**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide the assistance needed to maintain the ability to complete activities of daily living (ADLs) for one (#62) of two residents out of 35 sample residents. Specifically, the facility failed to identify and develop an intervention for the staff to assist Resident #62 with her ADLs effectively due to the resident's diagnosis of mental illness. Findings include: I. Facility policy The ADL policy, revised 8/2018, was provided by the nursing home administrator (NHA) on 11/30/23 at 10:05 a.m. It read in pertinent part, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities daily living. Residents who are unable to carry out activities of daily living independently will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Interpretation: The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff speak with the resident may be appropriate. II. Resident #62 A. Resident status Resident #62, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder, post-traumatic stress disorder, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity, need for assistance with personal care and muscle weakness. The 11/15/23 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 14 out of 15. She had no identified behaviors and rejection of care behaviors were not exhibited. B. Resident observation and interview On 11/27/23 at 1:54 p.m., Resident #62 was sitting on her bed. She had mid-length hair which was matted all around her head and unkempt in appearance with pink and brown unidentified substances extending to the bottom tips of her hair. Resident #62 said she would like to have her washed to get the stains out and untangle it, however she said she did not feel safe getting into the shower because she was fearful of falling. Resident #62 said staff had not offered her the use of a shower chair for her to sit down on during a shower to prevent her from falling. C. Record review The ADL care plan initiated, on 1/22/22 and revised on 12/22/22 revealed Resident #62 had an ADL self-care performance deficit and was a high risk for falls. -The resident did not have an individualized person-centered care plan addressing her shower needs, measures, and approaches for the facility staff to follow to assist Resident #62 with showers. The interdisciplinary team (IDT) assessment document titled The Story of Me, dated 12/21/21, revealed Resident #62 preferred showers over other forms of bathing such as tub baths and bed baths. -Progress notes date 3/16/23/, 6/7/23 and 8/22/23 documented Resident #62 was independent with showers. -On 10/2/23, occupational therapy treatment encounter notes documented Resident #62 was agreeable to participate in a restorative nursing program (RNP) and have help from restorative to shower to ensure she wouldn't fall. The licensed occupational therapy (OT) note documented that nursing should address and implement a RNP which included showers three times per week with the help of restorative. -There was no documentation indicating the RNP was implemented after Resident #62 agreed to participate on 10/2/23. -The progress note documented on 11/27/23 from Adult Spectrum Care (ASC) indicated Resident #62 appeared to be in poor hygiene. D. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 11/29/23 at 1:50 p.m. CNA #5 said Resident #62 had expressed fear of falling in the shower. She said the resident often applied hair glue and other substances to her hair and did not wash it. She said the resident's hair appeared matted for a long period. CNA #5 said Resident #62 was independent with showers. The director of nursing (DON) was interviewed on 11/29/23 at 2:53 p.m. The DON said Resident #62 needed assistance with personal care, however, the resident declined showers due to the fear of falling and losing her baby. The DON said Resident #62 was currently not involved in any RNP that she is aware of. The restorative registered nurse (RRN) was interviewed on 11/30/23 at 11:45 a.m. She said Resident #62 was currently not involved in any RNPs. The RRN said the resident's previous restorative program was terminated on 5/16/23 and she had since not been involved in any restorative care. She said she was not aware of any new recommendations from the OT department and she was going to follow up with the OT. The RRN said she was informed by the nursing staff about Resident #62's decline with ADLs. E. Facility follow-up The facility provided additional documentation on 12/1/23, a day after the survey exit. A review of the documentation revealed the following: The facility updated Resident #62's care plan to include the resident's preference for a bed bath with wipes. -The facility did not address the reason the resident was uncooperative with taking showers and the resident's continued poor hygiene. -There were no person-centered interventions updated on the resident's care plan. The facility provided a 30-day record of Resident #62's bed baths. The resident had nine bed baths in 30 days. -The facility did not provide documentation to indicate a resolution occurred for Resident #62's matted hair. The facility provided evidence of the OT treatment and evaluation for Resident #62 that resulted in the 10/2/23 OT recommendation for the resident to participate in a restorative nursing program for her shower, which the resident had agreed to. -The facility did not provide evidence the recommendation was implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure one (#43) of four residents reviewed for dementia care out of 35 sample residents received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop a comprehensive plan of care, to include person-centered interventions to address Resident #43's behaviors. Findings include: I. Facility policy and procedure The Care of Resident with Dementia policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 11/30/23 at 7:02 p.m. It revealed, in pertinent part, Residents who display symptoms or are diagnosed with dementia should receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial wellbeing. Providing care and services for residents living with dementia or dementia-like symptoms is an integral part of the person-centered care environment. This environment supports quality of life, meaningful relationships, and positive engagement. The facility provides treatment and services that include, but are not limited to: medical care, diagnosis, and support based on diagnosis including evaluation of sudden changes or worsening of behavioral expressions or indications of distress and subsequent care and/or intervention, and appropriate pharmacological interventions, when clinically indicated. Necessary person-centered care and services should reflect the resident's goals, choices, and preferences while maximizing their dignity, autonomy, privacy, socialization, independence, choice and safety. Individualized, non-pharmacological approaches to care that are purposeful and meaningful to the resident to enhance their well-being. The facility follows a systematic care process that includes an assessment of the resident's strengths and care needs, and development and implementation of an individualized, holistic care plan that includes input from the resident, the resident's family and/or representative, to the extent possible, and the interdisciplinary team. II. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included vascular dementia, cognitive social or emotional deficiency following cerebral infarction, mood disorder due to know physiological condition with depressive features and generalized anxiety disorder. According to the 10/12/23 minimum data (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS) and was identified as moderately impaired in his cognitive skills for daily decision making. The resident had disorganized thinking, delusions and behavioral symptoms directed towards others. Resident #43 resided on secured unit. III. Observation On 11/27/23 at 11:20 a.m. Resident #43 using profanity at Resident #44 and putting his middle finger about one foot away from her face. Certified nurse aide (CNA) #1 redirected Resident #43 back to his room. At 11:26 a.m. Resident #43 left his room and went back to the corner where Resident #44 was sitting and using profanity at her. There was not any staff in the vicinity that witnessed this interaction. Resident #43 returned to his room. Resident #44 stood up from her chair and looked down the hall to see where he went, then went back to reading her book. At 11:32 a.m. Resident #43 used profanity toward Resident #44. CNA #1 witnessed this and followed Resident #43 back to his room. At 11:33 a.m. CNA #1 returned to the main room and asked Resident #44 if she was ok. Resident #44 responded saying she was but she moved away from the corner because Resident #43 yelled at her. At 1:26 p.m. in the dining room, Resident #43 moved a chair at the table so he was positioned about eight feet to the left of Resident #44 and then he used profanity directed at her. Staff were present in the dining room and did not intervene. At 1:29 p.m. Resident #43 used profanity directed towards Resident #44. Staff were present in the dining room and did not intervene. At 1:31 p.m. Resident #43 used profanity directed towards Resident #44. Staff were present in the dining room and did not intervene. At 1:37 p.m. Resident #43 used profanity directed towards Resident #44. Staff was present in the dining room and did intervene but did not remove either resident from each other's proximity. The nursing home administrator (NHA) was made aware of Resident 43's behavior at 4:15 p.m. and the NHA said she would look into it. At 4:37 p.m. the regional vice president said Resident #43 was put on one-to-one staff observation. On 11/29/23 at 11:21 a.m. Resident #43 used profanity directed toward Resident #44 in the hallway on the secured unit while she was waiting to use the main bathroom. Resident #43 was on one-to-one observation and was redirected to his room and Resident #44 was directed to use the bathroom in her room. IV. Record review The resident's comprehensive care plan, revised 10/12/23, identified the resident could be verbally and physically aggressive due to cognitive deficits from his stroke, ineffective coping skills and poor impulse control. The care goal documented the resident's risk for verbally aggressive episodes would be minimized through the review date. Interventions included psychiatric/psychogeriatric consult as indicated, intervene before agitation escalated and guide away from source of distress. The rejection of care from the staff care plan, initiated 9/30/2020, revealed the resident had the potential to reject care from staff when required. The interventions included the staff would give the resident time and ask again. The activity care plan, revised on 11/18/22, revealed the resident was dependent upon staff for meeting his emotional, intellectual, physical and social needs due to the resident's cognitive deficits. It documented the resident enjoyed watching movies, reading, trivia, exercise and sitting outside. The interventions included: encouragement of ongoing family involvement; ensure activities the resident attended were compatible with the resident's mental capabilities and known interests; introduce him to residents with similar interests; and provide a program of activities that was of interest and empowered the resident allowing the resident a choice, self expression and responsibility. -The facility failed to develop a comprehensive care plan that addressed the resident's behaviors and psychosocial needs to include person-centered approaches. A review of progress notes from September 2023 to November 2023 revealed the resident was verbally aggressive on 20 occasions and physically aggressive on two occasions: On 9/18/23 an incident note documented Resident #43 initiated verbal aggressive behavior towards another resident in the dining room. Staff separated the residents. On 9/20/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. He was observed to throw an incontinence brief at the certified nurse aide, a verbal altercation with Resident #44 and yelling at staff members. The primary care physician (PCP) was notified and no new orders were given. On 9/21/23 an interdisciplinary team note documented the discussion of behavioral changes. It was determined these behaviors were within baseline. On 9/22/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. On 9/22/23 a physician visit progress note documented the resident was very agitated and kicked the physician and chased her out of the room. A registered nurse (RN) told the physician that his behaviors were a significant problem. The physician noted that the resident was a danger to staff, was frequently combative and his behaviors were uncontrolled. The physician documented the oxycodone (pain medication) was resumed twice a day last month due to the resident having pain in his scrotum. She opted to continue the narcotic pain medication noting his behaviors seemed to improve when it was taken regularly. On 9/23/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and monitoring for increased oxycodone dose. On 9/29/23 a nurse note documented the resident was on 15 minute checks for a verbal altercation with his roommate which he initiated. Resident #43 cursed and yelled at his roommate. On 9/29/23, a nurse note documented the resident continued on monitoring for increased oxycodone from 2.5 milligrams (mg) twice a day to 2.5 mg four times a day. On 10/1/23 an alert note documented the resident had been verbally lashing out all day and continues on monitoring for increased oxycodone dose and frequency. On 10/25/23 a nurse note documented the resident was on charting for his behavior. The resident yelled and screamed toward other residents in the hallway. On 10/26/23 an interdisciplinary team note documented the resident appeared to have increased agitation. On 10/31/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. The resident continued to yell in the hall using profanity and he was not easy to redirect. On 11/1/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and continued to yell in the hallway. He was redirected to the dining room. On 11/2/23 an interdisciplinary team follow up note documented the resident continued to be at baseline without any behavioral changes observed. On 11/5/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. The resident was yelling in the hallway and using profanity. On 11/8/23 a nurse note documented the resident had made physical contact with his roommate, Resident #65 and yelled at him on multiple occasions. Resident #65 was offered a room change and he agreed. Resident #43 continued on 15 minute checks for his behaviors. On 11/8/23 a nurse note documented the resident was yelling and calling two other residents names, one of which was Resident #44. He was redirected to his room and continued on monitoring for his behaviors. On 11/10/23 an interdisciplinary team follow-up note documented the resident continued to be at baseline without any changes observed. On 11/10/23 a nurse's note documented the resident was pointing and cussing Resident #44 and Resident #65 during breakfast. On 11/11/23 a nurse's note documented the resident continued on monitoring for his behaviors. He was observed yelling at Resident #44 and was redirected to stop with his behavior. On 11/12/23 a nurse note documented the resident was screaming at staff. Staff were able to redirect and escorted him to the smoking patio. On 11/13/23 a nurse's note documented the resident was screaming at staff and was redirected. He continued on 15 minute checks for his behaviors. On 11/15/23 an interdisciplinary team note documented the resident had shown increased agitation. On 11/15/23 a nurse note documented the resident was agitated in the morning, screamed at lunch and was redirected. He continued on 15 minute checks for his behaviors. On 11/17/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and had verbal aggression and yelling towards staff. On 11/23/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and had been screaming in the hallway. On 11/24/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and was screaming in his room. On 11/25/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and continued to yell when approached by staff. On 11/27/23 an incident note documented Resident #43 had called Resident #44 names while in the TV room. He was redirected to his room and the supervisor was notified and the social services department. On 11/28/23 a physician visit note documented the resident needed to be seen due to ongoing verbal aggression on the unit. He was noted to be on one-to-one monitoring. She documented the possibility of a trial of Zyprexa (a mood stabilizer) if he demonstrates more aggressive behaviors. V. Staff interviews CNA #1 was interviewed on 11/30/23 at 10:08 a.m. She said that all staff were responsible for separating residents involved in altercations and did their best to prevent altercations when possible. She said they redirected the residents and reported the incidents to their supervisor. She said they document the behaviors in a custom alert in the resident's electronic record and that all staff who witness behaviors were responsible for documenting that behavior. She said Resident #43 could have aggressive behavior toward other residents and staff members. She said she was not sure of any person-centered interventions that were successful for Resident #43, other than redirection. She said that behaviors were common on the secure unit. The NHA was interviewed on 11/30/23 at 1:40 p.m. She said if there was a safety concern after behavior incidents staff should separate the residents. She said staff should watch for behavior changes in general and residents acting out of their baseline to avoid escalating behaviors. She said in the situation with Resident #43, his behaviors were perceptional. She said Resident #43 might yell and cuss at someone as they walk by him but that behavior was not directed towards that resident, that is just how he is. She said each resident's comprehensive care plan should include person-centered interventions and approaches. She said each resident's behavior should be described and interventions included in the comprehensive care plan. She said the comprehensive care plan was part of the dementia care program. She said the comprehensive care plan should be a plan to provide care to all residents and dementia care services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for the residents of the facility on two out of three units. Specifically, the facility failed to ensure: -Residents were provided with hand towels and washcloths; and, -Residents' room windows and electrical outlets were properly maintained. Findings include: I. Lack of washcloths and hand towels in resident rooms A. Observations On 11/27/23 at 10:16 a.m. the following shared rooms had no hand towels and washcloths: -room [ROOM NUMBER], #308 and #312. On11/28/23 at 9:45 a.m: -room [ROOM NUMBER] had one washcloth in a shared room, otherwise no towels; -room [ROOM NUMBER] had no towels;and, -room [ROOM NUMBER] had no hand towels and washcloths for a three resident shared bathroom. On 7/29/23 at 3:28 p.m: -room [ROOM NUMBER] had one towel hanging in a shared bathroom of four residents; -room [ROOM NUMBER] had no towels in a four resident shared bathroom; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had no hand towels and washcloths; -room [ROOM NUMBER] had one used washcloth in a shared bathroom for three residents; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had only one used washcloth in a shared room; and, -room [ROOM NUMBER] had no towels. On 7/30/23 at 10:05 a.m.: -room [ROOM NUMBER] had no towels in a shared bathroom of four residents; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had no towels. One towel holder was not labeled with a resident name;. -room [ROOM NUMBER] only had one wash rag in a shared bathroom of four residents; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had no towels and washcloths in a shared room; and, -room [ROOM NUMBER] had no towels in a four resident shared bathroom. B. Resident interview Resident #19 was interviewed on 11/30/23 at 10:15 a.m. Resident #19 said staff were not providing washcloths and towels except when a resident requested them. The resident said he used a paper towel to wash his face or he would just go to the clean linen closet and get them himself. He said when the staff removed the used towels and washcloths the staff did not replace them unless the resident asked the staff to do so. II. Resident room windows and electrical power outlet not properly maintained. A. The Maintenance Service Policy was received on 11/29/23 at 4:01 p.m. from the nursing home administrator (NHA). The policy read in pertinent part, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. B. Observations On 11/27/23 at 10:25 a.m. Resident #56 was sitting on his bed in room [ROOM NUMBER] with a blanket covering both knees. The resident was painting on a piece of paper. -The left side window over bed C in room [ROOM NUMBER] did not close all the way. There was a blanket covering the space that would not close. On 11/28/23 at 2:15 p.m., the window in room [ROOM NUMBER] bed C had the left side cracked from top to bottom. The top of the ceiling has a dark brown color and the ceiling appears to be wet. On 11/29/23 at 10:14 a.m., an electrical outlet in the resident's common area on the fourth floor was open, exposing electrical cables. Three residents were sitting in the open area watching television. C. Resident interviews Resident #56, who resided in room [ROOM NUMBER], said he was cold even though he had the blanket covering his knees. Resident #56 said the left side window in his room did not shut all the way so it got really cold in his room. The resident said he reported it to staff and the staff used a blanket to cover the opened space. Resident #19, who resided in room [ROOM NUMBER], said the left side window had been cracked for over three years. He said he had e reported it to staff several times but it had not been fixed. The resident said there had been a leakage from the ceiling several times. III. Staff interviews The maintenance supervisor (MS) was interviewed on 11/29/23 at 12:03 p.m. The MS said he received reports about the cracked window in room [ROOM NUMBER] over three years ago and reported it to his superiors. The MS said the facility had still not allocated funds to maintain the window. The MS said it was a safety concern and it needed to be addressed. The MS said he was able to repair the window over bed B in room [ROOM NUMBER], however, the resident could not open and close the window until he received the parts needed to repair the window. The MS said he was able to fix the leakage on the ceiling and had replaced the wet ceiling tile. Housekeeper (HSKP) #1 was interviewed on 11/29/23 at 1:45 p.m. HSKP #1 said the housekeeping department ensured towels and linens were frequently sent to the floor throughout the day. She said the housekeeping department locked the towels in closets on each unit and it was up to the certified nurse aides (CNA) to ensure each resident room was supplied with hand towels and washcloths. CNA #5 was interviewed on 11/29/23 at 1:50 p.m. The CNA said most of the rooms had no towels. CNA #5 said linens were locked in closets in each unit's clean linen rooms. She said CNAs on both day and night shifts were responsible for supplying residents' rooms with towels and washcloths. The director of nursing (DON) was interviewed on 11/29/23 at 2:53 p.m. The DON said housekeeping and nursing staff were responsible for ensuring each resident had adequate towels and washcloths. The DON said the housekeepers washed dried and stored linens in the linen closet. The DON said it was important for each resident to have clean hand towels and washcloths each day for the resident's dignity and infection control. The DON said some rooms had no towels due to the cognitive level of the residents. He said the interdisciplinary committee would discuss and come up with ways to provide each resident with clean towels and linens without other residents touching them.

Based on observations and interviews the facility failed to ensure one out of two medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure the treatment carts were locked when left unattended; and, -Ensure controlled medications were in a locked storage container permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised November 2020, was provided by the nursing home administrator (NHA) on 11/28/23 at 1:36 p.m. It read in the pertinent part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. II. Observations On 11/27/23 at 9:05 a.m. the treatment cart on the second floor was unlocked and unattended. Several residents were in the hall and walked past the cart. The treatment cart contained prescription creams, ointments, over-the-counter creams and supplies for wound care. Licensed practical nurse (LPN) #2 was notified after she came out of a resident's room and several minutes had passed. At that point, she locked the cart. At 9:10 a.m. the medication room on the second floor was unlocked and unattended. Inside the medication room were multiple over-the-counter medications on open shelves, prescription cards with medications that were no longer being used and a medication refrigerator that was unlocked. The medication refrigerator contained multiple injectable medications, suppositories and other medications that required refrigeration. On 11/28/23 at 2:14 p.m. the treatment cart on the third floor was unlocked and unattended. Several residents were in the hall and passed the cart. The treatment cart contained prescription creams, ointments, over-the-counter creams and supplies for wound care. The director of nursing (DON) noticed the treatment cart was unlocked and he locked it at 2:33 p.m. On 11/30/23 at 11:14 a.m. the medication room on the fourth floor was observed with LPN #1. There was a medication refrigerator that contained three vials of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat agitation that tranquilizes the patient) and an influenza vaccine. The schedule IV controlled medications were in a ziploc bag on the bottom of the refrigerator next to the influenza vaccine. III. Staff interviews LPN #2 was interviewed on 11/27/23 at 9:15 a.m. She said the treatment cart should always be locked. She said residents could get into treatments that were not safe. She said the medication room should always be locked for the same reason. The DON was interviewed on 11/30/23 at 11:00 a.m. He said the treatment carts and medication rooms should be locked at all times. He said leaving either unlocked could result in a Health Insurance Portability and Accountability Act (HIPAA) violations, financial exploitation, missing medications and unauthorized staff or residents getting into the treatment cart and overdosing. He said he was not aware that the Ativan needed to be in a secured permanently affixed compartment in the refrigerator. The nursing home administrator (NHA) was interviewed on 11/30/23 at 1:40 p.m. The NHA said treatment carts and medication rooms should be locked at all times when not attended by a licensed nurse.

Based on observations, record review and interviews, the facility failed to ensure menus were followed. Specifically, the facility failed to ensure food items served were consistent with the daily menu. Findings include: I. Resident interview A group of residents (#63, #40, #64, #22 and #2) were interviewed on 11/28/23 at 4:00 p.m. Resident #63 said the meals served often did not match the posted menu. She said it bothered her when she thought she was getting fried chicken and it was baked instead or if enchiladas were on the menu but everyone received burritos instead. The resident group agreed with the statement provided. II. Lunch on 11/28/23 The 11/28/23 lunch menu revealed residents were to be served chicken fried chicken, mashed potatoes with gravy, broccoli salad, biscuits and peach cobbler for dessert. During a continuous observation on 11/28/23 beginning at 11:30 a.m. and ending at 2:30 p.m., the lunch being served was baked chicken breast, wings and thighs, mashed potatoes with gravy, green beans, biscuits and peach cobbler for dessert. At 12:10 p.m. the regional dietary consultant (RDC) substituted green beans for broccoli salad because the broccoli salad remained above a temperature of 41 degrees. At 2:00 p.m. the dietary manager (DM) delivered a tray of breaded and cooked cutlets to cook (CK) #1. The DM was interviewed at 2:00 p.m. She said the facility did not receive enough chicken fried chicken cutlets from a delivery and she substituted with baked chicken. She said she had intended to serve the chicken fried chicken first but accidentally sent out the baked chicken first. The DM was interviewed again on 11/28/23 at 3:12 p.m. She said she was unsure if the breaded cutlets served for lunch were made of chicken or steak. She said it looked like chicken fried steak. She said she did not look at the box it came in to confirm what protein was being served. At 3:00 p.m. the RDC produced a box that revealed the cutlets served for lunch were chicken fried steak and were made from steak and not chicken. III. Additional DM interview The DM was interviewed again on 11/30/23 at 2:00 p.m. The DM said she opened the box of chicken fried steak and cooked the lunch served on 11/28/23. She said she thought the cutlets looked odd for being chicken. She said she did not check the box to confirm the ingredients prior to serving the residents. She said it was problematic to serve a different type of protein than what the menu advertised because of allergies, dietary needs and cultural preferences.

Based on observations and interviews, the facility failed to label and date stored food items and distribute and serve food in a sanitary manner in two of three food storage units reviewed. Specifically, the facility failed to: -Ensure food was labeled and dated in the freezers in the main kitchen; and, -Ensure food that left the kitchen was covered. Findings include: I. Failure to ensure food was labeled and dated A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/11/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Facility policy and procedure The Food Wholesomeness policy, dated 11/29/23, was provided by the nursing home administrator (NHA) on 11/29/23 at 11:42 a.m. It revealed in pertinent parts: Frozen foods are cooked per manufacturer's instructions or thawed with dates of use and meal item. Foods not in original containers are labeled and dated with opening and suggested to have a use by date. C. Observations During an initial kitchen tour on 11/27/23 beginning at 9:20 a.m. and ending at 10:00 a.m., the following was observed: In the freezer of the main kitchen there was a plastic bag, blue in color, with circular pea sized objects inside with no label or date, two clear plastic bags of breaded items that were square in shape and beige in color, one clear plastic bag of chicken and a clear plastic bag containing burritos. -None of the items were labeled or dated. The ice chest freezer in the secondary storage area of the kitchen had three bags of collard greens, two bags of asparagus and one bag of broccoli out of the original box. -None of the items were dated. At 10:00 a.m. the dietary manager (DM) said the food item in the blue plastic bag of the main freezer could be peas, however, she was unable to locate a label or date. The DM was unable to locate labels and dates on the other unlabeled and undated items observed in the main kitchen freezer. -The DM was unable to locate dates on the undated items observed in the ice chest freezer. On 11/28/23 at 3:30 p.m., during an observation of the fourth floor refrigerator, a tray with five sandwiches in clear plastic bags was observed. There was no date or label on the bags or tray. An unknown staff member said kitchen staff was responsible for labeling and dating food they provided to the units for resident consumption. On 11/29/23 at 10:30 a.m. the following was observed: In the freezer of the main kitchen there was a plastic bag, blue in color, with circular pea sized objects inside with a second blue plastic bag on top of it, two clear plastic bags of breaded items square in shape, one clear plastic bag of chicken and a clear plastic bag containing burritos. -None of the items were labeled or dated. In the ice chest freezer of a secondary storage area of the kitchen there were three bags of collard greens, two bags of asparagus and one bag of broccoli out of the original box. -None of the items were dated. II. Failure to cover food leaving the kitchen A. Observations During a continuous observation on 11/28/23 beginning at 11:30 a.m. and ending at 2:30 p.m. cook (CK) #1 was observed handing an uncovered plate of baked chicken to an unknown staff member out of the kitchen to be delivered to an unknown resident in an area other than the dining room. -The unknown staff member did not cover the plate prior to leaving the dining room to deliver the food to a resident. III. Staff interviews The DM was interviewed on 11/29/23 at 10:23 a.m. She said the kitchen staff was responsible for dating sandwich trays delivered to individual units. She said if the floor staff removed the sandwiches from the tray they were responsible for dating individual sandwich bags. She did not know who was responsible for labeling the type of sandwich each bag contained. She said it was important to label the contents of individual sandwiches because of food allergies, dietary restrictions and cultural preferences. She said it was important to date individual bags to ensure freshness. She said education would be provided to kitchen staff to label and date individual bags. The nursing home administrator (NHA) was interviewed on 11/29/23 at 10:36 a.m. She was unable to locate labels or dates for items in the main kitchen freezer or dates on items out of the original box in the secondary storage area. She said items without labels or dates should be thrown out immediately. She said unlabeled food items presented concerns with dietary needs and food allergies. She said food that was labeled without a date of when it was removed from the original box presented concerns for quality of freshness. The regional dietary consultant (RDC) and DM were interviewed together on 11/30/28 at 2:00 p.m. The DM said plated food being served from the kitchen and delivered to an area other than the dining room should be covered. She said this ensured food stayed warm and prevented the potential for contamination. The DM said food items without labels or dates were problematic because not knowing ingredients impacted food allergies, dietary restrictions, cultural preferences and freshness of the food being served. She said all items found without labels or dates in the refrigerators and ice chest freezer had been discarded and education was being provided to staff. IV. Facility follow up At 1:00 p.m. the NHA said that all foods found without labels and dates had been removed from the refrigerators and ice chest freezer and staff education was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Failure to ensure hand hygiene was performed during medication administration On 11/28/23 at 11:00 a.m., licensed practical nurse (LPN) #1 got up from his desk where he had been typing on the computer and began preparing medications for a resident. -He did not use hand sanitizer or wash his hands before he began preparing medications. LPN #1 dispensed the medication from a bottle into a medication cup and carried the medication to a resident in room [ROOM NUMBER]. The resident took the medication and LPN #1 returned to the medication cart and began preparing medications for the next resident. -He did not use hand sanitizer or wash his hands prior to beginning preparation of the next resident ' s medications. At 11:10 a.m., LPN #1 dispensed medication from a bottle into a medication cup, retrieved a Boost (nutritional supplement) from the kitchenette and carried the items to a resident in room [ROOM NUMBER]. The resident took the medication and LPN #1 returned to the medication cart and began preparing medications for a third resident. -He did not use hand sanitizer or wash his hands prior to beginning preparation of the next resident ' s medications. At 11:15 a.m., LPN #1 dispensed medication from the controlled substance lock box in the medication cart into a medication cup and poured a powdered medication into a cup of water. He carried the medications to a resident in room [ROOM NUMBER] and she took the medications. -LPN #1 returned to the nurses station desk without using hand sanitizer or washing his hands. V. Additional interviews The DON was interviewed on 11/30/23 at 11:00 a.m. He said that staff should wash their hands or use hand sanitizer before and in between each resident during the medication pass. He said in some situations the nurses may also need to wear gloves. He said failure to perform hand hygiene could lead to a spread of viruses or infections in the facility. The infection control preventionist (ICP) was interviewed on 11/30/23 at 11:07 a.m. She said each nurse should use hand sanitizer before administering medications to residents to ensure they were not passing potential infections from resident to resident. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals; -Ensure proper infection control measures for housekeeping were followed; and, -Ensure appropriate hand hygiene was performed during medication administration. Findings include: I. Failure to ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. A. Professional reference The Center for Disease Control (CDC) Hand Hygiene in Healthcare Settings: Patients, retrieved on 12/4/23 from: https://www.cdc.gov/handhygiene/patients/index.html revealed in part, Clean Hands Count for Patients: As a patient in a healthcare setting, you are at risk of getting an infection while you are being treated for something else. Patients and their loved ones can play a role in asking and reminding healthcare providers to clean their hands. Your hands can spread germs too, so protect yourself by cleaning your hands often. When should you clean your hands: -Before preparing or eating food; -Before touching your eyes, nose, or mouth; -Before and after changing wound dressings or bandages; -After using the restroom; -After blowing your nose, coughing, or sneezing; and, -After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone. How should you clean your hands: With an alcohol-based hand sanitizer: Put the product on your hands and rub your hands together Cover all surfaces until hands feel dry This should take around 20 seconds With soap and water: Wet your hands with warm water. Use liquid soap if possible. Apply a nickel- or quarter-sized amount of soap to your hands. Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails. Continue rubbing your hands for at least 15 seconds. Need a timer? Imagine singing the 'Happy Birthday' song twice. Rinse your hands well under running water. Dry your hands using a paper towel if possible. Then use your paper towel to turn off the faucet and to open the door if needed. B. Facility policy The Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 11/29/23 at 2:02 p.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation included: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Residents, family members, and/or visitors will be encouraged to practice hand hygiene. 4. Use an alcohol-based hand rub containing at least 60% or soap and water for the following situations: Before and after coming into contact with residents, before and after eating or handling food. C. Observations On 11/27/23 at approximately 9:30 a.m., during breakfast, approximately 16 residents in the main dining room were not provided the opportunity to perform hand hygiene. -The meal trays were passed out without the staff offering hand hygiene to the residents. -There were no hand sanitizing wipes provided on the resident's dining table. -Some of the residents were in their wheelchairs and had wheeled themselves to the dining room, touching the dirty wheels of their wheelchairs prior to eating. -The menu for breakfast included toasted bread which the resident's ate with their fingers. On 11/28/23 at approximately 4:55 p.m. room trays arrived on unit three for five of the residents who stayed back and did not dine in the main dining room. -The staff passed the dinner trays and did not offer any of the resident's hand hygiene. -There were no hand sanitizer packets provided on the resident's trays. On 11/29/23 at 12:00 p.m., the staff started serving lunch in the first floor main dining room. -There was no hand sanitizer in the dining area and staff did not offer hand sanitizer wipes to the residents. -Approximately twelve residents in the dining room were not provided the opportunity to perform hand hygiene. II. Failure to ensure housekeeping followed proper infection control measures. A. Facility policy The Infection Control policy, dated 7/28/2023, was provided by the nursing home administrator (NHA) on 11/30/23 at 10:00 a.m. It read in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program is based on accepted national infection prevention and control standards. The infection prevention and control program is a facility-wide effort involving all disciplines, and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infections, and employee health and safety. B. Housekeeping observations On 11/29/23 at 10:35 a.m. housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER]. There were three residents living in the room. room [ROOM NUMBER] was on enhanced barrier precautions ( infection control interventions designed to reduce transmission of resistant organisms). HSKP #1 started cleaning the room by donning gloves. She sprayed a disinfectant solution on the surfaces of the television stand and bedside stands of the two residents on the same side of the room. HSKP #1 cleaned one stand belonging to the resident at bed A and continued cleaning with the same cleaning rag to the area of bed B. HSKP #1 returned to the cleaning cart to pick up a mop stick. She started mopping the floor around the resident in bed A and proceeded to mop the area of the resident in bed B with the same mop pad. HSKP #1 continued to mop the shared bathroom inside the resident's bedroom with the same mop pad and proceeded to mop the floor of the resident in bed C, all with the same mop pad. HSKP #1 left room [ROOM NUMBER] after completing her cleaning routine. HSKP #1 did not clean the door knob and the side rails in the hallway which wereboth high touch areas for staff and residents. III. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 11/29/23 at 2:30 p.m. CNA #6 said there were hand sanitizer dispensers on the walls for staff and residents to perform hand hygiene, however, most of the residents refused to utilize them. CNA #6 said hand hygiene was important to prevent the spread of infectious diseases. CNA # 6 said the resident's room trays did not have sanitizing wipes for hand hygiene. The director of nursing (DON) was interviewed on 11/29/23 at 4:25 p.m. The DON said the housekeeping staff were trained on infection control as well as all the other departments. The DON said disinfecting high-touch areas such as door knobs and side rails and offering each resident the opportunity to perform hand hygiene were important to prevent the transmission of infectious diseases. The DON said staff should encourage all residents to perform hand hygiene before and after meals. The infection control preventionist (ICP) was interviewed on 11/30/23 at 11:00 a.m. The ICP said the facility staff were to wash their hands before and after each resident contact, after performing a task, and when their hands were visibly dirty. Hand sanitizers were readily available throughout the facility for the staff to encourage all residents to perform hand hygiene before and after each meal service. The ICP said her focus was on staff education which included education on infection control measures and hand hygiene for all staff and residents.

Based on observations, interviews, facility document review, and facility policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure a staff member performed hand hygiene after touching her mask/eye wear during pureed food preparation. This had the potential to affect two (Residents #21 and #44) of two residents who were to be served a pureed diet; and 2. Ensure the dishwasher sanitizer concentration was within the required range and failed to test/document the dish machine wash cycle temperature and sanitizer concentration per their policy. This had the potential to affect 71 of 72 residents in the facility who were served food from the kitchen. (One resident had a feeding tube and received no nourishment/hydration per mouth.) Findings included: 1. A review of the facility's Handwashing policy and procedure, revised 10/24/2018, revealed, All dining service workers must wash their hands the right way frequently with antibacterial soap and warm water for at least 20 seconds. Be sure to wash hands with soap and warm water for at least 20 seconds.after touching or scratching areas of the body, such as ears, mouth, nose, or hair. On 08/23/2022 at 11:40 AM, Dietary Aide (DA) #1 was observed as she prepared pureed diets for two residents. On 08/23/2022 at 11:42 AM, DA #1 pulled her mask down from her nose to reposition the mask. She proceeded with the process to puree the food without washing her hands. At 11:44 AM, DA #1 then adjusted the position of her mask and proceeded with the process to puree the food without washing her hands. Further observations revealed at 11:49 AM, DA #1 touched her mask as she walked into the serving area across the hall. She returned to the kitchen and, without washing her hands, proceeded with the process to puree the food. At 11:50 AM, DA #1 then pulled her mask down from her face to taste broth and, without washing her hands, proceeded with the process to puree the food. Further observations revealed at 11:52 AM, DA #1 adjusted her protective eye wear and mask and proceeded with the process to puree the food without washing her hands. At 11:53 AM, DA #1 touched her mask with her right hand. Without washing her hands, she proceeded with the process to puree the food. At 11:58 AM, DA #1 touched her protective eye wear and mask. Without washing her hands, she proceeded with the process to puree the food. In a few more seconds, DA #1 touched her protective eye wear again and proceeded with the process to puree the food without washing her hands. On 08/23/2022 at 12:18 PM, DA #1 was interviewed. She stated a mask and protective eye wear being worn would be considered to be contaminated. She stated touching a mask and protective eye wear would contaminate one's hands. When the above observations were reviewed with DA #1, she stated she should have washed her hands after touching her mask and/or protective eye wear before she continued the process of preparing the pureed food. During an interview on 08/24/2022 at 12:03 PM, the Dietary Manager (DM) stated a staff member's hands would be considered contaminated after they touched their mask and/or eye wear. He stated he would expect staff to wash their hands after the staff touched their mask or eye wear. An interview with the DM on 08/25/2022 at 9:19 AM revealed two residents received a pureed diet, Resident #21 and Resident #44. A review of the Diet Type Report, dated 08/25/2022, verified that Resident #21 and Resident #44 were to receive a pureed diet. On 08/24/2022 at 1:40 PM, the Registered Dietitian (RD) was interviewed. The above observations were reviewed with the RD. She stated a staff member who touched their face would have contaminated their hands. On 08/25/2022 at 7:22 AM, the Administrator was interviewed. The above observations regarding DA #1's failure to perform hand hygiene during pureed diet preparation. She stated staff should wash their hands after touching their face and before continuing with food preparation. 2. A review of the facility's Dishwashing Machine Use, policy and procedure, revised 03/2010, revealed, Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine Maximum Concentration 50-100 ppm Contact time 10 seconds. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM]) after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. Corrective action will be taken immediately if sanitizer concentrations are too low. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. A review of an undated facility document titled, Dishwasher Job Descriptions During Covid revealed the following schedule: -6:00 AM Set up sanitizer water and soapy water for dishwashers' area and cooks' area. Make sure to document PPMs. Make sure to document dishwasher temperatures. -12:00 PM Change all sanitation waters and soapy water, test all waters for PPM documentation. -12:15 PM Fill out the dishwasher temperatures for 12:00 PM. -4:00 PM Set up sanitizer water and soapy water for dishwasher area and cooks' area. Make sure to document PPMs and document dishwasher temperatures. -6:00 PM Set up sanitizer water and soapy water for dishwashers' area and cooks' area. Make sure to document all PPMs. Observation and interview in the kitchen on 08/24/2022 at 12:05 PM revealed the Dietary Manager stated the dishwasher was a low temperature, chemical sanitizing machine. When asked to run the dishwasher to test the sanitizer concentration, he was unable to find a bottle of test strips and left the dishwasher area to obtain a bottle. When he returned, he was asked how often the dishwasher should be checked to ensure proper concentration of sanitizer. He stated test strips were to be used to check the sanitizer in the dishwasher three times daily at mealtimes. When asked if there was documentation of the testing, he presented a document titled, Dish Machine Log - Low Temp. The log had documentation of the wash temperature and sanitizer concentration check for the month of August 2022 as follows: -08/01/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/02/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/03/2022 - breakfast, 50 PPM; no documentation for lunch or supper -08/04/2022 - breakfast, 50 PPM; no documentation for lunch or supper -08/05/2022 - No documentation -08/06/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/07/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/08/2022 through 08/10/2022 - No documentation -08/11/2022 - breakfast, 50 PPM; no documentation for supper -08/12/2022 - No documentation -08/13/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/14/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/15/2022 through 08/19/2022 - No documentation -08/20/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/21/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/22/2022 through 08/22/2022 - No documentation On 08/24/2022 at 12:09 PM, the DM tested the dishwasher chlorine concentration to be 10 PPM. The DM stated the concentration should be at 50-100 PPM. He then noticed the chlorine sanitizer container under the dishwasher machine was low and left the dishwasher room. He returned with a full five-gallon container of Chlorine Sanitizer and changed it out with the empty sanitizer container. On 08/24/2022 at 1:11 PM, the DM tested the sanitizer concentration of the dishwasher to be 100 PPM. On 08/24/2022 at 1:40 PM, the Registered Dietitian (RD) was interviewed. The above observations were reviewed with the RD. The RD stated the facility's policy was to test the dishwasher sanitizer concentration at each meal. On 08/25/2022 at 7:22 AM, the Administrator was interviewed. The above observations regarding the dishwasher low sanitizer concentration and documentation of sanitizer concentration were reviewed with the Administrator. She stated the failure of the dietary staff to test the dishwasher sanitizer concentration three times daily was a problem.

Based on interviews, document review, record review, and facility policy review, it was determined that the facility failed to ensure residents, their representatives and families of residents residing in the facility were notified of a confirmed positive COVID-19 result in the facility by 5:00 PM the following calendar day. This had the potential to affect all residents. The facility's Daily Census, dated 08/22/2022, indicated there were 72 active residents. Findings included: A review of the facility's policy titled, Communication During Covid Policy, dated 02/01/2022, revealed, Upon receiving a new Covid positive test result from a care partner or resident, the Administrator or designee will provide communication to Care Partners, Community Partners, Family members, and Residents. The policy further stated the information will be communicated no later than by 5:00 PM the next calendar day. A review of laboratory results for Resident #71, dated 08/20/2022, revealed the resident tested positive for COVID-19. During an interview on 08/22/2022 at 9:26 AM, the Director of Nursing (DON) indicated Resident #71 tested positive for COVID-19 on Saturday, 08/20/2022. During an interview on 08/22/2022 at 11:35 AM, the Administrator indicated she had received an email of the positive results on 08/20/2022. The Administrator indicated she had notified the DON, staff, and Resident #71's guardian. When asked if all families and/or guardians had been notified, the Administrator indicated she had not sent out the notification. The Administrator indicated the notification should have been sent out by 5:00 PM on 08/21/2022. During a follow-up interview on 08/22/2022 at 12:10 PM, the Administrator indicated the notification normally would have been done. On 08/25/2022 at 10:39 AM, the Administrator indicated the messaging system included all residents, families and/or guardians, and staff members. During an interview on 08/25/2022 at 9:20 AM, the DON indicated notification related to a positive COVID-19 case should be done by 5:00 PM the next day to staff, residents, and family and/or guardians.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to notify the physician timely when there was a significant change in the resident'ss condition for one (#24) of two residents out of 26 sample residents. Specifically, the facility failed to notify the Resident #24's physician when enteral nutrition orders were not being followed by the staff. Findings include: I. Facility policy and procedure The Enteral Tube Feeding via Continuous Pump policy, revised November 2018, was provided by the quality improvement specialist (QIS) on 8/29/19 at 10:00 a.m. It read in pertinent part, -Report complications (diarrhea, gastric distention, respiratory distress) promptly to the supervisor and the attending physician. -Report negative consequences of tube use (agitation, depression, self-extubation, infections) to the supervisor and attending physician. -Notify the supervisor if the resident refuses the procedure. -Report other information in accordance with facility policy and professional standards of practice. The Enteral Medication Administration policy, revised 8/28/19, was provided by the QIS on 8/29/19 at 10:00 a.m. It read in pertinent part, -The facility ensures the safe and effective administration of enteral formulas and medications. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian and pharmacist. -Enteral formulas, equipment, route of administration and rate of flow are selected based on an assessment of the resident's condition and need. II. Resident #24 A. Resident status Resident #24, age [AGE], admitted [DATE] and readmitted [DATE]. According to the August 2019 computerized physician orders (CPO), diagnoses included cerebrovascular disease (stroke) and hemiplegia and hemiparesis (weakness and paralysis) affecting the left side. The 6/11/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with no assessment for brief interview for mental status (BIMS) score and severely impaoired decision making. The resident received 51 percent or more of his total calories by nourishment through artificial route in the form of tube feed and depended on staff for activities of daily living. B. Observation On 8/28/19 the resident's tube feeding pump was observed intermittently from 9:00 a.m. to 3:30 p.m in the day room adjacent to the nurses station. The resident was not connected via his percutaneous endoscopic gastrostomy (PEG) tube to the pump throughout that time. C. Record review The 4/25/19 physician order documented and re-ordered when resident readmitted from the hospital on 8/27/19, Glucerna 1.5 infused at 60ml (mililaters)/hour x 20 hours via PEG (percutaneous endoscopic gastrostomy) every shift for gastroparesis. The hours the resident was not to be connected to the continuous feed was from 1:30 p.m. to 5:30 p.m. -Review of the August 2018 medication administration record (MAR) indicated the tube feeding was administered on 8/27/19 at 6:30 p.m. from 6:30 a.m. and 8/28/19 from 6:30 a.m. to 1:30 p.m. (This documentation was in accurate and contradicts the observation above) Review of the nurse progress notes from 8/27/19 to 8/28/19 revealed the resident was sent to the hospital around 1:00 p.m. on 8/27/19 due to the resident having abdominal distention and vomiting. The resident returned to the facility at 7:00 p.m. the same day (8/27/19) The nurse notified the nurse practitioner, director of nursing and administration and documented the resident was at baseline. -There was no other documentation regarding the nurse practitioner holding the order or progress note from the nurse on 8/28/19 that she communicated with the physician to hold the resident's enteral nutrition orders while the resident remained in the facility before going to the hospital and/or after the resident returned from the hospital his tube feeding was not turned back on (see observations above and interview below). III. Staff interviews The registered dietitian (RD) was interviewed on 8/28/19 at 12:07 p.m. She said she provided the recommendations for the residents on enteral nutrition. She said she reviewed the resident's tolerance to the tube feeding regimen, the rate, and make formulary recommendations based on medical conditions. She said she came to the facility week to complete nutrition charting for residents in the facility. She said Resident #24 was on continuous tube feeding formula Glucerna 1.5 at 60 milliliters (ml) per hour for 20 hours. She said he had a four hour break from the continuous feeding from 1:30 p.m. to 5:30 p.m. She said the resident could not have food by mouth so the tube feeding regimen was his only source of calories and protein. She said the resident went to the hospital on 8/27/19 for a few hours due to him not tolerating his tube feeding regimen and she had not reassessed him since being back at the facility. She said she was not aware that the resident was not connected to his tube feeding since he returned from the hospital on 8/27/19 at 7:00 p.m. and the morning of 8/28/19. She said the nurses did not communicate to her when they disconnected him from the continuous feeding. She said she would expect the nurses or nurse management to communicate with her if the resident was not tolerating the formula or when they disconnect him from it due to an acute clinical condition. Registered nurse (RN) #1 was interviewed on 8/28/19 at 4:12 p.m. She said she had not connected Resident #24's enteral nutrition since she came on shift at 6:00 a.m. She said during shift report with the night nurse that he had returned from the hospital due to distension and vomiting and the hospital did an abdominal scan and it was negative. She said the night nurse said the hospital added miralax powder to be administered via his PEG tube but his previous medications orders had remained the same, including his enteral nutrition order. She said it was her nursing judgement to hold the enteral nutrition orders for Resident #24 because she said he still had abdominal distention. She said she had not communicated to the physician that the resident's enteral nutrition was held or the acute complications the resident had during her shift. The director of nursing (DON) was interviewed on 8/28/19 at 5:20 p.m. She said the nurses should follow all physician orders unless the resident was having acute complications then it would be communicated to the resident's physician immediately. She said she talked to the night shift nurse via the telephone, that worked the night the resident returned from the hospital on 8/27/19. She said per her telephone conversation the nurse said when she called orders in to the nurse practitioner she said to hold the enteral nutrition order and failed to document the order. The DON said all orders communicated by prescribers via the telephone should be entered into the resident physician's order. She said the hospital discharge orders were to continue with his feedings since his test obtained in the hospital were negative and to add Miralax. She said she would call the physician to see what course of action would be required due to the resident's abdominal distention and she said after communicating with the physician, his feeding was not held and was continued. IV. Facility follow-up The 8/28/19 nurse progress note documented in part, At around 4:00 p.m. the tube feeding was set up and it runs at 60cc (cubic centimeters/60 mililtiers) per hour. The resident was assessed and no s/s (signs and symptoms) of discomfort or pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interviews, the facility failed to inform a resident of the facility's bed hold policy for one (#71) of one resident reviewed for hospitalization out of 26 sample residents. Specifically, the facility failed to ensure Resident #71 was informed, in writing, of the bed hold policy when he transferred to the hospital while on leave from the facility. Findings include: I. Facility policy and procedure The Bedhold policy, dated 11/4/13, was provided by the quality improvement specialist (QIS) on 8/29/19 at 1:05 p.m. It read in pertinent part, -The resident and/or responsible party shall be notified of behold policies of the facility. The notification will be provided in writing upon admission and upon transfer for medical leave. -The admission Coordinator gives a notice of the facility's Behold policy to all new admissions during the admission process. -In case of emergency medical transfer, the Notice Regarding Behold and readmission form will be included with other paperwork, which accompanies the resident to the hospital. The health information manager will mail a copy of the form to the resident's legal representative within 24 hours unless the resident has been readmitted to the facility. II. Resident #71 A. Resident status Resident #71, age [AGE], was admitted [DATE]. According to the August 2019 computerized physician orders (CPO) diagnoses included diabetes mellitus, chronic kidney disease and dependence on renal dialysis. The 8/2/19 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had a reentry date of 5/27/19 and 7/25/19 from an acute care hospital. B. Record review The 5/22/19 nurse progress note documented the resident had critical renal labs and the resident was transported to the emergency room. The 7/24/19 nurse progress note documented the resident had cellulitis (bacterial skin infection) on his toe and was sent to the emergency room. A review of progress notes and the transfer/discharge paperwork failed to reveal the resident was notified by the facility of it's bed hold policy when he transferred to the hospital on 5/22/19 and 7/24/19. III. Staff interviews The director of nursing (DON) was interviewed on 8/28/19 at 5:00 p.m. She said when a resident is sent to the hospital, the involuntary transfer/discharge form was sent with the resident. She said it outlined in the form that when the resident was sent to the hospital that the facility followed the information provided in the bed hold policy the resident signed at admission. She said admission agreement with the bed hold policy and each involuntary transfer/discharge form was uploaded by medical records into the electronic medical record. She said for Resident #71, she did not locate the admission agreement signed by the resident when he admitted or any of the involuntary transfer/discharge form. She said she was going to resign the bed hold agreement with Resident #71 since the facility could not locate any documentation. IV. Facility follow-up The DON provided an updated admission agreement form that outlined the bed hold policy signed by Resident #71 on 8/29/19 at 8:53 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure residents with a gastrostomy tube received appropriate treatment and services to prevent complications for one (#24) of two reviewed out of 26 sample residents. Specifically, the facility failed to: -Label the tube feeding bag with the date and time, initials of the nurse hanging the tube feeding, type of tube feeding and flow rate upon administration; and, -Ensure the tube feeding equipment was stored in a clean and sanitary manner. Findings include: I. Facility policy and procedure The Enteral Tube Feeding via Continuous Pump policy, revised November 2018, was provided by the quality improvement specialist (QIS) on 8/29/19 at 10:00 a.m. It read in pertinent part, -Use aseptic technique when preparing or administering enteral feedings. -Check the enteral nutrition label against the order before administration. Check the following information: resident name and room number, type of formula, date and time formula was prepared, route of delivery, access site, method and rate of administration. II. Manufacturer recommendation for storage of formula The manufacturer's recommendation for storage of enteral tube feeding formula was provided by the registered dietitian consultant on 8/29/19 at 9:30 a.m. It read, in pertinent part, Feeding sets are for single-patient use only. Use clean technique to avoid set and/or product contamination. Hang product up to 48 hours after initial connection when clean technique and only one new feeding set are used. Otherwise, do not hang longer than 24 hours. II. Resident status Resident #24, age [AGE], admitted [DATE] and readmitted [DATE]. According to the August 2019 computerized physician orders (CPO), diagnoses included cerebrovascular disease (stroke) and hemiplegia and hemiparesis (weakness and paralysis) affecting the left side. The 6/11/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with no assessment for brief interview for mental status (BIMS) score and severely impaoired decision making. The resident received 51 percent or more of his total calories by nourishment through artificial route in the form of tube feed and depended on staff for activities of daily living. III. Observations On 8/26/19 at 10:00 a.m. the resident's tube feeding pump was observed connected to him while he was in a recliner prompt up watching television in the day room adjacent to the nurses station. The tube feeding pump was connected to an intravenous pole (IV) pole with two bags hanging from both sides. The tube feeding formula bag had written on it 8/26/19 in black marker with no other identifiable information. On 8/28/19 the resident's tube feeding pump was observed intermittently from 9:00 a.m. to 3:30 p.m in the day room adjacent to the nurses station. The resident was not connected via his percutaneous endoscopic gastrostomy (PEG) tube to the pump throughout that time. The tube feeding formula bag that hung on the IV pole had documented on it in black marker, 8/27/19 at 0100. (8/27/19 at 1:00 a.m.) The connector from the tube feeding pump was hanging from the pole with crusted formula at the end of the connector. III. Record review The 4/25/19 physician order documented, Glucerna 1.5 infused at 60ml (mililaters)/hour x 20 hours via PEG (percutaneous endoscopic gastrostomy) every shift for gastroparesis. The hours the resident was not connected to the continuous feed was from 1:30 p.m. to 5:30 p.m. IV. Staff interviews The RDC was interviewed on 8/29/19 at 9:30 a.m. She said tube feeding formula was good for up to 48 hours if the tube feeding connector was directly spiked into the 1000 milliliter bottles because there would be no potential for contamination. She said due to the spikes not being available to be ordered for the facility nurses, the nurses had to pour formula into a 1000 milliliter bag that had a connector to fit the PEG tube. She said the formula, since it had been removed from the original package would be good for 24 hours. Registered nurse (RN) #1 was interviewed on 8/28/19 at 4:12 p.m. She said she had not connected Resident #24's enteral nutrition since she came on shift at 6:00 a.m. She said when the tube feeding formula was hung a label should be placed on the bag with the nurse's initial, time it was initiated, the formula and rate. She said when she disconnected the tube feeding connector from the PEG tube she ensured the connector was cleaned and stored away covered with no residual left on it. The director of nursing (DON) was interviewed on 8/28/19 at 5:20 p.m. She said the tube feeding formula should have been discarded on 8/28/19 at 1:00 a.m. since the formula bag had the date of 8/27/19 at 1:00 a.m. on it. She said the tube feeding formula when hung should have the formula, rate, when it was administered at a minimum. She said it should be on a label and not written in marker on the formula bag. She said the tube feeding bags with connector should be discarded after 24 hours. She said she was providing inservice education to the nurses on proper management of the tube feeding formula, storage and labeling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure one (#71) of two out of 26 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to: -Ensure ongoing communication and collaboration with the dialysis center regarding dialysis care and services was completed for Resident #71; and, -A written contract between the dialysis center and facility was implemented to outline the provision of care of services for Resident #71. Findings include: I. Facility policy and procedure The Hemodialysis Residents policy and procedure, revised 2/4/16, was provided by the quality improvement specialist (QIS) on 8/27/19 at 3:33 p.m. It read in pertinent part, -The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes. -A Dialysis Communication Record is initiated and sent to the dialysis center each appointment; ensure it is received upon return. Key medical record documentation elements: vitals signs and weight. II. Resident #71 A. Resident #71 status Resident #71, age [AGE], was admitted [DATE]. According to the August 2019 computerized physician orders (CPO) diagnoses included diabetes mellitus, chronic kidney disease and dependence on renal dialysis. The 8/2/19 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 and received dialysis services. B. Record review The 12/5/18 renal insufficiency care plan documented the resident went to dialysis center with their contact information. Pertinent interventions were monitor clinical changes post dialysis and labs. The 6/26/19 physician order documented to take vital signs post dialysis on Monday, Wednesday and Friday. Review of the Dialysis Communication Record forms from 6/1/19 to 8/27/19 revealed the form was not completed by the facility staff. The top portion of the form to be completed by the facility nurses included vital signs prior to dialysis, assessment concerns such as significant weight changes, medication changes, refusal of diet or fluid restriction with the facility nurse signature and date. The contract between the facility and dialysis provider was requested on 8/27/19 at 12:00 p.m. and the QIS said there was not a written contract available (see interview below). III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/27/19 at 1:53 p.m. She said when a resident had dialysis care and services there would be a physician order with the date, location and time. She said the facility and the dialysis communicated after each session via the Dialysis Communication Record form. She said the nurse on shift filled out the top portion of the form with pertinent clinical information like weight, vital signs and changes with the resident. She said the form was placed into a dialysis binder and sent with the resident to the dialysis treatment. She said the dialysis center filled out the bottom portion of the form with weight, vitals, medications administered at the center and other pertinent information. She said the nurse on shift reviewed the form post dialysis and if there were changes, it was communicated with the physician. The director of nursing (DON) and QIS were interviewed on 8/27/19 at 2:05 p.m. She said in order to have consistent care and collaboration among the facility and dialysis providers the Dialysis Communication Record forms were filled out every treatment. She said the nursing staff were responsible for filling out the top portion of the form that included the daily vitals including weights and any issues or concerns with the resident. She said the dialysis center then filled out the bottom portion of the form with the same information and the nursing staff were responsible to view the form and communicate any new information. The DON said for Resident #9, his Dialysis Communication Record forms were not filled out by the nursing staff before he left for treatment. She said she would begin education with the nurses on the importance of the form and ensure that it was filled out before a resident left for dialysis treatment. The QIS said the dialysis center and facility should have had a contract in place to ensure the care provided by each entity was clearly defined. He said he told the facility to get the contract in place but it had not been done before 8/26/19. He said he reached out to Resident #9 ' s dialysis center to get a written contract in place. The dialysis clinic manager (DCM) was interviewed on 8/28/19 at 2:23 p.m. He said when a resident had a dialysis treatment the clinic filled out the information on the communication forms in order for the facility staff to have any pertinent clinical information. He said if the forms were filled out by both entities correctly then it provided communication to ensure the resident had consistent care. He said for Resident #9, his staff often indicated on the form that there was no information from the facility before his dialysis treatment. He said the resident faithfully brought the Dialysis Communication Record forms and brought them back to the facility. He said his staff often had to call the social worker or nurse on staff to ensure changes were communicated since his staff could not always rely on the facility staff reviewing for form with the written information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure resident use of psychotropic medication was appropriate for one (#9) of five residents reviewed for unnecessary medication use out of 26 sample residents. Specifically, the facility failed to: -Provide non-pharmacological interventions prior to the administration of an as-needed (PRN) psychotropic medication: and, -Provide documentation and rational to justify the continued use of a PRN psychotropic medication. Findings include: Facility policy and procedure The Psychopharmacological Medication policy, revised 1/10/19, was provided by the quality improvement specialist (QIS) on 8/29/19 at 9:38 a.m. It read in pertinent part: -The community supports the appropriate use of psychopharmacological drugs that are therapeutic and enabling for residents suffering from mental illness. -The licensed nurse and/or social service director will make every effort to determine if there are any potential behavior symptoms that may require special monitoring and/or care planning. -The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate. -The interdisciplinary team will review residents on psychopharmacological drugs at least quarterly. -The Psychopharmacological /Behavior Review Committee will review the residents on admission, quarterly, and change of status. Committee members will ensure the resident is on the most appropriate psychopharmacological drug for the specific behavior symptoms and/or diagnosis and at the lowest possible dose to control the symptoms and they have an appropriate corresponding diagnosis and rationale for continued use (Risk vs Benefit statement.) -The licensed pharmacist will review residents' psychopharmacological drug regimen on a monthly basis. -The primary physician will monitor residents who are prescribed psychopharmacological drugs at least quarterly to assure these drugs are utilized according to State and Federal regulations and for the appropriate treatment of resident diagnosis. Resident #9 Resident #9, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2019 computerized orders (CPO), the diagnosis included chronic obstructive pulmonary disease, personal history of traumatic brain injury and anxiety disorder. The 5/30/19 minimum data set (MDS) assessment revealed, the resident was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He received antianxiety, antidepressant and opioid medication. He needed limited to extensive assistance with most activities of daily living. He did not exhibit any behaviors but he did reject care one to three days of the week. He used supplemental oxygen and received hospice care. Record review The anti-anxiety medication care plan, revised 6/3/19, documented the resident had the following behaviors: anxiety when he remembers his daughters death and thinks it was recent, and anxiety when he became short of breath. Pertinent interventions listed were to monitor and record occurence of target behavior symptoms, anxiousness related to shortness of breath and memories that trigger anxiety and document per facility protocol, notify hospice for break through anxiety or unsuccessful interventions, provide one to one when he shows signs of anxiety and encourage him to talk about feelings and concerns and utilize non-pharmacological interventions as able. The mood care plan, revised 5/2/18, documented the resident had the following behaviors: mania, hypermania, racing thoughts, euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep and hyperactivity. Pertinent interventions listed were assist resident, family and caregivers to identify strengths, positive coping skills and reinforce them. Monitor/record / report to MD signs and symptoms of anxiety. The August 2019 CPO documented, Lorazepam (anti-anxiety medication) give 0.5 ml (millileters) by mouth every 2 (two) hours as needed for terminal agitation /shortness of breath. The medication was started on 6/15/18 with no end date documented. Review of the medication administration record (MAR) from 4/1/19 to 8/28/19 revealed the resident was administered the Lorazepam (brand name Ativan) PRN on 4/15/19, 5/7/19, 7/2/19 and 8/4/19. -There were not any non-pharmacological interventions documented in the resident ' s progress notes or any behavior documentation indicating why the PRN Lorazepam was administered. The 8/15/19 nurse practitioner (NP) note documented in part that the resident was being seen for a routine visit. He had no complaints of shortness of breath or anxiety. It read that the patient had a history of anxiety, which was stable, and was receiving Ativan PRN for anxiety. It read to continue the Ativan. The 5/20/19 psychotropic medication management review documented the resident was on Lorazepam 0.5ml every two hours as needed for terminal agitation and shortness of breath. No gradual dose reduction or non-pharmacological interventions were documented. Staff interviews The registered nurse (RN) #1 was interviewed on 8/28/19 at 2:48 p.m. She said when administering a PRN psychotropic medication the nurse needed to know first what the indication for use. She said she tried non-pharmacological interventions such as divert their attention or to engage them in an activity. If the non-pharmacological interventions failed, then she administered the PRN psychotropic, checked back with the resident in an hour and document if the symptoms were diminished and if the PRN medication was effective. She said the non-pharmacological interventions and behaviors would be documented in the resident ' s progress notes. She said for Resident #9 if he was having shortness she would check his oxygen saturation level and make sure he was wearing his oxygen before administering the PRN Lorazepam. She would document any abnormal breath sound, oxygen use, agitation, restlessness and his comfort level before administering his PRN Lorazepam. She said it was standard for hospice to have Lorazepam PRN for a resident in case it was needed. She said he received the PRN Lorazepam on 4/15/19, 5/7/19, 7/2/19 and 8/4/19. She said if the resident was in distress or had an increase in his anxious behaviors then she would communicate with the physician, hospice nurse and family. The director of nursing (DON) was interviewed on 8/28/19 at 5:28 p.m. She said the facility reviewed residents ordered psychotropics in their quarterly meeting. She said the mental health doctor, pharmacist, administrator, DON and social service director participated in the meeting. She said Resident #9 was on hospice, losing weight and had a history of anxiety. She said he was declining and had significant anxiety. She said he had been receiving the PRN Lorazepam for anxiety since 6/15/18. She said Resident #9 uses the PRN Lorazepam occasionally, but if he was anxious due to his shortness of breath then a breathing treatment often worked to relieve his anxiety. She said the nurse practitioner note dated 8/15/19 documented the resident was stable, appeared calm and was appropriate for the situation. It documented to continue the PRN Lorazepam. The social services director (SSD) was interviewed on 8/28/19 at 5:33 p.m. She said they reviewed psychotropic medications quarterly at the minimum and if there was a significant change. The psychotropic committee discussed behavior changes as well as medical concerns. They reviewed the psychotropic medications prescribed and past gradual dose reductions. She said the findings were documented on the interdisciplinary psychotropic evaluation. She said the pharmacist tracked the psychotropic medications and presented recommendations during the monthly psychotropic committee meeting. The pharmacy consultant (PC) was interviewed on 8/29/19 at 10:31 a.m. She said a medication regimen review (MRR) was completed monthly for each resident. She said her recommendations were sent to the DON and the staff development coordinator (SDC) and were addressed within 90 days. She said if the recommendations were more urgent she would expect it to be addressed within 30 days or if it was critical a call was placed to the DON to follow up on the recommendation immediately. The PC said she would review any psychotropic PRN monthly especially if it had been ordered since 6/15/18. She said that if a PRN psychotropic medication was ordered, the prescriber should reassess the resident after 14 days, document the need for continued use and duration if prescribed longer than the 14 days. The PC said Resident #9 was discussed in the monthly psychotropic committee meeting but she did not have any MRR for his Lorazepam PRN ordered.

Based on observations and interviews the facility failed to ensure safe medication and vaccine storage in two out of three medication rooms. Specifically, the facility failed to: -Store vaccines in a non-dormitory style refrigerator: and, -Monitor the temperatures of refrigerated medications, vaccines and biologicals. Finding include: I. Facility policy and procedure The storage of medications policy, revised April 2007, was provided by the quality improvement specialist (QIS) on 8/29/19 at 4:30 p.m. It read, in pertinent part: the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. It read that medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses ' station or other secured location. II. Professional reference According to the Centers for Disease and Control and Prevention (CDC) Vaccine Storage and handling (2019) retrieved from: https.//www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. Do not store any vaccine in a dormitory style or bar-style combined refrigerator/ freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an ice maker/freezer compartment. These units have been shown to pose a significant risk of freezing vaccines, even when used for temporary storage. All staff members who receive deliveries and/or handle or administer vaccines should be familiar with storage and handling policies and procedures at your facility. Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease. Vaccines must be kept refrigerated at 36-46 degrees F.(9/3/19) III. Observations and interviews A. Medication storage rooms 1. Fourth floor On 8/28/19 at 5:16 p.m. the fourth floor medication storage room refrigerator was inspected with licensed practical nurse (LPN) #3. The refrigerator was observed to be a dormitory style refrigerator with an internal freezer unit and four pneumococcal vaccine vials stored in the top shelf of the door. The temperature was 34 degrees F. The July 2019 temperature log documented that all 31 days the refrigerator temp was below 36 degrees F. The August 2019 temperature log documented that 25 out of 28 days the temperature was below 36 degrees F. LPN #3 said she did not know vaccines should not be kept in the door of the refrigerator or that the refrigerator should not have a freezer in it. She said she was not sure what the temperature range should be and that the night nurse checks the refrigerator temperature and logs it. She said she was not sure who should be notified if there are out of range temperatures. 2. Second floor On 8/28/19 at 5:35 p.m. the second floor medication storage room refrigerator was inspected with LPN #1. The refrigerator was observed to be a dormitory style refrigerator with an internal freezer unit. There were no vaccinations in the fridge and the refrigerator temperature was 46 degrees F. The July 2019 temperature log documented that two out of the 31 days the temperature was below 36 degrees F. The August 2019 temperature log revealed that five out of the 28 days the temperature was below 36 degrees F and one of the days it was 48 degrees F. The top of the log form read the refrigerator temperature should be between 36-38 degree F. LPN #1 said she did not know what the refrigerator temperature should be. She said the night nurse checked the temperature and then would log it. She was not sure who should be contacted if refrigerator temperatures were out of range but said the director of nursing (DON) or maintenance should also be notified. The DON and the quality improvement specialist (QIS) were interviewed on 8/29/19 at 11:38 a.m. They said they were aware that the medication room refrigerators were out of compliance and would be replacing all of them. The DON said if the medications were not stored properly it could affect the medications potency. She said the refrigerator temperature should be between 36-42 degrees F. The QIS said they had ordered a refrigerator just for the vaccines. The DON said the night nurse checked the refrigerator temperature nightly and should then document on the log. The QIS said if the temperature was not within range, the nurse should notify the DON and maintenance, remove the medications from the refrigerator and place them in another refrigerator or destroy them if needed. They said they had not been notified of out of range temperatures until the day before. They said the staff development coordinator should have educated the nurses on when to notify the DON and maintenance of incorrect refrigerator temperatures. They had not provided the training but would start the following day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#9) of two out of 26 sample residents. Specifically, the facility failed to: -Coordinate hospice services and develop a current care plan delineating the care provided by the hospice agency and the nursing facility for this resident's overall care and ensure adequate and timely documentation for Resident #9; and, -A written contract between the facility and hospice provider outlining provision of care and services. Findings include: I. Facility policy and procedure The Hospice Care policy, revised 10/26/18, was provided by the health information manager (HIM) on 8/27/19 at 3:00 p.m. It read in pertinent part, -When a facility resident elects to have hospice care, the facility staff communications with the hospice agency to establish and agree upon a coordinated plan of care that is based upon an assessment of the resident's needs and living situation in the facility. -Ensure that the hospice services meet professional standards and principles that apply to the individuals providing services in the facility and to the timeliness of services. -Ensure that the plan of care identifies the care and services which the facility and hospice agency will provide in order to be responsive to the unique needs of the resident and expressed desire for hospice care. Appoint a clinical member of interdisciplinary team to act as hospice coordinator. -Ensure that the facility staff is aware of their responsibilities in implementing the plan of care, as well as the responsibilities of the hospice staff. II. Facility and hospice written agreement The Hospice Services Agreement, dated 8/27/19 (during survey), was provided by nursing home administrator (NHA) on 8/27/19 at 2:50 p.m. It read in pertinent part, -The hospice must provide the nursing facility the most recent hospice plan of care, nurse and contact information for hospice personnel involved in hospice plan of care of each patient, physician certification and recertification of the terminal illness and hospice medication information specific to each patient. -Nursing facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each hospice patient receiving nursing facility services. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the August 2019 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), anxiety disorder and recurrent depressive disorders. The 5/30/19 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired according to the brief interview for mental status (BIMS) score of 10 out of 15 and received hospice care. B. Record review The 10/10/16 physician order documented the resident was admitted to hospice with end stage COPD. The 12/6/17 facility hospice care plan documented pertinent interventions of hospice nurse and certified nurse aide (CNA) visited at least once a week, hospice chaplain and social worker visited monthly, refer to hospice care plan and collaborate with hospice staff regarding the resident's care. Review of the Resident #9's electronic medical record revealed the last nurse visits, CNA visits and the hospice plan of care from June 2019. -There was no other current documentation from the hospice provider regarding current visits from the nurse, CNA, social worker or spiritual notes and the current hospice plan of care since June 2019. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/27/19 at 1:53 p.m. She said when the hospice staff visited a resident on their services they checked in with the nurse on shift to be notified of any changes with the resident. She said the hospice interdisciplinary visits and plan of care were provided via secure email to the health information manager and she uploaded them to the electronic medical record so that all care staff had access to their information. She said for Resident #9 the last updated information from hospice she saw uploaded in his medical record was from June 2019. She said she was not sure why the hospice information was not up to date in his electronic medical record. The quality improvement specialist (QIS) and HIM were interviewed on 8/27/19 at 2:33 p.m. The HIM said she had been in the position since February but had worked at the facility in another capacity previous. She said she was emailed from the hospice company any pertinent records such as visits and plan of care securely about one to two times a month. She said she then uploaded the information downloaded from her secured email into the resident's electronic medical record. She said for Resident #9 she had not uploaded his hospice records sent to her via email by the hospice company in July and August 2019. She said she was behind on her work and had not reached out to her consultant or facility staff to assist her. She said it was important to ensure Resident 9's hospice information was current for the coordination of his care with the facility staff and physicians. The QIS said the hospice and facility should have had a contract in place to ensure the care provided by each entity was clearly defined. He said he told the facility to get the contract in place but it had not been done before survey started on 8/26/19. He said he implemented with the hospice providers and the facility staff for the resident's hospice information to be emailed securely to both the director of nursing and the HIM in order to ensure that it was uploaded and current. V. Facility follow-up The current hospice plan of care and missing visits from the hospice interdisciplinary team was provided to the by the hospice company to the facility and was uploaded to Resident #9's electronic medical record by the HIM on 8/28/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Failed to implement appropriate hand hygiene during medication administration. A. Professional standards The Centers for Disease Control and prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 4/29/19, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations : Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer (ABHS) immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean site on the same patient, after touching a patient or a patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, or after known or suspected exposure to spores. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised August 2015, provided by the quality improvement specialist (QIS) on 8/29/19 at 4:30 p.m. documented the following: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Single use disposable gloves should be used before an aseptic procedure, when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident who is on contact precautions. Wash hands before applying non-sterile gloves and after removing them. The Medication Administration policy and procedure, dated 9/30/13, provided by the QIS on 8/29/19 at 4:30 p.m. documented the following: Wash hands or use hand sanitizer prior to medication preparation for each medication pass. If direct resident contact is made, the nurse must wash hands. Do not touch oral medications, topical medications, ointments or creams. C. Observation Registered nurse (RN) #1 was observed on 8/28/19 at 7:18 a.m. during medication pass. RN #1 used alcohol-based hand sanitizer (ABHS) and then donned gloves. She said she wore gloves because she had a hard time popping the pills out of the cardboard bubble pack. She removed the medication cart keys from her scrub top pocket. She touched the computer, the mouse, the top of the cart, the medication cart handles and medication cards. She removed the residents medication cards from the cart and laid them on top. She then held the blister pack and popped the medication out in to her gloved hand, which was contaminated by previous touched items. She them placed the medication into a souffle cup. She followed the same technique for the next three medications. She then locked the medication cart and asked the resident if he would like milk to take his medications. With the same gloved hands, she removed the keys from her pocket and unlocked the nourishment room door. She opened the refrigerator and poured a cup of milk for the resident. She removed the gloves in the nourishment room, and did not perform hand hygiene. She grabbed the cup around the lip of the drinking surface and gave it to the resident. RN #1 was observed again on 8/28/19 at 7:46 a.m. She used ABHS and then donned gloves. She used her gloved hand to remove the keys from her pocket. She touched the computer, the mouse, the top of the cart, the medication cart handles and medication cards. She removed the residents medication cards from the cart and laid them on top. She then held the blister pack and popped the medication out in to her gloved hand, which was contaminated by previous touched items. She them placed the medication into a souffle cup. She followed the same technique for the second medication. She then locked the cart and walked to the residents room. With the same gloved hands she knocked on the residents door. She entered the room and removed her gloves at the bedside before giving medications to the resident. She did not perform hand hygiene until after the medications were administered to the resident. RN #1 was observed a third time on 8/28/19 at 5:01 pm. While she was preparing to check a resident's blood sugar. She donned gloves and removed an alcohol wipe and a 4x4 gauze from the cart. She walked to the common area where the resident was sitting. She used her gloved hand to push her glasses on to her nose and then scratched her arm with the same gloved hand. Without changing gloves or performing hand hygiene, she wiped the residents finger with the alcohol wipe and used the gauze to wipe away the first drop of blood. She then held the residents finger and collected the sample. She again used gauze to apply pressure to the bleeding finger. She failed to do hand hygiene and don new gloves after touching her glasses and scratching her arm. D. Record review The RN training log was provided by the QIS on 8/29/19 at 4:30 p.m. It documented RN #1 had received hand hygiene training on 8/14/19. The skills check off form was provided by the QIS on 8/29/19 at 4:30 p.m. It documented that RN #1 was trained on handwashing, hand gel and glove use on 8/14/19 with satisfactory results. The document was signed and dated by RN #1. E.Staff Interviews The director of nursing (DON) and the QIS were interviewed on 8/29/19 at 12:00 p.m. The DON said when a nurse was preparing medications they should wash their hands and not touch the medication with their bare hands. The QIS said if a nurse chose to wear gloves, the only surface they should be touching was the medication card while the pill was being removed from. The QIS said if they touch any other surface they were to remove the gloves and perform hand hygiene before donning new gloves. The QIS said he would have to talk to the nurse in question and ask her why she was wearing gloves to pass medications. He said the nurse should not have worn gloves for the medication pass. The staff development coordinator (SDC), who was also the infection control preventionist, was interviewed on 8/29/19 at 1:30 p.m. She said the facility did hand hygiene training with the annual competencies, during the skills fair every three months, and during spot checks. She said staff should be washing their hands before and after donning gloves. She said if a nurse chooses to wear gloves the nurse should only be touching the medication card and nothing else. Based on observations, interviews and record review, 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: -Follow appropriate surface contact times with a disinfectant and perform hand hygiene with routine cleaning; and -Implement appopriate hand hygiene during medication pass. Findings include: I. Follow appropriate surface contact times with a disinfectant and perform hand hygiene with routine cleaning. A. Professional reference The Centers for Disease Control and Prevention (2019) Healthcare Environmental Infection Prevention and Control, retrieved from: https://www.cdc.gov/hai/prevent/environment/index.html. It read in pertinent part, -Throughout healthcare, the physical environment represents an important source of pathogens that can cause infections or carry antibiotic resistance.Sometimes, the healthcare environment is a primary source of germs. Consider that molds can be present on wet or damp surfaces or materials, and bacteria can be present in plumbing fixtures including sink drains or ice machines. -The way that humans interact with the healthcare environment also plays a role. For example, when a healthcare worker fails to wash their hands, they might touch and contaminate a piece of equipment or environmental surface; in turn the equipment or surface could wind up exposing a patient to pathogens. -These examples illustrate the importance of environmental infection prevention and control in the healthcare setting. Water and environmental surfaces are two intersecting parts of the healthcare environment that contribute to the spread of antibiotic resistance and healthcare associated infections. B. Manufacturer recommendations for directions of use of the disinfectant spray The manufacturer's recommendation for directions of use for the disinfectant spray, undated, was provided by the quality improvement specialist (QIS) on 8/29/19 at 4:22 p.m. It read in pertinent part, To clean and disinfect hard, non-porous surfaces: For heavily soiled areas, clean before disinfecting. Thoroughly wet hard, non-porous for 10 minutes, then rinse and wipe clean. C. Observations of housekeeping staff on 8/29/19 At 11:24 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. She donned gloves without performing hand hygiene previously and went into the bathroom with two clean rags. There was a brown substance on the base of the right side of the toilet. She sprayed the disinfectant directly onto the toilet seat, under the seat and base of the toilet. She immediately wiped the disinfectant with a rag starting on the toilet seat, the bowl rim and then cleaned the base of the toilet. The brown substance still remain at the base of the toilet even after she cleaned the toilet. She took the rag out of the bathroom and disposed of it on her cart. She doffed her gloves and donned new gloves without performing hand hygiene to clean the rest of the room. She did not follow the manufacturer's instructions to spray disinfectant directly on the surface ensuring thorough saturation to remain wet for 10 minutes (see manufacturer recommendation above) before wiping up it up. After cleaning room [ROOM NUMBER], she doffed her gloves and placed them in the trash and proceed to clean another residents room without performing hand hygiene. At 11:35 a.m. HK #1 was observed cleaning room [ROOM NUMBER]. She donned gloves without performing hand hygiene previously and went into the bathroom with two rags. She cleaned the sink area of the bathroom with one rag and left it on the counter after cleaning. She sprayed the disinfectant directly onto the toilet seat, under the seat and base of the toilet. She immediately wiped the disinfectant with a rag starting on the toilet seat, the bowl rim and then cleaned the base of the toilet. She then placed the rag she cleaned the toilet with onto the sink area where she had just cleaned to take the trash out of the bathroom. She took the two rags out of the bathroom once she emptied the trash and placed them in a bag on her cart. She did not change her gloves and proceeded to clean room [ROOM NUMBER]. After cleaning the room, she doffed her gloves and placed them in the trash and proceeded to clean another resident room without performing hand hygiene. D. Staff interviews The maintenance service director (MSD) was interviewed on 8/29/19 at 12:31 p.m. He said he managed the housekeeping, laundry and maintenance departments. He said the housekeeping manager was on vacation and he was not available. He said the previous housekeeping manager worked in medical records currently so she would be able to answer procedural questions on how to clean the room. He said the representative from the chemical company came in once a month to check the chemicals the facility was using to disinfect and clean the resident rooms. He said most of the housekeepers had been working at the facility for several years so they did not require additional training on how to clean and use the chemicals. He said when a housekeeper started, during initial training they were provided competency based training on how to clean the resident rooms. The health information manager was interviewed on 8/29/19 at 12:41 p.m. She said previous to starting her position in medical records, she was the housekeeping manager for about five years. She said the correct procedure to clean the room was to start in the bathroom where two rags were used, one for sink area and one for the toilet. She said after the sink was cleaned the rag was discarded into a bag and then the toilet was cleaned with disinfectant sprayed directly on it and wiped immediately. She said the rag to clean the toilet was placed in the bag and removed from the room. She said after the bathroom was cleaned and disinfected, the housekeepers were to change their gloves with performing hand hygiene in between before proceeding to clean the rest of the room. She said once the room was cleaned then the housekeepers doffed their gloves and performed hand hygiene before cleaning the next room. She said when she managed the department she would provide on the spot training if she saw the rooms were not being cleaned correctly but did not document or provide competency based training after the initial training. She said she did not know what the surface contact time was the disinfectant chemical the housekeepers used and it was being used when she was supervising the department. The staff development coordinator #1 was interviewed on 8/29/19 at 1:02 p.m. She said she was the infection control preventionist for the facility and oversaw the program. She said she had started a month previous in the position. She said she tracked the infections of the facility and had provided training to staff during monthly all staff meetings and skills fair training held every three months on hand hygiene, specifically when to use alcohol based hand rub or wash their hands. She said she did not know the surface contact time for the chemical used by the housekeepers. She said based on the observations (see above) that there could be a potential for spread of a healthcare associated infection. She said moving forward she would be working with all the departments to provide education on infection control prevention.

Based on record review and interview, the facility failed to ensure an effective training program for all staff included training on abuse, neglect, exploitation, and misappropriation of resident property. Specifically, the facility failed to ensure five employees received abuse training in the last 12 months after their initial training upon being hired. Findings include: I. Facility policy and procedure The Abuse Training policy, undated, was provided by the nursing home administrator (NHA) on 8/29/19 at 3:00 p.m. It documented in pertinent part, -Training programs are completed upon hire on abuse and neglect, The Elder Justice Act and resident rights. -Abuse prevention and The Elder Justice Act training for all staff is to be completed semi-annually. II. Record review Review of the course training data from 8/28/18 to 8/28/19 revealed that five staff had not had abuse and neglect training in the past 12 months: -Staff development coordinator (SDC) #2 hired on 9/4/12; -Laundry worker (LW) #1 hired on 6/14/18; -Certified nurse aide (CNA) #1 hired on 1/13/11; -Housekeeper (HK) #1 hired on 3/6/12; and -Licenced practical nurse (LPN) #5 hired on 1/20/14. III. Staff interviews The SDC #2 was interviewed on 8/28/19 at 9:19 a.m. She said she had started her position about a month previous but had worked in the facility in another capacity. She said since starting her role she ensured the nursing staff had their competency training which included an inservice about the types of abuse and reporting requirements. She said in addition to her training the nursing staff completed computer based training at a minimum annually but she did not have access to the system. She said she did not keep track of other staff ' s abuse and neglect training and she said the director of nursing (DON) would know who kept track of it. The DON was interviewed on 8/28/19 at 9:30 a.m. She said she did not keep track of all staff training of abuse and neglect training but the social service director (SSD) kept track of it and provided the abuse and neglect trainings at their all staff meetings. The SSD was interviewed on 8/28/19 at 9:35 a.m. She said she presented abuse and neglect training at all staff meetings. She said the staff who attended, signed in as being present, but she overall, did not keep track of who attended each meeting. The NHA was interviewed on 8/28/19 at 9:38 a.m. She said she thought the SDC kept track of all employee abuse and neglect training. She said she was going to keep track of the abuse and neglect training moving forward to ensure all staff had received the training wither in their all staff meetings held monthly, on the computer based system or any other abuse and neglect training provided by department managers.