Every finding on record at Suites at Clermont Park Care Center, The

Based on observations, interviews and record review, the facility failed to ensure one (#38) of two residents reviewed for resident rights out of 35 sample residents received appropriate treatment and services consistent with his interests, assessments and plan of care. Specifically, the facility failed to ensure Resident #38 received his showers consistently with his preferences. Findings include: I. Resident #38A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized orders (CPO), diagnoses included acute respiratory failure with hypoxia (low blood oxygen levels), urinary tract infection and muscle weakness. The 2/4/26 minimum data (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required moderate assistance for showering and was dependent on staff for toileting, dressing, eating, hygiene and transfers. B. Resident representative interview Resident #38's representative was interviewed on 2/16/26 at 1:50 p.m She said they were told Resident #38 would be getting showers twice a week on Wednesdays and Saturdays. She said Resident #38 had missed showers on two Saturdays in a row. She said she was concerned about him missing showers. She said she was told it was because Resident #38 required two people to assist him in the shower and they did not have enough staff on those days. C. Record review Resident #38's care plan, initiated 1/30/26, documented the resident needed substantial or maximal assistance for bathing or showering. The bathing task record documented Resident #38 preferred to be bathed on Wednesdays and Saturdays in the evening. The bathing task record from 1/30/26 to 2/15/26 documented Resident #38 received showers for three out of five opportunities. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 2/17/26 at 1:10 p.m. She said Resident #38 required two people to assist with activities of daily living (ADL) including transferring and showering. She said he did not refuse care. She said he preferred his showers in the evening. She said if a resident refused a shower, she would let the nurse know. Licensed practical nurse (LPN) #1 was interviewed on 2/18/26 at 11:37 a.m. She said Resident #38 could be combative with staff during cares at times. LPN #1 said when he had these behaviors, she would expect staff to step away and attempt to reapproach. She said the resident should be getting their showers twice a week and she was not aware of Resident #38 missing any showers. She said if a resident did miss a shower, she would expect staff to attempt later that shift or the next day. She said she would document a nursing progress note if she was informed about a resident missing their shower. The director of nursing (DON) was interviewed on 2/18/26 at 12:05 p.m. She said staff were expected to offer showers twice weekly to all residents. She said the nursing staff scheduled showers for the new residents initially and would adjust the showers days or times as needed while they get to know the resident preferences. The DON said if a resident missed a shower, she would expect staff to encourage the shower and reapproach later. She said she would expect the staff offering the shower to communicate it with the nurse when the resident missed a shower. The DON said she would expect the nurses to document a progress note if they had been notified of a resident missing a shower. The DON said she had recently learned about Resident #38 having behaviors and she would expect staff to document those behaviors.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.Specifically, the facility failed to rinse and store nebulizers (a small machine that turns liquid medication into a mist that can be inhaled to treat lung conditions) masks and reservoirs properly. Findings includeI. Professional referenceThe Center for Disease (CDC) Guidelines for the Prevention of Nosocomial Pneumonia, dated September 2024, was retrieved on 2/19/26 from https://www.cdc.gov/mmwr/preview/mmwrhtml/00045365.htm. It read in pertinent part: Outbreaks related to the use of respiratory-therapy equipment have been associated with contaminated nebulizers. When the fluid in the reservoir of a nebulizer becomes contaminated with bacteria, the aerosol produced may contain high concentrations of bacteria that can be deposited deep in the patient's lower respiratory tract. Contaminated reservoirs of aerosol-producing devices (nebulizers) can allow the growth of hydrophilic bacteria that subsequently can be aerosolized during use of the device and can multiply to substantial concentrations in nebulizer fluid and increase the risk for pneumonia in patients using such devices. Small-volume medication nebulizers and hand-held nebulizers should be disinfected, rinsed with water and air dried.II. ObservationsOn 2/16/26 at 2:34 p.m. Resident #27's nebulizer reservoir was attached to the mask in the top drawer of the night stand. The drawer included multiple papers, chapstick and creams. On 2/17/26 at 11:58 a.m. Resident #27's nebulizer reservoir was attached to the mask in the top drawer of the night stand. The drawer included a used tube of antifungal cream, a box of gloves, letters, papers and chapstick.On 2/18/26 at 10:20 a.m. Resident #27's reservoir was attached to the mask in the top drawer of the night stand. The drawer included a used tube of antifungal cream, a bottle of foam rinse cleaner, a box of gloves, a package of opened wet wipes, multiple papers and chapstick. III. Resident interviewResident #27 was interviewed on 2/18/26 at 10:25 a.m. She said she did not know when her nebulizer mask and reservoir had been cleaned. She said it was always stored in the top drawer of her night stand. On 2/16/26 at 11:09 a.m. Resident #34's nebulizer reservoir was l attached to the mask sitting on the back corner of the night stand. On 2/17/26 at 9:41 a.m. Resident #34's nebulizer reservoir was attached to the mask but not to the nebulizer tubing. The mask and reservoir were sitting on the back corner of the night stand. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/18/26 at 10:20 a.m. CNA #1 said the CNA and nurse were responsible for ensuring the nebulizer equipment was cleaned and stored properly. She said the staff used sanitary wipes to clean the mask and then dried it. She said the reservoir should be rinsed out and dried as well. She said she was not sure how or where it should be stored. Registered nurse (RN) #1 was interviewed on 2/18/26 at 10:30 a.m. RN #1 said the nurse was responsible for cleaning the nebulizer equipment after each use. He said the mask and reservoir should be rinsed out and left on a clean surface to air dry. He said after it dried it should be stored in a plastic bag. He said the equipment should not be stored in a drawer with other items or on top of the night stand. He said earlier in the morning he observed Resident #34's nebulizer mask and reservoir were not stored properly and discarded it in the trash can. He said after observing Resident #27's nebulizer mask and reservoir were not stored in the top drawer of her night stand, not stored properly, he discarded it in the trash can.The director of nursing (DON) was interviewed on 2/18/26 at 10:47 a.m. The DON said the nurse was responsible for cleaning the nebulizer equipment. She said it should be rinsed out after use and air dried on a clean surface. She said she was not sure how it should be stored. She said she was not sure how other nurses would know if the equipment was clean or not. The DON was interviewed a second time on 2/18/26 at 10:47 a.m. The DON said she spoke with the facility respiratory contractor and was told after the equipment was air dried it should be stored in a clean dry place. She said it should not be stored in a drawer with other items. The regional clinical nurse was interviewed on 2/18/26 at 1:22 p.m. The regional clinical nurse said the facility added storing the nebulizer equipment in a bag after being cleaned and dried to the nurse competency checklist. She said all nurses were educated that when giving a nebulizer treatment, and the equipment was not stored in a bag. She said the staff should rewash the equipment or replace it prior to administering the nebulizer treatment. She said a performance improvement plan (PIP) was initiated 2/18/26 and an audit of all residents using respiratory equipment. She said starting 2/18/26 all nurses would be educated on the proper cleaning and storage of the nebulizer equipment.

Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to follow up with residents' concerns regarding call light response times that were brought up by the resident council during regular meetings. Findings include: I. Facility policy The Grievance Management policy, which was undated, was provided by nurse consultant (NC) #2 on 1/10/24 at 6:02 p.m. It read in pertinent part: The community upholds and supports resident rights and seeks to address any alleged violation of such rights in a timely and effective manner. Any resident, resident representative or the resident advisory council had the right to voice grievances to the community without discrimination or reprisal or fear of discrimination or reprisal. A complaint or issue brought to the attention of the community by a resident or resident representative that is not resolved more informally and in a very timely manner (generally within three days) will be referred to the formal problem-resolution procedure outlined in this policy. The nursing home administrator (NHA), or designee, is the designated community associate responsible for receiving grievances. The NHA or designee shall investigate and confer with persons involved in the alleged incident and other relevant persons and, within three calendar days of receiving the grievance, shall provide a written explanation of findings and proposed remedies to the complainant. The final written outcome will be provided within a reasonable time, not to exceed 30 days following receipt of the grievance. II. Resident group interview Members of the resident council were interviewed on 1/9/24 at 10:57 a.m. The resident council president said residents had waited for over an hour for call lights to be answered when the staff were busy. She said some residents felt they could not file grievances due to retaliation or fear of retaliation. She said some staff retaliated towards the residents who filed grievances by being rude to the resident, the staff refused to work the resident's hall or some staff left the facility. III. Resident interviews Resident #46's medical durable power of attorney (MDPOA) was interviewed on 1/8/24 at 10:21 a.m. The MDPOA said the family visited Resident #46 every day and the call lights were not always answered timely. She said the resident waited 45 minutes to be toileted and ended up urinating on himself. She said she had to go find a staff member to change him because no one answered his call light. Resident #44 was interviewed on 1/8/24 at 11:12 a.m. Resident #44 said sometimes it took up to 30 minutes for his call light to be answered. He said he needed assistance to use the restroom but went by himself at night because the staff did not answer his call light. Resident #43 was interviewed on 1/8/24 at 11:12 a.m. Resident #43 said she waited one to two hours for her call light to be answered to use the restroom. She said she had gotten used to waiting for the bathroom because of this. Resident #262 was interviewed on 1/8/24 at 1:15 p.m. Resident #262 said it took a while for staff to answer his call light and, on average, he said he waited 30 minutes. Resident #45 was interviewed on 1/8/24 at 2:01 p.m. Resident #45 said the call light response time was usually 30 minutes. Resident #3 was interviewed on 1/8/24 at 2:19 p.m. Resident #3 was unable to say how long she waited for her call light to be answered but said that it always took a long time. She said she needed help to go to the bathroom but went by herself more often than not because her call light would not be answered. Resident #28 was interviewed on 1/8/24 at 3:48 p.m. Resident #28 said she waited up to 30 minutes for her call light to be answered. Resident #38 was interviewed on 1/8/24 at 4:32 p.m. Resident #38 said he waited up to 30 minutes for his call light to be answered. Resident #22 was interviewed on 1/8/24 at 9:15 p.m. Resident #22 said staff answered call lights anywhere from five minutes up to an hour and a half. He said longer call light times occurred during meal times. IV. Resident council notes Resident council notes from 9/28/23 documented the residents said call lights were taking a long time to be answered and that it seemed like the weekends were the worst. Resident council notes from 10/27/23 documented no follow-up for the call light concerns in September 2023 and the residents again expressed concerns over the time it took for their call lights to be answered. The resident council notes documented the director of nursing (DON) said she would look into the call light time reports and get back to the residents. Resident council notes from 11/17/23 documented a follow-up for the call light concerns in October 2023. The DON told the residents she reviewed the times and found that the times were longer than they should be. The DON said the higher numbers were found to be the result of a few outliers. The DON said some lights were not cleared by the nursing team immediately, some lights were not being responded to promptly because the nursing staff knew the need was not as urgent as others and some call lights needed to be addressed quicker. The DON said the facility ordered and received more call light phones for the nursing staff to carry. The DON said the facility was looking at staffing because typically using agency staff lead to higher call light times. The DON said she would be working on Sundays so the facility had regular nurse leadership present on the weekends. V. Observations On 1/10/24 at 2:32 p.m., four nursing staff were observed at the nurses's station on the second floor. Six call lights were displayed on the call light computer screen, however, the staff did not respond to the residents' rooms to answer the call lights. On 1/10/24 at 2:38 p.m., Resident #43 had to use the restroom badly and triggered her call light. A certified nurse aide (CNA) answered her call light 13 minutes later at 2:51 p.m. VI. Call light logs A. Resident #5 -On 12/22/23 the call light was triggered at 1:44 a.m. The staff responded 17 minutes later; -On 12/23/23 the call light was triggered at 2:36 p.m. The staff responded 32 minutes later; -On 12/23/23 the call light was triggered at 5:55 p.m. The staff responded 25 minutes later; -On 12/24/23 the call light was triggered at 5:36 a.m. The staff responded 17 minutes later; -On 12/26/23 the call light was triggered at 9:35 a.m. The staff responded 29 minutes later; -On 12/26/23 the call light was triggered at 2:19 p.m. The staff responded 31 minutes later; -On 12/27/23 the call light was triggered at 6:15 p.m. The staff responded 32 minutes later; -On 12/27/23 the call light was triggered at 7:54 p.m. The staff responded 83 minutes later; -On 12/28/23 the call light was triggered at 4:56 p.m. The staff responded 19 minutes later; -On 12/29/23 the call light was triggered at 3:40 p.m. The staff responded 19 minutes later; -On 12/29/23 the call light was triggered at 7:18 p.m. The staff responded 60 minutes later; -On 12/31/23 the call light was triggered at 4:09 p.m. The staff responded 40 minutes later; -On 12/31/23 the call light was triggered at 6:00 p.m. The staff responded 44 minutes later; -On 12/31/23 the call light was triggered at 10:38 p.m. The staff responded 16 minutes later; -On 1/1/24 the call light was triggered at 6:05 a.m. The staff responded 44 minutes later; -On 1/3/24 the call light was triggered at 1:57 p.m. The staff responded 23 minutes later; -On 1/4/24 the call light was triggered at 8:20 p.m. The staff responded 36 minutes later; -On 1/5/24 the call light was triggered at 11:26 a.m. The staff responded 22 minutes later; -On 1/5/24 the call light was triggered at 4:06 p.m. The staff responded 25 minutes later; -On 1/5/24 the call light was triggered at 6:36 p.m. The staff responded 20 minutes later; -On 1/6/24 the call light was triggered at 10:05 a.m. The staff responded 19 minutes later; and, -On 1/6/24 the call light was triggered at 7:36 p.m. The staff responded 28 minutes later. B. Resident #22 -On 12/21/23 the call light was triggered at 8:42 a.m. The staff responded 48 minutes later; -On 12/23/23 the call light was triggered at 6:07 a.m. The staff responded 52 minutes later; -On 12/24/23 the call light was triggered at 5:53 p.m. The staff responded 72 minutes later; -On 12/27/23 the call light was triggered at 7:04 a.m. The staff responded 20 minutes later; -On 12/27/23 the call light was triggered at 8:21 a.m. The staff responded 24 minutes later; -On 12/30/23 the call light was triggered at 5:52 p.m. The staff responded 23 minutes later; -On 12/30/23 the call light was triggered at 6:34 p.m. The staff responded 25 minutes later; -On 1/1/24 the call light was triggered at 7:59 a.m. The staff responded 133 minutes later; -On 1/2/24 the call light was triggered at 7:05 a.m. The staff responded 20 minutes later; -On 1/2/24 the call light was triggered at 6:22 p.m. The staff responded 33 minutes later; -On 1/3/24 the call light was triggered at 5:33 a.m. The staff responded 52 minutes later; -On 1/3/24 the call light was triggered at 7:35 p.m. The staff responded 32 minutes later; -On 1/5/24 the call light was triggered at 6:29 p.m. The staff responded 39 minutes later; -On 1/6/24 the call light was triggered at 5:09 p.m. The staff responded 47 minutes later; -On 1/4/24 the call light was triggered at 7:02 a.m. The staff responded 24 minutes later; and, -On 1/7/24 the call light was triggered at 7:33 a.m. The staff responded 34 minutes later. C. Resident #43 -On 12/21/23 the call light was triggered at 7:59 a.m. The staff responded 21 minutes later; -On 12/21/23 the call light was triggered at 10:46 a.m. The staff responded 27 minutes later; -On 12/21/23 the call light was triggered at 1:22 p.m. The staff responded 25 minutes later; -On 12/21/23 the call light was triggered at 8:55 p.m. The staff responded 21 minutes later; -On 12/21/23 the call light was triggered at 11:51 p.m. The staff responded 36 minutes later; -On 12/22/23 the call light was triggered at 8:42 a.m. The staff responded 21 minutes later; -On 12/22/23 the call light was triggered at 12:32 p.m. The staff responded 20 minutes later; -On 12/22/23 the call light was triggered at 8:52 p.m. The staff responded 37 minutes later; -On 12/23/23 the call light was triggered at 9:33 a.m. The staff responded 20 minutes later; -On 12/23/23 the call light was triggered at 1:30 p.m. The staff responded 20 minutes later; -On 12/24/23 the call light was triggered at 5:12 a.m. The staff responded 28 minutes later; -On 12/24/23 the call light was triggered at 9:32 a.m. The staff responded 17 minutes later; -On 12/25/23 the call light was triggered at 6:16 a.m. The staff responded 32 minutes later; -On 12/25/23 the call light was triggered at 9:43 a.m. The staff responded 24 minutes later; -On 12/25/23 the call light was triggered at 8:36 p.m. The staff responded 19 minutes later; -On 12/25/23 the call light was triggered at 9:14 p.m. The staff responded 34 minutes later; -On 12/27/23 the call light was triggered at 8:17 p.m. The staff responded 16 minutes later; -On 12/28/23 the call light was triggered at 8:29 p.m. The staff responded 27 minutes later; -On 12/29/23 the call light was triggered at 7:53 a.m. The staff responded 41 minutes later; -On 12/29/23 the call light was triggered at 8:12 p.m. The staff responded 23 minutes later; -On 12/29/23 the call light was triggered at 10:05 p.m. The staff responded 37 minutes later; -On 12/29/23 the call light was triggered at 10:51 p.m. The staff responded 23 minutes later; -On 12/30/23 the call light was triggered at 7:18 a.m. The staff responded 17 minutes later; -On 12/30/23 the call light was triggered at 10:48 p.m. The staff responded 20 minutes later; -On 12/30/23 the call light was triggered at 11:06 p.m. The staff responded 23 minutes later; -On 1/1/24 the call light was triggered at 8:49 a.m. The staff responded 60 minutes later; -On 1/1/24 the call light was triggered at 3:51 p.m. The staff responded 31 minutes later; -On 1/1/24 the call light was triggered at 5:04 p.m. The staff responded 23 minutes later; -On 1/1/24 the call light was triggered at 6:03 p.m. The staff responded 17 minutes later; -On 1/1/24 the call light was triggered at 6:37 p.m. The staff responded 40 minutes later; -On 1/1/24 the call light was triggered at 10:04 p.m. The staff responded 19 minutes later; -On 1/2/24 the call light was triggered at 5:08 a.m. The staff responded 30 minutes later; -On 1/2/24 the call light was triggered at 5:32 p.m. The staff responded 27 minutes later; -On 1/2/24 the call light was triggered at 8:34 p.m. The staff responded 20 minutes later; -On 1/4/24 the call light was triggered at 10:18 a.m. The staff responded 23 minutes later; -On 1/4/24 the call light was triggered at 10:55 a.m. The staff responded 23 minutes later; -On 1/4/24 the call light was triggered at 11:50 a.m. The staff responded 34 minutes later; -On 1/4/24 the call light was triggered at 2:30 p.m. The staff responded 26 minutes later; -On 1/6/24 the call light was triggered at 8:09 a.m. The staff responded 24 minutes later; -On 1/6/24 the call light was triggered at 8:53 a.m. The staff responded 30 minutes later; -On 1/6/24 the call light was triggered at 11:17 a.m. The staff responded 16 minutes later; -On 1/6/24 the call light was triggered at 4:38 p.m. The staff responded 40 minutes later; -On 1/6/24 the call light was triggered at 9:24 p.m. The staff responded 20 minutes later; -On 1/7/24 the call light was triggered at 8:35 a.m. The staff responded 16 minutes later; -On 1/7/24 the call light was triggered at 10:27 a.m. The staff responded 18 minutes later; -On 1/7/24 the call light was triggered at 8:17 p.m. The staff responded 18 minutes later; -On 1/7/24 the call light was triggered at 9:12 p.m. The staff responded 55 minutes later; -On 1/8/24 the call light was triggered at 9:59 p.m. The staff responded 21 minutes later; and, -On 1/9/24 the call light was triggered at 2:38 p.m. The staff responded 17 minutes later. C. Resident #44 -On 12/25/23 the call light was triggered at 9:04 a.m. The staff responded 26 minutes later; and, -On 12/30/23 the call light was triggered at 9:18 p.m. The staff responded 23 minutes later. D. Resident #34 -On 12/23/23 the call light was triggered at 9:20 a.m. The staff responded 29 minutes later; -On 1/2/24 the call light was triggered at 8:26 p.m. The staff responded 21 minutes later; and, -On 1/4/24 the call light was triggered at 3:33 a.m. The staff responded 27 minutes later. E. Resident #3 -On 12/27/23 the call light was triggered at 4:13 p.m. The staff responded 67 minutes later; -On 1/2/24 the call light was triggered at 4:25 p.m. The staff responded 20 minutes later; -On 1/3/24 the call light was triggered at 5:08 p.m. The staff responded 18 minutes later; and, -On 1/9/24 the call light was triggered at 10:04 a.m. The staff responded 18 minutes later. F. Resident #45 -On 12/21/23 the call light was triggered at 12:31 p.m. The staff responded 16 minutes later; -On 12/21/23 the call light was triggered at 5:54 p.m. The staff responded 29 minutes later; -On 12/22/23 the call light was triggered at 8:46 a.m. The staff responded 42 minutes later; -On 12/22/23 the call light was triggered at 7:08 p.m. The staff responded 16 minutes later; -On 12/22/23 the call light was triggered at 9:57 p.m. The staff responded 17 minutes later; -On 12/23/23 the call light was triggered at 8:29 a.m. The staff responded 25 minutes later; -On 12/33/23 the call light was triggered at 8:58 a.m. The staff responded 32 minutes later; -On 12/23/23 the call light was triggered at 10:48 p.m. The staff responded 20 minutes later; -On 12/23/23 the call light was triggered at 12:54 p.m. The staff responded 19 minutes later; -On 12/23/23 the call light was triggered at 4:54 p.m. The staff responded 39 minutes later; -On 12/23/23 the call light was triggered at 11:05 p.m. The staff responded 17 minutes later; -On 12/23/23 the call light was triggered at 11:37 p.m. The staff responded 67 minutes later; -On 12/24/23 the call light was triggered at 4:38 p.m. The staff responded 40 minutes later; -On 12/24/23 the call light was triggered at 11:55 a.m. The staff responded 58 minutes later; -On 12/24/23 the call light was triggered at 2:04 p.m. The staff responded 87 minutes later; -On 12/24/23 the call light was triggered at 3:40 p.m. The staff responded 135 minutes later; -On 12/24/23 the call light was triggered at 4:27 p.m. The staff responded 51 minutes later; -On 12/25/23 the call light was triggered at 7:08 p.m. The staff responded 60 minutes later; -On 12/25/23 the call light was triggered at 8:11 p.m. The staff responded 52 minutes later; -On 12/27/23 the call light was triggered at 8:30 a.m. The staff responded 48 minutes later; -On 12/27/23 the call light was triggered at 10:18 a.m. The staff responded 38 minutes later; -On 12/27/23 the call light was triggered at 11:58 p.m. The staff responded 19 minutes later; -On 12/29/23 the call light was triggered at 8:01 a.m. The staff responded 82 minutes later; -On 12/29/23 the call light was triggered at 8:33 p.m. The staff responded 84 minutes later; -On 12/30/23 the call light was triggered at 8:56 a.m. The staff responded 21 minutes later; -On 12/30/23 the call light was triggered at 6:59 p.m. The staff responded 27 minutes later; -On 12/30/23 the call light was triggered at 11:30 p.m. The staff responded 18 minutes later; -On 12/31/23 the call light was triggered at 1:21 a.m. The staff responded 25 minutes later; -On 12/31/23 the call light was triggered at 3:20 a.m. The staff responded 28 minutes later; -On 1/1/24 the call light was triggered at 6:59 a.m. The staff responded 77 minutes later; -On 1/1/24 the call light was triggered at 12:02 p.m. The staff responded 76 minutes later; -On 1/4/24 the call light was triggered at 6:50 a.m. The staff responded 41 minutes later; -On 1/4/24 the call light was triggered at 7:35 a.m. The staff responded 41 minutes later; -On 1/4/24 the call light was triggered at 5:47 p.m. The staff responded 21 minutes later; -On 1/5/24 the call light was triggered at 1:09 a.m. The staff responded 38 minutes later; -On 1/8/24 the call light was triggered at 8:43 p.m. The staff responded 42 minutes later; and, -On 1/8/24 the call light was triggered at 7:46 p.m. The staff responded 40 minutes later. G. Resident #262 -On 12/26/23 the call light was triggered at 5:21 a.m. The staff responded 23 minutes later; -On 12/26/23 the call light was triggered at 11:59 a.m. The staff responded 18 minutes later; -On 12/26/23 the call light was triggered at 1:45 p.m. The staff responded 26 minutes later; -On 12/26/23 the call light was triggered at 7:27 p.m. The staff responded 17 minutes later; -On 12/26/23 the call light was triggered at 7:49 p.m. The staff responded 16 minutes later; -On 12/26/23 the call light was triggered at 9:23 p.m. The staff responded 24 minutes later; -On 12/27/23 the call light was triggered at 6:13 a.m. The staff responded 43 minutes later; -On 12/27/23 the call light was triggered at 3:28 p.m. The staff responded 18 minutes later; -On 12/27/23 the call light was triggered at 5:10 p.m. The staff responded 52 minutes later; -On 12/29/23 the call light was triggered at 11:02 a.m. The staff responded 16 minutes later; -On 12/29/23 the call light was triggered at 3:49 p.m. The staff responded 21 minutes later; -On 12/30/23 the call light was triggered at 7:58 a.m. The staff responded 48 minutes later; -On 12/30/23 the call light was triggered at 9:49 a.m. The staff responded 46 minutes later; -On 12/30/23 the call light was triggered at 2:39 p.m. The staff responded 30 minutes later; -On 12/30/23 the call light was triggered at 9:18 p.m. The staff responded 23 minutes later; -On 12/31/23 the call light was triggered at 12:21 p.m. The staff responded 22 minutes later; -On 12/31/23 the call light was triggered at 11:58 p.m. The staff responded 48 minutes later; -On 1/1/24 the call light was triggered at 5:01 a.m. The staff responded 22 minutes later; -On 1/1/24 the call light was triggered at 10:09 a.m. The staff responded 24 minutes later; -On 1/1/24 the call light was triggered at 3:02 p.m. The staff responded 24 minutes later; -On 1/2/24 the call light was triggered at 10:52 a.m. The staff responded 21 minutes later; -On 1/2/24 the call light was triggered at 12:14 a.m. The staff responded 19 minutes later; -On 1/2/24 the call light was triggered at 1:00 p.m. The staff responded 16 minutes later; -On 1/2/24 the call light was triggered at 5:23 p.m. The staff responded 16 minutes later; -On 1/2/24 the call light was triggered at 11:33 p.m. The staff responded 19 minutes later; -On 1/3/24 the call light was triggered at 2:35 a.m. The staff responded 25 minutes later; -On 1/5/24 the call light was triggered at 6:18 a.m. The staff responded 22 minutes later; -On 1/8/24 the call light was triggered at 4:02 a.m. The staff responded 31 minutes later; and, -On 1/8/24 the call light was triggered at 8:13 a.m. The staff responded 21 minutes later. VII. Staff interviews The executive director (ED) was interviewed on 1/8/24 at 10:00 a.m. He said the facility did not write grievances after complaints were received in the resident council meetings. He said the staff documented the complaints on the resident council notes and follow-up was provided at the following resident council meeting. The assistant director of nursing (ADON) was interviewed on 1/11/24 at 2:48 p.m. She said the facility did not have a call light policy. She said it was brought to her attention within the last month that the call light phones were having issues. The ADON said information technology (IT) came into the facility, did a sweep, and checked if there were issues. She said an issue was identified that when the screen went black the phone never alerted the staff who carried the phone. She said she spoke with the provider of the system and was told it was a glitch on the provider's end and a ticket was entered to have it fixed. She said the facility still had glitches with it but it was being worked on. She said the ideal goal was for staff to answer the call lights within five to ten minutes but absolutely no later than 15 minutes. She said sometimes the residents triggered their call lights and then left their room. The nursing staff peeked into their rooms and saw they were not in there and did not turn off the call light. She said that based on the resident council's feedback she audited the call light logs once a month and she realized there was room for improvement.

Based on record review and interviews, the facility failed to maintain personal privacy during care for two (#36 and #4) of three residents reviewed for privacy of 41 sample residents. Specifically, the facility failed to: -Close Resident #36's bedroom door while she was assisted by staff with getting dressed after a shower; and, -Close Resident #4's bathroom and bedroom doors while she was assisted to the bathroom. Findings include: I. Facility policy The Resident Rights policy, implemented November 2022, was provided by the community executive director (ED) on 1/10/24 at 9:26 p.m. read in pertinent part: Residents have the right to be treated with respect and dignity. Residents have the right to privacy in treatment and caring for residents' personal needs. II. Resident #36 A. Resident status Resident #36, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO) diagnoses included Bell's Palsy (unexplained facial muscle weakness or paralysis) and neurocognitive disorder with Lewy bodies (Lewy body dementia-abnormal deposits of protein in the brain). According to the 12/13/23 minimum data set (MDS) assessment Resident #36 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Resident #36 was dependent upon staff for toileting hygiene, showering and getting dressed and needed substantial or maximal assistance. B. Observations On 1/9/24 at 2:45 p.m. Resident #36 received a shower in her room. Certified nurse aide (CNA) #1 left Resident #36's room at 3:22 p.m. to get clean linen and left the resident's bedroom door open. Resident #36 was lying on her bed naked and uncovered. An unidentified CNA inside the resident's room closed the door once she realized it was open. III. Resident #4 A. Resident status Resident #4, age over 65, was admitted on [DATE]. According to the January 2024 CPO diagnoses included osteoarthritis, urinary incontinence, age-related osteoporosis, Parkinson's, and mild dementia with psychotic disturbances. According to the 10/4/23 MDS assessment Resident #4 had a moderate cognitive impairment with a BIMS score of eight out of 15. Resident #4 required substantial or maximal assistance for toileting, bathing and getting dressed. B. Observations On 1/9/24 at 3:58 p.m. Resident #4 was sitting on the toilet with her bathroom door open, her bedroom door was partially opened and the curtain to the roommate's side of the room was partially opened with the roommate laying in bed. CNA #1 was in the bathroom and assisted Resident #4. At 3:59 p.m., CNA #1 left the bathroom to grab something from the resident's side of her room and noticed she left the door open and shut the door. IV. Staff interviews CNA #4 was interviewed on 1/11/24 at 11:49 a.m. She said for resident showers, the CNAs gathered everything needed for the shower before getting the resident undressed. She said she gathered bath towels, face towels, washrags and bed linens so she did not leave the resident's room. CNA #4 said she started the water and made sure the resident still wanted to shower. She said she closed the bathroom door for showers or if the resident used the bathroom. She said if the resident did not share a room she closed the bedroom door but if they had a roommate she closed the curtain between the resident rooms. The ED was interviewed on 1/11/24 at 12:26 p.m. He said the services the facility provided to residents were all about dignity and respect. V. Facility follow-up The ADON provided training documentation for CNA #1 on 1/16/24 at 8:19 a.m. The training documented a privacy and dignity competency to ensure CNA #1 provided privacy during intimate care. The verbal trainings were completed on 1/11/24.

Based on observations, record review and interviews the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for two (#18 and #30) of four residents out of 41 sample residents reviewed for ADLs Specifically, the facility failed to provide: -Assistance with hydration for Resident #30 and Resident #18; -Restorative therapy for Resident #18; and, -Change Resident #18 care plan when her assistance level had changed. Findings include: I. Resident #18 A. Resident status Resident #18, age72, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included lateral sclerosis (muscle twitching and weakness), chronic kidney disease and osteoarthritis (degenerative joint disease). The 11/16/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance from staff for most ADLs and was dependent on staff for mobility in her wheelchair. She needed moderate assistance with eating. She had limited range of motion in her upper and lower body. The resident participated in restorative therapy doing passive range of motion four times for 15 minutes in the last seven days. B. Resident #18 interview Resident #18 was interviewed on 1/8/24 at 1:17 p.m. Resident #18 said she was fully dependent on staff. Resident #18 said she used to have a power wheelchair and was able to feed herself. Resident #18 said she no longer could feed herself and she used a Broda chair (chairs that provide supportive positioning through a combination of tilt, recline, adjustable legrest angle, wings with shoulder bolsters and height adjustable arms) and was dependent on staff for all mobility. Resident #18 said she no longer received restorative therapy, however she really wanted staff to do it consistently. Resident #18 said sometimes the certified nurse aides (CNA) would try to do a range of motion with her but they did not do the same thing every time and did not seem to know what they were doing. Resident #18 had tears in her eyes when she said she had lost her ability to do the things she used to be able to do and it was a night and day difference when she would get restorative therapy. Resident #18 said she had less pain and could do more when staff was consistent with providing restorative therapy. Resident #18 said there was a print out of exercises on the closet but they were her roommate's and she did not have a print out of exercises in her room. -There was no printout of exercises for Resident #18 observed on her closet door. Resident #18 said staff did not bring water unless she asked for it. Resident #18 said staff would drop the water off but would not offer to help her drink. Resident #18 said the water would be placed out of her reach. Resident #18 said even if the water was placed in her reach she often was unable to drink it on her own. C. Resident #18 observations On 1/8/24 at 12:00 p.m., Resident #18 was brought into the dining room. The resident required full assistance with eating and drinking. The resident had a 12-ounce cup of liquid that appeared to be juice. The resident was not offered more to drink. On 1/8/24 at 1:17 p.m., Resident #18's lips were cracked and there was dried blood on her lips. She was tearful when talking about her decline. The resident was in her Broda chair, her hands were contracted, she could barely hold her remote and it was difficult for her to use her call light. There was a cup filled with water, the water was not in reach of the resident and was about seven feet from where the resident was sitting. On 1/9/24 at 12:30 p.m., Resident #18 was brought into her room after lunch in her Broda chair. Staff did not offer her a drink or any other services. The resident remained in her chair until 1:36 p.m. when staff transferred the resident to bed. -A full cup of liquid was ten feet from the resident and staff did not assist her to take a drink when they transferred her to bed. -Staff did not provide restorative therapy when they transferred the resident to bed. On 1/9/24 at 3:45 p.m., staff returned to Resident #18's room to transfer her back to her Broda chair. -The residents's lips were cracked and the resident said she was thirsty but staff did not offer her a drink. -Staff did not provide restorative therapy when they transferred the resident to her Broda chair. D. Record review Review of Resident #18's January 2024 CPO revealed the following physician orders: Restorative Nursing Program (RNP): nursing staff should help and assist the resident through seated balance exercises, while the resident is seated unsupported in her chair (See print out for Seated Core Balance Program in the resident's room). Perform each exercise 10 times for six to seven times per week. The order had a start date of 10/8/2020. RNP for seated bilateral therapeutic exercise and activity as shown on handout in room performing passive range of motion (PROM) and assisted active range of motion (AAROM) as tolerated to maintain hip, knee and ankle joint integrity. Perform 15 to 20 repetitions each one time per day in the evening for six days per week. The order had a start date of 10/8/2020. -However, the resident did not have any exercise handouts hanging in her room (see observations above). Resident #18's ADL care plan, initiated 3/20/16 and revised 8/30/23, documented the resident required assistance with meals, needed utensils close to her and needed help cutting up meat. According to the care plan, the resident was independent with getting to the dining room using her electric wheelchair. -However, per Resident #18's interview and observations (see above), she could no longer feed herself and she no longer used her electric wheelchair and was dependent on staff to push her to the dining room in her Broda chair. Resident #18's restorative therapy care plan, initiated 3/20/16 and revised 8/30/23, documented the resident should participate in active and passive range of motion according to the physician order. Staff should allow ample time for the exercises, allow rest periods, should not force the resident limbs and should inform nurses about the resident progress. -However, per Resident #18's interview and observations (see above), she was not receiving restorative therapy on a consistent basis according to the physician orders. A monthly evaluation of Resident #18, dated 1/6/24, documented the resident had upper and lower extremity impairment, an unsteady gait and poor balance. The resident was bed bound most, if not all, of the time. The resident continued to participate in physical therapy as ordered. -However, according to the January 2024 CPO, Resident #18 did not have physical therapy orders. The Kardex (a tool used to alert CNAs of their tasks for each resident), dated 1/5/24, documented the resident continued to use her motorized wheelchair. The resident had a cup holder on her Broda chair with a long straw to assist her with hydration. Staff should fill the cup with fluid of the resident choice. -The resident no longer used her motorized wheelchair. E. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 1/11/24 at 8:50 a.m. LPN #4 said Resident #18 required full assistance with all ADLs. LPN #4 said the resident needed assistance to mobilize and used a Broda chair. LPN #4 said the resident had used a motorized wheelchair but she did not know when that changed to the Broda chair. LPN #4 said the resident required assistance with drinking and if a cup was not close to the resident the resident would not be able to drink. LPN #4 said the resident had contractures and should be participating in the restorative therapy program. LPN #4 said CNAs were responsible for performing the restorative therapy program. LPN #4 said rehabilitation staff would train the CNAs when they could but did not have a schedule. LPN #4 said every resident had a different restorative program. LPN #4 said restorative therapy was important because the residents could lose ADL skills. LPN #4 said Resident #18 had a decline in ability to do ADLs on her own and could no longer use an electric wheelchair. The physical therapist (PT) was interviewed on 1/11/24 at 10:48 a.m. The PT said Resident #18 should be receiving restorative therapy. The PT said restorative therapy provided maintenance and could slow down a resident decline in ADLs. The PT said Resident #18 no longer used her motorized wheel chair because she could not control it. The PT said occupational therapists and physical therapists provided exercise sheets for the CNAs to follow. The PT said nursing was responsible for the restorative program and rehabilitation therapists helped initially train the CNAs. The PT said the assistant director of nursing (ADON) oversaw the restorative program and would schedule times for CNAs to be trained. The PT said CNAs should follow the physician orders for restorative therapy. The PT said the facility had a restorative coordinator that had left about a year ago. The PT said the facility hired a new restorative coordinator. Certified nurse aide (CNA) #6 was interviewed on 1/11/24 at 12:20 p.m. CNA #6 said Resident #18 required full assistance with drinking. CNA #6 said the resident could not independently get items that were placed out of reach. CNA #6 said the CNAs were supposed to refill drinks and assist residents when they used the call light and asked for help. CNA #6 said she would offer to assist with beverages when she entered the resident's room. CNA #6 said CNAs were required to do restorative therapy. CNA #6 said there was not a system to know who received restorative therapy and what exercises they should be performing. CNA #6 said rehabilitation staff would teach CNAs specific exercises as they were available. CNA #6 said Resident #18's range of motion could be performed when staff was getting the resident dressed and straightening her legs instead of performing a specific set of exercises. CNA #6 said Resident #18 did not have a print out of exercises in her room. The assistant director of nursing (ADON) was interviewed on 1/11/24 at 3:49 p.m. The ADON said Resident #18 required assistance with hydration. The ADON said the resident was not mobile and could not reach a drink that was placed out of reach. The ADON said signs of dehydration included cracked lips. The ADON said CNAs and nurses should offer drinks and assistance with drinks to residents throughout the day. The ADON said the restorative program was being revamped and they were hiring a restorative coordinator. The ADON said the restorative program was performed by the CNAs. The ADON said the nursing staff and rehabilitation staff would train CNAs when they could. The ADON said they did not have a list of CNAs that had been trained to perform restorative exercises with residents. The ADON said there were handouts explaining the individual exercises that were in the residents' rooms. The ADON said Resident #18 required restorative therapy. The ADON said Resident #18 recently had a decrease in ability and could no longer use an electric wheelchair. II. Resident #30 A. Resident status Resident #30, age greater than 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included dementia with behavioral disturbances, chronic kidney disease and major depression disorder. The 12/2/23 MDS assessment revealed the resident was severely cognitively impaired and unable to perform a BIMS. She required extensive assistance from staff for all ADLs. B. Observations On 1/8/24 at 10:49 a.m., Resident #30 was laying in her bed. The resident had cracked lips. There was not a cup of water in her room. On 1/9/24, during a continuous observation beginning at 10:29 a.m. and ending at 1:35 p.m., the following was observed: At 10:29 a.m. the resident was in her bed sleeping. The resident continued to have cracked lips. There was not a cup of water in the resident's room. At 11:00 a.m. the resident remained the same. Staff did not enter the resident's room and offer her a drink. At 12:07 p.m., LPN #1 entered the resident's room and asked if she had eaten yet and if she wanted a shake. The resident did not respond and LPN #1 left the room without offering the resident a drink. At 12:25 p.m. an unknown staff member entered the resident's room and helped her eat. The resident had a 12 ounce drink on the tray. The resident drank about half of the drink. At 12:45 p.m. the staff member left the resident's room. At 1:35 p.m. the resident remained in her bed and there was no water in the resident's room. On 1/10/24, the following observations were made: At 9:24 a.m. a CNA went into the resident's room and changed her. -The CNA did not offer the resident fluids. At 1:36 p.m. the resident was in her bed and there was no water in the resident's room. C. Record review According to the dehydration assessment, dated 11/17/23, Resident #30 was at risk for dehydration due to the resident being unaware of needing hydration. Resident #30's ADL care plan, initiated 4/17/19 and revised 11/26/23, documented the resident had ADL performance deficiencies. Interventions included staff was to provide extensive assistance with eating and drinking. Resident #30's hydration care plan, initiated 5/13/19 and revised 11/26/23, documented the resident was at risk of dehydration. Interventions included to encourage the resident to drink 240 cubic centimeters (cc) of fluid in between meals, assisting, encouraging and supervising the resident with fluid intake, monitoring and documenting fluid intake and documenting any signs of dehydration. D. Staff interviews LPN # 4 was interviewed on 1/11/24 at 8:50 a.m. LPN #4 said resident #30 required full care and needed help with hydration. LPN #4 said the resident could communicate at times but did not know how to use the call light. LPN #4 said staff should offer the resident fluids when they entered the resident's room. LPN #4 said the resident was at risk of dehydration. LPN #4 said ensuring residents were hydrated was important to overall health and well-being. CNA #6 was interviewed on 1/11/24 at 12:20 p.m. CNA #6 said staff should encourage hydration throughout the day and not just at meal times. CNA #6 said Resident #30 was at risk of dehydration. CNA #6 said Resident #30 needed assistance to drink and access water. CNA #6 said staff should offer Resident #30 something to drink every time they entered the resident's room. The ADON was interviewed on 1/11/24 at 3:49 p.m. The ADON said Resident #30 was at risk of dehydration. The ADON said CNAs and nurses should offer the resident fluids when they entered her room. The ADON said there should be fluids in the resident's room.

Based on observation, record review and interviews, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for two (#9 and #20) out of 41 sample residents. Specifically, the facility failed to: -Provide supervision to Resident #9 while suspended in a Hoyer mechanical lift; and, -Prevent skin injuries to Resident #20 during care with staff. Findings include: I. Resident #9 A. Professional reference The Hoyer lift User Manual, written in 2014, read in pertinent: The Hoyer lift is intended for indoor use only and must be operated by a minimum of two people or carers. B. Resident status Resident #9, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO), diagnoses included acquired absence of left leg below the knee (leg amputation), age-related osteoporosis, polyosteoarthritis (cartilage degeneration), chronic pain, dementia, Parkinsonism (brain condition that caused slowed movements and stiffness) and encounter for palliative care. According to the 10/5/23 minimum data set (MDS) assessment Resident #9 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. Resident #9 was not able to walk and was dependent upon staff for surface transfers, showering, toileting, bed mobility and getting dressed. B. Observations on 1/9/24 At 3:40 p.m. Resident #9 was in bed. Certified nurse aide (CNA) #1 entered Resident #9's room to transfer her to the wheelchair. CNA #1 used the Hoyer lift and applied the sling to Resident #9. CNA #1 hooked the sling to the Hoyer lift with the resident in it. She suspended the resident in the lift until her bottom were barely touching the bed. CNA #1 told Resident #9, I have to go get another staff to help me so I will be right back. Resident #9's sling straps were tight and only her bottom touched the bed while CNA #1 looked for another staff to help her. The hallway was empty and CNA #1 walked up and down the entire hallway to find a staff who could help. At 3:45 p.m. CNA #1 and registered nurse (RN) #3 entered Resident #9's room to transfer her to the wheelchair. She was left unattended suspended in the Hoyer lift for approximately five minutes. C. Staff interviews CNA #6 was interviewed on 1/11/24 at 1:18 p.m. She said it was the facility's policy that two staff were required to be able to use the Hoyer lift to transfer residents. She said using one staff was an accident waiting to happen. RN #1 was interviewed on 1/11/24 at 3:32 p.m. He said two staff were required to be able to use the Hoyer lift for resident transfers because of the facility's policy and for the staff and resident safety. The assistant director of nursing (ADON) was interviewed on 1/11/24 at 2:48 p.m. She said two staff needed to use the Hoyer lift at all times. She said it was a safety issue so the facility trained the staff to use two staff during transfers. She said she believed the manufacturer's recommendations said one staff could use the Hoyer lift alone. The ADON said she was unaware the manufacturer's recommendations documented two staff needed to use the Hoyer lift (see above). She said if the staff left the room the resident should be lowered back to the bed and the sling needed to be unhooked from the Hoyer lift before they left the room. The ADON said even if a staff left a resident suspended for ten seconds it was too long because the lift could malfunction or the sling could break and the resident would get hurt. She said CNA #1 should have had another staff with her to begin with. D. Facility follow-up The ADON provided training documentation for CNA #1 on 1/16/24 at 8:19 a.m. The training documented Hoyer lift competency to ensure CNA #1 used two staff with the Hoyer lift and did not leave a resident suspended while attached to the lift. The verbal trainings were completed on 1/11/24. 40467 II. Resident #20 A. Resident status Resident #20, age over 65, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included chronic pain syndrome, chronic systolic (congestive) heart failure, lower back pain, radiculopathy of the lumbar region and adult failure to thrive. According to the 10/1/23 MDS assessment, the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment did not identify Resident #20 had inattention or disorganized thinking. The MDS assessment did not identify behavioral symptoms or rejections of care. According to the MDS assessment, Resident #20 had upper extremity impairment on both sides. She needed partial to moderate staff assistance with dressing, toileting and transferring. She required substantial to maximal assistance with personal hygiene and bathing. B. Resident interview and observation Resident #20 was interviewed on 1/8/24 at 2:14 p.m. Resident #20 said a CNA's fingernail bumped into her arm when it was resting on the arm of her chair. The CNA's fingernail caused a blood blister which turned purple and ballooned up. The blister then turned into a bruise. The resident said the CNA did not injure her on purpose but she was rushing during care. Resident #20 said she asked the CNA to be more careful. The resident said the nurse looked at her arm and thought the injury would go away in a week. The resident said she still had the bruise and the incident with the CNA was about four weeks prior to the 1/8/23 interview. The resident showed a small red discoloration on her left forearm. The resident said she did not report the incident to anyone else because she did not want to complicate the CNA's job. -The CNA reported this to the nurse after it happened (see executive director interview below). C. Record review The skin integrity care plan, initiated on 9/28/23, read Resident #20 had potential/actual impairment to skin integrity. According to the care plan the resident had a right hand bruise. The care plan did not identify additional bruising to Resident #20's skin. The 9/28/23 skin care plan interventions read: -Educate the resident and the resident's caregivers of causative factors and measures to prevent skin injury; -Follow facility protocols for treatment of an injury; -Resident #20 needed assistance, supervision, and reminder to apply protective garments; Resident #20 needed a pressure relieving/reducing cushion to protect her skin while up in her chair; -Identify and document potential causative factors and eliminate/resolve where possible; -Monitor and document location, size and treatment of a skin injury. Report abnormalities, failure to heal, signs and symptoms of an infection and maceration to the physician; and, -Use caution during transfers and during bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. -The skin care plan did not identify new bruising (see below) to Resident #20's skin. -The skin care plan did not identify new interventions after the resident sustained new bruising. The 12/5/23 weekly body check assessment read the resident had a stye to her right eye and a bruise to the back of her right hand which was not new. The 12/12/23 weekly body check assessment read there were no new skin issues since the last assessment. The 12/19/23 weekly body check assessment read the resident did not have new skin issues since the previous assessment (see above) but marked the resident had bilateral upper extremity bruising and bilateral lower leg bruising. -The assessment did not provide a description of the bruises such as the size, coloring or the exact location of the bruises other than the bruises were on both sides of her upper and lower leg extremities. The assessment did not identify the cause of the bruises to the resident's upper and lower leg extremities or when the bruises occurred. The 12/26/23 body check assessment identified the resident had bilateral lower extremity edema and bilateral upper extremity bruising. The bruises were not identified as new. -The assessment did not identify the cause of the bruising or a description of the bruises. The 12/30/23 long term care skin evaluation read Resident #20 had scattered bruises on her left upper extremity and bilateral lower extremities. The resident did not have edema present. -The evaluation did not identify the cause of the scattered bruises or a description of the bruises other than scattered. -The review of Resident #20's progress notes between 11/1/23 and 1/9/24 did not identify a blister or bruise to the resident's left forearm. The progress notes did not identify a report of a CNA bumping into the resident and causing a blister or a bruise. -The review of December 2023 physician orders did not identify to monitor a bruise to Resident #20's left forearm. The 1/2/24 weekly note read Resident #20 had bilateral upper extremity bruising. The bruising was not identified as new. -The cause of the bilateral upper extremity bruising was not identified in the weekly assessment. D. Staff interview The ADON was interviewed on 1/10/24 at 5:38 p.m. The ADON said when a bruise was identified physician orders to monitor the bruise as part of the skin checks were put in place. She said the nurses would follow up on what caused the bruise and monitor the bruise until the bruise was resolved. The ADON said she was aware of bruising to Resident #20's right hand which had since been resolved and bruising to the resident's leg from the sit to stand transfer device (see details in facility follow-up below). The ADON said she was not aware of a report of an injury to the resident's left forearm caused by a CNA. The ADON reviewed the skin documentation of Resident #20 said she saw an opportunity to improve the skin check documentation. The ADON said the documentation did not identify the cause of the resident's bilateral upper extremity bruising and bilateral lower leg bruising. The documentation did not identify the color of the bruised, exact location of each bruise or the size of the bruise. The ADON said the staff always should gather baseline data regarding skin integrity issues to know if the skin issues were healing or improving. She said when there was a bruise of unknown origin the facility would immediately prompt an investigation to identify the potential cause of the bruise. The ADON said she would interview the nursing staff and the resident in regard to the above bruising. The ADON was interviewed again on 1/11/24 at 12:58 p.m. She said she spoke to Resident #20 and the resident informed her the bruise happened a month ago when the CNA reached for the call light and bumped her with her fingernail. The ADON said Resident #20 was on anticoagulants (blood thinners) and bruised easily. She said the first documentation of the identification bruise to her forearm could have been on the 12/19/23 weekly body check assessment when the nurse documented the resident had bilateral bruising to the resident's upper extremities. -However the 12/19/23 assessment read there were multiple bruises and the bruising was on each side of her upper extremity and it did not identify the bruise was new. The ADON said she believed the 12/19/23 assessment was documenting the bruise of the left forearm because of the timeline of when the bruise could have occurred versus the healing stage the bruise was currently in and a 12/19/23 hospice note read the said small bruise on left arm. The ADON said the lack in clarifying skin documentation and monitoring of the left forearm bruise was not the typical skin documentation process and follow up till resolution she would want to see. The ADON said the resident's left forearm bruise was currently yellowish red and in the healing stage. The ADON said the staff should have documented the cause of the bruise and documented the monitoring of the bruise. The ADON said the facility started an investigation related to the bruise to the resident's left forearm but had since closed the investigation because Resident #20 verified the bruise was an accident and could identify the cause. The ADON said the nurse should have documented how the bruise occurred and should have reported the bruise to the director of nursing (DON) or the ADON. The ADON said registered nurse (RN) #4 documented the bruise on 12/19/23 when he referred to the bilateral upper extremity bruising. The ADON said RN #4 did not report the bruise to the left forearm because the bruise to him appeared old and occurred at an earlier time. The ADON said Resident #20 was a slow healer due to other health factors. The ADON said RN #4 was a seasoned registered nurse who would have known the bruising stages and appropriately identity if the bruise was new or old. The ADON said she would provide immediate education to RN #4 on the bruising stages but it was possible the bruise to the resident's left forearm was not new and it did not occur on 12/19/23. She said the bruise should have been documented before 12/19/23. The ADON said to prevent similar occurrences from happening again staff would be educated on the risk factors of residents' fragile skin. The nursing staff would be educated to provide a description of any bruises on the skin such as size, coloring, location and cause. The ADON said the weekly body check assessments had been part of an ongoing staff documentation. She said the focus of the education was documentation of wounds but would make the next step of education to focus on bruises. The ADON said a bruise to the forearm could be identified as abuse and should have been investigated accordingly when the bruise occurred. The ADON said the facility missed the opportunity to timely investigate and document Resident #20's left forearm bruise. She said the staff was now starting the left forearm bruise documentation and monitoring. The ADON said she would educate staff on how to catch the bruises soon and use clarifying documentation. The ADON said bruises documented on 12/30/23 and 1/2/24 would be investigated. She said an investigation was started after a bruise to Resident #20's left knee was found (see below). The ADON said education would be provided to staff on staff's spatial awareness, allowing for more time and space during care. She said she would educate staff to immediately report when staff made physical contact with a resident so if an injury developed, the facility could identify the causation and time. RN #4 was interviewed on 1/11/24 at 2:06 p.m. RN #4 said he assessed Resident #20's skin on 1/10/23 and found a new bruise behind her left knee. He said he would monitor and do a risk watch to help prevent future bruising. He said when a new bruise was found he would document the bruise in the wound/skin progress notes and monitor and document the bruise for at least three days. RN #4 said he would call the resident's family and the physician. The RN said he would immediately try to find interventions to initiate and implement to prevent another similar bruise from happening again. RN #4 said Resident #20 was able to say what happened when an injury occurred. He said he was not aware of what happened when the resident acquired the left forearm bruise. He said the resident had already had bruises when he saw the bruise on her left forearm when she transferred from the second floor to the first floor and he became her nurse. RN #4 said when he saw the bruise to the resident's left forearm and two other bruises to her right arm. He said all the bruises were older and fading. He said both arms had some purple discoloration. He said the bruises occurred when the resident was on the second floor. The executive director (ED) was interviewed on 1/11/24 at 3:11 p.m. He said the facility initiated an investigation after the facility ADON became aware of the left forearm bruise on 1/10/24. He said he identified CNA #7 was involved in the left forearm injury to Resident #20. The ED said CNA #7 said she bumped into the resident's arm about a month ago and reported the incident to the nurse. E. Facility follow-up The 1/10/24 skin/wound note identified Resident #20 had two purple/blueish discoloration bruises to the back of her left knee. The first bruise was 2 centimeters (cm) by 0.5 cm. The resident's second bruise was 1 cm by 1 cm. The bruise may have occurred during a sit to stand transfer to the commode chair. The note read the rear of the left knee may have accidentally bumped the front of the commode frame. The physician and the family were notified of the bruises. Physician orders were placed to monitor the bruises until healed. The staff members were educated to be more careful during transfers to the commode and possibly use a towel as a cushion to prevent further injuries. The 1/10/24 nursing note read after reviewing the weekly skin checks for the resident, the weekly skin checks documented bruising in various locations. When interviewing the resident regarding bruise origins the resident said she was on a blood thinner and often bruised because of the medication. The resident said the bruising to her left forearm occurred when a staff member was reaching for the call light and her nail accidentally hit her arm which resulted in an immediate bruise approximately a month ago. The bruise was the appropriate stage of healing based on the resident report of time. CNA #7's witness report dated 1/14/24 read about a month ago in December 2023 she was the CNA for Resident #20. CNA #7 reached to turn off the light and bumped the resident's left arm. The resident said, You bumped me and I will have a bruise tomorrow. The CNA apologized to the resident and let the nurse know that if there was a bruise it was caused when the resident was bumped by the CNA.

Based on observations, interviews and record review, the facility failed to ensure residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being for two (#3 and #43) of four residents reviewed for dementia care out of 41 sample residents. Specifically, the facility failed to ensure Resident #3 and Resident #43, who had dementia, were provided consistent specialized services and support with activities of daily living (ADLs) and a meaningful activity program. Findings include I. Facility policy The Rhythms Dementia Services policy, which was undated, was provided by nurse consultant (NC) #2 on 1/10/24 at 9:26 p.m. read in pertinent: Our Rhythms Dementia Philosophy and Program recognizes that dementia changes the way a person experiences the world around them. Our job is to create [NAME] where life is worth living. We are committed to honoring and supporting people wherever they are in the rhythm of their life. The majority of distress that is experienced by people living with dementia is not due to the physical disease but due to the environment and how people interact with them. Behaviors and sundowning are communication of unmet needs or a person's attempt to tell us that something is not right in his or her world. It is our job to figure out what they are trying to tell us. We use a variety of tools and techniques (validation, life skills, music, arts) to meet each person's individual needs. We adapt our approach as needed. Deep relationships are the key to excellent care and support for people living with dementia. Consistency is a priority when making staffing decisions. II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO), diagnoses included atherosclerotic (build-up of fat) heart disease, dementia, major depressive disorder single episode, dependence on supplemental oxygen, insomnia, history of falling and encounter for palliative care. According to the 11/1/23 minimum data set (MDS) assessment Resident #3 had a mild cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #3 required a walker and supervision or touching assistance for walking, surface transfers, toileting and dressing. B. Resident interview Resident #3 was interviewed on 1/8/24 at 2:19 p.m. Resident #3 said she did not get the help she needed. She was observed with messy hair, in a plaid pajama top, without pants on and smelled of urine. She said she wanted physical therapy but was not receiving it. Resident #3 said she was sleeping too much and staff did not wake her up for activities or therapy. During the interview, Resident #3 requested some water and a shower. Certified nurse aide (CNA) #4 entered the room and told Resident #3 she was about to leave because her shift was over and asked Resident #3 if she could wait for a shower until the next CNA arrived. -Resident #3 did not receive a shower until 1/10/24 from her hospice provider. She continued to wear the same plaid pajama top. C. Observations on 1/9/24 On 1/9/24, during a continuous observation from 1:34 p.m. to 4:00 p.m., the following observations were made: From 1:34 p.m. to 2:07 p.m., Resident #3 was sleeping in her bed in the same plaid pajama top she had worn on 1/8/24 and covered with a blanket. At 2:06 p.m., Resident #3's roommate was invited to a concert but Resident #3 was not woken up or invited. At 2:07 p.m., Resident #3 used the restroom without staff assistance and returned to bed. From 2:10 p.m. to 3:05 p.m., Resident #3 was sleeping. At 3:05 p.m. Resident #3 was woken up by life enrichment associate (LEA) #1. LEA #1 talked with the resident in her room. At 3:29 p.m., LEA #1 left Resident #3's room. LEA #1 told registered nurse (RN) #3 that Resident #3 wanted to attend an exercise group the following morning on 1/10/24 and asked RN #3 to enter a progress note in the resident's chart for the scheduled CNA to get her ready before the group started at 9:45 a.m RN #3 said she would enter the note and communicate with the next shift. At 3:29 p.m., Resident #3 went back to sleep until 4:00 p.m. D. Observations on 1/10/24 At 10:06 a.m., Resident #3 was sleeping in her bed. She was wearing the same plaid pajama shirt she had been wearing on 1/8/24 and 1/9/24 and a light tan-colored pair of pants. -Resident #3 was not up or ready for the exercise group which had started 21 minutes prior, at 9:45 a.m., as had been discussed between LEA #1 and RN #3 on 1/9/24 (see observation from 1/9/24 above). At 10:23 a.m., Resident #3 was sitting up in her bed. An unidentified CNA was getting her roommate ready for church. Resident #3 used the restroom and the CNA said she would brush her hair. -The CNA did not ask Resident #3 if she would like to go to church. At 10:35 a.m., Resident #3 walked down the hallway and said she needed to strengthen her legs before she could not use them anymore. She was wearing the same plaid pajama top and light tan-colored pants. Her hair was brushed but she had white flakes all over the shoulder area of her plaid top. At 11:07 a.m., Resident #3 was sleeping in her bed. At 3:39 p.m., Resident #3 was observed in a music group with a volunteer for the facility. She wore the same plaid pajama top with white flakes on her shoulders and light tan-colored pants. The resident was sitting calmly on the couch in the activity room while she waited for the music to start and smiled when she received attention from staff members. E. Observations and interview on 1/11/24 At 11:25 a.m., Resident #3 was walking down the hallway alone with her four-wheeled walker. She had her oxygen tubing going down the left side of her body, wrapped behind both knees and going up the right side of her body. Resident #3 said she had been at a meeting about her care and found it interesting. She said the staff did not walk her back to her room but told her the meeting was over and she was able to leave. She said she did not feel she was getting enough care or support from the staff. She said she was not invited to activities or restorative therapy because she was always sleeping and no one wanted to wake her up. She said she wanted to be woken up for these things because she knew she would not be able to participate in activities or therapy for much longer. She said she felt isolated and forgotten. When Resident #3 entered her bedroom, CNA #4 entered and apologized for not having staff walk with her. CNA #4 asked Resident #3 if she could fix her oxygen tubing because she could trip with how it was wrapped around her. Resident #3 allowed CNA #4 to fix her oxygen tubing and asked for help to the restroom and to bed. CNA #4 proceeded to assist the resident to the restroom and to bed. F. Record review An activity assessment was completed for Resident #3 on 8/3/23. It documented the resident was interested in arts and crafts, exercising, music, reading, baking or cooking, watching television (TV) or movies, spiritual or religious activities, small groups and conversations. A progress note was entered into Resident #3's electronic chart on 1/9/24 at 3:40 p.m. It read, Resident #3 had expressed an interest in attending physical exercise on a more regular basis. The life enrichment team will work in partnership with the nursing team to help Resident #3 get to physical exercise programming and encourage her to attend on a regular basis if she is feeling up to it. -There was no progress note documented to indicate the scheduled CNA had been instructed to have the resident up and ready for the exercise group on 1/10/24 as had been discussed on 1/9/24 between LEA #1 and RN #3 (see observation from 1/9/24 above). Resident #3's care plan, initiated on 8/4/22, documented the resident had depression and dementia. She enjoyed getting up and moving and looked forward to one-on-one visits from the life enrichment department, chaplain and hospice teams. She enjoyed group programs involving music, food, crafts and attending chapel if she felt up to it. Pertinent interventions included interviewing the resident to find out her interests and how staff could best serve her, inviting the resident to events of interest such as chapel and programs involving music and food, offering the resident pet visits when available and offering social check ins with the resident as requested of needed.: Resident #3's activity participation records were reviewed from 12/10/23 to 1/10/24. During the timeframe reviewed there were 49 opportunities for the resident to participate in activities of interest. -The activity participation records documented Resident #3 did not attend any of the 49 activities. The resident was documented as participating in an independent activity of sleeping for all 49 activity participation opportunities. G. Staff interviews LEA #2 was interviewed on 1/10/24 at 1:47 p.m. She said she heard Resident #3 wanted to attend the exercise group on 1/10/24 but she was asleep so the staff did not wake her up to participate. She said the staff respected Resident #3 by not waking her up. LEA #2 said sleep was considered an independent activity. She said the [NAME] invited residents to activities based on their activity assessments and what the staff knew the residents enjoyed. The life enrichment director (LED) was interviewed on 1/10/24 at 3:15 p.m. He said the facility had a monthly printout of activities that they could work on with residents living with dementia. He said one-on-one visits were the heart of what the life enrichment department provided to residents who had a hard time engaging in group activities or disliked group activities. He said the independent living building next door had a program of volunteers made up of residents who went through training and were paired up with residents of the facility who benefitted from having a companion who was their age and in a similar living situation. The LED said sleep was really important to Resident #3 because she was very exhausted and disoriented. He said the staff did not generally shake Resident #3 awake because it was hard for her to sleep at night and she expressed to the staff that she needed her sleep. He said he was unaware she felt lonely and isolated. He said Resident #3 enjoyed walking and exercising. The LED was interviewed again on 1/11/24 at 9:00 a.m. He said on 1/10/24 LEA #1 went into Resident #3's room and lightly touched her shoulder and gave her a gentle shake while saying the resident's name. He said Resident #3 would not wake up. He said she was marked as absent from the exercise activity and documented as sleeping. The LED said he spoke to Resident #3 and she wanted the staff to wake her up if there was an activity going on that she enjoyed. He said Resident #3 enjoyed the fitness classes because she wanted to walk more and the social events were important because she wanted to interact with other residents. The LED said sleeping was considered an independent activity however he felt it should no longer be considered an independent activity. He said it should be a response as to why a resident refused to attend an activity. The LED said he was going to change the way activities were documented so sleeping was no longer an option as an activity. III. Resident #43 A. Resident status Resident #43, age greater than 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included pain, dependence on supplemental oxygen, macular degeneration (eye disease), insomnia, generalized anxiety, moderate major depressive disorder single episode, adjustment disorder with anxiety, encounter for palliative care, moderate dementia with psychotic disturbances, and brief psychotic disorder. According to the 11/17/23 MDS assessment Resident #43 had no cognitive impairment with a BIMS score of 13 out of 15. B. Observations on 1/9/24 On 1/9/24, during a continuous observation from 1:30 p.m. to 4:00 p.m., the following observations were made: From 1:30 p.m. to 1:49 p.m., Resident #43 was sitting in her wheelchair watching television in her room. At 1:49 p.m., Resident #43 received fresh ice water from registered nurse (RN) #3. From 1:50 p.m. to 2:26 p.m., Resident #43 continued watching television in her wheelchair. At 2:32 p.m., an unidentified certified nurse aide (CNA) entered Resident #43's room and talked with her for a few minutes. At 2:35 p.m., the unidentified CNA left Resident #43's room and the resident continued watching television in her wheelchair. At 2:45 p.m., the life enrichment associate (LEA) #1 entered the resident's room and talked with Resident #43. At 3:00 p.m., LEA #1 left Resident #43's room. Resident #43 continued watching television in her wheelchair. From 3:00 p.m. to 4:00 p.m., Resident #43 continued watching television in her wheelchair. C. Resident interview Resident #43 was interviewed on 1/10/24 at 2:38 p.m. Resident #43 said it would have been nice to be invited to church on 1/7/24 but she was not helped by staff to get ready. She said she had not gone to church in over a month because staff did not get her up in time and she missed services. She said no one invited her to the mid-week chapel on the morning of 1/10/24. She said no one invited her to the concert on 1/9/24. She said she may not have gone to the activities but she would like to have the option to accept or decline the activity. D. Record review An activity assessment was completed for Resident #43 on 11/22/23. The assessment documented music, going outdoors and spiritual or religious activities as activities of interest. Resident #43 expressed listening to music she liked, being around animals and participating in religious services as very important to her. Resident #43's care plan, initiated on 2/27/23, documented the resident would participate in religious activities if she was feeling up to it. Interventions were documented as inviting the resident to events that interested her, offering to connect the resident with other peers who had things in common, providing the resident with a copy of the events calendar and visiting her to check in and socialize. Resident #43's activity participation records were reviewed from 12/10/23 to 1/10/24. During the timeframe reviewed there were 20 opportunities for the resident to participate in activities of interest. -The activity participation records documented Resident #43 was absent or not interested in all 20 activities. -The activity participation records documented Resident #43 was absent due to watching television or sleeping for 16 of the 20 activities. -The activity participation records documented Resident #43 was not interested in four religious activities. -However, religious activities were important to her, and in her interview (see resident interview above) she said the nursing staff were not helping her get up in time for church. E. Staff interviews LEA #2 was interviewed on 1/10/24 at 1:47 p.m. She said Resident #43 enjoyed getting her nails done, attending concerts and talking about the ranch she used to own. She said Resident #43 did not like cooking, baking or arts and crafts. She said Resident #43 sometimes attended concerts but the resident was very selective on what activities she wanted to participate in. LEA #2 said Resident #43 had a very present family and loved seeing them. She said the resident liked to stay in her room because she feared she would miss a phone call from her family. She said she was unsure why Resident #43 was not at the concert on 1/9/24 or if the resident was invited. The LED was interviewed on 1/10/24 at 3:15 p.m. He said residents needed to be invited to all activities of interest to them even if they might refuse. The LED was interviewed again on 1/11/24 at 9:00 a.m. He said he spoke to Resident #43 and she said she had wanted to attend the concert on 1/9/24 at 2:30 p.m. The LED said he spoke to the LEA that was in charge of inviting the residents and she reported Resident #43 was sleeping in her recliner when she entered her room and she did not want to wake her. -However, based on observations from 1/9/24 (see observation above), Resident #43 was in her wheelchair and watching television at the time the concert was scheduled. The assigned LEA was not observed attempting to invite Resident #43 to the concert. The LED said he was going to follow up with the LEA about her statements.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to: -Discard prepared and contaminated medication that had not been administered; and, -Maintain the temperature of opened food items on the medication cart. Findings include: I. Facility policy The Medication Storage policy, revised January 2023, was provided by the community executive director (ED) on 1/17/23 at 4:45 p.m. It read in pertinent part: Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. The Food and Supply Storage policy, revised January 2023, was provided by nurse consultant (NC) #1 on 1/10/24. It read in pertinent part: Cover, label and date unused portions and open packages. Store foods in their original packages. Food that must be opened must be stored in NSF (National Sanitation Foundation) approved containers that have tight fitting lids, label the lids. II. Medication and food items On 1/9/24 at 4:23 p.m., the medication cart on Blue [NAME] unit was reviewed with licensed practical nurse (LPN) #1. In the second drawer of the cart, a 30 milliliter plastic clear medicine cup was found. The cup was one-third filled with applesauce and a plastic spoon was standing in the cup. The cup was uncovered and unlabeled. LPN #1 said the cup contained applesauce and 1000 milligrams of acetaminophen for Resident #6. She said she prepared the medication by crushing it and putting in applesauce, then attempted to give it to the resident approximately 20 minutes earlier. She said the resident was not ready to take the medication, so she put in the medication cart for storage until the resident was ready. The LPN said the medication cup was not labeled with the resident name or medication name and the cup was not covered. She said she did not know what the policy said about storing medication when a resident did not take it. She placed the uncovered, unlabeled cup containing the crushed medication and applesauce back in the same location in the medication cart. In the same drawer of the medication cart, an open container of applesauce (not labeled with date/time opened) and an unlabeled clear container which contained a food item, which was identified by LPN #1 as yogurt and not in original packaging that rested on a reusable ice pack. LPN #1 said the opened containers and ice pack were replaced at shift change every 12 hours. She said the ice pack and opened applesauce and yogurt were last replaced at approximately 6:00 a.m. on 1/9/24. The temperature of the applesauce was 65 degrees F. The temperature of the yogurt was 64 degrees F. Registered nurse (RN) #2 was interviewed on 1/9/24 at 5:00 p.m. She said she took applesauce or yogurt out of the refrigerator when it was needed and she did not store the applesauce on the medication cart. She said she used one applesauce for each resident. The assistant director of nursing (ADON) was interviewed on 1/9/24 at 5:11 p.m. She said if a resident did not want to take their medication, per facility policy the staff were to discard the medication immediately. She said at the beginning of the shift, the nurses gathered food supplements for use when medications were administered and they kept the supplements refrigerated. The ADON said the nurse should have used an open applesauce for one med pass, labeled with date and time so they knew when it was opened. She said they could check the temperature after two hours to see if it was at an appropriate temperature. She said the temperature should maintain for two hours. She said she did not know what education had been offered to staff regarding labeling and storage of food supplements for medication administration. The ADON said she was going to check whether it was acceptable to store the food in the cart. She said she educated LPN #1 best practice was to administer or discard medication immediately. She said the medication the nurse had stored in applesauce in the medication cart should not have been given as it was not labeled. She said if someone else were to open the medication cart, they would not know what was in the cup. She said nurses should check with residents prior to the preparation of medication. III. Facility follow-up On 1/15/24 at 6:24 p.m. the ADON provided a staff education document entitled What to do with applesauce, pudding, yogurt, and other food mediums you use for medication administration. This staff education document included 16 staff signatures for completed education between 1/9/24 and 1/15/24. It read, in pertinent part: Once applesauce or other food mediums are opened for use with medication administration, they can be kept at room temperature for up to four hours. All food mediums should be labeled with date and time of opening. It is not required that the applesauce is placed on ice, as it can remain open for up to four hours at any temperature. If there is no label with date and time of opening, throw it out and get a new one. Shelf stable items (like applesauce and pudding) are okay to remain at room temperature until they are opened. The food medium should be covered while not in use. It is recommended to store inside the medication cart separately from the medications. The lid can be left on the container for ease of recovering. Other options would be disposable compote cup with lid, saran wrap, or other appropriate cover.

Based on record reviews and staff 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 disease. Specifically, the facility failed to offer updated COVID-19 vaccinations and document consent or declination for vaccination for Residents #7 and #27. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Stay Up to Date with COVID -19 Vaccines/What You Need to Know, revised 11/16/23, retrieved on 1/16/24 from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html, in pertinent part: CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19. Everyone aged 5 years and older should get one dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. People who are moderately or severely immunocompromised may get additional doses of updated COVID-19 vaccines. II. Facility policy The COVID-19 Infection Prevention and Control Plan policy, revised January 2024, was provided by the nurse consultant (NC) #1 on 1/10/24 at 4:04 p.m. It read in pertinent part: The community will encourage staff and residents to receive COVID vaccinations and boosters in keeping with CDC Up to Date standards. Vaccination status will be tracked. III. Record review A review of Resident #7's electronic medical record (EMR) immunization tracking sheet showed no previous documentation of COVID-19 vaccination and documented consent for vaccination status as not eligible for SARS COV-2 (COVID-19) Moderna (Spikevax 2023-2024). -The EMR did not include why the resident was not eligible or declination for the COVID-19 vaccine. A review of Resident #27's EMR immunization tracking sheet showed SARS-COV-2 (COVID-19) booster on 9/19/22 and consent for vaccination status as immunization required for SARS COV-2 (COVID-19) Moderna (Spikevax 2023-2024). -The EMR did not include the COVID-19 was administered or declination for the vaccine. IV. Staff interviews The assistant director of nursing (ADON) was interviewed on 1/11/24 at 8:00 a.m. She said she did not know why the immunization history for Resident #7 revealed consent status of not eligible for SARS COV-2 (COVID-19) vaccine and SARS COV-2 consent status of immunization required for Resident #27. She said she would find this information. The ADON was interviewed on 1/11/24 at 4:25 p.m. The ADON said Resident #7 immunization status for COVID-19 vaccination was documented incorrectly as ineligible and she should have been a candidate for vaccination. She said the resident's power of attorney (POA) had today (1/11/24) approved the resident to receive the updated COVID-19 vaccine. The ADON stated she found Resident #27 had been out of the community when the vaccination clinic was held at the facility and he should have been a candidate for vaccination. She said his POA was contacted today (1/11/24) and has consented for him to receive the updated COVID-19 vaccine. V. Facility follow-up On 1/15/24 at 6:24 p.m., the ADON provided updated vaccine tracking records for Resident #7 and #27. Consent status for both residents was documented as complete and SARS-COV-2 vaccine revealed 1/12/24 as date given for both Resident #7 and #27.

Based on observations, record review and interviews, the facility failed to ensure one (#30) of two out of 26 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #30 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon admission Resident #30 reported he thought he had lost approximately 20 pounds (lbs) during the food preferences assessment. The resident weighed 164 lbs on 7/29/22. The facility failed to implement a nutritional intervention upon admission, despite the resident reporting weight loss prior to admission. On 8/2/22 the facility obtained a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nutritional assessment was completed on 8/10/22, 13 days after the resident was admitted to the facility. Resident #30 had already sustained a 6.4% (10.5 lbs) weight loss in 10 days, which was considered significant. The facility failed to implement a nutritional intervention to prevent further weight loss. Therefore, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The nutrition care manager (NCM) recommended a milkshake to provide additional nutrition for the resident under the resident's point of care (POC) staff directive sheet. A review of the POC staff directive sheet, revealed there was no documentation indicating Resident #30 had received the recommended milkshake. Additionally, the NCM recommended weekly weights to monitor the residents weight changes. The facility failed to obtain the residents weight on 9/11/22. Resident #30 sustained a 12.6% (20.6 lbs) weight loss from 7/29/22 to 9/4/22, which was considered significant. Findings include: I. Facility policy and procedure The Weight Management Protocol, undated, was provided by the nursing home administrator (NHA) on 9/15/22 at 12:40 p.m. It revealed in pertinent part Weigh all admits and readmissions on admission day and day two. Thereafter, weigh weekly for the first four weeks and then monthly unless the physician order states otherwise. The dietitian will use the weight to determine BMI (body mass index) and identify whether the resident is at nutritional risk. Weight all applicable residents by the 7th of the month. Reweigh residents with significant eight discrepancies within 24 hours, if needed. Reweigh the following: Residents weighing greater/equal to 100 lbs (pounds). If there is a +/- (gain or loss) 5 lbs weight variance from previous weight, reweigh within 24 hours. Record the reweight. If a discrepancy still exists and the change is unplanned or undesirable, place the resident on weekly weights or more often as ordered by physician. The dietitian will be responsible for reviewing all monthly weights. Residents who have a weight loss of greater than 3% or insidious weight change should be seen by the registered dietitian by the 12th of each month. Add all residents identified with significant or insidious weight loss to the Nutrition Alert list. Upon admission to Nutrition Alert, begin monitoring the resident's nutritional status in a frequent (weekly) and intensive manner. Discussion should include, but not limited to: the etiology/root cause of weight loss, resident goals and interventions based on the resident's goal(s) and evaluation of the effectiveness of current interventions to resolve the problem or prevent further problems. II. Resident #30 Resident #30, age 79, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/5/22 minimum data set (MDS) assessment revealed the resident had a short-term and long-term memory impairment. The resident did not have any swallowing difficulties. The resident had a weight of 163 lbs. The resident did not have weight changes and was on a therapeutic diet. III. Resident interview and observations Resident #30 was interviewed on 9/12/22 at 3:22 p.m. He said he did not like the food at the facility. During a continuous observation on 9/13/22 beginning at 7:11 a.m. and ended at 7:37 a.m. the following was observed: -At 7:11 a.m. Resident #30 was sitting outside the dining room. -At 7:14 a.m. an unidentified staff member opened the dining room doors and Resident #30 entered the dining room. He positioned himself at the dining table. An unidentified certified nurse aide (CNA) asked Resident #30 what he would like to drink. Resident #30 requested a glass of orange juice. -At 7:24 a.m. the NCM asked Resident #30 what he would like to eat for breakfast. Resident #30 said he would like two scrambled eggs. The NCM asked the resident if he would like any sides and he responded no. -At 7:26 a.m. Resident #30 received his breakfast. -At 7:32 a.m. cook #1 asked Resident #30 how his breakfast was, he responded fine. Cook #1 asked the resident if he would like anything else and he responded no. -At 7:34 a.m. the NCM asked the resident if he was done eating and encouraged the resident to sanitize his hands prior to leaving the dining room. -Resident #30 left the dining room and had only consumed a few bites of his breakfast (see record review below). At 9:59 a.m. Resident #30 was observed lying in bed. At 10:31 a.m. Resident #30 was observed lying in bed. During a continuous observation beginning at 11:11 a.m. and ended at 11:41 a.m. the following was observed: -At 11:11 a.m. Resident #30 transferred himself from his bed to his wheelchair and exited his room. He self propelled himself to the common area outside the dining room. -At 11:19 a.m. an unidentified activities staff member opened the doors to the dining room. -At 11:21 a.m. Resident #30 self propelled himself into the dining room. -At 11:26 a.m. an unidentified CNA asked Resident #30 what he would like for lunch. Resident #30 requested fish for lunch. The CNA asked Resident #30 if that was all he wanted and he said yes. -At 11:34 a.m. Resident #30 received a filet of fish that was not cut up or had additional sauce on it. -At 11:35 a.m. Resident #30 had taken three bites of his fish. -At 11:37 a.m. the NCM asked resident if he liked his food and Resident #30 responded no. The NCM asked the resident if he was hungry and the resident responded no. The NCM said to the resident to consume as much as he could. -At 11:38 a.m. Resident #30 pushed his plate away and said I do not want it. -At 11:40 a.m. Resident #30 unlocked his wheelchair and left the dining room. Resident #30 was interviewed again on 9/13/22 at 12:15 a.m. He said the fish that was served at lunch was terrible, so he only ate a couple bites of it. He said his food was supposed to be cut-up and have extra sauce on it. Resident #30 said his food often did not come cut-up. He said his fish was not cut-up at lunch today. Resident #30 said the food at the facility was not his preferred type of food. He said he enjoyed spaghetti and meatballs and other pastas. During a continuous observation on 9/14/22 beginning at 11:09 a.m. and ended at 12:17 p.m. the following was observed: -At 11:33 a.m. an unidentified CNA asked Resident #30 what he would like for lunch. Resident #30 responded tortellini. -At 11:38 a.m. Resident #30 received one cup of cheese tortellini with marinara sauce. -At 11:50 a.m. Resident #30 left the dining room. He consumed all of the pasta. IV. Record review 1. Nutritional care plan The nutritional risk care plan, initiated on 8/9/22, documented Resident #30 was at potential nutrition and hydration risk related to pain, reported weight loss, diuretics, cardiovascular medications, [CONDITION(S)] agents and high risk for developing pressure injuries. The interventions included: providing the resident's diet as ordered (no added salt, regular texture, thin liquids, providing additional moisture to meats at meals, providing the resident with a Magic cup once per day, offering the resident a chocolate milkshake once per day, honoring the residents food preferences, offering the resident snacks and fluids between meals, allowing the resident to eat at his own pace, honoring the residents preferred location for meals as safety allows (Resident #30 enjoyed eating in the dining room), monitoring the residents weights as available, monitoring changes of [CONDITION(S)], notifying the provider for any significant changes, reporting signs of aspiration, monitoring the residents food and fluid intake, monitoring nutrition-related labs as available. Another nutritional risk care plan, initiated on 8/9/22, documented Resident #30 was at potential nutrition and hydration risk related to pain, reported weight loss, diuretics, cardiovascular medications, [CONDITION(S)] agents and high risk for developing pressure injuries. The interventions included: providing the residents diet as ordered no added salt, mechanical soft and thin liquids, providing additional moisture to the residents meals, providing the resident with the ordered supplements: Magic cup once a day and a chocolate milkshake once a day made with one Ensure (nutritional supplement) and one Magic cup, offering assistance to cut the resident's food into small pieces, honoring the resident's food preferences, he enjoyed hotdogs pasta, fish and milkshakes and disliked bread and casseroles, encouraging the resident to try new things as he was a particular eater and changed his mind often about food items, providing the resident with encouragement at meals, allowing the resident to eat and drink at his own pace, offering the resident snacks and fluids between meals the resident had personal snacks in his room, monitoring the residents weight as available, monitoring changes in [CONDITION(S)]/fluid, notifying the provider of significant changes and monitoring the resident food and fluid intake, monitoring nutrition-related labs when available. 2. Resident #30's weights Resident #30's weights were documented in the resident's medical record as follows: -On 7/29/22, the resident weighed 164 lbs. -On 7/30/22, the resident weighed 162 lbs. -On 7/31/22, the resident weighed 163 lbs. -On 8/1/22, the resident weighed 162.6 lbs. -On 8/7/22, the resident weighed 153.5 lbs. -On 8/10/22, the resident weighed 153.2 lbs. -On 8/11/22, the resident weighed 153.2 lbs. -On 8/15/22 at 10:48 a.m. the resident weighed 148.6 lbs. At 9:28 p.m. the resident weighed 148.6 lbs. -On 8/16/22, the resident weighed 148.6 lbs. -On 8/21/22, the resident weighed 148.6 lbs. -On 9/4/22, the resident weighed 143.4 lbs. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2022 CPO revealed Resident #30 was to be weighed weekly on Sundays. -Resident #30 was not weighed on 9/11/22 as ordered. 3. Physician orders The July 2022 CPO revealed Resident #30 had the following physician orders related to nutrition: -Weights daily x3 (three times) and every Sunday, ordered 7/31/22; -[MEDICATION(S)] Tablet 20 milligrams (MG), give 0.5 tablet by mouth one time a day for fluid retention related to acute kidney disease, discontinued on 8/5/22; and, -No added salt diet, regular texture, thin liquids, ordered upon admission. The August 2022 CPO revealed Resident #30 had the following physician orders related to nutrition: -No added salt diet, mechanical soft meat texture, thin fluids consistency, please cut up food into bite sized pieces, ordered 8/26/22; -Frozen treat, one time per day for increasing calorie/protein intake, per family request. Magic cup once daily, prefers chocolate, ordered 8/2/22; and, The September 2022 CPO revealed Resident #30 had the following physician orders related to nutrition: -Supplement of choice one time a day for weight loss, poor appetite. Please provide Resident #30 with a milkshake once daily using one Ensure and one chocolate Magic cup. Milkshake can be made by dining staff at lunch time as requested, ordered 9/15/33 (during the survey process); and, -Weekly weights, one time a day every Sunday, ordered 9/4/22. The August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Nutritional assessments/progress notes The 7/29/22 nursing admission progress note documented the resident did not have [CONDITION(S)] present. The 7/30/22 nursing progress note documented the resident did not have [CONDITION(S)] present. The 7/31/22 nursing progress note documented the resident did not have [CONDITION(S)] present. The 8/2/22 nutrition screening and food preference record assessment documented the resident was prescribed thin liquids and did not have any preferences or the facility was unable to determine the residents preferences. The resident prescribed a no added salt diet. The resident did not have any food allergies. The assessment documented Resident #30 reported a desired weight of 160-165 lbs. The resident reported he was not aware of his usual body weight, but thought he had lost about 20 lbs prior to admission to the facility. Resident #30 also reported a poor appetite and disliking of the foods at lunch and dinner. The assessment documented Resident #30 requested to keep personal snacks in his room. Resident #30 drank plenty of fluids each day and had well fitting dentures. The resident did not report any oral or stomach pain. -The facility did not implement a nutritional intervention upon admission after Resident #30 reported weight loss prior to admission. The facility implemented a Magic cup on 8/2/22 per family request. -The assessment did not specify any dislikes the resident had. The 8/2/22 history and physical completed by the physician documented the resident had trace peripheral [CONDITION(S)]. The 8/2/22 nursing progress note documented the resident did not have [CONDITION(S)] present. The 8/3/22 nursing progress note documented the resident did not have [CONDITION(S)] present. The 8/4/22 nursing progress note documented the resident did not have [CONDITION(S)] present. The 8/5/22 nursing progress note documented the resident did not have [CONDITION(S)] present. The 8/5/22 physician's progress note documented the resident's diuretic was discontinued with improved [CONDITION(S)]. The 8/10/22 initial nutrition risk assessment, short-term stay assessment documented Resident #30 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was 70 inches and weighed 153.6 lbs. The resident's usual body weight was 160-165 lbs. The resident's body mass index (BMI) was 22, which was within normal limits. The assessment documented the resident weight history in the last six months was unknown (despite the resident reporting a weight loss prior to admission). The assessment documented to see the resident food preference record for any food/cultural/religious preferences with food. The resident had no food allergies and was prescribed a no added salt diet with thin liquids. The resident was receiving a Magic cup once daily. The assessment documented the resident needed 1845 calories per day, 70-87 grams of protein per day and 2095 milliliters of water per day (the facility did not increase the residents estimated nutrition needs based on the reported weight loss). It documented the resident was tolerating the current diet texture as ordered. The resident was consuming an average of 88% of his meals. It indicated the resident was consuming approximately 2226 calories per day and 89 grams of protein per day through meals and Magic cup supplement, which met 100% of the resident estimated nutrition needs. The resident was able to feed himself without assistant and had no oral concerns. It documented the resident did not have swallowing difficulties. The resident was prescribed losartan, [MEDICATION(S)] and diuretics. The resident's labs were reviewed. The resident was at risk for developing pressure wounds, but his skin was intact with some bruising. The assessment documented the resident was at risk for unintended weight loss related to pain and reported weight loss prior to admission. The resident was also at risk for dehydration related to diuretic medications, cardiovascular medications and [CONDITION(S)] agents. Resident #30 was also at risk for developing a pressure ulcer related to the at risk score and reported weight loss. The assessment documented the resident's nutrition goals werve to maintain the resident's weight between 149-158 lbs, the resident to tolerate his diet, the resident to maintain skin integrity and to show no signs or symptoms of dehydration. The nutrition interventions included: providing the diet as prescribed, providing nourishment/supplement, honoring the resident's food preferences, monitoring the residents weight monthly/weekly, monitoring food and fluid intake, monitoring for signs and symptoms of dehydration and monitoring the resident's labs. The assessment's progress note documented the resident had sustained significant weight loss since admission related to diuretic use and peripheral [CONDITION(S)]. Resident #30 had been great and accepted a supplement daily. Resident #30 provided feedback on food and made preferences known. The resident's meal intakes and weights were being monitored and interventions would be implemented as needed. -However, the resident's diuretic ([MEDICATION(S)] 20 mg .5 tablet once per day) was discontinued by the physician on 8/5/22. The resident had only lost 1.4 lbs prior to the diuretic being discontinued. -The resident had already sustained a 6.4% (10.5 lbs) weight loss in 10 days from 7/29/22 to 8/7/22 when the initial nutrition risk assessment was completed. The facility did not implement a person-centered intervention to prevent further weight loss from occurring. The 8/26/22 speech therapy note documented the resident was having difficulties swallowing. It documented the resident had sustained a 16 lbs weight loss in the last month. It documented the resident inconsistently drank a Magic cup in the evening. The 8/29/22 speech therapy note documented the resident reported he was supposed to receive a milkshake daily and did not always receive it. The 9/1/22 nutrition at risk (NAR) progress note documented Resident #30 was added to the nutrition at risk list. Resident #30 was particular with food choices and did not have a big appetite. Resident #30 would not eat much of his meal or milkshake if he did not like it. The NCM had planned to trial supplements with the resident, but he was not feeling well. The facility was to continue to encourage Resident #30 and offer different options. The 9/5/22 weight change progress note documented the resident had a significant weight loss. The resident was followed for being nutritionally at risk. Resident #30 continued to experience significant weight loss. The supplement frequency was increased and a milkshake was offered daily. The staff were to continue to provide encouragement at meals. The 9/8/22 NAR progress note documented Resident #30 continued to show significant weight loss. The NCM talked with Resident #30 each day providing encouragement of meals. The resident was very particular with food choices and his appetite has declined. Resident #30 was offered a milkshake daily made with one Ensure and one Magic cup. It documented the resident had not been feeling well, which has decreased his appetite. The resident accepts the Magic cup when he does not consume a milkshake. The NCM recommended continued encouragement at meal times as this increased his meal intake. The 9/15/22 nutrition progress note documented Resident #30 updated the NCM daily on his appetite. He also notified the NCM of his meals each day. Encouragement was provided with each meal and the NCM sat with Resident #30 to discuss what he wanted to eat at each meal. The resident was offered a milkshake made with Ensure and a Magic cup daily and he often consumed 75-100% of the milkshake. The note documented if the NCM was not present at the facility the dining team would make the milkshake at lunch. Resident #30 was now ordered a milkshake each day in order for the NCM to follow the percent of each milkshake the resident was consuming. The resident was followed weekly by NAR and was ordered weekly weights (see interview below, documented during the survey process). 5. Meal intakes On 9/13/22 at 1:18 p.m. two meal intakes were documented, the resident ate 25-50% of the meal (see observations above). On 9/14/22 at 12:37 p.m. one meal intake was documented, the resident ate 75-100% of the meal. A review of the point of care response history revealed Resident #30 had a task that specified offer a snack daily, preferably a chocolate milkshake per resident. The task sheet did not have any documentation indicating the resident had received the milkshake for 30 days. Resident #30 also had a point of care (POC) staff directive task for a snack daily that had responses that he had accepted a snack. V. Staff interviews The NCM was interviewed on 9/15/22 at 10:00 a.m. She said when a resident was admitted to the facility they are weighed upon admission and then weekly for four weeks. She said some residents were weighed daily if ordered by the physician. She said if a resident was having weight fluctuations, she recommended weekly weights to monitor. The NCM said residents who were deemed nutritionally at risk were reviewed weekly in the NAR meeting. She said nursing management and herself attended the meeting. The team discussed the residents weight loss and placed an intervention into place to prevent further weight loss. The NCM said the CNAs were responsible for documenting the amount of food the resident consumed at meals. She said if a resident only orders one menu item and consumes it all, it should not be documented as 100%. The NCM said if a resident was ordered small portions and the CNAs documented the resident ate 100% she would be alerted that the resident consumed a smaller portion of the meal. The NCM said if a resident regularly ordered one menu item it should be on their care plan, so she was aware when reviewing meal consumptions. The NCM said Resident #30 had sustained a significant weight loss since being admitted to the facility. She said Resident #30 needed encouragement at meals. The NCM said Resident #30 was very picky with his meals. She said she visited with the resident almost every day, but did not document the interactions. She said Resident #30 enjoyed pasta. She said she would speak with the chef to offer pasta at more meals. The NCM said Resident #30 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] The NCM said she had also implemented a chocolate milkshake once a day to prevent weight loss. She said she placed the milkshake under the residents point of care task system for the nursing staff to see. She said the milkshake was made out of one Ensure and one Magic cup per day. The NCM said she was responsible for making the milkshake Monday through Friday and provided it to the resident. She said she notified the CNAs when she provided the resident with the milkshake. She said the CNAs were responsible for documenting if Resident #30 received the milkshake. The NCM confirmed the documentation was blank for the resident's milkshake. The NCM said if Resident #30 accepted the milkshake it counted for his Magic cup of the day. The NCM said she would obtain a new order for a milkshake daily and have the nursing staff document the amount consumed on the MAR, so she was able to track the residents' acceptance of the milkshake. The NCM said she would notify the kitchen staff immediately to make the milkshake at lunch time and place it in the refrigerator, so it was ready when Resident #30 wanted it. The NCM said the regional registered dietitian completed the residents' admission nutritional assessment. She said she did not believe the resident had lost weight related to [CONDITION(S)] and diuretic use. She said the resident had a poor appetite, which likely led to his weight loss. The NCM said Resident #30 had emesis and did not feel well a couple days the previous week. The NCM said Resident #30 was reviewed weekly in the NAR meeting. She said Resident #30 weight loss was a big concern of hers and she was watching the resident. The NCM said Resident #30's weekly weight was not obtained and she had placed a message on the facility's communication board to obtain the resident's weight as soon as possible. The director of nursing (DON) was interviewed on 9/15/22 at 11:37 a.m. She said Resident #30 was sick for a couple days and did not eat well. She said the facility had tried several supplements, but the resident did not accept them. The DON said the resident was very picky with his foods and did not like them. She said she went to Dairy Queen and purchased milkshakes for the resident. -However, the milkshakes from Dairy Queen were not documented in the resident's medical record. The DON said the residents milkshake should have been a physician order and should not have been placed under tasks as it could easily have gotten misseed. VI. Facility follow-up The facility provided a POC response history for snacks. The resident had accepted snacks in the last 30 days, but the POC response history for the resident's daily milkshake was blank. The facility provided the POC response history for meal consumption and stated the resident consumed 52-77% of his meals in the last 30 days plus his supplement and milkshake. -However, observations revealed the facility did not always document accurate meal consumptions (see observations and record review above).

Based on interviews and record review the facility failed to honor resident choices for three (#16, #17 and #26) of four reviewed for self-determination, out of 26 sampled residents. Specifically, the facility failed to ensure dependent Residents #16, #17 and #26 received showers consistently according to their preference. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy was requested by the nursing home administrator (NHA) and director of nursing (DON) on 9/15/22 at 12:45 p.m. The DON said the facility did not utilize an ADL policy, but instead utilized a standard of practice competency. The Standard of Practice Giving a Tub Bath/Shower Competency was provided by the NHA on 9/15/22 at 12:30 p.m. It read in pertinent part, Check POC (point of care) to see if assigned residents are due for tub bath/shower and level of assistance. Always consider the resident's preferences for bathing, including type, time, products, etc. -However, the competency did not include documentation of the task and/or how/who to report refusals. II. Resident #26 A. Resident status Resident #26, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/26/22 minimum data set (MDS) assessment revealed Resident #26 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The 7/27/22 (MDS) assessment revealed Resident #26's BIMS was not assessed. She did not exhibit behaviors or resist care. She required limited to extensive one-person assistance with most all activities of daily living (ADLs). She was frequently incontinent of bowel and bladder. She required one-person physical assistance with physical help in part of the bathing activity. B. Resident interview Resident #26 was interviewed on 9/12/22 at 11:15 a.m. She said she had not been getting her showers twice weekly. She said she mentioned a couple of times to the staff that she would like a shower in the morning, because on Friday evenings she visited with her son and staff would not provide her a shower on that day. She said she told the nurses several times since she had lived at the facility, but felt she would not get any resolution and had succumbed to the resolution that her showers would have to stay on the evening shift. C. Record review Review of the ADL flow record under the assigned bathing task revealed Resident #26 was supposed to receive a shower every Wednesday and Saturday. The lookback period from 7/18/22 to 9/15/22 revealed Resident #26 received a shower eight times. Resident #26 had nine missed opportunities out of 17 opportunities. It was documented on 8/25/22 that the ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time. -There was no further documentation provided by the facility related to Resident #26's showers. The current ADL care plan with the review date of 10/25/22 revealed Resident #26 required extensive one-person assistance with bathing and she preferred a shower twice weekly on Wednesdays and Sundays. III. Resident #16 A. Resident status Resident #16, age less than 60, was admitted on [DATE]. According to the September 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/1/22 MDS assessment revealed Resident #16 was unable to participate in a BIMS assessment. He did not exhibit behaviors or resist care. He required extensive two-person assistance with most ADLs. He had an indwelling catheter and ostomy; his bowel and bladder habits were not rated. He required one-person physical assistance with physical help in part of the bathing activity. B. Record review The 8/19/22 at 12:41 p.m., communication note revealed Resident #16's guardian expressed concerns with Resident #16 receiving his showers. Review of the ADL flow record under the assigned bathing task revealed Resident #16 was supposed to receive a shower every Tuesday and Saturday. The lookback period from 7/18/22 to 9/15/22 revealed Resident #16 received a shower five times. Resident #16 had 15 missed opportunities out of 20 opportunities. It was documented 15 times that the ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time. -There was no further documentation provided by the facility related to Resident #16's showers. The current ADL care plan with the review date of 9/29/22 revealed Resident #16 required extensive two-person assistance with a shower/bed bath. IV. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 9/15/22 at 10:35 a.m. She said she worked at the facility for eight years during the day shift 6:00 a.m. to 6:00 p.m. She said the facility did not utilize a bath aide to perform showers. She said the CNAs on the floor were responsible for ensuring the residents were showered. She said staff documented a shower or bed bath was given in the resident's point of care (POC) task. She said the staff did not utilize any shower sheets, only POC for documenting. She said she did not know how much assistance Resident's #16 and #26 required or if they received showers per their preference because their baths were scheduled on evening/night shift. The director of nursing (DON) was interviewed on 9/15/22 at 11:39 a.m. She said Resident #26 had expressed moving back to assisted living and one of her requirements was to be able to shower herself. She said the resident did not like to participate and she was not aware of any concerns the resident had related to not receiving her scheduled showers. She had no explanation as to why the resident did not have further documentation of receiving her showers twice weekly. She said the resident had not filed any grievance related to showers. She said Resident #26 had always received his shower. She said the particular staff member that documented the activity did not occur was assigned to caring for Resident #16 but not responsible for the resident's showers and felt this was a documentation issue. She said per the resident's guardian request, there was only one particular CNA that gave the resident a shower/bed bath. She had no explanation as to why a staff member would document the actual task ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time. She said the resident's family had not filed a grievance related to showers in the last three months. The transition care manager (TCM) was interviewed on 9/15/22 at 12:05 p.m. She said she had a discussion with Resident #16's mother/guardian about him not receiving his showers sometime last month. She said she typically verified that a resident was receiving showers by looking in POC/tasks to see if it had been documented as completed. She said she did not know it was documented multiple times the ADL activity itself did not occur for Resident #16. She said just this last week she worked late in the evening and saw staff providing the resident his shower so that was how she verified the resident was receiving his shower. She said if she saw that particular documentation she would notify the assistance director of nursing (ADON) to further investigate and provide education. She said she could not recall if she notified the ADON to follow-up. V. Resident #17 A. Resident status Resident #17, age 70, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/4/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance of two people for bed mobility, transfers; extensive assistance of one person for dressing, eating, toileting; and, limited assistance of one person for personal hygiene. The MDS assessment documented the resident was total dependence of two people for bathing. B. Resident interview Resident #26 was interviewed on 9/12/22 at 10:07 a.m. The resident said she did not always get her showers as requested. Resident #26 said she had requested two showers a week, on Monday and Thursdays. She said her showers were often missed when agency staff were working on her unit. C. Record review The staff task sheet indicted Resident #26 preferred showers on Thursday and Monday mornings in her room. The shower documentation from 7/18/22 through 9/15/22 for Resident #26 was provided by the DON on 9/15/22 at 11:30 a.m. It revealed Resident #26 did not receive a shower on her preferred shower days on 7/25/22, 8/1/22, 8/29/22 and 9/12/22. The shower documentation did not reveal the resident had refused any showers in the review period. D. Staff interview CNA #2 was interviewed on 9/15/22 at 9:32 a.m. She said the CNAs were responsible for providing the residents their showers. She said after giving a shower the CNAs documented on the task sheet in the electronic medical record that the shower was completed. CNA #1 was interviewed on 9/15/22 at 9:35 a.m. She said Resident #26 required two person total assistance with showers. She said Resident #26 did not refuse showers. CNA #1 said Resident #26 had reported missing a couple showers when agency staff were working. The DON was interviewed on 9/15/22 at 11:37 a.m. She said she was not aware of Resident #26 missing showers. She said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said if Resident #26 refused a shower, it should be documented as a refusal in the medical record.

Based on observations and interviews the facility failed to ensure two out of two medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional principles. Specifically, the facility failed to: -Ensure multi-dose vials of [MEDICATION(S)] were dated when first opened; -Ensure alcohol for drinking was not stored with medications; -Ensure food and medications were not stored together; and, -Ensure expired medications were removed from the medication rooms. Findings include: I. Professional reference According to the [MEDICATION(S)] package insert, retrieved on 9/19/22 from https://www.fda.gov/media/ /download, A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. II. Facility policy and procedure The Storage of Medications policy and procedure, dated 2007, was provided by the director of nursing (DON) on 9/14/22 at 12:35 p.m. It read in pertinent part, Medications and biologicals were stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Refrigerated medications should be segregated from fruit juices, applesauce, and other foods used in administering medications. Outdated medications were immediately removed from stock and disposed of according to procedure for medication disposal. III. Observations and interviews On 9/14/22 at 10:01 a.m., the first floor medication room was observed with the transition care manager (TCM). Located in the medication refrigerator in the top shelf of the door was a single Yoplait yogurt and eight Acetaminophen 650 milligram (mg) suppositories with an expiration date of 7/18/21. In the bottom shelf of the door was a large bottle of white wine half empty. -The TCM immediately discarded the yogurt and the expired suppositories. She said the medication refrigerator was supposed to be checked daily for expired medications by the nursing staff. She said she was not aware that alcohol could not be stored with medications but did acknowledge that food should not be stored in the medication refrigerator. At 10:20 a.m., the second floor medication room was observed with the TCM. Located in the medication refrigerator were two vials of [MEDICATION(S)]. Neither vial had an open date on it, however the boxes had open dates on them. The first box was dated 8/11/22 and was past the recommended 30 days of use. The second box was dated 6/15 with no year. There were two individual wine containers, one half full in a four pack box on the bottom shelf of the refrigerator and a large bottle of unopened white wine in the bottom shelf of the door. -The TCM said the open dates should be on the [MEDICATION(S)] vial when it was opened by the nurse. She said the vials could be put into the wrong box which would not have an accurate open date if stored in the wrong box. She said the vials should be discarded after 30 days. IV. Administrative interviews The assistant director of nursing (ADON) was interviewed on 9/14/22 at 11:38 a.m. She said all vials should be dated when opened. She said the [MEDICATION(S)] vials should be disposed of 30 days after opening. She said food and alcohol should not be stored with medications and all the nurses were responsible for checking the medication refrigerator for expired medications. The director of nursing (DON) was interviewed on 9/14/22 at 1:40 p.m. She said the multi-dose vials should have been dated when they were opened because they could have been placed in the wrong box and should be discarded 30 days after opening. She said food and alcohol should never be stored with medications. She said the nursing staff were responsible for disposing of expired medications and night shift nurses had a checklist which was to be done nightly. V. Facility follow up The DON provided an action plan completed on 9/14/22 at 12:35 p.m. The plan documented an immediate audit of the medication refrigerator on the first and second floor were performed to address any additional expired medications. No additional medications were identified. A monthly audit would be performed for each medication refrigerator to ensure expired and discontinued medications were removed.

Based on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#37) of four residents reviewed for hospice services out of 26 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure for Residents #37, a written plan of care included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. Findings include: I. Resident #37 A. Resident status Resident #37, age 96, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/4/22 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had verbal behaviors directed toward others. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had a chronic condition with life expectancy less than six months. B. Record review The care plan, initiated 6/9/22 and revised 6/26/22, identified the resident was provided hospice care. Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Consult with physician and social services to have hospice care/comfort care for me in the community. Invite hospice interdisciplinary team members to all care conferences and include them in care plan changes. Ensure advanced directives are updated regularly and available across care settings. The August 2022 CPO included: admit to hospice with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The care plan failed to delineate the responsibilities of the facility versus what the hospice would provide in terms of services. -The facility failed to have the hospice staff notes available in the residents file at the facility. C. Interviews Certified nurse aide (CNA) #3 was interviewed on 8/13/22 at 7:38 a.m. She said she was not aware the resident was receiving hospice care. Registered nurse (RN) #1 was interviewed on 8/13/22 at 7:50 a.m. He said he was not sure what day the hospice provider was in the facility. He said if there was a problem with the resident he would verbally report it to the hospice nurse. He said, No, I do not document these conversations with hospice. Hospice registered nurse (HRN) #1 was interviewed on 8/13/22 at 3:05 p.m. She said she was familiar with the facility, as she had several clients in the facility. She said she was in the facility two times a week. She said she had not received any type of orientation from the facility. She said she would communicate verbally with facility staff if there were any issues with the resident. She said she had not been invited to the care plan conference by the facility. Hospice social worker (HSW) #1 was interviewed on 8/14/22 at 1:40 p.m. She said she worked closely with the Resident 37's daughter and family but really did not discuss issues with facility staff. She said she received orientation from her hospice employer but never received any type of orientation from the facility on their policies and procedures. She said she documented all her visits in her hospice notes at her office. The director of nursing (DON) was interviewed on 9/14/22 at 2:00 p.m. She said she was not familiar with the regulation specific toward hospice care. She said she and the assistant director of nursing (ADON) would keep in contact with hospice providers. She said the facility had seven different hospice providers that work in the facility. She said the facility had issues getting notes into the resident's charts and it had been taking longer to get them back from the hospice provider. She said the facility had no formal orientation for hospice aides. The DON was interviewed again on 9/15/22 at 9:20 a.m. She said the facility had got the ball rolling. She said the ADON would now be the coordinator of care between all of the hospice providers. She said the goal was to get the facility and hospice together to ensure all the required documentation was in the residents chart and to ensure all care plans were addressing each provider's responsibilities.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and likelihood of transmission of communicable diseases and infections, including coronavirus disease (COVID-19). Specifically, the facility failed to: -Ensure staff encouraged residents to wear a mask when out of their rooms; -Ensure proper cleaning of personal (staff) vital sign equipment, (cloth-covered wrist cuff); -Ensure contaminated medication was not administered to a resident; -Ensure alcohol based hand rub (ABHR), used by residents and staff, was not expired on one of two floors and the main entrance; -Offer hand sanitizer to residents prior to meals; and, -Ensure staff wore masks in the main kitchen. Findings include: I. Medication pass, resident mask use and disinfection of equipment According to the CDC website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes last updated [DATE], retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others enter their room. Accessed on [DATE]. The CDC (2019) Guideline and Recommendations for Disinfection in Healthcare Facilities, retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html read in pertinent part; -Disinfect non-critical medical devices (like blood pressure cuffs) with an EPA-registered disinfectant using the label's safety precautions and use directions. Most EPA-registered disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of disinfectants against pathogens with a contact time of at least 1 minute. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient). -If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient (who is in isolation) before using this equipment on another patient. Accessed on [DATE]. II. Facility policies and procedures The Covid-19 Guidelines policy and procedures, dated [DATE], provided by the IAED on [DATE] at 3:19 p.m., read in pertinent part: -Residents may remove their cloth face masks when in their rooms but should put them back on when leaving their room or when others (associates, visitors) enter the room. -Use dedicated or disposable non-critical resident care equipment (blood pressure cuffs). If equipment will be used for more than one resident, clean and disinfect such equipment before use on another resident according to manufacturer's instructions. III. Manufacturer's instructions Review of the manufacturer's instructions for the Oxivir Tb Wipes read in pertinent part: Oxivir Tb Wipes are intended for the cleaning and disinfecting of hard non-porous environmental surfaces. Kills bacteria and viruses in one minute including the COVID-19 virus. -Disposable latex or vinyl gloves must be worn during cleaning and decontamination procedures. -Wipe hard, non-porous environmental surfaces allowing the surface to remain wet for one minute. IV. Observations and interviews A. Medication pass On [DATE] at 9:35 a.m., registered nurse (RN) #1 was observed on Blue Violet hall preparing to administer medications to Resident #47. The RN obtained a packet of antacid tablets to administer two tablets per the physician order. She dispensed one tablet from the foil pack into the medication cup and when she dispensed the second tablet, it fell on to the top of the medication cart. She applied a glove, picked up the tablet and placed it into the medication cup with the resident's other medications and administered them to him. She said, that's what I normally do if I drop a pill onto the med (medication) cart. The director of nursing (DON) was interviewed at 11:40 a.m. She acknowledged the tablet dropped onto the medication cart should have been discarded and not administered to the resident. At 1:01 p.m., RN #1 said she should have discarded the tablet that fell on to the top of the medication cart. She said she should not have placed it in the medication cup and administered it to the resident. B. Resident mask use On [DATE] at 10:47 a.m. the resident in room [ROOM NUMBER] was seen repeatedly exiting her room into the hallway not wearing a mask and staff would pass by her and not encourage her to apply a mask. At 10:54 a.m. her son arrived for a visit. He was wearing a mask but he exited her room, with her in her wheelchair, and proceeded down the hallway to the front entrance to take her outside. She was not wearing a mask. They passed several staff members who did not encourage her to apply a mask. -At 12:23 p.m. an unknown resident was seen entering the dining room on the first floor. Her mask was down under her chin and an unknown staff member talked to her and did not encourage her to apply the mask correctly. -At 1:06 p.m., the resident in room [ROOM NUMBER] was seen in her wheelchair seated next to a nurse's medication cart not wearing a mask. The unknown nurse did not encourage her to wear one. On [DATE] at 8:50 a.m. the resident in room [ROOM NUMBER] was seen in her wheelchair in the hallway, approximately four feet from the door to her room. She was not wearing a mask and an unknown staff member walked past her and did not encourage her to apply a mask. On [DATE] at 8:36 a.m. the resident in room [ROOM NUMBER] was seen sitting in her wheelchair outside her room, approximately four feet into the hallway. She was not wearing a mask. A surgical mask was hanging on the handle of her wheelchair. A few feet away, licensed practical nurse (LPN) #1 stood at a medication cart. He did not encourage the resident to apply her mask. -At 8:56 a.m. the resident in room [ROOM NUMBER] approached the medication cart to talk to the nurse, she was not wearing a mask and LPN #1 did not encourage her to apply one. The DON, ADON, and the IAED were interviewed on [DATE] at 11:52 a.m. They said residents have the right to refuse to wear a mask but they did not have any residents currently that were refusing. They said staff were expected to encourage residents to wear their masks when they come out of their rooms. C. Blood pressure cuff On [DATE] at 9:04 a.m. registered nurse (RN) #1 was observed during a medication pass in the Blue Violet hall. She obtained a cloth-covered wrist blood pressure cuff from on top of her medication cart. She entered resident room [ROOM NUMBER] and placed the cuff on the bare wrist of the resident. After she obtained the blood pressure reading, she returned to the medication cart and placed the cuff on top of the cart. She did not clean it. The assistant director of nursing (ADON) was interviewed on [DATE] at 11:40 a.m. She acknowledged a wrist blood pressure cuff that was cloth-covered could not adequately be cleaned with the Oxivir wipes used to clean other equipment. -At 1:01 p.m. RN #1 said the wrist blood pressure cuff she used was her own. She said she would clean it after every use with Oxivir wipes. She did not know the dwell time of the wipe and was unaware the wipes were only to be used on hard non-porous surfaces. II. Hand sanitizer not expired A. Professional reference According to the FDA (Food and Drug Administration) Hand Sanitizers and COVID-19, last updated [DATE], retrieved [DATE], from: https://www.fda.gov/drugs/information-drug-class/qa-consumers-hand-sanitizers-and-covid-19 Hand sanitizers are over-the-counter (OTC) drugs regulated by FDA .Over the counter (OTC) drug products generally must list an expiration date unless they have data showing that they are stable for more than 3 years. FDA does not have information on the stability or effectiveness of drug products past their expiration date. B. Facility policy and procedure The Hand Hygiene policy, revised [DATE], was received from the nursing home administrator (NHA) on [DATE] at 5:07 p.m. The policy documented in pertinent part, Hand hygiene products and supplies shall be readily available and convenient for staff use to encourage compliance with hand hygiene policies. In most situations, the preferred method of hand hygiene with 70% alcohol-based hand sanitizer, as it is proven most effective. C. Observations On [DATE] at 9:21 a.m., the ABHR, on the wall at the main entrance to the facility, labeled Spectrum Hand Sanitizer, expired as of [DATE]. Four visitors were observed using the expired ABHR when entering the facility on [DATE] at 9:00 a.m., [DATE] at 9:00 a.m. and [DATE] between 9:00 a.m. and 9:21 a.m. On [DATE] at 9:22 a.m., the ABHR, on the wall in the second floor dining room expired in [DATE]. On [DATE] at 11:21 a.m., staff members were observed using the ABHR for hand hygiene while serving the meal. On [DATE] at 9:23 a.m., the following was observed: -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. -ABHR, on the wall inside resident room [ROOM NUMBER], expired [DATE]. D. Interviews The interim associate executive director (IAED) was interviewed on [DATE] at 12:27 p.m. She said the maintenance and housekeeping department replaced the hand sanitizer in resident rooms and common areas throughout the facility when it was empty. She said central supply ordered the hand sanitizer. The IAED said the facility had plenty of hand sanitizer to replace any empty containers. She said the new bottles of ABHR should have been checked by the housekeeper for an expiration date before it was replaced in each area. The nursing home administrator (NHA) was interviewed on [DATE] at 1:49 p.m. He said the facility staff were removing the expired hand sanitizer from the facility. The NHA said he thought maybe some of the old bottles were refilled during the pandemic, and the date had not been changed on them. The NHA said he had no way of knowing which bottles were actually expired and which had been refilled. He said the staff should have changed the dates on them if they had refilled them. The IAED was interviewed again on [DATE] at 2:44 p.m. She said the facility had removed and replaced 25 bottles of expired hand sanitizer. The building operations manager (BOM) was interviewed on [DATE] at 11:19 a.m. He said housekeepers replaced hand sanitizers when they were empty. He said the housekeepers should have checked the replacement bottles for an expiration before placing them in resident rooms and common areas for use. The BOM said the housekeepers would start checking the expiration dates. The manufacturer's instructions for use were requested from the BOM. He said he did not have anything from the manufacturer, and the instructions for usage were on the back of the bottles. E. Facility follow-up On [DATE] at 11:50 a.m., the BOM provided a plan for the expired hand sanitizer. The undated plan, titled Alcohol-Based Hand Rub Follow-Up Audit, documented in pertinent part,25 hand sanitizers were found in the health suites and immediately pulled from the location. Maintenance was able to replace most of the hand sanitizers .care partners were educated to use soap and water for hand hygiene, or a personal hand sanitizer in locations/suites that had empty sanitizer containers until they could be replaced .Moving forward the facility will audit the expiration date month for three months or until substantial compliance is achieved. After compliance is achieved, environmental services will check the expiration date every time the sanitizer is replaced. If the expiration date is within a six month time period, the sanitizer will be pulled from a suite and placed in a high-use location (front desk). III. Staff wore masks and offered hand hygiene to residents A. Facility policy and procedures The Hand Hygiene policy, dated [DATE], and revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 5:07 p.m. It read in pertinent part, The community considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene includes both hand washing and the use of alcohol based hand sanitizer. The Dining Competency, created 2018, was provided by the Interim Associate Executive Director (IAED) on [DATE] at 3:55 p.m. It read in pertinent part, Remind residents to perform hand hygiene and assist, as needed. This is done for residents eating in their rooms or in the dining room. B. Not offering hand sanitizer to residents prior to meals On [DATE] at 11:59 a.m. certified nurse aide (CNA) #3 went into resident rooms 176, 178, 180, 181, 183, 185, 187 to serve lunch but no hand sanitization was offered or encouraged to the residents in their rooms and there were no hand sanitizing wipes on the trays. On [DATE] at 11:20 a.m. CNA #1 served lunch to rooms (160 and 161) but no hand sanitizer wipes were on the trays and no hand sanitization was offered or encouraged to the residents. Trays for rooms 170, and183 had no hand sanitizing wipes. Resident #250 was assisted at 12:05 p.m. to the first floor dining room in her wheelchair. No hand sanitization was offered Resident #250 before she ate her meal. The resident drank her juice independently and bites of her food. A CNA came and sat with her and helped her eat a little more. C. Not wearing masks in the main kitchen On [DATE] at 9:15 a.m. during the initial kitchen tour the executive chef (EC) was not wearing a mask in the main kitchen. The dishwasher (DW) was not wearing a mask in the main kitchen. On [DATE] at 3:18 p.m. the staff in the main kitchen were not wearing a mask including the EC, DW, and two cooks (cook #1, #2). D. Interviews The registered dietitian (RD) was interviewed on [DATE] at 9:15 a.m. She said she was responsible for the infection control training for the kitchen staff. She said no masks were worn in the main kitchen because corporate had told them the dietary staff only needed to wear a mask when they were interacting with residents. The RD was interviewed again on [DATE] at 12:44 p.m. She said they continued to not wear masks in the main kitchen because of state guidance but acknowledged that there may be a conflict with Centers for Medicare and Medicaid services (CMS) guidance and she would review it since the facility would need to follow the most strict guidance for mask wearing. The RD said kitchen infection control education was offered daily to the dietary staff with tip of the day, with a test and return demonstration. The kitchen staff reviewed food borne illness. She said there was education for new hires online for hand washing, recognition of labels, company standards, first aid practices, and COVID-19 training. There was training provided in the kitchen in person monthly to review safety and sanitation. The RD said she did an on premise food safety audit one to three times per month. The RD said that the facility standard is for all residents to be offered hand hygiene before meals. IV. COVID-19 status The DON and the IAED were interviewed on [DATE] at 11:52 a.m. They said the facility currently had zero COVID-19 positive residents and zero positive staff members as well as zero presumptive positive residents or staff.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one main kitchen and one of two satellite kitchens. Specifically, the facility failed to: -Ensure appropriate use of gloves when handling ready-to-eat foods; and, -Ensure residents used clean utensils in the first floor dining room. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view on 7/29/21. It read in pertinent part; -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is reasonably expected to be consumed in that form. -Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. -Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. II. Facility policy and procedure The Disposable Glove Use policy and procedure, dated March 2006, revised January 2020, provided by the interim associate executive director (IAED) on 7/22/21 at 3:00 p.m. read in pertinent part: -Disposable, non-latex gloves must be worn at the following times: When handling ready-to-eat foods, over cut gloves when handling ready-to-eat foods, and in most cases, when serving food or assembling patient meals. -Disposable gloves must be changed and hands washed when the gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes. III. Observations A. Ensure appropriate use of gloves when handling ready-to-eat foods Observation of the lunch meal in the first floor satellite kitchen on 7/19/21 from 12:00 p.m. to 12:30 p.m. revealed the following: -At 12:07 p.m., FSW #1 was seen wearing gloves as he prepared meals. He touched multiple surfaces (cabinet/refrigerator handles, utensils, plates, slices of meat, bread, cheese) while preparing sandwiches for the meal, considered a ready-to-eat food. Wearing the same gloves he removed a sandwich from the flat top cooking surface with a spatula, placed it on a plate, held it down with his gloved hand and used a knife to cut it in half. -At 12:14 p.m., FSW #1 had washed his hands, retrieved a metal container of fruit from the refrigerator and donned a clean pair of gloves. He lifted the end of the plastic wrap from the container of fruit, used a spoon to place fruit into a bowl. He replaced the plastic wrap on the fruit container. Wearing the same gloves he obtained a loaf of bread in its plastic bag, reached inside the bag and retrieved four slices of bread. He then turned to the cooktop and used a flat scraper to clean the cooktop surface. He then picked up the four slices of bread and held a basting brush by the handle in one hand, the bread slices in the other hand, and applied butter to each slice, and placed them on the cooktop. Wearing the same gloves, after a sandwich was cooked, he removed it from the cooktop with a spatula and placed it on a plate, held the sandwich down with one hand, and used a knife to cut the sandwich in half. Still wearing the same gloves, he obtained two other slices of bread from the plastic bag and held the bread down with one gloved hand and used a knife to cut the edges from the bread. He turned to the cooktop and repeated the process of buttering the bread and placing them on the cooktop surface. He then removed multiple slices of cheese from a package and placed them on top of the slices of bread on the cooktop and used a spatula to turn the sandwiches. He then obtained several slices of ham from a package and applied them to the other sandwiches on the cooktop. He did not change gloves when moving from potentially contaminated surfaces to handling food. -At 12:23 p.m., an unknown kitchen staff member was seen wearing gloves and retrieved a small container of chicken salad from the refrigerator. He removed the plastic wrap from the top of the container. He then obtained a packaged loaf of bread from a cabinet and removed two slices and placed them on the counter. He then used a spoon to apply the chicken salad to the bread. He removed the gloves and washed his hands and applied new gloves. He then obtained a container of fruit from the refrigerator, removed the plastic wrap from the top of the container and used a spoon to place the fruit into a small bowl. He picked up a plate and placed the sandwich on the plate with the same gloved hand. On 7/20/21 at 11:45 a.m. observation of the lunch service in the first floor satellite kitchen/dining room revealed the following: FSW #1 was seen in the satellite kitchen preparing to make sandwiches. He applied gloves and retrieved a metal tray from a cabinet below the steam table. He placed the tray on a countertop. He placed two knives in the metal tray. He then opened a cabinet door and obtained a packaged loaf of bread. After touching multiple surfaces, he removed several slices from the bag, placed them on the counter and used one of the knives to cut the crust edges off the bread, holding the bread down with the other gloved hand. Wearing the same gloves he held a piece of bread in one hand and used a basting brush to apply butter to the slices of bread and placed them on the cooktop. He removed several slices of cheese from a package and placed them on the bread slices on the cooktop. He removed the gloves, washed his hands, and donned another pair of gloves. He opened the refrigerator door and removed a container that held chicken salad. He took it to the counter and opened the plastic wrap covering the container and used a spoon to place chicken salad onto bread slices that were on the counter. He then opened the cabinet door above the counter and obtained more slices of bread from a package, placed them on the counter and repeated the process of cutting the crust edges from the bread, holding the bread down with the other gloved hand. He applied more chicken salad to the bread slices and closed the plastic wrap on top of the container. He removed the gloves, washed his hands, and went to the freezer and removed a package of frozen hamburgers and placed it on the counter. He applied gloves again and retrieved small bowls from a stack, placing his fingers inside the bowls. He spooned soup into the bowls. He picked up two paper menu slips, obtained two plates and placed the chicken salad sandwiches and the bowls of soup onto the plates. Wearing the same gloves, he then opened the bag of frozen hamburgers and removed a couple of them and placed them onto the cooktop. B. Ensure residents used clean utensils in the first floor dining room -At 11:50 a.m., a female resident was seen seated at a table in the back of the dining room. A staff member was assisting her with a bowl of soup. She was using adaptive utensils. The resident recognized someone she knew in the hall and wanted to go back to her room. The staff member assisted the resident back to her room. When the staff member returned to the dining room she did not clear the table of the resident's soup bowl, utensils, glass of juice, placemat, or napkin. Meanwhile, at 12:03 p.m., a male resident who normally sat at the table in the same spot the female had just left, approached the table in his motorized wheelchair and sat facing the other resident's leftover soup and the other items mentioned above. He asked a staff member for a glass of milk instead of the glass of juice the other resident had left behind. He proceeded to use the adaptive utensils and eat the soup in the bowl. Staff were unaware he was eating the other resident's soup with the same utensils she had used. The director of nursing (DON) was notified immediately of what transpired with the male resident. She then approached the staff in the dining room. She talked to the resident. The staff removed the bowl, utensils, juice glass, placemat and napkin from the table in front of the resident. They disinfected the table and placed a clean placemat, napkin, and utensils for the resident. He was brought another bowl of soup but declined it saying, I already had soup. IV. Interviews The DON was interviewed on 7/21/21 at 10:00 a.m. She said the certified nurse aide (CNA) that assisted the female resident with the soup prior to the male resident arriving at the table was an agency CNA who had never worked in long term care, which the DON said they were not aware of when they agreed to use her. She said the agency company completed competencies with their staff and the facility also did some competencies with them but the particular dining competency had not been completed with her. She said the new competency will be taught and reviewed to care partners moving forward. The education includes nursing care partners as well as dining care partners and includes the understanding that all care partners' roles are responsible for ensuring this competency. She said the situation should never have happened and residents were not to share eating utensils under any circumstance. The registered dietitian (RD) was interviewed on 7/22/21 at 10:05 a.m. She said it was their policy to change gloves between tasks and if the dietary staff touch ready-to eat foods. She said it was not acceptable for dietary staff to wear gloves throughout a meal service touching multiple surfaces and then touching food items. She said FSW #1 had been educated previously on his glove use while preparing meals and she would need to re-educate him V. Facility follow-up The DON provided documentation of the investigation of the above incident and changes to their dining competency checklist, dated 2018, revised 7/20/21, that included: -The resident was involved in choosing where to eat. Do not pre-set a spot for a particular resident. -Resident should not be served food unless present and ready to receive it, and choices are verified. -If a resident vacates their spot in the dining room, and another resident wants to sit in the same location, ensure the area is cleared of food, drink, dishes, and silverware, and cleaned with approved cleaner. -If a resident vacates their spot and states they will return, the area should still be cleared. Education was provided to 11 staff members that were working on the first floor on the day of the incident, with competencies completed that included the new changes made to the dining competency checklist.

Based on observations, record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#12) of two residents reviewed for accident hazards out of 29 sample residents. Specifically, the facility failed to ensure Resident #12 was reassessed after placement of a wander guard bracelet, when he was found walking outside. The facility failed to ensure a verbal or written consent was documented in his chart, and that he was re-evaluated for the continued need of the wander guard after further wander risk assessments indicated he was at low risk of wandering or elopement. Findings include: I. Facility policy The Elopement policy, dated May 2008, revised March 2019, provided by the interim associate executive director (IAED) on 7/20/21 at 3:48 p.m. read in pertinent part: -The community has the privilege and responsibility to meet the various needs of residents and clients. This includes issues related to dementia and/or behaviors with the potential for a resident to elope from a supervised situation, placing the person at risk of harm. The community maintains an assessment process to identify residents/clients with a potential for elopement and provide such persons with an environment and supervision that offer the maximum possible reduction of potential for elopement, and develops policies and procedures to respond to suspected or actual elopement of a resident/client. The community provides protective oversight for residents/clients, and may include staff supervision, technologies to monitor wandering, and secured environments. -Wandering is defined as any behavior initiated by a cognitively impaired individual that is characterized by ambulation that may lead to safety problems. Elopement is defined as a situation in which a resident with impaired cognition or poor safety awareness or judgement successfully leaves the facility or a secure area undetected or unsupervised by staff. -Each community or service that provides protective oversight of residents/clients, will conduct a pre-admission elopement risk assessment of each prospective resident. The care or service plan developed for the resident identifies the level of elopement risk. -The elopement risk assessment is updated, as needed, to address any change in the resident ' s/client's condition, including behavioral manifestations that indicate an increased potential for elopement. -Any actual or attempted elopement triggers an immediate post-incident evaluation that includes but is not limited to: a. A full physical assessment of the resident/client with medical follow-up as indicated b. A review of the current care plan and evaluation of the need to provide the resident/client with a more secure environment to minimize potential for future elopements. Power of attorney (POA) and/or primary representative, if applicable, will be consulted. c. A quality improvement evaluation to identify and address any circumstances that may have contributed to the incident. d. Significant findings will be shared with other communities, as indicated. e. Details of event will also be reported to risk management meeting/s. -Associates working in a protective oversight community are trained in the prevention of and response to a resident elopement. II. Resident #12 A. Resident status Resident #12, age 89, was admitted [DATE]. According to the July 2021 computerized physician orders (CPO) diagnoses included dementia without behavioral disturbance, repeated falls, pain, presence of left artificial hip joint, and lack of coordination. The 4/28/21 minimum data set (MDS) assessment indicated Resident #12 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He was negative for mood and behavior symptoms and wandering behavior was not exhibited. He required limited assistance of one staff member for bed mobility, supervision of one staff member for transfers, and supervision setup help only for walking in the corridor. He had no impairment of upper or lower extremities and used a wheelchair and a walker for mobility. A wander/elopement alarm was used daily. B. Observations On 7/19/21 at 4:50 p.m. Resident #12 was seen seated in his recliner in his room. He had a wanderguard bracelet on his right ankle. He said he did not know what it was or why he had it. He did not go to the dining room for the evening meal and was not seen wandering in the facility. Observations of the resident on 7/20, 7/21, and 7/22/21 revealed the wanderguard was still in place. The resident was not seen outside his room or wandering in the facility on these days. C. Record review The 10/19/2020 admission elopement/wander risk assessment indicated Resident #12 was cognitively impaired with poor decision making skills, he did not ambulate independently, and was low risk for wandering and elopement. The 11/16/2020 behavior note, documented by registered nurse (RN) #2 at 11:15 a.m. read: Life enrichment told certified nurse aide (CNA) #2 that resident was seen outside the facility walking using back door. Resident was approached right away and redirected to come back to his room. Resident stated ' I just want to go outside for a walk. ' This nurse notified physician (PHY) and management and will ask for wanderguard. Resident was visited by PHY. Currently in his room watching television while eating lunch. Will monitor. Care has met. -Although it was documented the resident was outside the facility, a new elopement/wander risk assessment was not completed. There was no documentation of location or time of the wanderguard placement. There was no verbal or signed consent from the resident's POA in the chart for placement of the wanderguard. The 11/16/2020 physician progress note documented at 9:56 p.m. read in part: Nursing requested that I see the patient today. Nursing staff RN #2 report, patient tried to elope from the building today. Nursing staff RN #2 report patient had left the building with intention of elopement and patient was brought back. Patient with poor insight. Discussed with nursing staff, facility, and get a armband for patient. Monitor for safety patient. The care plan, initiated 11/23/2020 revealed Resident #12 was an elopement risk/wanderer. He was at risk of harm or injury to himself. He was disoriented to place, had a history of attempts to leave facility unattended, and had impaired safety awareness and cognitive deficits. Resident #12 would wander aimlessly. Interventions included: -Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. -Follow facility protocols for elopement risk and facility procedure for missing persons. -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is he looking for something? Does it indicate the need for more exercise? Intervene as appropriate. -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. -Safety Device: Wanderguard to right ankle. Review of the physician orders revealed the order for the wanderguard was not added to the chart until 12/24/2020 by the licensed practical nurse/minimum data set coordinator (LPN/MDS) when it was implemented on 11/16/2020 (see above). The 2/6/21 elopement/wander risk assessment indicated Resident #12 was not cognitively impaired nor had poor decision making skills. He ambulated independently and had no reported episodes of wandering in the last six months. -Although he was found outside the facility less than three months prior, on 11/16/2020. The 4/28/21 MDS assessment indicated Resident #12 did not exhibit wandering behavior yet a wander/elopement alarm was used daily. -Review of nursing behavior notes since the 11/16/2020 elopement revealed no documentation of Resident #12 wandering in the facility or attempting to exit the building. III. Interviews The IAED was interviewed on 7/20/21 at 3:48 p.m. She said she could not find documentation that the resident's daughter had been notified of the wanderguard placement nor a consent form signed by her. She provided the following documentation: AED (associate executive director) spoke with Resident #12s daughter 7/19/21 to ensure that she had been informed of wanderguard placement. Daughter stated that she was aware that resident originally had wanderguard on his walker, but was moved to his ankle due to wander risk and resident repeatedly stating ' I need to go to the store ' and attempting to leave the community. Daughter stated that she understood the reason for placement and agreed with recommendation. -Although the IAED confirmed the placement of the wanderguard (during survey), there was still no verbal consent form placed in his chart. The director of nursing (DON) was interviewed on 7/21/21 at 4:22 p.m. She acknowledged Resident #12 exited the building on 11/16/2020 and there was no documentation of placement of the wander guard bracelet or that the resident's daughter was notified, and a verbal/written consent obtained. She said after the 11/16/2020 incident another elopement/wander risk assessment should have been completed, as he was determined to be low risk on admission. She said since the 2/6/21 elopement/wander risk assessment documented he was low risk and the 4/28/21 MDS assessment documented wandering behavior not exhibited he should have been reassessed for the continued need for the wanderguard. She said, we can certainly reassess him. Registered nurse (RN) #2 was interviewed on 7/22/21 at 9:51 a.m. She said Resident #12 had the wanderguard bracelet because he was able to walk around with his walker looking for cigarettes and, we do not have time to watch him constantly and if he would get near an outside door it would beep. She said the nurse was responsible for ensuring the bracelet was in place. She said staff did not routinely ensure it was in working order, we just notice it beeping if he gets near an exit door. She said the resident had not been seen wandering lately. CNA #1 was interviewed on 7/22/21 at 12:56 p.m. She said Resident #12 did not wander and if his family visited, they would walk him down the hall, but she had not seen him try to go outside unaccompanied lately. She said she was unaware of who was responsible for ensuring the wanderguard was working properly. Resident #12's daughter was interviewed on 7/22/21 at 5:35 p.m. She said back in November of 2020 when the facility had to place the wanderguard, the facility called her to let her know but did not mention needing a consent form. She said, I don't recall if they said he actually got outside, I told them it was fine with me if they applied the wanderguard bracelet. They called this week to tell me they were thinking about removing it if he was reassessed at a low risk for wandering or eloping. -She was unaware he was assessed to be low risk for elopement/wandering in February 2021 and the MDS assessment documented he did not exhibit wandering behavior in April 2021. IV. Facility follow up On 7/22/21 at 8:31 a.m. the IAED provided the following documentation: The interdisciplinary team (IDT) team talked to life enrichment staff member and CNA #2 this same day (11/16/2020), as they reported it to nursing management. Resident was in the dining room waiting for lunch and opened the back door. The life enrichment staff member was in the dining room and notified CNA #2 that resident was by the back door with it open, and wondered if he could go outside unassisted. Because it was lunchtime, resident was redirected by CNA #2 to eat lunch, and she took him for a walk outside before nurse management had even been notified of the situation. No elopement assessment was performed. A wanderguard was discussed and placed as an alert to care partners of resident wanting to walk unassisted outside. -At 10:05 a.m. the IAED provided the wanderguard competency skills checklist, dated 2021, it read: -Elopement assessment is completed which determines resident is at risk and needs a wander guard or if completed elopement assessment determines resident is not a risk but resident has had a wandering/elopement instance and immediate safety need requires wander guard. -If resident has an elopement, conduct another elopement assessment. -Determine if wander guard should be placed on resident or on walker or wheelchair. -Obtain provider order for wanderguard and enter into computer. Order should include location of wander guard. -Test wander guard to ensure it is working (take it near an exit and trigger alarm). -Contact POA (power of attorney) to inform them of elopement status within 24 hours of wander guard placement. -Document POA conversation in nursing note. -Care plan should be updated with new elopement assessment result (if changed), location and reason for wander guard, and POA consent if applicable. -Wander guard need will be reassessed with new elopement assessments and as needed. The IAED said, This is the rough draft for the wanderguard competency. It was submitted to our corporate compliance nurses for review. Once edited and approved, the competency will be performed with both nurses and CNAs. It is noted that resident (#12) is 'low risk' for wandering/elopement. Current nurse is performing another elopement assessment on resident today. If he continues to be low risk, she will call the doctor to discontinue wanderguard and order, call daughter to inform, and remove the wanderguard.

Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two (#250 and #248) of four residents reviewed for respiratory care out of 29 sample residents. Specifically, the facility failed to: -Ensure oxygen tubing was marked with the date the tubing was replaced for Resident #250 and #248; -Obtain physician orders for oxygen that includes liter flow, frequency, and route for Resident #250 and #248; -Ensure oxygen was included on the comprehensive care plan for Resident #250; and, -Ensure oxygen tubing was stored in a sanitary manner and not on the bathroom floor for Resident #250. Findings include: I. Facility policy and procedures The Oxygen policy, dated August 2019 and revised December 2019, was provided by the Interim Associate Executive Director (IAED) on 7/21/21 at 3:51 p.m. It read in pertinent part, Prescriber orders will be obtained for residents requiring assistance with oxygen. Orders shall include liter flow, frequency, and route. Oxygen tubing will be changed at least monthly or more often as needed. The community will determine if this is a community task or oxygen provided task. II. Resident #250 A. Resident status Resident #250, age 92, was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to the resident adminitting on 7/13/21, a minimum data assessment had not been completed yet. The 7/13/21 clinical admission evaluation assessment revealed the resident was cognitively confused and disoriented. She had upper extremity impairment on one side (right) and no lower extremity impairment. Her mode of mobility was a wheelchair and she was on oxygen therapy. B. Observation On 7/19/21 at 2:23 p.m. the oxygen concentrator was in the bathroom to the right of the toilet. The oxygen tubing, attached to the concentrator was rolled up and stored on the floor and was not labeled. On 7/20/21 at 12:10 p.m. the oxygen concentrator was running in the bathroom to the right of the toilet, at 1.5 liters per minute (LPM). The oxygen tubing, attached to the concentrator was rolled up and stuck under the concentrator handle, no label or storage bag. On 7/21/21 at 9:13 a.m. the resident's nasal cannula (NC) was on the bed, oxygen running at 1.5 LPM. The oxygen concentrator was in the bathroom to the right side of the toilet. The oxygen tubing was not labeled. C. Record review -Review of the July 2021 CPO revealed the resident did not have orders in place for use of oxygen. -Review of the comprehensive care plan revealed the resident did not have a care plan in place for the use of oxygen. Review of progress notes revealed use of oxygen revealed: 7/13/21 at 5:30 p.m. the Clinical admission evaluation documented: Utilizing oxygen: Yes. Oxygen 2 liters at night via nasal cannula. Currently on respiratory antibiotics: Yes. 7/13/21 at 6:30 p.m. Skilled nurse respiratory evaluation, it read in pertinent part, No signs of difficulty breathing. Lung location: Right: Anterior Lower Lobe: Diminished on auscultation. Lung location: Left: Anterior Lower Lobe: Diminished on auscultation. Oxygen 2 liters. Humidification: No. Oxygen via nasal cannula. HOB (head of bed) elevated. Head elevated at 30 degrees. No cough. Currently on respiratory antibiotics: Yes. 7/15/21 at 12:35 a.m. pulse oximetry oxygen saturation at 92%. Method: oxygen via nasal cannula (NC). -However, there is no documentation of how many liters of oxygen. III. Resident #248 A. Resident status Resident #248, age 65, was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to the resident admitting on 7/9/21, a minimum data assessment had not been completed yet. The 7/9/21 clinical admission evaluation assessment revealed the resident was cognitively alert and orientated to person, place and time. No upper or lower extremity impairment. Her mode of mobility was a wheelchair and she was on oxygen therapy. B. Observation and interview On 7/19/21 at 4:22 p.m. an oxygen concentrator was in the bathroom. The oxygen tubing connected to the concentrator was not labeled. The resident was wearing the oxygen via NC set at 1 LPM. On 7/20/21 at 12:59 p.m. an oxygen concentrator was in the bathroom. The oxygen tubing was not labeled, it was connected to the concentrator and running at 1.5 LPM. The resident was wearing the NC. C. Record review Review of the July 2021 CPO revealed the following orders: -Change and date oxygen tubing every night shift every four weeks on Sunday (start date 7/11/21). -Oxygen titration 1. Decrease oxygen by 1 LPM for oxygen saturation level 90-95% or decrease oxygen by 2 LPM for oxygen saturation 95-99%. 2. Repeat oxygen saturation after five minutes. 3. If oxygen saturation is greater than than 90% then repeat steps 1 and 2. 4. If oxygen saturation is less than 90% then return oxygen setting to prior setting where oxygen needs were met. 5. Record final oxygen saturation and oxygen setting. Every day and night shift for oxygen titration. discharge date [DATE] at 7:23 a.m. -No physician orders werein place for oxygen liter flow, frequency, and route after 7/13/21. Review of the comprehensive care plan revealed the resident did not have a care plan in place for the use of oxygen except to say in pertinent part, Oxygen settings, oxygen via NC, see MD (medical doctor) orders for titration orders. Date initiated 7/11/21. Review of progress notes revealed use of oxygen. 7/9/21 at 5:36 p.m. the Clinical admission evaluation document: Utilizing oxygen: Yes. Oxygen titrate oxygen via nasal cannula. Currently on respiratory antibiotics: no. 7/11/21 at 12:55 a.m. Pulse oximetry, oxygen saturation 96%. Method: Oxygen via nasal cannula. -However, there was no documentation of how many liters of oxygen. 7/13/21 at 8:36 p.m. nurse skilled evaluation documents use of oxygen at 2 LPM via nasal cannula. 7/14/21 at 8:36 p.m. nurse skilled evaluation documents use of oxygen at 2 LPM via nasal cannula. 7/17/21 at 8:36 p.m. nurse skilled evaluation documents use of oxygen at 2 LPM via nasal cannula. IV. Interviews Registered nurse (RN) #3 was interviewed 7/21/21 at 9:22 a.m. She said that there should be labeling on the resident's oxygen tubing and the night nurse was responsible for labeling it. RN #3 observed the oxygen tubing for Resident #250 stored in the bathroom with no label. She disconnected the oxygen tubing and said she will get a fresh oxygen tubing for today. She said that she did not know how old the tubing was because there was no documentation or labeling. RN #3 looked in the Resident #250's CPO and found no orders for oxygen or care plan. RN #3 acknowledged that there were no physician orders and no label on the oxygen tubing. The DON was interviewed 7/22/21 at 2:10 p.m. She said the staff change the oxygen tubing weekly every Tuesday and they should be labeling it. She said if a resident was on oxygen there would be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the oxygen company was supposed to leave a sheet of what they did, such as who had oxygen and what services they provided that day. She said since the facility did not supply the sheet of documentation from the oxygen company, that maybe the oxygen company was putting it in the wrong mailbox. The DON said it was part of the nurses routine tasks to check the oxygen concentrators and setting. She said the nurses were responsible for checking and documenting oxygen settings. She said with Resident #250, oxygen tubing should be stored in a bag and if it touches the floor it should be disposed of and that it should be labeled. She said she should have oxygen orders. She said with Resident #248, the oxygen tubing should be labeled. The DON looked at the resident's CPO and acknowledged Resident #248's oxygen orders were incomplete.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 11.54%, or three errors out of 26 opportunities for error as a result of two medications administered two hours and 45 minutes past the scheduled administration time for two residents (room [ROOM NUMBER] and Resident #32), and one medication administered an hour and 45 minutes past the scheduled administration time for one resident (room [ROOM NUMBER]) out of six residents in two of four halls. Findings include: I. Facility policy The Medication Administration General Guidelines policy, dated 2007, updated 6/1/21, provided by the interim associate executive director (IAED) on 7/22/21 at 3:19 p.m., read in pertinent part: -Prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] -Medications are administered in accordance with written orders of the prescriber. -Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to two hours prior to meals. -Medications are administered within 60 minutes of scheduled time. -Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. II. Medication error observations and interview At 9:44 a.m., the following medications were colored red on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -room [ROOM NUMBER], [MEDICATION(S)] (hormone)100 microgram (mcg) was scheduled to be administered at 7:00 a.m. -Resident #32, [MEDICATION(S)] (to improve blood flow) extended release (ER) 400 mg was scheduled to be administered at 7:00 a.m. -room [ROOM NUMBER], Tylenol 1000 milligram (mg) every eight hours was scheduled to be administered at 8:00 a.m. RN #1 said those medications were colored red because she, had not gotten to them yet and they were not given at the scheduled time because those residents did not want to take them at those times. She said the medications turn red on the computer screen if they were not administered within an hour after they were scheduled to be given, so they were considered late. She said she did not know why they were scheduled for a specific time and not scheduled in a time frame like other medications. II. Interviews The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed on 7/21/21 at 11:40 a.m. The ADON said RN #1 approached her regarding the above observed medication errors and said she was contacting the physician on each resident to inform him of the late medications. She acknowledged medications were to be administered as scheduled and the nursing staff were allowed to administer medications an hour before, up to an hour after they were scheduled. The DON acknowledged that scheduled medications were to be given at the scheduled times and not administered late.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including properly preventing and/or containing COVID-19 in three of four units. Specifically, the facility failed to: -Timely isolate residents with known exposure by certified nurse aide (CNA) #2, who tested positive for COVID-19, using all recommended personal protective equipment (PPE) until results of residents/staff COVID-19 status was known on one of four units; -Timely increase resident COVID-19 monitoring to three times daily after a facility outbreak occurred for three of four units; and, -Ensure cleaning of high touch areas on the dedicated COVID-19 unit during outbreak status. Findings include: I. Failure to isolate residents with known exposure from a health care personnel (HCP) who tested positive for COVID-19 timely The facility layout consisted of two floors, four units with two units on each floor. The name of the units were Morning Glory (observation unit), Mountain Iris, Bell Flower and Blue Violet (dedicated COVID-19 unit). During the survey, the Blue Violet unit (dedicated COVID-19 positive unit) was closed off with a plastic barrier and isolation rooms remained closed with full PPE in isolation bins outside each room. A. Professional reference The Centers for Disease Control and Prevention, Preparing for COVID-19 in Nursing Homes, (updated [DATE]) retrieved on [DATE] from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html read, in pertinent part, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected .If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected . Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. B. Facility policies and procedures The Covid-19 Guidelines policy, revised [DATE], was provided by the executive director (ED) on [DATE] at 11:19 a.m. It read, in pertinent part, .Clinical isolation separates people who are infected with [MEDICAL CONDITION] away from people who are not infected. The community will place suspected or known covid-19 on clinical isolation. The Exposure Response and Return to Work policy revised [DATE], was provided by the ED on [DATE] at 11:19 a.m. It read, in pertinent part, .For associates sent home from work due to covid-19 symptoms, their workplace should be cleaned and disinfected. Contact tracing-information on persons who had contact with the ill associate during the time the associate had symptoms and 48 hours prior to symptoms onset should be compiled. Others at the community with close contact within 6 feet of the employee during this time would be considered exposed. Decision tree for an associate with suspected or confirmed covid-19. For a high risk exposure, residents who were cared for by this associate should be restricted to their room and be cared for using all recommended Covid-19 PPE until results of the associate's Covid-19 testing are known. C. Record review 1. County positivity rate The county positivity rate was 10.5% the week of [DATE] to [DATE] during the facility outbreak. 2. Line listing report The facility associate line listing report was provided by the director of nursing (DON) on [DATE] at 2:16 p.m. The associate line listing report documented a facility COVID-19 outbreak. It documented a staff member (CNA #2) had tested positive for COVID-19 [DATE]. The facility failed to isolate all residents timely on Blue Violet unit who had known exposure on [DATE] by CNA #2, who tested positive for COVID-19 (see interview below). Additionally, it documented several other staff who tested positive for COVID-19 and had worked on the Blue Violet unit from [DATE] to [DATE]. CNA #3 and registered nurse (RN) #2 worked on the Blue Violet unit and tested positive for COVID-19. Five other nursing staff tested positive during the outbreak who worked on other units other than the Blue Violet unit RN #3 & #4, licensed practical nurse (LPN) #1 and CNA #4 & #5. It was not until [DATE] when the facility stated they implemented a barrier on the dedicated COVID-19 (Blue Violet unit) and isolated the residents with full PPE (see interviews below). The resident line listing report documented all resident on the Blue Violet unit tested positive for COVID-19 with PCR (molecular test that look for the genetic material of [MEDICAL CONDITION] itself to determine if there is an active infection with [DIAGNOSES REDACTED]CoV-2) testing on [DATE] and [DATE]. D. Staff interviews CNA #2 was interviewed on [DATE] at 4:05 p.m. She said prior to becoming ill she worked at the current facility (facility #1) on [DATE] and on [DATE] worked at another facility (facility #2). She said at (facility #2) she had a COVID-19 test performed because it was her normal testing day on [DATE]. She said she reported being ill on [DATE] to both facilities and went to the emergency room and did not work while she was sick. She said she received her test results for COVID-19 on [DATE], which were positive and reported to the ADON on [DATE] at facility #1. The director of nursing (DON), assistant director of nursing (ADON), and executive director (ED) were interview on [DATE] at 3:10 p.m. They said during their interdisciplinary (IDT) review of their outbreak they found out their facility outbreak started with the staff member who tested positive on [DATE]. They said CNA #2 worked the (Blue Violet) unit on [DATE]. The ED said they continued to monitor the residents on the unit. They said at that time they did not isolate residents on the unit with full PPE, but continued to quarantine residents. The ED said they would have run out of PPE quickly and CDC's guidance did not warrant isolation, only to quarantine and monitor a resident when exposed by a staff member or resident tested positive. He said there were three residents who had multiple comorbidities, rapidly declined, positive with COVID-19 and were deceased . He said residents on the Blue Violet unit were monitored and isolated after Resident #11 showed signs and symptoms of COVID-19 on [DATE] or [DATE]. The ED said when the first resident on the Blue Violet unit became symptomatic they implemented their rapid response and tested all the residents on the unit via point of care (POC) testing (a rapid test which provides results in minutes) on [DATE] or [DATE] (see documentation below). He said Resident #11 had signs and symptoms of COVID-19 and tested positive with POC testing. He said they identified several other residents that were positive via POC and they initiated PCR testing (a molecular test COVID-19 test which detects genetic material of [MEDICAL CONDITION]) simultaneously to confirm the residents COVID-19 status. He said they also implemented a barrier to the Blue Violet unit with dedicated staff on [DATE] or [DATE]. The ED said prior to [DATE] they had been utilizing the state lab for their COVID-19 testing twice weekly for staff and residents, but they had not received their test results consistently in the recommended 48 hours, he had contacted the laboratory to obtain results and switched to a different laboratory for testing on [DATE]. Although the facility implemented their rapid response for COVID-19 with implementation of testing they acknowledged isolation of residents with full PPE did not occur until well after residents had signs and symptoms of COVID-19 or test results positive with COVID-19 (see interview above). The ED was interviewed a second time on [DATE] at 10:00 a.m. He said CNA #2 had a routine COVID-19 test at facility #2 (another facility) on [DATE] and her results were back on [DATE] and reported to their facility (facility #1). He acknowledged their facility did not implement full PPE in resident rooms after the first known date of CNA #2's positive COVID-19 results were reported on [DATE]. He acknowledged it was not until one week later on [DATE] that residents were placed on isolation with full PPE, which could have caused the spread of COVID-19 in residents and staff. II. Failure to increase resident COVID-19 monitoring after facility outbreak A. Professional reference The Centers for Disease Control and Prevention , Preparing for COVID-19 in Nursing Homes, (updated [DATE]) retrieved on [DATE] from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html read, in pertinent part, If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. B. Facility policy and procedure The Resident Care and Outbreak During Covid-19 Protocol, revised [DATE], was provided by the ED on [DATE] at 11:19 a.m. It read in pertinent part, .For a high risk exposure, residents who were cared for by this associate should be restricted to their room, placed on clinical isolation and be cared for using recommended Covid-19 PPE until results of the associate's Covid-19 testing are known. Monitor all residents twice daily for temperature, chills, rigors, myalgia, headache, cough, shortness of breath or difficulty breathing, sore throat, respiratory rate, BP (blood pressure), pulse ox, change in mentation, nausea, vomiting, diarrhea, olfactory and taste disorder, and rhinorrhea. Monitor suspected or confirmed Covid-19 residents for these same symptoms three times a day. C. Record review Review of five resident records revealed the residents had COVID-19 monitoring twice daily. The Respiratory Screener Assessments documented as follows: -Obtain Vital signs every shift; -Has Resident had any of the following occur in the last 12 hours?; -Temperature greater than 100.0?; -Pulse greater than 100?; -Respirations greater than 24?; -O2 (oxygen) sats less than 89%?; -Cough?; -Is the cough new or has it increased?; -Is the cough productive where mucus is produced?; -Is the resident more lethargic?; -Is the resident more confused than normal?; -Is there a change in level of consciousness?; -Is the resident experiencing any emotional changes that need additional support from the Care Team?; -Other symptoms (check all that apply) chills/shivering, muscle aches, headache, shortness of breath or difficulty breathing, sore throat, nausea, vomiting, diarrhea, changes in smell, changes in taste, runny nose; and -Are any of the above new or worsening symptoms? Residents (on three of four units) #1, #6, #7, #8 and #9 had only been monitored twice daily for COVID-19 signs and symptoms instead of three times daily during and after their facility COVID-19 outbreak per CDC guidance (see above). D. Staff interviews The DON was interviewed on [DATE] at 3:17 p.m. She said she was waiting for the corporation to implement appropriate monitoring under assessments or under orders for COVID-19 in the resident's electronic clinical record in order for the charting to be increased to three times daily. The ED, DON, ADON and environmental supervisor director (ESD) were interviewed during exit on [DATE] at 4:30 p.m. The DON said they monitored residents using their Respiratory Screener Assessment which was completed twice daily. The ED said he felt they were monitoring residents for COVID-19 signs and symptoms frequently because CNAs were in the room multiple times a day, assessing vital signs and nurses completed numerous assessments including skin assessments and monitoring residents while they passed medications. However, he acknowledged the Respiratory Screener Assessment monitoring was specific for COVID-19 signs and symptoms of infection and was not being completed three times a day. The ED retracted his statement above of not isolating the residents timely, stating the facility did isolate residents after known exposure to COVID-19 and would provide additional documentation of resident monitoring during the facility outbreak (see below). E. Facility follow-up The ED provided additional documentation of resident monitoring during the facility outbreak on [DATE] at 3:36 p.m. The Rapid Covid Screen, dated [DATE], documented the name of resident if they had tested positive for COVID-19 in the last six months if they had the following COVID-19 symptoms and if they had been exposed to COVID-19 (this was completed on 13 residents on the Blue Violet unit). The [DATE] Rapid POC documented 13 residents had the test performed, all of which resided on the Blue Violet unit, and eight out of 13 were positive. All thirteenresidents were later confirmed for COVID-19 with PCR testing. It was at this time the facility isolated residents with full PPE. Although documentation of POC testing of residents on Blue Violet unit was provided this did not include any documentation or evidence the residents were provided increased monitoring for COVID-19 or isolation with full PPE after known exposure to COVID-19 after the facility was notified of CNA #2 being positive for COVID-19 on [DATE]. III. Failure to ensure cleaning of high touch areas on the dedicated COVID-19 unit during outbreak status The facility failed to clean and disinfected five resident rooms according to the facility policy and procedure. There were three rooms were vacated on ,[DATE], ,[DATE], and [DATE] and the two residents rooms #283, #289 who completed isolation that were not disinfected (see observations below). A. Professional reference According to the Centers for Disease Control (CDC) Responding to Coronavirus (Covid-19 in nursing homes, (updated [DATE]) retrieved on [DATE] from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html. It read in pertinent part .Assign environmental services staff to work only on the unit. If there are not a sufficient number of EVS staff to dedicate to this unit despite efforts to mitigate staffing shortages, restrict their access to the unit. Also, assign HCP dedicated to the COVID-19 care unit (e.g., NAs) to perform cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. HCP should bring an Environmental Protection Agency (EPA)-registered disinfectant (e.g., wipe) from into the room and wipe down high touch surfaces (e.g., light switch, doorknob, bedside table) before leaving the room. 2. According to the CDC, Environmental Cleaning and Disinfection, (updated [DATE]) retrieved on [DATE] from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. It read in pertinent part .Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Use an EPA-registered disinfectant from on the EPA website to disinfect surfaces that might be contaminated with [DIAGNOSES REDACTED]-CoV-2. Ensure HCP are appropriately trained on its use. B. Facility policy and procedure The Resident Care and Outbreak During Covid-19 protocol, revised [DATE], was provided by the NHA on [DATE] at 11:19 a.m. It read in pertinent part, Communities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the resident. If this responsibility is assigned to environmental personnel, they should wear all recommended PPE when in the room. Once the resident is off isolation, vacate the room, close the door and do not enter for a minimum of two hours or until room air exchange is complete per local health department guidelines, then the room will undergo appropriate cleaning and surface disinfection before it is returned to routine use. C. Observations and interviews Observations and interviews of the dedicated COVID-19 unit Blue Violet neighborhood on [DATE] revealed the following: -At 11:11a.m., registered nurse (RN) #1 was observed going into resident rooms #289 and #283 without full PPE. RN #1 stated that these rooms were no longer on isolation precautions. -At 11:51 a.m., the Blue Violet main hallway and carpeting was observed. It was dirty with bits of paper, paper clip, and debris. Observations and interviews of the dedicated COVID-19 unit Blue Violet neighborhood on [DATE] revealed the following: -At 9:45 a.m., resident room [ROOM NUMBER] was observed not vacuumed or cleaned. The resident was up and dressed in her room. The bathroom floor was dirty with spots and bits of paper and the counter and mirror were dirty with spots. The toilet seat was dirty with yellow stains. There was dirt on carpet from a plant being tipped over, bits of potting soil debris on carpet. The resident did not express her feelings regarding the cleanliness of her room when asked. CNA #1 had said she completed her resident room cleaning in the morning when getting residents up and dressed for breakfast at 7:30 a.m; however the room was not clean. -At 10:04 a.m., resident room [ROOM NUMBER] was observed not vacuumed or cleaned. The resident was up and dressed seated in a wheelchair. There was food on the carpet, the bathroom floor dirty with spots, toilet seat dirty with yellow stains, the inside of the toilet bowl dirty with brown/yellow stains. The bathroom counters and mirrors were dirty with spots. The resident did not express her feelings regarding the cleanliness of her room when asked. -At 10:20 a.m., the Blue Violet main hallway and carpeting was observed. It was dirty with bits of paper, paper clip, and debris. D. Staff interviews RN #1 was interviewed on [DATE] at 11:11 a.m. RN #1 said resident room [ROOM NUMBER] had completed isolation and after completion, the resident still remained on the unit and housekeeping had not been in to clean the room. The environmental services director (ESD) was interviewed on [DATE] at 3:57 p.m. The ESD said that when the outbreak occurred on [DATE], the facility wanted to limit housekeeping staff on the unit to prevent the spread of COVID-19. He said if a resident was no longer in isolation they would clean the resident room, however housekeeping was not told by the nursing staff to clean rooms in the Blue Violet neighborhood (including those empty rooms vacated ,[DATE], ,[DATE] and [DATE]) or the two residents rooms (#283 and #289), who had completed isolation. He said they were not told to vacuum or sanitize the hallways in the Blue Violet neighborhood. RN #1 and CNA #1 were interviewed on [DATE] at 4:13 p.m. They said CNAs cleaned resident rooms in the mornings while getting residents up and ready for breakfast at 7:30 a.m. They said they did not vacuum the carpet, or clean the toilet because there was no toilet brush, mop, or vacuum available to them. They said they used disinfectant (EPA) wipes to wipe down the resident toilets, sinks, and floors. RN #1 was interviewed on [DATE] at 5:00 p.m. RN #1 said that the three vacated rooms had not been cleaned by housekeeping. She said the resident rooms were still dirty and had resident personal items. CNA #1 was interviewed a second time on [DATE] at 10:13 a.m. CNA #1 said she did not receive any special training on cleaning resident rooms that were COVID-19 positive. RN#1 was interviewed a third time on [DATE] at 10:15 a.m. RN #1 said they received generalized training through computer software online where they learned about various departments (such as the kitchen and housekeeping) and they learned that chemicals had a dwell time of one minute. She said there was no specific training on how to clean each resident's room during the COVID-19 outbreak or cleaning of high touch areas. RN #1 said she did not know the process of fully cleaning a resident room after they came off isolation or who would notify housekeeping to come clean the room. The ADON was interviewed on [DATE] at 10:30 a.m. She was unable to produce a list of residents on the COVID-19 unit who were to come off of isolation. She acknowledged there was no plan for when housekeeping would resume on the unit as each resident completed their isolation. As stated above in the facility policy, the housekeeping staff did not have a date when they would fully clean resident rooms after the resident's isolation was completed (see above). The director of nursing (DON) was interviewed [DATE] at 3:17 pm. She said typically nursing staff notified housekeeping when to clean/disinfect rooms on the positive COVID-19 unit. She said she notified housekeeping to clean the resident rooms and the empty resident rooms vacated ,[DATE], ,[DATE], and [DATE]. E. Facility follow up The ESD provided a statement dated [DATE] (during survey) which documented during the outbreak on the Blue Violet unit a resident was moved to another room [ROOM NUMBER], this room was deep cleaned on [DATE]. -However, it did not document the cleaning of the recently vacated resident rooms on ,[DATE], ,[DATE] and [DATE] The ED provided documentation after the survey, on [DATE] at 3:48 p.m., which stated the facility provided education for resident room cleaning to staff on [DATE] and during the survey [DATE]. However, signatures of staff were dated [DATE] due to no written training documentation for [DATE] or [DATE] was provided after the survey. Additionally, the undated documentation that was provided made reference that all designated staff in the Blue Violet unit were provided education on [DATE] on how to clean in the Blue Violet neighborhood, although the document was signed by staff and it was not dated. CNA #1 and RN #1 stated they had not received any specialized training for cleaning of resident rooms in the Blue Violet unit (see above). Although the facility said they had provided staff training of cleaning resident rooms and high touch areas. This was requested during the survey and was not provided. During survey staff were asked on Blue Violet, if specific training occurred in the interview and the staff said they did not receive training. However, after the survey additional information was provided documenting training was provided when staff interviews during survey revealed training had not been completed (see interviews). IV. Facility COVID- 19 status The director of nurses (DON) was interviewed on [DATE] at 3:17 p.m. She said they had nine current COVID-19 positive residents and 18 COVID-19 positive staff. She said there was one presumptive positive COVID-19 resident and several pending COVID-19 tests for staff from the previous week.

Based on observations, record review and interviews, the facility failed to follow an effective infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as Coronavirus disease (COVID-19) for the facility including four (#3, #4, #5 and #2) residents. Specifically, the facility failed to: -Use hand hygiene after touching potentially contaminated services; -Use proper personal protective equipment (PPE) in a isolation room with a Covid-19 positive resident; -Properly store PPE to prevent the spread of Covid-19; -Doff all PPE after exiting an isolation room with a Covid-19 positive resident; -Ensure Residents #4, #5, and #2 were not offered hand hygiene before meals; and, -Ensure face shield was properly disinfected before leaving the resident care area. Findings include: I. Facility policies and procedures A. Infection control The infection prevention and control program policy, last revised May 2020, was provided on 4/27/2020 by the director of nursing (DON). The policy read in pertinent part: It is a policy of this community to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections Standard precautions are observed for all residents. Nurses assess the resident's isolation needs, initiate appropriate precautions in accordance with our established policies and current CDC infection control isolations guidelines, consult with the medical director (and/or the resident's attending physician) as soon as possible to obtain written order A resident with an infection or communicable disease will be placed on isolation precautions Residents with Coronavirus (2019-n-CoV) are placed on airborne precautions. B. Personal protective equipment The personal protective equipment (PPE) during covid-19 policy, dated 4/20/20, read in pertinent part: Maintain full infection control program to prevent transmission. Provide hand hygiene supplies and continual hand hygiene re-education. Ensure rapid safe triage and isolation of residents with symptoms of suspected or confirmed covid-19 or other respiratory infections. Provide PPE education that includes training on covid-19, proper donning and doffing, proper disposal, when to use PPE, what PPE is necessary in a manner to prevent self-contamination The community is responsible for protecting their health care associates and residents from exposure to pathogens, including by providing appropriate PPE. II. Improper use of PPE A. Resident #3 1. Resident status Resident #3, age of 94, was admitted on [DATE]. According to the April 2020 computerized physician orders [REDACTED]. The 4/16/20 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview of mental status (BIM)s score of nine out of 15. The resident required extensive assistance with bed mobility, transfer, and dressing. He required limited assistance with eating. 2. Observation On 4/27/2020 at 9:25 a.m., registered nurse (RN) #2 was observed exiting from the room of Resident #3. The resident was in isolation with transmission based precautions for covid-19. A sign was not on the door or PPE cart indicating what PPE to use in the room. The RN did not wear protective eye wear as she exited the room. The RN did not remove her N95 mask. RN #2 walked down the hall to her nurse's cart. RN #2 stood next her cart and less than six feet away from certified nurse aide (C.N.A) #4. She left her cart, walked back down the hall with her N95 mask on and returned to the front entrance of the room of Resident #3. RN #2 removed her N95 mask and opened a drawer in a PPE cart located near the entrance of the room. She placed the mask inside the drawer. The contaminated N95 mask was not placed in a bag. The outer surface of the mask touched the bottom surface of the drawer and the mask exposed to the other PPE remaining in the drawer. A surgical mask was observed in a separate drawer on top of a small paper bag. RN #2 donned a surgical mask from the PPE cart. She did not use hand hygiene between doffing the N95 mask and donning the surgical mask. The RN sanitized her hands when she returned to her nurse's cart. 3. Interviews RN #1 was interviewed on 4/29/2020 at 9:40 a.m. According to the RN she said she chose not to wear eye protection in the isolation room of Resident #3 because she remained greater than six feet apart. The RN said she would usually use protective eyewear, which was located in the cart. RN #2 said she should have removed her N95 mask immediately with proper storage in the PPE cart. The assistant director of nursing (ADON), was interviewed on 4/29/20 at 11:55 a.m. She said she was in the process of conducting employee in-services related to improper use of PPE. The director of nursing was interviewed on 4/29/20 at 12:51 p.m. She said protective eye wear such as a face shield should be on at all times in an isolation room with a resident diagnosed with [REDACTED]. The DON said RN #2 should have performed hand hygiene before she donned a surgical mask to prevent cross-contamination. III. Hand hygiene A. Resident hand hygiene before meals 1. Resident #4 a. Resident status Resident #4, age of 88, was admitted on [DATE]. According to the 1/18/20 MDS, [DIAGNOSES REDACTED]. The extensive assistance with bed mobility and transferring. b. Observations CNA #5 was observed on 4/27/20 at 11:45. CNA #5 delivered a room tray to Resident #4. The CNA entered the resident's room and asked the resident to hold the room tray as she set up a small table in front of the resident. The CNA retrieved the tray from the resident and placed the plate lunch items on the small table. She did not offer or encourage the resident to practice hand hygiene before the meal. CNA #5 sanitized her own hands as she exited the room. 2. Resident #5 a. Resident status Resident #5, age of 78, was admitted on [DATE]. According to the MDS, [DIAGNOSES REDACTED]. b. Observations CNA #4 was observed on 4/27/20 at 12:10 p.m. CNA #4 delivered a room tray to Resident #4. The CNA entered the resident's room, rolled a bedside table in front of the Resident #5. The CNA placed the meal tray on the table. CNA #4 did not offer or encourage hand hygiene. CNA #4 washed her own hands in the resident's bathroom and exited the room. The resident proceeded to eat the provided meal. 3. Resident #2 a. Resident staus Resident #2, age 93, was admitted on [DATE]. According to the April 2020 CPO, [DIAGNOSES REDACTED]. The 2/20/20 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview of mental status (BIM)s score of six out of 15. The resident required extensive assistance with bed mobility, transfer, eating and toilet use. b. Observation On 4/27/20 at 11:54 a.m., certified nurse aide (CNA) #2 was observed standing in front of the resident's room door. The resident was on contact precautions. Resident #3's meal was observed on the isolation cart. CNA #2 donned gown and gloves. She picked up the meal from the isolation cart and went into the resident's room. She placed the meal on the table in front of the resident. She asked the resident if she would like her clothing protector, and she placed it on the resident. She uncovered the resident's meal and opened the resident's soda and left the room. She did not offer the resident to perform hand hygiene before she ate. The resident was observed to take a bit of her sandwich. 4. Staff interview The nursing home administrator (NHA), and the DON were interviewed on 4/27/20 at 12:20 p.m. According to the NHA and the DON, resident hand hygiene should have been conducted just before the meal was served to prevent the spread of infection. B. Staff hand hygiene and PPE 1. Observations The concierge was observed on 4/27/20 at 9:10 a.m., as she conducted the visitor health screening. During the screening process, the concierge touched the outer surface of the mask when she pulled down facemask to speak and adjust without sanitizing her hands. She touched her cheek as she brushed away her hair. She did not provide hand hygiene contaminating her hands. During the screening process she handled the thermometer, a pen and the screening log with hands. According to the concierge, staff used the same items to self-screen. At 10:33 a.m., CNA #1 was observed to exit a covid-19 positive room. She removed the face shield from her face and placed it on the isolation cart in front of the door. She performed hand hygiene. She picked up the face shield with her clean hands(contaminating her hands again after performing hand hygiene) and walked down the hall to another isolation cart.(potentially spreading the covid-19 virus on the unit) She placed the face shield on the cart. She took the Sani wipes and wiped down the face shield. She placed it in the brown paper bag which had her name. At 10:50 a.m. and 11:25 a.m., additional observations of the concierge were conducted. She continued to touch the outside of her mask multiple times and opened the door for a staff member with her left right hand and returned to her desk without demonstrating hygiene. The concierge proceeded to touch the desk surface, arms of chair, outer surface of left eye. 2. Interviews CNA #1 was interviewed on 4/27/2020 at 10:35 a.m. She said she was a new hire. She said it was her second day working at the facility. She said she was provided training on covid-19. She said she was trained on how to don and doff personal protective equipment (PPE.) She said there were no disinfectant wipes in the isolation cart at the door so she walked to another isolation cart to use the disinfectant wipes. The assistant director of nursing (ADON) was interviewed on 4/27/2020 at 10:42 a.m. She was also the infection control preventionist. She said the staff were trained to clean/disinfect the PPE immediately exiting the resident's room and store it in the brown paper bag that was assigned to the staff. She said all isolation carts should have disinfectant wipes to clean the PPE. She said CNA #1 should not have walked on the unit to another isolation cart with the face shield prior to disinfecting it. She said it was a potential for the spread of infection. She said she would provide education to all staff on the unit. The concierge was interviewed on 4/27/2020 at 11:30 a.m. According to the concierge, she should sanitize her hands after each screening and after opening doors. Tries to push the door open with hip or arm instead of arm so she would not contaminate her hands. She said she did not sanitize hands after touching every item because she is the only one at her desk. She said she was not aware she frequently touches her face and outer surface of the mask. The director of nursing (DON) was interviewed on 4/27/2020 at 12:15 p.m. She was also the infection control preventionist. She said all staff were trained to clean/disinfect the PPE immediately exiting the resident's room and store it in the brown paper bag that was assigned to the staff. She said CNA #1 should not have walked with the face shield to another isolation cart prior to cleaning and disinfecting it. She thought it was a potential for the spread of covid-19. She said all isolation carts should have disinfectant wipes. She said all staff should offer hand hygiene to residents before they eat to prevent infection. She said the ADON had started providing education to all staff on the unit. The DON was interviewed on 4/28/2020 at 3:35 p.m. The DON said hand hygiene should be conducted after touching potentially contaminating surfaces and would continue to remind staff of appropriate infection control practices. IV. Facility follow up The 4/27/20 in-service was provided by the facility on 4/27/2020 at 3:45 p.m. The provided copy of the in-service read in part: Please remember to comply with proper hand washing and hand sanitizing etiquette. Many people are testing positive without showing any symptoms. Assume everybody is positive and distance yourself/protect yourself as if this is the case. Full PPE should be worn when coming within 6 feet of any resident with confirmed or presumed Covid-19. Covid-19 PPE should include the following: Gown, gloves, N95, face shield or goggles, shoe covers Perform hand hygiene for each resident before and after they eat every meal. Care partners must perform hand hygiene between delivering each room tray. The undated education for proper mask utilization education was provided by the facility on 4/27/2020. The education read in part: Masks are only needed when working with residents with respiratory symptoms or communicable issues / isolation .Masks are often misused, as every time you touch the front of the mask - put it up, pull it down - you are actually risking more exposure of germs into your facial mucous membranes. Always sanitize hands before and after doffing / donning the mask. Masks should only be touched by the loops, make all effort NOT to touch the cloth / protective area unless you have immediately sanitized your hand and then only for fitting purposes. When you affix the mask around your nose, put it on, use a clean glove or hand. REPEAT - do not touch any mask with a hand that has not been cleaned or without a fresh glove .Do not touch the front of the mask, do not pull it down to talk or eat - this contaminates it and creates more risk every time you touch your face area - take it off by the loops or strings with a clean hand, do not pull it under the chin so germs there will not attach to the mask. If dry, and the layers and shape are intact, fold it in half inwards & amp; put it in a clean marked storage bag. Do not seal the bag fully when you store it (needs to air out). When issued an N95 you must label with your name, keep it in a marked storage bag and leave it at the community in the designated area. Do not put the N95 in a pocket - to be effective, it cannot get smooshed or contaminated When not in use, put the mask in a marked storage bag and put in a safe place (e.g. nurse station, utility room, designated area) PPE for those on clinical isolation: Wear full PPE for anyone on clinical isolation. This includes booties (optional- they are slippery on non-carpeted surfaces), gown, mask, goggles (if available), and gloves When taking off full PPE, remove in this order:1) Gloves 2) Hand Hygiene 2) Goggles 3) Gown - hang gown on back of door hook inside out and spray gown with oxivir 4) remove Mask from straps without touching face 5) Booties 2) Wash hands with soap and water or ABHR (alcohol based hand rub). Clean hands additionally in between steps if you believe they become contaminated

Based on record review and interviews, the facility failed to ensure one (#33) of six residents reviewed for accidents out of 27 sample residents remained free from falls and accidents. Specifically, the facility failed to ensure Resident #33 received necessary supervision and assistance she was assessed and expected to receive during cares. The resident fell in the bathroom when left unattended, sustaining a left [MEDICAL CONDITION] which required surgery. Findings include: Fall prevention A. Facility policy and procedure The Fall Prevention and Management policy, revised (MONTH) (YEAR), was provided by the director of nursing (DON) on 11/1/18 at 2:13 p.m. The policy revealed, in pertinent part, The purpose of the fall prevention and management program is to identify residents and areas at risk for falls, initiate interventions to prevent and respond to falls and thus reduce the risk of injury due to falls. Falls are a leading cause of morbidity and mortality among nursing home residents and can result in serious injury, especially [MEDICAL CONDITION]. Fall risk assessment will result in person centered care planning to reduce the risk of falls. The Urinary Management Clinical Standard policy, revised (MONTH) (YEAR), was provided by the nursing home administrator (NHA) on 11/1/18 at 5:46 p.m. The policy revealed in pertinent part, The interdisciplinary team (IDT) will update the plan of care and communicate to the nursing staff the suggested toileting plan for the resident based upon the information obtained from the data collection and the assessment. B. Resident #33 status Resident #33, age 94, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. Record review and interviews revealed the facility had knowledge of the resident's functional limitations (unsteady gait, impaired balance and history of falling) which placed her at risk for falls and which increased her need for care and supervision to prevent falls. Record review: The 8/30/18 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of two people with bed mobility, transfers and toileting. She required extensive assistance of one person with personal hygiene. The admission 6/30/18 fall risk assessment revealed the resident had unsteady gait, required assistance with stabilization and required assistance with mobility. She scored an 11.5, which indicated the resident was a high risk for falls. The activities of daily living (ADL) care plan, initiated on 7/2/18, revealed the resident had an ADL self-care performance deficit, muscle weakness and impaired decision-making. The resident required extensive assistance of one to two people with transfers and toileting. The impaired cognitive function care plan, initiated on 7/11/18, revealed the resident had impaired thought processes and required cues and supervision regarding tasks of daily life. The intervention included to provide supervision and assistance with all decision making. The high risk for falls care plan, initiated on 7/2/18, revealed the resident was a high fall risk, had repeated falls in the past and sustained a previous [MEDICAL CONDITION], had impaired balance and unsteady gait. C. Facility failure to provide Resident #33 the assistance and supervision she was known to need and expected to receive to prevent a fall with injury during toileting. The 8/10/18 nursing progress note revealed the resident had sustained a fall in the bathroom. Upon evaluation, the resident was sent to the hospital due to left hip pain. The 8/10/18 registered nurse (RN) post fall note revealed the nurse was notified at 1:00 p.m. the resident was found on the floor in the bathroom. Resident #33 was taken to the bathroom by the certified nurse aide (CNA) approximately 10 minutes prior to the resident being found on the ground at 1:00 p.m. The resident was found by the nurse to be supine (lying face upward) with the top half of her body in the bathroom and bottom half of her body outside the bathroom. The resident's left leg was bent at the knee and externally rotated. The RN note indicated the resident screamed in pain as the nurse palpated her left leg. The resident continued to experience extreme pain in the left hip area. The resident continued to scream in pain anytime the nurse moved the resident's left leg. The nurse practitioner (NP), who was on-site, made the determination to have the resident sent to the hospital by ambulance. The 8/21/18 fall occurrence report conclusion revealed the resident was taken to the bathroom approximately 10 minutes before 1:00 p.m. on 8/10/18 by the CNA. The CNA stated to the nurse the resident was left in the bathroom, on the toilet, alone to attend to another resident. The resident required extensive assistance with transferring, toileting and mobility. The report indicated the wheelchair was not left in close proximity to the resident by the CNA. The resident attempted to get up off the toilet and move without assistance, resulting in a sustained fall and subsequent left [MEDICAL CONDITION]. The 8/16/18 hospital discharge summary revealed the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was a very high risk for recurrent falls. The resident tripped in the bathroom at the skilled nursing facility. The X-rays showed a left subcapital [MEDICAL CONDITION]. The resident underwent [REDACTED]. D. Staff interviews CNA #1 was interviewed on 10/31/18 at 10:36 a.m. She said Resident #33 required extensive assistance to participate in ADL care. She said the resident required total assistance with toileting. She said prior to the resident's fall on 8/10/18, the resident would transfer to the toilet with staff assistance. She said since the fall, the resident was too afraid to use the bathroom and had requested the CNAs change her brief in the bed. She said the resident was considered a high fall risk since her initial admission on 6/30/18, prior to the fall with the sustained [MEDICAL CONDITION] on 8/10/18. She said she was informed, upon the resident's admission to the facility, the resident was a high fall risk by the nursing staff. She said it was a part of her care plan. She said the resident could be impulsive at times. She said she was not present for the resident's fall on 8/10/18. She said she was informed the CNA had left the resident alone in the bathroom after transferring the resident to the toilet. She said the resident should never have been left alone on the toilet because of the resident's dementia, impulsivity, and high fall risk. Licensed practical nurse (LPN) #3 was interviewed on 11/1/18 at 10:33 a.m. She said the resident required total assistance with all ADL care. She said the resident was incontinent of bowel and bladder. She said the resident wore briefs and staff also transferred the resident to the toilet. She said, prior to the fall, the resident required extensive assistance for all ADL care and was considered a high fall risk. She said the resident sustained [REDACTED]. She said the resident attempted to get up off the toilet by herself and then fell causing a left [MEDICAL CONDITION]. She said the resident should not have been left alone in the bathroom because of the resident's cognitive abilities, lack of remembering to use the call light, impulsivity and classification of a high fall risk. The physical therapy assistant (PTA) was interviewed on 11/1/18 at 11:11 a.m. She said she provided physical therapy treatment for [REDACTED]. She said it was reported to her the resident was a high fall risk and had impulsive behavior prior to the fall. The DON was interviewed on 11/1/18 at 12:08 p.m. She said the resident sustained [REDACTED]. She said the CNA left the resident alone in the bathroom to attend to another resident. She said the resident attempted to get up and sustained a fall with a subsequent left [MEDICAL CONDITION]. She said the resident was considered a high fall risk upon her initial admission to the facility on [DATE], a little over a month prior to the fall. She said the resident's high fall risk was identified on the care plan and the care directives for the CNAs. She said residents who had high fall risk and cognitive impairment, were unable to call for help and did not have good trunk control should not be left alone in the bathroom. She said Resident #33 had cognitive impairment, was a high fall risk and did not use her call light regularly. She said the standard of practice was for the CNAs to read the care plan and care directives, know a resident was considered a high fall risk and follow the plan of care. She said the CNA did not read the resident's care plan to identify the resident was a high fall risk and should not be left alone in the bathroom. She said following the resident's fall on 8/10/18, the CNA was provided education on reading and understanding each resident's plan of care, identifying residents that were a high fall risk, and understanding how much assistance each resident required. She said following the incident on 8/10/18, the facility put an assessment into place, for all residents, to determine if a resident could be left alone once transferred to the toilet.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents caused by hot beverage temperatures, affecting residents consuming hot beverages, including seven of 39 sample residents (#88, #38 #67, #68, #91, #103, and #114), all of whom drank hot beverages every day made with hot water from the facility hot beverage brewing machines. Specifically, the facility did not consistently monitor and record the temperature of hot water from the facility hot beverage brewing machines, resulting in hot water being provided to residents from these machines at a range of high temperatures that could exceed 180 degrees Fahrenheit (°F). The facility did not routinely evaluate residents for the safe consumption of hot beverages (hot water or coffee), did not timely and thoroughly investigate a second degree hot beverage burn sustained by resident #88, or implement a system after resident #88 sustained burns to ensure hot beverages were served to residents at safe temperatures. The facility failures created a situation of immediate jeopardy for serious harm to residents that consumed hot beverages. The findings include: I. Immediate Jeopardy A. Imposition of Immediate Jeopardy On 4/20/17 at 1:00 p.m., the nursing home administrator (NHA), director clinical services (DCS), director of nursing (DON), assistant director of nursing (ADON), and registered dietician (RD) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures in timely addressing concerns related to hot beverage temperatures served in the dining rooms which resulted in harm to one resident (resident #88), created a situation of immediate jeopardy for serious harm to resident safety. B. Facility Response to Immediate Jeopardy On 4/20/17 at 7:48 p.m., a plan was submitted by the facility to CDPHE. Abatement Plan Response to Immediate Jeopardy 1. Resident specific actions A. Resident (medical record number for resident #88) received burns to both thighs on 4/17/17 at 11:45 a.m. B. The resident received first aid for her wounds. Physician and family notified. C. Pain assessed 4 (four) times, then every shift following with no complaints. D. Acute care plan implemented on 4/20/17. E. Physician assessed on 4/18/17, orders written. F. Hot beverages are only to be served at 135 degree Fahrenheit in a cup with a lid. G. Skin observations completed on 4/17/17, 4/18/17 by the Director of Nursing, skin assessment was completed on 4/20/17. H. Incident report initiated then investigated completed on 4/20/17. I. Treatment included cold packs on 4/17/17, then orders initiated for daily dressing change of cleanse with normal saline, apply thin layer of Silvadene and cover with Xeroform, followed by Kerlix on 4/18/17. 2. Identifying other residents at risk A. Three residents drink hot tea and four residents drink hot cocoa every day, both made with hot water. There are five additional residents who enjoy hot cocoa on occasion. All are at risk if the water used to make those drinks is taken from the hot water spigot on the coffee makers. B. The hot water spigot on the coffee makers were removed at 3:00 p.m. on 4/20/17 to prevent its use from both Health Suites kitchenettes. No continued risk is identified. C. Cups with lids are now provided for beverages mixed with hot water. D. Hot beverages are tempted and are served only when they temp at 135 degrees or below. 3. Actions for correction A. A procedure water mixed hot beverages are served after they temp at 135 degrees or below, implemented on 4/20/17. B. Temperatures will be obtained during each meal service by the assigned kitchen cook for compliance, with ongoing monitoring completed by the Registered Dietician (RD), Dining Services Director (DSD) or their designee. Completion date: 4/20/17 C. The DSD contacted the coffee maker vendors and had the water spigots removed on both coffee makers on 4/20/17. D. The RD obtained cups with lids to use for residents with water based hot drinks and were made available on 4/20/17. A supply of cups will available in the kitchen cabinet and available to staff for resident use 24 hours a day. The RD or her designee will monitor their use on an ongoing basis, as well as ensure an adequate supply is always available with backup cups stored in the Central Supply closet, which is available to all nursing staff. E. Staff training and ongoing monitoring 1. Dining services staff who support the Health Suites kitchenettes received training on the hot beverage temperatures dictating that hot beverages be cooled to 135 degrees before serving, completed on 4/20/17. The RD and DSD will provide ongoing monitoring to ensure compliance, with any negative trends reported to the Quality Committee monthly. 2. Nursing and administrative staff received training regarding staff providing residents with hot beverages only after the dining room cooks have established that they have been properly temped, completed on 4/20/17. Dining room host will monitor during hosted meal and document on the hot audit form, reporting any identified issues to the RD, with any negative trends reported to the Quality Committee monthly. 3. Staff training has been initiated starting 4/20/17 with directions covering how to heat and temp beverages if a cook is unavailable. All nursing staff will be trained with this competency. The instruction will include how to heat the beverage, how take a temp, as well as how to cool down the beverage to 135 degrees or below. The DON will verify that all staff is trained cross reference the active associate roster to associates trained for full training for current employees. A skills checklist competency will be added to the new hire orientation checklist including this expectation. The staff will also be expected to log the food temps, which will receive ongoing monitoring by the RD, with any negative trends reported to the Quality Committee monthly. 4. Post injury assessment was initiated highlighting expectations training on 4/20/17. The DON and ADON will provide ongoing monitoring through the incident reporting system and the electronic health record (HER), which any negative trends reported to the Quality Committee monthly. 5. The ADON and DON, or their designee, will review all incident during morning nursing leadership huddle to assess and initiate investigation, and ensure appropriate notification and follow up was completed. Ongoing monitor will be conducted by the DON, with any negative trends reported to the Quality Committee monthly. 6. Skin expectations and competencies, including the frequency of assessment, training was initiated on 4/20/17. DON and Assistant DON will provide ongoing monitoring through the alert system initiated through the electronic health record (EHR) for appropriate follow up and actions, with any negative trends reported the Quality Committee monthly. 7. The skin competency expectation will be added to our online education system for completion by all nursing staff by 5/1/17. DON or her designee will monitor for full nursing staff completion. 8. A request has been made for the resident to have a follow up appointment on 4/21/17. The ADON will follow with the physician's office to ensure the resident is seen, then schedule any future follow ups needed. The DON will monitor for compliance. C. Removal of Immediate Jeopardy On 4/20/17 at 8:00 p.m., the NHA, executive director (ED), director of clinical quality and compliance (DOCQC), DCS, DON, ADON, and RD were notified the above plan was accepted and the immediate jeopardy situation was removed. However, based on observations, record review and interviews, the deficient practice remained at a G level, actual harm that is isolated. II. Failure to have a system to safely serve hot beverages A. Professional Reference According to the American Burn Association, Scald Injury Prevention Educator's Guide undated, http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf (May 2017), reveals the following pertinent information: -Older adults .have thinner skin so hot liquids cause deeper burns with even brief exposure . -Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids. Burns to the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Moving hot liquids can be extremely difficult for someone who uses a cane or walker. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger . -The water temperature for a third degree burn to occur: --155 degrees Fahrenheit (F) for one second; --148 degrees F for two seconds; --140 degrees F for five seconds; --133 degrees F for 15 seconds; --127 degrees F for one minute; --124 degrees F for three minutes; and --120 degrees F for five minutes. B. Facility Policy The NHA said the facility had a policy that set the temperature at which hot beverages must be maintained; however, the facility did not have a policy related to the maximum safe temperature for hot beverages, when the policy was requested on 4/20/17 at 12:17 p.m. The RD was interviewed on 4/20/17 at 12:35 p.m. She said there was not a policy regarding the maximum temperature of a hot beverage. C. Burn incident 4/17/17 Resident #88, in an interview on 4/20/17 at 11:09 a.m., said on 4/17/17, she sustained burns to both of her upper legs after very hot water/tea spilled onto her lap. A 4/17/17 incident report revealed on 4/17/17 at 11:45 a.m. the resident was eating in the dining room when she sustained a burns to her thighs. The report was completed by licensed practical nurse (LPN) #1 who witnessed the incident. The report documented the resident had a red and blistered burn to the left thigh. The section documenting immediate actions taken revealed the following: ice pack applied, placed in wheelchair, medicated ointment applied, cleanse area, dressing applied, and no pain when range of motion (ROM) performed. The section documenting other action taken revealed the resident had intact blisters to both inner thighs. See below for further details regarding the 4/17/17 incident. D. Observations Observations on 4/20/17 revealed the facility served residents hot beverages in heavy ceramic mugs. Hot water, used for tea and cocoa, was provided to residents directly from the hot water dispenser on the hot beverage brewing machines. Temperatures from the hot water dispenser exceeded 160°F. Dining room #1, located on the first floor, was observed on 4/20/17 beginning at 11:24 a.m. -At 11:24 a.m., multiple green ceramic mugs were located in the dining room and available for resident use. When lifted, the empty green ceramic mugs felt heavy and weighted. -The hot water dispenser, for making tea and cocoa, was located on the upper right side of the coffee machine. -At 11:27 a.m., cook #4 filled a green ceramic mug with hot water from the hot water dispenser. The ceramic mug was hot to touch and difficult to pick up. Using cook #4's thermometer, the hot water out of the hot water dispenser was 170.8 degrees F. -At 11:28 a.m., cook #4 filled a green ceramic mug with hot water from the hot water dispenser. Using cook #4's thermometer, the hot water measured 185 degrees F. Dining room #2, located on the second floor, was observed on 4/20/17 at 11:31 a.m. -At 11:31 a.m., multiple green ceramic mugs were located in the kitchenette cabinets and were available for resident use. -At 11:33 a.m. cook #3 filled a green ceramic mug with hot water from the hot water dispenser. Using cook #3's thermometer, the hot water out of the hot water dispenser measured 170.4 degrees F. -At 11:34 a.m., cook #3 filled a green ceramic mug with hot water from the hot water dispenser and carefully handed the mug to certified nurse aide (CNA) #1. CNA #1 delivered the hot water to a resident sitting in the dining room. -At 11:35 a.m. a cook #3 again filled a green ceramic mug with hot water from the hot water dispenser. Using cook #3's thermometer, the hot water out of the hot water dispenser was 183.4 degrees F. E. Staff Interviews Interviews with facility leadership, nursing staff and kitchen staff revealed the facility did not have a system to ensure hot beverages were served to residents at a safe temperature. Staff did not know what would constitute a safe temperature for hot beverages. Additionally, after resident #88 sustained a burn injury from hot water/tea on 4/17/17, the facility did not take steps to implement a system to ensure residents were served hot beverages at a safe temperature. Cook #4 was interviewed on 4/20/17 at 11:29 a.m. She said the thermometer to check hot water temperatures was calibrated daily. She said there was no maximum temperature for hot beverages served to residents, and she denied knowledge of any resident spilling hot water/tea onto him or herself. She confirmed the ceramic mug was hot to the touch when filled with hot fluids. The cook said the facility practice was to serve the residents hot water from the dispenser for hot cocoa or tea directly. CNA #7 was interviewed on 4/20/17 at 11:30 a.m. She said the green ceramic mugs were hot to touch when filled with hot liquids. She said the residents were aware the hot water and mugs were quite hot and waited to drink their beverages. To her knowledge, there were no insulated cups with lids available in the dining room. Cook #2 was interviewed on 4/20/17 at 11:33 a.m. She said the thermometer to check hot water temperatures was calibrated every few days using ice water. She said there was no maximum temperature for hot beverages served to residents. The cook said hot water was served to residents from the hot water dispenser on the hot beverage brewing machines directly in the green ceramic mugs, unless staff was directed differently. CNA #1 was interviewed on 4/20/17 at 11:34 a.m. She said she was unsure what water temperature would be considered unsafe. She said on most days, the cooks retrieve the hot water from the hot water dispensers on the hot beverage brewing machines and the CNAs serve the water with tea bags or hot chocolate to the residents in the dining room. She denied knowledge of any resident spilling hot water/tea onto him or herself. The minimum data set (MDS) specialist was interviewed on 4/20/17 at 11:35 a.m. She said she was unsure what temperature would be a maximum safe temperature for serving hot beverages to residents. Cook #3 was interviewed on 4/20/17 at 11:37 a.m. She said hot beverage temperatures were required to be around 180 to 190 degrees F prior to meal service. She produced the temperature log and checklist which revealed the coffee temperature currently was 181 degrees F. The hot water temperature was not recorded. Cook #4 was interviewed on 4/20/17 at 11:41 a.m. She said hot beverage temperatures were monitored during breakfast, lunch, and dinner meal service. She said the ceramic coffee mug held 240 cc of fluids. The NHA, DON, ADON, and DCS were interviewed on 4/20/17 at 12:17 p.m. All said they were unaware of the relationship between time and hot liquid temperatures to severe burns. All said they were unaware of the maximum temperature for safe service of hot beverages to residents but said, per facility policy, all beverages were required to be maintained above 150 degrees F. The NHA said the hot water temperatures on the hot beverage brewing machines in the dining rooms had not been reviewed, monitored, or lowered following the 4/17/17 incident involving resident #88. The RD and NHA were interviewed on 4/20/17 at 12:30 p.m. The RD said an outside company monitors the coffee machines with the hot water dispenser attached. She reported the company had not been contacted to evaluate the water temperature after the 4/17/17 incident, and confirmed the green ceramic mugs were hot to the touch. The NHA said the machine self-regulates hot water temperature; the facility is unable to adjust the temperature. The RD was interviewed on 4/20/17 at 12:35 p.m. She said, per facility policy, all beverages were required to be maintained above 150 degrees F. She said she was unaware of the relationship between time and hot liquid temperatures to severe burns and unaware of the maximum temperature for safe hot beverage service. The RD was interviewed on 4/20/17 at 12:40 p.m. She said the dietary staff were not informed of the 4/17/17 burn incident involving the hot water/tea served to resident #88. She revealed she did not know about the incident until Tuesday, 4/18/17, and confirmed the hot water temperature was not reviewed or lowered, and no process had been implemented to monitor water temperature after the incident. F. Record Review Temperature Logs: A review of the hot beverage temperature log demonstrated the facility's hot beverages were consistently over 160°F prior to the incident with a hot beverage on 4/17/17. The beverage logs demonstrated that the facility's hot beverages after the 4/17/17 incident continued to be at temperatures exceeding 160°F, with hot beverages logged as high as 181°Fon 4/20/17, which was three days after the hot beverage incident occurred. The Temperature Log and Checklist revealed hot beverages and soups were required to be held greater than or equal to 150 degrees F. The first floor temperature log and checklist revealed: -4/6/17, the breakfast hot water/coffee temperature was 169 degrees F. Lunch and dinner were not documented; -4/7/17, the breakfast hot water/coffee temperature was 172 degrees F and lunch was 168 degrees F. Dinner was not documented; -4/8/17, the breakfast hot water/coffee temperature was 168 degrees F. Lunch and dinner were not documented; -4/9/17, the breakfast hot water/coffee temperature was 179 degrees F and lunch was 182 degrees F. Dinner was not documented; -4/10/17, the breakfast hot water/coffee temperature was 170 degrees F and lunch was 171 degrees F. Dinner was not documented; -4/11/17, the breakfast hot water/coffee temperature was 170 degrees F. Lunch and dinner were not documented; -4/12/17, the breakfast hot water/coffee temperature was 171 degrees F and lunch was 167 degrees F. Dinner was not documented; -4/13/17, the breakfast hot water/coffee temperature was 170 degrees F, lunch was 167 degrees F, and dinner was 178 degrees F; -4/14/17, the breakfast hot water/coffee temperature was 172 degrees F and lunch was 165 degrees F. Dinner was not documented; -4/15/17, the breakfast hot water/coffee temperature was 171 degrees F and lunch was 170 degrees F. Dinner was not documented; and -There was no temperature log for 4/16/17. -4/17/17 , the breakfast hot water/coffee temperature was 171 degrees F and dinner was 178 degrees F. Lunch was not documented. -4/18/17, the breakfast hot water/coffee temperature was 172 degrees F and lunch was 170 degrees F. Dinner was not documented; -4/19/17, the breakfast hot water/coffee temperature was 168 degrees F and lunch was 170 degrees F. Dinner was not documented; and -4/20/17, the breakfast hot water/coffee temperature was 170 degrees F and lunch was 168 degrees F. The second floor temperature log and checklist revealed the following pertinent information: -4/6/17, the breakfast hot water/coffee temperature was 178 degrees F and lunch was 180 degrees F. Dinner was not documented; -4/7/17, the breakfast hot water/coffee temperature was 177 degrees F. Lunch and dinner were not documented; -There were no hot beverage temperatures documented on 4/8/17; -4/9/17, the breakfast hot water/coffee temperature was 169.8 degrees F, lunch was 170.6 degrees F, and dinner was 180 degrees F; -4/10/17, the breakfast hot water/coffee temperature was 180.1 degrees F, lunch was 176.1 degrees F, and dinner was 166.2 degrees F; -4/11/17, the breakfast hot water/coffee temperature was 167.5 degrees F and lunch was 168.1 degrees F. Dinner was not documented; -4/12/17, the breakfast hot water/coffee temperature was 176 degrees F and lunch was 182 degrees F. Dinner was not documented; -4/13/17, the breakfast hot water/coffee temperature was 178 degrees F and lunch was 180 degrees F. Dinner was not documented; -4/14/17, the breakfast hot water/coffee temperature was 181 degrees F, lunch was 178 degrees F, and dinner was 178 degrees F; -There were no hot beverage temperatures documented on 4/15/17; -There was no temperature log on 4/16/17; -There were no hot beverage temperatures documented on 4/17/17. -There were no temperature logs on 4/18/17 and 4/19/17; and -4/20/17, the breakfast hot water/coffee temperature was 181 degrees F and lunch was 172 degrees F. G. Additional Staff Interviews Interview with the NHA on 4/20/17 at 1:09 p.m. revealed the coffee machine was a high temperature machine, and coffee had to brew at 180 degrees F, which corresponded to the elevated temperatures on the temperature log and checklist above. Cook #3 and the RD, interviewed on 4/26/17 at 8:24 a.m. and 8:26 a.m., reviewed the temperature log and checklist and confirmed the temperatures recorded were coffee temperatures. Hot water temperatures were not obtained and/or documented on the logs. III. Resident #88 Cross-reference to F 309 for observations, interviews and record reviews evidencing the resident sustained [REDACTED]. A. Resident Status Resident #88, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 3/20/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance of one staff member with activities of daily living (ADLs), and supervision of one staff member with eating. She used a walker and wheelchair for mobility, and was unsteady during transitions and walking. She did not have a second or third degree burn(s), and denied pain during the pain assessment interview. She utilized corrective lenses, and height was 65 inches and her weight was 146 pounds. Prior MDS assessments completed on 12/18/16 and 5/6/16 documented the resident had functional limitations in range of motion (ROM) on one side of the upper extremity. The care plan initiated on 4/13/16 and revised on 1/6/17 identified the resident had an ADL self-care performance deficit. Interventions included supervision by one staff member to eat and cueing, encouraging and set-up assistance with meals. The care plan initiated on 4/14/16 identified the resident had impaired thought process including poor safety awareness and impaired decision making capacity. Interventions included cue, reorient and supervise resident as needed. The care plan initiated on 4/10/16 and updated on 8/18/16, identified the resident had limited physical mobility related to weakness. Interventions included monitor, document, and report any signs and symptoms of immobility, contractures forming or worsening, thrombus formation, skin-breakdown, and fall related injury and restorative walking, stand on her left side and provide cues to stand up tall as needed. The care plan initiated on 4/13/16 identified the resident had impaired visual function. Interventions included inform the resident where you are placing items and be consistent. The care plan did not specify placing items on the right side, which was the resident's stronger side. (See resident interview below) The care plan initiated on 4/15/16 and updated on 4/18/17, identified the resident was at-risk of a nutrition and hydration deficit related to burn, infection, pain, dysphagia, depression, Alzheimer's disease, esophageal stricture, laxative use, diuretic use, antidepressant use, limited mobility, and history of pressure injury and incontinence. Interventions included: - Provide the resident necessary assistance at meal time, and between meals-please place my cups and mugs to my right hand side; and - I have a special covered cup with the resident's name on it. Please use the cup for any hot beverages. (See below for resident and staff interviews that the resident did not use a special lidded cup at the time of the 4/17/17 burn incident.) B. Failures Contributing to the Hot Beverage Burn 1. Resident Interview The resident was interviewed on 4/20/17 at 11:09 a.m., and 9:36 a.m. The interview revealed: -The resident said enjoyed drinking hot tea daily at meals. She had left shoulder pain and weakness at times. According to the resident, staff did not always place hot beverages on her right side, which was her stronger side. -She said on 4/17/17, she sustained burns to both of her upper legs after very hot water spilled onto her lap. She reported she was wearing thin, blue pants with an incontinence brief underneath at the time of the incident. -Hot beverages were served in ceramic mug, which was heavy and could be hot to the touch. She said prior to the hot water burn incident, she did not have access to an insulated hot beverage cup with a lid. -The resident said on 4/17/17, staff placed the mug of hot water to her left side instead of her right side. She said when she attempted to move the heavy, hot, filled-to-the-top mug of hot water from the left to the right side of the table, the liquid was spilled onto her lap causing immediate pain. She began yelling for help, and licensed practical nurse (LPN) #1 threw cold water into her lap. -The resident said initially the skin on her thighs where she was burned was reddened; however, within hours of the incident her reddened areas turned to blisters. 2. Record Review A review of the clinical record failed to identify an assessment to determine the resident's safety with hot beverages. A review of the care plans (see above) revealed the facility did not have a resident-specific plan of care that instructed staff to place items, like hot beverages, on her right side at meal times. The 4/7/17 daily skilled note completed by RN #1 revealed the resident had reoccurring pain in the front of the left shoulder. She was independent with no setup or assistance from staff with eating. The 4/8/17 daily skilled note completed by LPN #2 revealed the resident had reoccurring pain, and received support from a pillow and Amicare gel to the left shoulder. The 4/9/17 daily skilled note completed by LPN #2 revealed the resident had new or worsening pain, but the pain rating and location were not documented. She was independent with setup help only with eating. The 4/10/17 and 4/11/17 daily skilled note completed by RN #1 revealed the resident had moderate pain in the front of the left shoulder. She was independent with no setup or assistance from staff with eating. In contrast to the above daily skilled notes, the undated, untitled ADL report revealed the resident required supervision by one staff member to eat. She required cueing, encouragement, and set-up assistance. All meals were required to be eaten in the dining room. She required .necessary assistance at meal time and between meals-please place my cups and mugs to my right hand side . She had limited movement in her arms, and required assistance with bathing and showering. The 4/17/17 Nurse's Note completed by LPN #1 at 4:46 p.m. revealed the resident spilled hot tea in her lap. This event occurred in the dining room. At 5:12 p.m. LPN #1 documented there were blisters on both inner thighs. Review of the 4/17/17-4/20/17 nurse's notes, including all progress notes did not reveal interventions to reduce the hot water temperature and/or interventions to prevent further injury from hot water temperature. 3. Staff Interviews Staff interviews revealed the resident was known to like her beverages hot, to move items on the table, and to have left sided pain/weakness. Facility leadership identified the need for, but did not timely implement, an insulated, lidded mug for the resident's safe consumption of hot beverages. Prior to the resident's hot beverage burn, the facility did not have a system in place to screen residents for hot beverage consumption safety. CNA #7 was interviewed on 4/20/17 at 11:30 a.m. She said the resident required placement set-up, with beverages placed on the right side during meals. The resident had left-side pain and weakness at times. Per the CNA, the resident was shaky and had memory impairment at times. The resident had a history of [REDACTED]. Cook #4 was interviewed on 4/20/17 at 11:41 a.m. The resident occasionally shook and liked to move objects on the table around or out of her way prior to being served a meal. She preferred her cups and mugs to be placed on her right side. The ADON was interviewed on 4/20/17 at 11:48 a.m. The ADON said staff discussed obtaining an insulated hot beverage cup with a lid for the resident either during the December 2016 or March 2017 care conference. The ADON said the insulated hot beverage cup with a lid was not purchased for the resident because in December 2016, the resident said she wanted to pick out her own cup. The ADON said the resident sustained [REDACTED]. The MDS specialist was interviewed on 4/20/17 at 11:51 a.m. and 3:32 p.m. The MDS specialist said staff discussed obtaining an insulated hot beverage cup with a lid for the resident either during the December 2016 or March 2017 care conference. The MDS specialist said the cup was never purchased. The MDS specialist said the resident enjoyed super-hot tea and the ceramic mugs were not holding the appropriate temperature to the resident's preference. The MDS specialist said a cup with a lid was discussed in order to promote safety while consuming the hot beverage. The MDS specialist reported she reviewed the care conference notes and this conversation was not documented. LPN #1 was interviewed on 4/26/17 at 9:33 a.m. She said the resident organizes items on the table prior to meal service, which includes moving around salt and pepper, beverages, and napkins. The resident required her hot tea and other beverages on her placed on her right side. The resident was shaky and had left-sided weakness and pain at times. More specifically, she had pain in the left shoulder and neck. LPN #2 was interviewed on 4/26/17 at 3:11 p.m. She said the resident had left-side pain, which required cares to be provided differently at times. She was known to rearrange items in the dining room, and required set-up assistance only with meals. She preferred certain items to be placed on the right side and others placed on the left side. Every once in a while the resident had tremors, and she was not always ambulatory. IV. Failure to Timely and Completely Investigate Burn Incident A. Record Review: On 4/20/17 at 4:49 p.m. the NHA provided a copy of the first incident report completed by LPN #1. Upon review, the incident report did not have witness statements, pain symptoms, wound measurements, staff interviews, root caus

Based on observations, interviews and record review, the facility failed to timely conduct assessments, consistently implement interventions to promote healing, prevent infection, and relieve pain of a known skin injury for one (#88) of three residents identified with skin impairment of 39 sample residents. Specifically, the facility failed to timely and comprehensively assess the resident'[MEDICAL CONDITION]-incident; utilize an appropriate initial treatment; implement wound treatment as ordered by the physician; update the care plan to reflect the presence of burn wounds to the bilateral thighs; treat the resident's pain prior to wound care; and timely follow-up on new reports of pain at the burn site. The facility failures contributed to the resident developing an infection to the burn on the left leg with increased pain, as well as unplanned, undesired changes in her quality of life. The findings included: Cross-reference F323 accident hazards and F325 nutritional status 1. Professional Reference Lloyd ECO, Rodgers BC, Michener M, and Williams MS. Outpatient Burns: Prevention and Care. American Family Physician. 2012;Vol 85, No 1. http://www.aafp.org/afp/2012/0101/p25.html (5/2017). -[MEDICAL CONDITION] considered trauma .The skin's three anatomic layers (i.e., epidermis, dermis, and subcutaneous tissue) have functions that are lost after burn injuries. The epidermis is a barrier to bacteria and moisture loss. After a burn injury, local wound care and fluid management are required . -Topical burn care is the topic of many studies and discussions. Burn wounds heal best in moist not wet environments that promote re-[MEDICATION NAME] and prevent cellular dehydration. This environment is best created by applying a topical agent or occlusive dressing to reduce fluid loss. Topical agents provide pain control, promote healing, and prevent wound infection and desiccation . - Infections can progress rapidly .Although [MEDICAL CONDITION] is not common in burns, it can cause the skin to become severely [DIAGNOSES REDACTED]tous, exudative, painful, and swollen . -Second-[MEDICAL CONDITION] all of the epidermis and part of the underlying dermis. Superficial partial-[MEDICAL CONDITION] the upper layers of the papillary dermis; they are identified by clear blisters and weeping, wet, [DIAGNOSES REDACTED]tous skin, and they blanch painfully when touched. [MEDICAL CONDITION] within two weeks and generally do not cause scarring; however, scarring and pigment changes are possible . -Deep second-[MEDICAL CONDITION] the deeper layers of the dermis (i.e., reticular dermis). They appear white and do not blanch. [MEDICAL CONDITION] not heal in less than three weeks and often result in scarring and contractures . -Third-[MEDICAL CONDITION] all skin layers, including underlying subcutaneous fat. They are dark brown or tan and have a leathery feel with no sensitivity to touch. These wounds often require skin grafts, and can result in contractures . 2. Facility Policy The director of nursing (DON) was interviewed on 4/20/17 at 12:10 p.m. She said the facility did not have a policy and/or protocol related to the assessment and treatment of [REDACTED]. (See facility follow-up below for Skin Integrity Clinical Standard policy and procedure developed during survey.) 3. Resident Status Resident #88, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 3/20/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance of one staff member with activities of daily living (ADL), and supervision of one staff member with eating. She used a walker and wheelchair for mobility, and was unsteady during transitions and walking. She did not have a second or third degree burn(s). The resident denied pain during the pain assessment interview. She had a scheduled, as needed (PRN), and non-medication interventions in place for pain management. The care plan initiated on 4/13/16 identified the resident had potential for impairment to the skin. The care plan had not been updated with new interventions since it was initiated. The care plan, initiated and last updated with new interventions on 4/13/16, identified the resident had chronic pain. Review of the 4/13/16 chronic pain care plan did not reveal resident-specific pain frequency, intensity, location and /or medication and non-medication interventions. Planned interventions included administering [MEDICATION NAME] per orders one half an hour before treatment or care. 4. Background/Risk Factors for Injury The resident was interviewed on 4/20/17 at 11:09 a.m. The resident said she enjoyed drinking hot tea daily at meals. She had left shoulder pain and weakness at times. According to the resident, staff did not always place hot beverages on her right side, which was her stronger side. She said hot beverages were served in ceramic mug which was heavy and could be hot to the touch. A nurse's progress note dated 4/18/17 at 5:58 p.m., read the resident moves dishes around table very quickly. Likes to be served right away so she can leave. Has knocked things over in the past . Cross reference to F323. The facility failed to assess and care plan the resident for hot beverage safety. Interviews with the director of nursing (DON) related to facility failures to have a process for residents' safe use of hot beverages. 5. Burn Incident The resident, during her interview on 4/20/17 at 11:09 a.m., said on 4/17/17 she [MEDICAL CONDITION] both of her upper legs after very hot water spilled onto her lap. She reported she was wearing thin, blue pants with an incontinence brief underneath at the time of the incident. The resident said on 4/17/17, staff placed the mug of hot water to her left side instead of to her right side. She said when she attempted to move the heavy, hot, filled-to-the-top mug of hot water from the left to the right side of the table, the liquid was spilled onto her lap causing immediate pain. She began yelling for help, and licensed practical nurse (LPN) #1 threw cold water into her lap. The resident said initially the skin on her thighs where she was burned was reddened; however, within hours of the incident her reddened areas turned to blisters. The 4/17/17 incident report revealed on 4/17/17 at 11:45 a.m. the resident was eating in the dining room when she sustained a first degree burn. The report was completed by LPN #1 who witnessed the incident. The report documented an ambulance was not called. The report documented the resident had a red and blistered burn to the left thigh. (But see professional reference above showing blisters indicate second degree burns.) The section documenting immediate actions taken revealed the following: ice pack applied, placed in wheelchair, medicated ointment applied, cleanse area, dressing applied, and no pain when range of motion (ROM) performed. The section documenting other action taken revealed the resident had intact blisters to both inner thighs 6. Initial Burn Observation and Interviews The resident's burn was observed on 4/20/17 at 4:45 p.m. with the DON, nursing home administrator (NHA), and registered nurse (RN) #1. RN #1 removed the Xeroform gauze and dressing to reveal the resident'[MEDICAL CONDITION] the hot water spill in the dining room. The right inner to upper thigh had four irregular shaped blisters that touched one another. One of the four blisters was open, and the skin surrounding the blisters was irregular, reddish-brown in color. The wound bed of the open blister to the right thigh was moist and pink in color. The left inner to upper thigh had an open area located below the groin area that was approximately 7 cm by (x) 4.5 cm in size. The wound bed to the open blister on the left leg was moist and pink in color. The skin surrounding the left leg blister was irregular, reddish-brown in color. There was an intact blister located on the left inner thigh. The shape of the burned area to both thighs was irregular and skin color was reddish-brown. The size of the burned area covered most of the resident's bilateral thighs. There were no signs of infection observed. The NHA was interviewed on 4/25/17 at 3:35 p.m. The NHA provided a copy of a document that calculated nine percent of the resident's body was covered by the burn area. According to the NHA, the document demonstrated the burned area included three quarters of the right and left front thighs. 7. Facility Failures Post-Incident a. Timely Assessment and Notification Record Review: A review of the resident's records showed the resident's burn wounds were not assessed by a RN on 4/17/17. The initial RN assessment of the wound was documented on 4/20/17 (during survey). The delay in assessment contributed to a delay in selecting an appropriate treatment for [REDACTED]. The 4/17/17 Nurse's Note completed by LPN #1 at 4:46 p.m. revealed the resident spilled hot tea in her lap. This event occurred in the dining room, and cold water was applied to stop the burning. The resident was taken to the room and pants removed. The resident had red thighs. Cold cloths were applied to the thighs. There were no blisters and skin blanched when touched. At 5:12 p.m., LPN #1 documented there were blisters on both inner thighs. Skin-prep was applied. The notes did not document either the DON or a RN was notified of the resident's injury. Review of the nursing notes failed to evidence RN assessment to the burn wounds on the resident's thighs on 4/17/17. Review of the assessments (skin assessments, wound assessment, change of condition) revealed no RN assessment to the burn wounds on the resident's thighs on 4/17/17. The 4/18/17 nurse's note completed by LPN #1 documented the blisters were intact to the resident's bilateral thighs. The surrounding skin was red and blanched with touch. The note did not contain measurements or other pertinent documentation (e.g., presence/absence of drainage, odor, and signs of infection) related to the burn wounds. A review of the nurse's notes failed to evidence RN assessment to the burn wounds on the resident's thighs on 4/18/17. Review of the assessments (skin assessments, wound assessment, change of condition) revealed no RN assessment to the burn wounds on the resident's thighs on 4/18/17. The 4/18/17 physician progress notes [REDACTED]. The physician documented the resident had second [MEDICAL CONDITION] the upper left and right legs which required conservative care and monitoring for infection. It was reported [MEDICAL CONDITION] 12 to 24 hours prior to the physician visit at nursing facility. Both the left and right leg had blisters and [DIAGNOSES REDACTED] (redness). The pain was a severity of five out of 10, which was determined to be moderate. The resident had tried running the burn under water and had received narcotic [MEDICATION NAME] for the symptoms. The treatment provided mild relief. The 4/20/17 at 5:09 p.m. Skin/Wound Note was completed by the DON and revealed the resident had Areas to Bilateral upper inner thighs: Blister areas are now open. Skin in these areas (is) clean and pink. Left upper thigh has two areas where blisters had been present. One area is measured at 7cm x 4.5cm. Another area on the left upper thigh is 1.75 x 1.75 distal to this. These areas are surrounded by light brown skin that was initially reddened and now measures at 12 x 13.75. Area to R. upper thigh has one open area where blister previously was and measures 1.8 x 1.8 and is quarter shaped. The area surrounding the area is a brown discolored area measuring at 15.75 x 10. No drainage noted, No signs or symptoms of infection. Resident currently denies pain . Staff Interviews: Staff interviews revealed the resident'[MEDICAL CONDITION] observed by a RN on 4/18/17; however, the wounds were not assessed and documented in the clinical record by a RN until 4/20/17. The NHA, DON, assistant director of nursing (ADON), and director of clinical services (DCS) were interviewed on 4/20/17 at 12:17 p.m. All said the resident sustained [REDACTED]. The NHA and DON said the nurse on duty failed to report the 4/17/17 incident to administration on 4/17/17. The wound was not assessed by a RN until the following day (4/18/17). The interview revealed a RN was required to observe and document assessment findings in the progress notes following an incident. All agreed a RN did not assess the resident on 4/17/17. The DON said the facility required a more timely response to incidents. The ADON said a skin/wound and pain assessment had not been completed on 4/17/17, 4/18/17, 4/19/17, and as of the time of the interview on 4/20/17. The DON was interviewed on 4/20/17 at 4:45 p.m. The DON was unable to describe the appearance of the burn prior to 4/20/17. She said the weekly skin assessment was not completed, and there was no progress note related to the wound by a RN from 4/17/17 to 4/20/17. The DON said a RN is responsible for completing a skin/wound assessment immediately following an incident. She revealed measurements of a burn were not a part of the facility's policy/protocol. She classified the burn on the left and right thighs as a second-degree burn. The DON explained this judgment was made because the damage extended beyond the top layer of skin; a second-degree burn caused the skin to blister and become extremely reddish-brown and sore. LPN #1 was interviewed on 4/26/17 at 9:33 a.m. The LPN said the physician and family member were notified of the incident on 4/17/17, but she did not notify the DON. She confirmed a RN had not assessed the resident on 4/17/17. The LPN said on 4/17/17, she informed the ADON, who was a LPN, in passing of the incident. b. Treatment Errors Record Review: A 4/17/17 telephone order (TO) documented an order to apply skin prep to bilateral blisters on front thighs every shift, two times a day, until resolved for hot tea burn. The order was written on 4/17/17 and discontinued on 4/18/17. The April 2017 treatment administration record (TAR) showed skin prep was applied to [MEDICAL CONDITION] both legs on 4/17/17 but was not applied on 4/18/17. (See interviews with physician and DON below for confirmation that skin prep is not an appropriate treatment for [REDACTED]. A 4/18/17 TO documented an order to apply [MEDICATION NAME] cream one percent to bilateral thighs topically every day shift for burn. The April 2017 TAR documented the treatment order for application of [MEDICATION NAME] cream one percent topically every day shift for burn was initiated on 4/18/17. The order did not include instruction to cleanse or dress the wound. The April 2017 TAR showed the treatment was completed from 4/18/17 through 4/25/17. The order was discontinued on 4/25/17. (See below: the left thigh burn was diagnosed as infected on 4/25/17.) A 4/18/17 TO documented an order to treat [MEDICAL CONDITION] the resident's thighs. The order directed staff to cleanse the area with normal saline; apply thin layer of [MEDICATION NAME] over blistered and reddened area; and cover wound with Xeroform gauze and wrap with Kerlix every day shift and as needed for burn treatment. The April 2017 TAR documented the order as above except for frequency; the April 2017 TAR documented this order was to be completed as needed only and not every day shift and as needed as the TO instructed. The order was completed one time only, on 4/20/17. The order was discontinued on 4/25/17. Physician Interview: The physician was interviewed on 4/25/17 at 2:05 p.m. She said skin prep was not the appropriate treatment for [REDACTED]. Staff Interviews: LPN #1 was interviewed on 4/26/17 at 9:33 a.m. The LPN said on 4/17/17, she provided the resident ice packs, then used skin prep and dressing as treatment to the burns. The DON was interviewed on 4/26/17 at 3:49 p.m., and 4/27/17 at 3:13 p.m. The DON agreed that the 4/18/17 order to clean the wound with saline, apply [MEDICATION NAME] cream, cover with Xeroform and Kerlix was documented on the April 2017 TAR as an as needed order and not a daily order per the 4/18/17 TO. The DON said the only daily wound treatment order was to apply [MEDICATION NAME] cream. The DON said the daily order for [MEDICATION NAME] cream only was discontinued on 4/25/17 because it did not include saline cleanse and protective dressing changes. She said skin prep was not the recommended treatment for [REDACTED]. c. Inconsistent Wound Monitoring Record Review: The 4/17/17 TO documented an order to monitor bilateral thighs for redness and blisters every shift, two times a day, until resolved for hot tea burn. The order was written and discontinued on 4/17/17. The April 2017 TAR did not evidence documentation of ongoing daily monitoring of [MEDICAL CONDITION] either leg. There were no progress notes, skin and wound notes, or assessments evidencing monitoring of the open burn wounds on 4/22/17. There were no progress notes, skin and wound notes, or assessments related to monitoring of the open burn wounds on 4/24/17. Staff Interview: The DON and ADON were interviewed on 4/25/17 at 2:02 p.m. Both revealed they had not seen the burn/wound since 4/21/17. The DON said she was not aware progress notes had not been completed on 4/22/17 and 4/24/17. She said the facility had documentation concerns, and progress notes were required to be completed daily in order to monitor signs and symptoms of infection or other complications. At 3:13 p.m., the DON confirmed the progress notes and wound observations on 4/22/17 and 4/24/17 were not available in the clinical record. d. Inconsistent Pain Assessment, Monitoring and Treatment Resident Interviews: The resident was interviewed on 4/25/17 at 12:48 p.m. She reported she was not always offered medication before wound care. She said when they scraped the wound, it hurt. The resident was interviewed on 4/25/17 at 2:08 p.m. The resident said she felt pain when the burn area was touched. She reported she had not been offered or received medication prior to the removal of the dressing and treatment. (See below: pain medication was given on 4/25/17 at 2:20 p.m., after the wound treatment at 2:00 p.m.) Record Review: Record review revealed the resident failed to timely receive a comprehensive pain assessment after the burn. When increased pain was noted on 4/23/17, it was not timely investigated. The staff did not pre-medicate the resident prior to wound care on 4/25/17. Following the burn incident on 4/17/17, no pain assessment was conducted until 4/20/17. The 4/20/17 Pain Evaluation revealed the resident had pain in the past five days. The pain was one to two days in frequency, and the location and type of pain was not documented. The resident had scheduled [MEDICATION NAME] for chronic neck and shoulder pain, but reported the medication upsets her stomach sometimes. Tylenol relieved her pain and ice was used as a non-medication intervention. The care plan, initiated on 4/20/17 and updated on 4/25/17, identified the resident had actual impairment to skin integrity. She acquired a second degree burn on 4/17/17. Interventions included offering pain [MEDICATION NAME] at least 30 minutes prior to daily wound dressing. The 4/23/17 nurse's note completed by LPN #1 revealed monitoring the blisters to thighs continued. The areas were red without drainage and odor. The resident had a complaint of discomfort to the left inner thigh in the morning. On 4/23/17, there was no note revealing the physician was notified of the resident's increased discomfort. The 4/25/17 at 2:49 p.m. late-entry nurse's note for 4/24/17 did not document if the resident had pain. However, the 4/25/17 Pain Evaluation revealed the resident had a significant change in condition. The resident had pain in the past five days. The indicators of pain changed from one to two days in frequency on 4/20/17 to daily. She had pain on the left thigh. The left thigh was painful when touched during dressing changes and cares. The description of the treatment and administration patterns of PRN, as needed medication was not documented on the assessment. There were no other interventions or additional comments. The 4/25/17 skin/wound note revealed the right thigh had granulation and pink tissue at the area of the burn. The physician was notified of the resident's increase in pain. The ADON contacted the wound team for an evaluation and treatment recommendations. The 4/25/17 physician progress notes [REDACTED]. There was increased redness and tenderness of the left anterior thigh burn. The resident reported the left leg was hurting more, and the right leg was pain free. The 4/25/17 orders-administration note revealed the resident was administered [MEDICATION NAME] tablet 650 mg, as needed at 10:37 a.m. and 2:20 p.m. Staff Interview: The ADON was interviewed on 4/20/17 at 12:17 p.m. The ADON confirmed a pain assessment had not been completed on 4/17/17, 4/18/17, 4/19/17, and 4/20/17. RN #1 was interviewed on 4/25/17 at 2:08 p.m. She said she did not offer or administer the resident pain medication prior to the wound observation on 4/25/17. LPN #1 was interviewed on 4/26/17 at 9:33 a.m. The LPN said the resident had a complaint of pain after the burn incident. The LPN said she provided pain medication. The LPN did not report initiating a new pain assessment or increased pain monitoring related to the burn wounds on the resident's legs. The LPN confirmed she did not report the increase in left leg pain to staff, including management and the physician on 4/23/16. e. Timely Update of Care Plan A review of the clinical record on 4/20/17 revealed the facility did not have an updated care plan or an acute temporary care plan in place to address the resident's burn injury. The MDS specialist was interviewed on 4/27/17 at 9:27 a.m. She said the care plans, including acute, were developed based of the MDS assessment schedule. The MDS assessments were completed on admission, quarterly, annually, and upon a change of condition. The 4/17/17 incident with hot drinking water which resulted in harm to a resident was not a change of condition. She reported a change of condition (MDS assessment) required two separate elements. She reported the pain from the incident was not considered a separate element. The DON was interviewed on 4/27/17 at 3:13 p.m. She confirmed an acute care plan for the burn with care and treatment had not been completed prior to 4/20/17. She reported an acute care plan was required to be created or updated within 24 to 72 hours following an incident. f. Additional Staff Interview RN #2 and LPN #2 were interviewed on 4/27/17 at 3:00 p.m. and 3:11 p.m. -RN #2 said skin prep was used for intact skin. After a burn, the affected area required cleaning with a saline solution, then a moisturizing product with antimicrobial properties. Both RN #2 and LPN #2 said RNs were required to assess, document, and report any incidents, including burns, to administration, physician, and family immediately. Daily skin observation, wound/skin observations and/or progress notes were initiated and completed daily to monitor for signs and symptoms of infection. A pain assessment was completed, and care plans were initiated and updated by the management staff. -RN #2 said the medication administration record (MAR) and TAR were used more often than the resident care plans for interventions. LPN #2 said the care plans were used often to determine the resident-specific interventions. Both revealed all assessments were required to be fully completed, and completed timely after an incident with injury. Both said pain medication was offered 30 minutes prior to wound treatment, and the decline, acceptance, and effectiveness documented on the MAR. Pain was assessed at every shift and as needed. RN #2 said an increase in pain required notification to a physician. 8. Outcomes a. Infection Observation: The resident's burn was observed on 4/25/17 at 2:00 p.m. with the MD, DON, ADON, and RN #1. The right inner to upper thigh was granulated, pink tissue over the burned area. The left inner to upper thigh had yellow slough, cover majority of the large burn area. The resident had increased pain on contact. Physician Interview: The physician was interviewed on 4/25/17 at 2:05 p.m. She said the right leg was healing, but the left leg wound was infected. The physician described the infection as [MEDICAL CONDITION]. The [MEDICAL CONDITION] required antibiotic treatment. Record Review: The 4/25/17 at 2:49 p.m. late-entry nurse's note for 4/24/17 by LPN #1 read the resident had bilateral open blisters to the inner thighs. The skin around both of the wounds was red, intact, and had no warmth. Blisters remained moist, had no odor, drainage, or signs or symptoms of infection. The 4/25/17 skin/wound note revealed the right thigh had granulation and pink tissue at the area of the burn. The left thigh had slough, yellow, fibrous tissue covering the majority of the burn. The physician was notified of the change of wound appearance and increase in pain. The ADON contacted the wound team for an evaluation and treatment recommendations. The 4/25/17 physician progress notes [REDACTED]. There was increased redness and tenderness of the left anterior thigh burn. The resident reported the left leg was hurting more and the right leg was pain free. The left thigh had [DIAGNOSES REDACTED] and some exudate (drainage) of a second-degree burn. The left burn wound had [MEDICAL CONDITION] and an antibiotic was added for treatment. The 4/25/17 at 2:20 p.m. infection note revealed the resident's left thigh had been evaluated by the physician. The resident had suspected infection, [MEDICAL CONDITION]. The resident had an increase in pain, redness and swelling to the left thigh. There was no drainage or odor. The physician wrote new orders and antibiotics were started. The order summary revealed on 4/25/17, the resident was started on Keflex capsule 500 mg by mouth four times a day for skin infection, left thigh for 10 days. Staff Interview: RN #1 was interviewed on 4/25/17 at 10:46 a.m. She said the resident had blisters on both her thighs last week. This morning she said she noted slough, granulation tissue. The RN did not refer to signs or symptoms of an infection. b. Unplanned Change of Routine/Habit The resident was interviewed on 4/20/17 at 11:09 a.m., 4/26/17 at 9:36 a.m., and 4/27/17 at 9:39 a.m. -The resident said that following the incident, she was no longer going to drink hot tea. She said the pain and burning she experienced after the incident had turned me off to drinking hot beverages. She said on 4/24/17, she was provided a cup with a lid, but she felt hesitant to try the intervention due to the pain of the burn. The resident said she would like to start drinking raspberry cold tea, and milk. -The resident said she enjoyed reading magazines and books but since the incident on 4/17/17, she finds it difficult to set the books in her lap and read without pain. 9. Facility Follow-up During the survey the facility developed a care plan related to the resident's burn, developed a policy and procedure related to skin injury management, and initiated a change of condition MDS related to the resident's second [MEDICAL CONDITION] infection to the burns. The care plan initiated on 4/20/17 and updated on 4/25/17 identified the resident had actual impairment to skin integrity. She acquired a second degree burn on 4/17/17. Interventions included: -Acute wound care orders; -Consult and evaluation with wound nurse consultant; -Following facility protocols and treatments for injury; -Alternating air mattress to protect skin while in bed, using disposable chux (bed pads) and draw sheets only on mattress; -Monitor and document location, size, and treatment of [REDACTED]. -Offer pain [MEDICATION NAME] at least 30 minutes prior to daily wound dressing; -Identify and document potential causative factors, eliminate and resolve where possible; -Wound to both thighs, pull pants up slowly when dressing, and inform nurse to pre-medicate before showers; -Administer Keflex, 500 mg (antibiotic) four times daily for 10 days per MD orders; -Maintain universal precautions when providing resident care; -Monitor/document/report to MD as needed for signs and symptoms of infection, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes; and -Monitor/document/report to MD signs and symptoms of [MEDICAL CONDITION], changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, and altered sleep cycle. The 4/26/17 Skin Integrity Clinical Standard was provided by the director of nursing (DON) on 4/27/17 at 2:03 p.m. The document revealed the following pertinent information: -If a skin issue is noted, first aid will be administered . -DON or designee will be notified for significant breaks in skin integrity or injury . -A progress note will be completed in the resident's chart to include injury or wound type, size, location, color, drainage and amount, odor, signs or symptoms of infection, pain, treatments and notification of physician and family. Incident documentation will occur every shift for the next 72 hours . -Incident report will be generated . -Care plan will reflect current interventions for skin integrity issue and include prevention measures . -Weekly documentation of skin issue will include response to current treatment plan as well as wound type, size, location, color, drainage and amount, odor, signs and symptoms of infection, pain and resident's tolerance of treatment . The MDS specialist was interviewed on 4/27/17 at 10:03 a.m. She said she would be completing a MDS change of condition due to the 4/25/17 infection.

Based on record review, observations and staff interviews, the facility failed to ensure the resident environment was as free of accident hazards as possible and failed to provide adequate supervision and/or assistive devices to prevent accidents for one (#40) of 31 sample residents. Specifically: Resident #40 was admitted with a history of falls from the adjoining Assisted Living area of the campus on 5/18/12. Resident #40 fell 13 times between 5/18/12 and 2/13/13, and sustained injuries, including bruising, abrasions, and laceration. Findings include: 1. Resident #40, an [AGE] year old female, was admitted to the facility from the adjoining assisted living facility on 5/18/12, following a hospitalization for a fall and head laceration on 5/15/12 in the assisted living facility. The resident was admitted to the facility for rehabilitation. Her [DIAGNOSES REDACTED]. 2. Resident Status - Known Fall Risk According to her admission Minimum Data Set (MDS), Section J (Health Conditions) of the MDS, completed on 5/25/12, the resident had sustained one fall in the month prior to admission, although review of all fall investigations for resident #40 revealed she had fallen twice; once on 5/13/12 and again on 5/15/12. The resident's "I Care Plan" (written in the first person) and initiated 6/18/12, read in pertinent part: - "...I moved to the Assisted Living here at (name of facility) several months ago, but I began to have problems with falling and one such fall resulted in my hitting my head, requiring stitches and necessitating my coming to the (SNF) for rehab. I suppose I need more help than can be provided for me in assisted living, as my (family member) and the health care team believed it was best that I remain in long term care ... - ...since I have Parkinson's, OA, dementia, poor vision and had been falling in my apt earlier this year, I need help with my ADLs. Just give me extra time and cueing to finish tasks... - ...I need one person to stand by while I transfer and help me if need be. Most of the time I can transfer myself, but if you're around I will accept your assistance ... - ...Because of dementia I can become confused, I forget that I need assistance to walk and try and walk on my own. Please remind not to transfer or walk without help ... - .....I can get around in my w/c (wheelchair), although I need assistance to get in and out of it ..." A Fall Risk Evaluation completed 5/18/12 revealed a score of 18. According to the evaluation form, "A resident who scores a 10 or higher is at risk." 3. Falls after Admission - Facility Response - Failures in Facility Response Review of the facility fall investigations, as well as the resident's care plan updates, revealed the resident repeatedly fell in her room, several times in or around the bathroom. The facility failed to thoroughly investigate the falls and the resident's needs in order to anticipate these needs and provide assistance and supervision. Moreover, the facility failed to re-evaluate the use of interventions that were known to be ineffective. a. Fall #1 5/29/12 - 9:00 p.m. - Resident self reported a fall. Told staff she fell earlier but got up by herself. -Independent for toileting: NO -Preventative measures at time of fall: Low bed - YES -Injuries: None noted -Immediate Actions taken: Neuro checks 5/30/12 - Self reported fall by resident, no injuries noted. She continues to work with therapy on safety awareness, gait and balance. Facility Failure: There was no evidence in the fall investigation that the facility investigated what the resident was doing at the time of the fall in an attempt to prevent another fall. b. Fall #2 6/14/12 - 1:00 p.m. - Resident was found sitting on the floor in room, stated she was looking for something, unsure what she was looking for. -Independent for toileting: NO -Preventative measures at time of fall: Low bed - YES -Injuries: None noted -Immediate Actions taken: Neuro checks, Placed in w/c, No pain during ROM 6/15/12 - Continues on therapy for gait balance and safety. Encouraged resident to call for assistance, reminded staff are here to help. Stated she understood. Facility Failure: There was no evidence in the fall investigation that the facility investigated what the resident was doing at the time of the fall in an attempt to prevent another fall or to amend the care plan to address the resident's safety needs. c. Fall #3 6/22/12 - 5:30 p.m. - resident sustained [REDACTED]. Resident was found lying on right side. Assisted X 2 to her feet and was able to walk with SBA (stand by assist) to her room. -Independent for toileting: Yes -Preventative measures at time of fall: Low bed - NO -Injuries: None noted Immediate Actions taken: Placed in a standing position. Resident believes her walker is faulty (too heavy) and caused her to fall. Walker appears to be operating normally. 6/25/12 - Moved to new room to complete rehab. Walker evaluated and looked over by therapy. Resident is to use a FWW (front wheeled walker) not 4 wheeled walker due to Parkinson's. Continue to work on gait safety. Staff is to supervise ambulation in the hallway. Facility Failure: There was no evidence the recommendation for staff supervision while ambulating was added to the resident's care plan to alert staff to provide such supervision. d. Fall #4 6/30/12 - 4:45 p.m. - Resident told day nurse she was going downstairs to meet her (family member) at 4 p.m. At 4:10 p.m., a call came in from (1st floor station) to say they had found her on the floor outside of the dining room. She was confused and perseverated that she was looking for her (family member). -Independent for toileting: Yes -Preventative measures at time of fall: Low bed - NO -Injuries: None noted -Immediate Actions taken: Neuro checks, Placed in w/c, No pain during ROM 6/30/12 - Still adjusting to walker and working with therapy/CNA. Reminded resident to inform staff when heading downstairs for assistance. Continue to work on change in surface (floor height changes) with walker. Facility Failure: Review of the fall investigation revealed the resident fell at the same place the last time she fell (6/22/12) - the wood between the wood floor and the carpet at the edge of the dining room. There was no evidence the facility considered this area hazardous for her and provided the resident supervision while ambulating "to meet her family member," even though per recommendations above, staff was to "supervise ambulation in the hallway." (See above) There was no care plan update regarding the resident's ambulation and need for supervision while ambulating until 8/8/12, over a month later. On this date, the resident's care plan was updated to read: ...8/8/12- I am currently working with PT to increase my strength and endurance with walking. I need assistance to walk with my FWW (walker) to at least 2 meals each day. I need you to follow and stand by me in case lose my balance or become tired. This helps me with my balance and increases circulation... e. Fall #5 8/12/12 - 7:45 a.m. - Resident was found on floor in BR (bathroom), lying on her left hip, her shins were against the front of the toilet, her feet were against the wall. Her back and head were supported by her w/c (wheelchair). Res used the BR, had a BM (bowel movement) and cleaned up. She then fell while trying to pull up underwear. Encouraged her to use call light. -Independent for toileting: Yes -Preventative measures at time of fall: Low bed - NO -Injuries: Left buttock - Scratch 2 cm in length and 1 cm wide -Right knee - abrasion circular 2 cm. -Immediate Actions taken: Neuro checks, Placed in w/c, No pain during ROM 8/15/12 - (Resident #40) has poor safety awareness at times and is impulsive. Needs reminders to use call light for assistance. Facility Failures: Although the care plan update 8/8/12 noted the resident could lose her balance, become tired, and was "impulsive," there was no evidence the facility considered increasing supervision of the resident while in the bathroom. The fall investigation continued to code the resident as "independent with toileting." A Fall Risk Evaluation 8/31/12 revealed the resident had a higher score than previously, scoring 21; no further interventions were added to the care plan to address the resident's increased risk. The resident's first quarterly MDS review, completed 8/15/12, documented she had one fall since the prior MDS (her admission); however, see above; she had experienced five falls since the prior MDS. f. Fall #6 9/11/12 - 5:30 a.m. - Resident was found on the floor sitting next to the bed early in a.m. and walker was not near resident so it appeared she was walking around room in the dark. -Independent for toileting: Not answered -Preventative measures at time of fall: Low bed - NO -Injuries: None noted -Immediate Actions taken: Neuro checks, Placed in bed 9/13/12 - Resident was walking in her room in the dark without shoes. Resident is independent in her room with her FWW. Educated the staff to leave underbed light on with HS (hours of sleep - bedtime) so resident is able to see if she awakens during the night. Facility Failure: There was no evidence in the fall investigation that the facility investigated what the resident was doing at the time of the fall in an attempt to prevent another fall or to amend the care plan to address the resident's safety needs. There was no plan to educate staff of the need to keep the resident's walker at the bedside. There was no update to the care plan to ensure this intervention was consistently implemented. g. Fall #7 10/1/12 - 3:15 a.m. - Res found on floor when CNA heard noise in her room and went to check on her. Res stated, "I was going to the bathroom and I fell ". Resident denies pain but says "I think I hit my head." -Independent for toileting: YES -Preventative measures at time of fall: Low bed - NO -Injuries: None noted -Immediate Actions taken: No pain during ROM -Other action taken: Resident helped to the chair and then to the bed. Denies pain but says she thinks she hit her head. No injury noted. MD notified via voice mail, family to be notified in morning. 10/2/12 - (Resident) did not use a call light for assistance to BR during the night. Stated, "I didn't want to bother anyone." Encouraged to use call light. We asked if we could leave light on in the BR (bathroom) and resident declined. Facility Failure: There was no evidence that after a third fall in the early morning in or around the bathroom, the facility considered increasing supervision of the resident during the early morning hours. h. Fall #8 10/3/12 - 3:45 a.m. - Resident found on the floor of her room sitting next to her bed. She stated, "I just got up to drink water and I fell . I don't know why." -Independent for toileting: NO -Preventative measures at time of fall: Low bed - YES -Injuries: None noted Immediate Actions taken: Neuro checks, Placed in bed, No pain during ROM 10/4/12 - Resident stated she had slipped off bed onto floor attempting to get water. Remind her to use her call light for safety. Call light was not on and reminded her to use it. She stated "I know but I can do it myself." Staff to anticipate needs, ensure frequently used items in place. Facility Failure: The above recommendation, for staff to anticipate needs, was not added to the care plan. Moreover, there was no explanation what anticipating the resident's needs entailed. Finally, the recommendation to "remind resident to use the call light" was known to be ineffective historically, as well as by the resident's response that she could "do it by myself." There was no plan to increase supervision of the resident during the early morning hours. i. Fall #9 10/29/12 - 11:45 a.m.- Resident found on floor lying on right side, walker next to her bed on the floor by the dresser. Raised area palpated on right upper scalp (from dresser possibly), several bruises noted on right wrist and forearm, large red blanchable area on right buttock. Resident states she had been on floor for 10-15 minutes. -Independent for toileting: NO -Preventative measures at time of fall: Low bed - NO -Injuries: Head Trauma - raised area Right buttock - blanchable, reddened area Bruise - several bruises right forearm and right wrist Immediate Actions taken: Neuro checks, Placed in chair, No pain during ROM 10/30/12 - Resident seen by CNA just prior to fall. Attempting to adjust some of her Parkinson's meds. Resident does not like to eat in DR (dining room) or attend activities where staff can observe her. Continue staff rounding. Facility Failure: There was no directive to staff on how frequently to 'round' in an attempt to anticipate the resident's needs. There were no care plan updates. j. Fall #10 11/4/12 - 3:30 p.m. - Resident was found lying on left side next to dresser. FWW also found toppled over. Resident stated she had just finished using the bathroom when she fell . She was only wearing socks; the call light had not been activated. -Independent for toileting: YES -Preventative measures at time of fall: Low bed - YES -Injuries: Hit right elbow on dresser caused ST size of dime. Immediate Actions taken: Neurological checks, Placed in Wheelchair, No pain during ROM, Cleanse area, Dressing applied 11/5/12 - Resident had recent change in Sinemet (increased on 10/31/12). Has had falls 10/1, 10/3 - labwork negative. Spoke with (family member) re: getting slipper socks - as resident does not remember to put shoes on before going to BR (bathroom). Resident has also started pulling out her hair. NP (Nurse Practitioner) to evaluate. A Fall Risk Evaluation on 11/5/12 revealed the resident's risk was scored at 20. Facility Failure: The resident's care plan was updated 11/12 to "Please keep my underbed light on at night so I can see to go to the bathroom ..." However, another light intervention was documented on 10/1/12 and it was noted that the resident declined this intervention. There was no evidence the resident's toileting scheduled was assessed to see if staff could anticipate the resident's need to go to the bathroom and provide her assistance. k. Fall #11 12/28/12 - 11:30 a.m. Resident was trying to use bathroom and lost balance and fell . -Independent for toileting: YES -Preventative measures at time of fall: Low bed - NO -Injuries: Hit right arm, Bumped right side of head (no redness or bump) -Immediate Actions taken: Neurological checks, Placed in bed, No pain during ROM 12/31/12 - CNA saw res(ident) 1/2 hr before fall and did not request assistance to BR. Remind her to call for assistance. Facility Failure: The above recommendation was known to be ineffective; there was no plan to evaluate the resident's toileting schedule in order to anticipate her need to ambulate to the bathroom. l. Fall #12 1/5/13 - 10:30 a.m. - Resident was found lying on floor on right side. It appears the resident was sitting on wooden chair and slipped off. -Independent for toileting: (left blank) -Preventative measures at time of fall: Low bed - NO -Injuries: Resident did at first report pain but has not since. -Immediate Actions taken: Neurological checks, Placed in Wheelchair, No pain during ROM 1/7/13 - Family to get cushion for wooden chair Facility Failure: Observations on 2/14/13 revealed two wooden chairs in the resident's room. Neither chair had a cushion to make them less slippery. The resident's quarterly MDS, completed 1/30/13, documented the resident had no falls since the quarterly MDS completed 8/15/12 (but see above; she had experienced seven additional falls). The MDS documented that she required extensive assistance of one staff member for ADLs (activities of daily living) which included bed mobility, transfers, dressing and toilet use. The resident's care plan was not updated to reflect the resident's decline in ADLs and increased need for assistance. m. Fall #13 2/13/13 - 1:45 p.m. - Resident was found on floor in room. She had fallen while attempting to get out of bed alone. -Independent for toileting: (left blank) -Preventative measures at time of fall: Low bed - NO -Injuries: 1 inch deep left side of scalp laceration that required three stitches, small ST (skin tear) 2 cm to left hand, abrasion to left knee -Immediate Actions taken: Neurological checks, Placed in Wheelchair, No pain during ROM, Non ER transfer (family took to ER) 2/14/13 - Documented that due to her constant movements she would not be a candidate for an alarm. Facility Failure: There was no evidence that the facility had investigated why the resident was attempting to get out of bed to determine how the facility could anticipate her needs and provide the assistance she was assessed to need. 4. Staff Interviews Director of Nurses (DON) The DON was interviewed, on 2/13/13 at approximately 3:30 p.m., regarding resident #40 and specifically in regard to their care planned interventions to keep the resident safe. The DON acknowledged that not all interventions noted in the fall investigations were transferred to the care plan. In regard to inconsistencies regarding the resident's assistance needs, she offered no explanation. Regarding the continued use of interventions that were known to be ineffective, the DON, likewise, offered no explanation. The MDS Coordinator was interviewed, on 2/14/13 at approximately 10:30 a.m. She was informed of the inaccuracies on the MDS for resident #40 regarding the number of falls she had experienced. She offered no explanation.