continuous observation on 4/30/25, beginning at 11:55 a.m. and ending at 12:18 p.m., the following was observed during the meal preparation and service in the kitchen: The posted menu was lazy stuff pepper, green salad, spring fruit cup and mushroom rice. At 11:55 a.m. a resident's lunch plate was assembled by cook (CK) #2 with pureed lazy stuffed pepper and pureed vegetables. The meal ticket on the tray documented a puree texture and the tray was placed on the cart for delivery. At 11:56 a.m. another resident's lunch plate was assembled by CK #2 with pureed lazy stuffed pepper and pureed vegetables. The meal ticket on the tray documented a puree texture and the tray was placed on the cart for delivery. -Both pureed meals had visible lumps in the pureed entree and pureed vegetables. III. Test tray A test plate for a pureed lazy stuffed peppers entree was evaluated by two surveyors immediately after the last resident had been served their lunch meal on 4/30/25 at 12:19 p.m. The pureed entree had visible lumps and pieces of red pepper. The pureed entree was not smooth and required chewing. IV. Record review The recipes for the 4/30/25 noon meal were provided by the nursing home administrator (NHA) 4/30/25 at 6:12 p.m. The recipes documented the pureed modifications of food items served during lunch meal service on 4/30/25 as follows: food should be smooth with no lumps and cohesive enough to hold its shape on the spoon. V. Staff interviews CK #1 and CK #2 were interviewed together on 5/1/25 at 12:45 p.m. CK #1 said modified textured diets were for residents who had difficulty chewing or swallowing. CK #1 said the risk of a modified texture not being produced correctly could cause a resident to choke or pocket food. CK #2 said he checked his puree textures before meals and was not expecting the rice in the lazy stuffed peppers to clump up like it did that day. The director of nursing (DON) and the NHA were interviewed together on 5/1/25 at 4:30 p.m. The DON said if he or any other staff observed food not prepared correctly in the past they have asked the kitchen staff to remake the item and the cooks were willing to remake it. The NHA said facility staff did receive training on swallowing and dysphagia but was unsure if it contained information on IDDSI textures. The quality director (QD) was interviewed on 5/1/25 at 5:00 p.m. The QD said the facility used a menu program but was unsure if all the IDDSI resources were included in the menu program. The QD said the facility had used IDDSI diets for approximately a year.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one of two units. Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care for Resident #1. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 5/5/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO. Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing). II. Observations During a continuous observation of wound care on 4/29/25, beginning at 2:36 p.m. and ending at 2:55 p.m., the following was observed: An EBP sign was posted on the outside of Resident #1's door. Registered nurse (RN) #1 and RN #2 entered Resident #1's room. RN #1 and RN #2 washed their hands and donned (put on) gloves before beginning Resident #1's wound care. RN #1 provided wound care and dressing changes for Resident #1's two wounds while RN #2 assisted. -However, RN #1 and RN #2 failed to don gowns prior to providing wound care for Resident #1. III. Staff interviews RN #1 and RN #2 were interviewed together on 4/29/25 at 3:00 p.m. RN #2 said that EBP was worn while doing tasks with a risk of getting wet, such as giving tube feedings and working with residents who had tracheostomies (an opening to the airway usually with a tube) and catheters. She said the personal protective equipment (PPE) requirements for EBP were similar to the PPE required for contact precautions. RN #1 said staff did not get training on EBP, but the former director of rehabilitation had put EBP signs on the doors of some residents and had PPE supplies placed in the halls. RN #1 said the former director of rehabilitation provided education regarding the new EBP signage to the staff who were working that shift when the signs were put up. However, she said any staff who was not working that shift, and any new staff, did not receive the EBP signage education. The director of nursing (DON) was interviewed on 5/1/25 at 12:32 p.m. The DON said EBP should be used for people with tracheostomies, catheters, central intravenous lines, or gastric tubes. He said gloves and gowns should be worn to do tracheostomy care or suctioning, catheter care, wound care, bathing, dressing, or doing big transfers with close contact for these residents. He said he had provided some education to staff and had printed more EBP education but had not gotten it out to staff yet. He said he had ordered racks for PPE supplies and had put PPE supply carts in the hallways.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal vaccinations for one (#5) of five residents out of 20 sample residents. Specifically, the facility failed to provide the pneumococcal vaccination to Resident #5. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2022, retrieved on 5/6/25, from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. II. Resident #5 A. Resident status Resident #5, over age 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included a history of intracranial injury and subdural hemorrhage (brain bleed), atrial fibrillation (abnormal heart rhythm), heart failure, legal blindness and benign prostatic hyperplasia (enlarged prostate gland). The 4/11/25 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems and had severely impaired decision making per staff assessment. He required partial assistance with eating and dressing his upper body and moderate assistance for most transfers and dressing his lower body. He used a manual wheelchair for mobility. The assessment documented that the resident's pneumococcal vaccination was not up to date. He was offered the vaccination and declined it. -However, the resident's representative signed a consent form on 1/12/25 indicating the resident was to receive the pneumococcal vaccination. B. Record review A consent for the pneumococcal vaccination, dated 1/12/25, was signed by Resident #1's representative. -However, a review of Resident #1's electronic medical record (EMR) revealed no documentation that the resident had received the pneumococcal vaccine. Review of Resident #5's EMR did not reveal documentation indicating the resident declined the pneumococcal vaccination. III. Staff interview The director of nursing (DON), who was also infection preventionist (IP) #2, was interviewed on 5/1/25 at 1:30 p.m. The DON said that there was no record that Resident #1 received the pneumococcal vaccination. He said he would have had to order the serum, but that the resident still should have received it. He said he would research why it was not given and if the resident still wanted to receive the vaccination, he would order and administer it. LPN #2 was interviewed on 5/1/25 at 3:02 p.m. LPN #2 said whoever obtained consent for the pneumococcal vaccine, would be the one to put in the order. LPN #2 said the physician would authorize it and then the serum would be ordered from the pharmacy.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for one (#15) of one resident reviewed for accidents and hazards out of 17 sample residents. Specifically, the facility failed to: -Ensure Resident #15 did not receive first/second degree burns to both thighs during the use of electrical stimulation in a physical therapy session; -Ensure Resident #15 had a physician order in place for use of neuromuscular electrical stimulation (NMES); and -Ensure the therapy care plan documented therapy use of NMES for Resident #15. Findings include: I. Facility policy and procedure The Physical Therapeutic Modalities policy and procedure, undated, received from the nursing home administrator (NHA) on 8/31/23 at 2:51 p.m. revealed in pertinent part: Scope: therapy staff physical therapist to facilitate various therapeutic treatments related to neuromusculoskeletal components following an injury or disease process. Modality is a type of electrical, thermal, or mechanical energy that causes physiological changes. Procedure: A comprehensive assessment by licensed physical therapist (PT); an order from the physician indicating the type, location, frequency, duration, and who is able to apply it; care plan reflecting the intervention focus, area and goal; the treating therapist must show competency of use through peer review. Types: NMES a device that sends electrical impulses to nerves causing muscles to contract, increase the strength in range of motion and offset effects of disuse. II. Professional references According to Burn Classifications from the National Institutes of Health website, retrieved on 9/9/23 from https://www.ncbi.nlm.nih.gov/books/NBK539773, A burn takes place when skin comes into contact with heat sources. Common sources that cause burns are fire, scalds, hot objects, electrical, and chemical agents. Superficial first degree involves the epidermis of the skin only. Appearance pink to red, no blisters. Superficial partial thickness second degree involves the superficial dermis appearing red with blisters. The Vectra Genesis manual received from the NHA on 8/31/23 at 1:37 p.m. documented: Safety precautions and adverse effects (page 8) additional precautions over areas of the skin which lack normal sensation and adverse effects of skin irritation and burns beneath the electrodes have been reported with use of powered muscle stimulators. Patient preparation (page 32) electrode placement; examine the skin for any wounds and clean the skin; apply electrodes to the treatment area; ensure electrodes are applied securely to the skin; and ensure good contact between each electrode and the skin. (Page 33) Dura-Stick electrodes are self-adhesive, disposable products. III. Resident #15 A. Resident status Resident #15, under age 65, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included quadriplegic (paralysis of all four limbs), cervical spinal cord injury at cervical vertebrae number one, cervical spinal fusion (fusion of cervical vertebrae), tracheostomy (opening in the neck to aid in oxygen reaching the lungs), and dependent on ventilator (machine used in to move oxygen to and from the lungs). The 7/27/23 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. He required extensive two person assistance with bed mobility, transfers, dressing and toileting. He required one person's assistance with eating and personal hygiene. He had upper and lower extremity limitations. B. Observation On 8/28/23 at 5:20 p.m. Resident #15's upper thighs were observed to have two scabs on the left thigh approximately 0.3 centimeters (cm) in diameter; the right thigh had three scabs approximately 0.3 cm in diameter. On 8/31/23 at 4:10 pm. the director of nursing (DON) observed two scabbed areas on the left thigh and three scabbed areas on the right thigh. C. Resident and family interviews Resident #15 and a family member were interviewed on 8/28/23 at 5:20 p.m. Resident #15 said he had been working with physical therapy and he received burns on his thighs from the NMES machine. Resident #15 said because he was unable to feel his legs due to his diagnosis he was not able to tell the physical therapist (PT) it was hurting him. Resident #15's family members said the areas were all red and had a raised center like a blister. Resident #15 and his family member were interviewed again on 8/31/23 at 11:55 a.m. Resident #15 said he had used the NMES machine in the facility four times since admission and the same electrode pads were used since his first time receiving this type of therapy. Resident #15 said no one in the facility educated him of the risks of using the NMES machine. Resident #15 said the PT spoke to him after the burns occurred that it might be a good idea to shave his legs in the area where the electrodes would go in the future to prevent further injury. Resident #15's family member said the next day after the burns occurred the PT told him bummer [NAME] like it was not a big deal that he got burned and that the NMES could not be used until his skin was healed. D. Record review The 8/7/23 activities of daily living (ADLs) care plan for Resident #15 documented an ADL deficit and physical therapy evaluation and treatment were initiated on 7/21/23. -The care plan failed to document the use of the NMES for Resident #15. A physical therapy progress note on 7/28/23 at 2:13 p.m. documented NMES was set up for bilateral quads (muscle group of the upper thigh) for 20 minutes total. The PT documented Resident #15 had slight redness under the electrodes following the treatment. A physical therapy progress note on 8/11/23 at 2:23 p.m. documented the NMES was set up for bilateral quads to reduce muscle atrophy and promote muscle activation. The NMES was used for 20 minutes with moderate redness observed under the electrodes at the end of treatment. A physical therapy progress note on 8/14/23 at 3:46 p.m. documented the NMES was set up for bilateral quads for 20 minutes. Following the NMES treatment there was moderate erythema (redness) to bilateral quads and five small circular abrasions less than one centimeter in diameter were observed under the electrodes. The PT then notified nursing staff and the DON who relayed pictures of the five circular abrasions to the certified wound nurse (CWN) to assess. The 8/14/23 physical therapy progress note documented the PT was recommending Resident #15 have hair removed prior to NMES use in the future to improve uniform conduction from the electrodes and reduce the risk of tissue damage. A late entry progress note on 8/14/23 at 4:51 p.m. by the CWN documented she received a call from nursing regarding redness to the right thigh post NMES. The right thigh presented with first degree burn with skin intact and no blistering. The CWN instructed nursing to manage the site with aquaphor (skin protection and healing ointment) two times a day and call for follow up. -There was no documentation regarding the resident's left thigh. A nursing progress note on 8/14/23 at 6:34 p.m. documented the nurse was notified by the PT of accidental burns to the resident's bilateral lower mid femur area of the legs by the NMES machine. The DON and CWN were notified and aquaphor was ordered twice daily. A daily nurse shift summary on 8/15/23 at 11:09 p.m. documented Resident #15's skin was assessed and color was normal; burn; rash; and itching. A late entry progress note on 8/16/23 at 4:16 p.m. documented the CWN received a call from nursing regarding an update on erythema to right and left thigh areas with one to three small areas of fading redness and approximately one to two millimeters in diameter. Aquaphor was discontinued and Bactroban (antibiotic ointment) was ordered per the physician to the remaining sites. The CWN documented the erythema/first degree burn resolved. -However, the physician ordered a new medication to be applied to remaining sites (see record review below). CPOs indicated Aquaphor to lower extremity mid femur burns two times a day for burn relief was ordered on 8/14/23 and discontinued on 8/17/23. Mupirocin 2% ointment (also known as Bactroban) was ordered on 8/24/23 to be applied to bilateral thighs topically four times a day for burns for five days. The CPOS failed to document the use of the NMES for Resident #15. The incident report dated 8/14/23 documented Resident #15 was receiving NMES to bilateral quads during a physical therapy session and sustained then less than one centimeter in diameter abrasions to the skin under the electrodes. A PT therapy note indicated Resident #15 accidentally sustained skin abrasions to bilateral quads following NMES and was a known risk for electrical stimulation of areas of impaired sensation. Resident #15 was not harmed in any aspect below the level of the skin. -However, the resident had received first and second degree burns. IV. Staff interviews The CWN was interviewed on 8/30/23 at 9:58 a.m. She said per her knowledge she was not aware of any issues to Resident #15's bilateral thighs. The CWN reviewed her notes and did not find anything about thighs. -However, see the 8/14/23 late entry progress notes above by the CWN. The DON was interviewed on 8/30/23 at 4:14 p.m. The DON said the NMES used by the physical therapist caused abrasions/burns to the resident's legs under the electrode pads. All residents had daily skin checks performed by the nurse. The DON said she was informed by both Resident #15's family member and the nurse about the burns. The DON said the nurse contacted the CWN, reviewed pictures and received orders (see record review above). The DON said the blisters never opened, were reabsorbed back into the resident's body and were dry in appearance. The DON looked at the images sent to the CWN and said the center of the burns were raised. Physical therapist (PT) #1 was interviewed on 8/31/23 at 9:43 a.m. PT #1 said the NMES was used for Resident #15 prior to the burns appearing on 8/14/23. PT #1 said she visually monitored muscle contraction during treatment to ensure the muscle was being stimulated. PT #1 said when she removed the electrode from Resident #15's upper legs she noted superficial abrasions and notified the nurse and the nurse notified the DON and the CWN. PT #1 said she had her doctorate degree in physical therapy and completed a competency evaluation for the facility for use of NMES. PT #1 said she educated all her patients on the risks of use of the electrical stimulation machine prior to use and Resident #15 agreed to the use of the electrical stimulation. PT #1 said Resident #15 had not been able to use the NMES since the abrasions occurred as they were waiting for the areas to heal and she was recommending Resident #15 shave the area of the legs where the electrodes were to be placed to help the electrodes make better contact and help prevent complications like the abrasions. PT #1 was unable to locate a tag on the NMES machine that would indicate the last time it was calibrated to ensure proper electrical pulses were being sent out by the machine. V. Facility documents A competency checklist for the occupational and physical therapist, received from the NHA on 8/31/23 at 1:37 p.m., documented PT #1 had met competency of NMES use, however was undated.

Based on record review and interviews, the facility failed to employ a director of food and nutrition services with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 19 census residents. Specifically, the facility failed to ensure the business office manager (BOM) who was in charge of the kitchen services, had sufficient qualifications for this position. Findings include: I. Facility policy and procedures The Dietary and Food Kitchen Supervisor policy, effective date of 2/12/19, was provided by the nursing home administrator (NHA) on 8/31/23 at 12:42 p.m. The policy revealed the kitchen supervisor was responsible for providing the day to day direction to kitchen staff, and overseeing food preparation. The supervisor was also responsible for the distribution of meals to residents served; maintained the cleanliness of the kitchen; ensured all quality assurance tasks were completed; and ensured compliance with local, state/federal regulations as well as company policies. The minimum qualifications for this position included a high school diploma or its equivalent and two years' experience in the food service industry. Supervisory experience was preferred. In addition, the individual should also possess a ServSafe (online education and assessment) certification, Allergen (online education and assessment) certification or other certifications as required by local jurisdiction. II. Record review The employee list, which included staff titles, was provided by the NHA on 8/29/23 at 11:09 a.m. No staff member was identified as the certified dietary manager (CDM). III. Staff interviews The business office manager (BOM) was interviewed on 8/28/23 at 10:30 a.m. She said she was in charge of the kitchen services. She said the facility did not have a dietary manager. The facility had a certified dietitian that was in the facility once a week. The BOM was interviewed again on 8/29/23 at 11:48 a.m. She said she had been in charge of the kitchen since March 2023. She said she had no CDM certification or another type of certification. She said she did not have an associates of arts (AA) degree in food service management nor two years' experience with some type of additional education in food safety or food handling. The NHA was interviewed on 8/31/23 at 3:23 p.m. The NHA said she was unaware of the need for the manager of the kitchen to have any specific training or certification. She said to her knowledge, this facility never had a dining service manager/director. She said when she became the NHA of the facility, she looked at the state regulations and not the federal regulations for the need for a dietary manager. She acknowledged the BOM did not have a ServSafe certificate nor any other certification.

Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#9) of one resident reviewed for hospice services out of 17 sample residents. Specifically the facility failed to: -Ensure a contract was signed between the facility and the hospice agency; -Ensure a hospice care plan was initiated for Resident #9 determining who was responsible for resident care; and -Ensure there was a medical diagnosis for hospice services. Findings include: I. Facility policy and procedure The Hospice protocol, dated 3/4/2020, received from the nursing home administrator (NHA) on 8/30/23 at 9:43 a.m., revealed in pertinent part, To ensure that all residents receiving hospice services have a plan of care that has a comprehensive plan of care that specifies delineation of services for the facility and the hospice company and to ensure all hospice members are trained on the facility policies and procedures. Procedure: an order for hospice services should be entered into the chart and placed on the treatment administration record (TAR) for each shift to acknowledge. Interdisciplinary team will meet with the hospice company, family and residents to develop a comprehensive care plan that delineates services that will be provided by each entity. The hospice team members will receive training on the facilities policies and procedures including abuse and neglect and documentation expectations. The Hospice company will attend by phone or in person, weekly interdisciplinary team meetings to ensure that the plan of care and delineation of services are appropriate. II. Resident #9 A. Resident status Resident #9, under age 65, was admitted on [DATE]. According to the August 2023 computerized physician orders, diagnoses included traumatic brain injury, hemiplegia (left sided paralysis), dysphagia (difficulty swallowing), and pneumonitis (inhalation of food into the lungs). The 6/9/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. He required one person's physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He required set up assistance for eating. Hospice care was initiated as a resident. B. Resident interviews Resident #9 was interviewed on 8/28/23 at 11:53 a.m. He said he was on hospice services and had no concerns with services he was receiving and was unable to recall when hospice staff visited him last. C. Record review The August 2023 CPO documented an order on 6/13/23 to discontinue physical, occupational, and speech therapy as Resident #9 was admitted to hospice. There was no order for hospice admission with a qualifying diagnosis. The NHA provided an order on 8/31/23 at 3:47 p.m. documenting an admission order to hospice services on 6/7/23 at 3:13 p.m. -However the order failed to have an admitting diagnosis for hospice services. The 6/21/23 care plan revealed resident hospice elections with code status change. Interventions in place were to assess the level of anxiety present in the family, include all family members as appropriate in discussion, provide/reinforce information about terminal illness, death and future family needs. Interventions were initiated on 6/12/23. Review of the facility's contract for hospice services documented there was no contract between the facility and the hospice company. The hospice binder at the nurse's station was reviewed on 8/31/23 at 1:23 p.m. It documented a registered nurse (RN) from the hospice visited on 8/3/23 where the resident reported no breathing issues or pain via a translator. The RN checked in with the facility nurse on any medication refill needs, none needed at the time of this visit. The social worker from hospice had visited on 6/8/23, consulted with the facility case manager, social worker and nursing staff. The resident was out at a Rockies game with facility activities and not available for the visit. The social worker from hospice completed a second visit on 7/5/23 for a routine visit and collaborated with Resident #9's nurse who reported the resident was doing well. A chaplain visited with Resident #9 on 6/19/23 and again on 7/25/23. The hospice collaborative care plan was blank and undated. D. Staff interviews The NHA was interviewed on 8/31/23 at 4:14 p.m. She said the facility did not have a signed contract with the hospice company and all care was provided by facility staff. The NHA said hospice staff had only been in the building when the resident was admitted to hospice services. The NHA said they did not have a medical diagnosis that would support hospice services.

Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from neglect. The facility failed to ensure Resident #1 was not neglected by staff on [DATE] by providing the care and services the resident required to maintain the highest practicable well-being. Resident #1 was left outside on [DATE] unchecked on the front patio of the facility in full sun, for at least three hours from approximately 11:00 a.m. until he was found by staff at approximately 2:00 p.m. When the resident was located on the patio, he was unresponsive and had a body temperature of 109 degrees fahrenheit. The resident was transported to a local hospital emergency room where he was diagnosed with [CONDITION(S)] secondary to hyperthermia and dehydration. Additionally, during this time the resident was left outside the facility failed to ensure Resident #1 received his [DATE] noon medications as ordered, was repositioned every two hours, and was offered his noon meal on [DATE]. The resident stated, On [DATE], he had gone outside to sit in the sun sometime in the morning. He said staff did not come out and check on him, or offer him lunch. He said the next thing he knew he woke up in the hospital a few days later. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, revised [DATE], was provided by the nursing home administrator in training (AIT) on [DATE] at 2:52 p.m. It read, in pertinent part, All employees, licensed independent contractors, licensed practitioners and volunteers (healthcare workers) are responsible for ensuring that all residents are free from abuse and neglect. Neglect means one of the following: 1. The negligent failure of any caretaker of an adult or child, to exercise that degree of care that a reasonable person in a like position would exercise. 2. That negligent failure of the person themselves (if an adult) to exercise that degree of care that a reasonable person in a like position would exercise. Neglect includes, but is not limited to: 1. Failure to assist in the personal hygiene, or in the provision of food, clothing, or shelter. 2. Failure to provide medical care for physical and mental health needs (unless it is withheld due to the person ' s reliance on treatment by spiritual means through prayer alone in lieu of medical treatment). 3. Failure to protect from health and safety hazards. 4. Failure to prevent malnutrition or dehydration. 5. Failure of a person to provide the needs specified in numbers 1 through 4, inclusive, for themselves due to ignorance, illiteracy, incompetence, mental limitation, substance abuse, or poor health. II. Resident #1 status Resident #1, age 67, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of two people with transfers and extensive assistance of one person with bed mobility, dressing, eating, toileting, and personal hygiene. He required set-up assistance only with locomotion on and off the unit using an electric wheelchair. It documented the resident did not have any behaviors or rejections of care. It also documented the resident at risk for developing pressure ulcers/injuries and was on a turning and repositioning program as well as a nutrition or hydration intervention. III. Failure to provide care to Resident #1; including failure to provide scheduled medications, failure to reposition the resident, and failure to offer the resident his noon meal. A. Record review A [DATE] at 3:34 p.m. alert nursing note documented the following: Around 1400 (2:00 p.m.) (an) admin assist (sic) called this nurse to the front of the building. Resident was in his w/c (wheelchair), not responding to stimuli. Ostomy bag was overly full and exploded. Resident was breathing and had a pulse at the time. Took four staff members to push (the) resident back to his room and into bed. While in bed residents still had a pulse but stopped breathing. Staff started bagging via Ambu bag. Temporal temp(erature) first said high and then 109 (fahrenheit). Cold packs were placed on resident. Resident had no pulse, started compressions, continued ambu bagging. MD was notifed (sic). New order noted to send (the) resident to Littleton Hosp(ital) emergently. Continued with compressions and bagging until EMS (emergency medical services) arrived. AED (automated external defibrillator) placed, resident did have a pulse and did not need anymore compressions. Resident had agonal breathing but still needed to be bagged. OPA (oropharyngeal airway; medical device used to maintain an open airway) was placed for better access. EMS left with (the) resident around 1430 (2:30 p.m.). MD (medical doctor) was updated. A [DATE] at 3:55 p.m. nursing health status note documented the following: At approx(immediately) 11ish pt (patient) was last seen by this nurse, pt (patient) asks nurse to assist him with a cookie pt (patient) was assisted to eat his snack. This nurse also performed foley care and ostomy care to pt (patient) prior to him wheeling away on his wheelchair. At this time pt (patient) appeared alert and oriented w/o (without) any visible s/sx (signs or symptoms) of distress/discomfort. At around 1300 (1:00 p.m.) this nurse asked 2nd nurse and CNA (certified nurse aide) if they had seen pt (patient) to which they responded 'No since this a.m.' at approx 1400 (2:00 p.m.) this nurse along with CNA and administration were taking another pt (patient) outside to visit with family and noticed (name of Resident #1) sitting out in the sun this nurse and CNA (certified nurse aide)attempted to get his attention but rapidly noticed pt (patient) was not responding. Pt (patient) had a pulse (caratoid)(sic) and was breathing yet unarousable. Pt (patient) was very warm to the touch, also nurse noted pt's (patients) ostomy bag was extremely full and had actually exploded. Pt (patient) was then taken into (the) facility pt (patient) was then transfer into bed by several staff members CPR (cardiopulmonary resuscitation) was initiated when unable to get a BP (blood pressure) and SpO2 (oxygen) reading at approx 1425 (2:25 p.m.) pt's (patients) temp at this time 109.8F (fahrenheit) pt (patient) was then covered with ice packs and CPR continued, unsuccessfully being able to obtain set of VS (vital signs) tem(sic) re-check104.5 (fahrenheit) at 1430 (2:30 p.m.) MD (medical doctor) was notified via phone by DON (director of nursing) and 911 was also called at approx 1436 (2:36 p.m.) EMS (emergency medical services) arrived to facility last temp check prior to departure to (name of local hospital) was 106.3. Pt (patient) (is) self responsible w/o (without) emergency/family contacts to (be) notified of this event. The [DATE] through [DATE] facility investigation documented the following: Incident summary: Resident was found outside unresponsive around ,d+[DATE]:10 p.m. Background information on the client, the placement of the staff or mentor: The Participant is a long-term resident of the (name of facility). He is an incomplete quadiplegic, with some movement in his upper extremities. He is independently mobile in his power chair and moves about the inside and outside freely. He has a history of non-compliance, refusal of cares and behavioral outburst. On [DATE] LPN (licensed practical nurse) #1 and CNA (certified nurse aide) #1 were assigned to care for the participant on the day shift. The participant was assisted with his ADLs (activities of daily living) and morning routine by CNA #1. He was wearing a hat, long sleeve flannel shirt, sweat pants and padded podus boots on his feet. His vital signs were within normal limits for this participant. Recently labs on [DATE] do not reflect any acute or infection issue. He was last seen by (name of CNA #1) at approximately 10:30 a.m. inside the facility. He was last seen by LPN #1 at approximately 11:00 a.m. inside the facility after she assisted with his foley and ostomy care and assisted with feeding him a cookie. LPN #1 noted no signs of distress. At approximately 12:00 social worker (name of social worker) observed the participant sitting outside her window in the sun and he appeared to be sleeping. At approximately 14:10 (2:10 p.m.) CNA #1, LPN #1 and Admin Assistant were assisting another resident outside for a family visit and checked on checked on (sic) Resident #1 and he was unresponsive. He was assisted to his room by 4 staff members (LPN #1, the DON (director of nursing); Administrative Assistant; and CNA #1) due to having to push the heavy duty power chair. The participant was transferred to his bed by the 4 employees. He was initially breathing and with pulse, however he did stop breathing and was without pulse for a period of time. B/P (blood pressure) was not able to be obtained, CPR (cardiopulmonary resuscitation) performed, MD (medical doctor) contacted and 911 was called. The participant had a temp of 109.8 and ice packs were used in an attempt to cool the participant down. EMT's (emergency medical technicians) arrived and the patient was hooked to the AED (automated external defibrillator) and determined to have a pulse. Rescue breathing using (an) AMBU bag was still needed, the participant was sent out to the acute setting. Upon admitting to the acute hospital the participant was found to have bacteremia, uremia and another opportunistic infection. Factual findings: DON (director of nursing) stated in her interview that she did not feel they were appropriately staffed. The facility census was at 21. They were staffed with 3 nurses and 2 CNAs. and 1 CNA that was doing orientation. There were 11 patients on Resident #1 unit, 2 of them were ventilators. The DON stated that the Matrix calls for 3 nurses and 4 C.N.A's. When interviewing LPN #1 and CNA #1, both stated that they were understaffed. Both said that they did not go to the DON to ask for help, but felt comfortable doing so if they felt they needed help. The participant has a history of moving freely about the facility and sitting outside in the sun. On [DATE] at 12:00 (p.m.) the participant was due for a scheduled medication that he did not get, due to him being off the unit and the nurse stating that she was busy assisting two vent patients that required her attention. The medication pass allowable time to administer medications is one hour before and one after the scheduled time. He was also due to be fed lunch at 12:00 (p.m.) but was off the unit and did not return at that time. The CNA stated that he usually comes in when he is hungry. The participant does need assistance with feeding. At 1300 (1:00 p.m.) the participant was due to be repositioned in his chair per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 1300 (1:00 p.m.) the LPN (#1) asked CNA #1 where the participant was and if anyone had seen him but neither went to look for him at this time. The participant was found unresponsive in the sun approximately 3 hours after being seen last. Both LPN #1 and CNA #1 stated that the participant was independent and would come to the unit to make his needs known and that it was not unusual for the participant to be off the unit for ,d+[DATE] hours at a time. Conclusion of facts (i.e., investigator's conclusion to the questions and issues raised by the incident): LPN #1 did not follow the medication pass policy and administer the participant's medications in the allowed time frame, nor did she attempt to locate the patient to administer the medication. CNA #1 and LPN #1 did not provide lunch to the participant during the lunch time period, Nor did they attempt to locate the participant during the lunch time hour to offer him his tray. The participant has an order to reposition him every two hours. The participant was not repositioned as ordered. The [DATE] hospital records documented the following: Hospital course: Resident #1 is a 67 yo (year old) male incomplete [CONDITION(S)] C5-C6 with chronic indwelling foley, diverting [CONDITION(S)] who resides at (name of facility) who was admitted [DATE] following [CONDITION(S)]. He is w/c (wheelchair) bound, LSN (last seen normal) approximately 1000 (10:00 a.m.) outside in sun, found 1500 (3:00 p.m.) later with depleted battery on w/c (wheelchair), unresponsive, no pulse. CPR x2 (time 2) rounds started by staff and EMS (emergency medical services) called. On EMS arrival, noted to have pulse, OPA (oropharyngeal airway) placed. On arrival to ED (emergency department), temp was 105, [CONDITION(S)] (rapid heart rate) and tachypneic (rapid breathing) with SBP (systolic blood pressure) 60's. Lab work reveals [MEDICATION(S)] (indication of lack of oxygen) 4.3, high sensitivity [NAME] (troponin, indication of a heart attack). EKG (electrocardiography) w/o (without) ischemic changes, reviewed by cardiolog. B. Staff interviews The quality assurance field service director (QIFSD) was interviewed on [DATE] at 12:15 p.m. She said she was responsible for completing the investigation, and as part of the investigation had interviewed staff and reviewed the residents medical record. The QIFSD said she was investigating the incident as neglect, but her conclusion had been that LPN #1 had failed to administer Resident #1 medication, and offer him lunch, as well as ensuring he had been repositioned. She had also determined CNA #1 had only failed to offer Resident #1 him his noon meal, and reposition him. The QIFSD said Resident #1 had multiple infections identified when he was admitted to the emergency room , because she felt like it was unknown if the staff had checked on him if the outcome would have been any different. The QIFSD said as a result of the incident and investigation, all facility staff received abuse and neglect training, but no additional training was provided to nurses on timely medication administration, repositioning or offering meals to residents. She said the resident's wheelchair had been assessed after the incident, and the battery still had power. The director of nursing (DON) was interviewed on [DATE] at 1:08 p.m. She said she was responsible for providing education to the nursing staff in the facility following the incident. She said she provided immediate training to CNA #1 regarding checking on residents every two hours, and making sure they were always offered their meal. The DON said CNA #1 no longer worked in the facility and LPN #1 was an agency nurse the facility no longer used. The DON said all staff were required to complete abuse and neglect training which the facility began on [DATE]. The DON said used Resident #1 as an example of neglect, as she felt the resident had been neglected by nursing staff, when they did not pass his medication, reposition him, or offer him his meal. C. Resident interview The resident was interviewed on [DATE] at 2:15 p.m. He said he remembered parts of what happened on [DATE]. He said he frequently gets cold, and enjoys sitting in the sun outdoors to warm up. He said on [DATE], he had gone outside to sit in the sun sometime in the morning. He said staff did not come out and check on him, or offer him lunch. He said the next thing he knew he woke up in the hospital a few days later. He said the doctors had told him he had died and they had to bring him back. He said he had suffered [CONDITION(S)] to the palms of his left hand and blisters to finger tips of his right hand. He said his palms face upward due to his paralysis, and he was not sure if the [CONDITION(S)] were from the sun, but that is all he could think of. He said he had never had any difficulty getting back into the facility when he had gone outside in the past, and he was unsure what happened, he just assumed he had passed out. He said he would still go outside, but only when it was warm out, as he did not like the cold, or feeling cold. IV. Facility follow-up The AIT was interviewed on [DATE] at 2:00 p.m. He said after the incident the facility ordered Resident #1 a call light that worked when the resident was outside. He said staff had also been completing two hour checks on all residents, but especially ensuring they were checking on the residents who liked to go outdoors. The AIT said staff was also making sure residents were dressed appropriately for the weather conditions, and ensuring all residents had access to fluids. The AIT said he would also be reporting LPN #1 and CNA #1 to the state board of nursing for their failure to provide care to Resident #1.

Based on observations, interviews and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as Coronavirus disease (COVID-19). Specifically, the facility failed to: -Ensure new admissions were placed on isolation for the required 14 days; -Ensure residents and staff followed guidelines for facial coverings to prevent the spread of infections; and, -Ensure disinfectant was not left out in common areas unattended. Findings include: I. Professional references According to the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance April 2, 2020, if possible, isolate all admitted residents (including readmissions) in their room for 14 days if their COVID-19 status is unknown. According to the Centers for Disease Control (CDC) website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (Retrieved 4/29/2020) cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect healthcare personnel (HCP) is unknown. HCP who enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use of respirator, gown, gloves and eye protection. When available, respirators should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring airborne precautions. The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Put on an N95 respirator (or higher level of respirator) or facemask (if a respirator is not available) before entry into the patient room or care area. Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19). Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others enter their room. II. Facility policy and procedure The Droplet Precautions policy and procedure, revised January 2007, was provided by the director of nursing (DON) on 4/28/2020 at 12:48 p.m. It revealed, in pertinent part, It is the intent of this facility to use droplet precautions to decrease the risk for droplet transmission of infectious agents. Droplet precautions shall be used in addition to standard precautions for residents with infections that can be transmitted by droplets. Droplets may be generated by the resident ' s coughing, sneezing, talking or during the performance of procedures. III. Failure to ensure residents admitted from a COVID-19 positive facility were placed on isolation for the required 14 days A. Observations During a continuous observation of the isolation room on the Columbine unit on 4/28/2020 beginning at 10:11 a.m., the following was observed: -The DON was interviewed on 4/28/2020 at 10:00 a.m. She said there was a resident placed under isolation for 14 days because she was a new admission to the facility. -The isolation room was observed. It did not have an isolation cart outside the resident ' s room. There was no signage observed to indicate the resident was on under isolation and which precautions should be used. -The isolation cart was observed on the right end of the nursing station next to an alcove wall. The isolation room was located on the left side of the nursing station. The isolation cart was not in close proximity to the resident ' s room. -At 10:27 a.m. two therapists opened the door to the isolation room and exited the room. One therapist was wearing a cloth mask without a surgical mask underneath and the other wearing a surgical mask. Both therapists walked down the hallway wearing the same facial masks. -At 10:34 a.m. registered nurse (RN) #1 was observed entering the isolation room. She wore a surgical mask. She did not don any other form of PPE. She exited the room at 10:36 a.m. B. Record review According to the 4/28/2020, Resident #1 was admitted to the facility from an acute care hospital on [DATE]. Resident #1 medical record was reviewed on 4/30/2020 at 1:20 p.m. and revealed the resident had [DIAGNOSES REDACTED]. C. Staff interviews RN #1 was interviewed on 4/28/2020 at 10:14 a.m. She said she was the nurse for the resident in room [ROOM NUMBER]. She said the resident was placed in isolation due to being a recent admission to the facility from an acute care hospital. She confirmed an isolation cart was not outside the resident ' s room. She said there were not any PPE inside the resident ' s room. She said facility staff were not donning full PPE to enter the resident ' s room. She said staff were wearing surgical masks to enter the room. She said she used the same mask to enter the isolation room as she used throughout the facility to take care of other residents. The DON and the nursing home administrator (NHA) were interviewed on 4/28/2020 at 10:52 a.m. The NHA confirmed a resident on the Columbine nursing unit was placed in isolation due to her recent admission to the facility from an acute care hospital. She said the resident was placed in isolation for 14 days. She said the facility staff did not don full PPE, expected with droplet precautions when they provided care to the resident or entered the resident ' s room. She said she had instructed the staff to wear surgical masks when entering the isolation room. She confirmed the resident came from an acute care hospital that was known to have positive COVID-19. She confirmed the guidance from CMS on 4/2/2020 indicated when possible to place any new admissions coming from a COVID-19 positive facility under isolation for 14 days. She confirmed COVID-19 was [MEDICAL CONDITION] that was transmitted by droplets. She confirmed COVID-19 required droplet precautions for isolation. She said she felt it was a waste of PPE because the resident had a negative COVID-19 test from the hospital. She confirmed an individual could test negative and potentially show symptoms for 14 days after potential exposure. She said she would provide education to the staff and resident that the resident would be placed on droplet precautions for the remainder of the 14 days since the admission to the facility. She said an isolation cart would be placed in front of the resident ' s room immediately. IV. Failure to ensure residents and staff followed guidelines for facial covering to prevent the spread of infections A. Observations During a continuous observation throughout the facility on 4/28/2020 beginning at 10:00 a.m., the following was observed: -At 10:11 a.m. a resident was observed in the therapy gym with a therapist. The therapist, who was wearing a mask, was in close proximity to the resident. The resident was not wearing a facial covering. -At 10:23 a.m., a resident was observed leaving his room in his electric wheelchair. He was not wearing a facial covering. He was observed passing by three facility staff members. The facility staff did not offer a surgical mask or any other facial covering to the resident. The resident was observed leaving the Columbine unit and went toward the front desk and facility common areas. -At 10:27 a.m. two therapists opened the door to resident room [ROOM NUMBER] and exited the room. One therapist was wearing a cloth mask without a surgical mask underneath. Both therapists walked down the hallway wearing the same facial masks. B. Interviews Resident #2 was interviewed on 4/28/2020 at 12:42 a.m. He said the facility had provided a facial mask when he was first admitted to the facility. He said the mask had to be tied around his head and he was unable to physically secure the mask. He said he required staff assistance to complete that task. He said the facility staff did not offer to assist him with the mask when he left his room to move about the facility. He said he was not aware he should be wearing a facial covering when he left his room or when the staff entered his room to assist him with care. He said he would be willing to wear a mask if the staff would assist him or provide him with one that wrapped around the ears. Certified nurse aide (CNA) #1 was interviewed on 4/28/2020 at 10:40 a.m. She said the facility did not provide facial coverings or masks to residents. She said if the resident left their room and were on isolation precautions, or went to an outside appointment, the facility would provide a surgical mask for the resident. She said they did not provide facial coverings for resident ' s moving about the facility. RN #1 was interviewed on 4/28/2020 at 10:43 a.m. She said if a resident requested a mask or facial covering the facility would provide them. She said it was not regular practice at the facility to ensure residents wore a mask when moving about the facility. She said some residents moved about the facility freely with electric wheelchairs. The director of therapy (DOT) was interviewed on 4/28/2020 at 10:44 a.m. He confirmed the facial mask the therapist wore to provide resident care in the isolation room was a cloth mask. He confirmed the mask did not have a surgical mask underneath the cloth mask. He confirmed the therapist should have been wearing a surgical mask underneath the cloth covering when having direct resident interaction. The DON and NHA were interviewed on 4/28/2020 at 10:52 a.m. The NHA said residents could have a mask if they requested a mask from the staff. She said the facility did not provide a mask to every resident. She said she was not aware of the guidance provided by CDC that residents should be wearing masks when they leave their rooms to move freely about the facility. She said some resident ' s refused to wear a mask in general. She confirmed that was not documented in the resident record. V. Ensure disinfectant was not left out in the common areas unattended A. Observations On 4/28/2020 at 10:17 a.m. in the Cottonwood room, a common area at the end of the Columbine nursing station, a bottle of Peroxide Multi-Surface Cleaner and Disinfectant was observed on a table in plain view. Facility staff were not present in the room. B. Staff interviews RN #1 was interviewed on 4/28/2020 at 10:43 a.m. She said some residents moved about the facility freely with electric wheelchairs. She said residents were able to go into the cottonwood room. She said it was considered a resident common area. She said a lot of the resident ' s at the facility had cognitive impairment due to neurological injuries. The DON and NHA were interviewed on 4/28/2020 at 10:52 a.m. The NHA said the disinfectant should not be left in public areas. She said the disinfectant should be locked up or with a staff member present to ensure residents did not ingest it by accident.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene was done by food service staff; and, -The cutting boards were free from deep scratches and stains making them an uncleanable surface. Findings include: I. Improper hand hygiene A. Professional references Colorado Retail Food Establishment Rules and Regulations, effective 1/1/19, section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment utensils, and unwrapped single, service and single use articles and: food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food clean equipment and utensils, and unwrapped single, service and single service articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; P48 (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. B. Observations Observation of the meal preparation was conducted on 2/11/2020 from 11:40 a.m. to 12:05 p.m. Observations in the primary production kitchen included: Cook (CK) #1 was serving lunch, wearing gloves. She proceeded to cut orange slices (ready-to-eat foods) on the cutting board. She wiped her gloved hand on the side of her pants. She then put on an oven mitt and reached into the oven and retrieved five plates. She placed all plates on the counter. She removed the oven mitt and proceeded to place the plates into the plate warmer. She wiped her gloved hands on the side of her pants again. She proceeded to grab five hamburger buns (ready-to-eat foods) out of the bag with her gloved hand. She placed the buns onto the metal countertop. She then placed one bun onto a plate. She proceeded to grab two chicken breasts with her gloved hand and place them onto the bun. She then grabbed the chicken sandwich with her gloved hand, placed the bun on the cutting board and cut it in half with the same knife as the orange slices. She grabbed both halves and placed the sandwich on the plate. The cutting board was not washed during this process She then walked over to the oven where she scooped a ladle full of macaroni and cheese and placed it on the plate. She wiped her hands on the side of her pants. She covered the plate with the plate cover and placed it on a tray on the metal rack. She adjusted her blouse with her gloved hand and repeated the same process for approximately 10 more times. She left the food area and walked over to the small refrigerator, reached for the door handle and opened the refrigerator. She then returned to the serving line. She proceeded to serve residents' meals. She maneuvered the metal racks with her gloved hands as each rack was ready for room delivery. She did not wash, change gloves, or sanitize her hands during this entire process. The dietary manager was preparing the side dishes for the meals. The DM was preparing the residents drinks for the meal trays. He bent down and opened the small refrigerator with his gloved hands. He removed several glasses of various drinks. He placed the drinks on the counter top. He then exited the food serving area and walked to the other refrigerator. He grabbed a large metal tray with bowls of coleslaw. He proceeded to grab a thermometer from the top of the metal counter and take the temperatures of the coleslaw. He did not sanitize the thermometer prior to taking the temperature. He lifted the clear plastic off of the bowl of coleslaw with his gloved hand and took the temperature of the coleslaw. The temperature was at 46 degrees Fahrenheit (F). The DM replaced the clear plastic wrap on the bowl of coleslaw. He placed the thermometer on the metal countertop. He wiped his hands on the side of his pants. He grabbed the tray of coleslaw and walked out of the food preparation area and placed the tray of coleslaw back into the refrigerator. He returned to the food preparation area and proceeded to place the drinks onto the meal trays. He maneuvered the metal rack with his gloved hand. He again left the food preparation food area and retrieved the tray of coleslaw from the small refrigerator. He returned to the meal preparation area and proceeded to take the temperature of the cole slaw. He again did not sanitize the thermometer before using it. He lifted the clear plastic wrap with his gloved hand and placed the thermometer in the coleslaw. The temperature read 39 degrees F. He replaced the plastic wrap on the bowl with his gloved hand and proceeded to place them onto the meal trays. He wiped his gloved hand on the side of his pants. He did not wash, change gloves, or sanitize his hands during this entire process. C. Staff interview The dietary manager (DM) was interviewed on 2/11/2020 at 4:21 p.m. He said all kitchen staff needed to wash their hands between every task. He said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they leave the kitchen area. The DM was told of the observations of staff during meal observation. The DM said staff should be washing their hands every time they changed their gloves. The DM said it was his expectation all dietary staff would have been washing their hands between tasks to avoid cross contamination. II. The cutting boards were free from deep scratches and stains A. Professional standard According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated January 1, 2019), page 132, 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 2/10/2020 at 8:55 a.m., revealed nine cutting boards that were heavily scored and stained. Each cutting board was scored with an area approximately nine inches by eight inches in circumference. On 2/11/2020 at 10:50 a.m. kitchen staff were observed using cutting boards to cut vegetables, breaded chicken and chicken sandwiches. C. Staff interview The dietary manager (DM) was interviewed on 2/11/2020 at 4:21 p.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. He acknowledged all of the cutting boards were discolored in the middle approximately eight inches in circumference. He said he had been employed since March of 2019 and they had not been replaced since then. He said, I will replace the cutting boards; they do need replacing.

Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days for two (#22 and #26) of five residents reviewed for unnecessary medications out of 17 sample residents. Specifically, the facility failed to discontinue a PRN psychoactive medication after 14 days without a physician's rationale for Resident #22, and Resident #26. Findings include I. Resident #22 A. Resident status Resident #22, age 48, was admitted on [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. According to the 1/24/2020 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 moderately impaired. The resident had mild depression with the resident scoring seven of 27 on the patient health questionnaire (PHQ-9). The resident had verbal behaviors directed at others.Anti psychotic were received on a routine and as needed basis (PRN). B. Record review The care plan, initiated 6/25/19 and revised 2/6/2020, identified the resident had a behavior problem related to [MEDICAL CONDITION]. When agitated the resident would call out, yell, bite, kick, and punch. Interventions include administering medications as ordered. Monitor and document for side effects and effectiveness. Caregivers provide opportunities for positive interaction. Stop and talk with him/her as you pass by. Document behaviors every shift in progress notes. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. The resident requires one-to-one sitter from 9:00 a.m., to 5:00 p.m. to help with redirection, reassurance and re-orientation. Document behaviors in a progress note every shift to evaluate the need for continued one-to-one sitter. The February 2020 CPO included: -[MEDICATION NAME] tablet 50 mg, give one tablet by mouth every six hours as needed (PRN) for severe agitation. Ordered 12/27/19. No stop date given on the order. The January 2020 Medication Administration Record [REDACTED]. The Febuary 2020 MAR indicated [REDACTED]. II. Resident # 26 A. Resident status Resident #26, age 39, was admitted on [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. According to the 1/30/2020 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had mild depression with the resident scoring five of 27 on the patient health questionnaire (PHQ-9). The resident had physical behaviors directed towards others. Antipsychotic were received on a routine basis. B. Record review The care plan, initiated 1/24/2020 and revised 2/6/2020, identified the resident had a mood problem related to anxiety, thoughts of suicide. Administer medications as ordered. Monitor and document for side effects and effectiveness. Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. Behavioral health consults as needed. Monitor, record and report to medical doctor (MD) prn mood patterns and signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. The resident needs time to talk as needed. Encourage the resident to express feelings. The February 2020 CPO included: -[MEDICATION NAME] 2 mg, give one tablet by mouth every four hours PRN for anxiety. Ordered 1/24/2020. No stop date given on the order. The January 2020 MAR indicated [REDACTED]. The February 2020 MAR indicated [REDACTED]. C. Staff interviews The director of nursing (DON) was interviewed on 2/12/2020 at 8:23 a.m. She said she was not too familiar with the new regulation specific to 14-day PRN psychoactive medication orders. She said she would get with the resident's provider and make changes to the PRN medications immediately.

Based on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#10) of one resident reviewed for hospice services out of 17 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure Resident #10, had a written plan of care which included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. Findings include: I. Resident #10 A. Resident status Resident #10, age 66, was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 CPO, [DIAGNOSES REDACTED]. According to the 12/18/2020 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had minimal depression with the resident scoring two of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. Revealed the resident was receiving hospice care and had a condition or chronic disease which may result in life expectancy of less than six months. B. Record review The February 2020 CPO included: -May continue hospice care while the patient was in the facility, start date 12/14/19. The care plan, initiated 12/13/19 and revised 12/23/19, identified the resident had a psychosocial wellbeing problem (actual or potential) related to end of life issues, hospice care. Interventions include assessing the degree of personal adjustment to diagnosis, such as anger, irritability, withdrawal, acceptance. Assess patients for stages of grief currently being experienced. Explain process as appropriate. Consult with pastoral care, social services, and psych services. Include all family members as appropriate in discussions. Provide and/or reinforce information about terminal illness and/or death and future family needs. May continue hospice care while the patient was in the facility. -The care plan failed to delineate the responsibilities of the facility versus what the hospice staff would provide in terms of services. II. Interviews Certified nurse aide (CNA) #1 was interviewed on 2/11/2020 at 10:00 a.m. CNA #1 said he was familiar with Resident #10. She said Resident #10 was not on hospice. Licensed practical nurse (LPN) #1 was interviewed on 2/11/2020 at 10:49 a.m. She said she was familiar with Resident #10. She said Resident #10 was not receiving hospice services but she would check and get back to this surveyor. -At 11:43 a.m., LPN #1 was interviewed again. She said Resident #10 was receiving hospice care. She said, I don ' t know what services they provide. The social service director was interviewed on 2/11/2020 at 6:01 p.m. She said she was the facility coordinator for hospice services. She said we had hospice stop CNA services because we provide all care for Resident #10. She said hospice provides social services and chaplain services for end of life for Resident #10. She said Hospice had their own care plan since we provide all care. The director of nursing (DON) was interviewed on 2/12/2020 at 8:23 a.m. She said she was not familiar with the regulation specific toward hospice care. She said social service was the coordinator between all hospice providers. She said the facility had no formal orientation for hospice aides. She said the facility will provide facility orientation to all hospice staff, which will entail policies and procedures of the facility, including patient rights. She said hospice staff would be provided access to the facility computer system so all staff could ensure residents' care was being provided.

Based on record review and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment of [REDACTED].#5) of one resident investigated for alleged abuse of 16 sampled residents. Specifically, the facility failed to timely report a suspected incident of physical abuse involving Resident #5. Findings include: I. Facility policy The buse policy, revised on 1/6/16, was provided by the nursing home administrator (NHA) on 1/22/19 at 3:00 p.m. The policy documented in part that care would be provided to all residents in an environment free from abuse. Definition of terms: -Abuse in part, Abuse of a resident is any of the following: physical abuse, neglect, financial abuse, abandonment, isolation, deprivation of goods or services . -Reasonable suspicion: means an objectively reasonable suspicion that a person would entertain based upon facts that could cause a reasonable person in a like position, drawing when appropriate upon his or the training and experience, to suspect abuse. -Mandated reporter: Any person who works for or has a contractual agreement with (name of facility), including administrators, supervisors, nursing staff, therapist, social worker, dietitian, including support and maintenance staff. -Prevention: .encourage all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately, identify, correct and intervene in situations in which abuse, neglect is more likely to occur. This includes an analysis of the supervision of staff to identify inappropriate behaviors, such as rough handling and ignoring residents while giving care . II. Resident #5 status Resident #5, over [AGE] years of age, admitted to the facility on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 10/19/18 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. He had moods to include trouble falling or staying asleep, or sleeping too much and feeling tired or having little energy. He did not have any identified behaviors. He required extensive assist of two staff for bed mobility. III. Resident interview and reporting to NHA Resident #5 was interviewed on 1/22/19 at 3:41 p.m.He said that a certified nurse aide (CNA #1) was physically abusive towards him. He said she was physical and rough when turning him in bed the other night. He said the registered nurse (RN #3) knew about it and was present during the incident and witnessed this. He said when CNA #3 was turning him she caused him pain in his legs from being so rough. He said he told her not to handle him roughly and she just ignored him and continued to do it anyway. The NHA was immediately informed of the above allegation made by Resident #5. The NHA stated she was not aware of this allegation and would be looking into the matter immediately. She stated the employees involved were aware of the facilities abuse prevention and reporting policies including mandatory reporting. IV. Record review Review of the resident ' s Kardex revealed in part under the section titled Safety, to use caution during bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. According to an activities of daily living (ADL) care plan, the resident had a self-care performance deficit related to a spinal cord injury (SCI), wounds and deconditioning. He required one to two staff to turn and reposition in bed every two hours and as necessary. According to an alteration in musculoskeletal status care plan related to SCI and osteo[DIAGNOSES REDACTED], the goals of the resident documented in part he would remain free from pain or at a level of discomfort acceptable to the resident of a level five through the review date and, he would remain free of injuries or complications related to immobility by the review date. Interventions included changing position every two hours and to alternate periods of rest with activity out of bed in order to prevent respiratory complications, dependent [MEDICAL CONDITION], flexion deformity and skin pressure areas. According to a psychosocial well-being care plan the resident had post-traumatic stress disorder ([MEDICAL CONDITION]). The goals documented he would have no indications of psychosocial wellbeing problems through the review date. Interventions included allowing him to answer questions and to verbalize feelings, perceptions and fears and provide opportunities for the resident to participate in care. The resident ' s clinical record from 1/17/19 to 1/22/19 revealed no documentation of the resident voicing he had been mistreated or alleged physical abuse. After the incident was brought to the facilities attention, there was no evidence found that a skin assessment was conducted following the report of physical abuse. V. Staff interviews The NHA was interviewed on 1/23/19 at 5:00 p.m. regarding her investigation findings. She said when she interviewed Resident #5 he stated a CNA (CNA #1) had been rough with him during turning and that it caused him pain. She said she interviewed CNA #1 and she said the resident told her she was smashing his leg while turning him. She said she asked RN #3 if she had received any reports of the resident being handled roughly. RN #3 said she did hear the resident say to the CNA: you are smashing my leg. RN #3 said CNA #1 had apologized to the resident but her tone could have been perceived to be rude. The NHA said that RN #3 was asked why she did not report it and she said she did not think it was a big deal at the time. The NHA said both employees had been suspended pending the outcome of the investigation. The NHA stated she had also reported the abuse allegation (physical) to the State agency line as it met the criteria for reporting of physical abuse. She also reported the incident to adult protective services (APS). CNA #1 was interviewed on 1/24/19 at 10:30 a.m. she said she regularly worked the night shift and took care of Resident #5 recently. She said the resident required extensive assistance and turning every couple of hours due to having wounds. She said the resident was alert and oriented. She said he did not have any behaviors but had recently been sick and was out of it. She said when she was turning the resident he said his knee was hitting the rail and that she was being rough with him. She said she was not turning him any differently than any other time she had turned him and she did not think she was being rough with him. She said she apologized to the resident. She said RN #3 was with her in the room but did not help her turn the resident. She said that she had received abuse training when she was first hired. RN #3 was interviewed on 1/24/19 at 11:05 a.m. She said she worked the night shift only and floated to all three units. She said the incident involving Resident #5 happened on 1/18/19 early in the shift around 11:30 p.m. She said Resident #5 required extensive assist with turning due to being a paraplegic. She said the resident was cognitively intact and did not have any behaviors. She said prior to the wound care on this night she told him they were going to be doing his wound care and medicate him for pain. She said CNA #1 had come into the room to help turn the resident for wound care. She said the CNA might have said hello to the resident but did not say anything else the entire time. She said the CNA was moving in a way that startled the resident and caused him discomfort. She said the resident verbalized to CNA #1 that she did not have to toss him around, (this contradicts the information provided by the NHA interview above). She said the CNA apologized but did not seem sincere. She said after the resident verbalized his displeasure of how he was being handled, CNA #1 stopped briefly and then proceeded with the turning. RN #3 said she should have gone back after the procedure to talk to the resident in private to see if he was ok. She said she should have handled the situation more professionally and exerted her authority with the CNA. She said CNA #1 continued to take care of the resident for the remainder of the shift. RN #3 said the CNA could have been more slow and gentle. She said the resident never said anything to her when she worked the next day. She said that she was aware of the facilities abuse policy and about being a mandatory reporter. The NHA was interviewed a second time on 1/24/19 at 6:30 p.m. she said that she had submitted all of her investigation to their corporate office and was awaiting further input and direction. She said that when interviewing RN #3 she told her that CNA #3 did not speak to the resident upon entering the room and just began to turn him without explaining to him what she was going to be doing. The NHA said she would have expected the CNA to approach the resident by asking his permission to begin the task and explain what she would be doing. The NHA said the CNA should have stopped when the resident voiced she was being rough with him. The NHA said following the report of the incident during the survey she spoke with staff one- o-one and asked them about their abuse reporting responsibilities. She said she did not begin a formal training. VI. Facility follow- up Following the survey exit on 1/25/19 the facility submitted written evidence showing that staff were educated on abuse and neglect prevention and mandatory abuse reporting on 1/24/19 and 1/25/19. The NHA stated that training would be ongoing until all staff received the training.

Based on observations, record review and staff interviews, the facility failed to ensure the medication error rate was not five percent or greater for two (#19 and #171) of five residents out of 16 sample residents reviewed. Specifically, the facility failed to: -Ensure Resident #19's pain medication was administered as ordered, and -Ensure Resident #171's vitamin ([MEDICATION NAME]) was administered as ordered resulted in a 6.06 percent error rate. Findings include: I. Professional Reference 1. According to Perry, Potter & Ostendorf, Clinical Nursing Skills & Techniques, 8th ed. 2014, pp 480-489: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation. Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication. When an error occurs, the patient's safety and well-being become the top priority. II. Facility policy The General Dose Preparation and Medication Administration policy, revised 1/1/13, was provided by the nursing home administrator (NHA) on 1/24/19 at 2:45 p.m. It read in pertinent part, Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. III. Residents status A. Resident #19 status Resident #19, age 61, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. B. Resident #171 status Resident #171, age less than 50, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. IV. Observations of medication errors and record review On 1/24/19 at 8:45 a.m. licensed practical nurse (LPN) #1 was observed preparing Resident #171's medications. She reviewed Resident #171's electronic Medication Administration Record [REDACTED]. She opened the bottle of vitamin B6 100 mg and poured one tablet into the medication cup along with other morning medication and administered the medication to the resident. -At 8:52 a.m. LPN #1 was interviewed. She acknowledged she administered the wrong vitamin. She said there was another resident on vitamin B6 and she just grabbed the wrong bottle thinking [MEDICATION NAME] was the same as B6. On 1/24/19 at 10:15 a.m. registered nurse (RN) #2 was observed preparing an as needed (PRN) dose of pain medication for Resident #19. She reviewed Resident 19's EMAR which read to administer [MEDICATION NAME] 10 mg via G tube every four hours PRN. A grayed out dispensing order read [MEDICATION NAME] 10 mg give 20 mg by mouth every four hours PRN for pain. She poured two tablets into the medication cup, then she poured them into a plastic sleeve crushed them and placed them back into the medicine cup. She said she was ready to administer them. Prior to administering the medication to the resident, RN #2 was stopped and informed she poured the wrong dose of medication for Resident #19. -At 10:30 a.m. RN #1 reviewed the physician orders [REDACTED].#2. They wasted the two crushed [MEDICATION NAME] and RN #2 administered [MEDICATION NAME] 10 mg per the physician order [REDACTED]. -At 11:30 a.m. RN #1 was interviewed. She said pharmacy did not update the dispensing label when Resident #19 ' s order changed. She said when the ordered changed on 1/7/19 the pharmacy should have changed their dispensing directions electronically. She said they called the pharmacy consultant, who in turn said they planned to correct the directions and provide education to their pharmacy staff on updating orders. She said education was given to RN #2 immediately to ensure the correct dosage of medication was administered per the physician order [REDACTED].#19 would also receive education as additional medication errors had been identified during survey. She said they placed a dose change label on the resident's medication card and the physician was notified of the medication errors. The nursing home director was interviewed on 1/24/19 at 1:45 p.m. She confirmed that the pharmacy had dispensed [MEDICATION NAME] with the incorrect dosage instructions on Resident #19's label. She said Resident #19's current order was correct. She said the resident received four incorrect doses of [MEDICATION NAME] since it had been decreased from 20 mg to 10 mg. She said she discussed the dispensing label with the pharmacist they planned to start educating their pharmacy staff regarding updating the dispensing orders in the electronic record when an order had changed. She said the physician was notified of the medication errors and the resident did not experience any side effects. She said she planned to provide education to the nurses to read the order completely to ensure they give the correct dose of medication in the future and apply direction change the label on the medication card if the dose had changed.

Based on observations, record review and interviews, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (#8) of one resident reviewed for social services of 16 sample residents. Specifically, the facility failed to: - Assist the resident to determine how he would like to make decisions about his health care, and whether or not he would like his parents to be involved in those decisions; and -Through the assessment and care planning process, identify ways to support the resident's individual needs. The findings included: Professional reference According to Standards of Practice, National Guardianship Association, reviewed on 10/16/17 at http://www.guardianship.org/documents/Standards_of_Practice.pdf, in part: NGA Standard 4 -The Guardian's Relationship with Family Members and Friends of the Person The guardian shall promote social interactions and meaningful relationships consistent with the preferences of the person under guardianship. A.The guardian shall encourage and support the person in maintaining contact with family and friends, as defined by the person, unless it will substantially harm the person. B.The guardian may not interfere with established relationships unless necessary to protect the person from substantial harm. II. The guardian shall make reasonable efforts to maintain the person's established social and support networks during the person's brief absences from the primary residence. NGA Standard 9 - Self-Determination of the Person I. The guardian shall provide the person under guardianship with every opportunity to exercise those individual rights that the person might be capable of exercising as they relate to the personal care and financial needs of the person. II. The guardian shall attempt to maximize the self-reliance and independence of the person. III. The guardian shall encourage the person to participate, to the maximum extent of the person's abilities, in all decisions that affect him or her, to act on his or her own behalf in all matters in which the person is able to do so, and to develop or regain his or her own capacity to the maximum extent possible. IV. The guardian shall make and implement a plan that seeks to fulfill the person's goals, needs, and preferences. The plan shall emphasize the person's strengths, skills, and abilities to the fullest extent in order to favor the least restrictive setting. V. The guardian shall wherever possible, seek to ensure that the person leads the planning process; and at a minimum to ensure that the person participates in the process. Facility Standard The Social Worker Competency Assessment, provided by the nursing home administrator (NHA) on 10/11/17 at 5:30 p.m., provided in part: 1. Evaluation skills - Cultural, spiritual, or ethnic factors that could influence care, treatment or services 2. Treatment skills - Assist residents in the following, when appropriate: coping skills; navigating relationships; solving personal and family problems/issues - Provide resident/caregiver education based on needs assessment 3. Management skills - Collaborates with other staff members of the interdisciplinary team, as appropriate, for case management. Resident #8 status Resident #8, age under 55, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 8/11/17 minimum data set (MDS) assessment, the resident had unclear speech, usually was understood and usually was able to understand others. His cognitive skills for daily decision making were moderately impaired. No hallucinations or delusions were recorded. No behavior of rejection of care or other behavioral symptoms were documented. The resident required extensive assistance of two plus persons with bed mobility, transfers, dressing, toilet use, and one person extensive assistance with eating and personal hygiene. He was totally dependent on staff with bathing. He received antipsychotic and hypnotic medications daily, and an antibiotic for four days. Record review According to the comprehensive care plan dated 10/7/17, the resident had impaired communication related to the [DIAGNOSES REDACTED]. Interventions included: speech/language function evaluation; attentive listening; encouragement to communicate; allowing time for correct words; providing acceptance; and limiting distractions such as noise and activity. The impaired cognition care plan related to orientation, memory, learning skills and judgment included the following interventions: -Assess and document resident's cognitive function -Provide familiar and consistent environment -Praise efforts frequently -Include resident in family teaching as able -Change sensory modality through the day; do not leave the radio or television on indefinitely -Treat at age level -Provide social interactions -Provide structured social and physical activities. The resident's care plan did not address daily visits with his parents. The resident's care plan did not address his parents assisting with feeding or their training/education related to the care they were providing during their visits. The care plan did not address the resident's choice of visiting with his parents in private. Physician Order On 2/24/17, a physician telephone order documented: Alert: Pt (patient) is not to be left alone with parents. If parents are visiting they must visit with Pt (patient) in the common area on the (name) unit. Viewable by the nurse. If family has questions, they need to contact the Pt (patient's) spouse and POA (Power of Attorney) (name) every shift for facility protocol. The above order was also documented in the resident's record on 7/1/17. Nursing Notes On 2/15/17, nursing notes documented, Alert: Per Pt POA (name), Pt is not to be left alone with parents at this time. Instructed parents that time with Pt will need to be in the common area of the (name) unit in view of the nurses station, until further notice or change from admin(istration) or POA. Parents verbalized understanding of this. Further record review revealed nursing notes documented the resident's parents were frequently assisting the resident with meal consumption. There were no notes with explanations why the above decision was made. There were no notes the resident's parents received any kind of training or education related to the resident's care. Social Service (SW) Notes On 8/11/17, social services notes documented, This patient continues as a permanent resident at (facility name) . Pt is out of his room at the nursing station and is comfortable. Although he is minimally talkative, he is able to make his needs known to nursing staff and does not complain of pain. On 5/19/17, This patient continues as a permanent resident at (facility name) . Pt is out of his room at the nursing station and is comfortable. Although he is minimally talkative, he is able to make his needs known to nursing staff and does not complain of pain. He is visited daily by his parents. On 2/22/17, Pt is medically stable at this time. SW visited briefly with the Pt; he replied using hand gesture that he was feeling 'so, so' . no further SW needs identified at this time. The social worker's notes did not address the resident's parents' visits or the restrictions to the visits. Observations The resident was observed on 10/10/17 between 3:30 p.m. and 5:30 p.m. He was sitting in his wheelchair, in the common area, next to the nurses' desk, in front of a television. At 5:05 p.m. the resident was observed being assisted by his mother with eating dinner. The resident was observed on 10/11/17 throughout the day. He was in his wheelchair, in the common area, next to the nurses' desk, in front of a television. Between 5:00 p.m. and 6:00 p.m. the resident was observed eating dinner with his mother's assistance. Interviews The residents' parents were interviewed on 10/10/17 at 5:10 p.m. They said they were coming to visit their son daily, in the afternoons, after work, during weekdays and earlier throughout the day on the weekends. They said that the resident's significant other, whom he lived with prior to his accident, had guardianship and was his medical power of attorney. They said the person named above was not visiting their son in the facility and was making all of decisions related to the resident's care, over the telephone. They said that since February (2017) they were prohibited by the facility from visiting privately with their son. They said he enjoyed being taken outside in his wheelchair for a walk around the facility when the weather was nice, and they could not do it anymore. They said they were not invited to the resident's care conferences, they were not informed of his healthcare status, and they could not participate in any of the decision making related to their son's care in the facility. The resident was interviewed in the presence of the a frequent visitor to the facility on [DATE] at 4:00 p.m. He said he enjoyed his parents' daily visits. He said his significant other/guardian was not coming to the facility to visit him, and he would not like it if she did. The resident was interviewed again on 10/12/17 at approximately 10:00 a.m., in the presence of his parents. The resident said he enjoyed the company of his parents. He said he enjoyed when his mother was assisting him during meals. He said he would like to be taken for a walk, outside of the facility with his parents. He said he felt safe in their company. The social worker was interviewed on 10/11/17 at 2:10 p.m. She said she worked part time in the facility. She said she was also a case manager and her time spent with residents was limited. She said she was not aware of the physician order [REDACTED]. She said the resident's guardian was not coming to the facility to visit the resident and all of the communication related to the resident's care was conducted over the telephone. She said the resident's psychosocial assessment was completed couple of years ago. She said she did not ask the resident of his wishes related to his parent's participation in the healthcare decisions as the resident's wife was the court appointed guardian. The NHA was interviewed on 10/11/17 at 4:45 p.m. in the presence of the social worker and the facility's frequent visitor. The NHA said she would organize a meeting with the resident's parents and his guardian. Facility Follow-up The NHA was interviewed on 10/12/17 at 11:42 a.m. in the presence of the social worker and the facility's frequent visitor. She said the resident's parents and his guardian were invited to the facility. She said the guardian agreed the resident's parents would be able to participate in the care conferences and would be able to take their son outside, on the facility property, for a walk. She said the resident's parents would have access to the resident's medical record. A physician's telephone order, dated 10/12/17, documented: Discontinue parental visitation restrictions.

Based on observations, record review and staff interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents throughout the facility. Specifically, biohazards and chemicals were not stored securely. The Findings include: Facility Policy The policy for infectious waste management dated 1/07 and provided by the nursing home administrator (NHA) on 7/14/16 revealed in part, Purpose: to decrease the potential of exposure to hazardous waste by appropriate management and disposal. Policy: OSHA has defined regulated waste to include: blood and blood products, pathological waste, microbiological waste, contaminated sharps (e.g., needles, lancets, scalpel blades .sharps will be placed directly into impervious, rigid, leak-proof and puncture-resistant containers to eliminate the hazard of physical injury. The containers will be appropriately marked with the bio-hazard symbol .the charge nurse or designated staff member will be responsible to see that the containers are removed from the use area . .storage of infectious (biomedical/regulated waste) shall be in a manner and location which affords protection from animals, insects and weather conditions; and which minimizes exposure to the public . Observations On 7/13/16 at 8:15 a.m. upon initial tour of the facility the following was observed in the west shower and hydro tub room (across from the shower room) in between Juniper and Ponderosa unit: - A small metal cabinet was mounted to the wall. A key was left inside the key lock despite a note taped to the front of the cabinet which read: Do not leave key in lock. The cabinet was approximately 60 inches above the floor. Just above the cabinet, approximately six inches above the cabinet was a hook where the key was to be stored. -inside the storage cabinet were containers of germicidal and non-acid cleaner spray and sani-cloth bleach wipes. Both of the containers held chemicals which needed to be stored safely and out of reach. -a sharps container, mounted on the same wall directly underneath the metal cabinet also had a key left inside the key lock (discarded safety razors were visible inside of the sharps container). -In the hydro-tub room, a safety razor was left on top of the tub and there were three safety razors left unattended on a rack next to the tub. -additional observations during the initial tour conducted revealed 22 out of 22 resident rooms had two different types of chemical wipes stored on metal mounts or setting on top of the paper towel holders. One of the containers was labeled super sani-cloth germicidal wipe, and, PDI sani-cloth bleach germicidal disposable wipes. Both of the items contained chemicals which needed to be stored safely and out of reach. On 7/13/16 at 8:40 a.m. a sharps container with the key left in the lock was observed next to the nurses' station (and room 105) located on the Juniper unit. On the front of the sharps container was the original label that stated the container was for biohazard sharps storage only. There was also a second, hand written label adhered to the front that said: Used batteries only. Discarded batteries and one discarded needle syringe were visible through the container. On 7/13/16 at 10:55 a.m., the utility room on the 100 hallway, which contained biohazard materials, was left open. There was a sign on the door which read, Please keep door closed at all times. -At 11:20 a.m., a certified nurse aide (CNA) entered the utility room with biohazard material. At 11:22 a.m., the CNA exited the room but did not close the door securely. -At 11:28 a.m., two staff members walked by the utility room on the 100 hallway. Neither staff member closed the door to the utility room containing bio-hazardous material as the sign on the door had directed. -On 7/14/16 at 9:40 am, the sharps container near Cottonwood nurses station (and room 306) contained a key that was left the key lock. On the front of the sharps container was the original label that stated the container was for biohazard sharps storage only. There was also a second, hand written label adhered to the front that said: Used batteries only. On 7/14/16 at 12:38 p.m., the utility room with biohazard materials on the 100 hallway was left open with the light on. There was a sign on the door which read, please keep door closed at all times. At 12:41 p.m. the nursing home administrator (NHA) walked by the utility room and closed the door. -At 2:28 p.m., the door to the utility room with biohazard material on the 100 hallway was left open with the light on. -At 2:41 p.m. the utility room with biohazard material on the 100 hallway was open with the light on. Two staff were observed passing by the room but did not stop to close the door. Interviews On 7/13/16 at approximately 8:30 a.m. the maintenance director (MD) was shown the shower room on the west side of the building. He said the keys should not be left in the cabinet or in the sharps holder. He said there were chemicals stored in the metal cabinet and the sharps container was for safety razors. He said the only reason the keys were in them was for easy availability for staff. He agreed it was a potential hazard for a resident to easily access the two storage units where hazardous materials were store. He then removed both of the keys. CNA #4 was interviewed on 7/13/16 at 11:45 a.m. She said the key to the cabinet in the shower room on the west side was supposed to be hanging on the hook and never in the key lock. She said the sign was on there because there were chemicals stored in the cabinet and you never knew if a patient might try and get inside the cabinet and it would be a safety hazard. The NHA was interviewed on 7/14/16 at 2:36 p.m. while turning the above areas of concern. Beginning on the Juniper unit he was asked if it was acceptable for the key to remain in the lock of the sharps container mount and, if it was the proper receptacle for discarding used batteries. He said he did not see anything wrong with it and the key was in it so that nursing could access it if needed. He was asked if the sign on the container said for used batteries only, should there be anything else discarded here. Upon observation of the container he was asked what other item(s) he saw discarded in the container. He did not reply. He was asked if he saw the syringe discarded in with the batteries. He shrugged his shoulders and said it (the container) was still a sharps container and no one could get into the container unless they pried it open. Again, he was asked if the key was in the lock could he see it created a potential hazard and someone could remove it from the mounted case. He said he did not understand, again, what the problem would be and would check if there was a specific facility policy in place. He then removed the key from the lock. -At 2:41 p.m. observations of the Cottonwood unit was conducted with the NHA. He was shown the sharps container unit that contained the key in the key lock. He opened the case, looked at the sharps container and said all he saw was discarded batteries. He then removed the key and said he did not know what the batteries were used for. -At 2:44 p.m. observations were made with the NHA of the utility door on the 100 hallway. At the time of this observation, the door was not completely closed. Upon entering the room a biohazard bin, a house keeping cart were among some of the items stored in the room. Setting on top of the cart was a bottle of chemical grease cleaner and a clear plastic spray bottle with clear liquid in it. The outside of the bottle was marked bleach. He said chemicals needed to be locked up then removed them and placed them across the hall in another locked utility room. He was asked if there had been a functional problem with the door. He responded it's closed, and would not offer any additional information. -At 2:55 p.m. the NHA was asked to provide a policy regarding storage of hazardous materials. He said he was working on that if one even existed (see above policy provided). The MD was interviewed a second time on 7/18/16 during the environmental tour at 12:09 p.m. He said he was not sure why the chemical wipes were kept in the resident rooms and that it involved nursing more. He said the biohazard rooms were not locked and the purpose of the sign was to remind staff to keep the door closed because the fan needed to be left on for odors. He said the biohazard waste was removed at the end of each shift. He said chemicals should never be stored in these rooms because the door does not lock. During the tour the mounted sharps containers were observed on the Cottonwood and Juniper units. There were no keys in the locks. The MD said as far as he knew the facility was being proactive for recycling of batteries. He did not know what the batteries were being used for. He said as far as he knew the containers were not being utilized for discarding sharps items. He said he would be responsible for removing the containers once they became full and he had a key for the locks. The activities director (AD) was interviewed on 7/18/16 at 12:57 p.m. she said she did not know the policy for storing the chemical wipes in the resident rooms but they had been there for a long time. She said one of the wipes contained bleach for disinfecting if there was an infectious disease in the room. She said the purple topped wipes were for general sanitizing over bed trays. She said the wipes could present as a potential hazard if someone with a brain injury were to ingest a wipe. CNA #3 was interviewed on 7/18/16 at 1:10 p.m. she said the chemical wipes have always been stored in the rooms. She said precautions had to be taken when using the bleach wipes by using gloves and being careful not to use these wipes on any items the resident's could potentially touch. She said if they had confused residents they could remove the wipes from the room.

Based on observations and interviews, the facility failed to follow proper infection control procedures to maintain safe and sanitary conditions and prevent the development and transmission of disease and infection. Specifically, the facility: -Failed to implement proper hand washing practices when assisting residents with cares; and, -Failed to sanitize resident rooms in a manner to reduce the spread of infections. The findings include: 1. Hand washing Observations Certified nurse aide (CNA) #4 was observed on 7/13/16 at 11:18 a.m. while assisting the resident in room [ROOM NUMBER]. The CNA emptied fecal matter from the bedside commode. The CNA washed her hands at the resident's sink as she turned on the faucet with her hands, obtained soap, lathered and rinsed the soap from her hands. With her wet hands, she turned off the faucet and then used a paper towel to dry her hands. The CNA did not protect the faucet handle from her potentially contaminated hands while turning the faucet on and did not protect her newly cleaned hands from the potentially contaminated faucet handle when turning the faucet off CNA #4 and a licensed practical nurse (LPN) were observed on 7/13/16 while assisting the resident in room [ROOM NUMBER]. Neither staff washed their hands or applied hand sanitizer before donning gloves. -At 1:41 p.m., CNA #4 removed the resident's foot pedals from his wheelchair and placed them near the sink. She also took a gel pillow from his behind his calves and placed it on the opposite side of the bed on the window bench. She removed another gel pillow from behind the resident's head. Another CNA entered and donned gloves without sanitizing or washing her hands and as the LPN exited the room. -At 1:43 p.m., CNA #4 lowered the transfer rail at the resident's bedside using the same gloves. -At 1:44 p.m., the two CNAs, with the use of a gait belt, transferred the resident to his bed. They lifted his legs into this bed and removed his shoes. His tray table was moved closer to him in bed. -At 1:46 p.m., the other CNA, while wearing same gloves she donned upon entering the room and assisting with care, opened the resident's brief to check for incontinence. Not seeing any, she stated such, and removed the gloves. She adjusted the resident's bed settings without sanitizing or washing her hands. -At 1:48 p.m., the CNAs exit the resident's room. One CNA used the hand sanitizer near the sink. The other CNA did not wash her hands. Two therapy staff were observed on 7/14/16 at 10:08 a.m. while assisting the resident in room [ROOM NUMBER]. The therapy staff was getting the resident up in his chair. They did not have gloves on as they transferred the resident from his bed to his wheelchair. One staff member was on the resident's bed behind the resident trying to direct him safely towards his chair. Once the resident was in his chair with foot pedals applied, the two staff members exited the resident's room without sanitizing or washing their hands at the sink. 2. Housekeeping Observations Housekeeper (HK) #1 was observed on 7/18/16 while cleaning resident room [ROOM NUMBER]. -At 8:21 a.m., the HK applied gloves, without first washing her hands, upon entering the resident's room. She said the gloves were worn for sanitation purposes. The HK stated when she walked into a room the first area she sprayed was the sink. She then removed her gloves and applied a new set of gloves without washing her hands. -At 8:23 a.m., the HK dusted around the resident's room. She stated she dusted the resident's keyboard, pictures, light, and closet. The HK dusted the television screen and the vents. She said the vents become extremely dusty. The HK stated she also wiped down the window sills. -At 8:31 a.m., the HK returned to the sink and began to take dry paper towels to wipe the sink. The HK then sprayed another chemical which she reported was left in the sink for one minute. She said after a minute, she took paper towels and wiped the cleaning solution in and around the sink. -At 8:35 a.m., the HK reported she was finished in the resident's room. She removed her gloves and did not use hand sanitizer or wash her hands at the resident sink before she exited the room. The HK did not clean commonly touched surfaces. She did not sanitize any door knobs, remote controls, call lights, transfer bars, or tray tables. -At 8:37 a.m., the HK moved to room [ROOM NUMBER]. She did not wash her hands before she applied gloves to enter the resident's room. The HK used disinfectant spray in the sink and moved into the resident restroom shared with room [ROOM NUMBER] and sprayed the hi-riser seat above the restroom toilet. She sprayed around and near the toilet. She removed her gloves and applied another pair without any hand washing performed. -At 8:43 a.m., the HK replenished the paper towels at the sink. She did not wash her hands. -At 8:45 a.m., the HK cleaned and wiped the sinks and toilet. She did not clean or sanitize the light switch, call light pull cord, toilet flush handle or the grab bars in the restroom. The HK said she cleaned and sanitized the room to prevent bacteria buildup. She said sanitizing rooms was done to reduce the spread of germs in the building. -At 8:48 a.m. and again at 8:52 a.m., the HK removed her gloves and applied a new set. She did not wash her hands. She said she could change her gloves anywhere from seven to ten times in one room. -At 9:03 a.m., the HK stated she had finished cleaning the resident's room. She did not clean or sanitize commonly touched surfaces such as telephone, transfer bars, call lights, remote controls, door knobs, or light switches. She exited the room without washing her hands. -At 9:06 a.m., the HK moved to room [ROOM NUMBER] for cleaning. She did not wash her hands before she applied gloves. She did not sanitize any door knobs, toilet flush handles, light switches, call lights, remote controls, phones, or transfer/grab bars. There was no hand washing performed. She finished cleaning the room at 9:33 a.m. -At 9:33 a.m., the HK went to the nurse station to wash her hands. 3. Interviews HK #1 was interviewed on 7/18/16 at 9:40 a.m. She said the only time she washed her hands during the observation was at the nurses' station after room [ROOM NUMBER]. She stated hand washing was necessary to prevent the spread of infections from room to room. She acknowledged hand washing practices should occur at least upon entering and exiting a resident room. The HK also confirmed she missed sanitizing commonly touched surfaces in all the rooms. She stated she did sanitize the light switches, call lights, remote controls, phones, transfer bars, toilet flush handles, tray tables, and door knobs. She said it was important to sanitize commonly touched surfaces because it helped with reducing the spread of germs and possible infections. The DON was interviewed on 7/18/16 at 10:25 a.m. She said staff should wash their hands and/or use sanitizing foam when going in and out of resident rooms. She said proper hand washing and sanitization was to prevent the spread of infection. The DON said commonly touched surfaces included door and toilet handles, bed rails, light switches, and surfaces touched my multiple people. She said commonly touched surfaces should be sanitized to reduce the spread of infections. She stated ongoing infection control in-servicing and education would continue throughout the facility.