Every finding on record at Walsh Healthcare Center

Based on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation. Specifically, the facility failed to ensure the exhaust fans in the shower room and resident bathrooms. Findings include:I. Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021, retrieved on 10/21/25 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. II. Observations On 10/16/25 at 11:00 a.m., during a walk through of the shower rooms and resident bathrooms, the following was observed:The resident shower room had four vents. There was no air flow coming from the ventilation fans in the shower room. The resident bathroom attached to room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] had no air flow coming from the ventilation fans. III. Staff interview and observationsThe maintenance director (MTD) was interviewed on 10/16/25 at 11:26 a m. while touring the shower rooms.The MTD said the facility used a mechanical ventilation system and if the belt on the motor drive was not functioning properly, this would cause a failure in air flow though the vents. The MTD said the ventilation system in the bathrooms and shower room should be checked daily by housekeeping and cleaned monthly. He said it was important to have proper air flow in the vents to keep moisture and contaminants out of the air. After inspecting the shower room, resident bathroom [ROOM NUMBER], resident bathroom [ROOM NUMBER] and resident bathroom [ROOM NUMBER], the MTD said there was not any air flow.

Based on staff interview and record review the facility failed to electronically submit complete and accurate direct care staffing information.Specifically, the facility failed to submit to the Center for Medicare and Medicaid Services (CMS) the Payroll Based Journal (PBJ) for the quarter (4/1/25 thru 6/30/25) due to staff errors. Findings include:I. Facility policy and procedureThe Payroll Based Journal policy, implemented 1/1/25, was provided by the nursing home administrator (NHA) on 10/16/25 at 10:27 a.m. It read in pertinent part, It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.II. Record reviewThe CMS submission report, dated 10/9/25, revealed the facility failed to submit the required data for the quarter. III. Staff interviewThe human resource director (HRD) was interviewed on 10/16/25 at 1:15 p.m. The HRD said the facility previously had used a third party to submit the PBJ. She said she was responsible for submitting the data and was having issues submitting the report. She said she was unable to submit the report for all three quarters prior to the deadline.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances identified during resident council. Findings include:I. Facility policy and procedureThe Resident and Family Grievance policy, revised 10/1/25, was provided by the nursing home administrator (NHA) on 10/14/25. It read in pertinent part, In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:The date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance and the date the written decision was issuedII. Resident group interviewFive alert and oriented residents (#4, #2, #16, #17 and #19) who regularly attended the resident council meetings were interviewed on 10/15/25 at 9:16 a.m. The residents were identified as alert and oriented through facility and assessment.The group of residents said the facility did not follow up on grievances brought up in the resident council meetings. The residents said they did not know how to file a grievance.Resident #17 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting, but the manager did not complete a grievance form. Resident #19 said if it was an individual grievance, the department head would follow-up with the individual resident. Resident #19 said if it was a group grievance a resolution was not consistently brought back to the next resident council meeting by the facility. Resident #17 said she has reported missing clothing before and was told by the staff that she would get the clothes back eventually. She said the facility was not good about completing formal grievance forms with the residents. III. Record reviewA review of a resident council meeting minutes, dated 6/30/25, revealed group grievances concerning needing more toilet tissue in shared resident bathrooms, water not being passed to residents on the weekends, the palatability of chicken and missing clothing from laundry. A review of the resident council meeting minutes, dated 7/28/25, revealed group grievances concerning some of the residents' rooms being too hot. -There was no documentation that indicated the resolutions for June 2025 grievances with the resident council. A review of the resident council meeting minutes, dated 8/25/25, revealed group grievances concerning some resident rooms being too hot and some resident rooms being too cold. -There was no documentation that indicated the resolutions for July 2025 grievances with the resident council. A review of the resident council meeting minutes, dated 9/29/25, revealed group grievances concerning needing more support staff on weekends to cover certified nurse aide (CNA) call offs. -There was no documentation that indicated the resolutions for August 2025 with the resident council. A review of the grievance forms dated 7/14/25 through 9/15/25 revealed:A grievance form, dated 7/15/25, revealed a resident had a concern for a missing shirt and the item was found in the laundry room. A grievance form, dated 7/28/25, revealed a resident had a regarding the room temperature being too hot. The resident was offered a fan and declined it. The maintenance director checked all the air conditioning units in the resident rooms to determine functionality. -However, there were no other grievance forms related to the concerns brought up in the resident council meetings in June 2025, July 2025, August 2025 and November 2025. IV. Staff interviewsA frequent visitor was interviewed on 10/15/25 at 10:14 a.m. She said she attended the facility resident council meetings. She said the facility staff did not go over resolutions of grievances during resident council and she did not know if the residents knew how to file grievances. The activities director (AD) was interviewed on 10/16/25 at 11:29 a.m. She said she was responsible for managing grievances. The AD said if a concern was brought up in the meeting and was isolated to one resident, the concern form was written as an individual grievance. She said if the concern brought up pertained to more than one resident, it would be written as a group concern. She said she was not aware a grievance should be written for every concern brought up during resident council and followed through the same way as an individual grievance.

Based on observations, record review, and interviews, the facility failed to ensure that its medication error rate was not greater than five percent (%).Specifically, the facility had a medication error rate of 48%, which was 12 errors out of 25 total opportunities for error. Findings include:I. Facility policy and procedureThe Medication Administration Policy, revised 6/17/25, was provided by the nursing home administrator (NHA) on 10/15/25 at 3:24 p.m. It revealed in pertinent part, Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and the right documentation.Administer within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. Medication administration timing twice a day at 8:00 a.m. and 6:00 p.m.II. ObservationsOn 10/14/25 at 1:45 p.m. licensed practical nurse (LPN) #1 was dispensing medications to Resident #6. LPN #1 prepared the following medications:loratadine (allergy medication) 10 milligrams (mg); One package of Arginaid (supplement); Metoprolol 12.5 mg; Colon Health (probiotic supplement) 1 capsule; Famotidine (anti-acid) 20 mg; TheraLITH XR (supplement) 1 tablet; Duloxetine (antianxiety) 90 mg; Oxybutynin (overactive bladder) 5 mg; Pantoprazole (reduce stomach acid) 40 mg; Baclofen (muscle relaxant) 10 mg; Trelegy inhaler saline nasal mist; Pataday eye drops; and,Iron 65 mg.At 1:45 p.m. LPN #1 gave the medicine cup with pills to Resident #6 and gave him water to drink. Resident #6 consumed the medications, and the nasal spray, inhaler and eye drops were administered. -LPN #1 administered the medications five hours after they were scheduled to be administered. -Resident #6 did not have a physician's order for iron (see record review below). III. Record reviewReview of Resident #6's October 2025 computerized physician orders (CPO) revealed the resident did not have a physician's order for Iron. Further review of Resident #6's EMR revealed the medications that were administered at 1:45 p.m., were ordered for 9:00 a.m. administration.Review of Resident #6's electronic medical record (EMR) did not reveal documentation that the physician was notified that the resident was administered his medication five hours late or that she was administered iron that was not prescribed. IV. Staff interviewsLPN #1 was interviewed on 10/14/25 at 11:00 a.m.LPN #1 said Resident #6 was asleep, so she would administer his medications later. She said he went to bed at 2:30 a.m. last night.LPN #2 was interviewed on 10/15/25 at 9:35 a.m. LPN #2 said Resident #6 did not have a physician's order for iron. LPN #2 said if a resident's medications were going to be administered late, the physician needed to be notified prior to the administration of the medication. She said the physician would then give instructions on administering the late medications. LPN #2 said she would write a progress note regarding the late medications and if the physician gave any new orders. The medical director (MD) was interviewed on 10/15/25 at 2:30 p.m. The MD said a medication should not be administered without a physician's order. The MD said Resident #6 was not ordered an iron supplement.LPN #2 was interviewed on 10/16/25 at 10:40 a.m. LPN #2 said when a medication was ordered for twice a day, it should be given 12 hours apart. She said if the medication was scheduled for 8:00 a.m., the second dose should be scheduled for 8:00 p.m. LPN #2 said some residents' medications were scheduled at 8:00 a.m. and then at 6:00 p.m. LPN #2 said the assistant director of nursing (ADON) and the director of nursing (DON) transcribed the physicians' orders into the MAR. She said the ADON and the DON decided what time the medication would be administered. LPN #2 said medications could be administered one hour prior and one hour after the scheduled administration time. LPN #2 said when she administered Resident #6's medications, she would wake him up and he would take the medications with no concerns. The DON was interviewed on 10/16/25 at 11:20 a.m. The DON said medications should be administered 30 minutes before or after the scheduled time. The DON said she was aware that LPN #1 dispensed medication that was not ordered and that the physician was notified. The DON said an incident report was initiated for the medication error. The DON said the nurse (LPN #1) was educated to call the physician when the medication was late, assure a physician's order was in place before administering a medication and document the interaction with the physician. The DON said the care team was in the process of establishing a more accurate medication time for Resident #6 since he liked to stay awake half of the night and sleep in till afternoon.

Based on observations, record review and interviews, the facility failed to ensure one (#7) of three residents reviewed received food and fluids prepared in a form designed to meet his or her needs out of 16 sample residents. Specifically, the facility failed to ensure Residents #7 was served a mechanically altered diet per physician's orders. Findings include:I. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and progressive neurological disorder (a condition that gradually damages and destroys parts of the nervous system). The 9/29/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. She required set up assistance for meals. The MDS assessment indicated the resident had signs and symptoms of a swallowing disorder to include coughing or choking during meals and required a mechanically altered diet. B. ObservationsDuring a continuous observation on 10/13/25, beginning at 12:00 p.m. and ending at 1:29 p.m., the following was observed:At 12:55 p.m., Resident #7 was in the dining room for lunch. The resident was served one inch sized cut up pieces of chicken breast with cream of chicken soap over the top, baked rice, whole broccoli florets, a dinner roll and a berry cobbler. Between 12:55 p.m. and 1:15 p.m. Resident #7 put food into her mouth five times before she had completed chewing and swallowing the previous bite. The resident was observed eating her meal without staff supervision or intervention. The resident's meal ticket documented she was on a ground diet. During a continuous observation on 10/14/25, beginning at 12:00 p.m. and ending at 1:30 p.m., the following was observed:At 12:30 p.m., Resident #7 was in the dining room during lunch. The resident was served a parmesan breaded pork chop, candied yams, a dinner roll and cherry chocolate cake. When the food was served, the pork chop was whole. A nursing staff member cut the pork into one inch pieces for the resident, however, some pieces had not been cut all the way through and were attached to other pieces. At 1:12 p.m. Resident #7 put two pieces of cut pork chop into her mouth that were still connected. The resident continued to chew the pork until 1:16 p.m when she put a spoonful of candied yams in her mouth before finishing chewing the pork and swallowing it. At 1:18 p.m. the resident put another spoonful of candied yams in her mouth before finishing chewing the pork and swallowing it. Between 1:03 p.m. and 1:30 p.m. the resident put food into her mouth six times before she had completed chewing and swallowing the previous bite. The resident was observed eating her meal without staff supervision or intervention. The resident's meal ticket documented she was on a ground diet.During a continuous observation on 10/15/25, beginning at 12:00 p.m. and ending at 1:30 p.m., the following was observed:At 12:15 p.m., Resident #7 was in the dining room during lunch. The resident was served a whole, uncut piece of salisbury steak, mashed potatoes and carrots. Between 12:15 p.m. and 1:15 p.m. Resident #7 put food into her mouth five times before she had completed chewing and swallowing the previous bite. The resident was eating her meal without staff supervision or intervention. The resident's meal ticket documented she was on a ground diet. At approximately 1:35 p.m., the dietary aide (DA) #2 prepared two test trays, one was requested to be mechanically soft and the other a regular texture. The meal was salisbury steak, mashed potatoes, and carrots. The two plates consisted of the same food textures. He said both plates were the same. On 10/16/25 at 1:25 p.m. Resident #7 was in the dining room during lunch eating a plate including fried chicken with bones. The resident's meal ticket documented she was on a ground diet. C. Record reviewThe October 2025 CPO revealed the following physician's orders:ST (speech therapist) two times a week for ninety days for oropharyngeal dysphagia (swallowing problems caused by impaired muscle problems in the mouth or throat), ordered on 7/28/25. Regular diet, mechanical soft texture, nectar thick liquid consistency, ordered on 9/10/25. Resident #7's nutrition care plan, revised 9/30/25, revealed the resident had nutritional deficits related to swallowing assessment results showing oropharyngeal dysphagia. Interventions included providing and serving the diet as ordered and monitoring for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, or pocketing food in the mouth. A review of Resident #7's electronic medical record (EMR) from 7/30/25 to 10/3/25 revealed the following progress notes:A dietary progress note, dated 7/30/25, revealed Resident #7 requested that her meat be ground due to her missing her lower teeth. The resident ate s with supervision and set-up help in the dining room.A quarterly nutrition progress note, dated 10/3/25, revealed the resident coughed during meals and had trouble swallowing at times. The resident received a mechanical soft texture die and nectar thick liquid consistency.A swallowing evaluation, dated 7/26/25, revealed Resident #7 had been evaluated due to coughing and choking during meals. The resident had decreased safety awareness during eating and required an altered diet texture for safety. A speech therapy note 10/8/25, revealed Resident #7 took longer than normal to move foods and liquids from the front of her mouth to then the back of her mouth to swallow, she required the size of the food presented to be smaller than a regular diet indicated, and showed excessive or prolonged chewing before she was able to swallow food. During speech therapy sessions, Resident #7 coughed while eating when the food was not mechanically altered and had to excessively chew the food before swallowing. It was recommended that Resident #7 take sips of fluid in between bites to promote taking a break in between and be provided minimal cueing to remind her to swallow before taking the next bite. A review of the menu for the week of 10/13/25 included instructions for modifying a diet to mechanical soft that included:On 10/13/25 the menu revealed the chicken should have been cut into one eighth of an inch pieces, the broccoli should have been cut into one eighth of an inch pieces, the dinner roll should have been moistened and cut into bite size pieces and the cobbler should have been softened with added milk, cut into one eighth of an inch pieces and without crumble topping. On 10/14/25 the menu revealed the chicken should have been cut into one eight of an inch pieces with a sauce to moisten and the dinner roll should have been moistened and cut into bite size pieces.On 10/15/25 the menu revealed the Salisbury steak should have been cut into one eighth of an inch pieces with a gravy sauce to moisten and the dinner roll should have been moistened and cut into bite size pieces.II. Staff interviewsDietary aide (DA) #2 was interviewed on 10/15/25 at 12:15 p.m. while preparing lunch. He said he had been trained as a dietary aide, dishwasher and cook. DA #2 said if a resident had a special diet, there were tickets on the wall indicating what diet the resident required. DA #2 showed the puree lunch meals. He said he was not able to describe what mechanically altered or ground, entailed. Certified nurse aide (CNA) #2 was interviewed on 10/15/25 at 1:38 p.m. CNA #2 said the staff did not check the meal tickets for diet orders before passing the trays to the residents. She said Resident #7 ate a regular diet, with no altered texture. -However, record review revealed Resident #7 was prescribed a mechanically altered diet (See record review above).The dietary supervisor (DS) was interviewed on 10/15/25 at 2:00 p.m. The DS said mechanical soft diets should be ground or cut into small pieces. She said she was not sure how the kitchen staff ensured the food was one eighth of an inch. She said each menu item had a recipe and at the bottom of the recipe were the instructions for how to alter the diet to mechanical soft or puree. The DS said she would expect the mechanical food items to be ground in the blender and then served to the resident. She said she cross trained all of her dietary staff how to also cook and showed them where to find the preparation on the menu to alter a diet texture. She said she had not done documented training with the dietary staff on different diet textures. The registered dietitian (RD) was interviewed on 10/15/25 at 3:50 p.m. He said it was important to follow the diet orders for the safety of the residents and to prevent choking or aspirating on food. He said he had not done documented training with the dietary staff on different diet textures. The director of nursing (DON) was interviewed on 10/16/25 at 1:13 p.m. She said if the facility noticed a resident having difficulty with a diet, the facility would involve the physician and request an order for a speech evaluation if necessary. The DON said once a diet order had been changed to an altered texture, like mechanical soft, the diet was changed in the resident's EMR and care plan. She said she expected the CNA's to check the meal tickets before serving the meal to the residents. The DON said that if a resident was not getting their correct diet, there could be aspiration or death.

Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#2 and #9) of three residents out of 16 sample residents.Specifically, the facility failed to:-Ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #9; and,-Ensure a system was in place to monitor Resident #2's prophylactic antibiotic use. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix B, 9/10/25, was retrieved on 10/20/25 from https://www.cdc.gov/antibiotic-use/media/pdfs/Consult-pharm-11by17poster-Urinary-Tract-P.pd.Antibiotics are frequently prescribed for prolonged duration for the prevention of infection or prophylaxis in nursing homes. While antibiotic prophylaxis may reduce recurrent UTIs (urinary tract infections) in specific populations, there is no clear evidence on prevention of recurrent UTIs among nursing home residents with asymptomatic bacteriuria. Furthermore, antibiotic use carries the risk of harm to residents, including adverse drug events and increased antibiotic resistance, which argue against the use of prolonged antibiotic therapy in nursing home residents.Identify residents on prolonged antibiotic therapy for the prevention of recurrent UTI. Discuss the indications, rationale, and planned duration of prolonged antibiotic therapy with healthcare professionals to ensure that the benefits outweigh the risk of adverse drug events.II. Facility policy and procedureThe Antibiotic Stewardship program policy and procedure, revised 6/17/25, was provided by the nursing home administrator (NHA) on 10/15/25 at 3:24 p.m. It revealed in pertinent part, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The medical director (MD) sets the standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics, oversees adherence to antibiotic prescribing practices, and reviews antibiotic use data and ensures best practices are followed.The director of nursing (DON) establish standards for nursing staff to assess, monitor and communicate changes in a resident's condition that could impact the need for antibiotics, use their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate, and educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use. The infection preventionist (IP) utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics.The program includes monitoring response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (antibiotic time-out). Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents, and families. -The policy did not address long term (prophylactic) antibiotics.III. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, cellulitis of the right finger and peripheral vascular disease (a disorder of the blood vessels). The 7/29/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. She was dependent on staff for most of her activities of daily living (ADLs). B. Record reviewReview of the September 2025 CPO revealed the following physician's order:Cephalexin (antibiotic) oral tablet 500 mg (milligrams), give one tablet by mouth two times a day related to cellulitis of the right finger for seven days, ordered 9/19/25. The 9/19/25 daily progress note documented Resident #9 had redness and swelling to her right pointer finger. The nurse practitioner (NP) ordered an antibiotic for seven days. Review of the October 2025 CPO revealed the following physician's order:Doxycycline Hyclate (antibiotic) oral tablet 100 mg, give one tablet by mouth two times a day related to cellulitis of the right finger for 10 days, ordered 10/2/25.The 10/2/25 daily progress note documented Resident #9's right finger was getting red and swollen again. The NP ordered a second antibiotic (Doxycycline) for ten days. Bactrim DS (antibiotic) oral tablet 800-160 mg, give one tablet by mouth two times a day related to cellulitis of the right finger for seven days, ordered 10/13/25.The 10/12/25 daily progress note documented Resident #9's affected finger was pinkish in color at the tip only. The 10/13/25 daily progress note documented the NP ordered a third antibiotic (Bactrim DS), epsom salt soaks to the right index finger two times a day until the infection resolved and a culture of the right index finger. Amoxicillin (antibiotic) oral capsule 500 mg, give one capsule by mouth two times a day related to cellulitis of the right finger for seven days, ordered 10/14/25.The 10/14/25 daily progress note documented the NP discontinued the Bactrim DS and started Resident #9 on Amoxicillin after the culture results were reviewed. -However, there was no documentation in the resident's electronic medical record (EMR) to indicate a culture and sensitivity (a laboratory test which identifies bacteria type and what antibiotics are best used to effectively treat the infection) was completed prior to prescribing the first three antibiotics (Cephalexin, doxycycline and Bactrim). IV. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included urinary tract infection, peripheral vascular disease and hydronephrosis (obstruction to urine flow).The 8/11/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS of nine out of 15. She was dependent on staff for toileting hygiene and was always incontinent of urine. She received an antibiotic. B. Record reviewReview of the October 2025 CPO revealed the following physician's order:Cefadroxil (antibiotic) oral capsule 500 mg, give one capsule by mouth one time a day related to urinary tract infection, ordered 6/13/23. -Review of Resident #2's EMR did not reveal documentation that the facility was monitoring Resident #2 for adverse reactions and the effectiveness of the prophylaxis antibiotic or justification for the continued use of the prophylactic antibiotic. -Review of Resident #2's comprehensive care plan revealed the facility failed to document a care plan focus to address the need for long-term use of an antibiotic.V. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 10/15/25 at 10:51 a.m. LPN #2 said if a resident was having signs and symptoms of an infection she would call the provider with the findings. She said Resident #9's finger was red and swollen with no pain or drainage. She said her finger started getting better when she was prescribed the first antibiotic but then started getting worse again. She said Resident #9 was then started on a different antibiotic. She said when Resident #9's finger continued to be red and swollen, the NP started her on a third antibiotic and ordered a wound culture. She said when the culture results were reviewed Resident #9 was started on the fourth antibiotic. She said the facility did not use a criteria to determine if a resident needed to be treated with an antibiotic. She said she did not know if a care plan was needed for the antibiotic use. LPN #2 said Resident #2's long term antibiotic was prescribed by a urologist (specialist in urinary organs) and should have been monitored for adverse reactions and effectiveness. She said she did not know how often a long term antibiotic needed to be reassessed for continued use. The MD was interviewed on 10/15/25 at 2:32 p.m. The MD said she was not aware the facility had a policy to use a criteria to help diagnose infections. She said she had never heard of the McGeer criteria and left it up to the NP's to assess the resident and identify the need for an antibiotic. The MD said said Resident #9 had gotten a manicure which resulted in a paronychia (an infection in the tissue that borders the side of the nail). She said the treatment for a paronychia was to soak the finger and a topical steroid. She said the infection did not require the use of antibiotics. She said a culture should have been collected prior to the use of an antibiotic. She said since Resident #9 had already received three different antibiotics, the culture results would not be accurate. The MD said Resident #2 was prescribed the long term antibiotic by her previous urologist. She said Resident #2 should see a urologist at least once a year to assess for continued use of the antibiotic. She said as far as she knew Resident #2 would be on the antibiotic indefinitely. The NP was interviewed on 10/15/23 at 2:44 p.m. The NP said she prescribed the initial antibiotic for Resident #9. She said when the first antibiotic was not effective she prescribed a second antibiotic. She said she was on vacation when the third antibiotic was ordered. She said when she returned from vacation she ordered a culture of the index finger and when the results were received she prescribed the fourth antibiotic. She said the culture should have been ordered prior to the use of an antibiotic. She said she had never heard of the McGeer criteria for diagnosis of infection and was not aware the facility followed any certain criteria when diagnosing an infection. She said she tried not to use long term antibiotics. The NP said said Resident #9 was prescribed the long term antibiotic by a urologist in 2023. She said as far as she knew Resident #9 had not had a follow up appointment with a urologist for the continued use of the long term antibiotic. She said the facility would have to add the use of long term antibiotics to the policy. She said the resident should have been monitored for adverse reactions and effectiveness as well as a follow up with a urologist for the continued use of the antibiotic. The IP was interviewed on 10/16/25 at 2:09 p.m. The IP said the facility followed the McGeer criteria to identify infections that may need to be treated with an antibiotic. She said the nurse called the provider and the facility followed the providers orders. She said the facility infection control plan was a team approach with herself, the providers, the pharmacist and the NHA. She said was not aware that the MD and the NP were not familiar with the Mcgeer criteria and a meeting was set up for the following day for training on the infection control program. She said a culture should have been ordered prior to the use of an antibiotic for Resident #9. She said the facility infection control policy did not address the use of long term antibiotics and a care plan with monitoring should have been initiated for Resident #2. She said the facility had not been following the facility criteria. She said going forward the facility would start at the beginning and start with the antibiotic tool kit and review it with the MD.

Based on observations and interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in the kitchen. Specifically, the facility failed to ensure: -Perishable foods were discarded after the date of expiration; and, -Perishable foods were labeled and dated. Findings include: I. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective [DATE]) retrieved [DATE] from https://cdphe.colorado.gov/environment/food-regulations it read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. II. Observation The initial kitchen tour conducted on [DATE] at 8:30 a.m. revealed in the walk in refrigerator five containers of spinach with an expiration date of [DATE] on the package, three gallons of milk with an expiration date of [DATE] and a gallon of milk with an expiration date of [DATE]. There was an unmarked zip lock bag on the shelf contained a salad mix which showed liquid residue in the bag and had changed color. Three bags of grapes were on another shelf which had started to show a white film on the exterior of most of the grapes. Items of produce such as lettuce, tomatoes, broccoli, onions, apples and bell peppers had been located which showed bruising and black spotting. Additional items of produce partially cut up were located on a shelf, each wrapped in plastic wrap, unmarked. Another tour of the walk-in refrigerator was conducted on [DATE] at 8:15 a.m. No expired or spoiled food had been removed. III. Staff interview The cook (CK) was interviewed on [DATE] at 9:00 a.m. He said the DM was responsible for cleaning out the walk-in refrigerator. When items such as produce were cut and partially used, the remaining portion should be wrapped and dated. The DM was interviewed on [DATE] at 8:36 a.m. The DM was shown the items in the walk-in refrigerator. She said food that had reached the expiration date on the package should be removed the same day or by the following day. She said the observed expired and spoiled food items should have been removed and items in plastic wrap should be dated and labeled. The DM was interviewed again on [DATE] at 2:15 p.m. She said she had cleaned the walk-in refrigerator earlier the same day (after being identified during the survey). -However, observation revealed two containers of spinach with an expiration date of [DATE] remained and two bags of grapes with white fuzziness remained. The DM removed the items.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews for four of four certified nurse aides (CNAs) reviewed. Specifically, the facility did not provide inservice education based on the outcome of the performance reviews for CNA #1, #2, #3 and #4. Findings include: I. Record review CNA #1 (hired 5/4/11) had a performance review on 5/31/23. CNA #2 (hired 2/4/16) had a performance review on 3/15/23 CNA #3 (hired 6/1/2020) had a performance review on 1/16/24. CNA #4 (hired 9/20/21) had a performance review on 10/1/23. -The CNAs did not have an inservice education plans based on the outcome of the reviews. II. Interview The director of nursing (DON) was interviewed on 1/23/24 at 3:10 p.m. She said the identified aides had completed annual training, however, she did not know the aides needed to have inservice education plans developed from the annual performance review. She said she would ensure going forward the aides had a plan in place to ensure safe care was provided to the residents.

Based on interviews and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure resident food was palatable in taste, temperature, texture and appearance. Findings include: I. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #8 was interviewed on 1/22/24 at 9:15 a.m. He said the food at the facility was alright but it was not very good. Resident #14 was interviewed on 1/22/24 at 9:21 a.m. She said the texture of the food was too hard for her and the food was often cold. Sometimes the food looked appealing and sometimes it did not. Resident #13 was interviewed on 1/22/24 at 9:40 a.m. He said the food was not very good but he ate it. There is no point in complaining about it. Resident #5 was interviewed on 1/23/24 at 10:02 a.m. She said the food did not taste appealing and was frequently cold. The food was either too mushy or too hard. II. Observations A test tray for a regular diet meal was evaluated immediately after the last resident had been served a tray for lunch on 1/23/24 at 1:45 p.m. At the end of the service, a request was made for a test tray. The cook (CK) plated the test tray and covered it with a warmer lid and walked it to the meeting room for temperature and taste testing. The test tray was assessed by two evaluators promptly at 1:55 p.m. The test tray consisted of a German meat stuffed roll, penne pasta, broccoli and carrots in pepper sauce and a slice of apple pie. -The German meat stuffed roll was dry and tough. The bottom of the roll was black and appeared burnt. The temperature was 155 degrees Fahrenheit (F). -The penne pasta had no flavor and was bland. There was a strong taste of olive oil only. The temperature was 92 degrees F. -The broccoli and carrots in pepper sauce had no flavor and had an after taste of vinegar. The temperature was 118 degrees F. -The slice of apple pie was not at a consistent temperature. The edges were 80 degrees F. while the center was 60 degrees F. III. Staff interview The dietary manager (DM) was interviewed on 1/23/24 at 2:15 p.m. She said she conducted a dining committee meeting after the resident council once a month to go over menus and concerns with the residents. If residents brought up concerns regarding the food such as taste or palatability, she addressed the concerns with the residents during the meeting. She did not have meeting minutes or completed grievance forms for the dining committee meetings. The DM was told of the results of the test tray and shown the German meat stuffed roll. She said the rolls were burnt at the bottom during the baking process. The rolls were stuffed by hand and then the dough was baked. She said she did not know how to stop the bottoms from burning. The vegetables were frozen and she did not know why there was vinegar after taste. The penne pasta should have had a flavor of seasoning in addition to olive oil. The apple pie was frozen and baked in the kitchen. The pie should not have been still cold in the center and should have been a consistent temperature throughout. 31820

Based on record review and interviews, the facility failed to ensure three (#12, #5 and #9) of six residents reviewed for unnecessary medications out of 11 sample residents were free from unnecessary drugs. Specifically, the facility failed to: -Have an effective method to track behaviors for efficacy of psychotropic medications for Residents #12, #5 and #9; and, -Obtain consent for psychotropic medications prior to administration for Residents #5 and #9. Findings include: I. Facility policy The Use of Psychotropic Medication policy, reviewed 10/4/23, was provided by the nursing home administrator (NHA) on 1/24/24. It read in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. Psychotropic medications shall be initiated only after medical, physical, functional,psychosocial, and environmental causes have been identified and addressed. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. II. Resident #12 A. Resident status Resident #12, age over 65, was admitted on [DATE]. According to the January 2024 computerized physicians orders (CPO), diagnoses included vascular dementia, bipolar disorder and anxiety. The 12/4/23 minimum data set (MDS) assessment revealed the resident had moderate cognition with a brief interview for mental status (BIMS) score of 11 out of 15. The assessment did not identify the resident had any behaviors during the assessment period. The assessment identified the resident was taking antipsychotic and antidepressant medications. B. Record review The care plan, initiated on 1/21/24 identified a mood problem related to the disease process of bipolar disorder and documented Resident #12 received antidepressant and antipsychotic medications. Interventions included: Monitor/record/report to medical doctor (MD) as needed (PRN) acute episode of feelings of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate and change in psychomotor skills. Observe for signs and symptoms of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep and agitation or hyperactivity. The January 2024 CPO revealed the following physician orders for psychotropic medications: -Risperidone 0.5 milligrams (mg) and 0.25 mg for bipolar disorder; -Fluoxetine 10 mg for depression; -Duloxetine 20 mg for depression; and, -Depakote 250 mg for bipolar disorder. -The CPO did not have an order for the nursing staff to monitor behaviors. The certified nurse aide (CNA) documentation for behaviors from 11/1/23 to 1/23/24 identified one episode of rejection of care on 1/8/24. The intervention for the identified behavior was to approach the resident in a positive manner. Further review of the CNA behavior documentation from 11/1/23 to 1/23/24 revealed the intervention to approach the resident in a positive manner was documented 13 times in November 2023, 19 times in December 23 and 12 times in January 2024 between 1/1/24 and 1/23/24. -The intervention was documented multiple times, however, there were no identified behaviors documented for the intervention on any of the occasions, aside from 1/8/24, when the intervention was documented. -The facility failed to have an effective behavior tracking system for the use of an antipsychotic medication and other psychotropic medications. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/23/24 at 2:10 p.m. She said Resident #12 did not have any behaviors. She pulled up the January 2024 CPO and could not identify any physician ordered behavior tracking. She said if Resident #12 displayed any behaviors she would write a progress note. She said CNAs documented in their own behavior tracking program. Certified nurse aide (CNA) #5 was interviewed on 1/24/24 at 9:15 a.m. She said Resident #12 never displayed behaviors. She said if she ever saw a behavior she would document it in the behavior tracking program for CNAs. The social services director (SSD) was interviewed on 1/24/24 at 10:58 a.m. She said Resident #12 only had behaviors at certain times of the year. She said it should have been communicated with the staff. She said the behavior tracking was a work in progress. The director of nursing (DON) was interviewed on 1/24/24 at 2:27 p.m. She said the behavior tracking the CNAs completed were for general behaviors and not resident specific. She said Resident #12 had not displayed a behavior for a while. She said there should be behavior tracking for the nursing staff. She said she would work with the staff to develop a more person centered individualized behavior tracking for Resident #12. 46849 III. Resident #5 A. Resident status Resident #5, age 70, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included depressive disorder and panic disorder. The 11/6/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Record review The comprehensive care plan, revised 8/16/23, revealed the resident was prescribed psychotropic medications related to a mood disorder, panic disorder, and depressive episodes. The resident had behaviors of picking at her skin when anxious or nervous. Interventions included providing a quarterly review of the resident's behaviors, providing one-on-one visits as needed, keeping the bathroom light off when no one was in the bathroom and developing and maintaining a daily routine for the resident. The January 2024 CPO revealed the following physician orders: Hydroxyzine (antihistamine) 25 milligram (MG)- give one time a day for anxiety-ordered on 4/7/21. Mirtazapine (antidepressant) 15 MG- give one time a day for depression-ordered on 4/7/21. Lithium (antipsychotic) 150 MG- give one time a day for mood disorder-ordered on 4/8/21. Document behaviors noted during shift. If noted, notify physician, medical director/nursing communication, director of nursing, and family twice a shift- ordered on 5/23/23. Duloxetine (antidepressant) 60 MG- give one time a day for depression-ordered on 12/1/23. A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 11/1/23 through 1/23/24 revealed one behavior had been indicated on 11/18/23. A review of the resident's progress notes from 11/1/23 to 1/23/24 revealed: Activities progress note dated 11/7/23 revealed the resident had a care conference and shared when she was experiencing anger, trauma or post traumatic stress she would isolate or play her music. Due to her history of trauma, she expressed she needed calming background noise on at all times and preferred her television remain on. -These behaviors and non-pharmacological interventions were not added to her behavior tracking or care plan. Medication administration note dated 11/18/23 revealed the resident had a documented behavior of telling another resident to quiet down. Psychotropic quarterly medication review assessment dated [DATE] revealed the resident was taking Lithium for a history of self harming behaviors. -The behaviors were not indicated on the behavior tracking or the care plan. A review of psychotropic medication consent forms revealed the consent for Lithium had been signed by the resident -However, it was undated and the resident had not marked she consented or did not consent to the medication. C. Staff interviews LPN #1 was interviewed on 1/23/24 at 11:06 a.m. LPN #1 said if a resident had behaviors, the nurse documented on the TAR and made a progress note. The progress note should have the resident behaviors, interventions, and outcomes. LPN #1 said Resident #5 had behaviors of becoming anxious. The resident took Lithium for anxiety and depression. LPN #1 did not know resident specific signs of depression or anxiety other than the resident picking at her skin. LPN #1 did not know the resident's specific non-pharmacological interventions. CNA #3 was interviewed on 1/23/24 at 11:34 a.m. She said she reported resident behaviors to the nurse to document. She said Resident #5 had no behaviors toward staff or other residents. She had no behaviors of self-harm. CNA #3 was not aware of specific behaviors in the resident's care plan to monitor or individualized interventions for the resident. The social services director (SSD) was interviewed on 1/24/24 at 10:43 a.m. She said behaviors were tracked on the MAR by the nurse. CNAs documented behaviors in the CNA task charting from the kardex (abbreviated care plan). -However, the task list had generic behaviors and every resident had the same list of behaviors. She said she was not involved in psychotropic drug meetings or gradual dose reductions. The SSD said the facility did not have an effective system for monitoring behaviors to determine efficacy of psychoactive medications. The SSD had been requesting changes to the way behaviors were tracked but the system had not been changed. The SSD said Resident #5 had behaviors of picking at her skin and a history of trauma. However, Resident #5 did not have a behavior of picking at her skin listed in the task behavior charting. The resident took Lithium for a mood disorder but the SSD did not know what specific behaviors were associated with the medication. The resident had a history of attempting suicide and suicidal ideations should be tracked and care planned. Resident #5 did not have a behavior of suicidal ideations listed in the task behavior charting. The DON was interviewed on 1/24/24 at 2:24 p.m. She said residents taking psychoactive medications have behavior tracking orders on the MAR. The order should include the resident's behaviors and non-pharmacological interventions. If a resident displayed new behaviors or worsening symptoms, a behavior tracker needed to be started on the MAR. A consent form was obtained from the resident or responsible party before the medication was started. If a resident expresses suicidal ideations or a history of suicidal ideations/attempts the behavior should be tracked and in the resident's care plan. The DON said the behaviors indicated on the trackers are generic and the same for all the residents. The CNA behavior trackers are also not resident specific. The DON did not know how the trackers could be customized for each resident and would have to look into the facility's system for tracking. Behaviors should be tracked in order to determine the appropriateness and efficacy for psychoactive medications. The DON said Resident #5 had behaviors of picking at her skin when she was anxious. The DON did not know why the resident took Lithium. She was not aware the resident was taking lithium for a history of self harm. She reviewed the consent for the resident's lithium and said if a resident or responsible party did not mark either boxes, if consent was given or was not given, the facility would proceed as consent was given. DON said Resident #5 was aware of the reason she was prescribed lithium so the consent was implied even though it was not marked by the resident on her consent form. IV. Resident #14 A. Resident status Resident #14, age 95, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included depressive disorder and dementia without behavioral disturbances. The 12/18/23 MDS assessment documented the resident was cognitively impaired with a BIMS score of three out of 15. No behaviors were indicated. B. Record review The comprehensive care plan, revised 12/19/23, revealed the resident was prescribed psychotropic medications related to a depressive disorder. The resident had behaviors of picking at her scalp, rejecting care, episodes of tearfulness, removing and playing with her partial denture, and increased sleeping. Interventions included approaching in a calm manner, maintaining a daily routine for the resident, offering snack and drink if she is restless at night, re approach if uncooperative, and monitor and report to the physician as needed per facility behavior monitoring. Staff were to rule out the resident's need if increased behaviors were noted such as toileting, drink, hunger, pain, or change of position. The January 2024 CPO revealed the following physician orders: Fluoxetine (antidepressant) 20 MG- give one time a day for depression-ordered on 10/07/21. Mirtazapine 15 MG- give one a day for depression- ordered on 12/6/23. -A review of the resident's MAR and TAR from 11/1/23 through 1/23/24 failed to reveal behavior tracking. A review of the resident's progress notes from 11/1/23 to 1/23/24 revealed: Daily progress note dated 11/18/23 revealed the resident had displayed disruptive behaviors during a group activity causing the staff to turn the television off in the room and remove the resident. Daily progress note dated 12/1/23 revealed the resident had expressed feelings of sadness and depression. The resident verbalized feeling down about herself and wanting to hurt herself. The resident was distracted with activities. Shift administration note dated 12/2/23 revealed the resident was in her bed yelling out. She expressed she believed someone to be in the room who was not there. The staff were unable to redirect the resident from her visual hallucinations and she continued to yell out. Daily progress note dated 12/31/23 revealed the resident was found wandering the facility in her wheelchair. She had been taking herself to the front of the facility. The resident was having increased difficulty sleeping and waking up very early in the morning. The resident believed she had cooked a meal and wanted to share the meal with staff. The resident was unable to return to sleep and then expressed paranoia about what the staff were doing. Daily progress note written by the medical director on 1/3/24 revealed the resident's medications were reviewed but there was no mention of the resident's increased behaviors. Daily progress note dated 1/11/24 revealed the resident woke up very early in the morning and when staff toileted her, the resident expressed delusions about the toilet leaking and wanting to go to another one. Psychotropic quarterly medication review assessment dated [DATE] revealed the resident was taking Fluoxetine for statements of suicidal ideations. -The behavior was not tracked or indicated in the care plan. -A review of psychotropic medication consents failed to reveal consent had been obtained for Mirtazapine or Fluoxetine. C. Staff interviews LPN #1 was interviewed on 1/23/24 at 11:06 a.m. LPN #1 said Resident #14 had behaviors of confusion, removing her partial dentures, and refusing care. Resident #14 was taking antidepressants for depression. LPN #1 did not know resident's specific signs of depression. LPN #1 did not know the resident's specific non-pharmacological interventions. CNA #3 was interviewed on 1/23/24 at 11:34 a.m. CNA # 3 said Resident #14 had behaviors of tearfulness and refusing care. She was easily redirected. The resident did not express thoughts of self harm. CNA #3 was not aware of specific behaviors in the resident's care plan to monitor or individualized interventions for the resident. The SSD was interviewed on 1/24/24 at 10:43 a.m. The SSD said Resident #14 had behaviors of tearfulness and refusing care. The SSD said these were reactions to living in a facility. She did not know the resident did not have behavior tracking on the MAR. The DON was interviewed on 1/24/24 at 2:24 p.m. She said Resident #14 had behaviors of becoming tearful and being hard to redirect. The DON said behaviors of hallucinations and delusions were not typical behaviors for the resident and should have been reported to the DON. She was not aware the resident did not have consents in the medical record for the Mirtazapine or the Fluoxetine. D. Facility follow up On 1/25/24 after survey exit, the DON provided consents for Resident #14 for Mirtazapine and Fluoxetine. The consent forms were signed 1/24/24. Behavior tracking from the CNA tasks for Resident #14 were provided. The tracking revealed the resident had episodes of tearfulness three times in December 2023 and 13 times in January 2024. -There were no behaviors on the tracker for wandering, hallucinations, delusions, or expressions of suicidal ideations.

Based on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects. Specifically, the facility failed to ensure trash in the kitchen lids were closed and not overflowing. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) the Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf. It read in pertinent part; - Receptacles and waste handling units for refuse, recyclables, and returnable used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. - Cardboard or other packaging material that does not contain food residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem. II. Observations On 9/26/22 at 10:00 a.m. the trash can in the kitchen was overflowing with trash. There were cardboard boxes, metal cans, and plastic wrap in the trash can. There were blue gloves on the floor as well as used paper towels. The lid to the trash can was against the wall behind the oven. On 9/27/22 at 9:54 a.m. the trash can in the kitchen was overflowing with trash. There was trash on the floor. The trash can lid was leaning against the wall behind the oven. On 9/28/22 at 11:00 a.m. the trash can was overflowing with trash. The trash had boxes, metal cans, plastic wrap, and used paper towels. There was food residue on the boxes. The lid was leaning against the wall behind the oven. III. Staff interview The dietary manager (DM) was interviewed on 9/29/22 at 11:13 a.m. The dietary manager was told of the observations above. She said all kitchen staff should be emptying the trash can every time they see it is full. She said she verbally educated staff that the trash can lids needed to be placed on the trash can. She said the trash can should be emptied and lid on to prevent insects such as flies and other pests.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -Cutting boards were free from deep scratches and stains; and, -Dishwasher maintained sufficient levels of sanitizing solution. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.47, 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 items and: -Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. The Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46, details for appropriate hand cleaning procedure included: Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations Observation of meal service was conducted on 9/27/22 at 12:59 p.m. Observations in the primary dining room included: Dietary aide (DA) #2 was observed pushing the food heating cart into the main dining room. He was wearing a pair of blue gloves. DA #2 proceeded to prepare the lunch meal. DA #2 started to tear apart the baked rolls with his gloved hands and place them back into the metal container. DA #2 left the dining room and proceeded to the kitchen. DA #2 returned to the dining room with baked potatoes in his hand. He placed the potatoes on the heating cart. He proceeded to start plating residents ' meals. He grabbed a baked roll with his gloved hand and placed it on the plate and then completed the meal order. DA #2 then exited the dining area again and returned moments later. He proceeded to serve the residents ' meals. DA #2 did not wash his hands or change gloves during this process. Observation of meal service was conducted on 9/28/22 at 1:07 p.m. Observations in the primary dining room included: DA #1 was observed entering the dining room. He put on a pair of gloves and did not wash his hands. DA #1 was observed preparing two plates of mechanically altered meals. He was observed removing the plastic wrap off of the plate and throwing the plastic in the trash can touching the lid with his gloved hand. DA #1 then proceeded to grab a food thermometer with his gloved hand. He placed the end of the thermometer into the mechanical altered food and took the temperature. He placed the thermometer on the counter and wrapped the plate with plastic wrap. He grabbed the plate and placed it into the microwave and reheated the plate. He then grabbed a sanitized wipe and proceeded to wipe the end of the thermometer. He wiped his gloved hand on the side of his pants. He then removed the plate from the microwave, placed the plate on the counter and removed the plastic wrap. He threw the plastic wrap into the trash again touching the end of the trash can. He rechecked the temperature of the meal and then covered the meal with plastic wrap. He grabbed another sanitizing wipe and wiped the end of the thermometer. DA #1 repeated the same process on the second plate of mechanical altered food. DA #1 did not wash his hand or change his gloves during this process. C. Staff Interview The dietary manager (DM) was interviewed on 9/28/22 at 11:29 a.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they leave the kitchen and dining area. The DM said it was her expectation all dietary staff would have been washing their hands between tasks to avoid cross contamination. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, it read in part, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 10/27/22 at 10:40 a.m. revealed two large white cutting boards, one small white cutting board; all cutting boards were heavily scored and stained. On 9/27/22 at 11:00 a.m. during kitchen observations the DM was observed cutting lettuce, tomatoes, cucumbers and apples on the white cutting board. C. Staff Interview The DM was interviewed on 9/29/22 at 11:13 a.m. The DM was told of the observations of the cutting boards in the kitchen. She confirmed the cutting boards were visibly stained and showed wear. She said she would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Chemical Sanitization 1. Professional Reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 132-137, read in part, Cleaning and sanitizing may be done by spray-type, immersion ware washing, or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. Chemical sanitizing ware washing machines (single-tank, stationary-tank, door-type machines and spray-type glass washers) may be used provided that: 1) The temperature of the wash water shall not be less than 120 F (49 C); 2) The wash water shall be kept clean; and 3) Chemicals added for sanitization purposes shall be automatically dispensed; and 4) Utensils and equipment shall be exposed to the final chemical sanitizing rinse in accordance with the manufacturer's specifications for time and concentration; and 5) The chemical sanitizing rinse water temperature shall not be less than 75 F (24 C) nor less than the temperature specified by the machine's manufacturer. 2. Failures A. Observation and Interviews At the beginning of kitchen observation on 9/28/22 at 11:00 a.m., the DA #1 started to wash the dishes from the morning meal. He said the water temperature of the dishwasher was supposed to be above 120 degrees F. DA #1 said the chemical solution was tested three times a day, but he had not tested it this morning. He said it was supposed to be between 50 and 100 parts per million (PPM). DA #1 took a reading of the sanitation level of the dishwasher. DA #1 ran a wash cycle, took a test strip from the container, and placed the strip into the dishwasher machine. DA #1 read the strip and stated zero. DA #1 then repeated the process three more times with the same result of zero PPM. DA#1 checked all of the sanitizing solutions and found the large container of sanitizing solution was empty. He removed the empty container and replaced it with a full container. He then ran another load of dishes with the same result of zero PPM. At 11:14 a.m. the dietary manager was told of the issues with the dishwasher. She had DA #1 run another load of dishes and have him test sanitation level. It read zero PPM. The DM asked DA #1 if he had primed the dishwasher to which he replied no. The DM continued to prime the sanitizing solution and ran two more loads with the level being zero. She again primed the dishwasher and then ran another load which showed a level of over 100 PPM. She instructed DA #1 that he had to prime the system to get the sanitization solution into the machine. DA#1 said, I was not aware of that. The DM stated all dishes would be washed again, which staff proceeded to do immediately. The DM was interviewed on 9/29/22 at 11:13 a.m. The DM said the dishwasher was checked three times a day for water temperature and sanitization levels. She said the machine was new and so were some of the staff, which was why DA #1 was not too familiar with the machine. She said it was her expectation that the water temperature would be over 120 degrees Fahrenheit and the sanitizing solution would be at 50-100 PPM. She said the importance of proper sanitization was to keep from spreading food borne illness and protect the residents. She said sanitization was the first line of defense.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication carts and one of one medication storage rooms. Specifically, the facility: -Failed to date [MEDICATION(S)] insulin when opened; -Failed to discard [MEDICATION(S)] when expired; and, -Failed to discard an expired [MEDICATION(S)] inhaler. Findings include: I. Professional references According to the [MEDICATION(S)] package insert, retrieved [DATE] from: https://www.fda.gov/media/ /download, A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. Prescribing information for [MEDICATION(S)] diskus, retrieved [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Advair_Diskus/pdf/[MEDICATION(S)]-DISKUS-PI-PIL-IFU.PDF [MEDICATION(S)] DISKUS should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard [MEDICATION(S)] DISKUS 1 month after opening the foil pouch or when the counter reads '0'. According to the prescribing information for [MEDICATION(S)], retrieved [DATE] from https://www.novo-pi.com/[MEDICATION(S)].pdf, The [MEDICATION(S)] vial you are using should be thrown away after 56 days, even if it still has insulin left in it and the expiration date has not passed. II. Observation and interview On [DATE] at 12:11 p.m. the medication cart contained a [MEDICATION(S)] insulin pen with no open date and an expired [MEDICATION(S)] inhaler. The medication room refrigerator had an open vial of [MEDICATION(S)] with an illegible open date. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 12:11 p.m. She said she had failed to date the [MEDICATION(S)] pen when she opened it that morning and did not know the [MEDICATION(S)] inhaler had expired. She said she could not read the open date on the [MEDICATION(S)] vial and said it was best practice to discard it to ensure the safety of the medication going forward. III. Administrative interview The director of nurses (DON) was interviewed on [DATE] at 11:L51 a.m. She said the insulin pen should have been dated when opened and the [MEDICATION(S)] inhaler should have been discarded when expired. She said the [MEDICATION(S)] vial should have been discarded if the open date could not be read. She said going forward she would educate staff to check the dates of the medications and verify when the medication was opened for the safety of the residents and the efficacy of the medications.

Based on record review and interviews, the facility failed to provide notification of a change in condition for three (#4, #5 and #14) out of 18 sample residents. Specifically, the facility failed to: -Notify the provider of elevated blood sugars for Resident #4; and, -Notify the provider of missed medications for Resident #5 and #14. Findings include: I. Resident #4 A. Resident status Resident #4, age 69, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/15/22 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. B. Record review The care plan, initiated 7/6/21 and revised 7/14/22, identified the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include alternate insulin injection sites. Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. Monitor/document/report to medical doctor as needed for signs and symptoms of [CONDITION(S)]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, and kussmaul breathing, acetone breath (smells fruity). The September 2022 CPO included: -Accucheck three times a day before meals and at bedtime. If blood sugars are over 250, give [MEDICATION(S)] 10 units subcutaneously. Order date 7/28/22. The August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 8/1/22 the resident's blood sugar was 275; 8/2/22 the resident's blood sugar was 352; 8/3/22 the resident's blood sugar was 337; 8/7/22 the resident's blood sugar was 258; 8/8/22 the resident's blood sugar was 272; 8/10/22 the resident's blood sugar was 340; 8/12/22 the resident's blood sugar was 324; 8/14/22 the resident's blood sugar was 342; 8/15/22 the resident's blood sugar was 311; 8/16/22 the resident's blood sugar was 285; 8/17/22 the resident's blood sugar was 252; and, 8/19/22 the resident's blood sugar was 311. The September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 9/1/22 the resident's blood sugar was 344; 9/2/22 the resident's blood sugar was 280; 9/3/22 the resident's blood sugar was 270; 9/4/22 the resident's blood sugar was 369; 9/5/22 the resident's blood sugar was 312; 9/6/22 the resident's blood sugar was 359; 9/7/22 the resident's blood sugar was 403; 9/8/22 the resident's blood sugar was 265; 9/11/22 the resident's blood sugar was 373; 9/13/22 the resident's blood sugar was 342; 9/19/22 the resident's blood sugar was 284; 9/20/22 the resident's blood sugar was 364; 9/23/22 the resident's blood sugar was 312; and, 9/26/22 the resident's blood sugar was 316. -Review of the resident's medical record reviewed no progress notes documenting the physician was notified of the elevated blood sugar levels. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 9/28/22 at 2:21 p.m. She said whenever a resident had elevated blood sugars, nursing staff were supposed to monitor the resident, recheck their blood sugar, report the information to the provider and document the blood sugar in the nursing progress notes. LPN #2 reviewed the dates and blood sugars (indicated above) on the September and August 2022 resident's MAR. She said the provider should have been contacted and a nurse progress note documenting the interventions used. The director of nursing was interviewed on 9/28/22 at 2:43 p.m. She said when a resident's blood sugars were elevated the nurse needed to monitor the resident for any side effects and recheck the blood sugar. She said the provider should be contacted so they could provide guidance on what interventions or follow up was required. The DON said a negative outcome for too high of blood sugars could be heart disease, kidney disease, vision problems and a stroke. II. Resident #5 A. Resident status Resident #5, over the age of 65, was admitted on [DATE]. According to the September 2022 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. No behaviors or refusal of care noted. B. Observation and interview The medication cart had a small cup of pre poured medications for Resident #5 on 9/28/22 at 12:11 p.m. the cup contained: -Iron tablet 325 milligrams (mg); -[MEDICATION(S)] 100 microgram (mcg); -Liothyronine 5 mcg; -[MEDICATION(S)] powder 8.5 grams (gm); -Senna Plus tablet 8.6/50 mg; -[MEDICATION(S)] 25 mg; -[MEDICATION(S)] tablet 20 mg; -Vitamin D3 capsule 50 mcg; and, -Tylenol 650 mg. Licensed practical nurse (LPN) #2 was interviewed on 9/28/22 at 12:11 p.m. She said Resident #5 was still asleep when the morning medications were set up and she placed them in the medication cart and had forgotten to re approach when she was awake. She said she would not administer the medications and discard them. She said she would have to mark the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] III. Resident #14 A Resident status Resident #14, age 85, was admitted on [DATE]. According to the September 2022 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Verbal behavioral symptoms were noted in the previous four to six days. No rejections of care. B. Observation and interview The medication cart had a small cup of pre poured medications for Resident #14 on 9/28/22 at 12:11 p.m. the cup contained: -Aspirin 81 mg; -Calcium 600 mg/ Vit D3 600/800 mg; -[MEDICATION(S)] 25mg half a tablet; -[MEDICATION(S)] 20 mg; -[MEDICATION(S)] powder 25.5 gm; -[MEDICATION(S)] 40 mg; -[MEDICATION(S)] 75 mg; -[MEDICATION(S)] S 8.6/50 mg; -[MEDICATION(S)] 100 mg; -[MEDICATION(S)] 10 mg; -[MEDICATION(S)] 25mg; -[MEDICATION(S)] Gel 0.4-0.3% one drop in both eyes; and, -Tylenol 650 mg. Licensed practical nurse (LPN) #2 was interviewed on 9/28/22 at 12:11 p.m. She said Resident #14 was still asleep when the morning medications were set up and she placed them in the medication cart and had forgotten to re approach when she was awake. She said she would not administer the medications and discard them. She said she would have to mark the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] IV. Interview The director of nursing (DON) was interviewed on 9/29/22 at 11:51 a.m. She said the provider should have been notified. The review of the progress notes did not have the nurse notifying the provider of the missed medications the day the medications were not administered. She said the nurse would have notified the provider when the medications were discovered they had not been administered. She said she would provide education on the importance of notifying the provider.

Based on observations, record review and interviews, the facility failed to ensure one (#12) of 18 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to elevate Resident #12's right leg as ordered by the provider Findings include: I. Resident #12 A. Resident status Resident #12, under [AGE] years old, was admitted on [DATE]. According to the September 2022 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/24/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. No behaviors or refusal of care noted. She needed extensive assistance with transfers, toilet use, and personal hygiene. B. Record review The care plan, created on 10/11/17 and revised on 8/23/22, identified the resident had a potential for skin breakdown due to spending most of the time in bed or the chair. Interventions included, keep her right leg elevated while sitting up, keep her leg on the wheelchair, may put her leg down for meals. Lay down one time a day with leg up. Do not leave legs dependent for longer than two hours at a time. The September 2022 CPO included: -Keep right leg elevated while sitting up- keep leg on wheelchair, may put down for meals. Lay down one time a day with leg up. Do not leave legs dependent for no more than two hours at a time. Ordered on 8/5/2020. C. Observations Resident #12 was observed in her wheelchair: -On 9/26/22 at 2:09 p.m. she was in the entry lobby without her right foot elevated. -At 3:11 p.m. she was in activities with her right foot down on her foot rest. -On 9/27/22 at 10:24 a.m. she was in the activities room with her right foot down on the foot rest. -At 2:38 p.m. she was in the entry lobby without her right foot elevated. -On 9/28/22 at 10:15 a.m. she was in the activities room without the right food elevated. D. Interviews Certified nurse aide (CNA) #1 was interviewed on 9/28/22 at 10:45 a.m. She said Resident #1 did not have any special positioning needs for her legs. Licensed practical nurse (LPN) #2 was interviewed on 9/28/22 at 11:00 a.m. She said Resident #12 had at one point had a small area on her right foot, but it had resolved. She said Resident #12 could have leg spasms, and her leg would fall off the elevated leg rest.She said the current order stated to elevate the right leg. She said she did not see Resident #12 with her right leg elevated. The director of nursing (DON) was interviewed on 9/28/22 at 11:10 a.m. She said at one point Resident #12 had a small wound on her right foot, however the area had resolved. She said the order was old, and had been written in 2020. She said according to the current order, Resident #12 should have the right leg elevated when not eating. She said she would follow up with the provider to see if the order could be discontinued.

Based on observations, record review and interviews the facility failed to provide hearing assistive devices to a resident daily for one (#2) out of 18 sample residents. Specifically, the facility for Resident #2: -Failed to ensure hearing aids were applied daily; and, -Failed to care plan the use of hearing aids. Findings include: I. Resident status A. Resident #2 Resident #2, age 86, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/21/22 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for a mental status score of 12 out of 15. No behaviors or refusal of care noted. She was identified as having minimal difficulty hearing. B. Record review The care plan, created on 7/20/22 and revised on 7/21/22, identified a communication problem related to minimal difficulty with hearing. Interventions included, -The resident has hearing aids. Staff to assist residents with the care of the aids, putting the aids in a.m. and taking aids out at bedtime. The case is labeled and in the resident's room for storage in between use. Spare batteries kept in the med (medication) room at nurses station. -The care plan intervention regarding the hearing aids was added after the interview was completed with the director of nurses (DON), see below. C. Observations Resident #2's hearing aids were in their case in her room on her dresser on 9/26/22 at 10:33 a.m. Resident #2's hearing aids were in their case in her room on her dresser on 9/27/22 at 2:38 p.m. Resident #2's hearing aids were in their case in her room on her dresser on 9/28/22 at 10:23 a.m. D. Interviews Certified nurse aide (CNA) #1 was interviewed on 9/28/22 at 10:35 a.m. She said she helped Resident #2 with her adaptive devices to include glasses and hearing aids when she gets ready in the morning. Licensed practical nurse (LPN) #2 was interviewed on 9/28/22 at 11:00 a.m. She said Resident #2 had glasses and hearing aids. She said Resident #2 would pull out the hearing aid from her right ear at times. She said Resident #2 should have her hearing aids placed every morning to help her hear. The DON was interviewed on 9/28/22 at 11:10 a.m. She said Resident #2 had received her hearing aids last week. She said the hearing aids were to be placed in the resident's ear/s in the morning, and to be out in the evening. She said there should have been a care plan in place. She said the hearing aids should be worn to assist the resident with hearing better and improve her interactions with others.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision and assistance devices to prevent accidents were provided, for one (#16) of one resident reviewed for smoking out of 18 sample residents. Specifically, the facility failed to provide qualified supervision during smoking for a resident who required supervision. Findings include I. Facility policy The Smoking Policy, no revision date, provided by the director of nursing (DON) on 9/29/22 at 10:30 a.m. Designated smoking areas are located outside of the facility with ash trays available. To protect all residents, staff and others, it is important to ensure that residents leave all oxygen equipment inside the building prior to going out into any designated smoking area. Any oxygen equipment, even when turned off, is not to be near any resident who is smoking. Residents are not to smoke with oxygen on. Residents with oxygen are not to be near a resident who is smoking. Residents that are smokers upon admission or who become smokers while living at our facilities will require a safe smoking assessment that will be updated every three months and as needed. II. Resident status Resident #16, age under 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included [CONDITION(S)] (paralysis of lower body), chronic nasopharyngitis (chronic tonsillitis), and low back pain. According to the 8/29/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. T B. Record review The care plan, initiated 10/17/19 and revised 9/12/22, identified the resident smoked cigarettes and has a history of smoking cannabis. The resident had limited cigarettes and funds. The resident has a limitation to right arm and has been found with burn holes in his clothing. The resident has a history of smoking in his room. Interventions include the resident must wear a smoking apron when smoking. Remind the resident to wear an apron while smoking for his safety. Keep a smoking apron on the back of the wheelchair. Place a smoking apron on the resident when getting him in the wheelchair. Smoking will be supervised. The smoking evaluation, dated 8/29/22, identified the resident needed supervision for smoking due to his needing adaptive equipment such as smoking apron and supervision. C. Observations and interview On 9/27/22 at 11:33 a.m. Resident #16 was observed outside smoking. No staff were noted to be with him. He said he can smoke by himself because he was assessed as an independent smoker. He was not wearing a smoking apron and was not 15 feet from the exit door. At 1:19 p.m. Resident #16 was observed smoking outside. No staff were noted to be with him. He did not have a smoking apron on and he was not 15 feet away from the door. On 9/28/22 at 10:03 a.m. Resident #16 was observed outside smoking. Resident #16 did not have a smoking apron on and was not 15 feet away from the door. Licensed practical nurse (LPN) #2 exited the door to administer Resident #16 his medication. She returned back into the common area and retrieved a smoking apron and placed it on the resident. LPN #2 then returned back into the facility after administering his medication. D. Interviews LPN #2 was interviewed on 9/28/22 at 10:07 a.m. LPN #2 said she was familiar with Resident #16. She said he was an independent smoker. She said she noticed he was not wearing a smoking apron so she placed one on him. LPN #2 reviewed Resident #16's smoking assessment. She said, Oh, I thought he was an independent smoker. She said we would need to inform staff that he was not an independent smoker. The director of nursing (DON was interviewed on 9/28/22 at 11:34 a.m. The DON said the resident was an independent smoker and was required to wear a smoking apron. She said the resident had a history of having burned holes in his clothes. The DON was told of the observations above. The DON reviewed Resident #16's care plan and smoking assessment. She said according to the assessments, he should be a supervised smoker. She said she would pass the information along to all staff to ensure he was being supervised.

Based on record review and interviews, the facility failed to ensure residents with as needed (PRN) orders for [CONDITION(S)] medications are only used when the medication is necessary and PRN use is limited for one (#7) of five residents investigated for unnecessary medication usage out of 16 sample residents. Specifically, the facility failed to ensure PRN [CONDITION(S)] medications were ordered for a designated time limit and evaluated every 14 days for appropriate usage for Resident #7. Findings include: I. Facility policy and procedure Review of the Use of [CONDITION(S)] Drugs policy provided by the director of nurses (DON) on 6/15/21 at 3:20 p.m , revised 11/1/2020, revealed in part PRN orders for all [CONDITION(S)] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). II. Resident status Resident #7, age 67, was admitted on [DATE]. According to the June 2021 computerized physician orders (CPO), diagnoses included depression and anxiety. The 5/9/21 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. No behaviors exhibited. The resident received antipsychotics, antianxiety, antidepressant medications over the previous seven day look back period. III. Record review Review of the care plan, initiated 5/10/21, revealed in part Resident uses [CONDITION(S)] medication related to dysthymia disorder. Diagnosis: other specified depressive episodes. Feeling down daily, feeling tired daily, having trouble concentrating on things daily, little interest in doing things she gets sidetracked easily, diagnosis: mood disorder. Diagnosis: panic disorder .Interventions included: try following interventions prior to PRN use of [MEDICATION(S)] 1. Remove from the source. 2. Quiet setting. 3. Phone, 4. Other. Review of the April 2021 medication administration record (MAR) revealed: -[MEDICATION(S)] tablet 0.25mg ([MEDICATION(S)]) Give one tablet by mouth every 12 hours as needed for panic related to anxiety disorder. Start date 4/7/21. The medication was given on 4/13/21 and 4/14/21. -According to the DON interview this order with a start date of 4/7/21 was supposed to be a one time order. No stop date was given. The medication was also given in May 2021 and remained on the orders through survey. Review of the May 2021 medication administration record (MAR) revealed -[MEDICATION(S)] tablet 0.25mg ([MEDICATION(S)]) Give one tablet by mouth every 12 hours as needed for panic related to anxiety disorder. Start date 4/7/21. The medication was given on 5/28/21. Review of the June 2021 medication administration record (MAR) revealed -[MEDICATION(S)] tablet 0.25mg ([MEDICATION(S)]) Give one tablet by mouth every 12 hours as needed for panic related to anxiety disorder. Start date 4/7/21. The medication was not given. Review of the June CPO revealed the following: -[MEDICATION(S)] tablet 0.25 milligrams (mg). Give one tablet by mouth every 12 hours as needed for panic related to anxiety disorder. Start date: 4/7/21. Review of the physician progress notes revealed the following: -8/7/19: Uses [MEDICATION(S)] only once weekly; when she has panic attacks she really needs it. -6/3/2020: Minimal panic attacks since not being able to go out- because of COVID. Will maintain [MEDICATION(S)] prn until we see how she does after COVID lockdown ends. -8/5/2020: Last [MEDICATION(S)] 7-23 .still needs . -10/7/2020: Still needs [MEDICATION(S)] prn panic attacks. -2/3/21: Meds reviewed. Doing quite well with only ordered [MEDICATION(S)] when she goes out. -4/7/21: Meds reviewed- still needs [MEDICATION(S)]- rarely uses it. No further progress notes to indicate continued assessed use for [MEDICATION(S)] order for May and June 2021. The DON was interviewed on 6/14/21 at 3:09 p.m. She said she was aware of the PRN medications and said the physician wrote notes on the prn usage. She said they used a table as a guide for the usage. The DON was interviewed again on 6/15/21 at 10:36 a.m. She said they reviewed the medications with the physician every other month. She said they completed a monthly medication review without the physician. She said she thought they had at least two residents currently on PRN [CONDITION(S)] medications. She said they were not reviewing the PRN medications every 14 days. She said this resident ' s most recent order was meant to be a one time order, but they received more than they wanted. She said this resident had not used it in a while. The NHA was interviewed on 6/15/21 at 2:20 p.m. She said she was not involved in the medication decision making process.

Based on observations, record review, and interviews, the facility failed to ensure for one (#9) of three residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan out of 16 sample residents reviewed for skin alteration. Specifically, the facility failed to identify, assess, and monitor a bruise for Resident #9. Findings include: I. Resident #9 A. Resident status Resident #9, age 84, was admitted [DATE]. According to the computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/27/21 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. She had mood and behavior symptoms and required limited assistance of one staff member for activities of daily living (ADLs). No skin issues were documented. B. Observation On 6/13/21 at 3:16 p.m. Resident #9 was seen lying on her bed. A reddish purple bruise was observed on the top of her left hand near her thumb, extending to just below the joints of the index and middle fingers. She was unable to explain how she obtained the bruise. C. Record review The 10/30/2020 CPO included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly nursing skin observation documentation for June 2021 revealed she did not receive a skin observation on 6/3/21 and none were documented after that date. Review of the certified nurse aide (CNA) skin observation documentation revealed bruising noted on 6/2, 6/7, 6/8, 6/9, and 6/14/21. -The documentation did not indicate where the bruising was located and it was documented that the areas were not new. Review of the 11/10/2020 care plan revealed Resident #9 had potential for alteration in skin integrity with interventions that included skin observation weekly, and report any skin issues or other areas of concern to the physician. II. Interviews Licensed practical nurse (LPN) #1 was interviewed on 6/14/21 at 4:16 p.m. She said she was unaware of the bruise to Resident #9 ' s left hand (she had been the resident ' s nurse the day before as well). She said she was not sure how she missed it. She said if a new area was identified they were to measure it, document it in the nursing progress notes, and monitor it for changes. At 4:21 p.m. LPN #1 said she checked with other staff who said they did not notice the bruise prior to now when it was brought to their attention. LPN #1 said she would measure the area and get it documented at this time, and notify the director of nursing (DON). LPN #2 was interviewed on 6/15/21 at 9:20 a.m. She said when a new bruise was identified, the area was to be measured, documented in the progress notes, and monitored until it was healed. She said, there was not normally an order put in to monitor the area but the DON said she was in the process of doing that. The certified nurse aide (CNA) was interviewed on 6/15/21 at 9:30 a.m. She said when a new skin issue was identified during showers or daily care, they were to notify the nurse so they could measure it and document it. She said the CNAs did not have a way to document descriptions of skin issues on shower days so they had to notify the nurse. The DON was interviewed on 6/15/21 at 10:56 a.m. She said when a new bruise was identified it was to be measured, documented, and monitored weekly during weekly skin checks on shower days. She said they usually did not put in an order to monitor the area on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She said any skin issues the CNAs would find during care or showers were documented in the point of care area and it would send an alert to the nurse so they could address it. III. Facility follow up On 6/14/21 at 8:51 p.m. a daily progress note documented by LPN #1 read in part: Was reported to this charge nurse that this resident had a bruise on her L (left) upper hand that is dark reddish/ purplish. Bruise is 4.5 cm x 3.2 cm, and unknown cause of bruise. On 6/15/21 at 4:00 p.m. the DON said she had started documentation regarding the cause of Resident #9 ' s bruise and determining interventions that needed to be put in place. She did not provide a policy or procedure related to alterations in skin integrity. She said it was in a binder that she could not find.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including the novel Coronavirus (COVID-19) on one of two hallways. The failure affected all residents present in the facility, which placed the facility in an immediate jeopardy situation. Specifically: Observations, record review and interviews on 11/23/2020 and 11/24/2020 revealed systemic failures in the facilities infection control program: -Staff failed to wear the appropriate personal protective equipment (PPE) when entering an isolation room; -Staff did not doff PPE appropriately and did not perform appropriate hand hygiene after removing gloves; -Staff failed to wear masks appropriately; -Staff did not encourage or assist the resident's to wear masks when out of their rooms; -Staff failed to ensure residents were social distancing while smoking and not sharing personal items while smoking; -The facility failed to isolate resident's after being out on pass overnight in hotspot counties (counties with high incidence of COVID-19); and, -The facility failed to ensure residents and staff were educated on updated COVID-19 precautions and continued on-going training. The facility had seven positive staff members and two positive residents as of 11/25/2020. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm due to potential of further transmission of the highly infectious COVID-19 virus to residents throughout the facility, staff and others, if not corrected immediately. Findings include: I. Facility status COVID-19 positive staff and residents The facility COVID-19 line listing documented seven positive staff members since 10/19/2020. The last positive staff person was identified on 11/23/2020. Results from the facility's COVID-19 testing performed 11/23/2020 identified two positive results for residents. The facility had four residents on isolation precautions as of 11/25/2020, one for being a new admission that had a positive COVID result prior to admission, two for having positive COVID-19 tests and one for being exposed to a COVID-19 positive resident. The facility had seven positive staff members and two positive residents as of 11/25/2020. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Multiple observations on 11/23/2020 and 11/24/2020 revealed direct care staff failed to don personal protective equipment (PPE) prior to entering an isolation room and providing care for residents in isolation for COVID-19. Staff reported they were educated to wear less than full PPE when entering the isolation room. Staff were observed doffing PPE inappropriately and failed to perform appropriate hand hygiene after removing PPE. Further observations on 11/23 and 11/24/2020 revealed residents outside their rooms without facemasks and interacting with staff who failed to encourage or assist them to wear a face covering. Staff were observed wearing their face masks below their chin. Observations revealed smoking residents were not supervised to ensure social distancing of at least six feet and prevent the sharing of personal smoking items. Record review revealed the facility failed to isolate resident's that left the facility overnight to hotspot counties for medical appointments. The facility also failed to ensure the staff received adequate education and updated, current information on COVID-19 precautions after obtaining their first positive COVID-19 results. These failures created the likelihood for serious harm to all facility residents due to potential transmission of the highly infectious COVID-19 virus. B. Facility notice of immediate jeopardy On 11/25/2020 at 4:36 p.m. the nursing home administrator (NHA) was notified that the failures above under F880 created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). C. Facility plan to remove immediate jeopardy On 11/25/2020 at 8:39 p.m. the NHA submitted a plan to remove the immediate jeopardy. The plan read: 1. All staff will wear the appropriate PPE in the appropriate manner. When in direct care of a non-COVID-19 positive resident, caregiver must wear a surgical mask and goggles. When in direct care of a COVID-19 positive resident and residents under observation, caregiver must wear a N95 mask, goggles, face shield, gown and gloves. The N95 mask may be worn the entire shift, but the mask may not be touched or removed. If the mask is touched, immediate hand hygiene must occur. 2. The proper PPE Protocols for donning and doffing will be followed when in direct care of COVID positive residents. Education will take place by Administrator/DON or designee. All staff will be trained prior to their next shift and all training will be complete by December 2, 2020. 3. The staff will wear their masks correctly. All staff will be trained prior to their next shift and training will be done by the Administrator/ DON or designee and be complete by December 2, 2020. 4. The Social Service Designee educated all residents on mouth and nose coverings during resident care on 11/25/2020. All residents will be highly encouraged to wear face masks when out of their rooms and during resident care. 5. Staff and Residents will be trained on proper hand hygiene by the Administrator/DON or designee. All staff will be trained before they work their next shift and all training will be completed by December 2, 2020. 6. Residents that smoke will have new smoking assessments completed and will be supervised while smoking to ensure the rules of not sharing smoking items and social distancing are being maintained. Markers will be placed in the smoking area to identify the proper distance to promote social distancing. 7. All Residents that leave the facility for an overnight stay will be isolated to their room for 14 days or until 2 weekly COVID-19 tests are shown to be negative. Residents will be monitored for symptoms twice a day. 8. Ongoing COVID-19 precaution training will be done by the Administrator/ DON or designee, at least monthly and when updated guidance is issued. 9. The positive COVID-19 Residents will be kept in their rooms with the door closed. The bathroom will not be shared with the residents in the next room. A commode will be placed in the positive resident room. Staff will be limited on entrance. The charge nurse, one C.N.A. and one housekeeper is all that is allowed in the room during each shift. If the resident requires restorative services, the restorative aide will use all appropriate PPE required while providing the service. The positive resident will have vital signs taken three times a day for symptoms. The facility will have a separate housekeeping cart with supplies and equipment to be used only for isolation rooms. Staff will be trained to clean all vital sign equipment with EPA approved disinfectant in between each resident by the NHA/DON or designee. All staff will be trained prior to their next shift and all training will be completed by December 2, 2020. 10. Upon receipt of all resident tests, the facility will develop a surveillance system which will identify all positive residents and surveillance tracking to determine how COVID is being spread throughout the facility. D. Removal of immediate jeopardy On 11/25/2020 at 9:00 p.m. the NHA was informed the immediate jeopardy was removed based on the facility's implementation of the above plan. However, deficient practice remained at an F level, potential for more than minimal harm that was widespread. III. Systemic failure to maintain an effective infection prevention and control program A. Failure to isolate readmitted residents and ensure staff donned PPE - gown, mask, gloves, and eye protection - when providing care for residents in isolation for confirmed and suspected COVID-19. 1. Facility policy and procedure The Coronavirus Exposure Control policy and procedure, last revised 4/15/2020, provided by the emergency manager (EM) on 11/23/2020 at 1:00 p.m., revealed in pertinent part, Droplet precautions shall be implemented for residents with suspected or confirmed Coronavirus for 14 days after illness onset or until 48 hours after the resolution of fever and respiratory symptoms, whichever is longer. Staff shall follow the facility's transmission-based precautions procedures while the droplet precautions are in effect. 2. Professional reference According to the Centers for Disease Control and Preventions (CDC), Responding to Coronavirus (COVID-19) in Nursing Homes, Considerations for new admissions or readmissions to the facility, updated 4/30/2020, retrieved on 12/1/2020 from: www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, Newly admitted or readmitted residents should be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE, which includes use of an N95 or higher level respirator (or facemask if a respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. Healthcare Providers (HCP) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to reuse. 3. Resident #1 a. Resident status Resident #1, age 72, was admitted on [DATE]. According to November 2020 computerized physician orders [REDACTED]. The resident did not have a minimum data set (MDS) assessment completed yet. According to the 11/16/2020 nursing review upon admission, the resident was alert and oriented to person and situation and required extensive assistance with most of his activities of daily living (ADLs). b.Record review An 11/16/2020 social service admission note revealed the resident was picked up from a rehab facility in the facility van and brought to this facility and put on two week quarantine. According to an 11/13/2020 laboratory report, Resident #1 was tested on [DATE] for COVID-19 and positive results were reported on 11/13/2020. c. Observations The following observations were made on 11/23/2020: -At 9:45 a.m., Resident #1's room had an isolation cart outside the door to the room in the hallway. A sign was posted for droplet/contact isolation including eye protection that was on top of the cart. The door to the room was wide open and the resident was sitting inside the doorway in his wheelchair. -At 11:45 a.m., Resident #1's room door was open and Resident #1 was sitting in his wheelchair in his room wearing a mask. -At 1:03 p.m., certified nurse aide (CNA) #1 took Resident #1's lunch plate straight from the kitchen to his room. She set the plate down on the isolation cart outside the room and put on a pair of gloves without performing hand hygiene first. She was wearing a surgical mask. She did not put on a gown or have eye protection on when she entered the room. She took the plate and set it on the over the bed table and uncovered the plate. She did not offer or assist the resident with hand hygiene prior to serving the food or before leaving the room. She removed her gloves at the door of the room, threw them away, came out of the room and walked down the hallway without doing hand hygiene. The following observations were made on 11/24/2020: -At 7:50 a.m., Resident #1 was sitting in his wheelchair in his room with the door wide open, eating his breakfast. -At 8:15 a.m., housekeeper (HSKP) #1 entered Resident #1's room wearing a pair of gloves and an N95 mask. She did not have on a gown or eye protection. She was helping the resident try to find his cell phone by looking all around the room and under the furniture. CNA #2 entered the room wearing a surgical mask and gloves to assist in finding the resident's phone. She was not wearing a gown or an N95 mask. Neither performed hand hygiene prior to putting on their gloves. Both exited the room after removing their gloves. The CNA went across the hall to use alcohol based hand sanitizer (ABHS), however, the housekeeper continued to walk down the hall without performing hand hygiene after removing her gloves. -At 8:27 a.m., HSKP #1 entered Resident #1's room again wearing only an N95 mask and gloves. She did not perform hand hygiene prior to putting on the gloves. The housekeeper took out her personal phone and dialed the resident's phone number to see if they could locate the resident's phone. She then put her phone back into her pocket without cleaning it first. She them attempted to have the resident stand up out of his wheelchair when CNA #2 entered the room to assist her. CNA #2 entered the room with only a surgical mask and gloves on. She did not perform hand hygiene before putting on the gloves. CNA #2 assisted Resident #1 to remove his phone from his pant leg. Afterwards, HSKP #1 and CNA #2 exited the room after removing their gloves and neither performed hand hygiene afterwards. -At 9:05 a.m., licensed practical nurse (LPN) #1 entered Resident #1's room wearing full PPE, including gown, gloves, surgical mask, and a face shield, to administer the resident's medications. Before exiting the room, the LPN removed her gloves, then her gown and threw them away. She gathered up the trash bag and walked out of the room and removed her face shield by grabbing the sides of the shield. She then walked down the hallway, opened the door to the dirty utility room and entered to throw the trash away, cleaned the shield and washed her hands. d. Facility records According to the facility's list of COVID-19 test results from 11/23/2020, HSKP #1 tested positive for COVID-19. 4. Resident #2 a. Resident status Resident #2, age 54, was admitted on [DATE] and readmitted [DATE]. According to the November 2020 computerized physician orders [REDACTED]. The 9/8/2020 MDS assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent with all his ADLs except he required limited assistance of one person for bathing and dressing. b. Record review The November 2020 CPO revealed Resident #2 had follow up appointments with physicians on 11/11/2020, 11/25/2020 and 12/16/2020. An 11/9/2020 daily progress note revealed the resident was out of the facility at 9:00 a.m. for physician appointments. An 11/10/2020 daily progress note revealed the resident returned to the facility at 8:10 p.m. from a doctor's appointment in a nearby city. (This city according to the County COVID-19 status was in a red/severe risk county). Observations made during the survey on 11/23/2020, 11/24/2020 and 11/25/2020 revealed Resident #2 was throughout the facility, in the hallways, dining area, television room, nurses station and outside in the smoking area. He was not wearing a mask, was not [MEDICATION NAME] social distancing and was not staying isolated in his room. 5. Staff interviews CNA #1 was interviewed on 11/23/2020 at 1:10 p.m. She said Resident #1 was supposed to be in isolation with precautions because he was a new admission to the facility. She said the nurse told her it was not necessary to wear a gown when entering the room, only gloves and a mask. LPN #1 was interviewed on 11/24/2020 at 9:15 a.m. She said Resident #1 had tested positive for COVID-19 at the facility he transferred from so they had implemented 14 day isolation precautions and full PPE should be used whenever entering the room. She said she was not able to clean the face shield when she came out of the room because the appropriate cleaning supplies were not available so she had to go down to the dirty utility to get it. She said she should have performed hand hygiene when she came out of the room but had her hands full with the trash and face shield. She said she was not aware the rest of the staff was not using the appropriate PPE when they entered the isolation room. CNA #2 was interviewed on 11/24/2020 at 9:45 a.m. She said she was told by the nurses it was not necessary to wear all the PPE in the isolation room. She said she was told she could go in with only gloves and a mask especially if they were not providing any type of personal care. CNA #2 said she was Resident #2's spouse and was taking him out of the facility approximately twice a month for physician appointments in the city. She said because the appointments were scheduled so early in the morning that they stayed in a hotel room. She said she tried to get Resident #2 to wear a mask when he was out but he was not always compliant. She said she thought that the resident should isolate when he returned but the facility was not mandating it so she thought it was okay. The nursing home administrator (NHA) and director of nurses (DON) were interviewed on 11/24/2020 at 10:30 a.m. The DON said any staff caring for a resident on isolation precautions should be wearing full PPE when entering the resident room, including gloves, mask, gown and face shield and/or goggles. The NHA said she preferred if the staff wore goggles and a face shield when entering an isolation room. The DON said hand hygiene should occur before and after putting on and taking off gloves. She said the door to the isolation room should also remain closed as much as possible. The NHA said they did not make Resident #1 go on isolation precautions when he returned from overnight stays because she had not thought of it being an issue but agreed that further precautions needed to be implemented when the resident returned from overnight appointments. B. Failure of resident's not wearing masks and staff wearing masks inappropriately 1. Professional reference According to the Centers for Disease Control and Preventions (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 Pandemic, Implement Universal Source Control Measures'' updated 11/4/2020, retrieved on 12/2/2020 from: www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed in pertinent part, Facemasks should cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Resident's should wear their own cloth mask when out of their rooms or when others are around. HCP should wear a facemask at all times while they are in the healthcare facility, including in break rooms and other spaces where they might encounter co-workers. Hand hygiene should be performed immediately before and after any contact with their face mask. 2. Observations The following observations were made on 11/23/2020: -At 9:48 a.m., Resident #7 and another female resident were sitting in recliners by the nurse's station. Another female resident, in a wheelchair, was sitting between them and none of them were wearing masks and were within less than six feet of each other. Two male residents were sitting next to each other, less than six feet apart, in the television room next to the nurse's station and neither were wearing masks. Staff sitting at the nurse's station table and walking by did not assist or encourage the residents to wear masks. CNA #4 was sitting at the nurse's station table with her mask under her nose. She pulled the mask up over her nose by grabbing the front of the mask. She did not perform hand hygiene after touching her mask. -At 2:00 p.m., multiple residents were sitting around the nurse's station in recliners or wheelchairs, not wearing masks and less than six feet apart. Resident #2 and another male resident were seen walking down the hallways within close proximity of each other without wearing masks. CNA #4 was sitting at the nurse's station table with her mask under her nose. -At 2:54 p.m., CNA #4 was sitting at the nurse's station table with a female resident within close proximity of less than two feet. The resident was not wearing a mask and CNA #4's mask was under her nose. She pulled the mask up over her nose by grabbing the front of the mask. She did not perform hand hygiene after touching her mask. Resident #7 was sitting in a recliner by the nurse's station and was not wearing a mask. The following observations were made on 11/24/2020: -At 7:54 a.m., HSKP #2 was cleaning room [ROOM NUMBER] with her mask under her nose. -At 7:56 a.m., Resident #2 was sitting in the television room and was not wearing a mask. -At 8:31 a.m., the medical records (MR) staff and CNA #4 were standing next to each other talking within close proximity of each other. The MR staff had her mask pulled down under her chin and CNA #4 had her mask under her nose. Both touched the front of their masks to pull them up over their noses and did not perform hand hygiene afterwards. CNA #4's mask continued to fall beneath her nose and she pulled l it back up multiple times without performing hand hygiene afterwards. -At 8:40 a.m., CNA #3 was assisting residents out of the main dining room in their wheelchairs and placing them in the sitting area next to the nurse's station without keeping them six feet apart. She did not offer, encourage or assist the residents to put on masks. -At 9:05 a.m., Resident #7 came out of her room without a mask on and went and sat in a recliner next to the nurse's station. Observations throughout the facility on 11/23/2020, 11/24/2020 and 11/25/2020 revealed the resident's did not wear masks whenever they were out of their rooms and the staff did not encourage or assist the resident's to wear masks. CNA #4 was observed throughout the facility with her mask below her nose and she did not perform hand hygiene after touching the front of her mask to pull it back up over her nose. 3. Record review According to the facility's list of COVID-19 test results from 11/23/2020, Resident #7 tested positive for COVID-19. 4. Staff interviews CNA #4 was interviewed on 11/24/2020 at 8:35 a.m. She said the residents refused to wear masks when they were out of their rooms. She said the facility had them available if the resident wanted to wear one. She said the facility had standing orders from the physician that indicated the resident had been offered and had declined the use of a face mask or cloth face covering when out of room. CNA #3 was interviewed on 11/24/2020 at 8:45 a.m. She said some of the residents would wear masks but for the most part, they did not like wearing them. She said the residents should all have a cloth mask in their rooms. The nursing home administrator (NHA) and director of nurses (DON) were interviewed on 11/24/2020 at 10:30 a.m. They said residents should be encouraged by the staff to wear a mask whenever they came out of their room. The DON said staff had been trained on the proper way to wear their masks also and this included keeping the mask over their mouth and nose and to perform hand hygiene after touching their masks. CNA #5 was interviewed on 11/25/2020 at 9:45 a.m. She said she tried to get the residents to wear their masks when the pandemic started but some of them refused and others would only leave them on for a short amount of time. She said after a while it just seemed like a waste of time so she stopped trying. C. Failure to ensure social distancing during smoking and prevent sharing of personal smoking devices 1. Professional reference According to the Centers for Disease Control and Preventions (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 Pandemic, Implement Universal Source Control Measures, Encourage Physical Distancing, updated 11/4/2020, retrieved on 12/2/2020 from: www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed in pertinent part, Implement aggressive social distancing measures (remaining at least six feet apart from others). Remind residents to practice social distancing, wear a cloth face covering and perform hand hygiene. 2. Observations Observations made throughout the survey on 11/23/2020, 11/24/2020 and 11/25/2020 revealed Resident #2 pushing Resident #6 in his wheelchair either out to the smoking area off the television room by the nurse's station or out the doors past the beauty shop to the side of the building. Neither resident was wearing a mask when out of their rooms. On 11/25/2020 at 9:56 a.m. Resident #2, Resident #6 and two other male residents were outside in the smoking area, sitting next to each other, passing a glass pipe between them. The seating in the smoking area did not allow for proper social distancing of at least six feet and there were no markings to indicate proper spacing. There was no signage to remind and encourage social distancing in the smoking area. 3. Staff interviews CNA #2 was interviewed on 11/25/2020 at 9:45 a.m. She said none of the residents actually smoked cigarettes and had been told that they were not to share their pipes. She said each of the residents were independent smokers and did not require supervision. CNA #5 was interviewed on 11/25/2020 at 10:50 a.m. She said the residents that went out to smoke were all independent smokers and had been told not to share their pipes with each other. She said sometimes the residents would go out the side door, to the side of the building to smoke if the wind was blowing too hard. The NHA was interviewed on 11/25/2020 at 2:30 p.m. She said the residents that smoked had been educated previously about not sharing their smoking items and were encouraged to socially distance. She acknowledged the smoking area was not set up to promote social distancing and said markings would be placed on the ground to indicate six feet distance to help remind the residents. D. Failure to ensure ongoing COVID-19 training and updates 1. Professional reference According to the Centers for Disease Control and Preventions (CDC), Preparing for COVID-19 in Nursing Homes, updated 11/20/2020, retrieved on 12/2/2020 from: www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed in pertinent part, Provide information about COVID-19 (including information about signs and symptoms) and strategies for managing stress and anxiety. Regularly review CDC's Infection Control Guidance for Healthcare Professionals about COVID-19 for current information and ensure staff and residents are updated when this guidance changes. Educate residents and families on topics including information about COVID-19, actions the facility is taking to protect them and/or their loved ones, any visitor restrictions that are in place, and actions residents and families should take to protect themselves in the facility, emphasizing the importance of hand hygiene and source control. 2. Record review According to the Respiratory Surveillance Line List, the facility's first positive COVID-19 test was obtained on 10/19/2020 with the results being received on 10/23/2020. 3. Staff interviews The NHA was interviewed on 11/23/2020 at 12:05 p.m. She said the DON had a binder that was kept at the nurse's station that had on-going education for the staff to review. CNA #1 was interviewed on 11/23/2020 at 1:10 p.m. She said she was told the facility had their first positive case of COVID-19 sometime in the middle of October. She said the facility put up a sign on the time clock that said the staff would be tested weekly on Mondays but no other education was provided. She said it had been months since they had received any new education about [MEDICAL CONDITION]. CNA #2 and CNA #5 were interviewed on 11/25/2020 at 9:45 a.m. They said they had not received any new training about COVID-19 in several months including after the facility first obtained their first positive case of COVID-19. LPN #1 was interviewed on 11/25/2020 at 10:05 a.m. She said the facility had not provided any new education about [MEDICAL CONDITION] in several months. She said the DON had kept a book at the nurse's station that contained educational handouts but she had not seen it in a while.