**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** X. Failed to ensure medical devices were not plugged into non-medical grade power strips. A. Environmental tour and staff interviews On 12/12/19 at 9:00 a.m. and on 12/16/19 at 2:30 p.m. the following observations were made of medical equipment being plugged into non-medical grade power strips: - Rooms #1105, #1208, #1204 and #1510 the oxygen concentrators were plugged into power strips. - room [ROOM NUMBER] the continuous positive airway pressure (CPAP) machine was plugged into a power strip. - room [ROOM NUMBER] the bed and oxygen concentrator were plugged into a power strip. - room [ROOM NUMBER] the gastric tube feeding dispensing machine was plugged into a power strip. The environmental tour was conducted with the maintenance director (MTD), his assistant the maintenance worker (MW) and the housekeeping manager (HM) on 12/16/19 at 2:30 p.m. The MTD said medical equipment could not be plugged into power strips and only plugged into the wall. He said some of the rooms needed more power outlets installed and since there were not enough outlets some of the families and residents were plugging the medical equipment in the power strips. The MTD, MW and HM were observed unplugging the medical equipment and plugging it into the walls in rooms #1105, #1208, #1204, #1402, #1509 and #1510 as they were being shown the concerns during the tour. In room [ROOM NUMBER] the MTD said he wanted to communicate with the floor nurse for a safe time when the resident was not using it to unplug the feeding tube machine. Based on observations, record review and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents. This failure affected one (#33) of 56 total sample residents. Specifically: Falls -The facility failed to protect Resident #33 from numerous falls which resulted in major injuries. Equipment -The facility failed to ensure space heaters were not used in resident areas. -The facility failed to ensure medical devices were not plugged into non-medical grade power strips. Findings include: I. Falls A. Immediate jeopardy 1. Situation of Immediate Jeopardy Resident #33, age [AGE], was admitted on [DATE] with a readmission date of 7/14/19. According to the December 2019 computerized physician orders (CPO) the diagnoses included, essential (primary) hypertension, type 1 diabetes mellitus with hyperglycemia, traumatic subdural hemorrhage with loss of consciousness of specified duration, muscle weakness, unspecified lack of coordination, cognitive communication deficit, fracture of unspecified part of the body left mandible, subsequent encounter fracture with routine healing, fracture of unspecified part of the body right mandible, subsequent encounter fracture with routine healing. The 9/18/19 minimum data set (MDS) assessment revealed the BIMS interview could not be conducted because the resident was rarely to never understood. He required extensive assistance from one person for bed mobility, dressing, toilet use, and personal hygiene, extensive assistance from two people for transfers, was totally dependent with eating, and was not walking (used a wheelchair). On 12/17/19 at 11:46 a.m., the nursing home administrator (NHA) was notified Resident #33 sustained 26 falls within five months with major injury, which included, numerous major injuries which included, head trauma, bone fractures, lacerations, and black eyes. Resulting in a significant cognitive and mobility decline with a recent diagnosis of traumatic brain injury (TBI). These failures created a situation of immediate jeopardy. The facilities response was as follows: Resident (#33) was placed on 1:1 for monitoring of intervention effectiveness on 12/17/19 at 11:50 a.m. 1:1 to use call light and or ask floor staff for coverage when a break is needed. These interventions were implemented on December 17, 2019. - Physician order for Hospice Consult 12/17/2019 -Restorative Nursing Plan ordered/implemented, stand pivot transfer assist to promote upright functional mobility. Assist with ambulation as tolerated using walke-6 times/week for 15 min. Restorative Nursing Program to be completed by CNA (certified nurse aide) and monitored by DON (director of nurses). -Vitamin D B-12 Level (Drawn 12/17/2019 WNL (within normal limits) -Motion Lights placed in room to improve lighting and behaviors due to impulsivity on 12/17/2019 -Binder with the following information has been presented to staff with education. The binder is kept in the residents room. Behavior Modification Techniques Likes/Dislikes pulled from care plan: -Likes: Reading the newspaper, walking, lavender oil, hip hop on his phone, going outside, watching TV, snacks, enjoys comedies and National Geographic -Dislikes: close supervision, group activities, helmet -New staff will be educated during orientation to the floor. Education initiated by the DON on 12/17/19 to include but not limited to floor staff. Training to include residents fall mitigation efforts to reduce injury. Continue to participate in Pet visits as scheduled and resident allows, at least weekly. -Knee pads, elbow pads and a variety of helmets for the resident to choose from offered and accepted. Residents requests items to be removed and they are removed when requested. Offer to resident every shift. CNA will document in POC refusal or acceptance under the Task tab. -Use a soft approach soft tone of voice, talk slowly in short simple sentences re-approach later -Monitor and track hours of sleep -Room de-cluttered, padding added to the sink and bed board. Excess furniture removed and TV hung on the wall to attempt to reduce major injury with fall. -Monitor and report changes in alertness, attention, sleep patterns, behavior, or mood to physician, DON and CED (center executive director/ nursing home administrator). -Basil plant given to resident with scheduled watering times. Interviews initiated by DON or designee with staff on the resident's unit. Questions targeted to assess the effectiveness of interventions, gain information related to residents needs for direct care staff and to implement appropriate newly suggested interventions. 1. What interventions do you feel are working to prevent falls? 2. What fall interventions are not working. 3. What suggestions do you have to prevent falls. 4. Have you received enough education related to fall interventions. -Physicians will continue to evaluate the need for additional interventions to assist in preventing falls with major injury. -On December 17, 2019 the team held an Immediate QAPI meeting to identify any root cause or trends for resident falls. Incidents reviewed to include activity during fall, staff interviews, time of day and number of falls and effectiveness of current interventions. Trend identified for two times frame, scheduled timed toileting was added at 1400, 2200, 0600. Scheduled water times for plan on Tuesday/Friday at 1600. CNA Fall Care communication tool was developed 12/17/2019. -Nurses will monitor completion of documentation, intervention appropriateness/effectiveness each shift, to be reviewed by the IDT (interdisciplinary team) . 2. Based on review of the facility's removal plan, observations and record review, the NHA was informed the Immediate Jeopardy situation was removed on 12/18/19 at 11:00 a.m. However, deficient practice remained at a G level. The NHA said the abatement plan interventions had been implemented as of 12/17/19 after the immediate jeopardy was called. B. Facility Policy The fall policy dated 3/15/16 documented in pertinent parts, .Patients will be assessed for fall risks as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause Communicate patients fall risk status to caregivers, Develop individualized plan of care, Review and revise care plans regularly Conduct Interdisciplinary team meeting with 72 hours of falls The Center Executive Director (NHA) and Center Nurse Executive (director of nurses) will conduct a post fall review . II. Resident #33's- multiple falls with major injury The nurse's notes, interdisciplinary team (IDT notes) event summaries and care plan were reviewed. The medical record documented the resident had fallen at least 25 times between 7/11/19 and 12/15/19. The facility failed to protect the resident from multiple falls, and two falls resulted in major injuries, and ten with minor injuries and 13 falls with no injuries. Although an event summary report was completed on the falls, the facility failed assess and implement effective fall interventions and re-evaluate the fall interventions after a fall for effectiveness. The facility failed to investigate to identify root cause of falls to determine trends then modify the fall interventions and failed to provide adequate supervision to prevent further falls and/or further injury from frequent falls. As a result the resident sustained numerous major injuries which included, head trauma, bone fractures, lacerations, and black eyes. Resulting in a significant cognitive and mobility decline with a recent diagnosis of traumatic brain injury (TBI). Although, the 25 (no event summary completed for 8/20/19) event summary reports were completed, and had a root cause conclusion, the reports documented the events of the falls and poor safety awareness and did not have a root cause. On 9/4/2019 at 4:39 p.m. the physician progress note documented in pertinent part: . the resident was alert, with no acute distress, his jaw wired shut, and he was unable to verbalize and has a bruise over the left eye. (Traumatic brain injury) TBI without LOC of unspecified duration sequelae. Given the patient's fall history over the past year, I think he has sustained enough head trauma and accumulated enough injury to be consistent with traumatic brain injury. His personality and decision-making capacity certainly is impaired compared to 6-12 months ago. I discussed this with the NP as well as nursing and the patient's mother. I think the patient has sustained significant brain trauma that has led to at least a mild cognitive deficit . Prior to the falls with major injuries which occurred on 8/20/19 the resident experienced two falls with minor injuries, and three falls with no injury. The resident experienced six falls with minor injuries and five falls prior to the second fall with major injury on 9/19/19. The falls with major injuries were as follows: 1. Major injury fall #1 -On 8/20/19 the IDT progress note documented, social services director (SSD) received call from a nearby medical office that Resident #33 stopped in the medical office and did not feel well. The medical office said called the facility to report that Resident #33 had fainted face first to the floor, and as a result suffered a laceration to the front and back of his head and appeared to have broken teeth. The resident was sent to the emergency room. -On 8/24/19 the progress note documented the resident was readmitted to the facility after a stay in the hospital for post/trauma/accident. The resident had a fracture of mandible fracture and a subdural hematoma. His jaw was wired shut. The medical record failed to show an event summary report was completed in relation to this fall in order to identify root cause, and to evaluate interventions. 2. Major injury fall #2 On 9/19/19 at 9:26 p.m., the resident experienced a fall with the one to one sitter. The progress note documented the resident was agitated. On 9/19/19 at 7:05 p.m., the event summary report documented, the agency CNA stated that she stood up to call a facility aide to relieve her, and the resident stood up to follow her and fell forward onto the floor. The resident injured his knees and elbows bilaterally. The report documented the interventions which were in place prior to the fall were as follows: - Medications reviewed by NP and dose adjustments were made to his insulin and B/P medications. -Monitor vital signs, including orthostatic B/P as needed and report to MD as indicated. -NP reviewed medications and made adjustments with his insulin and B/P medications. -Offer/assist resident with urinal/commode as requested/needed. -Staff continue to remind him to ask for assistance. -Utilize night light in the room/bathroom. -Medication evaluation as needed. -Place call light within reach when in bed or close proximity to bed. -Resident had one on one supervision. After the fall an x-ray was ordered, as the resident was complaining of pain. The report documented, the resident refused all the imagining to be completed and he was sent to the emergency room for evaluation. 3. A summary of the falls with minor injuries were as follows: --On 7/11/19 at 1:30 p.m., the event summary report documented, the resident was in the lobby, he stated he was sitting for about 15 minutes, stood up and started walking. He got dizzy and fell to his knees. The resident's blood glucose (BG) level was 358. He was assisted back to his room. The neurological check (neuro checks) and assessment were completed. The report documented the preventative measures which were in place prior to the fall were call light and personal items were within reach, and room was clutter free. The resident experienced an abrasion to bilateral knees. The corrective action was the resident had a history of dizziness, and had been instructed not to ambulate (walk) self or go outside. The resident was impulsive. The progress note at 3:07 p.m. read in pertinent part, Orders obtained include: assist resident to his room and encourage him to use call light for assistance . -On 7/26/19 (no time indicated), the event summary report documented, the resident was noted to be walking outside the facility this shift. Resident traveled to Target shopping center where two employees discovered the resident. Resident returned to the facility via employee transportation. Resident #33 stated the scraps and cuts on his right knee and right palm of hand, came from a fall in the parking lot. -On 7/26/19 at 1:35 a.m., the event summary report documented, the resident was observed on the floor next to bed. The resident received a 3 cm laceration to the back of the resident's head and abrasion on his left elbow. Resident had regular socks on at the time of the fall. The resident was educated to use the call light when trying to go to the bathroom. Non-slip socks were placed on the resident. Preventative measures were put into place prior to the fall included, call light and personal items within resident's reach and clutter free environment. - On 9/2/19 at 1:00 p.m., the event summary report documented, the resident was found on the floor face down. The resident was assisted into a chair then assessed by the licensed nurse. The resident had hit the back of his head (soft bump noted). The report documented a meeting was to be scheduled with the family to discuss his multiple falls. -On 9/5/19 at 2:15 p.m., the event summary report documented, the primary nurse reported that the resident had a fall in his room and sustained lacerations on his forehead. The nurse practitioner ordered STAT x-ray of the c-spine and skull. Resident #33 said he was trying to pick up the TV remote and he fell. --On 9/5/19 at 4:25 p.m., the event summary report documented, NP had just finished speaking to the resident regarding increased recent falls and she was standing at nurse's cart when NP and RN heard a loud crash from the resident's room. When they entered his room they found him lying face up on the floor, unresponsive. Resident had a heartbeat with agonal breathing. Staff assisted the resident with breathing via ambu bag and called 911. Resident was responsive, breathing independently and able to answer questions when emergency medical services (EMS) arrived. Resident transported to ER for further evaluation. -On 9/11/19 at 12:28 a.m., the event summary report documented, the resident was wheeling himself around the unit, he stood up, resulting in a fall and landed on his right elbow. Resident reported pain in his elbow and it was red. He was able to move all extremities. A STAT x-ray of elbow was ordered due to pain. Resident continued to try and stand even when educated that he was too weak. The license nurse and certified nurse aide (CNA) were taking turns with 1:1 attention for the resident. -On 9/18/19 at 1:30 a.m., the event summary report documented, the resident was found on the floor of his room. He had bleeding to his upper eye from the previous fall. The resident had fallen the previous day on 9/17/19 at 9:15 a.m., by rolling out of bed. He said he wanted to get into his wheelchair. -On 9/19/19 at 6:30 p.m., the event summary report documented, the resident was transferring from his wheelchair to bed, and threw himself backwards onto the bed, striking his head on the door handle of the door. The incident was witnessed and he had a bump on the upper back of his head. -On 12/10/19 at 5:00 a.m., the event summary report documented, the resident was noted to be on the floor in his room. Resident said he hit the back of his head. The report documented, the care plan was followed. The interventions put into place was to attempt to assist the resident out of bed as early as possible when he awakes. IV. Resident fall history after 9/13/19 Abbreviated survey On 9/13/19 during an abbreviated survey, the facility was cited for F 689 at a harm level; upon exit (9/13/19) until compliance (10/7/19) Resident #33 also sustained two falls (see above). After the facility was back in compliance the resident sustained: - On 10/19/19 at 2:00 p.m., the event summary report documented, the resident was sitting in his geri-chair when he told the sitter he had to go to the bathroom. The sitter was positioned in front of the chair, she turned slightly to unplug the tube feeding (TF), he then stood and slid to the floor. He did not hit his head. - On 10/28/19 at 7:15 p.m., the event summary report documented, the sitter informed the nurse while the resident attempted to ambulate independently after sitting up in bed; the resident was unsteady and fell back onto the bed. - On 11/28/19 at 4:00 p.m., the event summary report documented, the resident had an unwitnessed fall and was found on the floor in the library room. The report documented no injury. - On 12/6/19 at 4:00 p.m., the event summary report documented, the emergency bathroom light came on in the residents room. The resident was found in the bathroom between the toilet and the wheelchair (w/c). The w/c brakes were locked. The resident was sitting on the floor facing the wall with his pull-ups and pants just above his knees. He was not able to tell the nurse what had happened. He had rapid respirations and was wide eyes as if very frightened. The resident experienced a second fall on 12/6/19 at 8:15 p.m., the resident fell while trying to stand up in the dining room. Resident #33 became agitated with staff when attempting to redirect. - On 12/10/19 at 10:50 a.m., (second fall for the day) the event summary report documented, the resident was in the hallway, and was seen holding onto the rails with buttocks on the floor, w/c behind him. A CT-Scan was ordered for his head. -On 12/15/19 at 8:40 p.m. the event summary report documented, the resident self propelled in w/c, closely monitored by nursing staff. During the end of shift reported the resident rolled around the corner to another hallway away from nurses. Residents in the atrium hollered to get the nurses attention that the resident was on the floor. Resident noted on the floor with mild twitching lasting approximately 30 seconds. Once eyes opened, they were slow to respond. Pupils sluggish and unchanged. V. The facility failed to implement effective fall interventions and re-evaluate the fall interventions after a fall for effectiveness. The director of nurses (DON) was interviewed on 12/17/19 at 9:45 a.m. The DON said that after each fall the care plan was updated. She said the care plan was updated to include, how and when the resident fell, then the interventions were listed. She said the resident had experienced so many falls, that the program had a difficult time with keeping all of the information. The care plan last updated, on 12/10/19 identified the resident was at risk for falls related to experiencing dizziness, diabetes mellitus (DM) with uncontrolled blood sugars (BS). The resident was ambulatory with poor safety awareness and impulsiveness. The care plan was updated with dates and interventions after each fall included: -Utilize night light in the room/bathroom. 7/29/19 -Medication evaluation as needed. 7/29/19 -Place call light within reach, anticipate resident's needs as he may not use the call light related to the decline in cognitive status. 7/29/19 -Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. 7/29/19 -When the resident is in bed, place all necessary items within reach. 7/29/19 -Monitor for and assist with toileting needs. 7/29/19 -Encourage resident to attend all activities that maximize their full potential while meeting their need for socialization. 7/29/19 -Monitor vital signs including orthostatic blood pressure as needed and report to MD. 7/29/19 -Offer/assist the resident with the urinal/commode as requested/needed. 7/29/19 -Assess for changes in medical status, pain status, mental status and report to MD.7/29/19. -NP reviewed medications and made adjustments to his insulin and B/P medications. 8/12/19 -Medications reviewed by nurse practitioner (NP), dose adjustments made to insulin and blood pressure (B/P) medications. 8/18/19 -Resident has a history of dizziness and falling, staff continue to remind the resident to ask for assistance. The resident is impulsive and continues to transfer on his own. 9/6/19 -Resident was placed in a recliner in the atrium for closer supervision. 9/10/19 -Resident has refused therapy, will try again and see if he will participate. 10/19/19 -Soft helmet related to recent fall and impulsiveness. Therapy to address fall. 10/29/19 -The wheel chair cushion was re-evaluated with the second fall.12/10/19 The facility failed to show that the interventions were evaluated for effectiveness, and were timely. The interventions in the event summary report, had listed, he was reminded to use the call light and to wait for assistance, however, this intervention proved to not be effective as he continued to fall 23 more times since the intervention was put into place. The intervention of encourage resident to attend all activities, was added to the care plan however, according to the interview with the nursing home administer on 12/17/19 at 3:45 p.m., the resident did not like to attend group activities. Review of the activity participation records for November and December 2019 showed he did not attend activities that he preferred in room activities. The regional nurse consultant said on 12/17/19 at 3:45 p.m., he was being evaluated for pet therapy as he liked dogs. The resident was observed on 12/10/19 at 3:21 p.m. in his room with a 1:1 CNA. They were sitting in the room, not engaged in any interactions, i.e talking or other activities. The resident began moving his feet back and forth, the CNA got up and took him to the bathroom. Afterwards, they returned to where they were sitting previously. They remained in the room until 4:06 p.m. The CNA took the resident out of his room and walked around the unit. The intervention of resident refused therapy was added on 10/19/19 and that they would attempt again if he would participate. However, the facility was aware he was not wanting to participate in therapy according to the interview with the NHA on 12/17/19 at 3:45 p.m. The NHA said the resident was referred to therapy 13 times and he refused nine times and worked with therapy five times. The intervention with soft helmet was added on 10/29/19, however, he had 20 falls prior to the soft helmet addition on the interventions. The summary event reports showed he had eight unwitnessed falls, and eight falls which resulted in a head injury or report that he hit his head. The remaining four falls were witnessed and staff reported he did not hit his head. The NP was interviewed on 12/17/19 at 12:50 p.m. The NP said the resident did not like to wear the soft helmet and he would throw it across the room. The event summary reports were reviewed and none of them reported the soft helmet was on when the resident sustained falls and injuries. The NHA was interviewed on 12/17/19 at 3:45 p.m. The NHA said the resident was always walking, and enjoyed going outside to walk. She said he was difficult to keep sitting, as he always enjoyed walking. The facility failed to include the resident in a restorative walking program. The medical record showed no evidence the resident was on a restorative program which would have allowed the resident to safely engage in an activity he enjoyed. The care plan failed to include, from the event summary report on 12/10/19 showed the interventions put into place after the fall was to attempt to assist the resident out of bed as early as possible when he awakes. VI. The facility failed to ensure the certified nurse aides and the licensed nurses were aware of the plan of care Observations On 12/16/19 at 9:45 a.m., the registered nurse (RN) #3 was observed to keep the resident near the nurses cart. She was observed to pass medications to other residents. When she would leave the cart to go to another resident room, she would push the resident to the room and have him sit outside the room while she cared for the other resident. On 12/16/19 at approximately 4:00 p.m., the certified nurse aide was sitting with the resident. The CNA said he was on a one to one sitter with Resident #33. VII. Interviews RN #3 was interviewed on 12/16/19 at 9:43 a.m. she stated she was pretty much 1:1 with him. She said she wasn't sure if there was an order or not but he would get up and fall. RN #3 said she tried to keep him close. She said she had him sit at the cart while she went into other rooms so he could be close to her The director of nurses (DON) was interviewed on 12/17/19 at 9:45 a.m. The DON confirmed the resident had fallen 26 times since July 2019. She said an event summary and fall investigation should be completed after each fall. She said interventions should be implemented and added to the care plan after each fall. She said when the IDT reviews the falls then the IDT team will add more interventions as needed. She said she keeps a log of all falls, however, she does not have any information from July 2019 to September 2019. She said a unit manager was keeping the log and she could not find the information. She said she took over monitoring the falls in September 2019. She said a fall investigation should have been completed when he fell outside of the facility. The DON said Resident #33 had a sitter since September 2019, however, she said it was discontinued in early November 2019 as the criteria to use a one on one sitter was to prevent falls, however, he had three falls with the one on one sitter, and the IDT reviewed the falls and determined to remove the one on one sitter, and just keep an eye on him. She said the NP reviewed the medication on 8/14/19. She said the soft helmet was added to the care plan 10/29/19. The DON said in July 2019, he was alert and oriented, and he has now had a significant change in his cognitive status. She said it was a combination of falls and diabetes. The DON said the NP said that he had a traumatic brain injury. The DON said the logs were used to track and trend, however, she confirmed she only had the logs since September. She said most of his falls were in his room, but she was not sure of the times he fell. The medical director was interviewed on 12/17/19 at 12:50 p.m. The MD said earlier in the resident's stay at the facility he had been the primary physician. He said he was aware the resident had sustained numerous injuries, which included bone fractures and head trauma. He said Resident #33 had been discussed at the quality assurance performance improvement (QAPI) meeting and the falls were unresolvable until his condition worsened. He said the sitter was unsuccessful as the resident became angry. He said the resident had lost all muscle tone and when he stood up he fell. He said there was nothing more they could do to keep him from falling. He said if there was anything that could prevent him from falling, it would of been added a year ago. The MD said the facility could not be held accountable for keeping people safe when they made poor decisions. The primary physician (PP) was interviewed on 12/17/19 at 12:50 p.m. The primary physician heard the medical director's reasons for the falls and then replied the resident had type one diabetes and he also had a condition that his blood pressure dropped when he stood. The tachycardia could contribute to passing out. He said the resident was extremely brittle diabetic. His blood sugar was difficult to regulate. The primary physician confirmed the resident had sustained subdural hematomas as a result of hitting his head. He said the resident had poor judgement. The primary physician said the resident had fallen when he resided at an assisted living prior to moving to the facility. The PP said short of chemically restraining the resident he was not sure what else could be done. The NHA was interviewed on 12/17/19 at 3:45 p.m. The NHA said while he had the sitter, he would become agitated and did not like the sitter. She said the resident was not on a one to one sitter prior to the immediate jeopardy at 11:50 a.m. She said the staff take it upon themselves to keep him on a one to one, because they know he has had multiple falls. He liked to go outside and he wears a wander guard as he did not sign out like he should. She said the only resort they had to keep him safe was restrain him. She said the family was pleased with the care and had no suggestions. IX. Space heaters A. Observations On 12/9/19 at 12:00 p.m., residents were observed in the main dining room awaiting their meal. The dining room had three space heaters which were spread across the dining room. The space heaters were currently being used. On 12/9/19 at 2:00 p.m., room [ROOM NUMBER] had a space heater. The resident was in her room lying in bed. B. Interviews The MTD was interviewed on 12/9/19 at 4:50 p.m. The MTD said that the space heaters had been in the building since the day after Thanksgiving. He said the circle pump on the was being replaced as it was not pumping hot water through the furnace. He said the parts had been ordered, but the space heaters four in the dining room were being used and one in 801 and one in 1202. He said that the main dining room was cold and therefore the space heaters were requested to assist in warming the dining room. The MTD said the space heaters did not have breakers on them, so the nurses were responsible to turn them off and on. He said he knew the facility was prohibited from using space heaters. The nursing home administrator (NHA) was interviewed on 12/9/19 at 5:07 p.m. The NHA said she knew she could not use space heaters in the facility, however, she would rather use the space heaters, then have the resident ' s be cold or to infringe on their rights to move. She said she would rather take a citation then let the residents be cold. The NHA said she would not have the space heaters removed. C. Follow-up On 12/9/19 at approximately 7:00 p.m., theNHA had the four space heaters in the dining[TRUNCATED]