Every finding on record at Sunny Vista Living Center

Based on observations, interviews and record review, the facility failed to store, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure kitchen equipment was stored in a clean and sanitary manner; and, -Ensure perishable foods were discarded after the date of expiration. Findings include: I. Failure to ensure stored kitchen equipment were clean and sanitary A. Professional referenceThe Colorado Department of Public Health and Environment (2021) The Colorado Retail Food Establishment Rules and Regulations, retrieved 7/30/25 revealed in pertinent part, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. (4-501.12) Non food-contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (4-601.11).B. ObservationsThe initial kitchen tour was conducted on 7/21/25 at 8:15 a.m. The following was observed-Eight stacks of steam table pans were on a metal storage shelf and had moisture in between the pans.-Three red , two green and two white cutting boards were scored.-One white cutting board had a large circular burn resembling the bottom of a pot. On 7/23/25 at 11:20 p.m. a walk through of the walk-in refrigerator was conducted with the regional dietary resource. The following was observed:-There were two scored red and one scored white cutting board (with numerous gouges creating more than superficial indentations) ; and,-Three steam table pans that were stacked on top of each other were on a shelf were and were wet in between the pans. II. Failure to ensure perishable foods were discarded after the expiration date A. Professional reference The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)A. ObservationsThe initial kitchen tour was conducted on 7/21/25 at 8:15 a.m. The following was observed:-A pan labeled egg salad with a discard date of 7/7/25;-A pan of undated blueberries that had a white film on the exterior of the blueberries; and,-A pan of undated lettuce that had a white film on the exterior of the lettuce. III. Staff interviewsThe regional dietary resource was interviewed on 7/23/25 at 11:20 p.m. He said when cutting boards became scored, damaged or pitted the boards were replaced. He said if a cutting board was burned it was immediately replaced. The regional dietary resources said the kitchen staff utilized a cleaning schedule. He said twice a week when they received the food deliveries, the staff went through the walk-in refrigerator and discarded expired foods. He said if the kitchen staff saw any foods in the walk-in refrigerator that were spoiled, the food was to be thrown out right away. The regional dietary resource said there were drying racks for the steam table pans and the pans were to be completely dry before being stacked together. He said if the pans were stacked when wet, the moisture could cause bacteria growth. He said if the residents were served expired food it had the potential to make the residents ill if eaten by them.

Based on record review and interviews, the facility failed to ensure five (#63, #46, #73, #112 and #50) of nine residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 52 sample residents. Specifically, the facility failed to:-Ensure prescribed as needed (PRN) antipsychotic medication for Resident #63 had corresponding documentation of identified behaviors and use of non-pharmological interventions; -Ensure resident specific care approaches, to include medication specific target behaviors and person-centered interventions were documented and monitored for Resident #63, #46, #73, and #112's psychotropic medications; and,-Identify specific resident behaviors, conduct behavior monitoring and ensure the least restrictive intervention was used prior to administration of psychotropic medications for Resident #50's.Findings include: I. Facility policy and procedure The Psychotropic Medication Management policy, approved December 2024, was provided by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It revealed in pertinent part, Psychotropic medications include but are not limited to the categories of anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. All medications included in this definition may affect brain activities associated with mental processes and behavior and may include medications such as central nervous system agents, mood stabilizers, NMDA receptor modulators and over the counter natural or herbal products. Antipsychotic medications may be indicated if: behavioral symptoms present a danger to the resident or others, expressions or indications that cause significant distress to the resident, or iff not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which are presenting a danger or significant distress. If antipsychotic medications are prescribed, documentation must show; indication for the antipsychotic medication, multiple attempts to implement care planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of the interventions with rationale for decisions.” II. Resident #63 A. Resident status Resident #63, over the age of 75, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included anxiety, major depressive disorder and dementia. The 7/8/25 minimum data set (MDS) assessment revealed Resident #63 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment indicated the resident had behaviors of difficulty focusing his attention, disorganized thought processes, hallucinations, and delusions. B. Record review The behavior care plan, revised 4/16/25, revealed Resident #63 had a diagnosis of major depressive disorder, anxiety, and insomnia. The resident displayed behaviors of difficulty sleeping, irritability, tearful/sad, and anxiety with movement. Interventions included monitoring for intentional acts of harming self or others, refusing to eat or drink, refusing medications or therapies, a sense of hopelessness or helplessness, impaired judgment or safety awareness (initiated 4/7/25). -The behavioral care plan failed to document triggers for Resident #63’s behavior and provide person-centered interventions. The comprehensive care plan did not include documentation of Resident #63’s use of anti-psychotic medications. Review of Resident #63’s July 2025 CPO revealed the following physician’s orders: Trazodone (an antidepressant medication) 50 milligram (mg). Give 0.5 mg at bedtime for insomnia, ordered 6/29/25. Monitor behaviors for major depressive disorder and anxiety: difficulty sleeping, irritability, tearful/sad, anxious with movement, and can be abrasive. Non-pharmological interventions included: 1. Redirect. 2. Provide one-on-one. 3. Offer snacks or drinks. 4. Offer to come out of the room. 5. Contact family for additional support, ordered on 4/30/25 and discontinued on 7/23/25 (during the survey process). Haloperidol (an antipsychotic medication) liquid concentrate 2 mg/ml (milliliter). Give 0.25 ml every 12 hours as needed (PRN) for agitation.- ordered on 7/19/25 with an indicated end date of 8/1/25. The medication was discontinued 7/22/25 (during the survey process). Risperdal (an antipsychotic medication) 0.5 mg. Give one time a day for dementia with psychosis, ordered 7/23/25. Review of the medication administration record (MAR) and treatment admission record (TAR) from 7/1/25 to 7/22/25 revealed the following: Haloperidol was administered to Resident #63 on 7/19/25 and 7/22/25. Behavior monitoring reviewed for 7/1/25 to 7/22/25 failed to document the resident’s behaviors on 7/19/25 and 7/22/25. Review of Resident #63’s electronic medical record (EMR) from 4/1/25 to 7/23/25 revealed the following: A nursing note, dated 7/19/25 at 2:24 a.m., revealed the resident had been yelling and displaying restlessness due to pain. The resident pulled out his catheter, began hitting himself in the head and ribs, and tried to communicate his needs to the nurses. The resident calmed down briefly after the catheter had been reinserted but then began to hit himself again. The nurse called the responsible party and requested to administer anti-psychotic medication to the resident to calm him down. The nurse notified the physician who advised the inappropriateness of medication at this time (use of the anti-psychotic medication) and instructed the nurse to send the resident to the hospital for further evaluation of his expressed pain. The resident was transported to the hospital. A nursing note, dated 7/19/25 at 12:04 p.m., revealed the resident had returned from the hospital with orders for Amoxicillin (an antibiotic medication) twice a day for 10 days related to a diagnosis of a urinary tract infection (UTI). A readmission note, dated 7/19/25 at 1:21 p.m., revealed the resident's mood had been pleasant with no behaviors witnessed. A nursing note, dated 7/19/25 at 2:50 p.m., documented due to Resident #63’s displayed behaviors of agitation the previous night, the on-call provider ordered Haloperidol 0.25 ml every 12 hours PRN for agitation. However, the nurses note on 7/19/25 at 2:24 a.m. documented the provider communicated the use of an anti-psychotic medication for Resident #63’s behavior was inappropriate. -Review of Resident #63's progress notes in the electronic medical record (EMR) failed to reveal behaviors on 7/19/25 and 7/22/25 when the Haloperidol had been administered for agitation. A nursing note, dated 7/23/25 at 8:32 a.m. (during the survey process), revealed Resident #63 was restless and agitated. He had ripped his nasal cannula off, removed some of his clothing and picked at his skin and catheter. The staff offered distractions and offered to call his family, but the resident remained agitated. A physician note, dated 7/23/25 at 9:45 a.m. (during the survey process), documented the physician’s order for Haloperidol was due to the resident’s fluctuating hospice care. It indicated the Haloperidol was used for delusions, self-harming behaviors and hallucinations. -However the CPOs revealed the PRN Haloperidol was ordered on 7/19/25, which was the date of Resident #63’s agitation due to his expressed pain from the catheter. The resident’s medical record failed to document any other behaviors of agitation prior to the start of the medication on 7/19/25. A review of the EMR failed to document Resident #63 had been receiving hospice care from his admission date of 4/1/25 to 7/23/25, when the resident’s responsible party was contacted (during the survey process) by the social services director (SSD) to consider hospice support for the resident. A review of the Resident #63's comprehensive care plan and behavior monitoring failed to document any behaviors of hallucinations or self-harm. III. Resident #46 A. Resident status Resident #46, over the age of 75, was admitted on [DATE]. According to the July 2025 CPOs, diagnoses included dementia and major depressive disorder. The 7/8/25 MDS assessment revealed Resident #46 had severe cognitive impairment with a BIMS score of seven out of 15. The MDS assessment indicated the resident had behaviors of hallucinations and rejecting care. B. Record review The behavior care plan, revised 11/13/24, revealed Resident #46 had a diagnosis of major depressive disorder, anxiety, and dementia. Behaviors included depressed mood, crying/tearfulness, self-isolation, verbal aggression, and visual hallucinations. Interventions included monitoring for signs and symptoms of hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Non-pharmological interventions included providing meaningful activities of interest, encouraging the resident to express their feelings, and providing adequate rest periods. The psychosocial care plan, initiated 11/13/24, revealed Resident #46 was prescribed an antipsychotic medication due to a diagnosis of dementia. Interventions included monitoring for adverse reactions (side effects), administering medication as ordered, and providing education to the resident and/or family regarding risks, benefits, and side effects. The mood care plan, revised 4/7/25, revealed Resident #46 was prescribed an antidepressant medication due to a diagnosis of dementia with behavioral disturbances. Interventions included monitoring for behavior/mood/cognition; hallucinations/delusions, social isolation, suicidal thoughts and withdrawn behaviors. A review of Resident #46’s July 2025 CPO revealed the following physician’s orders: Lexapro (an antidepressant medication) 5 mg. Give once a day for dementia- ordered 1/10/25. Monitor behaviors for depressed mood: crying/tearful, self-isolation, and hallucinations (believing staff are trying to kill her). If the behavior occurs, document in a behavior progress note the description of behavior, non-pharmacological interventions, and resident response. Interventions included repositioning, offering snacks or drinks, redirect to an activity, offer independent activities, assist outside, call a loved one, sit with the resident and provide active listening- ordered 11/28/23. Seroquel (an antipsychotic medication) 25 mg. Give 0.5 tablet twice a day for dementia with severe psychotic disturbances - ordered on 6/26/25. Mood charting for one month- Add a progress note at the end of each shift documenting overall mood. Examples: Positive mood, attending activities, happy demeanor, increased isolation, declining cares, increased hours of sleep, decreased appetite every shift, ordered on 6/26/25. A review of Resident #46’s MAR and TAR from 6/1/25 to 7/23/25 did not reveal Resident #46 exhibited any behaviors Review of Resident #46’s EMR from 5/23/25 to 7/23/25 revealed the following: A nursing note, dated 7/7/25, revealed the resident refused pericare or a shower. -The resident’s EMR failed to reveal any additional documentation of behaviors displayed or mood charting had been completed as ordered by the physician. A psychologist progress note, dated 6/11/25, revealed the psychologist completed a diagnostic depression screening for Resident #46, which revealed a score of 10 out of 27, which indicated moderate depression. The psychologist documented the resident had symptoms of severe dementia with distressing delusional thinking and visual hallucinations. The recommended non-pharmological interventions included: behavioral and psychological interventions such as validation therapy with the resident by acknowledging feelings and perceptions rather than challenging delusions directly, with focus on empathy rather than confrontation; providing reminiscence therapy, such as using photos, music, or objects from the past to trigger positive memories and reduce anxiety or confusion that can lead to delusions; environmental modifications to reduce triggers such as identifying and removing triggers of hallucinations or delusions such as e.g., shadows, mirrors, noisy rooms; and providing sensory based interventions such as music therapy with personalized playlist or familiar soothing music to reduce agitation, anxiety, and delusional thinking. A psychologist progress note, dated 7/9/25, revealed the psychologist received historical details from the nursing staff regarding Resident #43’s behavior. The behaviors included on 6/29/25, the resident appeared withdrawn; on 6/27/25, the resident had episodes of hallucinations; on 7/3/25, the resident refused and tried to swat at a nurse; and on 7/4/25, the resident had episodes of hallucinations throughout the night. -A review of the progress notes and behavior monitoring in Resident #46’s EMR failed to reveal documentation of the behaviors communicated to the psychologist, descriptions of the behaviors, and any effective non-pharmacological interventions. A psychologist progress note, dated 7/7/25, revealed the resident had exhibited symptoms of non-compliance with care, hallucinations, delusions, and withdrawn behavior. -Review of Resident #46's EMR failed to reveal the individualized non-pharmological interventions recommendations made by the psychologist had been incorporated into the comprehensive care plan or behavior monitoring. The trauma screening, dated 10/9/24, documented Resident #46 did not suffer from any indicators of trauma responses. The trauma screening, dated 4/2/25, revealed Resident #46 suffered from sleep disturbances, upsetting thoughts or memories that were intrusive related to trauma, and acted as though the event was happening. It did not provide additional documentation to indicate the specifics of the resident’s experienced trauma, nor how it had changed from 10/9/24 to 4/2/25. The trauma screening, dated 7/8/25, revealed Resident #46 suffered from upsetting thoughts or memories that were intrusive related to the trauma, upsetting dreams/nightmares regarding the trauma, acting as though the event was happening, bodily reactions such as fast heartbeat, dizziness, sweatiness, or stomach churning when reminded of the event, irritability or outbursts of anger, heighten awareness of potential dangers to self (hypervigilance), and being jumpy and easily startled. -Review of Resident #46's EMR failed to reveal that the increase of trauma responses were incorporated into the comprehensive care plan or behavior monitoring. IV. Resident #73 A. Resident status Resident #73, under the age of 65, was admitted on [DATE]. According to the July 2025 CPOs, diagnoses included intellectual disability and anxiety. The 5/12/25 MDS assessment revealed Resident #73 had mild cognitive impairments with a BIMS score of 11 out of 15. The MDS assessment indicated the resident did not have behaviors. B. Record review The behavior care plan, revised 8/12/24, revealed Resident #73 had behaviors of verbal and physical aggression, yelling, making sexually inappropriate statements/comments, angry outbursts when his personal belongings were misplaced, self-isolation, and being worrisome. Interventions included providing a room change to a quieter environment to assist the resident in being calm and relaxed. -There were no additional person-centered interventions documented for the resident's identified behaviors in the behavior care plan. Review of Resident #73’s July 2025 CPO revealed the following physician’s orders: Duloxetine (an antidepressant medication) 60 mg. Give once a day for depression- ordered 6/23/24. Monitor for behaviors of angry outbursts when he felt his personal belongings (toys) were moved or lost, withdrawn, self-isolating behaviors, worries, sexually inappropriate comments to staff and homicidal statements, ordered 11/18/22. Monitor for behaviors for antidepressant use of angry outbursts when he felt his personal belongings (toys) were moved or lost, withdrawn, self-isolating behaviors, worries, sexually inappropriate comments to staff and homicidal statements. Interventions included providing redirection, offering one to one support, offering activities, returning the resident to his room, offering toileting, offering food and fluids, adjusting the room temperature, calling the family for support and providing medications as ordered - ordered 7/22/25 (during the survey process). -A review of Resident #73’s July 2025 CPO revealed non-pharmological interventions were not included in the behavior monitoring as a least restrictive alternative until 7/22/25 (during the survey process). Review of Resident #73’s MAR and TAR from 5/1/25 to 7/23/25 revealed Resident #73 did not exhibit any documented behaviors except on 7/8/25 and 7/23/25,. -The behavior monitoring did not indicate the specific behaviors Resident #73 displayed. A review of Resident #73’s EMR from 5/23/25 to 7/23/25 revealed the following: A nursing note, dated 5/23/25, revealed that due to blood sugar levels, the physician instructed the nurse to hold the resident's insulin. When the resident was informed, he became upset, told the nurse he would end up in the hospital, it would be the nurses fault and her job would be on the line. A behavior note, dated 6/5/25, revealed the resident had been frustrated with his glucose monitor when the display read 'high' instead of displaying numbers. As a result, the resident threw the monitor at the wall. The note failed to include the non-pharmacological interventions provided and Resident #73's response. A nursing note, dated 7/3/25, indicated the resident had made negative comments to a certified nurse aide (CNA), however it failed to include a description of the behavior, the non-pharmacological interventions attempted and Resident #73's response. A risk management note, dated 7/10/25, revealed the resident became frustrated and communicated in a manner that may have unintentionally come across as unpleasant. The facility moved the staff member to another unit. The progress note failed to include a description of the behavior, the non-pharmacological interventions tried and Resident #73's response to the non-pharmacological intervention of removing the staff member from his care and care unit. A nursing note, dated 7/19/25, revealed the resident was upset when he asked for a condiment that was unavailable. The resident threw his plate on the floor, breaking the plate. The resident went to his room and began yelling at the nurse and throwing items out of a bag onto the floor. The nurse left the resident alone in his room. Approximately 20 minutes later, the resident appeared to be calm, but refused to eat. -A review of Resident #73's progress notes in the EMR failed to reveal any additional behaviors displayed or behaviors on 7/8/25 or 7/22/25 when the TAR indicated behaviors had occurred. V. Resident #112 A. Resident status Resident #112, age of 69, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included schizoaffective disorder, major depressive disorder and cognitive communication deficits. The 4/29/25 MDS assessment revealed Resident #112 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment indicated the resident did not have behaviors. B. Record review The behavior care plan, revised 8/12/24, revealed Resident #112 had a diagnosis of schizoaffective disorder and depression with manifested behaviors such as self-isolation, delusions, false beliefs, crying and withdrawn. Interventions included monitoring for withdrawing, displaying delusions and false beliefs, and crying; encouraging the resident to express her feelings and attempt to determine the underlying cause of the behavior such as to consider the location, time of day, persons involved, and situation surrounding the behavior and document the potential causes; providing re-positioning; offering a snack or drink; redirecting to an activity; offering independent activity supplies; offering to call a loved one; assisting the resident to go outside; sitting with the resident as needed; and providing active listening and validation (initiated 10/29/21). A review of Resident #112’s July 2025 CPO revealed the following physician’s orders: Lexapro (an antidepressant medication) 10 mg. Give once a day for depression, ordered 2/8/25. Lamotrigine (an anticonvulsant medication used as a mood stabilizer) 25 mg. Give once a day for schizoaffective disorder, ordered on 2/27/25. Monitor for behaviors related to schizoaffective disorder: withdrawn to room, delusions, false beliefs, crying/tearful, and depression. If behavior occurred, document in the behavior progress note description of behavior, non-pharmacological interventions used and the resident’s response. Interventions included offering repositioning, snacks, fluids; redirecting the resident to an activity; offering independent activities; offering to call a loved one; assisting the resident outside; and sitting with the resident, ordered on 11/01/2020. A review of Resident #112’s MAR and TAR from 5/1/25 to 7/23/25 revealed the resident did not exhibit any behaviors from 5/1/25 to 7/23/25. A review of Resident #112’s EMR from 5/1/25 to 7/23/25 revealed the following: A social services summary note, dated 5/14/25, revealed the resident had a recent depression screen with a score of six out of 27, which indicated mild depression and the resident expressed feeling down, depressed and hopeless. A social services note, dated 5/23/25, revealed a staff member reported the resident was acting out of character and said she did not want to be at the facility any longer. The SSD followed up and the resident, who denied suicidal ideations but could not explain why she made those statements. The resident signed a safety agreement. -A review of Resident #112's progress notes in the EMR did not reveal any additional behaviors displayed or mood charting. The trauma screening, dated 10/9/24, revealed Resident #112 did not suffer from any indicators of trauma responses. The trauma screening, dated 4/20/25, revealed Resident #112 suffered from sleep disturbances, upsetting thoughts or memories that were intrusive related to trauma, upsetting dreams/nightmares regarding the trauma, feeling upset about reminders of the trauma, difficulty with concentrating, heighten awareness of potential dangers to self (hypervigilance), and being jumpy and easily startled. However, the trauma screening did not provide details regarding the resident’s experienced trauma, nor any documentation in the EMR to indicate an event had occurred between 10/9/24 and 4/20/25 to explain the difference in the trauma screenings. The facility failed to ensure trauma informed care was included in the comprehensive plan of care and behavior monitoring. A psychologist progress note, dated 7/7/25, revealed the psychologist completed a depression screen with Resident #112 and the score was an eight out of 27 and documented the resident had displayed behaviors of non-compliance with care and appetite disturbances. -The 7/7/25 psychologist visit note depression screen indicated Resident #112’s depression screen score had increased from a six on 5/14/25 (see above) to a eight, however, updated and changes were not made to Resident #112's comprehensive care plan or behavior monitoring. A psychologist progress note, dated 7/9/25, revealed Resident #112 had displayed behaviors of visual and auditory hallucinations intermittently. The psychologist recommended the following non-pharmological interventions: providing psychoeducation on the nature of schizoaffective disorder and depressive symptoms with early warning signs of relapse; enhancing the family’s ability to support the resident’s recovery and avoid relapse triggers; providing wellness interventions of regular exercise to improve depressive symptoms and cognitive function; promoting healthy diet and sleep hygiene to stabilize mood and energy levels; and providing stress management techniques to include meditation, relaxation training and journaling. A psychologist progress note, dated 7/15/25, revealed recommendations monitoring any changes in mood and behavior i.e., cognitive functioning, psychosis, depression, sleep disturbance, irritability, low frustration and stress tolerance, sensory dysregulation, mental and physical fatigue, and behavioral disturbance; encouraging adherence to daily schedules; and providing opportunities during the day for cognitive and mental stimulation. -A review of Resident #112's EMR failed to reveal documentation of resident specific behaviors to monitor and individualized non-pharmological intervention recommendations made by the psychologist had been incorporated into the comprehensive care plan (last updated in 2024) or behavior monitoring (last updated in 2020). VII. Staff interviews Registered nurse (RN) #2 was interviewed on 7/22/25 at 12:20 p.m. RN #2 said when administering an as needed or PRN psychotropic medication, the nurse should document the observed behaviors, attempt non-pharmacological interventions, and then document if the interventions were effective or ineffective prior to medication administration. She said behaviors were documented TAR but the TAR did not always include non-pharmological interventions. RN #2 said when the non-pharmological interventions were not included on the TAR, the interventions were generic. She said the facility staff would do trial and error interventions, but the behavior monitoring on the TAR was not always updated with resident specific interventions. RN #2 said Resident #63 exhibited behaviors related to trying to express unmet needs. She said effective non-pharmological interventions for that resident included siting with him and encouraging him to reminisce about his daughter and providing him snacks, especially soda. She said she had not seen an increase in agitation for Resident #63 and did not know why he was prescribed Haloperidol. RN #2 said Resident #46 had cognitive deficits with moments of agitation. She said effective non-pharmological interventions included offering to decrease the stimulation in her room such as adjusting the lights and sounds as well as offering her favorite candies. RN #2 said Resident #73 displayed behaviors of anger, inappropriate comments and requests from female staff, and childish expressions. She said effective non-pharmological interventions included encouraging or complimenting him on his crafts. She said he enjoyed making jewelry. She said when Resident #73 had strong feelings, he would express those feelings immediately, like a child. RN #2 said he had requested staff get into bed with him and he had also attempted to make inappropriate requests towards visiting family members he did not recognize. She said Resident #73 was able to be redirected without an angry outburst if the staff member reminded him how his inappropriate comments and requests made others feel. RN #2 said Resident #112 she was not aware of any exhibited behaviors and was social with staff and other residents. CNA #3 was interviewed on 7/22/25 at 12:30 p.m. She said the CNAs documented resident behaviors in the CNA charting system, but it only identified a list of generic behaviors and interventions. She said if the intervention was not listed, the CNA informed the nurse and the nurse documented the intervention in a progress note. CNA #3 said Resident #63 only displayed behaviors when he was in pain. She said when he was in pain, Resident #63 would become agitated, strike out at staff, or refuse care. She was not aware of any effective non-pharmological interventions other than pain management. CNA #3 said Resident #46 did not exhibit any behaviors. CNA #3 said Resident #73 exhibited verbally inappropriate behaviors toward staff and other residents as well as anger outbursts. She said the effective non-pharmological interventions included allowing the resident to calm down and offering him specific activities he enjoyed, such as art. CNA #3 said Resident #112 did exhibit any behaviors. CNA #4 was interviewed on 7/22/25 at 1:00 p.m. CNA #4 said nurse management would verbally communicate any newly displayed resident behaviors. She said interventions were not communicated by nursing management, however the CNAs talked amongst themselves to determine interventions that worked for each resident CNA #4 said Resident #63 had not exhibited behaviors lately, but used to strike out at staff when attempting to provide care if he was in pain. She said the resident had not done this for the past month. She said effective interventions included singing and providing him space when he was upset. CNA #4 said she was not aware of any behaviors for Resident #46 or Resident #112. CNA #4 said Resident #73 had behaviors of being sexually inappropriate toward staff and when he was told these comments or requests were inappropriate, he would become verbally abusive. She said she was not aware of any non-pharmological interventions that worked for him. Licensed practical nurse (LPN) #4 was interviewed on 7/22/25 at 1:12 p.m. LPN #4 said behaviors were documented in the nursing progress notes of the resident's EMR. She said she did not know where to find the resident specific behaviors or individualized non-pharmological interventions for behaviors. LPN #4 Resident #63 exhibited behaviors of agitation recently when he was diagnosed with a urinary tract infection but had calmed down after being treated with antibiotics. LPN #4 said he was prescribed Haloperidol for agitation PRN, but she was unable to locate any monitoring with indicators of agitation to administer the Haloperidol. LPN #4 said Resident #46 did exhibit any behaviors but could become agitated and refuse care. LPN #4 said effective non-pharmological interventions included calming her down, ensuring she was compliant with care, providing positive affirmations, and offering her pudding. LPN #4 said Resident #73 exhibited behaviors of yelling, using profanity, racial slurs, and making threats towards staff. LPN #4 said effective non-pharmological interventions included offering his favorite juice or coffee and providing him a private space, like his room, to yell and vent. LPN #4 said Resident #112 did not exhibit any behaviors and she was not aware why she was prescribed Lamotrigine. The social services director (SSD) #1, the NHA, and the assistant director of nursing (ADON) were interviewed together on 7/22/25 at 2:33 p.m. The NHA said resident behaviors were discussed in the morning and afternoon interdisciplinary (IDT) meetings every day. He said the floor nurses attended and contributed to those meetings. The NHA said he was not aware of the facility process for behavior monitoring. The ADON said she had been in her role as of February 2025 and there was no current DON in the facility. The ADON said when a resident admitted on a psychoactive medication or had been prescribed a psychoactive medication after admission, a behavior monitoring order was put into the CPO by the nurses. She said behaviors and non-pharmological interventions on the order should be resident specific and not generic. SSD #1 said he had worked at the facility for approximately six weeks. He said behavior monitoring was reviewed during the psychoactive medication management meeting every quarter. The medical director (MD) was interviewed on 7/23/25 at 11:39 a.m. The MD said behavior monitoring should be documented in the EMR and reviewed during the quarterly psychotropic medication management meeting. He said behavior monitoring was utilized to determine

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication storage rooms and three of five medication carts.Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened;-Ensure expired medications were removed and discarded from medication carts and storage refrigerators; and,-Ensure the temperature in a medication storage refrigerator was maintained within an acceptable temperature range.Findings include:I. Facility policy and procedureThe Medication Storage policy, dated January 2025, was received by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It read in pertinent part, Medications requiring refrigeration or temperatures between 2 degrees celsius (C)/(36 degrees fahrenheit (F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 8 degrees C (46 degrees F) and 15 degrees C (59 degrees F). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. 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, and reordered from the pharmacy, if a current order exists.II. Failed to ensure medications were labeled with the date they were openedA. Observations and staff interviewsOn 7/23/25 at 3:23 p.m. the [NAME] 1 medication cart was observed with LPN #5. The following items were found:-An opened bottle of Lastacaft (allergy itch relief) 0.25% eye drops was labeled with a resident's name, but was not labeled with the date opened.LPN #5 said dates should be labeled on medications so staff were aware of when they were opened and when they needed to be discarded.On 7/23/25 at 4:39 p.m. the East 2 medication cart was observed with LPN #8. The following items were found:-An opened bottle of Flonase 50 microgram (mcg) nasal spray (steroid nasal spray) was labeled with a resident's name but was not labeled with the date opened. The pharmacy issue date listed on the bottle was 5/13/25. LPN #8 said Flonase nasal spray should be discarded 60 days after being opened.III. Failed to ensure expired medications were removed and discarded from medication carts and storage refrigeratorsA. Observations and staff interviewsOn 7/23/25 at 3:10 p.m., the [NAME] 1 medication storage room and medication refrigerator were observed with licensed practical nurse (LPN) #7. The following items were found:-A Bisacodyl 10 milligrams (mg) suppository (laxative) with an expiration date of April 2024.-Two individually packaged Bisacodyl 10 mg suppositories were labeled with a current resident's name. The suppositories had expiration dates of 12/16/24 and 4/11/25.LPN #7 said any nurse on duty could clean out the medication refrigerator. LPN #7 said expired medications could potentially harm and cause damage to a resident. -A box of DexcomG6 (glucose monitoring) sensors was not labeled with a resident's name and had an expiration date of 5/31/25.LPN #7 said the sensors were not kept as floor stock and should have a resident label. On 7/23/25 at 4:39 p.m. the East 2 medication cart was observed with LPN #8. The following items were found:-An opened bottle of Nighttime Relief lubricant (moisturizing) eye drops labeled with a resident's name. The product box instructed staff to discard the medication 30 days after opening. The open date labeled on the bottle was 5/15/25. LPN #8 confirmed the eye drops should have been discarded 30 days after the open date.-An opened Advair Diskus 250 mcg - 50 mcg inhaler was inside an Advair Diskus box labeled with a resident's name. The Advair Diskus containing the medication was labeled with the resident's name. The open date on the inhaler was 5/6/25.LPN #8 said the Advair Diskus medication should have been discarded 30 days after opening.-Additionally, an opened Albuterol inhaler was inside the Advair Diskus box alongside the Advair Diskus medication. The albuterol inhaler had a resident's room number written on it, which matched the room number written on the Advair Diskus box, but the inhaler was not labeled with the resident's name. The Albuterol inhaler did not have an open date labeled on it. LPN #8 confirmed the Albuterol inhaler should not have been in the box with the Advair Diskus. She confirmed the inhaler should have had a resident's name and an open date on it. LPN #8 said she would discard both inhalers and have them reordered. LPN #8 said the night shift nurse primarily audited the medication carts, however, she said all nurses should perform audits when passing medications to look for unlabeled and expired medications.-An opened tube of Equate anti-itch cream with an expiration date of May 2024.-An opened tube of Terbinafine hydrochloride 1% (antifungal) cream with an expiration date of June 2025.-An opened bottle of Ultra sunscreen lotion sun protection factor (SPF) 30 with an expiration date of 7/1/24.IV. Failed to ensure the temperature in a medication storage refrigerator was maintained within an acceptable temperature rangeA. Observations and staff interviewsOn 7/23/25 at 3:55 p.m., the [NAME] 2 medication storage room and medication refrigerator were observed with registered nurse (RN) #4. A temperature log for the medication refrigerator was posted on the wall next to the refrigerator. The temperature reading inside of the refrigerator was observed to be 48 degrees F, which was above the appropriate temperature range of 36 degrees F to 46 degrees F. RN #4 said the temperature of the medication refrigerator should be less than 41 degrees F. RN #4 was unsure what to do for a medication refrigerator temperature reading outside of the required temperature range. He said she would have to find out. Review of the [NAME] 2 medication refrigerator temperature log revealed the following: -On 7/21/25 the medication refrigerator temperature was 55 degrees F; -On 7/22/25 the medication refrigerator temperature was 58 degrees F; and,-On 7/23/25 the medication refrigerator temperature was 58 degrees F.On 7/23/25 at 4:02 p.m., the regional director of clinical operations entered the [NAME] 2 medication storage room. She said the medication refrigerator temperature should be less than 41 degrees F. The regional director of clinical operations said staff would remove the medications currently in the refrigerator. She said she would follow up with the facility's pharmacist to determine if any of the medications needed to be discarded and re-order any needed medications. On 7/23/25 at 4:06 p.m. the facility's maintenance director (MTD) entered the [NAME] 2 medication storage room. The MTD used a temperature gun to check the medication refrigerator's. The reading on the temperature gun was 51 degrees F. On 7/23/25 at 4:20 p.m. the East 2 medication storage room and medication refrigerator were observed with LPN #8. A temperature log for the medication refrigerator was posted on the wall next to the refrigerator. The temperature reading inside of the refrigerator was observed to be 48 degrees F. LPN #8 said facility management just replaced the thermometer previously in the refrigerator with a new one, so it needed to adjust to the accurate temperature. V. Additional staff interviews and observationsThe regional director of clinical operations was interviewed on 7/24/25 at 9:46 a.m. She said she spoke with the facility's pharmacist and was told the medications in the [NAME] 2 medication storage room refrigerator were good for at least 14 days at room temperature. She said the medications were labeled with an open date of 7/21/25.On 7/24/25 at 10:08 a.m., the [NAME] 2 medication storage room was observed with RN #4. The medication storage refrigerator was not observed in the storage room. RN #4 said the refrigerator was removed and a new one was ordered. RN #4 said any new refrigerated medications received would be stored in the [NAME] 1 medication storage refrigerator until the new refrigerator arrived.On 7/24/25 at 10:17 a.m., the East 2 medication storage room refrigerator was observed with LPN #6. The refrigerator temperature was observed to be 38 degrees F.

Based on observations, record review and interviews, the facility failed to ensure one (#4) of two residents who required respiratory support received care consistent with professional standards of practice out of 52 sample residents. Specifically the facility failed to obtain a physician ordered bilevel positive airway pressure (BiPAP) machine (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) for Resident #4 to use during sleep hours.Findings include: I. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE] and discharged on 7/23/25 to the community. According to the July 2025 computerized physician orders (CPO), diagnoses included acute respiratory failure, obstructive sleep apnea (breathing stops during sleep) and tachycardia (heart beats too fast). The 5/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He had no behaviors and did not reject care. He required assistance with toileting, dressing, bathing and transferring. He required supervision with eating and oral hygiene. The MDS assessment indicated the resident utilized a BiPAP.B. Resident representative interviewResident #4's representative was interviewed on 7/21/25 at 10:30 a.m. The representative said Resident #4 was admitted to the facility in mid-May 2025 and did not have access to his BiPAP device from the time of his admission to the facility until 7/18/25. She said that the BiPAP machine was lost during the resident's hospitalization prior to admission, and although this information was communicated to facility staff upon admission, no replacement device was obtained until 7/18/25. The representative said the current BiPAP machine was a loaner device and he would still need his own personal machine upon his discharge to home. The representative said that the BiPAP machine replacement fell through the cracks with the nursing home facility and the facility did not follow up on obtaining a BiPAP machine in a timely manner. The representative said that Resident #4 did not experience any adverse effects or medical complications during the time he was without the BiPAP machine, however, she expressed concern that the lack of BiPAP therapy may have affected his memory or cognitive functioning.C. ObservationsOn 7/22/25 at 11:08 a.m. Resident #4 was speaking with social services director (SSD) #1 in the common area of the facility. During the conversation, the resident asked SSD #1 for an update on his BiPAP machine. SSD #1 responded that he was working on the resident's BiPAP.On 7/23/25 at 10:40 a.m. Resident #4 was being discharged from the facility, leaving with his wife while facility staff carried his belongings. Resident #4 said the facility had taken care of ordering his new BiPAP machine for home and he would receive it in the mail. D. Record reviewA review of the hospital discharge paperwork which accompanied Resident #4 upon admission to the facility, dated 5/22/25, revealed that several medications were check marked by facility nursing staff. -However, the order for the resident to have a BiPAP at bedtime did not have a checkmark. Review of Resident #4's July 2025 CPO revealed the resident had a physician's order for oxygen at 4 liters/minute via BiPAP at night only, ordered 5/22/25.-However, Resident #4 did not have access to a BiPAP machine from admission [DATE]) until 7/18/25 (see resident representative interview above and staff interviews below). Review of Resident #4's care plan, dated 5/23/25, identified the resident's need for nighttime BiPAP use related to ineffective gas exchange. Interventions included oxygen therapy and monitoring for signs and symptoms of respiratory distress. -However, the facility did not ensure Resident #4 had access to a BiPAP machine for almost two months after his admission to the facility (see resident representative interview above and staff interviews below).II. Staff interviewsRegistered nurse (RN) #2 was interviewed on 7/23/25 at 9:15 a.m. RN #2 said the facility had a few ways to ensure residents had a BiPAP machine for use upon admission. RN #2 said the facility checked for a physician's order, some residents brought their own devices, and if not, the facility worked with companies to obtain a BiPAP machine. RN #2 said once a BiPAP machine was in place, the nurses assessed the settings to ensure they were correct and functioning properly. RN #2 said the nurses also asked the resident if they were comfortable and observed them to ensure they were comfortable using the device. RN #2 said the BiPAP machine notified staff if it did not have a good seal on the resident's face so they could adjust it. RN #2 said she did not know why Resident #4 did not receive his BiPAP machine when he was admitted to the facility. RN #2 said she typically referred those situations to social services to see if they could get a loaner BiPAP machine. RN #2 said she did not know the reason for the delay for Resident #4's BiPAP. SSD #1 was interviewed on 7/23/25 at 10:52 a.m. SSD #1said that if a resident needed respiratory equipment, nursing handled the process of obtaining it. SSD #1 said that if the resident was discharging home, then social services placed the order and coordinated with the equipment company. SSD #1 said that for Resident #4, the respiratory company requested a sleep study and he needed to find out who would pay for it. SSD #1 said documentation from the nurse practitioner was also needed. SSD #1 said that as far as he could remember, a BiPAP machine was on the Resident #4's table.The medical director (MD) was interviewed on 7/23/25 at 11:39 am. The MD said the BiPAP and continuous positive airway pressure (CPAP) machines were used to effectively treat sleep apnea which was associated with conditions such as depression, anxiety, diabetes, heart failure and stroke. The MD said that if a resident had a physician's order for a BiPAP or CPAP machine, the resident should use it regularly. The assistant director of nursing (ADON) was interviewed on 7/23/25 at 12:01 p.m. The ADON said residents who required BiPAP or CPAP equipment were discussed during stand-up meetings before the resident was admitted to ensure the respiratory equipment was obtained. The ADON said she typically handled calling the oxygen company and placing an order for the device unless the resident was bringing one from their home. The ADON said Resident #4's BiPAP machine was lost at the hospital. She said the resident's representative contacted the hospital but the hospital could not locate it. The ADON said Resident #4 had a history of noncompliance with BiPAP use but he maintained oxygen saturation levels (level of oxygen in the blood) above 90% (percent). The ADON said Resident #4's BiPAP machine was not ordered for nearly two months after readmission because the hospital discharge orders did not include it. She said although the BiPAP machine was documented on the care plan, it was not entered as a physician's order when the resident was admitted to the facility. The ADON said the MDS assessment nurse identified the omission and entered a new BiPAP machine order on 6/9/25. The ADON said without the BiPAP machine, the resident could experience nighttime breathing difficulties that may worsen his arrhythmia (abnormal heart rhythm). -However, Resident #4 did not receive the ordered BiPAP until 7/18/25 (see resident representative interview above).Licensed practical nurse (LPN) #2 was interviewed on 7/24/25 at 1:20 p.m. LPN #2 said the admitting nurse was responsible for checking admission orders. LPN #2 said the physician's orders were then given to the facility's physician for final review. LPN #2 said she was not sure why Resident #4's BiPAP order was missed on admission, but she said she would report any issues to management.The regional director of clinical operations was interviewed on 7/24/25 at 2:43 p.m. The regional director of clinical operations said the admitting nurse was responsible for transcribing and ensuring the accuracy of discharge orders. She said a manager usually reviewed the physician's orders; however, this was not part of the formal process. She said the facility was currently discussing ways to improve the process.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing for one (#12) of six residents out of 52 sample residents. Specifically, the facility failed to:-Ensure individualized care approaches were provided and monitored with ongoing assessment for Resident #12 in order to meet the emotional and psychosocial needs of the resident;-Ensure Resident #12, who had expressed suicidal ideations with intent and a history of trauma, was monitored for signs and symptoms of suicidal ideation; and, -Ensure expressions of suicidal ideations were addressed in a timely manner in order to secure Resident #12's safety.Findings include:I. Facility policy and procedureThe Psychosocial Evaluation Procedure policy, dated December 2024, was provided by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It revealed in pertinent part, If a member of the interdisciplinary team (IDT) notices the resident has element(s) of psychosocial unmet needs, such as but not limited to: self-injurious behavior or suicide ideation that IDT member initiates the psychosocial evaluation and notifies supervisor, each IDT member completes their section of the evaluation (if appropriate), the social services member completes the evaluation, and the psychosocial evaluation is used when reviewing psychotropic medications. II. Resident #12A. Resident statusResident #12, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included post traumatic stress disorder (PTSD) and major depressive disorder. The 6/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident's depression screen assessment, dated 6/25/25, revealed Resident #12 had indicated she was moderately depressed with a score of 10 out of 27.B. Resident interview and observationResident #12 was interviewed on 7/21/25 at 1:46 p.m. Resident #12 said her depression was her own fault because she was struggling to adjust to placement in the facility. She said she had previously lived in an assisted living facility and had to move to long term care and leave all her close friends. Resident #12 said she made the decision to move to her current facility to be closer to her daughter, but she said she did not see her daughter often and the two of them fought frequently. She said the fighting triggered her depression and reminded her of what she had lost (former friends and independence). Resident #12 was evasive to answering questions regarding previous threats of self harm but did share a history of suicide attempts made by her mother. She said she was aware of how traumatic it would be for her family if she killed herself, but she said she still could not help thinking about it at times. During the interview, Resident #12 denied a current plan or intent to self harm. During the interview, Resident #12's window was observed to have a bar which prevented the window from opening more than approximately four inches. C. Record reviewThe mood care plan, revised 12/24/24, revealed Resident #12 had a diagnosis of PTSD and major depressive disorder. The resident suffered from childhood trauma manifesting as isolating in bed, declining activities of enjoyment, perseverations of childhood trauma and hallucinations. Interventions, initiated 9/18/24, included monitoring for signs and symptoms of hopelessness, anxiety, sadness, insomnia, anorexia, negative statements, and tearfulness. -The care plan failed to reveal any revisions to include threats of self harm after the 12/21/24 or 7/10/25 incidents (see psychologist visit notes and progress notes below).Review of Resident #12's July 2025 CPO revealed the following physician's orders:Effexor (an antidepressant) 75 milligrams (mg). Give 75 mg to equal 225 mg (three capsules) in the morning for major depressive disorder, ordered 9/18/24 and decreased 6/25/25 (see physician's order below).-Resident #12's dosage of the antidepressant was decreased on 6/25/25, despite recommendations by the physician managing the resident's psychoactive medications to not make reductions and instead add another antidepressant (see psychologist visit notes below). Effexor 150 mg. Give 150 mg to equal 225 mg (two capsules) in the morning for PTSD, ordered 9/21/24 and discontinued 7/9/25. Effexor 37.5 mg. Give one capsule in the morning for major depressive disorder, ordered 6/25/25. Behavior monitoring for depressed mood, self-isolating in bed, perseverations on trauma, perseverations on spouse and hallucinations. Non-pharmological interventions included to offer food/fluids, offer to call a loved one, take for a walk, validate feelings and encourage an activity, ordered 9/18/24. -The July 2025 CPO did not include a physician's order to monitor for potential signs and symptoms of suicidal ideation.Progress notes reviewed from 12/21/24 to 7/22/25 revealed the following:A nursing note, dated 12/21/24, revealed the nurse had followed up with Resident #12 regarding comments made to another nurse about suicidal thoughts. Resident #12 denied suicidal ideations and the nurse notified the physician.-The nursing note failed to indicate whether a psychosocial evaluation had been performed to ensure resident safety, as was identified as the process when a resident expressed suicidal ideation (see facility policy above). A social services note, dated 12/23/24, revealed Resident #12 had experienced highs and lows in her mood with continued difficulty with adjustment to placement as she did not feel she could relate to the other residents because she was more physically capable than them. -The note did not identify if the social services director (SSD) addressed the resident's suicidal comments from 12/21/24. A behavior note, dated 1/3/25, revealed the resident displayed anxiety, sadness, and difficulty with adjusting to placement.A behavior note, dated 1/4/25, revealed Resident #12 had asked to speak to the nurse and stated she was depressed. The nurse spent thirty minutes talking to Resident #12 about her struggle to adjust and her triggers.A behavior note, dated 2/9/25, revealed the resident had been observed to be depressed and self-isolating. Resident #12 expressed to the nurse feeling upset and distressed about not being able to return to her prior living situation.A depression screen note, dated 3/21/25, revealed Resident #12 had endorsed having little interest in things she used to like, feeling down/depressed/or hopeless, difficulty with sleeping, and decreased energy. The resident reported feeling down just because, experiencing adjustment issues and suffering from nightmares. The screen revealed a score of four, indicating minimal depression.A nursing note, dated 4/24/25, revealed the resident reported to the nurse feelings of sadness. A nursing note, dated 4/26/25, revealed Resident #12 had been observed by the nurse to be sitting in her room in the dark with a flat affect. The resident had endorsed feeling depressed. A depression screen note, dated 6/25/25, revealed the resident had endorsed having little interest in things she used to like, feeling down/depressed/or hopeless, difficulty with sleeping, changes in appetite and decreased energy. The screen revealed a score of 10, indicating moderate depression.-The 6/25/25 depression screen note indicated Resident #12's depression screen score had increased from a four on 3/21/25 (see above) to a 10, however, the dosage of the resident's antidepressant medication was decreased on 6/25/25 despite the increase in the depression screen score.A nursing note, dated 7/3/25, revealed the resident had reported feeling decreased energy and extremely tired.A nursing note, dated 7/9/25, revealed Resident #12 had reported feeling tired and had been observed to be withdrawn and self-isolating.A nursing note, dated 7/10/25 at 3:24 p.m., revealed the resident had been noted to be displaying emotional outbursts to include anger throughout the day.A behavior note, dated 7/10/25 at 5:30 p.m., revealed the resident had told the nurse I want to kill myself, I am done. The nurse tried to reassure the resident. The resident then told the nurse she was considering overdosing on her medications but also was considering going out of her second floor window as a method to kill herself. The nurse contacted the on-call physician and requested a one time dose of Ativan (an antianxiety medication). -The progress note, on 7/10/25, failed to reveal a call was made to the director of nursing (DON), the NHA, the SSD, or Resident #12's representative. -The nursing note failed to indicate a psychosocial evaluation was performed to ensure resident safety (see facility policy above). A nursing note, dated 7/10/25 at 11:45 p.m., revealed Resident #12's physician discontinued the Ativan and instructed the facility to move the resident to a room on the first floor due to the resident's recurrent threats of jumping out of the window. The physician had been informed by the facility that the move would not occur until the following day.-There was no documentation in the resident's electronic medical record (EMR) to indicate the facility put any interventions in place to keep the resident safe until the move to the first floor could take place after the 15 minute checks ended on 7/11/15 at 5:45 a.m.-Additionally, resident interview, observations, and record review revealed Resident #12 had never moved rooms (see resident interview and observations above).A mental health provider note, dated 7/11/25 at 3:00 p.m., revealed Resident #12 had been assessed due to making suicidal statements with a viable plan. The mental health physician concluded the resident was no longer a danger to herself and could be removed from 15-minute checks by staff. -However, review of the facility's 15 minute check logs for the resident, dated 7/10/25 to 7/11/25, revealed Resident #12 had been removed from 15-minute checks at 5:45 a.m. on 7/11/25, approximately nine hours before being cleared by the mental health physician (see 15 minute check logs below).A nursing note, dated 7/22/25, revealed Resident #12 had been observed to be tired and agitated.-Progress notes in the EMR failed to reveal that social services had followed up with an evaluation after the 12/21/24 or the 7/10/25 threat of suicide.Psychologist visit notes, reviewed from 1/6/25 to 7/7/25 revealed the following:A psychologist visit note, dated 1/6/25, revealed the staff reported to the psychologist that Resident #12 had expressed increased depression over the past few weeks and made suicidal comments. When asked by the psychologist, the resident said it had not been serious. The psychologist triggered in the note that the resident had symptoms of suicidal ideations. The psychologist completed a diagnostic depression screening and the resident had a score of seven, indicating mild depression. A chart (EMR) review made by the psychologist revealed that on 12/21/24, after an argument with her daughter, the resident told the staff that sometimes I think that since I'm only one floor up maybe I should just jump out the window but after considering the possibility of broken bones, she then told the staff she would rather purchase a gun to shoot herself in response to her negative feelings. -The specific EMR note referenced by the psychologist was requested during the survey, but was never provided by the facility. A psychologist visit note, dated 1/14/25, revealed Resident #12 reported to the psychologist that sometimes she feels like giving up. The psychologist triggered in the note the resident had trauma related symptoms. A psychologist visit note, dated 2/12/25, revealed Resident #12 had been displaying behaviors of depression, sadness, isolation, social withdrawal and agitation over the past thirty days. A psychologist visit note, dated 3/5/25, revealed Resident #12 had expressed being troubled by intrusive memories of her past trauma and hypervigilance to triggers surrounding the loss of control and the resident feeling on edge. The psychologist completed a diagnostic depression screening and the resident had a score of seven, indicating mild depression.A psychologist visit note, dated 3/7/25, revealed Resident #12 had displayed behaviors of anxiety, depression, sadness, isolation, social withdrawal and agitation over the past thirty days. A psychologist visit note, dated 6/25/25, revealed Resident #12 had expressed ongoing depression, with feelings of hopelessness, difficulty adjusting and loss of appetite with weight loss. The psychologist recommended adding Remeron (an antidepressant) for mood and appetite. The psychologist documented in the visit note that a reduction of the residents' psychoactive medications would be clinically inadvisable (likely to have unfortunate consequences).-However, the facility decreased the resident's dosage of her antidepressant medication on 6/25/25 (see physician's orders above).A psychologist visit note, dated 7/7/25, revealed Resident #12 expressed ongoing depression, with isolation and loss of appetite. The psychologist completed a diagnostic depression screening and the resident had a score of 10, indicating moderate depression (an increase since 3/5/25, see psychologist note above). A psychologist visit note, dated 7/16/25, revealed Resident #12 was unavailable for a visit. The note did not indicate the facility had communicated to the psychologist regarding the resident's suicidal ideations on 7/10/25. -A review of Resident #12's EMR failed to reveal Remeron was ever started, per the psychologist's recommendations on 6/25/25. A nurse practitioner visit note, dated 12/26/24, indicated Resident #12 had expressed her remarks of suicidal ideations were misunderstood humor, however the resident did endorse depression and difficulty adjusting. -Despite visiting Resident #12 and discussing the incident on 12/21/24, the nurse practitioner did not follow up with the resident until five days after Resident #12's threats of suicide. A nurse practitioner visit note, dated 1/3/25, indicated Resident #12 was negative for displaying suicidal ideations during that visit.A nurse practitioner visit note, dated 7/18/25, indicated Resident #12 had been positive for depression and had a risk factor of a history of a parent attempting suicide multiple times.-Physician, psychologist, and nurse practitioner notes failed to reveal Resident #12 had been assessed for suicide lethality or safety on 12/21/24 or 7/10/25, when she made the threats of wanting to kill herself.A review of 15-minute check logs, dated 7/10/25 to 7/11/25, revealed Resident #12 had been on 15-minute checks from 4:45 p.m. on 7/10/25 until 5:45 a.m. on 7/11/25. There were no 15-minute check logs provided by the facility for 12/21/24. The social services quarterly psychosocial assessment, dated 12/23/24, revealed Resident #12 had struggled with adjustment to placement. No changes in behavior were indicated, despite recent suicidal comments (see psychologist notes above). The social services quarterly psychosocial assessment, dated 6/25/25, revealed Resident #12 had struggled with feelings of depression, experiencing a loss of appetite and a decreased interest in activities she enjoyed. Facility conducted depression and trauma screening assessments revealed the following;On 3/21/24, Resident #12 had a score of four, indicating minimal depression. On 6/25/25, the residents' depression score had increased to 10, indicating moderate depression. The trauma screening, dated 3/21/25, revealed Resident #12 suffered from sleep disturbances related to her history of trauma. The trauma screening, dated 6/25/25, revealed the resident suffered from sleep disturbances and upsetting thoughts or memories that were intrusive related to her history of trauma. -Depression and trauma screens, on 6/25/25, indicated increases in depressive symptoms and trauma responses for Resident #12, however, these increases were not addressed by the facility or reported to the physician/psychologist. -Psychotropic medication meeting minutes were requested on 7/23/25 but were not provided by the end of the survey on 7/24/25.-Contact information for the psychologist seeing Resident #12 was requested on 7/23/25 but was never provided by the facility during the survey.IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 7/22/25 at 12:08 p.m. LPN 33 said if a resident expressed suicidal ideations, the nurse notified the physician, kept a visual on the resident and notified nurse management and the SSD. LPN #3 said Resident #12 was being monitored for anxiety, verbal expressions of sadness and self-isolation. She said she thought Resident #12 had a history of making statements of suicidal ideations but no one had told the nurses to monitor for that specifically. LPN #3 said she had just read about the resident's statements in the progress notes.Registered nurse (RN) #2 was interviewed on 7/22/25 at 12:20 p.m. RN #2 said if a resident expressed suicidal ideations, the nurse would stay with the resident to ensure their safety and have other staff contact nurse management, the SSD, the family, and the physician. She said nurse management would give the nurses direction on interventions, such as if the resident needed one-on-one supervision. RN #2 said Resident #12 expressed depression through behaviors of agitation, non-compliance with care and verbal expressions of anger towards staff. She said she was aware Resident #12 suffered from difficulty with placement, trauma, and major depression but she said she had not been told by nurse management that Resident #12 suffered from suicidal ideations or to monitor for suicidal ideations.Certified nurse aide (CNA) #3 was interviewed on 7/22/25 at 12:30 p.m. CNA #3 said if a resident expressed suicidal ideations or statements, the CNAs were to notify the charge nurse and the NHA. She said she had worked with Resident #12 since her admission and was not aware she had a history of suicidal ideations. CNA #5 was interviewed on 7/22/25 at 1:44 p.m. CNA #5 said if a resident was expressing suicidal ideations, she would sit and talk with the resident and notify the charge nurse. CNA #5 said she was aware that Resident #12 had PTSD and depression and that her depression manifested as increased sleeping, decreased appetite and verbal statements. She said talking about art or scripture helped Resident #12 when she was depressed. CNA #5 said she was told by other staff members that Resident #12 had made statements about wanting to kill herself and jump out of her window, but CNA #5 said she had been told by other staff that those statements had been a joke. SSD #1, the NHA, and the assistant director of nursing (ADON) were interviewed together on 7/22/25 at 2:33 p.m. The NHA said he had worked at the facility since 2021. He said resident behaviors were discussed in the morning and afternoon IDT meetings everyday and floor nurses attended those meetings. The NHA said if a resident showed new or worsening behaviors, it would be discussed in that meeting. The NHA was not aware of the specific process the facility used to respond to resident's expressions of suicidal ideations or the facility's specific process for monitoring, he said he would have to ask the previous SSD (SSD #2), who now worked at the organization's new building across the street. The NHA said his expectation if a resident expressed suicidal ideations was that the resident would get help as soon as possible but he would have to ask SSD #2 as to the timeframe. The NHA was unable to say if he knew or did not know that Resident #12 had made statements of suicidal ideations prior to 7/10/25, he said he would have to talk to SSD #2.The ADON said she had been in her role as of February 2025 and there was no current DON in the facility. The ADON said she was aware that Resident #12 had made statements of suicidal ideations and the facility contacted the physician and the psychiatrist. The ADON said the psychiatrist came out the following day, 7/11/25, after Resident #12 threatened to jump out of her window on 7/10/25. She said the nurse and a member of nurse management provided one-on-one supervision of Resident #12 on 7/10/25 and then after a few hours, switched to 15-minute checks after the resident appeared to calm down. The ADON was unaware of how specifically the facility assessed and determined Resident #12 was no longer a danger to herself on 7/10/25 and she was unaware that Resident #12 had made statements of wanting to kill herself previously. The ADON was additionally unaware if a facility psychosocial evaluation had been completed for Resident #12 following her expressions of suicidal ideation. SSD #1 said he had worked at the facility for approximately six weeks. He said if a resident had a history of or current expressions of suicidal ideations, behavior monitoring would be implemented. SSD #1 said the process he would follow if a resident expressed suicidal ideations would be to immediately have someone provide one-on-one supervision of the resident. He said he would assess the resident for thought process, intent and risk. SSD #1 said he would create a safety plan with the resident and do a sweep of the resident's room for items the resident could use to harm themselves. SSD #1 said the resident would be removed from any method they had expressed using to kill themselves, for example if the resident said they intended to throw themselves down the stairs, staff would keep the resident away from stairs. SSD #1 said he was not aware if all the staff in the facility had been educated on how to assess an individual with suicidal ideations. He said he would attempt to get the resident assessed by the mental health physicians and if this was not possible, he would send the resident out to the hospital to be assessed, if applicable. SSD #1 said he had not completed a psychosocial assessment with Resident #12 because he was out of town on 7/10/25, but he could not say why the behavior monitoring or care plan had not been updated to include suicidal ideations after 7/10/25. SSD #2 was interviewed on 7/22/25 at 3:15 p.m. SSD #2 said if a resident expressed active statements of self harm or suicidal ideations, the facility would complete a room sweep for any dangerous items, put the resident on 15-minute checks and contact the physican. She said the facility was not equipped to provide one-on-one supervision and if that was necessary, the resident would be sent out to the hospital. SSD #2 said she was aware Resident #12 had made statements of suicidal ideations on 12/21/24 but said that there was not a serious threat determined which necessitated reaching out to the mental health physician or the telehealth physician. SSD #2 said Resident #12's psychologist was aware of the resident's statements on 12/21/24 and met with the resident on 1/7/25. SSD #2 said she did not update the care plan or add behavior monitoring because Resident #12 had not made a statement that she specifically had a plan and the nurse had determined Resident #12 was stable and did not intend to hurt herself. She said the nurse assessed Resident #12 on 12/21/24 and determined the resident did not have a plan, however, she was unable to find nurse documentation of the 12/21/24 assessment. SSD #2 said the physician assessed Resident #12 the following day, 12/22/24, and determined the resident was safe. SSD #2 said she would reach out to the physician for that documentation. -Documentation provided by the facility was the 12/26/24 nurse practitioner visit note located in the EMR (see NP note above). The psychiatrist was interviewed on 7/22/25 at 4:20 p.m. She said when she was contacted by the facility on 7/10/25, she was advised by the facility that SSD #1 or someone else had assessed Resident #12 for ideations and safety. The psychiatrist said, based on the facility assessing the resident, numerous staff talking to the resident about the situation and the physician being called for an order of Ativan, she felt it was safe to wait until the following day to assess Resident #12 herself. She said she did not recommend the facility move Resident #12's room downstairs because this could have been perceived by the resident as another loss of control in her life. The psychiatrist said she had believed the resident had been on 15-minute checks until she assessed her the following afternoon. She said she was unaware the resident had made prior statements before 7/10/25 about wanting to kill herself and the psychiatrist was unable to say if she would have made the same recommendations if she had been aware of this history. The medical director (MD) was interviewed on 7/23/25 at 11:39 a.m. The MD said if a resident expressed suicidal ideations or expressions, he would recommend the facility begin behavior monitoring in the EMR. The MD was not aware of the facility's specific process when it came to suicidal ideations, however, he said Resident #12 should have been moved to the first floor after making the first threat of jumping out of her window.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure housekeeping staff completed proper hand hygiene, cleaned high-touch surfaces and followed the appropriate guidelines for disinfectant solution when cleaning residents' rooms; and,-Ensure appropriate infection control procedures were followed urinary catheter care for Resident #68. Findings include: I. Failed to ensure housekeeping staff completed proper hand hygiene, cleaned high-touch surfaces and followed the appropriate guidelines for disinfectant solution when cleaning residents’ rooms A. Professional references According to The Centers for Disease Control And Prevention’s (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers (February 2024), retrieved on 7/28/25 from: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, “Recommendations to clean your hands include immediately before touching a patient, before performing an aseptic technique, before moving from work on a soiled body site to a clean body site, after touching a patient or patient’s surroundings, after contact with body fluids and immediately after glove removal.” According to the CDC’s When and How to Clean and Disinfect a Facility (April 2024), retrieved on 7/28/25 from https://www.cdc.gov/hygiene/about/when-and-how-to-clean-and-disinfect-a-facility.html#:~:text=At%20a%20glance,people%20have%20obviously%20been%20ill, “Regularly cleaning surfaces in your facility helps prevent the spread of germs that make people sick. Clean high-touch surfaces regularly (pens, counters, shopping carts, door handles, stair rails, elevator buttons and touchpads). Clean other surfaces that are visibly dirty.” According to the The Waxie Product Specification Sheet for 764 Lemon Quat Disinfectant Cleaner (2022), retrieved on 7/28/25 from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.waxie.com/pdf/spec-sheets/170700-WAXIE-spec-sheet.pdf on 7/28/25, “Every microorganism tested with the disinfectant aside from COVID-19, had a contact time of 10 minutes. Contact time for COVID-19 was one minute. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised December 2024, was received from the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It documented in pertinent part, “The facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene includes both handwashing and the use of alcohol-based hand sanitizer. In most situations, the preferred method of hand hygiene is with 70% (percent) alcohol-based hand sanitizer, as it is proven most effective. The following situations require the use of hand washing of 20 seconds using soap and water: when hands are visibly dirty or soiled, after contact with blood, bodily fluids, secretions, mucous membranes, or non-intact skin, after handling items potentially contaminated with blood, bodily fluids, or secretion, and before eating and after using a restroom.” C. Observations During a continuous observation on 7/23/25, beginning at 10:56 a.m. and ending at 11:30 a.m., the following was observed: Housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER]. HK #1 began by putting gloves on her hands. She took a spray bottle with 764 Lemon Quat Disinfectant Cleaner and a rag into the room. She sprayed the disinfectant on the rag and wiped the bedside table. She sprayed the window sills with the disinfectant and immediately wiped them down with the rag. She sprayed picture frames with the disinfectant and immediately wiped them down with the rag. She sprayed the closet and television stand (all one unit) and immediately wiped it down with the rag. She sprayed the headboard of the bed with the disinfectant and immediately wiped it down with a rag. HK #1 returned the disinfectant and rag to her cart, disposed of the rag, removed her gloves and donned clean gloves without performing hand hygiene. She set the disinfectant solution aside and went back into the room. She removed the trash bags in the room and replaced them with empty bags. She took the vacuum out of the cart and vacuumed the carpet in the resident’s bedroom. After vacuuming the carpet, HK #1 grabbed a new rag and the disinfectant solution and sprayed the bathroom counter and sink. She immediately wiped the surfaces with the rag. She sprayed the shower chair and immediately wiped it with the rag. She sprayed the grab bars in the shower and immediately wiped them with the rag. She sprayed the toilet and immediately wiped it with the rag. HK #1 returned to the cart and removed her gloves. She donned clean gloves without performing hand hygiene. She mopped the bathroom floor. She removed her gloves. She moved her cart to resident room [ROOM NUMBER]. She donned clean gloves without performing hand hygiene. HK #1 entered room [ROOM NUMBER] and sprayed the bedside table in the resident’s room with disinfectant and immediately wiped the surface with the rag. She sprayed the window sill and immediately wiped it with the rag. She sprayed the closet and television stand and immediately wiped them with the rag. She removed her gloves and donned clean gloves without performing hand hygiene. She removed the trash from the room and bathroom. She disposed of the trash in her cart and then began to clean the bathroom. -HK #1 did not perform hand hygiene in between glove changes or between cleaning different residents’ rooms. -HK #1 did not allow the disinfectant to remain on surfaces for the full 10-minute recommended dwell time before wiping off the surfaces (see disinfectant product specifications above). -HK #1 failed to disinfect high-touch surfaces such as the call light, the television remote, the door knobs and the light switches. D. Staff interviews The maintenance director (MTD) was interviewed on 7/24/25 at 9:00 a.m. The MTD said the disinfectant the housekeepers used to sanitize residents’ rooms was 764 lemon quat disinfectant solution. He said the dwell time for that solution was 10 minutes. He said the solution should sit on a surface for 10 minutes before it got wiped down with a rag. He said the housekeepers had a checklist they all followed to tell them the order in which to clean a resident’s room and what to clean. He said high-touch surfaces, such as phones, remotes, call lights, door knobs and light switches should be sanitized daily. He said hand hygiene should be performed after the use of gloves. The assistant director of nursing (ADON) and the regional director of clinical operations were interviewed together on 7/24/25 at 11:00 a.m., in place of the infection preventionist (IP). The regional director of clinical operations said housekeepers should be waiting for the appropriate dwell time for disinfectant solutions prior to wiping the solution away. The regional director of clinical operations said housekeepers should be disinfecting high touch surfaces as part of their daily cleaning of resident rooms. II. Failure to ensure appropriate infection control procedures were followed during urinary catheter care for Resident #68 A. Professional reference According to the CDC’s Clinical Safety: Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 7/31/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety: When to clean your hands: -Immediately before touching a patient; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or patient's surroundings; -After contact with blood, body fluids, or contaminated surfaces; and, -Immediately after glove removal. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves. When to wear gloves: -When needed for standard precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment); and, -When needed for transmission-based precautions. When to change gloves and clean hands: -If gloves become soiled with blood or body fluids after a task; -If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; and, -If they look dirty or have blood or body fluids on them after completing a task. B. Facility policy and procedure The Hand Hygiene policy, dated December 2024, was received by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It read in pertinent part, “The facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene includes both handwashing and the use of alcohol-based hand sanitizer. “The following situations require the use of hand washing of twenty (20) seconds using soap and water: -When hands are visibly dirty or soiled; -After contact with blood, body fluids, secretions, mucous membranes, or non- intact skin; -After handling items potentially contaminated with blood, body fluids, or secretions; -Before eating and after using a restroom; -Before inserting urinary catheters, peripheral vascular catheters or other invasive devices that do not require surgery; and, -When there is a likely exposure to C Diff (clostridium difficile) and Norovirus or GI (gastrointestinal) symptoms. “The use of gloves does not replace hand hygiene.” The Foley catheter policy, dated December 2024, was received by the NHA on 7/24/25 at 11:00 a.m. It read in pertinent part, “A urinary catheter is any tube system placed in the body to drain and collect urine from the bladder. The facility is committed to serving the present and future needs of our residents/guests, utilizing a wide variety of resources. Urinary catheters are used to drain the bladder and the prescriber may recommend a catheter for short-term or long-term placement due to urinary incontinence associated with a specific diagnosis, urinary retention, surgery, or other medical condition. “Handwashing is to be performed by the nursing personnel prior to cleansing and after cleansing of the Foley catheter.” C. Observations On 7/23/25 at 11:40 a.m. the infection preventionist (IP) #2 was providing catheter care to Resident #68. The following observations were made: IP #2 applied gown and gloves before entering Resident #68’s room. IP #2 said she performed hand hygiene at the desk before going to Resident #68’s room. Resident #68 was sitting in a chair in his room. IP #2 assisted Resident #68 with ambulating to and lying down on his bed. IP #2 went into Resident #68’s bathroom and filled a basin with warm, soapy water. IP #2 brought the basin into the room and placed it next to Resident #68 on his bed. -IP #2 did not remove her gloves or perform hand hygiene after assisting Resident #68 to lie down in bed and touching the faucet in the bathroom while filling the basin with water . IP #2 lowered Resident #68’s pants to below his belly button. Resident #68 had a urinary catheter securely inserted into his belly button (suprapubic catheter). IP #2 grabbed a washcloth and submerged it in the water basin. IP #2 used the washcloth to wipe Resident #68’s catheter site from the inside out toward his left side. IP #2 wiped the site approximately three to five times, going from inside to out. IP #2 folded the washcloth and used a new spot with each wipe. IP #2 placed the washcloth in the dirty laundry bin, removed her gloves and donned a new pair of gloves. -IP #2 did not perform hand hygiene before donning the new pair of gloves. IP #2 took a new washcloth and submerged it in the water basin. IP #2 used the washcloth to wipe Resident #68’s catheter site from the inside out, towards his right side. IP #2 wiped the site approximately three to five times from the inside to out and refolded the washcloth to wipe the site with a new spot each time. IP #2 placed the washcloth in the dirty laundry bin, removed her gloves and donned a new pair of gloves. -IP #2 did not perform hand hygiene before donning a new pair of gloves. IP #2 emptied the water basin in Resident #68’s bathroom. Wearing the same gloves, IP #2 returned to Resident #68 and pulled up his pants over his catheter site. IP #2 then assisted Resident #68 into a sitting position at his bedside. D. Staff interviews The assistant director of nursing (ADON) and the regional director of clinical operations were interviewed together on 7/24/25 at 11:00 a.m., in place of the infection preventionist (IP). The regional director of clinical operations said hand hygiene should be performed before and after resident care. She said it should be performed after the removal of gloves. She said this was important for reducing the transmission of infections.

Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#3 and #4) of three residents reviewed out of four sample residents. Specifically, the facility failed to identify Resident #3 and Resident #4's post traumatic stress disorder (PTSD) and identify triggers which may retraumatize them. Findings include: I. Facility policy and procedure The Trauma Informed Care policy and procedure, undated, was provided by the director of nursing (DON) on 9/4/24 at 4:38 p.m. It read in pertinent part, It is the policy of the community to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice. Each resident will be screened for a history of trauma upon move-in by the community's social service or designee. If the screening indicates that the resident has a history of trauma and/or trauma-related symptoms, an order will be obtained for the resident to be evaluated by mental health professional who is qualified and experienced in working with those exposed to trauma. Once the order is received, the referral to the mental health professional will be made. The community will account for residents' experiences, preferences, and cultural differences to eliminate or mitigate triggers that may cause re-traumatization of the resident. II. Resident #3 A. Resident status Resident #3, age 78, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD) and anxiety disorder. The 7/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He was dependent on staff assistance for lower body dressing, putting on/taking off footwear, chair/bed to chair transfer, toilet transfer, tub/shower transfer, showering/bathing self and toileting hygiene. B. Resident interview Resident #3 was interviewed on 9/4/24 at 11:35 a.m. Resident #3 said he served in the Navy for four years and was an aircraft carrier in Vietnam. He said he had been diagnosed with PTSD. He said he was not receiving services for PTSD. C. Record review The feelings care plan, revised on 10/26/21, documented Resident #3 was at risk for feelings of sadness, emptiness, anxiety, uneasiness, depression, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation and withdrawal from care/activities and loss of independence. Pertinent interventions included monitoring the resident's mental status and mood state changes when new medication was added and involving the resident in making his own schedule. The mood care plan, revised on 6/26/24, documented Resident #3 had a mood challenge related to insomnia. Interventions included monitoring and recording the resident's mood to determine if problems seem to be related to external causes, medications, treatments and or concerns over diagnosis; tracking hours of sleep and having caregivers to assist the resident/family in identifying the residents strengths, encouraging positive coping skills and reinforcing them. The behaviors care plan, revised on 12/27/21, documented Resident #3 had behavior challenges related to sexually inappropriate behaviors towards female staff. Interventions included providing the resident the opportunity for positive interaction and attention, stopping and talking with resident when passing by, having the nurses monitor the resident's behaviors for inappropriate sexual comments to female staff, offering and documenting non pharmacological interventions as needed , setting clear boundaries, educating on appropriate ways to speak to staff, offering snack or drink, redirecting to an activity, offering independent activity supplies for validation and providing encouragement to express feelings appropriately. -Review of the resident's comprehensive care plan did not reveal a care plan related to Resident #3's PTSD to include person-centered individualized interventions, personalized triggers or personalized signs and symptoms. The 1/3/24 social services quarterly assessment revealed Resident #3 had minimal depression. The resident self-reported little interest in doing things, depressed mood and feeling bad about himself. The assessment documented Resident #3 had PTSD and anxiety. -Review of Resident #3's electronic medical record (EMR) did not reveal the facility had determined what triggered Resident #3's PTSD. III. Resident #4 A. Resident status Resident #4, age 79, was admitted on [DATE]. According to the September 2024 CPO, the diagnoses included congestive and diastolic congestive heart failure, acute kidney failure and PTSD. The 7/30/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent on staff assistance with toileting hygiene and showering/bathing self. He required substantial/maximal assistance with lower body dressing, putting on/taking off footwear, sitting to standing, chair/bed to chair transfer, toileting transfer and tub/shower transfer. B. Record review The medications care plan, revised on 8/13/24, documented Resident #4 prescribed mirtazapine (for appetite stimulation) and duloxetine HCI ( pain medication). Interventions included administering antidepressant medications as ordered by the physician, monitoring/documenting side effects and effectiveness every shift, educating the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressant drugs being given, monitoring/documenting/reporting as needed adverse reactions to antidepressant therapy and monitoring for changes in behavior/mood/cognition. The depression care plan, revised on 8/13/24, documented Resident #4 had been diagnosed with depression however was not currently on a medication to treat it specifically. Resident #4 was prone to exhibiting the following behaviors that needed to be monitored: depressed mood, isolation, appetite changes and low energy. Interventions included assisting the resident in developing/providing resident with a program of activities that was meaningful and of interest, encouraging and providing opportunities for exercise, encouraging the resident to express his feelings and giving him time to talk, monitoring/documenting/reporting as needed any signs or symptoms of depression, including hopelessness, anxious or health-related complaints and tearfulness. -Review of Resident #4's comprehensive care plan did not reveal a care plan related to his diagnosis of PTSD post-traumatic stress disorder to include person-centered individualized interventions, personalized triggers or personalized signs and symptoms. The 2/8/24 psychosocial evaluation documented Resident #4 was very pleasant. There were no psychosocial signs or symptoms noted at that time. The 8/13/24 social services quarterly assessment documented Resident #4 reported no depression. -The assessment did not indicate the resident had a diagnosis of PTSD. -Review of Resident #4's EMR did not reveal the facility had determined what triggered Resident #3's PTSD. IV. Staff interview The social service director (SSD) was interviewed on 9/4/24 at 3:41 p.m. The SSD said the social services department was responsible for completing a depression screening and offering psychiatric services based on a diagnosis of trauma. She said if the resident had PTSD from Vietnam or was having nightmares that she would refer the resident for psychiatric services. She said if a resident was receiving psychiatric services she would make sure the residents' needs were being met. She said social services was responsible for making sure care plans were implemented and updated. She said care plans should be updated as needed and quarterly. She said Resident #3 had a diagnosis of PTSD and anxiety. She said Resident #3 was not prescribed any medications for his PTSD. The SSD said she did not know that Resident #4 had a diagnosis of PTSD. She said she did not know that he did not have a care plan addressing his PTSD. She said social services was responsible for implementing care plans for behaviors. The SSD said she was not a licensed social worker, so she did not feel comfortable doing a trauma assessment for residents. She said there was not another designated staff member to complete trauma assessments. She said she understood that resident's triggers needed to be identified. She said she now knew what areas she needed to work on improving. She said she would work on getting these areas fixed.

Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for psychosocial concerns out of four sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to: -Provide Resident #2 with psychosocial support who had increasing depression since February 2024; -Update Resident #2's comprehensive care plan to identify the resident's increasing depression and recent wish to die; and, -Develop a comprehensive care plan that depicted Resident #2's accurate antidepressant medication. Findings include: I. Facility policy and procedure The Psychosocial Evaluation policy and procedure, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:30 p.m. It revealed in pertinent part, The community will evaluate and intervene in residents' psychosocial unmet needs to improve their well-being. A member of the interdisciplinary team (IDT) notices the resident has element(s) of psychosocial unmet needs, such as but not limited to: self-injurious behavior; anger, agitation and/or distress that caused aggression - hitting, shoving, biting, suicide ideation, crying, moaning, screaming, expressions of avoidable pain that is severe, fear or anxiety that may be manifested as panic, immobilization, screaming, trembling, avoidance, resistance to care, sleeplessness, fear of speaking. That IDT member initiates the psychosocial evaluation and notifies the supervisor. Each IDT member completes their section of the evaluation, if appropriate. The social services member completes the evaluation. II. Resident #2 A. Resident status Resident #2, age 79, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included major depressive disorder and aphasia (language disorder that affects a person's ability to communicate due to damage to the brain's language centers). The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment indicated that the resident felt down, depressed and hopeless nearly every day, felt bad about herself or that she was a failure nearly every day, had trouble concentrating two to six days (several days) during the assessment period with a total PHQ-9 (Patient Health Questionnaire for depression) severity score of seven out of 27, which indicated that the resident had mild depression. B. Resident's representative interview The resident's representative was interviewed on [DATE] at 1:00 p.m. She said Resident #2 had been having a hard time mentally. She said Resident #2 had increasing depression and the facility was not providing psychosocial support. She said social services did not refer Resident #2 to the psychologist until she insisted upon it in [DATE]. C. Record review The [DATE] CPOs revealed the following physician orders: -Sertraline HCI (Zoloft) (antidepressant medication) oral tablet 100 mg (milligram), give one tablet by mouth one time per day for depression, ordered on [DATE]; -Monitor for depressed mood, crying or tearful, self-isolation, appetite changes, and/or feeling bad about herself. If the behavior occurs. Document in the behavior progress notes description of the behavior, non-pharmacological interventions, and resident response. Every shift for behavioral monitoring. Monitoring interventions that can be used are: re-positioning, offer a snack/drink, redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with resident as needed, active listening and validation, ordered on [DATE]; and, -MediTelecare to evaluate and treat for psychiatric and psychological help, ordered on [DATE]. The antidepressant medication care plan, initiated on [DATE] and revised on [DATE], documented that the resident used the anti-depressant medication of Lexapro. -The care plan was inaccurate as the resident was not currently prescribed Lexapro, but instead Zoloft, which was originally prescribed on [DATE]. The [DATE] PHQ-9 documented Resident #2 felt tired or had little energy two to six days per week. The resident scored a two out of 27, which indicated no to minimal depression. The [DATE] nursing progress note documented Resident #2 said she stayed in bed all day. I just did not feel like getting up. My appetite is off, I am not hungry and nothing tastes right. The [DATE] physician progress note documented Resident #2 was very tearful and stated she would like to die, but does not have a plan. The physician recommended to refer the resident to psychology services and increase the Zoloft. -However, the resident was not referred to psychological services until [DATE], at the insistence of the resident's responsible party. The [DATE] PHQ-9 documented by social services, indicated Resident #2 had little interest or pleasure in doing things, felt tired or had little energy and felt bad about herself or has let her family down with a score of three out of 27, which was a one point increase from February 2024 and indicated minimal depression. -Social services documented that the resident had a recent evaluation confirming the resident had dementia and had been taking the diagnosis hard and caused tearfulness or isolation, however record review did not reveal additional psychosocial support was provided to the resident by social services, including a psychological evaluation referral that was not completed until [DATE]. The [DATE] nursing progress note documented the resident was informing her family and staff that she is ready to die. I have lived a good life and it is time for me to go. The nurse documented that she sat with the resident and said Resident #2 would be missed if she died tonight and informed the resident staff would check on her through the night. -The resident was placed on monitoring for three days, however a review of the resident's electronic medical record (EMR) did not reveal documentation that social services had met with the resident and provided additional psychosocial support. The [DATE] physician progress note documented that Resident #2's anxiety and depression was severe. The resident was very tearful and perseverated on death and not wishing to be alive any longer. Resident #2 said she felt she was a burden to her family. The [DATE] PHQ-9 documented Resident #2 felt down, depressed or hopeless almost every day, felt bad about herself or that she was a failure or have let her family down every day and had trouble concentrating two to six days of the assessment period with a score of seven out of 27. -Resident #2 had a four point increase on the [DATE] PHQ-9 assessment since [DATE]. -A review of the resident's EMR did not reveal documentation that the resident had been provided psychosocial supportive services by the social services department, other than a referral to psychology services on [DATE], which was prompted by the resident's family member, not the facility staff (see resident representative interview). The mood care plan, initiated on [DATE] and revised on [DATE], documented Resident #2 had a diagnosis of depression. It indicated to monitor for the following: depressed mood, crying or tearful, self-isolation, appetite changes, and/or feeling bad about herself. The interventions, which had not been revised since [DATE], documented arranging for a psych consult, following up as indicated encouraging the resident to express her feelings and give her time to talk, providing adequate rest periods, encouraging and reminding the resident to rest throughout the day, providing re-positioning, offering a snack/drink, redirecting the resident to an activity, offering independent activity supplies, offering to call a loved one, assist outside sit with resident as needed, providing active listening and validation and monitoring/documenting/reporting any signs and symptoms of depression. -The care plan did not address Resident #2's PHQ-9 score increased since February 2024 from two (no or minimal depression) to seven (mild depression) on [DATE]. It did not address the resident's recent statement of being ready to die and referral to psychiatric services, nor any identified behaviors of depression or triggers for depression. III. Staff interviews The social services director (SSD) and the director of nursing (DON) were interviewed together on [DATE] at 3:40 p.m. The SSD said PHQ-9's were completed for every resident every quarter, annually and as needed by the social services department. She said the PHQ-9 score determined if a resident was offered psychological services. The SSD said upon completion of the PHQ-9, the social worker reviewed the potential need for psychological services and ensured the referral was provided. She said social services was responsible for developing the mood and behavior care plan. The SSD said the care plan should be reviewed and updated every quarter, annually and as needed with signs and symptoms of depression. She said any changes in a resident's mood or behavior should be updated on the care plan. The SSD said Resident #2 was admitted to the facility for rehabilitation, however ended up staying under long-term care. She said the resident had difficulty adjusting at first, but made a male friend who she spent a lot of time with. The SSD said Resident #2 had noted depression and had recently been referred to a counselor and psychiatrist. The SSD said she was not aware Resident #2's PHQ-9 had been increasing which indicated the resident had worsening depression. She confirmed the care plan had not been updated with Resident #2's worsening depression or recent statement of wanting to die. The SSD confirmed the facility did not have any documentation indicating the resident had received additional psychosocial support through her worsening depression, other than a referral to psychological services. The SSD confirmed the care plan documented in the resident's medical record documented that the resident was taking the antidepressant Lexapro. The SSD said Resident #2 was no longer prescribed Lexapro, but was instead prescribed Zoloft.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen, one of four serving areas, two of six dish machines in four serving areas and two of two resident snack refrigerators. Specifically, the facility failed to: -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in one of four serving areas; -Ensure the high temperature dish washing machines maintained sanitizing rinse temperatures for two of six dish machines in four serving areas; and, -Maintain the kitchen in a sanitary condition. Findings include: I. Hand hygiene A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 12/4/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Employees are preventing cross-contamination of ready-to-eat food with bare hands by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves to initiate a task that involves working with food; after engaging in other activities that contaminate the hands. Food employees shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: Rinse under clean, running warm water; apply an amount of cleaning compound recommended by the cleaning compound manufacturer; rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails during the cleaning procedure and creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers. Thoroughly rinse under clean, running warm water. Immediately follow the cleaning procedure with thorough drying using a method to avoid re-contaminating hands or surrogate prosthetic devices. Food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a handwashing sink. B. Facility policy and procedure The Hand Hygiene policy, dated November 2022, was provided by the nursing home administrator (NHA) on 11/30/23 at 11:07 a.m. It revealed in pertinent part, The community considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene includes both handwashing and the use of alcohol-based hand sanitizer. Associates are trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Associates will follow the hand hygiene procedures to help prevent the spread of infections to other associates, staff, residents and visitors. The use of gloves does not replace hand hygiene. C. Observations On 11/27/23 at 11:27 a.m., lunch service was observed in the west first floor dining room. The meal was brought to the dining room from the main kitchen. The main server, dietary aide (DA) #1 placed the hot foods in the preheated steam table. DA #1 failed to perform proper hand hygiene while serving residents their meals. At 11:33 a.m. DA #1 while wearing single use disposable gloves, inserted a food temperature into a pan of food and then wrote down the temperature of the food on a temperature log. DA #1 then handed a resident a clean empty plate and silverware rolled in a paper napkin with her gloved hands. The resident took the plate and rolled silverware and sat at a dining room table. At 11:37 a.m. still wearing the same pair of gloves, DA #1 opened a drawer, removed food serving utensils from the drawer and placed them in the serving area food hot pans. DA #1 then opened three more drawers still wearing the same pair of gloves. At 11:38 a.m. while wearing the same pair of gloves, DA #1 opened the refrigerator, removed two pitchers of drinks and set them on a drink cart by the window. DA #1 then went back to the refrigerator and while wearing the same pair of gloves, removed a gallon of milk from the refrigerator and placed it on a drink cart by the window. At 11:39 a.m. while wearing the same pair of gloves, DA #1 removed three six inch round plates from the cupboard and placed them on the counter. DA #1 then removed three more six inch round plates from the same cupboard and then closed the cupboard door. At 11:40 a.m. while still wearing the same pair of gloves, DA #1 removed one each fork, spoon and butter knife from a silverware holder, placed the clean silverware into a paper napkin and rolled the silverware. DA #1 still wearing the same set of gloves rolled another set of silverware and handed that rolled silverware to a staff member who set it in front of a resident seated at a dining room table. DA #1 began rolling a third set of silverware still wearing the same pair of disposable single use gloves. -DA #1 failed to remove her contaminated gloves and perform hand hygiene before handling clean utensils used by the residents. At 11:45 a.m. DA #1 removed her gloves and discarded the gloves in the trash receptacle. She went to the hand sink, turned on the faucet with her hand, applied soap to her hands and washed her hands for five seconds. DA #1 then turned off the faucet with her hand and used a single-use towel to dry her hands. DA #1 then put on a new pair of single-use disposable gloves. At 11:47 a.m. DA #1 used a single-use towel to pick up the phone receiver, hung up the phone and threw the single-use towel in the trash receptacle. She then removed her gloves and discarded the gloves in the trash receptacle. DA #1 went to the hand sink, turned on the faucet with her hand, applied soap to her hands, washed her hands for five seconds, turned the faucet off with her hand and used a single use towel to dry her hands. DA #1 then put on a new pair of single-use disposable gloves. -DA #1 failed to wash her hands for the proper amount of time and failed to turn off the faucet with a disposable clean towel instead of her hand in both instances. At 11:57 a.m. DA #1 returned to the serving area from the main kitchen with about six plates of food with clear plate covers on a cart. DA #1 wore single use disposable gloves while pushing the cart. At 11:58 a.m. DA #1 removed her gloves and discarded them in the trash receptacle. She went to the hand sink, turned on the faucet with her hand, applied soap and washed her hands for four seconds, shut off the faucet with her hand and then dried her hands with a single use towel. DA #1 then dried her hands again on a cloth towel on the counter and then put on a new pair of single use disposable gloves. -DA #1 failed to wash her hands for the proper amount of time, failed to turn off the faucet with a disposable clean towel and then touched a towel on the counter which was not a single use towel before donning a new pair of single use disposable gloves. At 12:04 p.m. DA #1 removed a slice of bread from a bread bag while wearing gloves and placed the bread on a cutting board. DA #1 held a container of peanut butter with one hand and used a knife with the other to scoop peanut butter from the tub. DA #1 removed her gloved hand from holding the peanut butter tub to instead hold the slice of bread and spread peanut butter on the bread with the knife in the other hand. DA #1 then opened an overhead cupboard door and wearing the same gloves, DA #1 placed a slice of bread on top of the bread with peanut butter to make a sandwich. DA #1 then put the peanut butter sandwich on a plate. -DA #1 did not wash her hands or change her gloves after touching the cupboard door and before touching the ready to eat food. At 12:05 p.m. while still wearing the same gloves, DA #1 filled a bowl with soup and placed it on the shelf above the steam table. DA #1 then picked up a clean paper napkin and placed a fork, knife and spoon onto the napkin. DA #1 then scooped mashed potatoes into a bowl. While still wearing the same gloves, DA #1 removed bowls from the overhead cupboard, opened the door to the hot box and placed the bowls inside the hot box. While continuing to wear the same gloves, DA #1 picked up and adjusted the cloth towel she previously dried her clean hands on next to the steam table. At 12:09 p.m. while wearing the same gloves, DA #1 resumed rolling silverware. DA #1 rolled one set of completed silverware, grabbed a paper napkin and on the napkin placed a butter knife, fork and spoon. DA #1 continued to assemble plates of food for resident meal time while an unidentified staff member finished rolling the silverware. At 12:16 p.m. while wearing the same pair of gloves, DA #1 rolled two more sets of silverware for resident meal trays. At 12:19 p.m. while still wearing the same pair of gloves, DA #1 opened the refrigerator door and removed a container of butter. An unidentified certified nurse aide (CNA) said there was a smaller packet of butter on the counter that was already soft. DA #1 then opened an overhead cupboard and removed a small six inch plate. DA #1 removed a slice of bread from the bread bag and placed the sliced bread on the plate and handed the plate to another staff member. The bread was served to a resident. At 12:26 p.m. while wearing the same gloves, DA #1 grabbed a paper napkin, fork, knife and spoon and rolled the silverware in the paper napkin. She then rolled another set of silverware for resident meals. On 11/28/23 at 11:30 a.m., lunch service was observed in the west first floor dining room. DA #2 failed to perform proper hand hygiene while serving residents their meals and handling ready to eat food. At 11:56 a.m. DA #2 turned on the faucet with her hand, applied hand soap and washed her hands for 11 seconds and turned off the faucet before drying her hands. DA #2 then reached into a bread bag with her bare hand and removed a slice of bread and placed the bread on a plate. While holding the peanut butter tub with one hand, she used the other hand and utensil to scoop and spread peanut butter onto the slice of bread. DA #2 then used a utensil and spread jelly on the sliced bread, placed two slices together to make a sandwich. DA #2 then pulled the front of her surgical mask down with her bare hand, walked to the roll of plastic wrap, removed a square of plastic and wrapped the peanut butter and jelly with the plastic wrap. -DA #2 failed to handle ready to eat food with utensils or single use disposable gloves and failed to perform hand hygiene after touching her mask with her bare hand. D. Staff interviews The dietary manager (DM) and registered dietitian (RD) were interviewed on 11/30/23 at 10:00 a.m. The RD said she previously provided in-services regarding handling of ready to eat foods to the dining staff and there was an in depth handwashing training staff took online for their initial training. The RD said DA #1 completed the training. The DM said staff were previously provided handwashing in-services. The DM said she completed an additional observation of dining staff during the survey (11/28/23 to 11/20/23) and provided an additional handwashing in-service then. The DM said she provided a handwashing in-service to DA #1 and showed DA #1 to how to properly perform handwashing during a survey. The DM said DA #1 then demonstrated the handwashing incorrectly so the DM showed her again how to properly wash her hands. The DM said DA #1 was a newer staff member who had only been at the facility for a short time and might have missed previous handwashing in-services. The DM said she would change how she trained her new staff on handwashing in the future. II. High temperature dish machine sanitizing temperatures A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 12/4/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, for Mechanical warewashing equipment and hot water sanitization temperatures in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold (dish compartment space) may not be less than 180 degrees Fahrenheit. B. Facility policy and procedure The General Hazard Analysis Critical Control Points Guidelines for Food Safety policy, dated 2023, was provided by the NHA on 11/29/23 at 9:04 a.m. The policy revealed in pertinent part, Food and nutrition services staff will be educated and supervised on all hazard analysis critical control points (HACCP) information and procedures. A good training program and the proper systems and tools will help assure a successful HACCP/Food Safety program. Dishwashing: Be sure the wash and rinse temperatures are appropriate for the dish machine (see manufacturer's information). Document temperatures regularly on a temperature log. C. Observations Dish machine wash and rinse cycles with temperature monitoring in four serving areas were observed on 11/28/23 starting at 11:30 a.m. with the DM. Two of five dish machines observed failed to reach the minimum sanitizing temperature of 180 degrees Fahrenheit (F) for at least 10 seconds as written on the dish machines' manufacturing label instructions. Dish Machine temperature logs also revealed staff recorded rinse temperatures for the dish machines as below 180 degrees F. One of two dish machines on the west first floor serving area was observed to have rinse temperatures below the manufacturer's instructions. The manufacturing instruction label on the dish machines documented a high temperature rinse must reach a minimum 180 degrees F for at least 10 seconds. The dish machine rinse cycles were observed on the west first floor from 11:30 to 11:39 a.m. At 11:31 a.m. the dish machine observed had a maximum rinse temperature of 146 degrees F on the dish machine's digital temperature display during the first rinse cycle observed. At 11:33 a.m. the dish machine was observed for a second rinse cycle and only reached a maximum rinse temperature of 148 degrees F on the dish machine's digital temperature display during the rinse cycle. At 11:35 a.m. a dishwasher temperature test strip was run through the dish machine that had previously displayed lower than acceptable rinse temperatures on the digital display. The temperature test strip had a blue stripe on the end. Directions on the temperature strip documented when the water turned 180 degrees F, the stripe turned orange. When the temperature strip was removed from the dish machine, the stripe did not turn all the way orange and blue color remained on the strip indicating the temperature did not reach 180 degrees F. A review of the temperature logs for west one showed that one set of dish machine operating temperatures were recorded once a day. The DM said she was unsure which dish machine temperatures were being recorded on the log. At 11:37 a.m. the second dish machine was observed for a third rinse cycle and only reached a maximum temperature of 145 degrees F on the dish machine's digital temperature display. At 11:39 a.m. the DM turned off the second dish machine so it would not be used. One dish machine on the east second floor serving area was observed to have rinse temperatures below the manufacturer's instructions. The manufacturing instruction label on the dish machines stated a high temperature rinse must reach minimum 180 degrees F for at least 10 seconds. The dish machine rinse cycles were observed on the east second floor from 11:48 a.m. to 12:00 p.m. At 11:48 a.m. the dish machine had a maximum rinse temperature of 174 degrees F on the dish machine's digital temperature display during the first rinse cycle observed. At 11:50 a.m. the dish machine had a maximum rinse temperature of 172 degrees F on the dish machine's digital temperature display during the second rinse cycle observed. At 11:53 a.m. the dish machine had a maximum rinse temperature of the rinse 177 degrees F on the dish machine's digital display during the third rinse cycle observed. At 11:56 a.m. the dish machine was run for a fourth time. The dish machine reached 181 to 185 degrees F for 10 seconds. A dishwasher temperature test strip was run through the dish machine that had previously displayed lower than acceptable rinse temperatures on the digital display. The temperature test strip had a blue stripe on the end. Directions on the temperature strip documented when the water turned 180 degrees F, the stripe turned orange. When the temperature strip was removed from the dish machine, the stripe turned orange indicating the water temperature reached 180 degrees F. D. Record review The dish machine logs were reviewed on the east second floor serving area on 11/28/23 at 9:00 a.m. The dish machine logs revealed the dish machine rinse temperatures were recorded below 180 degrees F numerous times in the 60 days prior. The log contained a column for corrective action and corrective actions were not recorded. -The east second floor dish machine logs were requested and not provided. The dish machine logs were reviewed on the west first floor serving area on 11/30/23 at 3:45 p.m. for November 2023. The recorded temperatures showed some rinse temperatures were not recorded and some rinse temperatures that were below the required minimum of 180 degrees F for at least 10 seconds. The dish machine logs revealed the following: -There were multiple days dish machine rinse temperatures were not recorded: eight days at breakfast, nine days at lunch and six days at dinner; -From 11/1/23 to 11/5/23 the rinse temperature was recorded as 179 degrees F; -On 11/19/23 the rinse temperature was documented as 161 degrees F; -On 11/21/23 the rinse temperature was recorded as 108 degrees F; and, -On 11/28/23 the rinse temperature was recorded as 140 degrees F. E. Staff interviews The DM was interviewed on 11/28/23 at 9:40 a.m. The DM said the certified dietary manager (CDM) reviewed the temperature logs and if the CDM noticed temperatures out of range the CDM provided an in-service to the staff. The DM said the CDM monitored food temperatures but did not monitor the dish machine temperatures. The maintenance supervisor (MS) and DM were interviewed on 11/29/23 at 12:45 p.m. The MS said the dish machines operated with a high temperature rinse but had a chemical sanitizer backup in case the dish machine did not reach the required rinse temperature of 180 degrees F. The MS said the dish machines have operated this way forever and the staff should mark the chemical sanitizer bottle connected to the machine to ensure the amount of chemical sanitizer was monitored. -Observations of dish machines in all four serving areas on 11/29/23 at 9:30 a.m. revealed there was no chemical sanitizer connected to any dish machine. The DM said the sanitizer concentration inside the dish machine was not recorded and she was not aware there was a chemical sanitizer backup installed. Dietary aide (DA) #2 was interviewed on 11/30/23 at 9:15 a.m. while working in the west first floor serving area. DA #2 said she only recorded the temperature of one of the two dish machines in the serving area. DA #2 said she tried to use the second dish machine but the dish machine was not working correctly so she used only the dish machine that was working properly. DA #2 said she recorded the dish machine temperature of the dish machine she used. The DM was interviewed on 11/30/23 at 10:00 a.m. The DM said dietary staff were trained to record the wash temperature on the dish machine and when the dish machine transitions to the rinse cycle the staff record the temperature of the rinse. The DM said noticed some dietary staff recorded just the first number displayed when the dish machine was turned on. The DM did not recall if staff told her the second dish machine on the first floor was not working. The RD was interviewed on 11/30/23 at 10:00 a.m. The RD said staff could write in the maintenance log if an item needed to be fixed. If a dishwasher needed to be fixed, the staff could use a different dishwasher in the building and the dishwasher can be labeled out of order until it was fixed. F. Facility follow-up On 11/30/23 at 9:40 a.m. the DM said she bought the flat thermometers to monitor internal temperatures inside the dish machines. The DM said the supervisor with her contract food service company confirmed there was no chemical sanitizer connected to the dish machines and the machines were required to have 180 degree F rinse temperature. The DM said she was going to update the dish machine logs, provide education to the dietary staff on how to read and record the dish machine temperatures the correct way and have them sign the inservice paper. The DM said she was going to place a new log on the wall for the dish machines and label the dish machines so she would be able to track the recorded temperatures of each machine. III. Kitchen sanitation. A. Professional reference The Food and Drug Administration (FDA) Food Code, reviewed 3/27/23 and retrieved 12/4/23 from https://www.fda.gov/food/fda-food-code/food-code-2022, revealed in pertinent part, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 12/4/23 from https://cdphe.colorado.gov/environment/food-regulations revealed in pertinent part, Physical facilities shall be cleaned as often as necessary to keep them clean. Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. B. Facility policy and procedure The Cleaning and Sanitation of Dining and Food Service Area, dated 2023, was provided by the NHA on 11/30/23 at 11:07 a.m. It revealed in pertinent part, The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the Department. Tasks shall be designated to be the responsibility of specific positions in the department. Staff will be trained in the frequency of cleaning as necessary. The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. A complete cleaning schedule will be posted for all Cleaning tasks and staff will initial the tasks as completed. Staff will be held accountable for cleaning assignments. A sample cleaning schedule provided revealed the floors were to be cleaned daily. C. Observations A kitchen observation was conducted on 11/29/23 at 10:45 a.m. The floor under the hot food holding table had build up of grease covered with black dirt and large pieces of food debris and crumbs in an area that covered approximately one foot by four feet of the floor. Multiple pieces of debris were found under the ice machine and prep table next to the ice machine. The debris under the prep table and ice machine extended along the wall in an area approximately three feet long and six inches wide. A brown sticky substance was on the floor and pieces of debris. Items under the prep table and ice machine included plastic utensils and paper cups. Other items mixed in with the debris were unidentifiable. The cleaning list was reviewed on 11/29/23 at 11:00 a.m. The cleaning tasks were written on a dry erase board hanging in the main kitchen. The task 'floors' was written on the dry erase board. -There were no instructions on how to clean the floors, or what method to use to clean the floors. D. Staff interviews The DM was interviewed on 11/29/23 at 11:15 a.m. The DM said the cleaning assignments listed on the dry erase board in the kitchen did not have instructions on how to clean each item listed. The DM was interviewed on 11/30/23 at 10:00 a.m. The DM said the kitchen floors were cleaned every night and she would have a plan to correct and clean the floor. The DM said it was possible when the staff cleaned the floor and moved the water toward the drain that the debris was pushed under the tables instead of being removed. The DM said the dietary staff had not yet seen the areas under the prep table, ice machine and hot line that needed to be cleaned but the DM was going to show the staff. The DM said the dietary staff previously did power wash behind the cooking equipment but had not gotten around to cleaning the rest of the kitchen yet.

Based on observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition, and failed to display required precautionary signs where oxygen was stored for four of four carts reviewed out of a sample of four emergency (crash) carts. Specifically, the facility failed to: -Ensure staff were trained on how to use the emergency oxygen cylinders, how handle and when to replace empty cylinders; -Ensure staff completed daily the equipment checks; -Ensure expired items were removed from the crash cart; -Ensure missing items were replaced on the crash cart; -Ensure staff were trained on where the crash carts were located; and, -Ensure signs were displayed on store rooms where oxygen was stored. Findings include: I. Professional references A.According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue a case study review. Retrieved on 11/29/23, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part, A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the card cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment. Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection. Top shelf/drawer -The top section typically has the most frequently used equipment employed in a resuscitation event such as power cords and personal protective equipment. Side or rear -The oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level; -A suction apparatus/charging battery for the portable use; -A sharps container should be secure on cart; and, -A rigid plastic/fiberglass backboard for chest compressions. Recommended equipment and medications -Organization and location specific. Recommended maintenance -Check expiration dates on equipment and medications per organization policy and replace as required. Schedule inventory check The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies. Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders. The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients. B. The National Fire Protection Agency (NFPA) code 99-2018, sections 11.3.10.1 and 11.3.10.2 applies to all healthcare organizations and was retrieved on 11/29/23, from https://edufire.ir/storage/Library/other/NFPA%2099-2018.pdf and read in pertinent part, Storage rooms that contain nonflammable gases must have a precautionary sign, readable from a distance of five feet and must be displayed on each door of the storage room. The sign must include at a minimum: -CAUTION; -OXIDIZING GAS(ES) STORED WITHIN; and, -NO SMOKING. II. Facility policy The facility policy for maintaining a crash cart or resident care emergency equipment was requested from the nursing home administrator (NHA) on 11/29/23 and not received by the exit of the survey 11/30/23. III. Observations and interviews Crash cart #1 was observed on 11/29/23 at 9:02 a.m. with licensed practical nurse (LPN) #2. Observations revealed the daily checklist was not completed for nine of 31 days in October 2023 and 14 of 29 days in November 2023. The crash cart contained two 100 milliliters (ml) bottles of sterile water that expired on 4/10/21. LPN #2 said it was the responsibility of the night shift staff to check the crash cart and replace expired items. LPN #2 was able to open and verify the oxygen cylinder was not empty or not full. She did not know at what level the oxygen cylinder should be replaced. Crash cart #2 was observed on at 9:17 a.m. with LPN #1. The crash cart daily checklists were completed. The crash cart did not contain medications, sterile water or normal saline. LPN #1 said she was unable to determine if medications were required on the crash cart. LPN #1 was able to open the oxygen cylinder and verified the oxygen was not empty or not full and did not know when the cylinder should be replaced or where a new cylinder was stored. Crash cart #3 was observed at 9:27 a.m. with LPN #3. LPN #3 was unaware where the crash cart was located on the unit. LPN #3 was unable to locate the crash cart for the unit. LPN #3 said the unit did not have a crash cart. After prompting, LPN #3 found the crash cart located in an unlabeled, closed door, store room next to the elevator. LPN #3 said the room was unlabeled and she would ensure proper signs were added to the storage door. Observations revealed the crash cart contained two 100 ml bottles of normal saline that expired on 6/1/22. The ambu (manual self-inflating resuscitator) bag on the crash cart expired on 1/30/22. LPN #3 said it was the responsibility of the night shift staff to check the crash cart and replace expired items. LPN #3 said she did not know why normal saline was on the crash cart or why one cart had sterile water and another had normal saline. LPN #3 said she had not been trained on crash cart #3 but was trained on a different crash cart on another unit. LPN #3 was unable to open the oxygen cylinder to verify the level of oxygen and she had not been trained on how to use the oxygen cylinder. She was unable to determine what equipment and or medications should be stocked and ready for use on the crash cart. LPN #3 provided the daily crash cart checklists for crash cart #3. The checklists revealed: -July 2023: the daily checks were completed seven out of 31 days; -August 2023: the daily checks were completed three of 31 days; -September 2023: the daily checks were completed seven out of 30 days; -October 2023: the daily checks were completed zero of out 31 days; -November 2023: the daily checks were completed zero out of 29 days. Crash cart #4 was observed at 9:50 a.m with registered nurse (RN) #2. RN #2 verified the crash cart contained an ambu bag that expired on 4/10/21. -However, the crash cart daily checklist indicated the ambu bag was checked daily. RN #2 said she did not know how to open the oxygen cylinder to use the oxygen or how to check the volume of oxygen. She was unsure if the crash cart contained required oxygen tubing and connections needed to connect to the oxygen cylinder and administer oxygen in an emergency situation. The oxygen cylinder did not have a key to open the cylinder but it was located beneath miscellaneous items stored on the top of the crash cart. The suction machine was located on the top of the crash cart but failed to include a collection canister and was not ready for use. RN #2 was unable to locate a new canister in the crash cart or in the medication and supply room where the cart was stored. The crash cart included two one milligram (MG) rapid emergency glucagon syringes. RN #2 said the glucagon was used to treat low blood sugar but could not find a glucometer on the crash cart. RN #2 was unsure if a physician's order was required for the emergency use of medications on the crash cart. RN #2 said she worked at the facility for six months but had not received training on the use of the crash cart, emergency equipment or how to set up and connect to the emergency oxygen. -All four crash carts were stored in closed storage rooms. The carts on the east hallways were stored in the medication storage rooms and the carts on the west hallway were stored in a closed room used for elevator access. None of the rooms were labeled with oxygen safety signs used to caution that oxygen was stored and used in the rooms and failed to post a precautionary sign that oxidizing gas(es) were stored inside the room and failed to display no smoking sign outside each room. III. Facility administration interview The NHA was interviewed on 11/29/23 at 2:25 p.m. He said the facility did not have a crash cart or emergency equipment policy or procedure. He said the director of nursing (DON) completed immediate education on 11/29/23 for nursing staff for the daily inspection and check of the crash carts. The NHA provided a copy of a new daily audit tool and it was completed on 11/29/23. The DON was interviewed on 11/30/23 at 9:20 a.m. The DON reviewed the daily checklists provided by LPN #3 on 11/29/23 and she said the checklists included several unchecked days. The DON said it was the responsibility of the night shift nurse on each unit to check the crash cart and to verify equipment was available and ready for use in an emergency situation. The DON said new employee orientation included the location of the crash carts but not portable oxygen use and safety. The DON said standing physician orders were available for emergency medications but was unsure what emergency medications were located on the crash carts. She was unsure why two of four crash carts contained 100 ml bottles of sterile water or normal saline but said it could be used to verify the suction machine was working properly. The DON said that she would contact the facility oxygen vendor for staff education and training on the proper use and storage of oxygen cylinders. IV. Facility follow-up On 11/30/23 at 10:45 a.m. the NHA provided a copy of immediate education provided for nursing staff on how to use a portable oxygen cylinder.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to: -Ensure resident refrigerator temperatures were monitored correctly for refrigerated food storage; and, -Implement the facility policy for food brought by visitors and ensure food that was kept in resident's refrigerators had safe and sanitary storage. Findings include: I. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 12/4/23 from https://cdphe.colorado.gov/environment/food-regulations revelaed in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified. The FDA (Food and Drug Administration) food code reviewed 3/27/23 and retrieved 8/23/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 revealed in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. II. Facility policy and procedure The Use and Storage of Food Brought in for Residents, revised July 2022, was provided by the nursing home administrator (NHA) on 11/28/23 at 9:00 a.m. It revealed in pertinent part, Temperature control for safety foods must be in a safe container. Foods brought into the community must be labeled with the name of the resident, name of items, and date brought into the community and date to discard. Protein may be kept for three days. Lunchmeat and cheese may be kept for seven days. Non temperature control for safety foods must be labeled with the resident's name, date and content. Education should include but not limited to letters to families regarding safe food handling and the need for labeling and dating foods, inservice education to staff on receiving, storage and disposal of foods and discussion at family meets and/or care plan meetings as warranted. III. Observations On 11/27/23 at 11:03 a.m. Resident #63's personal refrigerator was inspected. Resident #63's refrigerator log was present on top of her refrigerator. The refrigerator log listed all 12 months of the year and there were multiple days of the year no refrigerator temperatures were recorded. A clear square plastic container with a blue lid was inside Resident #63's refrigerator. The container had no label or date and inside the container was brown food in liquid. Resident #63 also had a plate of cookies in the refrigerator that were not labeled and a container of salsa that was not dated. On 11/28/23 at 9:58 a.m. Resident #63's personal refrigerator was inspected. The clear container with the blue lid was cleaned, empty and on top of Resident #63's personal refrigerator. On 11/29/23 at 1:11 p.m. Resident #31's personal refrigerator was inspected. The inside of Resident #31's personal refrigerator had a sticky brown residue on the sides and bottom shelf. There were four containers inside Resident #31's refrigerator that were not dated or labeled and three of the four contained temperature control for safety food: -A disposable aluminum loaf pan approximately six inches long was covered with foil, not dated or labeled, and the food inside appeared to be a pasta with cheese. Resident #31 said she did not know where the foil container came from and did not know what was inside the container. Resident #31 said she did not want to keep the container in her refrigerator. -An eight ounce plastic deli container was covered with a clear lid and not dated or labeled. Resident #31 said she thought her granddaughter brought the container but was unsure when her grandaughter brought it, and it contained Thanksgiving dinner. Resident #31 said she did not think she would eat the food in the container and asked for the container and food to be discarded. -A container of sliced deli meat was in the freezer compartment of the small refrigerator, not dated and the lid revealed commercially processed ham slices, but two different kinds of deli meat were inside. Resident #31 said she would not eat the food from the container because she did not know what food was inside. -A small round black container was covered with a clear lid. The lid was stamped with kfc and the container had cooked greens inside. Resident #31 said she did not know what food was in the container and asked for the container to be thrown out. IV. Record review Resident #31's personal refrigerator temperature log was reviewed in her room on 11/29/23 at 1:11 p.m. Recorded refrigerator temperatures were missing in October 2023 for nine days and were recorded at 42 degrees F and above on 12 days in October 2023. Recorded refrigerator temperatures were missing in November 2023 on 10 days and were recorded at 42 degrees F and above on eight days in November 2023. The refrigerator log documented the refrigerator temperature must remain between 36 and 46 degrees. -However, the refrigerator temperature should be 41 degrees F and below (see reference above). V. Staff interviews The dietary manager (DM) was interviewed on 11/30/23 at 10:00 a.m. The DM said the dining staff who worked at the facility long term said the dining department did not monitor the residents' personal refrigerators. The registered dietitian (RD) was interviewed on 11/30/23 at 10:00 a.m. The RD said staff from the maintenance department monitored and recorded the resident's personal refrigerator temperatures. The RD said the facility did review the visitors' food policy at family council meetings. The nursing home administrator (NHA) was interviewed on 11/30/23 at 3:00 p.m. The NHA said the facility hosted a quarterly family council and the visitor food policy was discussed then. He said the policy was discussed at resident council meetings. He said the maintenance assistant monitored the resident's personal refrigerator temperatures. The NHA said there was a new contracted food service company starting in about 30 days and he wanted to review the contract food service company's process for monitoring the residents' food inside their personal refrigerators. The director of nursing (DON) was interviewed on 11/30/23 at 3:00 p.m. The DON said residents were told part of having food in personal refrigerators was having food dated and safe. The DON said certified nurse aides (CNAs) should check food that came in the facility and label the food. The DON said it was difficult when families brought food to residents and placed it in the resident's personal refrigerator without notifying staff and that should be something the facility needed to keep an eye on. VI. Facility follow-up On 11/30/23 at 9:45 a.m. the NHA said a facility audit was completed. The NHA said some of the resident's personal refrigerator logs were not the correct logs and the incorrect logs were replaced.

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of seven sample residents. Specifically, the facility failed to ensure Resident #1 was not administered Ativan (anti-anxiety medication) by licensed practical nurse (LPN) #3 that was not ordered for her. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 1/31/23 to 2/2/23, resulting in the deficiency being cited as past noncompliance with a correction date of 9/16/22. I. Facility policy and procedure The facility policies and procedures for medication administration and medication orders were requested from the facility on multiple occasions from 2/2/23 to 2/8/23 and were not provided by the facility. II. Resident #2 A. Resident status Resident #1, age 79, was admitted on [DATE] and passed away on 9/13/22. According to the September 2022 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, hyperlipidemia, hypothyroidism, seizures, insomnia, major depressive disorder, and anxiety. The 7/28/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score of one out of 15. She required extensive assistance of two staff members with mobility and activities of daily living (ADLs). The resident received hospice services. B. Record review -Review of the resident record from September 2022 revealed the resident received hospice services and the resident's condition was declining. A nursing note dated 9/6/22 revealed the resident tested positive for COVID-19 that morning with notifications made to the resident's daughter and hospice provider. The resident was placed on isolation and was resting comfortably in her room with a mild cough. The resident was noted to have poor food intakes though was accepting fluids. A nursing note dated 9/7/22 at 3:26 a.m. revealed the resident was resting in her room with decreased fluid and food intakes and was provided turning and repositioning and general assessment every two hours. A nursing note on 9/7/22 at 7:41 a.m. revealed the resident was thrashing and grabbing at her bed and was noted to have an oxygen saturation level of 54% on room air. Oxygen was placed at 2 liters per minute (LPM) and the resident's oxygen saturation level increased to 89%. The nurse called the resident's hospice provider for consideration of comfort medication. An order for morphine sulfate solution 20 mg/ml, 0.25 ml by mouth every hour as needed for pain or air hunger was added for comfort. No order for an antianxiety medication was added. A nursing note dated 9/12/22 at 7:26 p.m. revealed the nurse was notified at 4:30 p.m. that Resident #1 had been provided a drink of water and was choking/aspirating. The nurse entered the room and the resident was sitting up in bed, discolored and gasping for breath. A registered nurse (RN) was at bedside as well as the resident's daughter and hospice chaplain, who had given the resident water. The resident's oxygen saturation level was in the low 60s. The resident was turned on her left side and oxygen was turned up to 5 liters per minute (LPM) and oxygen saturation increased to 78%. Percussion was performed on the resident and a high flow oxygen concentrator was obtained and resident's oxygen was increased to 10 LPM. Resident remained discolored and gasping for breath. The resident's morphine was administered by the RN and was ineffective and a second dose was administered and was ineffective. The nurse contacted the hospice provider and advised of the situation with the resident and requested a PRN Ativan order for air hunger and anxiety. The nurse was informed the resident's case manager was on vacation and the on-call provider would call back. The on-call provider called back at 4:45 p.m. and advised the resident's Ativan would be delivered by the pharmacy in the 9:30 p.m. delivery. A progress note dated 9/13/22 at 2:00 a.m. revealed the resident passed away at 1:49 a.m. on 9/13/22. III. Facility investigation A facility investigation was conducted when the facility was notified Resident #1's nurse (LPN #3) had administered the resident crushed Ativan without a physician order. The facility investigation included interviews with all staff members on the unit on the night of 9/12/22 as well as the resident's daughter. The conclusion of the investigation revealed the resident was experiencing episodes of extreme discomfort and panic. The LPN (#3) (agency nurse) attempted non-medical interventions without success. The nurse notified hospice to attempt to get an order for Ativan, but was told it would take several hours to get the medication to the facility. The nurse then gave the resident Ativan that was the nurse's own personal medication. The resident passed away at 1:40 a.m. The resident had been assessed after being administered the medication and was calm and her vital signs were stable with no adverse reactions noted. The agency nurse was immediately removed from the schedule and her agency was notified of the incident. The nurse was suspended from the agency and was reported to the Board of Nursing. All facility staff were provided training on proper medication administration. Staff interviews from the night in question revealed the LPN (#3) provided the resident crushed Ativan from her personal prescription. The RN reported the LPN's actions to the NHA and additional staff interviews corroborated the series of events. The resident's daughter was interviewed by the NHA on 9/13/22. The interview revealed the nurse (LPN #3) stated she was going to get an order for the medication and returned a short time later and stated she received the order and administered the medication to the resident. She stated the medication did help calm the resident down. The facility educated all nursing staff members on the Rights of Medication Administration and obtaining and entering medication orders on 9/14/22. The facility conducted medication administration competency checks on all nurses by 9/16/22. The director of nursing and assistant director of nursing (DON and ADON) reviewed all resident medication orders, with special focus on hospice residents, from 8/1/22 to 9/13/22 to ensure no discrepancies were identified. Additionally, all new medication orders were being reviewed in the daily morning meeting which began on 9/13/22 and was ongoing at the time of the onsite investigation. IV. Staff interviews LPN #1 was interviewed on 2/1/23 at 3:15 p.m. She stated a nurse should not administer medication to a resident without an order. She stated the order needed to state the medication, the dose, the route, the time, and the reason for the medication. She stated if a nurse administered medication without an order as it could negatively affect the resident. She stated she had recently returned to employment at the facility and had received medication administration training upon returning. LPN #2 was interviewed on 2/1/23 at 3:20 p.m. She stated medications could not be administered to residents without an order and verification from the physician. RN #1 was interviewed on 2/1/23 at 3:30 p.m. He stated medication administration education was provided to him at time of employment, though it was also a professional standard of nursing that medications could not be administered to residents without an order from a provider. The DON was interviewed on 2/1/23 at 3:45 p.m. She stated the nurse should not have administered the medication without obtaining a written order. She also stated the nurse should not have administered medication from her own personal supply. She stated the nurse was trying to help the resident and provide relief, though she broke multiple facility policies and nursing practices and was removed from the schedule immediately once the administration was notified of the incident. The LPN was reported to the board of nursing as a result of the incident as well. Additionally, remaining staff were immediately interviewed and educated on the Rights of Medication Administration, obtaining orders and nurses were observed for correct medication administration practices. The NHA was interviewed on 2/1/23 at 4:30 p.m. He stated the nurse did not follow facility policy or standard nursing practice and was removed from the facility schedule. All nursing staff were educated and observed for proper medication administration and the facility continued daily reviews of medication orders. He stated all new nursing staff hired to the facility received the medication administration education upon hire.

Based on observation, record review, interviews, facility policy review, and review of current Centers for Disease Control and Prevention (CDC) guidance, it was determined that the facility failed to ensure an effective infection control program was implemented to prevent the spread of COVID-19 throughout the facility. Specifically, the facility failed to: 1. Ensure staff working during a COVID-19 outbreak wore N95 masks in accordance with CDC guidelines and failed to ensure staff wore appropriate personal protective equipment (PPE) while providing direct care to a resident (Resident #76) who was COVID-19 positive; 2. Ensure staff were fit tested for N95 masks before use; 3. Ensure proper signage was posted on the residents' doors to indicate what PPE precautions should be in place for five residents on precautions (Resident #64, Resident #35, Resident #105, Resident #73, Resident #46); and 4. Ensure a COVID-19 positive resident's (Resident #76) room door was kept closed while on a unit that housed residents that were not COVID-19 positive. The facility reported a census of 106 residents. The first COVID-19 positive resident in the facility had been identified on 07/18/2022. Sixteen residents had tested positive for COVID-19 from 07/18/2022 through 08/11/2022. Findings included: 1. A review of the facility's policy titled, Residential Care Facility (RCF) Comprehensive Mitigation Guidance, dated 04/18/2022, revealed, HCP [healthcare personnel] caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 [severe acute respiratory syndrome coronavirus 2] infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). A Centers for Disease Control (CDC) publication, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated 02/22/2022 and located online at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). A record review of Personal Protection Inventory indicated the facility had 5,489 N95 masks available for use. A record review of a progress note, dated 08/08/2022 at 11:48 AM, revealed Resident #76 tested positive for COVID-19. There was no PCR (polymerase chain reaction) laboratory documentation provided to the surveyor regarding the resident's COVID-19 test results. Resident #76's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 08/09/2022 at 8:38 AM, Resident #76 had an isolation PPE bin located outside of the resident's room. Certified Nursing Assistant (CNA) #1 entered Resident #76's room wearing a KN95 mask, a face shield, a gown, and gloves and provided the resident with their breakfast meal tray. After removing PPE and sanitizing their hands, CNA #1 stated she was wearing a KN95 mask and was not sure if the facility had any N95 masks. A record review of the untitled facility rapid testing log indicated Resident #35 tested positive for COVID-19 on 08/08/2022. A record review of a PCR (polymerase chain reaction) lab result, dated 08/11/2022, indicated Resident #35 tested positive for COVID-19. A record review of Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 08/09/2022 at 8:40 AM, Resident #35 had an isolation PPE bin located outside of the resident's room. CNA #2 entered Resident #35's room wearing a KN95 mask, a face shield, a gown, and gloves and provided the resident with their breakfast meal tray. After removing PPE and sanitizing their hands, CNA #1 stated she was wearing a KN95 but that N95s were available, she just was not wearing one. During an observation and interview conducted on the COVID-19 unit on 08/09/2022 at 9:15 AM, the Environmental Services Director (ESD) was wearing a KN95 mask. The ESD stated that the facility had approximately 6000 N95 masks and was unsure why staff were not wearing them. The ESD assumed that staff were not wearing the N95 masks because they were not comfortable. A record review of the untitled facility rapid testing log indicated Resident #105 tested positive for COVID-19 on 08/08/2022. A record review of a PCR lab result, dated 08/11/2022, indicated Resident #105 tested positive for COVID-19. Resident #105's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 08/10/2022 at 7:13 AM, Licensed Practical Nurse (LPN) #1 was in room [ROOM NUMBER], which was a COVID-19 positive room, providing medication to Resident #105. The resident's door was open, and LPN #1 was seen wearing an N95 mask and a face shield. LPN #1 was not wearing a gown or gloves when providing medication to the resident. Resident #105 was lying in bed and neither LPN #1 nor Resident #105 appeared to be in any distress. Upon exiting the room, LPN #1 applied alcohol-based hand rub (ABHR) to her hands. LPN #1 stated she was not wearing a gown or gloves while in the COVID-19 positive resident room because the resident was about to fall, and she ran into the resident's room. LPN #1 stated the resident should be off isolation precautions that day and had not taken the precaution signs off the resident's door. During a follow up interview on 08/10/2022 at 4:03 PM, CNA #1 stated after the previous interview, she spoke with the Infection Preventionist (IP) who advised her that the KN95 mask was an acceptable replacement for the N95 mask while providing care to COVID-19 positive residents. During an interview on 08/10/2022 at 4:03 PM, CNA #5 stated the IP provided the staff with a new KN95 mask every day and they were not required to wear an N95 mask. During an interview on 08/10/2022 at 4:30 PM, the Infection Preventionist (IP) stated the Colorado Department of Public Health and Environment (CDPHE) had advised the facility was allowed to wear a KN95 mask when providing direct care to a COVID-19 positive resident, in lieu of a N95 mask. The IP was asked for a document from CDPHE with that guidance, but it was not received by the time of exit. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that before entering a COVID-19 positive resident room, staff should wear gloves, gown, goggles and/or face shield, and an N95 mask. The DON stated that KN95 masks are allowed to be worn in the hallway, however, they should not be worn in a COVID-19 positive resident room. The DON stated she was not aware that staff were wearing KN95s in COVID-19 positive resident rooms. She stated the IP was investigating the differences between the KN95 mask and the N95 mask and when each are allowed to be used in the facility. She stated that all staff were previously wearing a different brand of N95 mask, but staff were complaining about the fit of the mask. During an interview on 08/11/2022 at 2:23 PM, the Administrator (ADM) stated that before entering a COVID-19 positive resident room, staff should don gloves, gown, goggles and/or face shield, and an N95 mask. The ADM stated that per the facility policy, staff were to wear N95 masks when providing direct care to a COVID-19 positive resident. 2. A review of the facility's policy titled, Residential Care Facility (RCF) Comprehensive Mitigation Guidance, dated 04/18/2022, revealed the facility must, Implement a respiratory protection program that is compliant with the OSHA respiratory protection standard (29 CFR 1910.134) for employees if not already in place. The program should include medical evaluations, training, and fit testing . A review of the facility's policy titled, Respiratory Protection Program (RPP)/N95 Respirator Mask (N95) Protocol, dated July 2021 revealed, This program applies to all associates who are required to wear N95 respirators during normal or emergency work operations. Further review indicated the roles and responsibilities of the supervisor was, 1. Training associates using the N95 Respirator Associate Training Power Point . 2. Ensuring the Community follows RPP protocols, procedures, and education, including fit testing and medical evaluation, if applicable. 3 Ensuring the availability of appropriate N95 respirators and accessories . Further review indicated that associates were responsible for, 1. Wearing their N95 respirator when and where required and in the manner in which trained . A Centers for Disease Control (CDC) publication, The Respiratory Protection Information Trusted Source: Fit Test FAQ [frequently asked question], reviewed on 08/11/2022, indicated The Occupational Safety and Health Administration (OSHA) (29 CFR 1910.134) requires respirator users to be fit tested to confirm the fit of any respirator that forms a tight seal on your face before using it in the workplace. Fit testing is important to ensure the expected level of protection is provided by minimizing the total amount of contaminant leakage into the facepiece through the face seal. During an observation and interview on 08/09/2022 at 8:38 AM, Certified Nursing Assistant (CNA) #1 wore a KN95 while providing care to residents with confirmed COVID-19. CNA #1 stated she was wearing a KN95 mask and was not sure if the facility had any N95 masks. CNA #1 stated she had not been fit tested for a N95 mask. During an observation and interview on 08/09/2022 at 8:40 AM, CNA #2 wore a KN95 while providing care to residents with confirmed COVID-19. CNA #1 stated she was wearing a KN95 mask and was aware there were N95 masks available, however, she had not been fit tested for a N95 mask. During an observation and interview on 08/10/2022 at 7:13 AM, Licensed Practical Nurse (LPN) #1 had entered a COVID-19 positive resident room wearing an N95 mask. LPN #1 stated she had not been fit tested for the N95 mask she was wearing, and the facility had not provided her with any training related to the fit of the mask. During an observation and interview on 08/10/2022 at 8:10 AM, LPN #2 was assigned to care for one resident that was confirmed COVID-19 positive (Resident #46). LPN #2 stated she had not been fit tested for the N95 mask she was wearing, and the facility had not provided her with any training related to the fit of the mask. During an interview on 08/10/2022 at 4:03 PM, CNA #5 wore a KN95 while providing care to residents with confirmed COVID-19. CNA #5 stated she was wearing a KN95 mask and was not required to wear an N95 mask, for which she had not been fit tested . During an interview on 08/11/2022 at 1:55 PM, the Infection Preventionist (IP) stated she had not been trained on how to complete fit testing on the facility staff, but that someone was coming to the facility to train her soon. The IP stated the facility had the supplies to complete the fit testing and that the Director of Clinical Staff Development (DCS) had been at the facility on 04/27/2022 and completed training on some of the staff. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that the IP is responsible for ensuring staff were fit tested for the use of N95 masks. During an interview on 08/11/2022 at 2:23 PM, the Administrator (ADM) stated the IP was responsible for ensuring staff were fit tested and they have had a corporate staff member come in to educate staff on fit testing. The ADM stated that the IP had been trained on how to properly fit test staff members. 3. A review of the facility's policy titled, Residential Care Facility (RCF) Comprehensive Mitigation Guidance, dated 04/18/2022, revealed the facility should, .3. Ensure everyone is aware of recommended IPC practices in the facility. a) Post visual alerts (e.g., signs, posters) at the entrance and in strategic places .with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene. A record review of the untitled facility rapid testing log indicated Resident #64 tested positive for COVID-19 on 08/08/2022. A record review of a PCR (polymerase chain reaction) lab result, dated 08/11/2022, indicated Resident #64 tested positive for COVID-19. Resident #64's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/09/2022 at 8:07 AM, room [ROOM NUMBER] and Resident #64's room shared a bathroom that was in the entryway before the residents' door. There was a PPE bin located outside of the resident's rooms. There was no indication of which resident was on isolation precautions. A record review of the untitled facility rapid testing log indicated Resident #35 tested positive for COVID-19 on 08/08/2022. A record review of a PCR lab result dated 08/11/2022 indicated Resident #35 tested positive for COVID-19. Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/09/2022 at 8:14 AM, Resident #35's room and room [ROOM NUMBER] had a PPE bin located outside of the resident's room, in between the two rooms. There was no indication and/or signage of which resident was on isolation precautions. A record review of the untitled facility rapid testing log indicated Resident #105 tested positive for COVID-19 on 08/08/2022. A record review of a PCR lab result dated 08/11/2022 indicated Resident #105 tested positive for COVID-19. Resident #105's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the untitled facility rapid testing log indicated Resident #73 tested positive for COVID-19 on 08/08/2022. A record review of a PCR lab result dated 08/11/2022 indicated Resident #73 tested positive for COVID-19. Resident #73's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/09/2022 at 8:45 AM, Resident #73's room and Resident #105's room had a PPE bin located outside of the resident's room, in between the two rooms. There was no indication and/or signage of which resident was on isolation precautions. A record review of the untitled facility rapid testing log indicated Resident #46 tested positive for COVID-19 on 08/04/2022. A record review of a PCR lab result dated 08/06/2022 indicated Resident #46 tested positive for COVID-19. Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/10/2022 at 4:22 PM, room [ROOM NUMBER] and Resident #46's room had a PPE bin located outside of the resident's room, in between the two rooms. There was no indication and/or signage of which resident was on isolation precautions. During an interview on 08/10/2022 at 4:30 PM, the Infection Preventionist (IP) stated that staff and residents are made aware of a resident that was COVID-19 positive by having a droplet isolation precaution sign on the door as well as a donning and doffing sign. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that staff and residents are made aware of a resident that was on isolation precautions by having an isolation cart outside of the resident's room and that signage stated what type of isolation the resident is on should be posted on the resident's door. During an interview on 08/11/2022 at 2:23 PM, the Administrator (ADM) stated that staff and residents are made aware of a resident that was on isolation precautions by having isolation PPE bins outside of the resident's room and there should be signage on the resident's door that indicated what type of isolation precaution the resident is on as well as how to don and doff PPE. 4. A review of the facility's policy titled, Residential Care Facility (RCF) Comprehensive Mitigation Guidance, dated 04/18/2022, revealed, .A resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. A Centers for Disease Control (CDC) publication, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated 02/22/2022, indicated HCP [healthcare personnel] caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. During an interview on 08/08/2022 at 8:35 AM, the Administrator stated the facility did not have a dedicated COVID-19 unit because all resident rooms were private, and they were to isolate in their rooms. A record review of a progress note, dated 08/08/2022 at 11:48 AM, revealed Resident #76 tested positive for COVID-19. There was no PCR (polymerase chain reaction) laboratory documentation provided to the surveyor regarding the resident's COVID-19 test results. Resident #76's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/08/2022 at 11:15 AM, Resident #76 had a PPE bin located outside of the room with a droplet precaution sign on the door. The room door was wide open. room [ROOM NUMBER], a COVID-19 negative room, was adjacent to Resident #76's room and 709's door was also open. During an interview on 08/08/2022 at 11:40 AM, Resident #10 stated they were concerned about having a COVID-19 positive resident next door to the resident and stated that sometimes the COVID-19 positive doors were left open when they should be shut. During an observation on 08/08/2022 at 11:48 AM, Resident #76's door remained open. During an observation on 08/09/2022 at 8:00 AM, Resident #76's door remained open, and Resident #76 was heard coughing. During an interview on 08/10/2022 at 4:30 PM, the Infection Preventionist (IP) stated if a COVID-19 positive resident is not on a dedicated COVID-19 unit, the resident's door should be closed. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated if a COVID-19 positive resident is not on a dedicated COVID-19 unit, the resident's door should remain shut. During an interview on 08/11/2022 at 2:23 PM, the Administrator stated if a COVID-19 positive resident is not on a dedicated COVID-19 unit, the resident's door should remain shut.

Based on observation, interview, record review, and facility document review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs), specifically nail care, received the necessary services to maintain clean, trimmed nails for two (Resident #39 and Resident #20) of two residents reviewed for ADLs. Findings included: A review of an undated facility Nail Care Competency check-off competency form indicated that staff were to, 11. Inform supervisor if nails need to be cut. (Note: Caregiver, CNA, or PCA should never cut nails. 1. A review of the Admission Record revealed the facility admitted Resident #39 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required extensive assistance of two persons for personal hygiene. A record review of Resident #39's care plan, initiated on 05/02/2019, revealed the resident had ADL self-care performance deficit. The facility developed an intervention that included caregivers were to check the resident's nail length and trim and clean them, as necessary. A facility document/staff task in the electronic health record, titled, Nail Care, was reviewed for the last thirty days. The question asked on the task form was, Nail care provided? There was no data found for the last 30 days lookback period, which indicated there was no documented nail care provided. During an observation and interview on 08/08/2022 at 11:23 AM, Resident #39 was lying in bed, in the resident's room. The resident's fingernails were approximately 1/2 inch long with brown debris underneath all the nails. Resident #39 stated that nobody in the facility would trim or clean their nails. The resident stated that a nurse told the resident that the facility would put the resident on a podiatry list to see if the podiatrist could trim the resident's fingernails. During an observation on 08/10/2022 at 4:00 PM, the resident's nails were observed and were in the same condition as the observation on 08/08/2022. The resident stated he/she wanted the nails to be trimmed but stated again that the staff told the resident that only a podiatrist could trim the resident's fingernails. The resident stated he/she remembered the conversation on 08/08/2022 with the surveyor and thought their nails would have been trimmed by now. During an interview on 08/10/2022 at 4:03 PM, CNA (certified nursing assistant) #5 and CNA #1 both stated that the nurse was responsible for trimming Resident #39's nails because the resident was diabetic. CNA #5 stated that the nurse was responsible for trimming both the fingernails and toenails. Both CNAs stated the CNAs were responsible for notifying the nurse of the resident's nails. Neither CNA could state what the resident's nails looked like. Neither CNA knew how often the resident's nails should be trimmed or where it was documented. During an interview on 08/10/2022 at 4:18 PM, Licensed Practical Nurse (LPN) #1 stated she was responsible for trimming Resident #39's nails and it should be done every Sunday. LPN #1 was unsure where it would be documented. LPN #1 stated if the resident's nails needed to be cut, this could be done at any time. LPN #1 stated she had been in the resident's room that day; however, she did not notice the resident's nails. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that CNAs were responsible for trimming Resident #39's fingernails during the resident's shower time. The DON stated any staff member could trim the resident's nails, if needed, unless the resident was a diabetic. The DON stated it was a safety concern if the resident was scratching themself. The DON stated the nail care should be documented in the CNA task area under nail care unless a nurse did it. Then it would be documented in the progress notes. The DON stated that her expectation regarding nail care would be that staff would check the resident's nails with every shower and ensure the nails were clean and if attention was needed. During an interview on 08/11/2022 at 2:23 PM, the Administrator (ADM) stated the nursing department was responsible for providing nail care to the residents and it should be done as needed. The ADM stated he was unsure where it was documented. The ADM stated his expectations of staff were to notify the nurse to ensure the resident's nails were taken care of. 2. A review of the Admission Record revealed the facility admitted Resident #20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the resident required extensive physical assist of one person for personal hygiene. A record review of Resident #20's care plan, initiated on 05/02/2019, revealed the resident had ADL self-care performance deficit. The facility developed an intervention that included caregivers were to check the resident's nail length and trim and clean them, as necessary. A facility document/staff task in the electronic health record, titled, Nail Care, was reviewed for the last thirty days. The question asked on the task form was, Nail care provided? There was no data found for the last 30 days lookback period, which indicated there was no documented nail care provided. During an observation on 08/08/2022 at 11:30 AM, Resident #20 was lying in bed in their room. The resident's fingernails were approximately 1/2 inch long with brown debris underneath all the nails. During an interview on 08/10/2022 at 4:03 PM, CNA #5 and CNA #1 both stated the nurse was responsible for trimming Resident #20's nails. Both CNAs stated the CNAs were responsible for notifying the nurse of the resident's nails. Neither CNA could state what the resident's nails looked like. During an interview and observation on 08/10/2022 at 4:14 PM, Resident #20 was lying in bed. The resident's nails had the same appearance as on 08/08/2022 and some of the nails had a jagged appearance. Resident #20 stated their nails were to be trimmed by a nurse, but it had not been done. The resident stated he/she had scratched their own face because their nails were jagged and would love for them to be trimmed. During an interview on 08/10/2022 at 4:18 PM, Licensed Practical Nurse (LPN) #1 stated that the resident asked her today if the nurse could trim the resident's nails, and the LPN stated she was going to do it that day. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that CNAs were responsible for trimming Resident #20's fingernails during the residents' shower time. The DON stated any staff member could trim the resident's nails, if needed, unless the resident was a diabetic. The DON stated that some residents preferred their nails to be longer, but it was a safety concern if the resident was scratching themself. The DON stated the nail care should be documented in the CNA task area under nail care unless a nurse did it. Then it would be documented in the progress notes. The DON stated that their expectation regarding nail care would be that staff would check the resident's nails every shower and ensure the nails were clean and if they needed attention. The facility was unable to provide a policy related to activities of daily living.

Based on observation, record review, interviews, and facility policy review, the facility failed to provide a meaningful program of activities for one (Resident #50) of one resident reviewed for activities. Specifically, the facility failed to ensure the activity program was designed to meet the individual activity needs, interests, and abilities for Residents #50, who was bedbound. Findings included: A review of the facility policy and procedure titled, Community Life, dated 07/2022, indicated the facility would make available regular opportunities for residents to participate in resident engagement both within and outside the facility. Examples of activities included individual or group conversation, recreation, art, crafts, and music. General guidelines included gathering information about the resident's interests, hobbies, goals, and religious preferences at move in. A review of Resident #50's undated Admission Record revealed the facility had admitted Resident #50 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #50's quarterly Minimum Data Set, dated dated [DATE], indicated the facility had a Brief Interview for Mental Status score of zero (0), indicating severe cognitive impairment. The MDS revealed Resident #50 had no speech and was rarely or never understood and required extensive assistance with bed mobility, dressing, and hygiene. The assessment indicated Resident #50 was totally dependent on the physical assistance of two persons for transferring, locomotion, bathing, and toileting. A review of Resident #50's care plan, revised on 03/25/2022, revealed that Resident #50 was unable to verbalize activity/leisure pursuits due to [CONDITION(S)] brain injury. The care plan further indicated that through family interviews, the facility determined that Resident #50 enjoyed listening to music, watching TV, going to the movies, going for scenic drives, listening/observing during bingo, live music, aromatherapy, healing hands, and having their hair brushed. The care plan indicated a goal of Resident #50 participating in the therapeutic one-on-one (1:1) program one to three times per week with interventions that also included staff providing Resident #50 with one to three therapeutic one-on-one visits throughout the week where Resident #50 and staff would together engage in Resident #50's interests such as listening to music, watching music videos, enjoying aromatherapy, and engaging with religious material. Observations on 08/08/2022 at 12:50 PM, 08/09/2022 at 8:27 AM, 08/09/2022 at 2:38 PM, and 08/10/2022 at 9:43 AM revealed Resident #50 lying in bed with the TV on. In an interview on 08/09/2022 at 3:49 PM, Registered Nurse (RN) #1 stated she sometimes would transport Resident #50 out to the dining area for activities, but that there was no specific times or schedule for this. In an interview on 08/10/2022 at 10:04 AM, the Life Enrichment Director (LED) stated that she completed one-on-one visits with residents who could not get up to attend activities. The LED stated that she had a list of residents with whom she completed one-on-one visits. The LED stated she previously had Resident #50 on the one-on-one schedule but not currently. The LED stated she sometimes rotated who was getting one-on-one visits due to time constraints. The LED stated that Resident #50 enjoyed hand massages and essential oils. The LED stated that one-on-one visits were documented in the resident's progress notes. The LED reviewed Resident #50's progress notes and stated that the last time Resident #50 had one-on-one visits was 09/13/2021. The LED stated that she found out who needed to be on one-on-one visits through the initial admission assessment or anyone who was bed bound and/or did not come out of the rooms to attend activities. A review of the current activity 1:1's Assigned Sheet, undated, revealed Resident #50 was not included in the one-on-one assignment list. A review of Resident #50's activity Progress Notes revealed that the most recent one-on-one activity for Resident #50 was reading the weather to Resident #50 on 09/13/2021. The note indicated the resident was alert and lying in bed during the activity. Prior to 09/13/2021, Resident #50 had one-on-one activities documented three times per week. In an interview on 08/11/2022 at 1:38 PM, the Director of Nursing (DON) stated that her expectation for bed-bound residents was that everyone who went in the residents' rooms daily should interact with them. The DON stated she expected all residents to be invited to activities and that the activity department did a one-on-one program with bed-bound residents. In an interview on 08/11/2022 at 2:06 PM, the Administrator stated that his expectation was that the staff members were offering residents activities at residents' level and he wanted residents at all levels to be offered activities.

Based on observations, interviews, record review, and review of facility document, it was determined that the facility failed to provide enteral nutrition per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the facility failed to provide Resident #66's tube feeding per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: A review of a facility document titled, Administration of Tube Feedings: Intermittent or Continuous Competency, created 2018, revealed the steps of administration. The first step listed indicated, Verifies practitioner's order for enteral feeding. After administering tube feeding, the steps indicated that staff, Documents type and amount of feeding, verification of tube placement, amount of water given, and residents (sic) tolerance of the procedure. A review of Resident #66's Admission Record indicated the facility admitted Resident #66 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #66's annual Minimum Data Set (MDS), dated [DATE], revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating Resident #66 was cognitively intact. The MDS revealed Resident #66 had received 51% or more of the total calories through tube feeding during the assessment period. A review of Resident #66's care plan, dated 07/11/2021, indicated Resident #66 had a problem with nutrition related to a history of throat cancer and received almost all their nutrition via tube feeding due to dysphagia. Interventions included providing tube feeding per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #66's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Enteral Feed Order in the morning and at bedtime, only use gravity bag. -Enteral Feed Order in the morning for tube feeding, give 1 carton of [MEDICATION(S)] 1.5 at 9:30 AM. Order date: 06/13/2022. -Enteral Feed Order in the afternoon for tube feeding give 1.5 cartons of [MEDICATION(S)] 1.5 at 1:30 PM daily. Order date: 06/13/2022. -Enteral Feed Order in the evening for tube feeding give 1.5 cartons of [MEDICATION(S)] 1.5 at 5:30 PM daily. Order date: 06/13/2022. In an interview on 08/09/2022 at 6:07 PM, Resident #66's responsible party (RP) stated that an unknown temporary nurse had reported to the RP that she had only been giving Resident #66 one carton of [MEDICATION(S)] 1.5 per feeding. Specific dates of this report were unknown. A review of Resident #66's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #66's Progress Notes, revealed a medication error was reported on 08/11/2022. During the 1:30 PM tube feeding administration, Resident #66 was given 1 carton, rather than 1.5 cartons of [MEDICATION(S)]. The family, director of nursing (DON), and nurse practitioner (NP) were notified. The resident was notified. The NP gave an order to give an extra ½ carton at 8:00 PM to correct the calorie deficit. In an interview on 08/11/2022 at 1:38 PM, the Director of Nursing (DON) stated that she expected staff to follow the tube feeding order as it was written. The DON stated if the nurse did miss a feeding, they should notify the physician, DON, and dietitian and get new orders on how to proceed. In an interview on 08/11/2022 at 2:06 PM, the Administrator stated that a tube feeding order should be followed like any physician order. The order should be followed timely. In an interview on 08/11/2022 at 6:36 PM, the DON stated that when a medication error occurred, the nurse did a medication error report. Depending on the severity of the error, the DON would either write up the nurse or educate the nurse. The DON stated the nurse that committed the tube feeding error the previous night (08/10/2022) was not on the schedule until the next week. The nurse called the DON the previous night and told the DON about the tube feeding error that occurred on 08/10/2022. The nurse filled out the medication error report. The DON stated that she planned to educate the nurse when she returned. The DON stated the nurse reported she just got really nervous and missed it. The DON stated she not aware of a missed feeding on 07/23/2022. The DON was not sure whether it was a documentation error or truly missed but stated that if the nurse did not document it, it was not done.

Based on observation, interviews, and facility policy review, it was determined the facility failed to ensure medication carts were locked when unattended for one medication cart (700 Hall) of three medication carts that were observed during medication administration observations. Findings included: A review of the facility's policy titled, Medication Storage, dated 11/2017, revealed, [3.] In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. During an observation and interview on 08/10/2022 at 7:13 AM, Licensed Practical Nurse (LPN) #1 was in room [ROOM NUMBER] providing medication to the resident, who was lying in bed. There was an unlocked, unattended medication cart located on the opposite side of the hallway to room [ROOM NUMBER] and approximately five to six feet down the hall from the room. LPN #1's back was turned to the resident's door and not within sight of the medication cart. Neither LPN #1 nor the resident appeared to be in any distress, and there was no sense of urgency observed. LPN #1 exited the resident's room and stated the medication cart was unlocked because the resident almost had a fall and she had rushed in there to assist the resident. LPN #1 stated the medication cart should be locked when not in use. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing stated that if a medication cart was unattended, it should be locked. She stated that the consequences of an unlocked cart could lead to a staff member stealing medication or a confused resident could take medication that was not prescribed for that resident. During an interview on 08/11/2022 at 2:23 PM, the Administrator stated if a medication cart was unattended, it should be locked. Consequences of an unlocked medication cart could lead to a resident getting into the cart as well as unauthorized staff.

Based on record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#3 and #6) of four residents out of five sample residents. Specifically, the facility failed to: -Provide consistent showers according to her bathing preferences for Resident #6; and, -Provide any showers for Resident #3 during her 15 day respite stay. Findings include: I. Facility procedure The facility's shower and bathing, grooming or activities of daily living (ADL) policy was requested from the nursing home administrator (NHA) on 5/3/22 at 9:28 a.m. The NHA said he did not have those policies. He said the facility followed the federal regulations for these areas. II. Resident #6 A. Resident status Resident #6, age 84, admitted [DATE] and readmitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/19/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status score of 11 out of 15. She required limited one person assistance with transfers, bed mobility, dressing, personal hygiene and toileting. The assessment documented bathing did not occur. B. Resident interview and observation Resident #6 was interviewed on 4/27/22 at 8:49 a.m. Resident #6 said she was happy with the care provided by the facility staff, but was not happy with the care provided by the agency or contract nursing staff. Resident #6 said she frequently did not get her showers as scheduled, and had not had a shower in over a week. The resident said she preferred to get her showers during the day time. She said she did not get her shower last week because the person that did showers was not at the facility on her shower day. Her hair was uncombed and clumped together. On 4/27/22 at 10:00 a.m. the health information manager (HIM) was in the room with Resident #6. Resident #6's hair was wet, and she said she had just had a shower. The HIM said the resident had asked her to give her a shower, and she did. The HIM said she was a certified nurse aide (CNA). C. Record review On 4/27/22 at 1:00 p.m., Resident #6's ADL, bathing and showers task record in the resident's electronic medical record (EMR) was reviewed for the last 30 days. The shower record documented the following in pertinent part: -On Thursday, 3/31/22 at 2:54 a.m., not applicable; -On Monday, 4/4/22 at 12:48 a.m., not applicable; -On Wednesday, 4/6/22 at 7:10 p.m., resident refused; -On Sunday, 4/10/22 at 9:33 p.m., resident refused; -On Thursday, 4/14/22 at 5:59 a.m., not applicable; -On Sunday, 4/17/22 at 2:54 a.m., physical help provided, and then at 10:15 p.m. on the same day, independent, no help provided; -On Thursday, 4/21/22 at 3:22 a.m., not applicable; and, On Monday, 4/25/22 at 2:24 a.m., not applicable. The shower records revealed Resident #6 only had one shower in the last 30 days on 4/17/22 either at 2:54 a.m., or 10:15 p.m. The documentation was not clear. The record documented she refused a shower on 4/6/22 at 7:10 p.m., and 4/10/22 at 9:33 p.m. Resident #6's ADL care plan, initiated 3/6/18 was reviewed on 4/27/22 and 5/2/22. On 4/27/22, during the survey, the shower preferences were revised, and documented, I prefer to have my showers on Mondays and Wednesday. On 4/29/22, during the survey, the care plan was revised again and documented, I prefer my showers done on Wednesdays and Sunday each week. Both of these preferences continued to be listed on the care plan as of 5/2/22. It remained unclear which days the resident was to be showered, or what time of day was preferred. C. Staff interviews CNA #4 was interviewed on 5/2/22 at 10:27 a.m. She said showers were documented in the resident's electronic medical record with the amount of help needed, or refused. She said she did not know what not applicable was used for. She said she thought maybe it meant the resident was out of the building. CNA #5 was interviewed on 5/2/22 at 10:40 a.m. She said not applicable meant the resident did not get a shower. She said she did not know why that would be documented. CNA #5 said if the resident refused, there was an area to document the refusal. CNA #5 said in addition to documenting the shower in the resident's EMR, the staff were supposed to fill out a bath sheet and give it to the nurse. CNA #6 was interviewed on 5/2/22 at 10:53 a.m. She said the facility had shower aides who gave baths, but not all the time. She said sometimes the CNAs that were assigned to the resident did them. CNA #6 said the resident's care plan told the staff when to bathe the resident and then the amount of help required for the bath was documented in the resident's EMR. She said additionally, there was a bath sheet that should be filled out and given to the nurse. The director of nursing (DON) was interviewed on 5/2/22 at 1:54 p.m. She said she was actively revamping the shower process. She said the social services department had interviewed the residents about two months ago to update their preferences for showers, but residents often changed their minds and it was difficult to keep up with. She said the admission nurse should ask the resident about shower preferences on admission, including frequency and time of day. The DON said the resident's shower preference should be on the resident's care plan. Additionally, she said two months ago she had created a shower sheet the CNA was to fill out regarding the resident's skin condition, and this sheet was to be given to the nurse after the showers. The DON said she did not know why the staff would document a shower as not applicable. She said they should document the amount of help they provided or if the resident refused the shower. She reviewed a printed copy of the shower records for Resident #6 that had been provided by the SSD on 4/27/22 at 1:00 p.m. She said she did not know why the resident's shower had been documented as not applicable five times in the last 30 days. The DON said she would look to see if she had any shower sheets that had been completed by the CNAs for the last 30 days. On 5/2/22 at 10:00 a.m., the DON provided two shower sheets for the resident. One dated 4/27/22, during the survey, one dated 3/17/22, and one dated 2/27/22. She said she had no other shower sheets for the resident that would have documented she had been given a shower. The HIM was interviewed on 5/3/22 at 10:10 a.m. She said when she had been visiting with Resident #6 on the morning of 4/27/22. She said Resident #6 had told her she had not had a shower in over a week. The HIM said that really bothered me, and since I am a CNA, I gave her a shower. III. Resident #3 A. Resident status Resident #3, over [AGE] years old, admitted [DATE] and discharged on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/2/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. She required extensive two person assistance with assistance with bed mobility, transfers, dressing, and toileting. She required one person, extensive assistance with personal hygiene. The assessment documented bathing did not occur. B. Record review Residents #3's care plan was reviewed. The ADL care plan, initiated 2/18/22, documented I have an ADL self-care performance deficit, I will have care needs met and maintain cleanliness and dignity through review period. See my current kardex/task tab for ADL and mobility assistance needs as they may change through my stay. -There was no documentation on the care plan regarding any ADL care, including showers, preferences or needs. -The medical record was reviewed on 4/27/22. There was no kardex (a staff directive) for Resident #3. -The shower and bathing records were reviewed. There were no shower or bathing records for Resident #3. C. Interview The DON was interviewed on 5/2/22 at 10:00 a.m. She said she had no shower sheets for Resident #3. The DON said the resident had no care plan for ADLs. She looked at her laptop, and said the nursing staff failed to write a care plan for the residents ADL needs including showers. The DON said the admitting nurse should have written a baseline care plan and educated the CNAs on what care was needed.The DON said there was no documentation Resident #3 had a shower or bath during her 15 day respite stay.

Based on record review and interviews, the facility failed to ensure two (#1 and #2) out of four sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure Resident #1's risk of wandering and elopement was assessed and safety measures put into place following an exit seeking attempt on 8/6/21 prior to a documented incident of elopement by Resident #1 from the facility on 9/5/21; Additionally, the facility failed to ensure an assessment was completed and documented by a registered nurse (RN) following falls sustained by Resident #1 and Resident #2; and, And ensure neurological checks were completed thoroughly following unwitnessed falls. Findings include: I. Failure to ensure safety measures were in place to prevent an elopement A. Resident #1 status Resident #1, age 65, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), the diagnoses included [CONDITION(S)], dementia with lewy bodies and repeated falls. The 8/29/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of eight out of 15. She required extensive assistance of one person with bed mobility, toileting, locomotion on the unit and personal hygiene. She required limited assistance of one person with transfers, locomotion off the unit, walking in the room and corridor. It indicated the resident did not wander during the assessment period. B. Record review The impaired cognitive function care plan, initiated on 6/15/21 and revised on 10/9/21, revealed Resident #1 had impaired cognitive function or impaired thought processes related to dementia. The interventions included asking yes or no questions in order to determine the resident's needs and engage the resident in simple, structured activities that avoid overly demanding tasks. The behavior care plan, initiated 6/18/21 and revised on 9/10/21, documented the resident had a diagnosis of [CONDITION(S)], anxiety and auditory hallucinations related to [CONDITION(S)]. It is indicated to monitor the resident for auditory hallucinations, depressed mood, withdrawal from peers/staff, restless, anxious with worries and adjusting to long-term care placement and wandering and exit seeking. The interventions included: anticipate and meet the resident's needs; behavioral monitoring for auditory hallucinations, depressed mood, withdrawal from peers/staff, restless, anxious with worries, adjusting to long-term care placement and wandering/exit seeking behaviors (initiated on 6/18/21 and revised on 9/29/21); monitor behavior episodes and attempt to determine underlying causes; and offer/document non-pharmacological interventions prior to administering such as range of motion, massage, relaxation and breathing techniques, re-positioning, offer a snack, redirect to an activity, offer independent activity supplies, offer a call to a loved one, sit with the resident as needed and provide active listening and validation. The 8/6/21 nursing progress note documented Resident #1 was found attempting to open to the outside doors on the east side of the facility. It indicated the resident appeared confused, but followed the nurse back to her room without complaint. -A review of the resident's medical record on 10/26/21 at 2:46 p.m. did not reveal documentation a risk of elopement or wandering assessment had been completed upon the resident's admission to the facility or after the incident of exit seeking from the facility on 8/6/21. C. Incident of elopement The 9/5/21 nursing progress note revealed the nurse was notified by the certified nurse aide (CNA) at 3:00 p.m. Resident #1 was not in her room. During the previous rounding check, completed at approximately 2:00 p.m., the resident was resting quietly in her bed. At 2:41 p.m. Resident #1 exited the facility through the east door. A CNA witnessed Resident #1 a few blocks from the facility walking, using her front wheel walker, at approximately 3:40 p.m. The resident returned to the facility through the north entrance with the CNA at 3:48 p.m. Resident #1 was unable to verbalize specifics of why she left the facility, but responded yes when asked if she wanted to get some fresh air. A head to toe evaluation was completed upon the resident's return to the facility without any injuries noted. The resident was offered some water and returned to her room to eat dinner. The physician and family were notified. The resident was placed on 15 minute safety checks. The risk management review progress note documented Resident #1 had impaired memory, confusion, poor impulse control, poor safety awareness and dementia. The resident's family assisted the resident outside during visits at the facility. The facility placed door bells in place on all exit doors and 15 minute safety checks were put into place. Social services spoke with the family regarding alternate placement for the resident. The 9/5/21 wander/elopement risk evaluation, completed by the social worker, documented the resident routinely wandered or paced and ambulated independently. The resident was placed on 15 minute safety checks following the resident's elopement from the facility. It indicated the resident would remain on 15 minute safety checks until placement was obtained in a secure environment. D. Staff interviews CNA #1 was interviewed on 10/27/21 at 4:58 p.m. She said Resident #1 was confused and had dementia. She said Resident #1 walked with a walker and was able to ambulate without staff assistance. She said Resident #1 verbalized that she wanted to go home and would get upset that her daughter did not visit as often as she wanted. She said Resident #1 would try to leave the unit, however they had closed the double doors and the resident was unable to push the doors open. She said the resident had been placed on 15 minute safety checks since the resident's elopement from the facility on 9/5/21. She said each staff member documented the location and position of the resident on a form that was kept at the nursing station every 15 minutes. She said she would look in at the resident in her room as she passed by, even if it was not time for the 15 minute safety check. The social services director (SSD) and NHA were interviewed on 10/27/21 at 11:36 a.m. The SSD said she had worked at the facility for nine years. She said she was notified via telephone on 9/5/21 of Resident #1's elopement from the facility. She said she assisted in completing the elopement assessment. She said the facility placed the resident on 15 minute safety checks immediately following the incident and she started the process for finding an alternate secured placement for the resident. She said the activity staff has been assisting with redirection for the resident and had been taking the resident outside for walks regularly. She said she felt the facility was providing care to ensure the resident's safety following the 9/5/21 elopement. She said she was unaware of Resident #1's incident of exit seeking documented on 8/6/21. She said following the exit seeking attempt, an elopement/wander assessment should have been completed, care plan initiated and safety interventions immediately put into place. The NHA confirmed the resident's medical record did not reveal documentation any of those steps had been completed following the 8/6/21 exit seeking in an attempt to prevent the resident from eloping from the facility. II. Failure to ensure RN assessments were completed and documented post fall A. Resident #1 1. Record review The fall risk care plan, initiated on 6/15/21 and revised on 10/11/21, documented Resident #1 was a high risk for falls related to a diagnosis of [CONDITION(S)], incontinence of bowel and bladder, anxiety, cognitive communication deficit, muscle weakness and difficulty walking. The 7/13/21 nursing progress note documented the CNA alerted the nurse the resident was found lying on the floor in the bathroom, next to the wheelchair. It documented the RN performed an assessment, however the progress note was written by a licensed practical nurse (LPN). -The resident's medical record did not contain documentation an RN assessment had been completed. The 8/11/21 nursing progress note documented the staff informed the nurse Resident #1 had fallen out of bed. The resident attempted to get out of bed and fell out of it, while the bed was in the lowest position. Resident #1 said she hit her head on the chair next to the bed. It documented an RN performed an assessment, however the progress note was written by an LPN. -The resident's medical record did not contain documentation an RN assessment had been completed. The 8/20/21 nursing progress note revealed a CNA found Resident #1 lying on her right side on the bathroom floor. It appeared the resident had been changing her undergarments. An abrasion measuring 1 cm (centimeters) x 1 cm to the right upper side of the head and left wrist. It documented the RN was notified and assessed the resident, however the progress note was written by an LPN. -The resident's medical record did not contain documentation an RN assessment had been completed. The 10/3/21 nursing progress note revealed the resident was found on the floor in the doorway, sitting on her buttocks with her head against the wall. The resident was unable to verbalize how she fell . It documented an RN assessed the resident, however the progress note was written by an LPN. -The resident's medical record did not contain documentation an RN assessment had been completed. B. Resident #2 status Resident #2, age 94, was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 CPOs, the diagnoses included Alzheimer's disease, muscle weakness, difficulty in walking and unsteadiness on feet. The 10/22/21 MDS assessment revealed the resident had short-term and long-term memory impairment and had severe impairment in making decisions regarding tasks of daily life. She required extensive assistance of two people with bed mobility, transfers and extensive assistance of one person with dressing, eating, toileting and personal hygiene. It indicated the resident had two or more falls with an injury since the previous assessment and one fall with a major injury. 1. Record review The high fall risk care plan, initiated 4/5/21 and revised on 10/24/21, revealed the resident was a high risk for falls related to confusion, weakness, use of assistive devices, use of oxygen, Alzheimer's disease, unsteady on her feet, difficulty walking and [CONDITION(S)]. The 7/13/21 nursing progress note revealed the resident called out for the nurse and was found on the floor with her left hand behind the head, with the shirt stained with blood by the left elbow. The call light was still on the bed. The nurse documented that she elevated the resident's head from the ground by placing a pillow and exited the room to get help and called the physician for an order to send the resident to the hospital. The progress note was completed by an LPN. -The resident's medical record did not reveal documentation an RN assessment had been completed prior to the LPN moving the resident's neck and head to place a pillow or leaving the room or at all following the fall. C. Staff interviews The director of nursing (DON) and NHA were interviewed on 10/27/21 at 10:53 a.m. The DON said an RN assessment should be completed after a resident sustained a change of condition. She said an LPN was not able to conduct an assessment because it was not within their scope of practice. She said it was important for an RN to complete an assessment to ensure the resident did not sustain any underlying injuries. She said the RN assessment should be documented in the resident's medical record. The DON said the facility did not have documentation of RN assessments being completed for the falls involving Resident #1 on 7/13/21, 8/11/21, 8/20/21 and 10/3/21 and Resident #2 on 7/13/21. III. Failure to ensure neurological checks were completed thoroughly A. Resident #1 1. Record review The 8/20/21 nursing progress note revealed a CNA found Resident #1 lying on her right side on the bathroom floor. It appeared the resident had been changing her undergarments. An abrasion measuring 1 cm (centimeters) x 1 cm to the right upper side of the head and left wrist. The fall was unwitnessed. -A review of the resident's medical record did not provide documentation to indicate neurological checks had been completed following the fall. B. Resident #2 1. Record review The 4/6/21 nursing progress note revealed the resident sustained an unwitnessed fall. Resident #2 fell while attempting to transfer herself without assistance. -The neurological flow sheet showed missing documentation for the resident's level of consciousness, movement, hand grasps, pupil size and reaction to the right and left eyes, and speech were left blank for three neurological check time slots on 4/6/21 at 7:30 p.m., 11:30 p.m. and 3:30 a.m. The 6/3/21 nursing progress note revealed the resident sustained an unwitnessed fall. Resident #2 attempted to transfer herself without assistance from the wheelchair. -The neurological flow sheet showed missing documentation on 6/6/21 at 8:00 a.m. for the resident's level of consciousness, movement, hand grasps, pupil size and reaction to the right and left eyes, and speech. It was missing a nurse's signature on nine opportunities. The 8/30/21 nursing progress note revealed the resident sustained an unwitnessed fall out of bed. Resident #2 was found lying next to her bed on the ground. -The neurological flow sheet showed missing documentation on 8/31/21 at 8:30 p.m. and 9/1/21 at 1:30 a.m. for all neurological assessment measures. C. Staff interviews The DON and NHA were interviewed on 10/27/21 at 10:53 a.m. The DON said neurological checks should be completed for all residents who hit their head or for an unwitnessed fall. She said neurological checks should be documented on the neurological flowsheet at the indicated time intervals. She said neurological checks were important to ensure the resident did not sustain a serious head injury. She said each section should be filled out completely. She confirmed the missing documentation indicated the neurological check was not completed and did not indicate the residents refused.

Based on observations, record review and interview, 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, and the possible cross-contamination of Coronavirus disease (COVID-19). Specifically, the facility failed to ensure staff performed hand hygiene between resident area contact. Findings include: I. Professional reference The Center for Disease Control (CDC), Hand hygiene in healthcare setting (4/15/2020), https://www.cdc.gov/handhygiene/providers/guideline.html, Hand Hygiene Guidance; The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. The super sani cloth product information, Sani Cloth germicidal wipe (4/16/2020), https://pdihc.com/wp-content/uploads/2018/08/SuperSaniClothProdInfo 608.pdf displayed a picture of the container that clearly showed an icon on the side of the bottle that identified the wipes were not a skin or baby wipe. II. Observations The second floor west hall was observed on 4/15/2020 at 10:00 a.m. An activity aide (AA #1) was conducting a bingo game on the hallway with four residents who were in their doorways, separated with appropriate distance. -At 10:04 a.m. AA #1 used a PDI sani wipe from the purple top container to clean her hands. She placed the wipe on the top of her cart and started back to the bingo game. -At 10:13 a.m. AA #1 set up a fifth resident to play bingo. She did not wash her hands before or after the set up. -At 10:14 a.m. AA #1 removed the used bingo cards from the first four residents, took the used cards to the trash, and wiped her hands with the same wipe on the top of the cart. She did not clean her hands before touching the tables nor after touching the residents' areas. -At 10:23 a.m. a resident called out bingo, AA #1 checked the card and placed a quarter on the resident's table. She did not clean her hands before or after touching the resident's area. -At 10:26 a.m. AA #1 gave another winner a quarter. She did not clean her hands before or after touching the resident's area. -At 10:27 a.m. AA #1 gave the last winner of that game a quarter. She did not clean her hands before or after touching the resident's area. She went to all five residents' areas, picked up the old bingo cards, and took the old cards to the trash. She did not clean her hands before or after touching the residents' areas. -At 10:28 a.m. AA #1 returned to the cart and wiped her hands with the same wipe. -At 10:29 a.m. AA #1 dropped a bingo ball onto the floor. She picked up the ball, wiped the ball with the same wipe, placed the ball back into the bingo wheel, and wiped her finger tips with the wipe. -At 10:39 a.m. AA #1 awarded a winner with a quarter. She did not clean her hands before or after touching the resident's area. -At 10:40 a.m. AA #1 awarded the second winner a quarter. She did not clean her hands before or after touching the resident's area. III. Interviews AA #1 was interviewed on 4/15/2020 at 10:42 a.m. She said she had received training on hand washing. She said she needed to wash her hands when going into a resident's room, leaving a resident's room, and from one resident to another. She said she didn't think to wash her hands during bingo and between resident area contact. The assistant director of nursing (ADON) who was also the infection control preventionist (ICP) was interviewed on 4/15/2020 at 10:50 a.m. She said staff needed to wash their hands when entering and exiting a resident room and in between resident contact. She said the sani-wipes with the purple top were not designed to be used on hands. She said AA #1 did not usually run the bingo games. She said she understood how important it was for staff to perform hand hygiene between resident contact. She said she had provided training to AA #1 on hand hygiene. She said AA #1 had completed a competency on hand washing on 2/13/2020. She provided a copy of the competency evaluation.

Based on interviews and record review, the facility failed to ensure an effective quality assurance committee to identify and address facility compliance concerns was implemented which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to weight loss, documentation of resident's nutritional status and physicians not being notified of laboratory results in a timely manner. Cross reference to F692 Nutrition and Hydration for the facility not performing routine nutrition assessments and identifying and intervening for significant weight loss. Cross reference to F773 Laboratory services for the facility failing to notify the ordering physician of abnormal lab values Findings include: I. Nursing home administrator (NHA) interview The current NHA and chief executive officer was interviewed on 1/17/2020 at 12:01 p.m., She said she stepped into the NHA position at the end of December and had identified multiple issues in the facility the previous NHA had not addressed. She said she had identified a concern in October with the NHA performance and initiated an action plan at that time. She said she did not attend the QAPI meeting before, but would review all the reports presented at the meeting. She said she was out of town and unable to attend the QAPI meeting in November and the meeting for December was cancelled due to adverse weather and was not rescheduled. II. Record review The action plan, initiated 10/28/19, for problems identified with the previous nursing home administrator (NHA) was reviewed on 1/17/2020. It revealed: -The NHA was not attending weekly skin and weight meetings (in fact the meetings were not occurring at all); -There were training concerns; -The 24 hour meeting was not effective; and -The NHA oversight of nursing was not adequate. The QAPI meeting agenda and sign-in sheets for the November 2019 and December 2019 meetings were requested and not provided by the facility. III. Interviews The director of nursing (DON) was interviewed on 1/17/2020 at 12:01 p.m. The DON stated she started in November 2019 after the November QAPI meeting had already occurred so she was not present for that meeting and the meeting in December 2019 was cancelled so she had not had an opportunity to participate in the QAPI program. The NHA was interviewed on 1/17/2020 at 12:01 p.m. She said the QAPI meeting was to be held monthly with the medical director, NHA, DON, director of rehab (DOR), the pharmacist, social services, the registered dietitian, both assistant director of nursing (ADON)s, and the wound nurse. In the meeting, they review customer service reports, grievances and consultation reports. She said they had a program that graphed out each care area for the team to review. They reviewed concern forms and resident council notes. She said they looked for trends as they reviewed falls, weights and skin concerns. She said concerns from the previous meeting should be reviewed for resolution or on-going problems.

Based on observations, interviews and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status unless clinically unavoidable for six (#2, #5, #7, #3, #1 and #8) of eight residents reviewed for nutrition and hydration of the 12 sample residents. Specifically, the facility failed to: -Timely complete a comprehensive nutrition and hydration assessment and failed to consistently monitor intakes for Resident #2's nutritional supplements and meals. The facility's failure to assess and monitor Resident #2's nutrition and hydration status contributed the resident, who was admitted with conditions that included [DIAGNOSES REDACTED]. -Complete a comprehensive nutrition assessment, obtain a weight in (MONTH) 2019, and monitor amount of nutritional supplements consumed to ascertain the approach's efficacy for Resident #5, who experienced a severe weight loss of 10% between 10/2/19 admission and (MONTH) 2019. The facility's failure contributed to continued unplanned, severe weight loss when from the date of admission when the resident was weighed in (MONTH) 2020. -Accurately identify Resident #7's severe unplanned weight change and complete a comprehensive nutrition assessment related to that change at the beginning of (MONTH) 2019. The failure contributed to continued severe weight change of greater than 5% in one month when the resident was re-weighed at the end of (MONTH) 2019. -Failed to monitor meal intakes in accordance with Resident #3's nutrition care plan. The failure to monitor intakes contributed to Resident #3's severe 13.27% unplanned weight loss between (MONTH) 2019 and (MONTH) 2020. Additionally, the facility failed to have a comprehensive nutrition assessment completed for Resident #3. -Provide adequate nutrition, accurate intake monitoring, and nutritional assessment for Resident #1, who had difficulty eating resulting from an oral infection. -Complete a comprehensive nutritional assessment for Resident #8. -Clarify the orders for the ordered dietary supplements for Resident #2, #7, #5, and #1. Cross-reference F658, failure to provide services that meet professional standards. Cross-reference F773, failure to report laboratory (labs) results in a timely manner. Findings include: I. Facility policy and procedure The Weight Management Policy and Procedure, last revised 1/2020, provided by the nursing home administrator (NHA) on 1/15/2020 at 3:15 p.m., included in pertinent part, Residents are monitored for significant weight change on a regular basis. Results are reviewed and analyzed by the facility for intervention as appropriate. Residents identified with significant weight change will be assessed by the interdisciplinary team (IDT) and further interventions will be implemented to minimize the risk for further weight change where possible and promote weight stability. Residents will be screened for their risk for weight change on admission, quarterly, annually and with significant change of condition. Residents with weight variance (loss or gain) are reweighed within at least 24 hours. Significant weight variance is defined as a five percent weight loss/gain in one month. IDT meets weekly to review residents with identified weight change, develops a plan, implements, evaluates and re-evaluates interventions to minimize the risk for weight change. Nursing staff is to notify Food and Nutrition services and the registered dietitian of a residents weight change. The RD further assesses the resident and makes recommendations as indicated to reduce or stabilize the weight change. II. Resident #2 [NAME] Resident #2 status Resident #2, age 74, admitted [DATE] and discharged [DATE]. According to the (MONTH) 2019 computerized physician order [REDACTED]. The 12/15/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. She did not have a swallowing disorder and no weight loss or gain documented. B. Family interview The resident's family was interviewed on 1/14/2020 at 11:13 a.m. He said they had concerns about the resident's fluid intake while at the facility. He said he did not think staff were charting her intake accurately because she was losing weight or being weighed as she should because of the large weight loss. He said when he was at the facility he did not observe facility staff encourage her to eat or offer her any other interventions to encourage weight gain. He said the physician told him he had not received the lab results timely and the results indicated she was dehydrated. He said they sent his mother out to the hospital and the emergency room physician had told him she had profound dehydration and was going into kidney failure because she was so dry. C. Record review The care plan, initiated 12/12/19, revealed the resident had a potential for nutritional risk. Interventions included: -Explain food service, resident choice and open dining menu; -Monitor for altered nutrition related labs and notify the physician as necessary; -Monitor for signs and symptoms of dehydration; -Obtain and monitor lab and [DIAGNOSES REDACTED]. -Obtain weights as ordered/per facility protocol and report significant changes to the physician; -Provide 24 hour access to the hydration and snack station; -Provide and serve diet as ordered. Monitor intake and record every meal; and -Registered dietitian (RD) to evaluate and make diet change recommendations as needed. According to the (MONTH) 2019 CPO, admission orders [REDACTED] -Regular diet with regular texture with thin consistency fluids and -Admit weight now and day two and three. According to the 12/12/19 physician progress notes [REDACTED]. Part of the assessment and plan was to have nutrition follow. Labs were ordered and Chocolate Boost or similar one by mouth twice a day was ordered. On 12/14/19 magicup one time a day for supplement was added. The (MONTH) 2019 Medication Administration Record [REDACTED]. According to the weights and vitals summary the resident weighed 147.7 pounds on 12/11/19 when she was admitted and on 12/17/19 she weighed 140 pounds, a 7.7 pound weight loss, 5.2% (severe weight loss), in six days. The 12/18/19 nutritional history was not completed in full. The section for food preferences and intolerances was incomplete, clinical data including lab values was incomplete, and the section identifying the estimated caloric, protein and fluid needs was incomplete. According to the 12/17/19 interdisciplinary team (IDT) care plan review, grand rounds were done on 12/19/19. The resident had a poor appetite per her spouse. According to the 12/19/19 nutrition note, weight loss likely a combination of natural elimination of fluids received intravenously (IV) at the hospital along with true weight loss of up to five pounds since hospitalization to current. The resident reports poor appetite with minimal intake. Her current oral intake was estimated at 500-700 kilocalorie (kcal) daily. A taste test was done with various supplements. The resident agreed to the following: fortified orange juice daily, mighty shake twice a day, and continue the magicup daily. This regimen would offer roughly 1,000 kcal with 30 grams (g) of protein while promoting fluid intake. The estimated needs were 1,590 to 1,900 kcal and 65-75g of protein. The supplements would provide 60 percent of energy needs and 45 percent of protein needs. No estimated fluid needs were provided. According to the 12/19/19 physician progress notes [REDACTED]. There had been no significant change to her adult failure to thrive diagnosis. The physician reviewed labs that had been collected on 12/12/19, noting a low [MEDICATION NAME] level of 13.8 milligrams per deciliter (mg/dl). Normal is 17.6-36 mg/dl. Nutrition was following. According to the (MONTH) 2019 CPO, the following orders were received on 12/19/19: -Mighty shake one carton two times a day for weight and wound management; and -Protein fortified orange juice one carton in the morning for weight and wound management. The (MONTH) 2019 Medication Administration Record [REDACTED] -Chocolate boost was being signed off as being administered twice a day, however, the amount consumed was not being recorded until 12/16/19; and -No documentation on 12/15/19 in the morning for the boost. According to the 12/23/19 physician progress notes [REDACTED]. Her blood-urea nitrogen (BUN) was 27mg/dl (normal is 7-25mg/dl) and creatinine was 2.2mg/dl (normal is 0.4-1.5mg/dl). The plan was to continue the supplements and encourage fluids. According to the 12/24/19 physician progress notes [REDACTED]. Fluids were encouraged. Stat labs were ordered and were to be called in to the ordering physician (these lab results were not called in to the physician as ordered). The resident may need IV fluids. Nutrition was following the resident's [DIAGNOSES REDACTED]. According to the (MONTH) 2019 CPO, an order was received on 12/24/19 for 8 ounces of chocolate milk three times a day. According to the (MONTH) 2019 MAR indicated [REDACTED]. The lab results report for labs collected on 12/24/19 revealed the resident's BUN level was 47mg/dl and creatinine was 3.67 mg/dl. According to the 12/26/19 IDT care plan review, grand rounds were done on 12/27/19 at 9:05 a.m. The physician reviewed the resident's medications and informed the son there were signs and symptoms of dehydration. IV fluids were to be started. The physician addressed with the power of attorney (POA)/spouse that since the resident was not eating if they wanted to move forward with placing a tube for feeding. The physician explained a nasogastric (NG) tube to start with, as it would take one to two weeks for a feeding tube to be placed. The family stated their biggest concern currently was the resident's intake and weights. The physician was making a referral for a feeding tube placement. According to a 12/27/19 nurse's note at 11:11 a.m. an IV was started in the left hand with normal saline running. The resident tolerated the procedure well. According to the 12/27/19 physician progress notes [REDACTED]. Results were reviewed that day with noted elevation in the BUN and creatinine. STAT labs were ordered, IV fluids were to be started and an NG tube was to be placed until a feeding tube could be placed. However, after discussion with the director of nursing (DON) and the consideration that the BUN and creatinine may be even more elevated as the most recent results were 3 days old now, that it would be in the resident's best interest to send her to the hospital for acute kidney injury and likely feeding tube placement. (Cross-reference F773, failure to report laboratory results in a timely manner) According to the 12/27/19 discharge note, the resident was discharged at 2:00 p.m. by stretcher (to the hospital). According to the lab results for specimens collected on 12/27/19 at 11:30 a.m. the BUN was 50mg/dl and creatinine was 3.21mg/dl (see normal ranges above). These results were reported from the lab to the facility at 4:45 p.m. Review of the resident's meal intakes from 12/12-12/26/19 revealed the following: -No intake was recorded two of the 15 days; -Only one or two of the three daily meal intakes were recorded 10 out of the 15 days. (Cross-reference F658, failure to accurately document meal intake) III. Resident #5 [NAME] Resident #5 status Resident #5, age 94, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 10/9/19 MDS assessment revealed the resident had severe cognitive function with a BIMS score of three out of 15. She did not have a swallowing disorder and no weight loss. She was on a mechanically altered diet. Her current weight was 115 pounds. B. Observations and interviews On 1/15/2020 at 8:10 a.m. the resident's breakfast tray was on top of the over the bed table pushed to the side of the bed. She had taken bites of her french toast and drank approximately one third of a glass of juice. There were two half pieces of french toast left on the plate and a piece of sausage. There was a full glass of water sitting on the table next to the tray. The resident said she was done eating. She said she was not offered an alternate meal because she did not like french toast. According to the residents meal intake record, the staff documented she refused fluids, food and her supplement and that no alternative was offered. C. Record review The care plan, last revised on 10/21/19, revealed the resident had a potential for nutritional risk. Her diet was regular with mechanical soft texture and thin liquids. She was on a 1,000 milliliter (ml) a day fluid restriction. She could receive 1,000 ml on days and 500 ml on nights. Goals were for the resident to be offered foods and fluids at their request and to be weighed per the facility protocol or as ordered by the physician. Interventions included: -Explain food service, resident choice and open dining menu; -Obtain and monitor lab and diagnostic work as ordered. Report results to the physician and follow up as indicated; -Monitor for altered nutrition related labs and notify the physician as necessary; -Monitor for signs and symptoms of dehydration; -Obtain weights as ordered per facility protocol and report significant changes to the physician; -Provide 24 hour access to the hydration and snack station; -Provide and serve diet as ordered. Monitor intake and record every meal; and -RD to evaluate and make diet change recommendations as needed. According to the (MONTH) 2020 CPO, orders included: -Regular diet with mechanical soft texture and thin consistency liquids. Fluid restriction of 1,500 milliliters in 24 hours. Give 1,000 ml on days and 500 ml on nights. Please moisten all foods or provide gravy on the side due to dry mouth and difficulty chewing; -Ensure Plus every day shift for nutrition supplementation. (The order did not include how much was to be administered.) According to the (MONTH) 2020 MAR indicated [REDACTED]. According to the (MONTH) 2020 treatment administration record (TAR), the resident's fluid intake was not documented on 1/5/2020 for the monitoring of the fluid restriction. The average fluid intake for the resident from 1/1/2020 to 1/15/2020 was 985mls/day. Far less than the ordered restriction (see orders above). The vital signs and weights summary revealed the following: -The resident's weight the first three days after admission were 116.2 pounds, 114.6 pounds and 114.5 pounds; -No weight was obtained in (MONTH) 2019; -The resident's weight in (MONTH) 2019 was 103 pounds; an 11.5 pound weight loss, 10.0%, since admission two months earlier (a severe weight loss); and -The residents weight in (MONTH) 2020 was 100.8 pounds; a 15.4 pound weight loss, 13.4%, in three months (a severe weight loss). Review of the resident's record on 1/15/2020 revealed the resident did not have a comprehensive nutritional assessment to indicate food preferences/intolerances, clinical data to include nutrition based labs, and the resident's estimated protein, calorie and fluid needs. Furthermore, the record did not include any dietary or nutritional progress notes since the resident was admitted except during three IDT care plan reviews done in (MONTH) 2019 documenting no dietary concerns or questions. According to the 1/9/2020 physician progress notes [REDACTED]. (This was the first mention of the resident having dementia) The resident was declining mentally as well as physically. She had lost ten pounds in two months, at times not eating well. The plan was for a hospice consultation. The Ensure plus was to be continued and weight loss was expected as her dementia progressed. IV. Resident #7 [NAME] Resident #7 status Resident #7, age 77, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/2/19 MDS assessment revealed the resident had severe cognitive function with a BIMS score of one out of 15. B. Record review The care plan, last revised 1/10/2020, revealed a potential for nutritional risk with an unplanned/unexplained weight loss related to inadequate food intake. She had a strawberry allergy and was lactose intolerant however often asked for yogurt at meals. She was on psych medications that may affect her appetite and weight. She preferred not to consume pork but loved cheese sandwiches. She also enjoyed consuming Pepsi soda. Her diet was regular with mechanical soft texture with thin liquids (this did not match the current physician orders). She was to have one to one supervision during meals at all times. She was not to have anything by mouth if she was not fully alert. Interventions included: -To be fully upright during all meals. Head of bed was to be elevated after meals; -Encourage to maintain proper fluid intake and hydration by consuming fluids; -Explain food service, choice and open dining menu; -Monitor for altered nutrition related labs and notify the physician as necessary; -Monitor for signs and symptoms of dehydration; -No strawberries, offer [MEDICATION NAME] milk and may have yogurt upon request; -Provide accommodation or assistance in eating as needed/ordered; -Provide and serve supplement as ordered: Glucerna every day (the resident did not have a current order for this); -Provide diet per order, monitor intake and record every meal; -Alert dietitian if consumption is poor for more than 48 hours; -Will remain on weekly weights until determined nutritionally stable; -If weight decline persists, contact physician and dietitian immediately; -Offer meal, snack and beverage substitutes as requested or indicated; and -Provide with supplements as ordered: Nepro for high kcal/protein content. According to the (MONTH) 2020 CPO, orders included: -Regular diet with pureed texture and thin consistency liquids. Straws to be used with fluids; and -Nepro one container in the afternoon for nutrition supplementation. According to the (MONTH) 2019 and (MONTH) 2020 MAR, the Nepro was being signed off twice a day as being administered but the amount consumed was not being documented. Review of the resident's record on 1/15/2020 revealed the resident did not have a comprehensive nutritional assessment to indicate food preferences/intolerances, clinical data to include nutrition based labs, and the resident's estimated protein, calorie and fluid needs. The 9/1/19 MDS assessment revealed the resident's weight was 109 pounds. The 12/2/19 MDS assessment revealed the resident's weight was 93 pounds, a 16 pound weight loss, 14.7% (severe weight loss) in three months. The 12/30/19 MDS assessment revealed the resident's weight was 88 pounds, a 5 pound weight loss, 5.4% (severe weight loss) in less than a month. According to the 12/12/19 nurse practitioner (NP) visit note, the resident had decreased oral intake and alertness. She ate approximately 25% of breakfast in the dining room and had minimal intake for lunch. The plan was to encourage oral intake, monitor intake and overall condition for changes. According to the 12/13/19 NP visit note, the resident had ongoing poor oral intake over the past two to three days. The resident had increased fatigue and lethargy. She refused breakfast and was taken back to bed. A chest x-ray was ordered with results pending. Stat labs and IV fluids were ordered. Increased fluid and food intake was to be encouraged and oral intake was to be monitored. According to the 12/16/19 physician note, the resident's oral intake remained very poor. IV fluids continue to infuse since 12/13 in the afternoon when the IV was placed. The plan was to continue the IV fluids for four more days, encourage oral intake and monitor output. If her condition significantly worsened despite treatment, hospice should be considered. According to the 12/18/19 nurse practitioner (NP) progress note, the resident had improved alertness but ongoing poor food and fluid intake. The plan was to continue current supplements, monitor intake and weight. According to the 12/19/19 NP progress note, the resident had been receiving IV fluids since 12/13 but the IV infiltrated that morning. IV had to be restarted times two in the last week. The resident had increased alertness but oral intake remained poor. The resident had chronic generalized muscle and subcutaneous fat loss. The resident was to continue with current supplements. Monitor intake and weight. IV was to remain out due to infiltrate times two. If the resident became lethargic and declined again in the next few days, the spouse was open to hospice consultation and comfort focused care. According to the 12/19/19 nutrition progress note, the resident's weight had been stable for six weeks at 93 pounds, which was inaccurate, the resident had a significant weight loss from (MONTH) 2019 to (MONTH) 2019, more weight loss from (MONTH) to (MONTH) 2019. The resident's weight was stable from (MONTH) 2019 to the beginning of (MONTH) 2019 when the resident started losing weight again. The Nepro was well tolerated and effective in combating further weight loss. Continue with the current nutrition plan of care. The dietitian did not address the resident's gradual weight loss). According to the (MONTH) 2020 CPO, the resident was admitted to hospice services on 12/23/19 with a dementia diagnosis. V. Resident #3 [NAME] Resident #3 status Resident #3, age less than 65, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/28/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident had no swallowing disorder, no weight loss or gain, was on a therapeutic diet and his current weight was 113 pounds. An admission MDS assessment, dated 9/27/19, revealed the resident weighed 113 pounds. B. Record review The care plan, last revised 10/10/19, revealed the resident had a potential for nutritional risk and had diabetes mellitus. His diet was low concentrated sweets with regular texture and thin liquids. Interventions included: -Dietary consult for nutritional regimen and ongoing monitoring; -Explain food service, resident choice and open dining menu; -Obtain and monitor lab and diagnostic work as ordered. Report results to the physician and follow up as indicated; -Monitor for altered nutrition related labs and notify the physician as necessary; -Monitor for signs and symptoms of dehydration; -Obtain weights as ordered per facility protocol and report significant changes to the physician; -Provide 24 hour access to the hydration and snack station; -Provide and serve diet as ordered. Monitor intake and record every meal; -RD to evaluate and make diet change recommendations as needed; and -Monitor and report to the physician as needed for signs and symptoms of hyper/[DIAGNOSES REDACTED] (high/low blood sugar). According to the (MONTH) 2020 CPO, orders included a low concentrated sweets diet with regular texture and thin liquid consistency. The resident was to be out of bed three times a day for meals. The weights and vitals summary revealed the resident's weight on 12/1/19 was 113 pounds and on 1/9/2020 it was 98 pounds, a 15 pound weight loss, 13.27% (severe weight loss), in a month. There was no documented re-weigh. Review of the resident's record on 1/15/2020 revealed the resident did not have a comprehensive nutritional assessment to indicate food preferences/intolerances, clinical data to include nutrition based labs, and the resident's estimated protein, calorie and fluid needs. Furthermore, the record did not include any dietary or nutritional progress notes since the resident was admitted except during a care conference in (MONTH) 2019 where the resident stated the food was disgustingly delicious. He reported he liked what was available and had no dietary concerns. Review of the resident's meal intakes from 12/1/19 to 12/31/19 revealed the following: -No intake was recorded four of the 31 days; -Only one or two of the three daily meal intakes were recorded 17 out of the 31 days. Review of the resident's meal intakes from 1/1/2020 to 1/15/2020 revealed only one or two of the three daily meal intakes were recorded six out of the 15 days. VI. Resident #1 [NAME] Resident #1 status Resident #1, age 75, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/25/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident had no swallowing disorder, no weight loss or gain, on a therapeutic diet and her current weight was 181 pounds. B. Observations and interview On 1/14/2020 at 5:03 p.m. the resident was in her room, lying in bed and was served her dinner tray which consisted of a cup of soup and a carton of Glucerna. The resident's family was in the room at the time and said the resident was mostly taking a liquid diet at this time because she had sores in her mouth. According to the resident's meal intake, the staff documented she had eaten 76-100%, however the meal only consisted of the cup of soup and a carton of Glucerna instead of the full meal served to other residents. On 1/15/2020 at 8:00 a.m. the resident was sitting in her wheelchair with the over the bed table in front of her with her breakfast tray on it. She had a carton of Glucerna and a cup of coffee on the tray. She had dropped her piece of toast on the floor, and approximately 12 minutes later a dietary aide brought the resident another piece of toast, which she ate except the crust. No other breakfast foods were offered to the resident at that time. According to the resident's meal intake, the staff documented she had eaten 76-100%, however the meal only consisted of a piece of toast, coffee and Glucerna instead of the omelet, ham and toast served to other residents. C. Record review The care plan, initiated 12/12/19, revealed the resident had a potential for nutritional risk. Interventions included: -Explain food service, resident choice and open dining menu; -Monitor for altered nutrition related labs and notify the physician as necessary; -Monitor for signs and symptoms of dehydration; -Obtain and monitor lab and [DIAGNOSES REDACTED]. -Obtain weights as ordered/per facility protocol and report significant changes to the physician; -Provide 24 hour access to the hydration and snack station; -Provide and serve diet as ordered. Monitor intake and record every meal; and -RD to evaluate and make diet change recommendations as needed. According to the (MONTH) 2020 CPO, orders included: -Low concentrated sweets diet with regular texture and thin liquid consistency, -Glucerna three times a day for nutritional support (did not include how much to administer) and -[MEDICATION NAME] swish and swallow 5 milliliters (ml) by mouth four times a day for thrush and pain related to infection. According to the (MONTH) 2020 MAR, Glucerna was being signed off as being administered three times a day however the amount administered or the amount consumed was not being documented. Review of the resident's record on 1/15/2020 revealed the resident did not have a comprehensive nutritional assessment to indicate food preferences/intolerances, clinical data to include nutrition based labs, and the resident's estimated protein, calorie and fluid needs. The RD failed to address the resident's [DIAGNOSES REDACTED]. VII. Resident #8 [NAME] Resident #8 status Resident #8, age 76, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/28/19 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident had no swallowing disorder, no weight loss or gain her current weight was 117 pounds. B. Record review The care plan, last revised 6/21/19, revealed the resident had a potential for nutritional risk. had a history of [REDACTED]. No added salt diet with cut up textures and thin liquids. Interventions include: -Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage her to comply. -Explain the consequences of refusal, obesity and malnutrition risk factors; -Explain food service, choice and open dining menu; -Monitor for signs and symptoms of dehydration; -Provide diet per order, monitor intake and record every meal; -Lab and diagnostic tests per physician; -Provide 24 hour access to the hydration and snack station; RD had provided diet education on weight management and proper nutrition for stage of life. Will continue to educate as necessary; -Weight per facility protocol report significant changes; -Will provide nutrition supplementation as ordered; mighty shake three times a day (this did not match the supplement currently ordered). According to the (MONTH) 2020 CPO, orders included: -No added salt diet with cut up texture and thin liquid consistency. The resident disliked cumin. Provide all beverages and soups in a blue mug with a handle; -Nepro administer one container in the afternoon for nutrition supplementation. Review of the resident's record on 1/15/2020 revealed the resident did not have a comprehensive nutritional assessment to indicate food preferences/intolerances, clinical data to include nutrition based labs, and the resident's estimated protein, calorie and fluid needs. VIII. Interviews Registered nurse (RN) #2 was interviewed on 1/14/2020 at 4:30 p.m. She said STAT labs meant to get the labs collected right away, which usually meant within four hours after the lab company had been called. She said the results should be called to the ordering physician as soon as they are received especially if the results are abnormal. She said the receiving of the labs and notifying the physician should be documented in a progress note. Certified nurse aide (CNA) #1 was interviewed on 1/15/2020 at 8:52 a.m. She said they documented the resident's meal intake after each meal into the computer. She said sometimes it did not get done until the end of their shift. She said she charted the percentage of what the resident ate according to what was served on the tray, whether it was a cup of soup or an entire meal

Based on record review and interviews, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of the clinical reference range, in accordance with the facility policy and procedures for notification of a practitioner or per the ordering physician's order [REDACTED].#2, #1 and #4) of four residents reviewed of the 12 sample residents. The facility failed to report Resident #2's lab values to the physician when they were received, resulting in a delay of treatment for [REDACTED]. Specifically, the facility failed to: -Report Resident #2 ' s lab values to the physician in a timely manner. The physician ordered STAT labs for the resident on 12/24/19 with specific instructions to call the ordering physician with the results, even providing the phone number however the abnormal results were not reported for three days resulting in a delay of treatment for [REDACTED]. -Report Resident #1 ' s critical lab value to the physician in a timely manner; and -Report Resident #4 ' s abnormal lab results to the physician in a timely manner. Cross Reference F692 for failure to provide adequate nutritional and hydration care and services Finding include: I. Facility policy and procedure The Laboratory and Radiological Services Policy and Procedure, last revised 1/2020, provided by the nursing home administrator (NHA) on 1/15/2020 at 3:15 p.m., included in pertinent part, When the physician orders [REDACTED]. The order is placed on a lab requisition form to be completed upon the next laboratory visit. The nurse completes a Lab and Diagnostic Order'' (LDO) and it is entered in the electronic medication record. The LDO is in effect for three days and prompts the nurses on each shift to monitor lab results, report results to the physician and notify the family. The nurse creates a progress note with the lab results to include who was notified and when. II. Resident #2 [NAME]Resident #2 status Resident #2, age 74, admitted [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician order [REDACTED]. The 12/15/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status ( BIMS) score of 10 out of 15. B. Family interview The resident's family was interviewed on 1/14/2020 at 11:13 a.m. He said they had concerns about the resident's fluid intake while at the facility. He said he did not think staff were charting her intake accurately because she was losing weight or being weighed as she should because of the large weight loss. He said the physician told him he had not received the lab results timely and the results indicated she was dehydrated. He said they sent his mother out to the hospital and the emergency room physician had told him she had profound dehydration and was going into kidney failure because she was so dry. C. Record review According to the 12/24/19 physician progress notes [REDACTED]. Fluids were encouraged. Stat (as soon as possible) labs were ordered and were to be called in to the ordering physician. The resident might need IV fluids. According to the 12/27/19 physician progress notes [REDACTED]. Results were reviewed on 12/27/19 with noted elevation in the blood urea nitrogen (BUN) and creatinine indicating possible dehydration or kidney failure. STAT labs were ordered, intravenous (IV) fluids were to be started and an nasogastric (NG) tube was to be placed until a feeding tube could be placed. However, after discussion with the director of nursing (DON) and the consideration that the BUN and creatinine may be even more elevated as the most recent results were 3 days old now, that it would be in the resident ' s best interest to send her to the hospital for acute kidney injury and likely feeding tube placement. According to the 12/27/19 discharge note, the resident was discharged at 2:00 p.m. by stretcher. The lab results report for labs collected on 12/24/19 revealed the resident ' s BUN level was 47mg/dl and creatinine was 3.67 mg/dl. According to the lab results for labs collected on 12/27/19 at 11:30 a.m. the BUN was 50mg/dl and creatinine was 3.21mg/dl. These results were reported at 4:45 p.m. According to the 12/27/19 hospital Health Summary Report, the resident was admitted to the hospital with [REDACTED]. The care plan, initiated 12/12/19, revealed the resident had a potential for nutritional risk. Interventions included: -Obtain and monitor lab and diagnostic work as ordered. Report results to the physician and follow up as indicated. III. Resident #1 [NAME] Resident #1 status Resident #1, age 75, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/25/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. B. Record review According to the (MONTH) 2020 CPO, a STAT order for labs was received on 1/8/19. It included a complete blood count (CBC) and complete metabolic profile (CMP), a flu swab, and blood cultures times two. According to the results of the labs collected on 1/8/2020, the resident had a critical high glucose level of 426 mg/dl (normal is 70-99 mg/dl). Review of the resident ' s record on 1/15/2020 revealed no documentation of the physician, resident or family being notified of the critical glucose level from the lab collected on 1/8/2020. The care plan, initiated 1/10/2020, revealed the resident had diabetes mellitus. She was currently on oral antidiabetics and a low concentrated sweets diet. Interventions included: -Monitor and report to the physician as needed signs and symptoms of hypo/[MEDICAL CONDITION] (low/high blood sugar); -Random finger stick as ordered by the physician; and -Additional lab work as ordered by the physician. IV. Resident #4 [NAME] Resident #4 status Resident #4, age 79, admitted [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/11/19 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. B. Record review According to the (MONTH) 2019 CPO, a STAT order for labs was received on 12/21/19 at 7:20 p.m. The order was for a complete blood count (CBC), complete metabolic panel (CMP). Review of the resident ' s record on 1/15/2020 revealed no documentation of the lab results being received and the abnormal results reported to the physician, resident and family. According to the lab report for the labs collected on 12/22/19, the results were not reviewed by the physician until 12/27/19 when she accessed the system for the results. The care plan, last revised 1/15/2020, revealed the resident was at risk for fluid imbalance and nutritional risk. Interventions included: -Obtain and monitor lab and diagnostic work as ordered. Report the results to the physician and follow up as indicated. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 1/14/2020 at 4:30 p.m. She said STAT labs meant to get the labs collected right away, which usually meant within four hours after the lab company had been called. She said the results should be called to the ordering physician as soon as they are received especially if the results are abnormal. She said the receiving of the labs and notifying the physician should be documented in a progress note. The director of nursing (DON) was interviewed on 1/15/2020 at 12:17 p.m. She said after she had been notified of the physician not being notified of Resident #2 ' s lab results, a full house audit had been done of all resident lab results for the last month and identified a problem with notification and documentation occurring. She said they had put an action plan in place for it and have had to adjust it twice since starting when they identified continuing problems.

Based on observations, interviews and record reviews, the facility failed to ensure one (#1) of three sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to honor Resident #1 ' s request to use either a bed pan or incontinent brief, and instead had the resident use the toilet. Furthermore, the resident had just returned to the facility from the hospital following a blood transfusion, and told the staff member she felt too weak to use the toilet. The staff member continued to transfer the resident but failed to use a second staff member or a gait belt when transferring the resident; therefore the resident fell when getting off of the toilet and suffered a broken right wrist and a broken left ankle. Findings include: I. Resident status Resident #1, age 70, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 9/13/19 minimum data set (MDS), the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She did not have any behaviors or rejections of care. She required two person physical assist with bed mobility, transfers and toilet use. II. Resident interview and observation Resident #1 was interviewed on 9/25/19 at 10:11 a.m. She said she had been at the facility since the first week of September, but much of her time in the facility had melded together since she began taking more pain pills following a fall. The resident said she had recently been assisted off the toilet by a certified nurse aide (CNA) and during the transfer she had fallen and broken her right wrist and left ankle. The resident said she was first admitted to the facility for a major infection that required a blood transfusion. The resident said she and her family had only planned on her being in the facility for a few weeks, so she could get the transfusion and then complete some therapy for strength training and return home with her son where she was going to live. The resident said, the morning of 9/13/19, she had gone to the hospital for the blood transfusion and when she returned to the facility from the transfusion, she was tired and weak and just wanted to get into her bed at the facility. The resident said she needed to use the restroom, and had been using her brief and or a bedpan. The resident said the CNA working with her insisted she use the toilet in her bathroom. The resident said she refused multiple times, stating she was too weak, and did not feel like her body could tolerate using the toilet. The resident said the CNA would not listen, and took her into the bathroom. The resident said she was able to get herself on the toilet and use the toilet by herself, but had the fall when she was trying to return to her wheelchair, without staff assistance. The resident said the CNA was alone during the transfer, and did not place a gait belt on her. The resident said she was able to stand and turn herself off of the toilet, but the next thing she knew, she was on the floor of the bathroom. She said her legs were underneath her and she knew she had broken something because of the way she felt. She said five staff members came into her bathroom, and slid her on a blanket to a larger area of her bathroom. Staff placed a sling under her, and using a mechanical lift, they were able to get her off of the floor and back into her bed. The resident said at home, she was not using the toilet, and had not used a toilet for years. She said when she used the bathroom, she had a condition that would make her extremely weak afterward, and the safest thing was to use a bedpan. She said she was using a bedpan prior to the fall in the facility, and this was the one and only time staff had insisted on taking her to the toilet. The resident said she was angry at the time of the fall because she had not wanted to use the toilet in the first place, and because she knew that her time at the facility was going to be much longer now with broken bones. The resident said she began experiencing pain all over her body, but especially in her right wrist and left ankle. The resident said it took over ten hours before she had xrays, and was transported to the local hospital. Observations revealed the resident had a cast on her right arm, and a cast on her lower left leg. III. Family interview Resident #1 son was interviewed on 9/30/19 at 9:42 a.m. He said his mother was very excited about going to the facility prior to her fall, but her outlook had since changed. He said she was no longer leaving her room for meals, she had increased pain, as well as increased anxiety about her ability to return home. The son said when his mother was first admitted to the facility, he had a conversation with facility staff during Grand Rounds regarding her preference to use a bedpan or to be changed in bed. He said his mother had a condition and following using the bathroom she became very weak, and was unable to move. He said a few years ago his mother had fallen in the bathroom, and after that she no longer used the toilet for safety reasons. The son said he had spoken with his mother after the fall, and she said CNA#2 insisted she use the toilet. The son said that was the only time his mother had used the toilet in the facility. The son said when his mother returned to the facility, both he and his mother had spoken to facility staff during the Tuesday grand rounds. The son said at that meeting both he and his mother requested that CNA #2 no longer work with his mother. The son said he requested any and all documentation related to his mother ' s fall, and upon review the information was inconsistent and inaccurate. The son said the facility had yet to provide any additional follow-up documentation regarding his mother ' s fall. IV. Staff interviews regarding Resident #1 transfer status and fall on 9/13/19. CNA #1 was interviewed on 9/25/19 at 1:20 p.m. She said she had worked with Resident #1 prior to her fall on 9/13/19. She said prior to the residents fall she had never taken the resident to the bathroom. She said the resident would either use a bedpan, or would call after she needed to be changed in her bed. The CNA said she was always with another CNA when she changed the resident due to the residents size, and to ensure the resident was safe at all times. A registered nurse (RN) #2 was interviewed on 9/25/19 at 1:27 p.m. She said if a resident had received a blood transfusion, she would want to make sure the resident was transferred in the safest way possible, which would mean the nurse first assessing the resident, and then using two CNAs to ensure both the resident and/or staff were not injured. CNA #2 was interviewed on 9/25/19 at 1:25 p.m. She said she was the CNA working with the resident the day of the fall. She said she assisted the resident to the bathroom following her blood transfusion appointment. The CNA said the resident just slid down and sat on the floor,'' as she was trying to hold the resident up by the gait belt. The CNA said the resident ' s legs were bent under her when she fell , and it took five staff members to slide the resident to the larger area of her bathroom, so they could use the mechanical lift to lift the resident off the floor. CNA #2 said she had changed the resident in bed that morning and gotten the resident into her electric wheelchair prior to her appointment with the assistance of another CN[NAME] The CNA said she did not know why she used help in the morning and not in the afternoon, but said she felt able to assist the resident on her own in the afternoon. The CNA said that was the first time she had taken the resident to the bathroom; up until that time, the resident used the bedpan or was changed in bed. The CNA said she thought the resident was a one person transfer because she had seen the therapy department working with the resident and only using one person. The CNA said she had not been trained on how to assist Resident #1 by any of the therapy staff. The CNA said she still worked on the hall where the resident resided, but she was no longer allowed to work with her, and she was unsure why. RN #1 was interviewed on 9/25/19 at 2:14 p.m. She said she was the nurse working the afternoon the resident had fallen. The RN said CNA#2 had told her the resident had slid down her wheelchair and fallen after she had used the bathroom. The RN said she completed an assessment following the fall, and the resident was complaining of wrist and ankle pain. The RN said the doctor was notified and ordered x-rays, but they were not ordered as stat (immediately). The RN said it did take several hours for the x-ray technician to arrive at the facility. The RN confirmed it did take approximately 10 hours from the time of the fall, until the resident was sent to the hospital for evaluation. The RN did confirm the resident had a blood transfusion the morning of the fall. The RN said she would think the resident might have increased weakness, and was probably tired from being out all morning as well as getting the transfusion. The RN said, if the resident was complaining of fatigue, she would want at least two CNAs transferring the resident to ensure the resident was transferred safely. V. Record review, progress notes related to Resident #1 9/13/19 fall. A general nurses note, completed on 9/15/19, with an effective date of 9/14/19, documented the following: Alerted by CNA that patient had been transferring with CNA assist from bathroom commode back into electric wheelchair and slid off chair of wheelchair, butt had not been completely on cushion enough total assessment completed .during initial assessment patient complained of right wrist pain, cold packs applied, [MEDICATION NAME] 50 mg (milligram), no abnormalities noted, no swelling, no redness .continued to check on patient who complained of right wrist pain and left ankle pain. A 9/17/19 social service readmission note documented the following: Patient readmit to (facility) from hospital with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Alert and oriented times 4 (answered four out of four questions correctly to determine cognitive status), independent decision making, communicates verbally, understood and understands. A 9/18/19 general nursing note, written by the ADON, reviewing the resident's fall documented the following: Review of fall 9/14/19: Witnessed fall with fracture noted to right distal ulnar shaft and left distal fibula. Resident was being assisted in the bathroom by CN[NAME] She was transferring from the bathroom toilet into her electric wheelchair and slid off of the wheelchair as her bottom had not been completely on cushion. Gait belt was in place and used. She states I fell . She was assisted off the floor using a hoyer lift. She complained of pain to her right wrist. Cold packs and [MEDICATION NAME] administered by a nurse. X-Rays were completed to right wrist and lower extremity which showed fractures. MD (medical doctor) was contacted and orders were given to send resident to the hospital for further evaluation. She returned on 9/16/19 with orders for NWB (non-weight-bearing) to LLE (left-lower-extremity) and WBAT (weight-bearing-as-tolerated) to RUE (right-upper-extremity). Writer spoke with DOR (director of rehabilitation) upon return to facility and DOR to implement increased transfer training on and off the toilet to/from electric wheelchair with therapy. She was also increased to a two assist transfer with nursing. A physician encounter note, dated 9/17/19, documented, in pertinent part: Chief complaint: f/u (follow up) right radial fracture; closed fracture of medial malleolus of left ankle brother (son) discussed the event of her falling, he and patient requesting CNA present at that time not be assigned to patient, ADON (assistant director of nursing) investigating. RN#1 and RN#2 were interviewed a second time on 9/25/19 at 4:45 p.m. Both said if a resident refused to use the toilet and wanted instead to use a bedpan or be changed in bed, they would first attempt to educate the resident. If the resident continued to refuse, both RNs stated that was the resident ' s choice and they would honor the resident ' s choice. VI. Staff interviews regarding the investigation of the fall The director of rehabilitation (DOR) was interviewed on 9/25/19 at approximately 1:30 p.m. He said when a resident was first admitted to the facility, the therapy department does a through chart review, which would include looking at hospital records and also talking with the resident to determine the safest way to transfer the resident. When Resident #1 was first evaluated by the therapy department on 9/9/19, the determination was made that she would be safest as a two person transfer. The DOR said he was unaware of any changes made to the residents transfer status and would need to review her therapy records to determine if and when any changes were made. The director of nursing (DON) and ADON were interviewed on 9/25/19 at 3:00 p.m. both stated they were unaware of the meaning of the scoring for the fall risks the facility completed for residents. They said Resident #1 scored a 16, they were unsure what the number was out of, or how the score was used. The ADON said it was more content based to determine the risk factors. The DON said Resident #1 did not have a fall care plan prior to the 9/13/19 fall. The ADON said Resident #1 was admitted to the facility for a [DIAGNOSES REDACTED]. The ADON said she was not sure when the resident became a one person physical transfer. The DON said the transfer status of all of the residents in the facility should be documented in the CNA task sheets, that are generated by the computer. The DON said according to the kardex (printed task sheets) for Resident #1, it was never documented if the resident was a one or two person transfer. The DON said any CNA should have received that information from the report given by the CNA working prior with the resident. The DON said she could see how it could be confusing to know what a resident ' s transfer status was and it was something the facility would look into. The ADON said she was not aware there was an issue with Resident #1 transfer, which resulted in the fall, until the resident had returned from the hospital on [DATE]. The ADON said when the resident returned, she stated she no longer wanted to work with the CNA who had done the transfer with her in the bathroom. The ADON said when she spoke with the resident regarding the fall, the resident continued to change her story. The ADON could not provide exactly what had changed in the residents' story, and said she would need to look into it. The ADON said she would need to bring in the documentation regarding why the resident no longer wanted the CNA working with her. She said she was unaware of the physician note from 9/17/19. The ADON was interviewed a second time on 9/25/10 at 3:25 p.m. She said the therapy department had changed the resident to a one person transfer on 9/11/19. The ADON was unable to provide any documentation regarding nursing being notified of the change in the residents transfer status. The ADON said the facility had begun a performance improvement plan (PIP), as of 9/25/19 (during the survey), ensuring resident transfer status is correct on CNA kardex sheets. The ADON said she educated the CNA who had done the transfer with Resident #1, and also removed the CNA from her care. The ADON also stated the note written regarding the resident fall had been written on 9/15/19, and stated the resident had fallen on 9/14/19. The ADON said the resident had actually fallen on 9/13/19, and the nurse responsible for the note had been disciplined regarding timely writing progress notes. The ADON said she was unaware of any medical doctor (MD) visit note that referenced Resident #1 concerns with the CNA taking care of her. The ADON said she was unaware of any comment regarding her looking into it. The nursing home administrator (NHA) was interviewed on 9/25/19 at approximately 4:30 p.m. She said when the investigation was completed, it was completed from the fall investigation standpoint. The NHA said the facility had investigated the fall, and determined CNA#2 had done the transfer correctly, but the facility did not look into why the resident was transferred to the toilet in the first place. VII. Facility follow-up On 9/25/19 at 5:00 p.m., the NHA said the facility had suspended CNA #2, and was going to begin a thorough investigation into Resident #1 ' s fall and and the residents concern regarding working with CNA #2.

Based on observations, record review and interview, 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. The failure affected 24 residents, who shared seven blood glucose meters, one on each of the seven medication carts which placed the facility in an immediate jeopardy situation. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. Findings include: I. Immediate Jeopardy [NAME] Findings of Immediate Jeopardy Blood glucose meter The facility had seven blood glucose meters, which were shared among 24 residents who required routine blood sugar checks. This included one resident who had a [DIAGNOSES REDACTED]. The facility's policy and procedure documented to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current standards of practice. Observations On 7/24/19 at 3:35 p.m. registered nurse (RN) # 1 was observed checking the blood glucose of a resident. She entered the resident's room with a plastic basket which contained a blood glucose meter, a bottle of blood glucose monitor strips, two alcohol pad wipes, and a single use lancet. She applied gloves, and cleaned the right index finger of the resident. She lanced the resident ' s index finger to draw blood, and applied the blood to the test strip located in the Evencare G2 blood glucose meter. The blood glucose level was 383. She said the blood glucose level was outside of the physician parameters and she would need to call the physician for insulin orders. She returned to the medication cart and placed the blood glucose meter in the top drawer on top of the disposable lancets and locked the cart. She did not clean the machine after use. On 7/24/19 at 3;55 p.m. licensed practical nurse (LPN) #1 was observed checking the blood glucose of a resident. She applied gloves, and cleaned the left index finger tip of the resident. She lanced the resident ' s finger to draw blood, and applied the blood to the test strip located in the Evencare G2 blood glucose meter. The blood glucose level was 137. She wiped the front of the meter with a wipe from a container labeled Super Sani-cloth and put the glucometer in the medication cart on top of the disposable lancets in the top drawer. The Super Sani cloth container was observed and documented a two minute dwell time (the amount of time the surface must remain visibly wet with the cleaning agent in order to be effective) for the product to be effective. Interviews LPN # 1 was interviewed on 7/24/19 at 4:23 p.m. She said she used a Evencare blood glucose machine and pulled it from the top drawer of her cart where it was sitting on top of disposable finger stick lancets. She said she used the purple top wipes to clean the meter. She said it dried instantly therefore there was no dwell time. RN #2 was interviewed on 7/24/19 at 4:09 p.m. regarding cleaning and disinfecting blood glucose meters. She said she cleaned the glucometer on the front and back with a Super Sani-cloth. She said there was no specific dwell time and the product dried quickly. LPN # 2 was interviewed on 7/24/19 at 4:35 p.m. Her blood glucose meter was sitting on the medication cart in a white plastic basket. She said she cleaned the blood glucose meter with alcohol wipes and that the night shift cleaned it and calibrated it. She did not have access to the manufacturer ' s instructions on her cart. RN # 3 was interviewed on 7/24/19 at 4:40 p.m. She said ran out of disinfecting wipes and had not had any since this morning. She said she borrowed MadaCide-FDW-Plus wipes from another cart. She said they dry quickly and then let it sit for 15 minutes. The staff development coordinator/infection control preventionist (SDC/ ICP) was interviewed on 7/24/19 at 4:51 p.m. He said training on diabetes for the licensed nurses, was scheduled for (MONTH) 2019. He further said if an issue came up with a nurse he would provide training immediately. A list of licensed nurses trained on cleaning blood glucose machines was requested, no documents were received. The director of nursing (DON) was interviewed on 7/24/19 at 4:25 p.m. The DON said the blood glucose machine should be put away clean after each use. She did not know what product the nurses were supposed to clean and disinfect the blood glucose meter with. She said the residents did not have their own blood glucose meters, they shared one glucometer on each medication cart. She further said she just put out these new blood glucose meters on Monday, however, she did not provide any training on how to clean the meters to any of the nurses. She did not know if they had access to the manufacturer ' s instructions. On 7/24/19 at 4:39 p.m., manufacturer ' s instructions for the use and cleaning of the Evencare G2 blood glucose meter were not located on any of the medication carts. The DON stated she might have a copy in her office. There were seven medication carts observed, and each had one blood glucose meter. There were 24 residents sharing the blood glucose meters, including one resident who had a known [DIAGNOSES REDACTED]. -The West 2 medication cart had one blood glucose meter which was shared by nine different residents. -West 1 medication cart had one blood glucose meter shared by three residents. -East 1 A medication cart had one blood glucose meter shared by four residents. -East 1 B medication cart had one blood glucose meter shared by four residents. -East 2A medication cart had one resident. -East 2B medication cart had one resident. -The central medication cart had two residents One of those residents had a known [DIAGNOSES REDACTED]. Facility policy and procedure The Infection Control Monitoring policy, dated 9/2018, was provided by the nursing home administrator (NHA) on 7/22/19 at 9:00 a.m. The policy documented in pertinent part that nursing care equipment used for mulitple residents was to be properly cleaned and disinfected. B. Facility notice of Immediate Jeopardy On 7/24/19 at 5:03 p.m. the NHA was notified of the Immediate Jeopardy under F880, infection prevention and control. On 7/24/19 at 5:54 p.m. the facility submitted documentation indicating the nurse managers would ensure all licensed nurses scheduled that night, and day shifts for the next day had been trained on the proper cleaning of the blood glucose meters per the manufacturer's instructions. The training was reviewed on 7/24/19 and included in pertinent part, the blood glucose machines should be sanitized between each resident use. Nurses are to ensure the blood glucose meters are sanitized with the purple top sanitary wipes immediately after each use, and to keep the blood glucose meter wrapped in the wipe for a two minute period. The DON was interviewed again on 7/24/19 at 5:58 p.m. She said there was no record of any training for diabetes or using and disinfecting blood glucose meters for the licensed nurse. The nurse consultant (NC) was interviewed on 7/25/19 at 12:57 p.m. She said she had developed a competency checklist for the blood glucose meters on 7/24/19. The competency checklist was reviewed and included in pertinent part that the licensed nurse will clean and understand maintenance of glucometer per manufacturer. It further documented to use the purple top Super Sani-Cloth Germicidal Wipes. C. Facility plan to remove Immediate Jeopardy On 7/25/19 at 1:36 p.m., the NHA provided a plan to remove the Immediate Jeopardy. The plan read: In response to the above IJ allegation the facility has taken immediate action to ensure the safety of all residents. That action includes the following: 1. Education immediately initiated with all licensed nurses working at this time regarding Glucometer Cleaning policy on 7/24/19 between the hours of 5:15 p.m.-8:15 p.m. by Nurse Managers. At this time all glucometers were cleaned prior to any further patient use. 2. On 7/24/19 between the hours of 5:45 p.m.-7:00 p.m. the nurse managers educated with return demonstration ALL licensed nurses that work the 6p-6a (overnight) shift on this date were educated with return demonstration prior to providing any care. On 7/25/19 nurses reporting for duty at 6 a.m. will all be educated by nurse managers prior to providing any care. 3. The policy on cleaning glucometers was printed and given to all nurses at the time of their training on 7/24/19 and 7/25/19 for reference and comprehension. 4. All nurses working on 7/25/19 received training and education on appropriate use of wipes along with storage and [MEDICATION NAME] location prior to performing any blood glucose checks. Nurse managers provided this education. 5. Return demonstration was completed on 7/24/19 and 7/25/19 with all licensed nursing staff regarding how to clean glucometers, per manufacturer ' s recommendations, including dwell time. This includes: a.Always ensure that blood glucose meters are cleaned before and after resident use with purple top Sani wipes with a two minute dwell time. 6. DON/designee to complete three random observations a week, until substantial compliance is achieved, to ensure that nursing staff know how to clean glucometers between residents. Identified concerns to be addressed with staff immediately. 7. NHA reviewed policy and DON was in-serviced on 7/24/19 on the policy to sanitize glucometers. 8. Lancets that contaminated glucometer was placed on top of were disposed of immediately on 7/24/19. Clean lancets are stored in the medication cart. 9. Individual Medline Evencare G2 glucometers have been ordered 7/25/19 and will be delivered at approximately 6 p.m. on 7/25/19 for every diabetic resident. Glucometers will have resident ' s name on them and will be stored in the medication carts in individual plastic bags with resident ' s name on it. 10. Upon discharge, the resident ' s glucometer will be sent home with the resident. 11. All new admissions will receive a new glucometer provided by facility for individual use beginning 7/25/19. 12. One patient identified in the facility with a [DIAGNOSES REDACTED]. This patient received her own, new glucometer which is stored in a plastic bag with her name on it in the medication cart in the am of 7/25/19. 13. Manufacturer ' s Operator Manual with instructions for Evencare G2 was put in the charge nurse reference book located in each nurse ' s station on 7/25/19. D. Removal of Immediate Jeopardy The facility's plan to remove Immediate Jeopardy was accepted and the Immediate Jeopardy was lifted on 7/25/19 at 1:36 p.m. Record review and observations revealed the facility had implemented their policy and procedure for blood glucose meter cleaning. They purchased new blood glucose meters for each resident. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice. [NAME] Blood glucose meters care and facility expectations. 1. Professional standards According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (6/2019): The CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_ on 6/20/19, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. 2. Manufacturer instructions Manualslib, Medline Evencare G2 user manual, retrieved from: https://www.manualslib.com/products/Medline-Evencare-G2- 72.html.Cleaning allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter. Cleaning and Disinfecting Your Meter: To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipes directions for use. Wipe meter dry or allow to air dry. Dispatch®( EPA Registration Number: -8) Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: -10- ) Clorox Healthcare (EPA Registration Number: -12) Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: -1) Wipe meter dry or allow to air dry. Wash hands with soap and water and dry thoroughly. Other EPA Registered wipes may be used for disinfecting the EvenCare G2 system, however, these wipes have not been validated and could affect the performance of your meter. B. Facility cleaning product after immediate jeopardy The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices after the immediate jeopardy. The wipe required a two minute dwell time and was documented to be effective against non-[MEDICAL CONDITION], bacteria, [MEDICAL CONDITION], fungi, multidrug resistant organisms and blood borne pathogens. The nurse consultant was interviewed on 7/25/19 at approximately 11:00 a.m. The NC said new glucometers were purchased for each resident who required a blood sugar monitoring. The glucometer would then be given to the resident upon discharge.