Every finding on record at San Luis Care Center

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure the kitchen was maintained, in good repair to be able to have a cleanable surface.Findings include: I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 8/4//26. It revealed in pertinent part, Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4, 5 and 6) Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. (4-501.12)II. Observations During the initial kitchen walk through on 7/27/26 at 8:07 a.m. the following was observed: -The kitchen hand washing ink had brown residue throughout the bowl, rim and near handles. -The floor was sticky throughout all areas of the kitchen. -There were two large black floor mats between the preparation tables, the stove and the steam table. The edges of the floor mats were deteriorated, had missing pieces and the mats were discolored from wear. The edges where the floor met the walls were noted to have dirt and debris.-Under the dish drying racks there was paper and food on the floor. -There were white water stains under the three compartment sink and under the dish machine. -The stove handles to the oven and handles to storage drawers on two preparation tables were greasy to touch. Coffee stains on the floor under the coffee machine. A follow up observation of the kitchen on 7/28/26 at 3:35 p.m. the following was observed:-The hand washing sink was dirty. There was debris throughout the kitchen on the floor.-The coffee stains on the floor under the coffee machine were still present.-There was a wood preparation table that had gouges (deep grooves cut into the surface) along the flat surface and the side edge of the table.-The steam table had a wood surface on the front that had several gouges into the surface. -The walk in refrigerator had three large fountain soda containers from a local convenience store on the shelf. Two of the containers had straws in them ready to drink. There were no names or dates on the soda containers. -The floors throughout the kitchen continued to be sticky.On 7/30/26 at 9:37 a.m. the following was observed in the presence of the dietary manager (DM). -The floors were sticky throughout the kitchen.-The floor mats were deteriorating with missing pieces. -Two cutting boards out of nine on the storage rack had gouges on them.-There was debris throughout the kitchen on the floor. III. Record reviewThe DM provided the cooks daily cleaning list on 7/30/26 at 10:30 a.m. The list included instructions for the morning shift and evening shift cooks to complete: wipe down and sanitize all preparation tables; clean steam table and grill; wipe down all used appliances; clean can opener and surrounding area; toss out any expired items from the refrigerator; clean the plate warmer (under and filter); wash all pot and pans (allow air dry before storing); sweep under all equipment/tables and mop floors; clean sink and washboards; insure meat was pulled for upcoming meals; wipe down wall by trash can and rag bins; ensure staff snack bins have items in them; and nourishment refrigerator was stocked. Review of the cooks daily cleaning list from 7/1/26 to 7/29/26 revealed the cooks were signing off on cleaning being completed. -However, observations revealed debris throughout the kitchen (see observations above). The DM provided the aide/hostess weekly cleaning schedule on 7/30/26 at 10:30 a.m. It documented items to be cleaned; clean the coffee machine, clean the trash cans; sweep and mop the dish room area (move mats, carts and bins); clean shelves on aids side (include under preparation tables and restock items); clean aides side of reach in refrigerator; clean juice machine; clean and wipe down all drawers and cabinets in the dining room; wipe down the wall by machines and drink station; and clean the dining room trash can and cabinet. Review of the aide/hostess weekly cleaning schedule from 7/1/26 to 7/29/26 revealed the following:-The cleaning of trash cans was done four times out of eight opportunities;-Sweeping and mopping the dish room area was done six times out of nine opportunities;- Clean the aide's side of the reach in the refrigerator was done two times out of five opportunities;-Clean and wipe down all drawers and cabinets in the dining room were done five out of eight opportunities;-Wipe down the wall by machines and drink station was done one time out of eight opportunities;-Clean dining room trash can and cabinet was done three out of nine opportunities.IV. Staff interviewsDietary aide #1 was interviewed on 7/30/26 at 9:20 a.m. Dietary aide #1 said the kitchen had a schedule for cleaning. She said every one had tasks for cleaning assigned to them based on their shift. Dietary aide #1 said the dish machine gets a deep clean frequently because it tends to get built up water residue. The DM was interviewed on 7/30/26 at 9:37a.m. during the observations of his kitchen. The DM said he had worked at the facility for three years.The DM said the floor mats had been in use for a while and he had asked for new ones but had not received them. He was unable to recall when he asked for replacement mats. The DM said he had replaced his cutting boards about a month ago. He said some could be removed because of gouges on them. The DM said the kitchen had a cleaning schedule for certain things to be cleaned at weekly intervals but he did not have a deep cleaning schedule of the entire kitchen.

Based on observations, record review and interviews, the facility failed to ensure one (#60) of three residents reviewed for abuse were kept free from abuse out of 34 sample residents.Specifically, the facility failed to protect Resident #60 from sexual abuse by Resident #48.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, revised 7/18/23, was received from the nursing home administrator (NHA) on 7/27/26 at 11:34 a.m. It revealed in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Establish a safe environment that supports, to the extent possible, a residents consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which may lead to conflict or neglect, such as: verbally aggressive behavior; physically aggressive behavior; sexually aggressive behavior; taking touching, or rummaging through other's property; and wandering into others room/space.II. Incident of sexual abuse by Resident #48 towards Resident #60 on 9/5/25A. Facility investigationOn 9/5/26 at approximately 3:15 p.m. Resident #60 reported to the nurse on the 200 hall that Resident #48 came up from behind and hugged her. Resident #60 said Resident #48 told her You have a nice breast and then proceeded to reach down and touch one of her breasts. Resident #60 told Resident #48 that his actions were not okay with her and Resident #48 left.The facility placed the Resident #48 on one-to-one monitoring with a staff member to ensure the safety of other residents. Resident #60 was assessed by a registered nurse (RN) and no injuries were noted. Facility staff conducted interviews with both residents. Resident #48 verbalized to facility staff that he did speak to Resident #60 and touched her breast. The facility conducted interviews with five other residents and family members. No issues were identified from the interviews.The facility substantiated the allegation based on both parties being alert and oriented. Resident #48 (assailant) did have a history of making inappropriate comments towards female staff along with wandering into other residents' rooms or staff only areas within the building. Along with resident interviews, it was determined Resident #48 did put his arms around Resident #60 and touched her breast. B. Resident #48 (assailant)1. Resident statusResident #48, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes , malignant neoplasm of the kidney (cancer of the kidney) and hypertension.The 7/9/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview of mental status (BIMS) score of 11 out of 15. He was able to ambulate independently with a walker. The MDS assessment indicated Resident #48 had behavioral symptoms not directed towards others (pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste) which occurred on one to three days during the assessment look-back period. 2. Record reviewThe sexual inappropriateness care plan, initiated on 5/20/25 and revised on 9/10/25, documented Resident #48 had the potential to exhibit sexual inappropriateness. Interventions included redirection and reporting to the nurse if any inappropriate contact was attempted, behavioral health services were offered to the resident, education to not enter any female rooms even if invited and education he was not to touch any female resident or staff member inappropriately. An event progress note, dated 9/5/25 at 5:00 p.m., documented an assessment of Resident #48 was completed with no pertinent findingsAn alert charting note, dated 9/7/25 at 12:44 p.m., documented Resident #48 was on alert charting related to inappropriate behaviors with one-to-one supervision. The resident had spent most of his time in his room with no inappropriate behaviors reported by the one-to-one staff member. A progress note, dated 9/10/25 at 10:00 a.m., documented a huddle was performed with all nursing staff on the floor. The incident (with Resident #60) was reviewed with staff. Resident #48 would require one-to-one monitoring until further notice. The staff discussed the need to monitor residents in common areas when Resident #48 was among other residents. Staff was educated on redirecting residents if seen attempting to enter other residents' rooms.A psychosocial progress note, dated 9/11/25 at 12:08 p.m., revealed a behavioral health group met with Resident #48 related to counseling services. During the intake, Resident #48 refused services. A physician progress note, dated 9/12/25 at 1:00 p.m., revealed Resident #48 was observed to be groping a female resident's breast and making sexually suggestive comments. Both residents were separated immediately and Resident #48 was placed on one-to-one monitoring. Resident #48 was confronted about his behavior and he immediately apologized, admitted it was improper and promised not to do it again. The resident admitted to his age and that he was not sexually active with women anymore. He had, in the past, requested medication for erectile dysfunction (ED), stating he had ED and wanted to see if it still worked. Resident #48 also conveyed he masterbated privately. The physician documented this behavior did not seem to be compulsive and the resident had never been observed masterbating in a public setting. The physician documented Resident #48 was agreeable and got along well with others but at times refused care (such as showers), but for the most part he was cooperative. A plan of care note, dated 9/16/26 at 3:45 p.m., documented the interdisciplinary team (IDT) met to discuss the removal of one-to-one supervision for Resident #48. The physician, behavioral health services and all parties that were consulted felt one-to-one supervision for Resident #48 could be removed at that time. C. Resident #60 (victim) 1. Resident StatusResident #60, age greater than 65, was admitted on [DATE] and discharged from the facility on 5/29/26. According to the May 2026 CPO, diagnoses included type 2 diabetes, hypertension and bipolar disorder (mood swings).The 5/29/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment did not indicate the resident had behaviors. 2. Record reviewThe 5/29/25 impaired through process related to bipolar disorder care plan, initiated 5/29/25, revealed Resident #60 was at risk of sexual inappropriateness (initiated on 9/11/25). Interventions included behavioral health services were to follow the resident (initiated 9/9/25). An event note, dated 9/5/25 at 3:10 p.m., documented Resident #60 reported to the nurse she was sitting in the dining room when a tall, skinny man who lived in the facility and wore a red jacket and hat, approached her from behind, hugged her, groped her and told her she had nice breasts. Resident #60 reported to the nurse that she told him to stop and that it was not okay for him to touch her. Resident #60 reported the incident scared her and made her very uncomfortable. Resident #60's hands were tremulous (shaking). The nurse and Resident #60 then ambulated to the center court to identify the other resident. Resident #60 was not able to locate the alleged assailant (Resident #48) at that time and returned to her room. Resident # 60's responsible party was notified and questioned if the incident was observed by anyone. The nurse notified the responsible party that no one had come forward but the facility would be conducting an investigation. The responsible party questioned if it could have been the resident's psychosis. The responsible party was advised the alleged perpetrator (Resident #48) was placed on one-to-one supervision for safety. An event note, dated 9/5/25 at 5:10 p.m., revealed that during a skin assessment, Resident #60 stated He was so close to me that I could feel his whiskers on my face a couple times. It really scared me and made me feel uncomfortable. A late entry event note, dated 9/6/25 at 11:51 a.m., documented the social services director (SSD) met with Resident #60 to discuss how she was feeling regarding the incident with Resident #48 on 9/5/25. Resident #60 stated she was okay and did not feel fearful in the facility nor was she fearful of the alleged perpetrator (Resident #48). Resident #60 was informed that the SSD would meet with her over the next four days to ensure the resident continued to feel safe in the facility and address any concerns she may have. Resident #60 was also encouraged to let any staff members know if she needed anything. An alert note, dated 9/6/25 at 11:25 p.m., documented Resident #60 was on charting after being the receiver of inappropriate behaviors on 9/5/25. Resident #60 was anxious in the evening as she talked about the situation. Resident #60 was administered an as needed medication, hydroxyzine, to alleviate her anxiety. A psychosocial note, dated 9/7/25 at 10:05 a.m., documented the SSD met with Resident #60 to follow up with the encounter with the alleged perpetrator (Resident #48) on 9/5/25. Resident #60 reported she was doing just fine and was not fearful in the facility. Resident #60 reported she had trouble sleeping last night (9/6/25). However, the resident did not know if it was from the incident or her upcoming surgery. Resident #60 said she was not fearful of the male resident (Resident #48). However, she did not want to be near him because it made her feel creepy. III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 7/29/26 at 3:28 p.m. CNA #2 said Resident #48 kept to himself and liked to eat in his room for meals. She was unaware of any sexually inappropriate behaviors Resident #48 had towards female residents or staff members. CNA #2 said if she observed or suspected abuse she would ensure resident safety and notify the nurse of any concerns. She said the nurse would then make notifications as needed for an investigation. CNA #1 was interviewed on 7/29/26 at 3:50 p.m. CNA #1 said Resident #48 was stubborn. She said if he did not want to do something he would refuse. She said the resident did interact with other residents at times but mostly liked to be by himself. CNA #1 said she was unaware Resident #48 had sexually inappropriate behaviors towards female residents or staff members. RN #3 was interviewed on 7/29/26 at 4:42 p.m. RN #3 said Resident #48 did have behaviors. She said he liked to spit in public spaces, he had sexual behaviors privately in his room. RN #3 said Resident #48 had an incident a while ago where he touched a female resident's breast (Resident #60), who no longer resided at the facility. RN #3 said both residents were able to make their needs known. RN #3 said Resident #60 came to her and reported what happened in the dining room with Resident #48. RN #3 said she ensured Resident #60 was safe and then reported the allegation to her charge nurse, the director of nursing (DON) and the NHA.RN #3 said Resident #60 was educated to not have her back to where people could come from behind her and she could not see them. RN #3 said a resident who spent a lot of time in the dining room/activity room changed where she sat to be able to see who was coming towards her. RN #3 said Resident #60 became more aware of her surroundings after the incident with Resident #48. RN #3 said the facility had a list of residents at the nurses' station to help identify residents at risk for sexual inappropriateness. RN #3 said both Resident #60 and Resident #48 were on the list, despite Resident #60 no longer residing in the facility. -RN #3 reviewed the list of residents at risk for sexual inappropriateness and said the last time the list was updated was 12/1/25.The SSD was interviewed on 7/30/26 at approximately 3:00 p.m. The SSD said she was new to the facility as of July 2026 and was still getting to know the residents.The SSD said Resident #48 tended to keep to himself. She said she was aware he had sexually inappropriate behaviors towards female staff and residents. The SSD said staff would advise her of him asking for a kiss in behavior notes. The SSD said the facility had trained staff on how to redirect Resident #48 when he was being inappropriate.The SSD said Resident #48 was able to advocate for his needs independently and was redirectable.The NHA and the DON were interviewed together on 7/30/26 at 4:48 p.m. The NHA said if abuse was observed or suspected, staff were to ensure resident safety first, separating residents to ensure safety. The NHA said notifications needed to be made to the NHA, the DON, the physician, the police and the responsible party after an abuse incident. She said an investigation was started to determine what occurred. She said the investigation included interviewing the residents involved and anyone who may have witnessed the incident. The NHA said the facility completed other resident interviews and family interviews to ensure safety in the facility. The NHA said the facility would then implement interventions to prevent recurrence of the incident. The DON said Resident #48 liked to wander the facility. She said the incident on 9/5/25 between Resident #48 and Resident #60 was first incident of Resident #48 being sexually inappropriate with another resident. The DON said Resident #48 sometimes refused care from staff stating he was old enough and would do what he wanted. The DON said even though he refused care,Resident #48 was redirectable. The DON said during the investigation of the 9/5/25 incident, Resident #48 said he thought he and Resident #60 were good friends and it was a welcome interaction, so he made a comment about her breasts and then proceeded to touch them.The NHA said Resident #48 would tell female staff members that they were beautiful and request a kiss from them. She said staff had been educated to tell the resident that it was not appropriate behavior and report it to the nurse. The DON said Resident #60 enjoyed sitting in the dining room reading and doing puzzles. The DON said Resident #60 was alert and oriented. The DON said she felt Resident #48 and Resident #60 were establishing a friendship, as they had started to sit together at times. The DON said Resident #48 reported during the investigation that Resident #60 would hug him at times and he felt touching her would be okay with her. The NHA said based on resident interviews, Resident #48 admitted to touching Resident #60 breasts so the facility substantiated the allegation. The DON said all staff members were able to review the residents' care plans for behaviors and interventions to use. She said new issues arose that were added to care plans and discussed in huddles on the floor to ensure staff awareness of the concerns.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (#7 and #13) of seven residents reviewed for care plans out of 34 sample residents.Specifically, the facility failed to:-Develop and implement a person-centered comprehensive care plan which included Resident #7's use of antipsychotic medications; and,-Develop and implement a person-centered comprehensive care plan which included Resident #13's oxygen use. Findings include: I. Facility policy and procedure The Comprehensive Care Plans and Revisions policy, revised August 2025, was provided by the nursing home administrator (NHA) on 8/4/26 at 10:40 a.m. It revealed in pertinent part, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team (IDT) composed of individuals who have knowledge of the residents and their needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about their care. A comprehensive care plan must be developed within seven days after completion of the comprehensive assessment, prepared by an interdisciplinary team, that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and to the extent practicable, the participation of the resident and the resident's representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. The facility should monitor the resident over time to help identify changes in the resident's condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery. It can include additional interventions on existing problems, updating goal or problem statements, adding a short-term problem, goal, and interventions to address a time-limited condition. II. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included severe vascular dementia with agitation, cognitive communication deficit, post-traumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder. The 6/18/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. She required minimal assistance from one staff member to move between surfaces, for showers, and for toileting. B. Record review Review of Resident #7's July 2026 CPO revealed the following physician's order: Quetiapine fumarate (an antipsychotic medication) 50 milligrams (mg). Give one tablet by mouth two times a day for severe vascular dementia, with agitation, ordered 5/4/26. -However, Review of Resident #7's comprehensive care plan, did not reveal a care plan focus related to the resident's use of the antipsychotic medication quetiapine. -Additionally, the care plan did not include side effects or behaviors to monitor related to the resident's use of the antipsychotic medication. C. Staff interviews Registered nurse (RN) #3 was interviewed on 7/30/26 at 4:43 p.m. RN #3 said psychotropic medication secondary effects were part of Resident #7's daily assessments. -However, during the interview, RN #3 reviewed Resident #7's electronic medical record (EMR) and confirmed there was no comprehensive care plan focus for the resident's use of quetiapine. RN #3 said the MDS coordinator was in charge of updating the residents' care plans for psychotropic medications. The director of nursing (DON) was interviewed on 7/30/26 at 5:10 p.m., with the NHA present. The DON said the MDS coordinator would be responsible for the initial development of the residents' care plans and then nursing staff completed a final review of the care plans. The MDS coordinator was interviewed on 7/30/26 at 6:21 p.m. The MDS coordinator said she tried to add a new medication order or intervention to the residents' care plans immediately, which included psychotropic medications. -However, during the interview, the MDS coordinator reviewed Resident #7's EMR and confirmed there was no comprehensive care plan focus for the resident's use of quetiapine. III. Facility follow-up A performance plan improvement (PIP) was provided by the NHA on 7/30/26 at 7:29 p.m. -However, the PIP did not indicate the date that it was initiated by the facility and was not provided until after the concern was brought to the attention of the facility during the survey. III. Resident #13 A. Resident Status Resident #13, age [AGE], was admitted on [DATE]. According to the June 2026 CPO) diagnoses included fracture of the right ischium (the lower and back part of the hip bone) with routine healing, Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills, primarily manifesting as memory loss, confusion, and behavioral changes), cognitive communication deficit and generalized muscle weakness. The 6/29/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment revealed the resident used continuous oxygen therapy. B. Record review A review of Resident #13's June 2026 CPO revealed the following physician's orders: A physician skilled note, dated 6/26/26 at 11:21 a.m., revealed nursing staff would monitor Resident #13 for an increased work of breathing and oxygen saturation measures. A physician skilled note, dated 6/29/26 at 8:29 a.m., revealed Resident #13 was placed on oxygen at 1 LPM per the physician's order. Oxygen at 1 liter per minute (LPM) continuously with nasal cannula (a light plastic device with two small prongs that delivers oxygen into the nose from a tank), ordered 6/26/26 and discontinued on 7/26/26 at 3:29 p.m. A nursing progress note, dated 7/26/26 at 3:29 p.m., revealed a nursing communication with the physician to report Resident #13's peripheral oxygen saturation measurement using a pulse oximeter (a non-invasive fingertip device for the measurement of oxygen in the bloodstream) was at 84% at 1 LPM of oxygen. The physician ordered Resident #13's supplemental oxygen to be increased to 2 LPM via a nasal cannula. A review of Resident #13's June 2026 and July 2026 medication administration records (MAR) and nursing progress notes revealed oxygen was documented as administered to Resident #13 as ordered by the physician at 1 LPM from 6/26/26 through 7/26/26, and oxygen was administered to the resident at 2 LPM as ordered by the physician beginning on the evening shift of 7/26/26. Review of Resident #13's comprehensive care plan revealed there was no care plan focus for oxygen therapy from the resident's admission on [DATE] until 7/30/26 at 6:49 p.m., when the MDS coordinator added an oxygen therapy focus to Resident #13's care plan (during the survey). C. Staff interviews The DON was interviewed on 7/30/26 at 5:10 p.m., with the NHA present. The DON said that for residents who had a physician's order for oxygen, the expectation was to include oxygen therapy as a focus area in a resident's care plan. She said this was important so that staff knew how to care for residents, and the information was incorporated into the Kardex (a comprehensive tool utilized by staff to provide consistent resident care) for CNAs. The DON said the MDS coordinator was responsible for the initial development of the oxygen focus in a resident's care plan, and then nursing staff completed a final review of the care plan.

Based on observations, record review and interviews, the facility failed to ensure residents were kept free of significant medication errors for one resident (#24) of three residents out of 34 sample residents. Specifically the facility failed to:-Ensure the correct insulin (medication used to move sugar from the blood into the cells for energy) was administered to Resident #24; -Ensure the insulin pen was primed prior to drawing up an insulin dose; and, -Ensure the proper insulin administration technique was used when administering insulin to Resident #24.Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment . Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration . To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights : -The right medication;-The right dose;-The right patient;-The right route;-The right time;-The right documentation; and,-The right indication.According to the How To Use Your Lantus (insulin glargine) SoloStar Pen Guide (2022), retrieved on 8/3/26 from https://www.lantus.com/dam/jcr:2cfa1d37-1b5d-445d-83cd-8eaaeaeef48b/lantus-quick-reference-patient-brochure.pdf, Step 2: Wipe the pen tip (rubber seal) with an alcohol swab. Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on. Step 3: Perform a safety test. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that the insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Step 4: Select the dose. Make sure the window shows 0 and then select the dose. Otherwise you will inject more insulin than you need and that can affect your blood sugar level. Step 5: Inject your dose. Clean the site with an alcohol swab. Keep the pen straight, insert the needle into your skin. Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) Release the button and remove the needle from your skin. Step 6: Remove the needle. Insulin pens, needles, or syringes must never be shared between patients. Do not reuse needles. After injecting, always remove the needle to prevent contamination and leaking. Put the outer needle cap back on the needle and unscrew (or pull) the needle from the pen. Throw the needle away in a sharps container. Put the pen cap back on the pen and store in a safe place at room temperature. The most common side effect of insulin, including Lantus (insulin glargine) is low blood sugar (hypoglycemia) which may be serious and life threatening.II. Facility policy and procedureThe Medications Administration Guide, revised July 2023, was received from the nursing home administrator (NHA) on 8/4/26 at 10:46 a.m. It revealed in pertinent part, Ten (10) rights related to administration of medication: 1. Right resident; 2. Right assessments/reason; 3. Right education; 4. Right to refuse; 5. Right medications; 6. Right dose/dosage; 7. Right time; 8. Right route; 9. Right response; and 10. Right documentation.III. Resident # 24A. Resident statusResident #24, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (abnormal glucose control), kidney disease stage 4 (abnormal kidney function) and hypertension (high blood pressure).According to the 5/26/26 minimum data set (MDS) assessment resident was severely cognitively impaired with a brief interview of mental status (BIMS) score of five out of 15. The MDS assessment documented the resident had received insulin injections every day over the seven day assessment look-back period.B. ObservationsOn 7/29/26 at 8:07 a.m. registered nurse (RN) #4 was preparing medications for Resident #24. RN #4 pulled an insulin lispro pen with Resident #24's name on it out of the medication cart. RN #4 reviewed the physician's order indicating the resident was to receive 12 units of insulin glargine (see physician's order below).-RN #4 retrieved the wrong insulin for Resident #24 from the medication cart. RN #4 proceeded to dial the insulin lispro pen to 12 units. RN #4 applied clean gloves, took an alcohol swab to clean the injection site on Resident #24's abdomen, and attempted to administer the insulin lispro to the resident without attaching a needle to the end of the insulin pen. She pressed the injection button on the end of the pen firmly, but nothing happened.-RN #4 failed to prime the insulin pen prior to drawing up the 12 units of insulin lispro. -RN #4 failed to attach a needle to the end of the insulin lispro pen.RN #4 attempted two more times to administer the insulin to Resident #24's abdomen by applying the tip of the pen to the resident's abdomen without a needle. She pressed the button on the end of the pen firmly both times and nothing happened. RN #4 told Resident #24 she was having issues with the insulin pen and needed to ask another nurse for assistance. RN #4 went to another unidentified nurse who was sitting with residents in the common area. The unidentified nurse instructed RN #4 to ensure Resident #24's skin was pulled taut (tight) between her fingers when administering the insulin. RN #4 returned to Resident #24, applied new clean gloves and cleaned the back of the resident's right upper arm with an alcohol swab. RN #4 attempted two more times to administer the insulin lispro to the resident's arm without a needle applied to the insulin pen.RN #4 was observed pushing the button firmly again and a single clicking sound was heard. RN #4 said Finally and proceeded to chart the insulin as administered to Resident #24.-However, the insulin pen dial was observed to be at 11 units, indicating no insulin was administered to the resident -RN #4 failed to administer the correct insulin medication ordered to Resident #24 and failed to apply a needle to the insulin pen in order to deliver the medication subcutaneously as ordered. C. Record reviewReview of Resident #24's July 2026 CPO revealed the following physician's order: Insulin glargine solution 100 units/milliliters (ml). Inject 12 units subcutaneously (into the fat tissue just below the skin) once a day for diabetes, ordered on 5/11/26.-Review of the July 2026 CPO revealed Resident #24 did not have an active physician's order for insulin lispro. IV. Staff interviewsRN #4 was interviewed on 7/29/26 at 9:36 a.m. The insulin orders for Resident #24 were reviewed with RN #4. RN #4 said she administered the incorrect insulin medication to the resident. She said she administered insulin lispro instead of the insulin glargine that was ordered. She said the resident was placed at risk for low blood sugar level as the insulin lispro was a fast-acting insulin compared to insulin glargine, which worked more slowly to decrease blood sugar levels in the body.RN #4 said she was not familiar with insulin pens as she used to work in a hospital setting where they used insulin vials and syringes instead of pens. RN #4 said she had only worked in the facility a few months and rarely worked the cart. She said she normally was a charge nurse at the facility.RN #4 said the process of administering insulin via an insulin pen was to dial the pen to the dose ordered, clean the area of injection with an alcohol swab and administer the insulin into the subcutaneous tissue by placing the pen against the resident's skin and pressing the button at the end of the pen to push the medication into the resident.-RN #4 was unaware she needed to apply a needle to the pen for administration. RN #4 said during her orientation, she was told there was a needle built into the pen (see professional reference above). RN #4 said had Resident #24 received the wrong medication, she would have needed to complete an incident report along with notifying the physician, the director of nursing (DON), and the responsible party for the resident. She said the resident would then require monitoring for side effects. RN #3 was interviewed on 7/29/26 at 9:45 a.m. RN #3 said when administering insulin, nurses needed to make sure they had the correct insulin for the right resident. She said nurses should review the physician's order, dial the insulin pen to two units and waste/prime it to remove any air bubbles in the pen. RN #3 said after priming the insulin pen, she would dial the pen to the correct dose, apply a new needle to the insulin pen, apply clean gloves, ask the resident which area they preferred for the injection site, clean the site with an alcohol swab, place the needle to the resident's skin firmly and then press the button on the end of the insulin pen slowly until it was at zero units. She said she would hold the needle in place for 10-15 seconds after the insulin was injected and then remove the pen with the needle from the resident's skin and dispose of the needle in a sharps container. She said the insulin pen could then be returned to the medication cart for storage. -RN #3 said was unaware she needed to apply the needle before priming the pen with two units (see professional reference above).The DON was interviewed on 7/29/26 at 2:26 p.m. The DON said the facility followed the five rights of medication administration: right resident, right medication, right time, right dose, and right documentation to ensure residents received medications according to physician orders. The DON said when administering insulin pens to residents, nurses should review the physician's order, clean the tip of the pen with an alcohol swab, apply a new needle and turn the insulin pen dial to the right dose of insulin. The DON said after drawing up the correct dose of insulin, nurses should locate the resident, apply clean gloves, clean the injection site area with an alcohol swab, place the needle to the resident's skin, press firmly and then press the button on the end of the insulin pen until it read zero. She said the nurse should hold the needle in place for 10 seconds after injecting the insulin and then the needle could be retracted from the resident's body. The DON said the needle should be placed into a sharps container after each use. The DON said priming an insulin pen was important to remove air bubbles from the needle and to ensure the resident received the correct dose of insulin as ordered. The DON said she was unclear on priming of the insulin pens as she thought some insulin pens needed priming and some did not require priming.The DON said she had started education (during the survey) with her nursing staff regarding proper administration of insulin and medications. The DON said Resident #24 was administered the correct insulin once the concern was brought to their attention (during the survey).The DON was interviewed again on 7/30/26 at 5:05 p.m. The DON said all nurses completed training prior to working the floor and then they were additionally oriented to the floor by other nurses. The DON said insulin pen administration was covered in orientation.

Based on observations and interviews, the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for one of one medication storage rooms reviewed for storage and labeling. Specifically, the facility failed to ensure insulin (medication for diabetes) pen injection devices were stored and labeled appropriately with open dates and disposed of when expired.Findings include:I. Professional referenceAccording to the Tresiba (insulin degludec) injection package insert, retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/203314s018s020lbl.pdf, Store Tresiba vials in the original carton to protect from light. Store unused Tresiba in a refrigerator (36 degrees Fahrenheit (F) to 46 degrees F). In-use (opened), it can be stored at room temperature/in the refrigerator for 56 days.According to the Humalog (insulin lispro) injection package insert, retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf, Unopened Humalog should be stored in a refrigerator (36 degrees F to 46 degrees F). In-use Humalog vials, cartridges, pens, and Humalog KwikPens should be stored at room temperature, below 86 degrees F (30 degrees Celsius - C)) and must be used within 28 days or be discarded, even if they still contain Humalog. In-use (opened) pens should not be refrigerated.II. ObservationsOn [DATE] at 4:55 p.m. the medication storage room was observed with registered nurse (RN) #3. The following items were found in the medication refrigerator:One Tresiba flex touch insulin pen had an open date of [DATE]. -The Tresiba insulin pen reached its 56 days expiration date from opening on [DATE]. The Tresiba insulin pen was 169 days past the manufacturer's storage recommendations for discarding the medication(see professional reference above). One insulin lispro pen had an open date of [DATE]. -The insulin lispro pen reached its recommended 28 days expiration date from opening on [DATE]. The insulin lispro pen was 47 days past the manufacturer's storage recommendations for discarding the medication (see professional reference above). III. Staff interviewsRN #3 was interviewed on [DATE] at 5:00 p.m. RN #3 said insulin pens or vials were good for 30 days once they were opened. RN #3 said she was not aware of who was assigned to review the medication storage room refrigerator for expired or discontinued medications. RN #3 said she would ask the unit manager. RN #4, who was also the unit manager, was interviewed on [DATE] at 5:17 p.m. RN #4 said all nurses were responsible for ensuring medications were removed from the medication storage refrigerator or medication carts when the medications expired. The director of nursing (DON) was interviewed on [DATE] at 5:21 p.m. The DON said insulins were only good for 30 days once opened and needed to be discarded after 30 days, even if they still had insulin in them. The DON said once an insulin was opened, it should not be put back into the medication storage refrigerator. The DON said the charge nurse/night shift nurses should be monitoring the medication storage refrigerators for expired or discontinued medications. The DON said the facility did not have a set schedule for this to be completed or a log for tracking that the monitoring was being completed.

Based on observations, resident and staff interviews, the facility failed to ensure safe food handling practices for two out of two residents with refrigerators in resident rooms.Specifically, the facility failed to: -Remove expired foods from residents' personal refrigerators; and, -Ensure food that was kept in residents' refrigerators was labeled and dated. Findings include:I. Facility policy and procedureThe Resident Refrigerators Policy and Procedure revised 5/22/26, was received from the nursing home administrator (NHA) on 7/30/26 at 8:48 p.m. It read in pertinent part, The facility will meet the safety and sanitation requirements for the residents, as set forth by the facility, local, state, and federal regulations when using personal refrigerators to store food for resident consumption. The established guidelines are set forth to ensure safe food practices, appropriate temperature control, and life safety codes. Facility staff will check individual food items weekly for expiration dates and discardoutdated food promptly from the residents' personal refrigerator. Food will be labeled and dated, appropriately to monitor food safety. All food items should be consumed or discarded after three (3) days. Food items in unmarked or unlabeled containers should be labeled with contents, and the date the food item was stored. Any food suspected of being contaminated or with visible signs of contamination should be discarded immediately.II. ObservationsA. room [ROOM NUMBER]On 7/29/26 at 9:30 a.m. resident room [ROOM NUMBER] refrigerator had a peanut butter and jelly sandwich with a use by date of 7/25/26.On 7/29/26 at 1:20 p.m. the refrigerator had the following: one chicken salad sandwich with use by date of 7/25/26; one peanut butter and jelly sandwich with use by date 7/27/26; and one tortilla with cheese and lunch meat wrap with a use by date of 7/28/26.On 7/30/26 at approximately 10:00 a.m. room [ROOM NUMBER] was observed with the dietary manager (DM). The DM removed the following from the resident's refrigerator: a chicken salad sandwich with a use by date of 7/25/26, one peanut butter and jelly sandwich with use by date 7/27/26, a tortilla wrap with cheese and lunch meat with use by date of 7/28/26.B. room [ROOM NUMBER]On 7/27/26 at 9:45 a.m. resident room [ROOM NUMBER]'s refrigerator was observed to have a food container not labeled or dated and a peanut butter and jelly sandwich with a use by date of 7/18/26.On 7/29/26 at 1:30 p.m. the refrigerator had the same container of food not labeled or dated; a peanut butter and jelly sandwich with a use by date of 7/18/26 and ham and cheese sandwich wrapped in clear plastic [NAME] with no label or date. On 7/30/26 at approximately 10:00 a.m. room [ROOM NUMBER] was observed with the DM. The DM removed a peanut butter and jelly sandwich with a use by date of 7/18/26, a container with no date or label, a ham and cheese sandwich with no date or label from the resident's personal refrigerator. IV. Staff interviewsThe DM was interviewed on 7/30/26 at approximately 10:00 a.m. The DM said the residents' refrigerator we cleaned weekly by himself but he did not have a log in places at this time. He said sandwiches were good for five days and then needed to be discarded. The DM said after five days the sandwich could start to grow bacteria placing residents at risk for food borne illness. Certified nurse aide (CNA) #3 was interviewed on 7/30/26. She said housekeeping usually cleaned resident refrigerators but they could also clean them with a disinfectant wipe if they observed something spilled or if they smelled something weird from the refrigerator. CNA #3 said they could look into the refrigerator if they smelled something or if they had time during their shift they could review them to remove expired foods.The director of nursing (DON) was interviewed on 7/30/26 at 5:11 p.m. The DON said it was the responsibility of the dietary department to ensure resident refrigerators were clean and monitored for expired foods.

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 possible development and transmission of infectious diseases on two out of two units.Specifically, the facility failed to: -Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms;-Ensure housekeepers cleaned high touch surface areas; and,-Ensure dwell times (time needed to kill bacteria) were followed during resident room cleaning.Findings include:I. Housekeeping failuresA. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 8/4/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 8/4/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.According to the United States Environmental Protection Agency (EPA), dated 5/3/21, retrieved on 8/4/26 from https://www3.epa.gov/pesticides/chem_search/ppls/070627-00074-20210503.pdf., Oxivir is a one-minute bactericidal, virucidal, and fungicidal A disinfectant and cleaner (that cleans, disinfects and deodorizes in one labor saving step) when used according to disinfection directions for use.According to Diversey Crew NA SC Non-Acid Bowl & Bathroom Disinfectant Cleaner, dated 2022, retrieved on 8/4/26 from https://products.solenis.com/product/crewr-na-sc-non-acid-bowl-bathroom-disinfectant-cleaner-1ea-12ct-D03975, Non-acid toilet bowl and urinal disinfectant/cleaner directions: Empty toilet bowl or urinal and apply a 1 oz. per gallon use-solution to exposed surfaces and under the rim with a cloth, mop, sponge or sprayer. Brush or swab thoroughly, allow to stand for 10 minutes and flush.B. Facility policy and procedureThe Daily Room Cleaning policy, revised October 2025, was received from the nursing home administrator (NHA) on 7/30/26 at 8:48 p.m. It revealed in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections. Clean and disinfect using a hospital grade EPA registered cleaner/disinfectant solution. The facility should refer to the Diversey - Approved Housekeeping Chemicals guide for a listing of appropriate cleaning and disinfectants. Daily cleaning of resident rooms includes:-Using a damp cloth, dust the room starting with the resident's area (overbed table, bedside table, and phone) and move to the rest of the items in the room. This includes windowsills, door frames, shelves, walls, and doors;-Clean high-touch surfaces at least daily including hand washing sinks;-Daily cleaning of resident bathrooms; and,Clean and disinfect high touch/frequently contaminated surfaces (sinks, faucets, handles, door handles, and clean toilet seat last) at least daily.II. ObservationsOn 7/27/26 at 8:30 a.m. housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER], a double occupancy room currently occupied with one resident. HK #1 said the solution in the top container of the cleaning cart was from the premixed Oxivir 1 (disinfectant ) solution dispensed in the janitor's closet.HK #1 applied gloves and entered the resident's room carrying a spray bottle labeled Oxivir 1 and a rag wet with the Oxivir 1 solution from the cleaning cart bin. She sprayed the sink and counter and began wiping down the counter, the top of the sink, the bowl of the sink, then back to the counter and sink handles, and moved to cleaning underneath the sink.-HK #1 failed to complete hand hygiene and change gloves after moving from cleaning dirtier areas to cleaner areas.HK #1 then exited the room and placed the dirty rag in the dirty rag bin on the cart.With the same dirty gloves, she picked out a clean rag from the disinfectant solution on the cart and entered the resident's room carrying the clean rag and the Diversey Crew (a toilet bowl and urinal disinfectant/cleaner) spray bottle. HK #1 sprayed the toilet bowl rim, the toilet bowl, and the surrounding floor. HK #1 unwrapped the toilet brush stored in plastic wrap on the floor, and scrubbed inside the bottom of the toilet bowl and then scrubbed the rim of the toilet with the brush. She then scrubbed the legs and bottom of the elevated toilet seat. She proceeded to flush the toilet without waiting the recommended dwell time of 10 minutes (see professional reference above).-HK #1 failed to follow the product dwell time when cleaning the toilet bowl.At 8:50 a.m. HK #1 said she was finished cleaning the room.-HK#1 failed to clean all high touch areas in the resident's room, such as the light switches, door handles, resident call light, and closet handles. On 7/29/26 at 9:50 a.m. HK #2 was cleaning resident room [ROOM NUMBER], a double occupancy room currently occupied with one resident.HK #2 said the solution in the top container of the cleaning cart was from the premixed Oxivir 1 solution dispensed in the janitor closet.HK #2 entered the resident's room with a spray bottle of Oxivir 1 solution and a clean rag, and sprayed the counter and sink area. HK #2 cleaned the top of the sink, the bottom of the sink bowl, underneath the sink area. Using the same rag used to clean the sink area and bowl, she proceeded to wipe down the resident's closet door and handles.-HK #2 failed to complete hand hygiene, change gloves and use a clean rag when moving from a dirtier area to a cleaner area. HK #2 retrieved a clean rag from the clean rag solution on the cleaning cart and re-entered the resident's room. She wiped down the headboard of the unoccupied bed next to the window in the room, and then wiped the bottom of the bed and surrounding floor. HK #2 moved to the occupied side of the room near the door and used the same gloves and rag to wipe the resident's bedside table and personal items on the bedside table, such as the water container, flowers in a vase and lotion. -HK #2 failed to complete hand hygiene and change gloves when moving from cleaning the floor to the resident's bedside table and touching the resident's personal items on the bedside table. III. Staff interviewsHK #1 was interviewed on 7/27/26 at 8:55 a.m. HK #1 said she was trained by HK #2 and spent several days cleaning with HK #2 when she first started as a housekeeper in the facility. HK #1 said residents' rooms were cleaned daily. HK #1 said she changed the clean rag water in the cart after cleaning about every six resident rooms.HK #2 was interviewed on 7/29/26 at 10:30 a.m. HK #2 said every resident room was cleaned daily. HK #2 said she always completed hand hygiene and changed gloves when she left a resident's room. HK #2 said she changed the clean rag water and mop water on the cart every three resident rooms.The housekeeping supervisor was interviewed on 7/30/26 at 9:40 a.m. The housekeeping supervisor said she could train new housekeeping staff, or other experienced housekeeping staff could train new housekeeping staff. The housekeeping supervisor said she provided ongoing education to housekeeping staff with a daily huddle, and completed additional training of housekeeping staff as needed.The housekeeping supervisor said housekeeping staff were trained on the cleaning process, which was to clean from cleanier areas to dirtier areas. She said hand hygiene should be performed and gloves should be changed every time after cleaning a dirtier area, not just when exiting the resident's room. She said the appropriate cleaning process should be followed to prevent the spread of germs.The housekeeping supervisor said high touch contact areas, such as light switches and door handles, should be cleaned with every room cleaning to prevent the spread of germs.The infection preventionist (IP) was interviewed on 7/30/26 at 1:00 p.m. The IP said she provided oversight and training to the housekeeping staff, including the use of personal protective equipment (PPE) and hand hygiene.The IP said housekeeping staff should clean from cleaner areas to dirtier areas and from top to bottom. She said housekeeping staff should practice hand hygiene and glove changes when moving from dirtier areas to cleaner areas to prevent the spread of infections.The IP said she did not recall the dwell time for the Diversey Crew toilet cleaning product.The IP said housekeeping staff should not use dirty gloves to clean a bedside table and should not touch residents' personal care items with soiled gloves because this could spread germs.

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. Specifically, the facility: -Failed to update the facility assessment annually; -Failed to include all current diagnoses the facility currently cared for; and, -Failed to develop a facility assessment which included staff education and staff competencies. Findings include: I. Facility assessment The facility assessment was provided by the nursing home administrator (NHA) on 6/17/24 at 11:25 a.m. It was updated on 2/27/23 and reviewed by the quality assurance performance improvement (QAPI) committee on 2/28/23. The facility assessment failed to include the following: -Diagnoses of current residents including intermittent explosive disorder (mental disorder that causes sudden, impulsive and aggressive outbursts) , schizophrenia (mental illness causing episodes of psychosis), anxiety, seizures and methicillin resistant Staphylococcus aureus (MRSA); -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; and, -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population. The NHA provided information regarding resident specific care needs on 6/18/24 at 3:16 p.m. which included the following: -Four individuals needed a two-person lift; -13 residents receiving respiratory care; -Four residents receiving insulin; and, -11 residents were on a specialized diet. -The facility assessment did not include these specialized resident specific care needs. II. Staff interviews The NHA was interviewed on 6/19/24 at 9:00 a.m. The NHA said she was not aware the facility assessment was not current. The NHA reviewed the facility assessment and said it did not identify current diagnoses for some of the residents the facility was caring for at that time. The NHA reviewed the facility assessment and said the assessment did not have specific training staff needed to help care for the residents at the facility. She said the facility assessment should reflect the needs of the residents. The NHA said she and the interdisciplinary team would review the facility assessment and create a new one. The NHA said the current facility assessment was missing current diagnoses of residents in the facility and staff training and competencies necessary for the care of the residents and would be updated to ensure the training and education programs would cover the residents' needs. She said it was important to have a complete assessment to provide for the residents in the facility.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of five CNAs reviewed. Specifically, the facility: -Failed to ensure CNA #3 and CNA #5 received annual dementia management training; -Failed to ensure CNA #1 received annual abuse training; and, -Failed to ensure CNA #5 received 12 hours of annual training. Findings include: I. Record review of insufficient in-service training in the last 12 months for three CNAs CNA #1 was hired on 9/7/22. She had not had annual abuse training in the past 12 months. CNA #3 was hired on 5/3/23. She had not had annual dementia management training in the past 12 months. CNA #5 was hired on 1/13/22. She had not had annual dementia management training or 12 hours of training in the past 12 months. II. Interview The director of nursing (DON) and staff development director (SDC) were interviewed together on 6/18/24 at 5:20 p.m. The SDC said she could not find documentation that the facility had provided annual abuse and/or dementia management training and 12 hours of training for CNA #1, #3, and #5 in the past 12 months. She said all CNAs providing care should be trained on abuse and dementia management as well as receive 12 hours annually of training in order to provide appropriate care for the facility ' s residents.

Based on record review and interviews, the facility failed to inform one (#39) of three residents reviewed for beneficiary notices and appeal rights out of 21 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to: -Obtain a signature from the resident's authorized representative on liability notices for Resident #39, who had memory impairments; and, -Provide written notification of Medicare Non-Coverage letters to the resident's representative of Medicare-covered services ended for Resident #39. Findings include: I. Facility policy The Denial or End of Benefits policy, revised 7/11/23, was provided by the nursing home administrator (NHA) on 6/19/24 at 10:40 a.m. It revealed in pertinent part, The Denial or End of Benefits process is in place to help the resident and family understand their options and needs they might have regarding their care. Upon end of coverage under Medicare, the resident and family will receive notice that specifically states the reason for non-coverage. The NOMNC (Notice of Medicare Non Coverage), Form CMS-10123, is given to all Medicare beneficiaries at least two days before the end of a Medicare-covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. II. Record review A. Resident #39 A review of Resident #39's electronic medical record (EMR) revealed the resident had short-term and long-term memory deficits through staff assessment. The EMR revealed Resident #39 was discharged from Medicare Part A funded therapy services on 1/25/24. -The NOMNC notice was signed by the resident's representative on 1/25/24, the same day Resident #29's Medicare Part A benefits ended. The resident continued to live in the facility. The medical record revealed Resident #39 was restarted on Medicare Part A funded therapy services on 4/13/24. Resident #39 was discharged from Medicare Part A funded therapy services on 4/26/24. The resident signed the NOMNC on 4/24/24 The skilled nursing facility advanced beneficiary (SNF ABN) was provided to the resident. The resident printed their name and ask her in the signature line of the patient or authorized representative section. -A review of the resident's EMR revealed the resident's representative was not provided notice to indicate Resident #39's Medicare part A services were ending, given the estimated cost of services the resident would incur if they choose to pay out of pocket to continue services, the reason why Medicare was no longer continuing to pay for the particular service and the information to appeal if desired. III. Staff interviews The social services director (SSD) was interviewed on 6/19/24 at 9:48 a.m. The SSD said she started working at the facility in January 2024. The SSD said she and the minimum data set coordinator (MDSC) were responsible for notifying the resident or resident's representative when the Medicare benefits were ending. The SSD said when a resident's Medicare services were going to end, she would schedule a family meeting to review when the benefits would end. The SSD said during the meeting, the resident's representative signed the NOMNC if the resident was unable to sign the form. The SSD said the resident's representative was provided the NOMNC form and the SSD explained the appeal process. The SSD said the resident or resident's representative told the SSD if they wanted to appeal during the meeting. The SSD said she did not document when she contacted the family to schedule the meeting, the outcome of the meeting or if the NOMNC and SNF ABN were provided and signed by the resident or resident's representative. The SSD said she needed to better document the NOMNC process so it was clear the resident or resident's representative was notified, options were explained and the outcome was determined. The SSD said she was familiar with Resident #39 and her Medicare part A services. The SSD said she had Resident #39 sign the NOMNC and ABN on 4/24/24. The SSD said she went to the resident's room to explain the NOMNC and SNF ABN. The SSD said the resident appeared alert and oriented. The SSD said after she talked to the resident, she contacted the resident's representative over the phone. The SSD said she did not have it documented when the representative was notified and she did not know if the NOMNC and SNF ABN form were provided to the resident's representative in person or by mail.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for one (#18) of three residents out of 21 sample residents for services to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being that included measurable objectives and timeframes. Specifically, the facility failed to develop an activities care plan focus for Resident #18. Findings include: I. Facility policy and procedure The Activities Progress Notes policy, revised 9/21/23, was provided by the nursing home administrator (NHA) on 6/19/24 at 12:11 p.m. It read in pertinent part, Progress notes are written at least every 90 days from the date of the last progress note. These notes will include the status of activity problems, needs and concerns identified in the care plan, a description of the resident's progress towards achieving care plan goals, the documentation of specific recreation approaches in the care plan and the evaluation of approaches toward achieve goals and changes to be incorporated into the care plan based on evaluation information. II. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized physician order (CPO), diagnoses included Alzheimer's disease, depression, anxiety and difficulty in walking. The 3/19/24 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. He was dependent on showering and used a walker. B. Record review The 12/29/23 initial baseline care plan was reviewed. -An activity focus area was not included in the initial baseline care plan. -A review of Resident #18's comprehensive care plan, revised 3/22/24, did not reveal person centered activity preferences and interventions to meet the residents recreational needs and goals. D. Staff interviews The activities director (AD) was interviewed on 6/19/24 at 11:20 a.m. The AD said she was responsible for creating the resident's recreation care plans. She said she had only implemented two activity care plans since she started in January 2024. The AD said she did not create an activity specific care plan for Resident #18 because he participated in group activities and conversed with residents and staff. The AD said she created care plans when residents did not participate in activities and isolated themselves. The nursing home administrator (NHA) was interviewed on 6/19/24 at 11:35 a.m. The NHA said all residents should have an activities care plan.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals for two (#3 and #25) of three residents out of 21 sample residents. Specifically, the facility failed to: -Offer non-pharmacological interventions for pain management for Resident #3 and Resident #25; and, -Ensure the location of pain was identified when administering pain medications for Resident #3 and Resident #25. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, revised 9/12/23, was provided by the nursing home administrator (NHA) on 6/19/24 at 11:24 a.m. It revealed in pertinent part, The facility will address and treat the underlying causes of pain, to the extent possible and develop and implement both non-pharmacological and pharmacological interventions and approaches to pain management. Identify and use specific strategies for preventing or minimizing different levels or sources of pain based on the resident-specific assessment. II. Resident #3 A. Resident status Resident #3, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included systemic lupus erythematosus (a chronic autoimmune disease that causes the body's immune system), hemiplegia (paralysis on one side) and hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (a stroke) affecting the right dominant side, falling, chronic kidney disease, bipolar disorder, schizophrenia, hallucinations and unsteadiness on feet. The 3/29/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview mental status (BIMS) score of 15 out of 15. She required set-up assistance with toileting, dressing and personal hygiene. She required partial assistance with showering. The assessment indicated she received as needed pain medications and non-medication interventions for pain management. She had pain almost constantly which interfered with day to day activities almost constantly. She described her pain as an 8 on a pain scale of 1-10. -However, a review of the resident's electronic medical record (EMR) did not reveal non-medication interventions for pain management were consistently offered. B. Resident interview Resident #3 was interviewed on 6/17/24 at 9:43 a.m. She said at the time of the interview, she was in pain. Resident #3 said on a pain scale from 1-10, she rated her pain as an 8. She said she took Tylenol and the last time she took Tylenol was last night (6/16/24). She said watching television, listening to music, seeing family and lying down helped alleviate her pain. She said she had a bad fall about two months ago. She hit her head and she went to the hospital for 19 stitches. Resident #3 said her head hurt after the bad fall. C. Record review The pain care plan, revised 3/13/24, revealed the resident had pain related to the disease process of lupus and headaches. Interventions included to attempt non-pharmacological interventions that included repositioning, use of pillows and wedges, reassurance, redirection, heat and ice. -The care plan did not identify the location of her pain. The 4/30/24 pain assessment revealed the resident had pain in the back of her head and her neck. -The pain assessment did not identify what made the pain worse, the pain better, her acceptable level of pain, pharmacological and non-pharmacological interventions and their effectiveness. The June 2024 CPO revealed the following physician's order for pain management: Acetaminophen 325 milligrams (mg). Administer two tablets by mouth every four hours as needed for pain level 5-10 on a scale of 1-10, ordered 5/6/24. Acceptable level of pain 5 out of 10. Location of pain: back, legs, headache, feet. Non-pharmacological interventions: repositioning, positive distractions and offering fluids and snacks, ordered 4/7/22. The January 2024 medication administration record (MAR) revealed acetaminophen was administered 17 days out of 31 days. -A review of the resident's EMR revealed non-pharmacological interventions were not offered on 13 out of 17 days when acetaminophen was administered. The February 2024 MAR revealed acetaminophen was administered on 21 days out of 29 days. -A review of the resident's EMR revealed non-pharmacological interventions were not offered on 14 out of 21 days when acetaminophen was administered. The March 2024 MAR revealed acetaminophen was administered on 15 days out of 31 days. -A review of the resident's EMR revealed non-pharmacological interventions were not offered on 13 out of 15 days when acetaminophen was administered. The April 2024 MAR revealed acetaminophen was administered on 23 days out of 30 days. -A review of the resident's EMR revealed non-pharmacological interventions were not offered on 17 out of 23 days when acetaminophen was administered. The May 2024 MAR revealed acetaminophen was administered on 12 days out of 31 days. -A review of the resident's EMR revealed the location of the pain was not identified on three days of the 12 days acetaminophen was administered and non-pharmacological interventions were not offered on five days of the 12 days acetaminophen was administered. The June 2024 MAR (6/1/24 to 6/18/24) revealed acetaminophen was administered on 14 days out of 18 days. -A review of the resident's EMR revealed the location of the pain was not identified on 12 days of the 18 days acetaminophen was administered and non-pharmacological interventions were not offered on 12 days of the 18 days. III. Resident #25 A. Resident status Resident #25, age 79, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included malignant neoplasm of the left kidney (kidney cancer), end-stage renal disease, dialysis, type II diabetes and atherosclerotic (plaque buildup in the walls of arteries) heart disease. The 5/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent for oral hygiene, toileting, dressing and personal hygiene. She required supervision for showering and set-up assistance for eating. The assessment indicated the resident was not on a pain medication regimen and did not receive non-medication interventions for pain. She did not have pain in the past five days. B. Resident interview and observation Resident #25 was interviewed on 6/17/24 at 2:07 p.m. Resident #25 said she had pain in two of her fingers on her left hand. She said she took Tylenol and the facility did not offer non-pharmacological interventions. She said she had surgery related to her dialysis port and she was not getting proper circulation on her left extremity. Resident #25 eyes squinted and she grimaced throughout the interview while she described the pain. Resident #25 had two band-aids on her left index finger and left middle finger. She had a bruise on her upper left arm located on the side closest to her chest. C. Record review The pain care plan, revised 5/15/24, revealed the resident had pain in her abdomen, her head, fistula site and her left pointer finger. The pain was related to GERD (gastro esophageal reflux disease), dialysis, injury to her finger and osteoarthritis. Interventions included administering medication and treatments as ordered and the acceptable level of pain was 3 out of 10 using a numeric pain scale of 1-10. -The care plan did not identify non-pharmacological interventions. The initial pain assessment on 5/6/24 revealed the resident did not have pain in the past five days. The June 2024 CPO revealed the following phsycian's orders for pain management: Lidocaine-prilocaine 2.5% cream. Apply cream to fistula site topically one a day every Monday, Wednesday and Friday for pain control for fistula access. Apply cream to the fistula site 60-90 minutes prior to leaving for dialysis, ordered 5/10/24. Acetaminophen 325 mg. Administer two tablets by mouth every four hours as needed for pain, ordered 5/3/24. Acceptable level of pain: 3 out of 10, on a scale of 1-10. Location of pain: pointer finger, abdomen and head. Attempt non-pharmacological interventions prior to administering pain medications: rest, distraction and ice, ordered 5/3/24. -The physician's order did not identify what type of pain the acetaminophen attempted to alleviate. The May 2024 MAR revealed acetaminophen was administered on 12 days out of 29 days. -A review of the nurse progress notes from May 2024 (5/3/24 - 5/31/24) revealed that the location of the pain was not identified on two days of the 12 days acetaminophen was administered. - A review of the resident's EMR revealed non-pharmacological interventions were not offered on four days of the 12 days the acetaminophen was administered. The June 2024 MAR (6/1/24 to 6/18/24) revealed acetaminophen was administered on four days out of 18 days. -A review of the resident's EMR revealed that non-pharmacological interventions were not offered on two days of the four days the acetaminophen was administered. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 6/18/24 at 4:21 p.m. LPN #1 said pain was assessed throughout her shift. She said interventions were based on what she knew about the resident's pain history, their facial expressions throughout the day and she monitored their effect throughout her shift. She said she documented when a resident had pain in the MAR and as a progress note. LPN #1 was familiar with Resident #3 and Resident #25. She said Resident #3 had generalized pain in her legs, in her shoulders and she had headaches. She said Tylenol, repositioning, food and distraction helped alleviate her pain. She said she documented non-pharmacological interventions as a progress note. LPN #1 said Resident #25 had pain on her left hand on her second and third finger. She said the resident had ulcers at the tip of each finger that were being treated. She said the ulcers were due to the fistula she had for dialysis treatments. She said Tylenol, repositioning and elevating her hand helped alleviate Resident #25's pain. The director of nursing (DON) was interviewed on 6/18/24 at 4:49 p.m. The DON said a pain assessment was completed at the time of admission, then every six hours for three days. The DON said pain was assessed prior to each pain medication administration. The DON said the assessment covered the onset, presences, duration, characteristics, cause, locations and interventions. She said interventions were personalized to each resident. She said non-pharmacological pain interventions included resting, elevating the part of the body that was in pain and an activity to distract the resident from their pain. The DON said interventions were documented in the assessment and as a progress note. The DON said she was familiar with Resident #3 and Resident #25. She said Resident #3 did not have pain that often and the location varied. The DON said Resident #3 had a lot of headaches. She said a quiet and dark environment helped alleviate Resident #3's pain. The DON said she was not as familiar with Resident #25's pain because she was a new resident. She said Resident #25 had pain surrounding her fistula site used for dialysis. The DON said a cream helped the resident's pain for her fistula. The DON said was not aware that non-pharmacological interventions were not consistently offered for Resident #3 and Resident #25. V. Facility follow-up The 6/18/24 DON's nurse progress note for Resident #25 revealed the nurse asked if the resident experienced pain frequently and the resident denied. The resident said she did not experience pain very often. The nurse asked the resident when she did have pain if she was provided with interventions and Tylenol. The resident said yes when she had pain she took Tylenol and at times elevated her hand. The nurse asked if those interventions and medications alleviated her pain and the resident said yes. The nurse asked the resident about her fingers that tended to bother her and cause her pain. The resident said yes, she had pain in her fingers, but over the past week the pain has not been too bad. The nurse asked if there was anything else the facility could do to address her pain and the resident said no. The nurse told the resident to make sure the hall nurse knew when she experienced pain so the nurse could address it. The resident verbalized understanding. -However, the pain care plan was not updated and the acetaminophen physician's order was not updated.

Based on record review and interviews, the facility failed to ensure residents who (#25) required dialysis received dialysis services consistent with professional standards of practice for one (#25) of one resident reviewed for dialysis out of 21 sample residents. Specifically, the facility failed to: -Ensure the physician's order for Resident #25' s fistula care was followed; and, -Ensure the physician was notified when Resident #25' s fistula site healed. Findings include: I. Facility policy and procedure The Hemodialysis Offsite policy, revised 8/23/23, was provided by the nursing home administrator (NHA) on 6/17/24 at 11:21 a.m. It read in pertinent part, The facility should provide immediate monitoring and documentation of the status of the resident' s access site upon return from the dialysis treatment to observe for bleeding or other complications. Notify the physician of any change in mental or physical status. II. Resident #25 A. Resident status Resident #25, age 79, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included malignant neoplasm of left kidney (kidney cancer), end-stage renal disease, dialysis, type II diabetes mellitus and atherosclerotic (plaque buildup in the walls of arteries) heart disease. The 5/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with oral hygiene, toileting, dressing and personal hygiene. She required supervision with showering and set-up assistance for eating. The assessment revealed the resident was receiving dialysis while she resided at the facility. B. Record review The dialysis care plan, revised 5/3/24, revealed the resident received dialysis treatment related to stage four kidney disease. The chronic renal failure care plan, revised 5/16/24, revealed the resident had chronic renal failure related to end-stage disease and malignant neoplasm of the left kidney. Interventions included giving medications and supplements as ordered. -A review of the dialysis and chronic renal failure care plans revealed there were no interventions for the skin treatment and monitoring of the fistula site (access site for dialysis). The 6/6/24 skin assessment revealed the resident had bruises on her left upper arm dialysis shunt site. The 6/13/24 skin assessment revealed the resident had bruises on her left upper arm shunt site. The June 2024 CPO revealed the following treatment orders related to the resident' s fistula site: -Left fistulogram. Apply antibiotics and band-aid until healed to the left upper arm, monitor for signs and symptoms of infection. Complete every day shift for wound, ordered 6/6/24 and discontinued on 6/8/24. -Left fistulogram. Apply antibiotics and band-aid until healed to the left upper arm, monitor for signs and symptoms of infection. Complete every day shift for wound, ordered 6/8/24. -The physician' s orders failed to indicate what antibiotic to apply to the fistula site. -Review of the resident' s June 2024 medication administration record (MAR) revealed the treatment to the fistula site was not completed on 6/13/24, 6/14/24, 6/15/24 and 6/16/24. -Review of Resident #25' s electronic medical record (EMR) did not reveal the physician was notified when the physician' s order was not followed from 6/13/24 to 6/16/24. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 6/18/24 at 4:21 p.m. LPN #1 said when a resident received dialysis care she monitored the resident' s vital signs and weight before and after her shift. LPN #1 said she also monitored the fistula site for any changes or abnormalities. LPN #1 said she had worked with Resident #25. She said Resident #25 had a fistula on her left arm for dialysis. She said antibiotics and a band aid were applied until she noticed a scab had formed. LPN #1 said she did not follow the physician' s order because a scab was nature' s version of a band-aid. She said she monitored the site daily for signs and symptoms of infection. She said she did not notify the physician when she did not use antibiotic cream and a band aid when the scab developed . The director of nursing (DON) was interviewed on 6/18/24 at 4:49 p.m. The DON said when a resident received dialysis care the nursing staff monitored fluid intake and urine output, weight, blood sugar and the dialysis access site. The DON said she was familiar with Resident #25 and her dialysis treatment. She said she was not aware that the physician was not notified when a scab appeared on the resident' s left upper arm near the fistula site. She said the licensed nursing staff needed to notify the physician when the order was not followed so the physician could provide further orders if needed. The DON said the nursing staff documented when a physician was notified about skin and dialysis care as a progress note. V. Facility follow up The June 2024 CPO was updated on 6/19/24 at 8:25 a.m. with the following order: -Monitor for signs and symptoms of infection to the resident' s left upper extremity. Scab in place, discontinue order when the scab is gone. Complete every shift for scab monitoring. Discontinue when healed, ordered 6/19/24. -However, the dialysis and chronic renal failure care plan were not updated with interventions for the skin treatment at the fistula site.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections in four out of four units. Specifically, the facility failed to ensure: -Staff completed the screening process prior to entering resident care areas; -Staff wore appropriate personal protective equipment (PPE) prior to entering droplet precaution (with eye protection) resident rooms; and, -Kitchen staff performed hand washing with soap and water when working with food items and wore PPE appropriately. Findings include: I. Status of COVID-19 in the facility The nursing home administrator (NHA) and infection prevention and control nurse (IPCN) were interviewed on 7/15/2020 at 5:15 p.m. The IPCN said that she was covering/acting as the director of nursing (DON) until the newly hired DON was in place. She said her primary responsibilities were infection control. She said she provided the staff training. The NHA said the resident census was 36. The NHA said that they received all the tests back that were done on the staff and residents from last week. He said that the results were all negative. He said no staff or residents tested positive for COVID-19. He said another round of testing was done with residents and staff yesterday. He said it would take up to five days to receive the results. He said that the County Health Department told the facility that they had to have two weeks of negative test results before the facility would be considered clear of COVID-19. The NHA and IPCN said the facility had a COVID-19 designated unit on the 300 hallway. The NHA said that the unit was not in use as of today. The IPCN said that the last resident came off isolation protocol today and was moved to the other units. The IPCN said that staff were required to be screened by another staff member prior to entering the facility. She said that all other doors were locked so that staff, visitors and vendors had to enter through the main doors. She said that staff were issued masks at the doorway. She said that the N95 masks were collected at the end of every shift and disinfected for reuse the next day. The masks were stored in paper bags labeled with their names. The NHA said that the N95 masks were worn up to ten times before disposal. The surgical masks were changed and disposed of when staff entered and exited the COVID-19 isolation rooms. He said that staff wore surgical masks over the N95 masks. The NHA and IPCN said that if it was after 7:00 p.m. when the receptionist left for the day, then the front door was locked and staff/visitors/vendors would ring the bell for assistance. The NHA said that the nurses worked 12 hour shifts, 6:00 a.m. to 6:00 p.m. and the CNA staff worked 8 hour shifts. The IPCN said that one nurses station was assigned to do the screening after 7:00 p.m. The IPCN said that she provided the staff training for screening, signs and symptoms of COVID-19, taking of the temperature upon entering the facility, and the interview/screening questions about exposure risks, travel internationally and taking of the temperature upon exit. She said the training included the screener to ask the symptoms of COVID-19. She said the screeners know that if there were symptoms, she was to be notified and the person would be refused entrance to the facility. She said if there was a ' yes ' response to the screening questions then she would be notified to conduct an assessment to determine if staff would stay or be sent home. The IPCN said that she provided the hand hygiene training to the staff. She said that she constantly watched staff practices to identify breaks in infection control practices and provided education at that time. The IPCN said that she provided training to the staff regarding mask fitting and donning and doffing of PPE. She said this training was provided during and after the fit testing of the N95 masks, which were issued to all staff that provide direct resident care. II. Screening process A. Facility policy and procedure The Coronavirus (COVID 19) Associate Screening/Education/Assignment/Risk Classification policy, last revised 5/29/2020, was provided by the IPCN via email on 7/22/2020. It read in pertinent part, All associates will be actively screened at the beginning of their shift in accordance with current guidance from The Centers for Disease Control (CDC), The Centers for Medicare and Medicaid Services (CMS), and local and state health departments. For screening purposes, associates are defined as any person employed by the facility, or other entities that provide care or direct services in our facilities. B. Professional reference The CMS (4/2/2020) COVID-19 Long-Term Care Facility Guidance. Retrieved from: https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf (7/9/2020). It read in pertinent part, Long-term care facilities should immediately implement symptom screening for all. Facilities should limit access points and ensure that all accessible entrances have a screening station. All long-term care facility personnel should wear a facemask while they are in the facility. C. Training The 6/27/2020 Screening Process in-service was provided by the IPCN on 7/27/2020 via email. It read in pertinent part, Staff cannot go to the unit or department prior to being screened. Staff will need to use the designated entrance and be screened-in before proceeding to their department. D. Observations and interviews On 7/15/2020 at 6:05 p.m., certified nurse aide (CNA) #2 and #3 were observed entering the designated COVID-19 unit from an unlocked exterior door. They unzipped the plastic temporary wall which separated the COVID-19 designated unit from the rest of the 300 hall. They walked into the resident care areas on the 300 hall to access the screening area at the reception desk. CNA #2 and #3 were interviewed immediately after the observation and said they were usually screened at the reception desk then went around to the COVID-19 unit entrance, but there was no one to screen them at the desk. They said that they worked in the COVID-19 designated unit and usually entered through the COVID-19 entrance door. E. Staff interviews The NHA was interviewed on 7/15/2020 at 7:37 p.m. He stated staff were screened at the front door reception area then went down the halls to work in their assigned units, including the COVID-19 unit. The IPCN was interviewed on 7/16/2020 at 8:18 a.m. She stated all staff were screened at the reception desk at the main entrance before going to their assigned halls/units and she expected the staff working in the COVID-19 unit to use the same process. The NHA was interviewed again on 7/16/2020 at 9:25 a.m. He stated all the doors should be locked with the exception of the front entrance. He said the front entrance was unlocked when the receptionist was present. III. Personal protective equipment (PPE) A. Facility policy and procedure The Guide to Infection Prevention and Control policy, Personal Protective Equipment (PPE), revised 5/29/2020, was provided by the NHA via email on 7/15/2020. It read in pertinent part, The facility should train associates on PPE, this training should include appropriate don/doff process. PPE should be appropriately discarded after resident care prior to leaving the room, followed by hand hygiene. When donning (putting on) PPE, perform hand hygiene and apply the gown. If facility-wide facemask/respirator/eye protection use has been implemented, prior to starting work work at the beginning of shift and after breaks. Perform hand hygiene and put on gloves prior to reapplying face mask/respirator/eye protection. B. Professional reference The CDC, (6/9/2020) Using PPE, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html (7/23/2020). It read in pertinent part, How to put on (Don) PPE (personal protective equipment) gear. Perform hand hygiene. Put on an isolation gown. Put on an N95 filtering facepiece respirator or higher. Put on a face shield or goggles. Enter the patient room. How to take off (doff) PPE gear. Remove gloves. Remove the gown, do so in a gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull the gown down and away from the body. Rolling the gown down is an acceptable approach Dispose in a trash receptacle. Healthcare personnel may now exit the patient room. Perform hand hygiene, face shield/goggles, remove and discard respirator. C. Training The 3/13/2020 Coronavirus (COVID-19) policy and staff in-service on the policy was provided by the IPCN via email on 7/20/2020. It read in pertinent part, Perform hand hygiene before donning and doffing PPE, airborne or droplet precaution rooms require N95 mask, goggles or face shield, gloves and fluid resistant gown. D. Observations and interviews There were a total of seven droplet precaution (with eye protection) rooms in the facility. Each room had a sign posted at the entrance of the door that read Entry requires an N95 respirator mask, goggles/face shield, isolation gown and gloves. On 7/15/2020 at 5:38 p.m., CNA #5, donned an isolation gown then gloves before entering a droplet precaution room, room [ROOM NUMBER]. She failed to perform hand hygiene prior to donning the gloves and entering a droplet precaution room. She entered the room wearing a surgical mask. -CNA #5 failed to don an N95 mask and eye protection. CNA #5 was immediately interviewed after the observation and said that she did not wear an N95 respirator mask because it made her sick. She stated that the facility allowed her to wear a surgical mask instead of an N95 respirator mask. She said that she was not instructed to not enter resident rooms with known COVID-19 positive status located in the COVID-19 designated unit. -CNA #5 failed to recognize that the resident rooms that were on droplet precautions (with eye protection), required an N95 respirator mask and eye protection, therefore she could not enter since she did not wear the appropriate PPE. -From 6:11 p.m. to 6:29 p.m., CNA #2 and #3 wore N95 respirator masks, donned surgical masks over the top, and donned isolation gowns and gloves. -CNA #2 and #3 failed to don eye protection prior to entering droplet precaution room [ROOM NUMBER] with a full-body style mechanical lift. -CNA #2 exited the room with the mechanical lift without doffing PPE and walked across the hall to retrieve disinfecting wipes for the lift. She disinfected the lift in the hallway then discarded the PPE in a trash bin located across the hallway from room [ROOM NUMBER]. -CNA #2 failed to don eye protection and doff PPE prior to exiting a droplet precaution (with eye protection) resident room. -CNA #3 exited the room without doffing PPE and walked across the hall to discard the PPE in a trash bin located across the hallway from room [ROOM NUMBER]. -CNA #3 failed to don eye protection and doff PPE prior to exiting a droplet precaution (with eye protection) resident room. -At 6:55 p.m., CNA #3 donned surgical mask over top of N95 mask, gown and gloves entering room [ROOM NUMBER]. -CNA #3 failed to don eye protection prior to entering room [ROOM NUMBER] which was a droplet precaution (with eye protection) room. E. Staff interviews The IPCN was interviewed on 7/16/2020 at 8:18 a.m. She stated that the staff were trained on how to don and doff PPE for droplet precaution rooms, including how to wear an N95 respirator mask in March 2020. The IPCN stated CNA #5 had an allergic reaction to the N95 respirator mask and was instructed not to enter droplet precaution rooms. She said she was not aware that CNA #5 had entered droplet precaution (with eye protection) rooms. IV. Kitchen staff performed hand washing and wore masks appropriately A. Observation On 7/16/2020 at 6:37 a.m., 7:11 a.m., and 8:40 a.m. the cook wore a surgical mask under her chin exposing her mouth and nose while preparing, cooking and serving food with two other dietary aides present. She adjusted the mask to cover her mouth and nose when a CNA entered the kitchen to talk about the menus. The cook returned to preparing, cooking and serving the breakfast meal to all the units after moving the mask below her chin exposing her mouth and nose again. B. Staff interviews Dietary aide #1 was interviewed on 7/16/2020 at 7:11 a.m. She said that she received training on wearing a mask at all times and performing hand hygiene frequently while reaching for the alcohol based hand rub (ABHR) dispenser. She said she performed hand hygiene by using the ABHR frequently. The dispenser was on the wall located inside the door into the kitchen. She said that she was not aware that she needed to wash her hands with soap in water when working with food. She said her training included the use of ABHR for hand hygiene even in the kitchen. The NHA and IPCN were interviewed on 7/16/2020 at 8:40 a.m. The IPCN said that the kitchen manager provided hand hygiene and mask wearing education in June. The IPCN said that she provided training to all staff including the kitchen staff on the proper use and application of the masks. She said that hand hygiene training was ongoing and frequently provided to all staff including the kitchen staff. The IPCN said she would instruct on the requirement for soap and water to be used with hand hygiene when working with food items.

Based on observations and interviews, the facility failed to ensure two (#1 and #2) of two sample residents had a right to personal privacy during personal care. Specifically, the facility failed to ensure Residents #1 and #2's bodies were fully covered during transportation to and from the shower. Findings include: I. Observations 7/16/2020 -At 5:38 a.m., certified nurse aide (CNA) #1 wheeled Resident #1 in a shower chair from the spa room to the resident's room. A blanket was draped over the resident exposing the resident's side of buttocks. -At 6:13 a.m., CNA #5 wheeled Resident #2 in a wheelchair from the resident's room to the spa room. A sheet was draped over the resident exposing the resident's side of buttocks. II. Staff interview The director of nursing (DON) was interviewed on 7/16/2020 at 8:18 a.m. She stated the residents should be completely covered when going to and from the spa room.

Based on observations, record review and interviews, the facility failed to ensure effective infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Specifically, the facility failed to ensure: -Staff were following guidelines for proper personal protective equipment (PPE) use; and, -Residents were offered and assisted with hand hygiene prior to meals. Findings include: I. Professional reference The Centers for Disease Control (CDC) Key Strategies to Prepare for Coronavirus COVID-19 in Long Term Care Facilities, dated April 2020, read in pertinent part: If COVID-19 was identified in the facility, have health care providers (HCP) wear all recommended PPE for care of all residents (regardless of symptoms) on the affected unit (or facility-wide depending on the situation). This includes: an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and gown. HCP should be trained on PPE use including putting it on and taking it off. This approach is recommended because of the high risk of unrecognized infection among residents. Recent experience suggests that a substantial proportion of residents could have COVID-19 without reporting symptoms or before symptoms develop. II. Facility policy and procedures The Hand Hygiene for Residents policy, revised 4/16/2020, was provided by the nursing home administrator (NHA) on 6/25/2020 at 10:13 a.m. It read, in pertinent part, Hand hygiene should be offered/performed: upon waking, after toileting, after coughing or sneezing, prior to the handling and/or consumption of food, prior to leaving his/her room for therapy or shared activities, after ending therapy and shared activities, anytime hands are visibly soiled, after touching cloth face covering or face mask, and upon request. The Personal Protective Equipment (PPE) policy and procedure, revised 5/29/2020, was provided by the nursing home administrator (NHA) at 10:13 a.m. It read, in pertinent part, Donning (putting on) PPE: 1. Identify and gather appropriate PPE; 2. Perform hand hygiene using hand sanitizer; 3. Apply gown; 4. If appropriate facemask is not already in place, perform hand hygiene and put on gloves then apply face mask or appropriate N95 respirator and eye protection. Discard gloves. 5. Perform hand hygiene before putting on gloves. Gloves should cover the cuff of the gown. 6. Enter the resident room. Doffing (taking off PPE): 1. Remove gloves, ensure removal does not cause additional contamination of hands. 2. Remove gown. Disrobe in a manner that prevents touching of the outside of the garment. If reusable, hang gown on hook with clean side out or place in laundry receptacle. 3. Exit the resident room. 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove and discard respirator or facemask (unless reusable). 7. Perform hand hygiene after removing the respirator or facemask. III. Status of COVID-19 in the facility The infection preventionist (IP) was interviewed on 6/24/2020 at 4:00 p.m. upon entrance to the facility. She reported the facility census was 40 and 13 residents confirmed positive for COVID-19, however, there were nine residents on droplet precautions due to COVID-19 symptoms. She reported ten staff members were out of work due to COVID-19 or symptoms of illness.The last confirmed case was from testing completed on 6/18/2020. The facility is currently testing all residents and staff on a weekly basis. The IP said staff received education handouts upon arrival at work for PPE use and COVID precautions. She said she completed training on the spot with CNAs while she worked the floor. IV. Failure to follow droplet precautions with the appropriate PPE in the non-COVID confirmed unit A. Observations The non-COVID confirmed unit was observed on 6/24/2020. There were nine residents on droplet precautions due to COVID-19 symptoms. The following observations were made: -At 4:13 p.m., CNA #1 was observed putting on PPE for an isolation room. She failed to put on any eye protection before she entered the isolation room. -At 5:25 p.m., CNA #1 and CNA # 2 were observed in an isolation room providing resident care. Both CNAs failed to wear eye protection in the isolation room. CNA #2 doffed her PPE in the following order: gown, then mask, then gloves. Her gloves were contaminated when she touched her face to remove her mask. -At 6:17 p.m., CNA #1 passed a room tray to a resident on isolation precautions. She wore her personal glasses on her head and failed to put on eye protection. -At 6:23 p.m. CNA #1 put on PPE in the following order to enter an isolation room: gown, then gloves, then surgical mask over her N95. She did not perform ABHR at any time during the process and she failed to put on eye protection. She removed her PPE in the following order: gown, then surgical mask, then gloves. The non-COVID confirmed unit was observed again on 6/25/2020. The following observations were made: -At 8:50 a.m., licensed practical nurse (LPN) #1 entered an isolation room without eye protection. B. Interviews CNA #1 was interviewed on 6/24/2020 at 5:25p.m. She said she used her personal glasses for eye protection but other eye protection was available for her to use. She said she did not know why she was not wearing any eye protection. LPN #1 was interviewed on 6/25/2020 at 9:01 a.m. She said she did not know why nursing staff on the non-COVID unit was not wearing eye protection. She said it was available to use. V. Failure to offer residents hand hygiene A. Observations of two different meal, on two separate days On 6/24/2020 at 6:10 p.m., CNA #3 and CNA #4 were observed delivering meal trays to residents on the COVID-19 isolation unit. Residents were not offered hand hygiene prior to eating their meal. On 6/24/2020 from 5:34 p.m. to 6:45 p.m., CNA #1 and CNA #2 were observed delivering meals to residents in the non-COVID unit. None of the residents were offered hand hygiene prior to eating their meal. On 6/25/2020 from 8:28 a.m. to 8:50 a.m., CNA #1 and LPN #1 were observed delivering meals to residents in the non-COVID unit. None of the residents were offered hand hygiene prior to eating their meal. B. Interviews CNA #3 was interviewed on 6/25/2020 at 7:32 a.m. She said residents' hands were washed before every meal. She said she offered hand hygiene at mealtimes. The IP was interviewed on 6/25/2020 at 9:07 a.m. She said residents ' hands should be washed before each meal. She said there wasn ' t a system in place to ensure this was being completed by staff with the residents prior to meal service.

Based on observation and interview, the facility failed to secure medications and limit access to authorized personnel consistent with professional standards of practice for one of two med storage rooms in the facility. Specifically, the facility failed to store all the over-counter-medications for its residents in a secure location accessible only to nursing staff. Findings include: A. Observations An observation on 4/28/2020 at 3:26 p.m. revealed several shelves of over-the-counter medications were stored in a room where one could see them from a door which led to a main hallway. One could see the laundry room through a door in the room in which they were stored. There was no nursing staff in the room. B. Staff interviews The central supply (CS) staff was interviewed on 4/28/2020 at 3:28 p.m. She said she ordered and stored all of the over-the-counter medications for the facility in that room, and had done so for at least a year. She, the laundry staff, and the maintenance director all had keys to both doors to that storage room, and they all had unrestricted, unsupervised access to it as well. The assistant director of nursing (ADON) was interviewed on 4/28/2020 at 3:48 p.m. She said the over-the-counter medications should not be stored in an unattended room and be accessible to staff who are not nurses. The nursing home administrator (NHA) was interviewed on 4/28/2020 at 3:55 p.m. He said residents ' over-the-counter medications should not be accessible to staff who were not nurses. He said he would have the over-the-counter medications moved to a more secure room, have the door to the room rekeyed, and ensure only nurses had access to the room.

Based on observations and interviews, the facility failed to maintain an infection and prevention control program to provide a safe environment to help prevent the development and transmission of COVID-19. Specifically, the facility failed to: -follow proper protocol for use of personal protection to ensure adequate supplies for respiratory hygiene and cough etiquette were provided to residents. -Ensure hand hygeine was completed appropriatly; and -Vital machine was cleaned after use. Findings include: I. Face masks for residents A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (4/30/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. B. Facility policy According to the Infection and Prevention Control Plan (IPCP), provided by the nursing home administrator (NHA) on 4/30/2020 at 7:20 p.m., it was to address the detection, prevention, and control of infection among residents. According to the Group Programming During Public Health Emergency, provided by the nursing home administrator (NHA) on 4/30/2020 at 7:20 p.m., the facility was to implement social distancing and limit social gatherings to less than 10 people. C. Observations On 4/28/2020 at 2:30 p.m., Resident #1 was observed without a mask on at the entrance of the facility; the receptionist was at the entrance and did not offer her a mask. On 4/28/2020 at 2:40 p.m., Resident #5 was observed without a mask as she sat in her wheelchair in the common area of the facility, staff passed by her and did not make attempts to assist or encourage her to place a mask over their nose and mouth On 4/28/2020 at 2:50 p.m., Resident #3 was observed without a mask, he was in his wheelchair next to the medication cart. Registered nurse (RN) #1 stood at the medication cart and did not offer him a mask. On 4/28/2020 at 2:57 p.m. There were 13 residents in the dining room playing bingo and none wore masks which covered their mouth and nose. One male resident wore a mask under his chin and a female resident wore a mask which hung on her ear. There were staff in the dining room and they made no attempt to assist or encourage residents to wear masks, or attempt to assist the male or female resident to place the mask over their nose and mouth. On 4/28/2020 at 3:11 p.m. There were 13 residents in the dining room playing bingo and seven wore masks which covered their mouth and nose. There were staff in the dining room and they made no attempt to assist or encourage the remaining residents to wear masks. On 4/28/2020 at 3:15 p.m. Resident #5 wore a mask under her chin as she self-propelled along the hallway of the facility and stopped in the common area of the facility; she passed by staff who made no attempt to assist or encourage her to place the mask over their nose and mouth. On 4/28/2020 at 3:30 p.m., Resident #5 was observed without a mask as she sat in her wheelchair in the common area of the facility; staff passed by her and did not make attempts to assist or encourage her to place a mask over their nose and mouth. On 4/28/2020 at 3:35 p.m. There were 13 residents in the dining room playing bingo and five wore masks which covered their mouth and nose. One male resident wore a mask under his nose. There were staff in the dining room and they made no attempt to assist or encourage the other residents to wear masks, or attempt to assist the male resident to place the mask over his nose and mouth. On 4/28/2020 at 4:03 p.m. Three residents were observed in the same common area of the facility without a mask on; staff passed by them and did not make attempts to assist or encourage them to place the mask over their nose and mouth. On 4/28/2020 at 4:11 p.m. Two residents (#1 and #2) were observed in the same common area of the facility without a mask on, were next to each other, and Resident #1 placed her hand on Resident #2 ' s arm; staff passed by them and did not make attempts to assist or encourage them to place the mask over their nose and mouth, nor move them apart six feet. Down the hall from this common area Resident #3 was observed without a mask, he was in his wheelchair next to the medication cart. RN #1 stood at the medication cart and did not offer him a mask. B. Resident interview Resident #3 was interviewed on 4/28/2020 at p.m. He said the masks the facility provided residents were too small (as he displayed his attempts to put the mask on the elastic appeared too tight and the surface of the mask did not thoroughly cover his mouth and nose, and it did not reach his chin). He said he could not wear the mask (he held the mask in his hand after he took it off to show how tight it was on his head). C. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 4/28/2020 at 3:04 p.m. He said residents were to wear masks when they were out of their rooms. RN #1 was interviewed on 4/28/2020 at 3:21 p.m. She said residents were to wear masks when not in their rooms. If they take the mask off, or do not wear the mask, staff were supposed to remind them or encourage them to wear a mask to protect them. The infection control preventionist (ICP) was interviewed on 4/28/2020 at 4:18 p.m. The ICP said the residents should be wearing masks when out of their rooms. She said that staff and residents had both been educated on the importance of wearing the masks when out of their rooms. II. Hand washing According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. Observations On 4/28/2020 at 4:36 p.m., CNA #7 was observed to enter a resident ' s room. She assisted the resident in bed B, and then assisted the resident in bed A. She did not wash her hands in between residents. The CNA #7 was interviewed on 4/28/2020 at approximately 4:45 p.m. The CNA #7 confirmed she did not wash her hands in between the two residents. She said she should of washed her hands. Interviews The infection control preventionist was interviewed on 4/28/2020 at approximetly 5:00 p.m. The ICP said the staff had been trained on hand washing. She said the staff were to wash for 20 seconds. III. Equipment cleaning A. Observation On 4/28/2020 at approximately 5:00 p.m., CNA # 1 was observed to push the vital machine into a room and proceeded to take the vitals on a resident. The CNA then proceeded to push the vital machine into the hallway. She left the vital machine in the hallway and did not clean it. Interview The ICP was interviewed at approximately 5:00 p.m. The ICP was informed of the above observation. She said that the vital machine should be cleaned with appropriate cleaning wipe prior to it being left in the hallway. She said she would provide training.

Based on record review and interviews; the facility failed to act promptly and resolve the concerns of resident groups' grievances and recommendations concerning issues of resident care and life in the facility of 29 sample residents. Specifically, the facility failed to ensure resident group concerns and grievances related to call light response times were resolved in a timely manner. I. Policy and procedure Review of the Grievance Procedures and Concern and Comment Program policy, dated 5/6/19, provided by the health information management (HIM) staff on 2/26/2020 at 11:23 a.m. revealed in part, Use of the Concern and Comment Program in response to a reported concern: Fosters a timely and quality response to the concern and/or comment; Allows for identification of possible trends and patterns; Identifies special needs of families and/or residents; ensures appropriate follow-up and systemic analysis. II. Resident group interview A group interview was completed on 2/24/2020 at 10:41 a.m. with 10 residents the facility deemed as interviewable. The group said the call light response time took over an hour, sometimes in the morning. They said this occurred before breakfast. They said the staff shut the call lights off and don ' t come back. III. Resident interviews The resident council vice president was interviewed on 2/26/2020 at 10:35 a.m. He said the longest call light time was about an hour and 20 minutes which occurred about a month ago. He said the staff was busy talking with each other instead of getting them up in the mornings. He said he felt like they needed a part time helper in the mornings. The resident council president was interviewed on 2/26/2020 at 11:15 a.m. He said the call light issue occurred early morning, about 5:00 a.m. He said it took as long as an hour and 15 minutes for a response. He said the concerns were sometimes getting addressed. IV. Record review Review of the September 2019 Resident Council Meeting minutes revealed in part, Old business: Slow response to call lights being answered: In the process of call light audit, will follow up at the next meeting. Review of the October 2019 Resident Council Meeting minutes revealed in part, Old business Slow call light response in the mornings: Follow up- executive director (ED) explained that call light audit was finished and lights are being answered within 30 seconds to a minute. Explained to residents that sometimes call light answers are a little slower in the morning due to everyone wanting up at the same time. Residents were pleased. Review of the November 2019 Resident Council Meeting minutes revealed in part, Resolved issues: (Resident name) brought up call light response issues from the previous month. Call lights are getting better but the morning times are very busy. Noticed that 200 halls are busier this month with high acuity. Review of the December 2019 Resident Council Meeting minutes revealed in part, Unresolved issues: (Resident name) brought up the call light response time .Resolved issues: For the call light situation, staff discussed that we as a facility are short staffed and are gaining new staff members. Review of the January 2020 Resident Council Meeting minutes revealed in part, Unresolved issues: (Resident name) brought up the call light response time in the morning .Resolved issues: For the call light situation, ED discussed that a blue card (grievance form) be written over the situation of the call light. Review of the Concern and Comment form, dated 1/15/2020, revealed the following: -Concern: resident council; -Date: 1/15/2020; -Description: Residents are concerned about call lights in mornings, response time; -Was the staff member able to resolve the concern at the time it was shared? Yes; -Investigation findings: Residents make same complaint of long wait times during shift change for most if not all resident council meetings; -Actions taken to resolve/respond to concern: Call light audits have been done as well as re-education; -Party ' s response to outcome: agreeable with plan of correction (POC) for continuous re-education. Cautious but optimistic; Signed 1/20/2020. Documentation of the call light audits were not available. Review of the February 2020 Resident Council Meeting minutes revealed in part, New business: (Resident names) all stated the wait times for the call lights is becoming too long and that they would like that to change .Resolved issues: For the call light situation .will look into the situation. V. Staff interviews The director of nurses (DON) was interviewed on 2/26/2020 at 10:16 a.m. She said they were unable to find any call light audits. She said she thought they had them. The nursing home administrator (NHA) was interviewed on 2/26/2020 at 11:30 a.m. He said they were unable to find any call light audits. He said they just started an audit 2/25/2020, but they did not complete any for the early morning times. He said this was something we need to deal with. He acknowledged he was ultimately responsible for the grievances and ensuring they were resolved.

Based on interviews and record review; the facility failed to honor one (#11) of one resident's rights to participate in a person centered care plan out of 29 sample residents. Specifically, the facility failed to: -Allow Resident #11 and her family to participate in the development and implementation of the person centered care plan with a care conference after each quarterly assessment. Findings include: I. Facility policy and procedure The Resident Assessment Instrument and Care Plan policy was provided by the health information manager on 2/26/2020. It read, in pertinent part, The resident assessment instrument (RAI) is not all inclusive therefore other sources of information are to be included when developing an individualized person-centered care plan for each patient that is reviewed by the interdisciplinary team with each assessment including the patient and other participants as the patient desires. II. Resident status Resident #11, age above 90, was admitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 12/14/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. She required total dependence and one person physical assistance with activities of daily living. III. Family interview The resident's power of attorney was interviewed on 2/24/2020 at 12:40 p.m. She said the family was not invited to participate in a care conference for the resident in almost a year and she would like to be included in quarterly care conferences. IV. Staff interviews The health information manager (HIM) was interviewed on 2/25/2020 at 10:58 a.m. She said there was no record of a care conference for Resident #11 since 5/8/19, over six months ago. The social services director (SSD) was interviewed on 2/25/2020 at 2:05 p.m. She said care conferences were completed with residents and their families quarterly, annually, and as needed for a change of condition. She said the previous SSD did not complete two quarterly care conferences for Resident #11 and she had not yet identified this resident had missed care conferences. She said she would set up a meeting with the family immediately.

Based on observations, record review, and resident and staff interviews the facility failed to ensure that each resident received and provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (#11) of two residents reviewed for pain out of 27 sampled residents. Specifically, the facility failed to address resident #11's pain timely resulting in refusal to participate in group exercise class and decreased appetite. The findings include: I. Facility's Policy and Procedure The pain management protocol dated (revised) 3/2007 read that nursing staff would complete and initiate a plan of care to address the resident's individualized needs for pain management. Nursing staff would monitor and document the effectiveness of the pain management program in the resident medical record (nurses' notes, pain management flow sheet, or medication administration record) as appropriate for the resident condition. Each resident who had been identified to have pain would have their pain assessed at least once per shift to include vital signs. Documentation of this assessment and vital signs would be placed on the pain flow sheet. The Director of Nursing (DON) would monitor effectiveness of the pain management program to identify any resident whose pain was not being controlled. The DON would then communicate to the care plan coordinator of any resident needing further assessment and planned interventions. II. Resident #11 Resident #11, a [AGE] year old, was admitted to the facility on [DATE], according to the face sheet, with the [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. She required extensive assist of two persons with bed mobility, transfers, dressing, and toilet use. The pain assessment interview indicated the resident had experienced pain or hurting frequently in the past five days. She reported that the pain had made it hard for her to sleep at night. Her pain intensity over the past five days was a six, on a zero to ten pain scale, with zero being no pain and ten as the worst pain you could imagine. The pain care plan dated 5/3/15 read she had a potential for pain as evidenced by her verbalization of pain or discomfort. She experienced pain related to [MEDICAL CONDITION] arthritis with decreased mobility and muscle spasms. The goal read she would state or demonstrate relief of or a reduction of pain intensity within one hour after receiving interventions. The interventions included; Administer medications and treatments as ordered and monitor for effectiveness. Educate and encourage the resident to voice any pain or discomfort to staff. Invite her to attend recreation events consistent with her interests as a diversion from pain. Notify the physician if she did not state or demonstrate relief or reduction of pain after one hour of receiving intervention. Monitor for non-verbal signs of pain such as facial grimacing, crying, restlessness, agitation, and resisting care. Encourage the resident and family to teach staff successful pain interventions used in the past. Report changes in pain location, frequency, and intensity to the physician. Resident had stated that an acceptable level of pain for her was three. A. Resident Observations/Interview On 6/17/15 at 6:00 a.m. the resident was observed lying in bed. At 6:40 a.m. certified nurse aide (CNA) #4 and licensed practical nurse (LPN) #5 (not the residents assigned nurse) assisted her to the toilet with the use of a standing pivot transfer device. The resident reported to the staff that she had a headache and that her throat and leg hurt. On 6/17/15 at 6:50 a.m. during medication pass with LPN #4, CNA #4 verbally reported to the LPN, who was assigned to her care, that the resident had continued complaints of pain. On 6/17/15 at 7:14 a.m. the resident was observed in her room in the wheelchair. The resident reported that she had reported pain to the CNA earlier this morning and had still not received anything for pain. On 6/17/15 at 7:20 a.m. CNA #4 was observed taking the resident's vital signs. On 6/17/15 at 7:22 a.m. the resident was transferred back into bed by CNA #4 and CNA #3. She verbalized to the staff that her head and back hurt. CNA #4 told the resident that she had told LPN #4 about her pain. On 6/17/15 at 8:00 a.m. the resident was lying in bed on her left side. Upon interview she stated her pain was an eight on a pain scale of zero to ten, with ten being the worst pain. She reported the pain was in her lower back and head (the headache had been first reported to staff at 6:00 a.m., see above). On 6/17/15 at 8:14 a.m. a review of the resident's Medication Administration Record [REDACTED] On 6/17/15 at 8:18 a.m. CNA #4 and CNA #3 assisted her to the toilet. She stated that her pain was the same (eight of ten) and she was nauseated. She reported that she had not received anything for pain. She was observed to propel herself in the electric w/c to the dining room for breakfast where she was observed to eat half a pastry. On 6/17/15 at 9:05 a.m. she propelled herself to the nurses' medication cart in the hallway. She reported to LPN #4 that she continued to be nauseated. LPN #4 did not acknowledge this complaint. LPN #4 stated, Are you having any pain? She replied, Yes LPN #4 asked her, Do you want your [MEDICATION NAME]? She replied, Yes, it hurts to swallow. After the resident took her medications, LPN #4 asked her if she was hurting anywhere other than her throat? She replied, My head. LPN #4 asked, What would you rate your pain? She replied, 10. , Based on the above observations there was a three hour delay from when the resident first reported her pain to the facility staff and when the pain medication was administered . On 6/17/15 at 10:03 a.m. the restorative nurse aide (RNA) reported that the resident had declined to participate in the group exercise because she was in pain and nauseated. B. Record Review The pain assessment dated [DATE] read the resident was at risk for pain and had experienced pain in the past. The origin of her pain was identified as right shoulder and arthritis pain. It read that prescribed medications, over-the-counter medications, and non-medication interventions had been effective. The form was not completed to identify what would make her pain worse and how much relief she had received after pain medications or treatments were provided. The computerized physician order [REDACTED]. - Pain assessment every shift. Document based on a pain scale of zero to ten. The resident's acceptable level of pain was three. - [MEDICATION NAME] 200 milligram (mg) tablet, give one tablet by mouth (po) daily for [MEDICAL CONDITION] arthritis. - Tylenol 650 mg po, give one tablet every four hours as needed (PRN) for pain or fever. - [MEDICATION NAME] 5mg-325mg tablet, give one tablet po every four hours PRN for pain of three to six. - [MEDICATION NAME] 5mg-325mg tablet, give two tablets po every four hours PRN for pain of seven to ten. - [MEDICATION NAME] 750 mg tablet, give one tablet po twice daily (BID) PRN for muscle spasms. The Pain Flow Sheets revealed the resident's pain had not been at her acceptable level of three out of 10 after one hour post intervention eight times in 6/15, ten times in 5/15, and 20 times in 4/15. The Pain Flow Sheets and MAR's revealed the resident had received two tablets of [MEDICATION NAME] when her pain was reported as six or less seven times in 6/15, 28 times in 5/15, and 37 times in 4/15, which was inconsistent with the physician's orders [REDACTED].>The Occupational Therapy (OT) progress report dated 4/22/15 read the target goal was the resident would report decreased pain to her right shoulder and ribs to a four out of ten through the use of modalities, positioning, use of a sling, and kinesio taping. This was inconsistent with the resident's acceptable level of pain. C. Resident Interview On 6/18/15 at 8:30 a.m. the resident stated, Yes, I get tensed up and can't do things. She reported that her appetite had declined since her throat started to hurt. She stated, I used to do everything myself, but expressed she was now limited due to the pain in her shoulder. She reported that the [MEDICATION NAME] did help to reduce her pain. She denied that any other non-pharmacological interventions (hot packs, massage, or ointment) had been used. No documentation was found to show non-pharmacological interventions were used. She reported that her pain had worsened since she had been admitted to the facility. She reported that she thought a hot pack would feel good on her shoulder. Throughout the interview she displayed a pained facial expression. D. Staff Interviews On 6/17/15 at 10:46 a.m. CNA #4 reported she would verbally report any complaints or signs of pain to the nurse. She reported that a stop and watch form was also used. The stop and watch form was a duplicate communication tool used by the facility to report changes in a resident ' s condition. She reported that she had informed the nurse (LPN #4) that morning about the resident's complaints of pain. She stated that she would report to the charge nurse if the floor nurse did not take care of the complaint. On 6/17/15 at 8:45 a.m. RNA reported she had worked at the facility for four years. She reported the residents would have group exercise on that day at 10:00 a.m. rather than individual restorative programs. She stated that she did exercises that would incorporate everyone's restorative program. She reported she would work on resident #11's right arm and shoulder for range of motion (ROM). She said the resident usually participated in the restorative program and group exercises. She reported the group exercises were held three times per week on Monday, Wednesday, and Friday. She stated the facility began doing the group exercise because a lot of the residents on restorative programs did not want to go to the gym, but they would participate in a group exercise. The RNA later reported the resident had declined to participate in the group exercise program that day due to her pain and nausea. She again reported that the resident usually participated in the group exercise program. On 6/18/15 at 8:27 a.m. CNA #5 reported she had worked at the facility for three years. She stated that she would notify the nurse verbally and with the stop and watch tool if a resident complained of or had signs of pain. She reported that she would give the stop and watch tool to the nurse as soon as she would see them or leave it on the medication cart. She stated that she would report the concern to the charge nurse, administrator, or DON if the floor nurse did not do anything about the concern. She reported that an ointment could be used as a non-medication intervention to help reduce a resident's' pain. On 6/17/15 at 11:01 a.m. LPN #3 reported the facility used a zero to ten scale to assess a residents pain. She stated the CNA's were to report any complaints of pain to the nurse verbally. She reported that she would administer Tylenol if ordered and check if something stronger was ordered. She stated that non-pharmacological interventions used included turning and repositioning, warm packs, and range of motion. On 6/17/15 at 11:15 am LPN #4 reported she would ask the residents every shift if they had pain. She stated that staff was to give the stop and watch form to the nurse when pain was identified. She stated that CNA #4 had reported verbally that resident #11 was in pain and she asked for CNA #4 to obtain the resident's vital signs. She stated CNA #4 had given her the stop and watch form about resident #11 at 11:00 a.m. She reported that she would contact the physician if the resident's pain was not relieved. On 6/18/15 at 8:30 a.m. the DON reported the facility used the stop and watch tool to report changes in a residents' condition including pain. She stated the staff should tell the nurse verbally and then fill the stop and watch form out and give the yellow copy to her. She stated the nurse should offer or give a PRN pain medication and if one was not ordered the nurse should call the physician. The staff should follow through on the PRN medication to assess the effectiveness. The nurse should notify the physician if the pain was not resolved. The nurse was supposed to ask each resident every shift about their pain and should call the physician if the acceptable level of pain was not reached.