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

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

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

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

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication storage rooms and three of five medication carts.Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened;-Ensure expired medications were removed and discarded from medication carts and storage refrigerators; and,-Ensure the temperature in a medication storage refrigerator was maintained within an acceptable temperature range.Findings include:I. Facility policy and procedureThe Medication Storage policy, dated January 2025, was received by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It read in pertinent part, Medications requiring refrigeration or temperatures between 2 degrees celsius (C)/(36 degrees fahrenheit (F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 8 degrees C (46 degrees F) and 15 degrees C (59 degrees F). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.II. Failed to ensure medications were labeled with the date they were openedA. Observations and staff interviewsOn 7/23/25 at 3:23 p.m. the [NAME] 1 medication cart was observed with LPN #5. The following items were found:-An opened bottle of Lastacaft (allergy itch relief) 0.25% eye drops was labeled with a resident's name, but was not labeled with the date opened.LPN #5 said dates should be labeled on medications so staff were aware of when they were opened and when they needed to be discarded.On 7/23/25 at 4:39 p.m. the East 2 medication cart was observed with LPN #8. The following items were found:-An opened bottle of Flonase 50 microgram (mcg) nasal spray (steroid nasal spray) was labeled with a resident's name but was not labeled with the date opened. The pharmacy issue date listed on the bottle was 5/13/25. LPN #8 said Flonase nasal spray should be discarded 60 days after being opened.III. Failed to ensure expired medications were removed and discarded from medication carts and storage refrigeratorsA. Observations and staff interviewsOn 7/23/25 at 3:10 p.m., the [NAME] 1 medication storage room and medication refrigerator were observed with licensed practical nurse (LPN) #7. The following items were found:-A Bisacodyl 10 milligrams (mg) suppository (laxative) with an expiration date of April 2024.-Two individually packaged Bisacodyl 10 mg suppositories were labeled with a current resident's name. The suppositories had expiration dates of 12/16/24 and 4/11/25.LPN #7 said any nurse on duty could clean out the medication refrigerator. LPN #7 said expired medications could potentially harm and cause damage to a resident. -A box of DexcomG6 (glucose monitoring) sensors was not labeled with a resident's name and had an expiration date of 5/31/25.LPN #7 said the sensors were not kept as floor stock and should have a resident label. On 7/23/25 at 4:39 p.m. the East 2 medication cart was observed with LPN #8. The following items were found:-An opened bottle of Nighttime Relief lubricant (moisturizing) eye drops labeled with a resident's name. The product box instructed staff to discard the medication 30 days after opening. The open date labeled on the bottle was 5/15/25. LPN #8 confirmed the eye drops should have been discarded 30 days after the open date.-An opened Advair Diskus 250 mcg - 50 mcg inhaler was inside an Advair Diskus box labeled with a resident's name. The Advair Diskus containing the medication was labeled with the resident's name. The open date on the inhaler was 5/6/25.LPN #8 said the Advair Diskus medication should have been discarded 30 days after opening.-Additionally, an opened Albuterol inhaler was inside the Advair Diskus box alongside the Advair Diskus medication. The albuterol inhaler had a resident's room number written on it, which matched the room number written on the Advair Diskus box, but the inhaler was not labeled with the resident's name. The Albuterol inhaler did not have an open date labeled on it. LPN #8 confirmed the Albuterol inhaler should not have been in the box with the Advair Diskus. She confirmed the inhaler should have had a resident's name and an open date on it. LPN #8 said she would discard both inhalers and have them reordered. LPN #8 said the night shift nurse primarily audited the medication carts, however, she said all nurses should perform audits when passing medications to look for unlabeled and expired medications.-An opened tube of Equate anti-itch cream with an expiration date of May 2024.-An opened tube of Terbinafine hydrochloride 1% (antifungal) cream with an expiration date of June 2025.-An opened bottle of Ultra sunscreen lotion sun protection factor (SPF) 30 with an expiration date of 7/1/24.IV. Failed to ensure the temperature in a medication storage refrigerator was maintained within an acceptable temperature rangeA. Observations and staff interviewsOn 7/23/25 at 3:55 p.m., the [NAME] 2 medication storage room and medication refrigerator were observed with registered nurse (RN) #4. A temperature log for the medication refrigerator was posted on the wall next to the refrigerator. The temperature reading inside of the refrigerator was observed to be 48 degrees F, which was above the appropriate temperature range of 36 degrees F to 46 degrees F. RN #4 said the temperature of the medication refrigerator should be less than 41 degrees F. RN #4 was unsure what to do for a medication refrigerator temperature reading outside of the required temperature range. He said she would have to find out. Review of the [NAME] 2 medication refrigerator temperature log revealed the following: -On 7/21/25 the medication refrigerator temperature was 55 degrees F; -On 7/22/25 the medication refrigerator temperature was 58 degrees F; and,-On 7/23/25 the medication refrigerator temperature was 58 degrees F.On 7/23/25 at 4:02 p.m., the regional director of clinical operations entered the [NAME] 2 medication storage room. She said the medication refrigerator temperature should be less than 41 degrees F. The regional director of clinical operations said staff would remove the medications currently in the refrigerator. She said she would follow up with the facility's pharmacist to determine if any of the medications needed to be discarded and re-order any needed medications. On 7/23/25 at 4:06 p.m. the facility's maintenance director (MTD) entered the [NAME] 2 medication storage room. The MTD used a temperature gun to check the medication refrigerator's. The reading on the temperature gun was 51 degrees F. On 7/23/25 at 4:20 p.m. the East 2 medication storage room and medication refrigerator were observed with LPN #8. A temperature log for the medication refrigerator was posted on the wall next to the refrigerator. The temperature reading inside of the refrigerator was observed to be 48 degrees F. LPN #8 said facility management just replaced the thermometer previously in the refrigerator with a new one, so it needed to adjust to the accurate temperature. V. Additional staff interviews and observationsThe regional director of clinical operations was interviewed on 7/24/25 at 9:46 a.m. She said she spoke with the facility's pharmacist and was told the medications in the [NAME] 2 medication storage room refrigerator were good for at least 14 days at room temperature. She said the medications were labeled with an open date of 7/21/25.On 7/24/25 at 10:08 a.m., the [NAME] 2 medication storage room was observed with RN #4. The medication storage refrigerator was not observed in the storage room. RN #4 said the refrigerator was removed and a new one was ordered. RN #4 said any new refrigerated medications received would be stored in the [NAME] 1 medication storage refrigerator until the new refrigerator arrived.On 7/24/25 at 10:17 a.m., the East 2 medication storage room refrigerator was observed with LPN #6. The refrigerator temperature was observed to be 38 degrees F.

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

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

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility document review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs), specifically nail care, received the necessary services to maintain clean, trimmed nails for two (Resident #39 and Resident #20) of two residents reviewed for ADLs. Findings included: A review of an undated facility Nail Care Competency check-off competency form indicated that staff were to, 11. Inform supervisor if nails need to be cut. (Note: Caregiver, CNA, or PCA should never cut nails. 1. A review of the admission Record revealed the facility admitted Resident #39 with diagnoses that included unspecified dementia without behavioral disturbance, hemiplegia/hemiparesis (paralysis of one side of the body), and contracture of muscle in left upper arm. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required extensive assistance of two persons for personal hygiene. A record review of Resident #39's care plan, initiated on 05/02/2019, revealed the resident had ADL self-care performance deficit. The facility developed an intervention that included caregivers were to check the resident's nail length and trim and clean them, as necessary. A facility document/staff task in the electronic health record, titled, Nail Care, was reviewed for the last thirty days. The question asked on the task form was, Nail care provided? There was no data found for the last 30 days lookback period, which indicated there was no documented nail care provided. During an observation and interview on 08/08/2022 at 11:23 AM, Resident #39 was lying in bed, in the resident's room. The resident's fingernails were approximately 1/2 inch long with brown debris underneath all the nails. Resident #39 stated that nobody in the facility would trim or clean their nails. The resident stated that a nurse told the resident that the facility would put the resident on a podiatry list to see if the podiatrist could trim the resident's fingernails. During an observation on 08/10/2022 at 4:00 PM, the resident's nails were observed and were in the same condition as the observation on 08/08/2022. The resident stated he/she wanted the nails to be trimmed but stated again that the staff told the resident that only a podiatrist could trim the resident's fingernails. The resident stated he/she remembered the conversation on 08/08/2022 with the surveyor and thought their nails would have been trimmed by now. During an interview on 08/10/2022 at 4:03 PM, CNA (certified nursing assistant) #5 and CNA #1 both stated that the nurse was responsible for trimming Resident #39's nails because the resident was diabetic. CNA #5 stated that the nurse was responsible for trimming both the fingernails and toenails. Both CNAs stated the CNAs were responsible for notifying the nurse of the resident's nails. Neither CNA could state what the resident's nails looked like. Neither CNA knew how often the resident's nails should be trimmed or where it was documented. During an interview on 08/10/2022 at 4:18 PM, Licensed Practical Nurse (LPN) #1 stated she was responsible for trimming Resident #39's nails and it should be done every Sunday. LPN #1 was unsure where it would be documented. LPN #1 stated if the resident's nails needed to be cut, this could be done at any time. LPN #1 stated she had been in the resident's room that day; however, she did not notice the resident's nails. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that CNAs were responsible for trimming Resident #39's fingernails during the resident's shower time. The DON stated any staff member could trim the resident's nails, if needed, unless the resident was a diabetic. The DON stated it was a safety concern if the resident was scratching themself. The DON stated the nail care should be documented in the CNA task area under nail care unless a nurse did it. Then it would be documented in the progress notes. The DON stated that her expectation regarding nail care would be that staff would check the resident's nails with every shower and ensure the nails were clean and if attention was needed. During an interview on 08/11/2022 at 2:23 PM, the Administrator (ADM) stated the nursing department was responsible for providing nail care to the residents and it should be done as needed. The ADM stated he was unsure where it was documented. The ADM stated his expectations of staff were to notify the nurse to ensure the resident's nails were taken care of. 2. A review of the admission Record revealed the facility admitted Resident #20 with diagnoses that included unspecified absence of left and right leg below knee and muscle weakness. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the resident required extensive physical assist of one person for personal hygiene. A record review of Resident #20's care plan, initiated on 05/02/2019, revealed the resident had ADL self-care performance deficit. The facility developed an intervention that included caregivers were to check the resident's nail length and trim and clean them, as necessary. A facility document/staff task in the electronic health record, titled, Nail Care, was reviewed for the last thirty days. The question asked on the task form was, Nail care provided? There was no data found for the last 30 days lookback period, which indicated there was no documented nail care provided. During an observation on 08/08/2022 at 11:30 AM, Resident #20 was lying in bed in their room. The resident's fingernails were approximately 1/2 inch long with brown debris underneath all the nails. During an interview on 08/10/2022 at 4:03 PM, CNA #5 and CNA #1 both stated the nurse was responsible for trimming Resident #20's nails. Both CNAs stated the CNAs were responsible for notifying the nurse of the resident's nails. Neither CNA could state what the resident's nails looked like. During an interview and observation on 08/10/2022 at 4:14 PM, Resident #20 was lying in bed. The resident's nails had the same appearance as on 08/08/2022 and some of the nails had a jagged appearance. Resident #20 stated their nails were to be trimmed by a nurse, but it had not been done. The resident stated he/she had scratched their own face because their nails were jagged and would love for them to be trimmed. During an interview on 08/10/2022 at 4:18 PM, Licensed Practical Nurse (LPN) #1 stated that the resident asked her today if the nurse could trim the resident's nails, and the LPN stated she was going to do it that day. During an interview on 08/11/2022 at 2:05 PM, the Director of Nursing (DON) stated that CNAs were responsible for trimming Resident #20's fingernails during the residents' shower time. The DON stated any staff member could trim the resident's nails, if needed, unless the resident was a diabetic. The DON stated that some residents preferred their nails to be longer, but it was a safety concern if the resident was scratching themself. The DON stated the nail care should be documented in the CNA task area under nail care unless a nurse did it. Then it would be documented in the progress notes. The DON stated that their expectation regarding nail care would be that staff would check the resident's nails every shower and ensure the nails were clean and if they needed attention. The facility was unable to provide a policy related to activities of daily living.

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

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

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

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