**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for three (#7, #16 and #5) of five residents reviewed for antibiotic use out of 29 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Residents #7, Resident #16 and Resident #5. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on 1/11/24, included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections. II. Facility policy and procedure The Antibiotic Stewardship policy, dated 12/7/23, was provided by the nursing home administrator (NHA) on 1/3//24 at 3:39 p.m. It revealed in pertinent part, Purpose: to provide guidance for (facility name) locations for antibiotic stewardship plans, to decrease the incident of multi-drug resistant organisms (MDROs), promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use; and to provide standard definitions to be sued as guidelines when initiating antibiotics. Urinary Tract Infections: Residents without indwelling catheter: acute dysuria or fever and new or worsening in at least one of the following): in the absence of fever, two or more of the following): costovertebral angle tenderness, frequently, gross hematuria, suprapubic pain, urgency and urinary incontinence. III. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and heart disease. The 10/25/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with short-term and long-term memory deficits. She was dependent for oral hygiene, toileting, showering, lower body dressing and personal hygiene. The MDS assessment documented the resident was frequently incontinent of bowel and bladder. B. Record review The September 2023 CPO revealed the following physician order: -UA with urine culture one time only for confusion, ordered 9/26/23. The 9/28/23 progress note documented an urinary analysis (UA) was obtained using a sterile technique with a straight catheter. The resident tolerated will. The lab requisition was filled out and the urine was placed in the refrigerator. -A review of the resident's medical record did not reveal the resident had a fever or leukocytosis and did not meet McGeer's criteria. The incontinence care plan, initiated on 3/1/22 and revised on 7/31/23, revealed the resident had incontinence of bowel and bladder with no awareness of elimination patterns. The interventions included: checking and changing the resident per facility protocol, checking the resident at regular intervals and assisting with toileting as needed and providing incontinence products. IV. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included: heart disease, obesity, depression and chronic pain. The 12/6/23 MDS assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) with a score of 11 out of 15. She required set-up assistance with eating and oral hygiene. She was dependent for toileting, showering and lower body dressing. She required substantial assistance for upper body dressing and personal hygiene. The MDS assessment documented the resident was always incontinent of bowel and bladder. B. Record review The 10/3/23 communication with the physician progress note documented the nurse practitioner ordered a UA to be completed after the resident had a shower. The note documented the resident's urine was positive for mixed flora. The nurse and resident were made aware. -A review of the resident's medical record did not reveal the resident had a fever or leukocytosis and did not meet McGeer's criteria. The 10/8/23 communication note documented the urine culture results were called to the provider and an order was given for cephalexin 500 milligrams (mg) twice a day for 10 days. The incontinence care plan, initiated on 12/27/21, revealed the resident was incontinent of bowel and bladder. The interventions included: checking the resident at regular intervals throughout the day and providing hygiene and providing incontinence products. V. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included lymphedema (swelling) and mixed irritable bowel syndrome. The 10/25/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of six out of 15. She required set-up assistance for eating and oral hygiene. She required substantial assistance for toileting, showering and lower body dressing. She required parietal assistance for personal hygiene. The MDS assessment documented the resident was frequently incontinent of bladder and occasionally incontinent of bowel. B. Record review The incontinence care plan, initiated on 2/10/22 and revised on 10/26/23, revealed the resident was frequently incontinent of bowel and bladder. The interventions included: encouraging residents to drink more fluids, using incontinence products and offering assistance as needed with toileting. -A review of the resident's medical record did not reveal the resident had symptoms that meet the McGreer's criteria to complete a UA. The medical record did not reveal a culture was completed prior to the start of the Augmentin antibiotic on 12/27/23. VI. Staff interviews The infection preventionist (IP) was interviewed on 1/8/24 at 3:11 p.m. The IP said Resident #7's family requested for the UA to be completed because they felt the resident had increased confusion. The IP said the nurse practitioner ordered the UA and did not ensure the resident met McGreer's criteria prior to ordering it. The IP said Resident #7 was started on Amoxicillin on 9/30/23 and ended the antibiotic on 10/5/23. The IP said the medical director completed training with the licensed nurse staff regarding McGreer's criteria and the signs and symptoms the residents needed to have prior to getting a UA order. The IP said she had noticed the nurse practitioner had ordered UAs for residents who did not meet the criteria. The IP said she was going to request the medical director to do training with the nurse practitioner regarding the McGreer's criteria. The IP said the resident needed to have certain symptoms and a fever or leukocytosis per McGreer's criteria to have an UA and cultures ordered. The IP said Resident #16 had confusion and painful urination prior to the order of the UA. The IP said the resident did not have a fever or leukocytosis, so therefore she did not meet the criteria to have an UA ordered. The IP said the resident was started on Cephalexin for 10 days. The IP said Resident #5 did not have a fever or leukocytosis, therefore she did not meet the criteria to have an UA ordered. The IP said the resident was started on Augmentin for seven days. The IP was interviewed again on 1/9/23 at 10:12 a.m. She said the facility used McGreer's criteria for antibiotic use. The IP said Resident #7, Resident #16 and Resident #5 should have not had a UA conducted as they did not meet the criteria. The IP said Resident #7, Resident #16 and Resident #5 should have not been prescribed antibiotics for a urinary tract infection as they did not meet the McGreer's criteria for antibiotic use. The IP said Resident #7, Resident #16 and Resident #5 were all incontinent. The IP said it would have been beneficial to review the cultures of the residents' UAs to determine if the cultures were related to fecal material. The IP said if she monitored which cultures were found in UAs she would be able to provide education to staff. The IP said for example if a lot of residents had bacteria cultures that were found in fecal matter, she would provide education on incontinence care to the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for eight (#9, #18, #21, #32, #5, #25, #3 and #16) of 10 residents reviewed for immunizations out of 29 sample residents. Specifically, the facility failed to: -Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #9, #18, #21, #5 and #25; -Offer Resident #32 a pneumococcal vaccination upon admission; -Offer Resident #32 an annual influenza vaccination; and, -Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #16 and Resident #3. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 12/13/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: age [AGE]-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy and procedure The Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19 policy, dated 9/21/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 11:00 a.m. It revealed in pertinent part, Purpose: to provide residents and clients the opportunity to receive immunizations as they fit into their healthcare goals and to provide guidance for the location's immunization program including recommended vaccinations. Upon admission, each client, resident and/or resident representative will receive the Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines and the VIS or Fact Sheet for Recipients and Caregivers for the COVID-19 vaccine. If the client, resident and/or the resident representative consent to vaccination: ensure physician's order has been obtained for the vaccine(s) to be administered, obtain written consent if required by state regulation, if written consent is not required, obtain and document verbal consent, complete vaccine screening prior to administering vaccination and administer vaccination or refer to Provider or Pharmacy for vaccine administration. Pneumococcal Vaccination: it is recommended that all clients and residents receive pneumococcal vaccination(s) per CDC (Center for Disease Control) guidelines for eligibility and timing. Annual Influenza Vaccination: It is recommended that all clients and residents receive influenza vaccination for the current year based on CDC recommendations. Residents admitted during influenza season should be vaccinated at the time of admission, if not previously vaccinated for the current influenza season. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included epilepsy (seizure disorder) and type two diabetes mellitus. The 11/8/23 minimum data set (MDS) assessment revealed indicated the resident was not up to date on her pneumococcal vaccination but did not specify the reason. B. Record review A review of Resident #9's EMR revealed the resident was administered the Prevnar 13 vaccination on 4/11/17 and 8/15/19. -There was no documentation that indicated the resident had been offered the updated pneumococcal vaccination. IV. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart failure, gastro-esophageal reflux disease (GERD) and lymphoid leukemia (cancer). The 12/6/23 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not indicate a reason. B. Record review A review of Resident #18's EMR revealed Resident #18 received the Prevnar 13 vaccination on 3/21/17. -There was no documentation that indicated the resident had been offered an additional pneumococcal vaccination. V. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included mild protein-calorie malnutrition and hypertension (high blood pressure). The 12/19/23 MDS assessment indicated the resident was up to date on her pneumococcal vaccination. B. Record review A review of Resident #21's EMR revealed Resident #21 had received the Prevnar 23 on 2/18/13 and the Prevnar 13 on 4/19/17. -There was no documentation that indicated the resident had been offered an additional pneumococcal vaccination. VI. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included dementia, anxiety and constipation. The 11/23/23 MDS assessment indicated the resident had not been offered the influenza or pneumococcal vaccinations. B. Record review -A review of Resident #32's EMR revealed Resident #32 had not received an annual influenza vaccination or a pneumococcal vaccination. VII. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included gastro-esophageal reflux disease (GERD), opioid dependence, depression and lymphedema (swelling). The 10/25/23 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not indicate a reason. B. Record review A review of Resident #5's EMR revealed Resident #5 had received the Prevnar 13 vaccination on 12/2/15. -There was no documentation that indicated the resident had been offered an additional pneumococcal vaccination. VIII. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart failure and type two diabetes mellitus. The 11/1/23 MDS assessment indicated Resident #25 was offered the pneumococcal vaccination and declined. B. Record review -A review of Resident #25's EMR revealed no documentation that Resident #25 had received or declined the pneumococcal vaccination. IX. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included heart disease, lymphedema (swelling) depression and history of COVID-19. The 12/6/23 MDS assessment indicated Resident #16 was offered the pneumococcal vaccination and declined. B. Record review -A review of Resident #16's EMR revealed the resident had refused the pneumococcal vaccination on 3/31/21 (see the director of nursing interview below). -A request for the 3/31/21 declination form and risk versus benefit for Resident #16 was requested on 1/8/24. The declination form and risk versus benefit were not provided during the survey process (1/3/24 to 1/9/24). The facility did not offer the pneumococcal vaccination annually. X. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2024 CPO the diagnoses included multiple sclerosis (disease of the central nervous system) and history of COVID-19. The 11/8/23 MDS assessment indicated Resident #3 was offered the pneumococcal vaccination and declined. B. Record review -A review of Resident #3's EMR revealed the resident had refused the pneumococcal vaccination on 5/28/19 (see the director of nursing interview below). -A request for the 3/31/21 declination form and risk versus benefit for Resident #3 was requested on 1/8/24. The declination form and risk versus benefit were not provided during the survey process (1/3/24 to 1/9/24). The facility did not offer the pneumococcal vaccination annually. XI. Staff interviews The director of nursing (DON) was interviewed on 1/8/23 at 2:00 p.m. The DON said the admissions coordinator and herself were responsible for determining which vaccinations a resident had received prior to admission. The DON said she was responsible for determining which vaccinations the resident needed, obtaining consent, obtaining physician orders and administering the vaccination. The DON said at times she delegated some of the tasks to the charge nurse. The DON said she utilized the State Immunization System to determine which vaccinations each resident needed to receive. The DON said according to Resident #9's EMR, she had received the Prevnar 13 vaccination on 8/15/19. The DON said the resident should have been offered an additional dose of the pneumococcal vaccination one year after the resident received the Prevnar 13 vaccination. The DON said Resident #18 had received the Prevnar 23 vaccination on 3/21/17. The DON said she was unsure of how often the Prevnar vaccination should be offered and she would consult with the medical director for further guidance. The DON said Resident #21 received the Prevnar 23 vaccination on 2/18/13 and the Prevnar 13 vaccination on 4/19/17. The DON said typically the Prevnar 13 vaccination was given a year prior the Prevnar 23 vaccination. The DON said she would need to consult with the medical director to see if the resident should be offered an additional dose of the pneumococcal vaccination. The DON said Resident #32 admitted to the facility in November 2023. The DON said Resident #32 had not been offered an annual influenza vaccination since admission. The DON said she would reach out to the resident's representative to offer the annual influenza vaccination. The DON said she was unsure if Resident #32 had received any pneumococcal vaccinations. The DON said she would utilize the State Immunization System and the resident's family to determine if Resident #32 had received any pneumococcal vaccination and then offer the pneumococcal vaccination if needed. The DON said Resident #32 should have been offered the influenza vaccination upon admission. The DON said Resident #5 received the Prevnar 13 vaccination on 12/2/15. The DON said the resident should have been offered the Prevnar 23 a year after receiving the Prevnar 13. The DON said Resident #5 needed to be offered the Prevnar 23 vaccination. The DON said she was unsure if Resident #25 had received any pneumococcal vaccinations. She said she would look up the resident in the State Immunization System to determine if the resident needed to be offered a pneumococcal vaccination. The DON said according to the immunization tab in Resident #16's EMR she refused the pneumococcal vaccination on 3/31/21. The DON said according to the immunization tab in Resident #3's EMR she refused the pneumococcal vaccination on 5/28/19. The DON said the residents should be offered the pneumococcal vaccination yearly after refusing it initially. The DON said the declination form and the risk versus benefit education should be documented in the resident's EMR annually. The DON said she needed to review all of the residents' pneumococcal vaccinations to ensure the pneumococcal vaccinations were up to date. The DON said going forward she would review all of the residents' EMR annually at the start of the influenza season to determine if they needed additional doses of the pneumococcal vaccination.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated in the nourishment rooms; and, -Ensure timely inspection of the ice machine and ice machine water filter. Findings include: I. 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 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; 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. (Retrieved 1/11/24). B. Facility policy and procedure The Food and Supply Storage policy, revised January 2023, was provided by the nursing home administrator (NHA) on 1/9/24 at 2:49 p.m. It revealed in pertinent part, Cover, label and date unused portions and open packages. Date and rotate items; first in, first out (FIF). Discard food past the use-by or expiration date. The Safe Handling of Personal Food (Outside Food) policy, dated 11/26/18, was provided by the NHA on 1/3/23 at approximately 11:30 a.m. It revealed in pertinent part, All food items must be covered, dated and labeled with common name of the items. Most refrigerated foods must be labeled with the date they are to be discarded. A general rule would be three days from the time it was prepared. C. Observation On 1/3/24 at 1:45 p.m. the following was observed in the rehabilitation unit nourishment room: -In the refrigerator, there was a container of clam chowder with a manufacturer expiration date of 12/13/23, a peanut butter and jelly sandwich that was dated 12/26/23, a loaf of bread with no label or date. -In the dry-storage, there were seven cartons of orange juice with a manufacturer expiration date of 12/2/23. -In the freezer, there was a package of frozen cheeseburger with no label or date. At 1:56 p.m. the following was observed in the long term care unit nourishment room: -In the refrigerator, there was an opened jar of mayonnaise with a manufacturer expiration date of 7/4/22, an opened container of coffee creamer with a manufacturer date of 7/1/23, a container of an unknown food item that had a one-fourth inch layer of black on the top of it with no label or date, a container of blueberries with white fluffy substance on it with no label or date, a container of blackberries with white fluffy substance on it with no label or date, an opened container of prune juice with a manufacturer expiration date of 12/2/23 and a ham and cheese sandwich dated 1/24. -In the freezer, there were two containers of unknown food items with no label or date, a box of frozen yogurt sticks that expired on 12/25/23 and three frozen milkshake beverages with no label or date on them. On 1/4/24 at 10:35 a.m. the following was observed in the long term care unit nourishment room: -In the refrigerator, there was a ham and cheese sandwich that was labeled 1/24, a container of blueberries with a white fluffy substance on it with no label or date, an opened container of coffee creamer with a manufacturer date of 7/1/23, a container of blackberries with a white fluffy substance on it with no label or date, a carton of prune juice with a manufacturer expiration date of 12/2/23, a container of an unknown food time with a layer of black substance on it and an opened jar of mayonnaise with a manufacturer expiration date of 7/4/22. The DM was interviewed during the observation and said the sandwich was labeled incorrectly and needed to be disposed of. The DM said the prune juice, coffee creamer, blueberries, blackberries, mayonnaise and unknown food item needed to be disposed of. -In the freezer, there were two containers of unknown food items with no label or date, a box of frozen yogurt sticks that expired on 12/25/23 and three frozen milkshake beverages with no label or date on them. The DM said the yogurt sticks and milkshakes needed to be disposed of. On 1/4/24 at 10:40 a.m. the following was observed in the rehabilitation unit nourishment room: -In the refrigerator, there was a container of clam chowder with a manufacturer expiration date of 12/13/23 and a loaf of bread with no label or date. The DM said the clam chowder and the loaf of bread needed to be disposed of. -In the dry storage, there were seven cartons of orange juice with a manufacturer expiration date of 12/2/23. The DM said the orange juice needed to be disposed of. D. Staff interviews The DM was interviewed on 1/4/24 at 10:35 a.m. The DM said the dietary department was responsible for ensuring the nourishment rooms were clean, food was labeled and dated and expired foods were disposed of timely. The DM said the nourishment room on the long term care unit needed attention. The DM said whoever put the food item into the refrigerator or freezer was responsible for ensuring the food was labeled and dated. The DM was interviewed again on 1/9/24 at 10:30 a.m. He said he spoke with the infection preventionist (IP) and the night shift nursing staff were going to begin double checking the nourishment rooms to ensure all food was properly labeled and dated. The IP was interviewed on 1/9/24 at 3:11 p.m. The IP said all food should be labeled and dated. The IP said expired foods should be disposed of timely. II. Ensure timely inspection of the ice machine and ice machine water filter A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 1/11/24) B. Facility policy and procedure The Ice Machine Cleaning procedure, dated 5/30/12, was provided by the NHA on 1/9/24 at 8:40 a.m. It revealed in pertinent part, Ice machines are cleaned and sanitized on a regular basis and checked by the Supervisor or Manager. Ice scoop is sanitized daily through the dishmachine. C. Observation and interviews On 1/3/24 at 1:41 p.m. the ice machine scoop holder had brown particles floating in the bottom of the holder. On 1/4/24 at 10:35 a.m. the ice machine scoop holder had brown particles floating in the bottom of the holder. The water filter was changed on 2/17/21. The water filter read to change the filter every 12 months. The DM was interviewed during the observation and said he would remove the ice machine scoop and ensure the ice scoop and the ice scoop holder were cleaned. The DM said an outside company came every six months to clean the filter. The DM said the filter needed to change annually and had not been changed since 2/17/21. The DM was interviewed again on 1/9/24 at 10:30 a.m. The DM said he implemented a new system to clean the ice machine scoop and the ice machine holder every night. The DM said the ice scoop and the ice scoop holder should be clean and free of debris. The DM said he had the outside company service the ice machine and change the filter.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to: -Ensure professional standards of infection control were followed when cleaning resident rooms and bathrooms; and, -Ensure the facility followed the infection control program when Resident #17 had gastrointestinal symptoms. Findings include: I. Ensure professional standards of infection control were followed when cleaning resident rooms and bathrooms A. Facility policy and procedure The Housekeeping and Custodial Overview policy, dated 4/14/23, was provided by the nursing home administrator (NHA) on 1/3/23 at 2:07 p.m. It revealed in pertinent part, Housekeeping and custodial staff members are critical participants in infection control programs. Without solid cleaning practices, the ability to break the cycle of infection in any building becomes unobtainable. The Hand Hygiene policy, dated 3/29/22, was provided by the NHA on 1/9/23 at 2:49 p.m. It revealed in pertinent part, Health care workers will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: before entering patient room or before donning sterile gloves B. Observations During a continuous observation on 1/8/24 beginning at 12:34 p.m. and ended at 12:55 p.m. the following was observed: -At 12:38 p.m. maintenance assistant (MA) #1 entered the room with gloves on. MA #1 began vacuuming the resident room. MA #1 got down on his hands and knees to vacuum underneath the resident bed, chair and other furniture items. MA #1 stood up and returned to the housekeeping cart to get a clean towel and entered the resident room again without performing changing his gloves. MA #1 began wiping down the bathroom sink. MA #1 returned to the cart, disposed of the towel, got a clean towel and returned to the bathroom to wipe off the toilet riser. -With the same dirty gloves, MA #1 gathered the trash bag from the bathroom and placed the bag in another trash can in the room. MA #1 returned to the housekeeping cart, disposed of the dirty towel, got a new clean towel and returned to the bathroom to wipe off the toilet. MA #1 flushed the toilet. -MA #1 returned to the housekeeping cart, disposed of the dirty towel and took off his gloves. MA #1 put on new gloves without performing hand hygiene. MA #1 returned to the resident bathroom and returned the toilet riser to the correct position. -MA #1 went back to the housekeeping cart and got the mop. MA #1 moped the bathroom. MA #1 returned to the cart. MA #1 got a clean towel and began dusting the resident's room without performing hand hygiene. -MA #1 removed three drinks and some personal items from the resident's bedside table. MA #1 placed the items onto the ground. MA #1 wiped off the resident's bedside table. MA #1 used the same gloved hands and picked the resident's hot chocolate up by the rim of the mug where the resident's mouth would touch and placed it back on the bedside table. MA #1 placed the other items back on the resident's bedside table. C. Staff interviews The infection preventionist (IP) was interviewed on 1/8/24 at 2:00 p.m. The IP said the housekeeping staff were responsible for cleaning the resident rooms daily. The IP said all staff including housekeeping staff should always conduct hand hygiene prior to putting on gloves and after taking off gloves. The IP said the housekeeping staff needed to perform a glove change and hand hygiene every time they returned to the housekeeping cart. The IP said MA #1 should have changed his gloves and performed hand hygiene after crawling on the floor to vacuum. The IP said personal items including drinks should never be placed on the floor. The IP said cups should not be handled with dirty gloves or handled from the part of the glass that the resident's mouth would touch. The maintenance supervisor (MS) was interviewed on 1/9/24 at 9:59 a.m. The MS said he was in charge of the housekeeping department. The MS said MA #1 worked as a maintenance assistant and a housekeeper. The MS said hand hygiene should be performed before and after glove usage. He said gloves should be changed when moving from a clean surface to a dirty surface or anytime they returned to the housekeeping cart. The MS said MA #1 needed to change his gloves and perform hand hygiene after crawling on the floor. The MS said the floor was a dirty surface. The MS said MA #1 should have wiped around the resident's items, instead of putting them onto the floor and cleaning. The MS said he would provide education to MA #1 and the other housekeeping staff. D. Facility follow-up The MS provided a copy of the education that was provided to MA #1 on 1/9/24 at 11:14 a.m. It revealed in pertinent part, Gloves are not to be worn in hallways with the exception of cleaning or sanitizing surfaces with chemical cleaners, the use of carpet extraction equipment, transport of dirty laundry carts. II. Ensure gastrointestinal symptoms were reported to the IP and the physician timely to prevent the spread of the norovirus A. Facility policy and procedure The Identification and Reporting of Suspected Infections policy, dated 12/15/22, was provided by the NHA on 1/3/24 at 3:39 p.m. It revealed in pertinent part, Purpose:to provide guidance in order to identify and contain, as rapidly as possible, any infection that is suspected in any client to prevent spread of infection to others. Any of the following occurrences signals potential infection and will be reported Nurse and Infection Preventionist (Rehab/skilled): nausea or vomiting lasting more than 24 hours and diarrhea lasting more than 24 hours. B. Record review documented in Resident #17's medical record The 11/25/23 progress note documented Resident #17 complained of nausea today and had emesis three times. Resident #17 had refused her meals, but had accepted ginger ale, Sprite and water. The resident did not have a fever and was negative for COVID-19. The 11/26/23 progress note documented Resident #17 was in the bathroom and said she was nauseated. The resident was spitting up large amounts of mucous. The resident denied a sore throat, refused an oral nutritional supplement and refused all medications. The 11/27/23 progress note documented at 3:48 p.m. revealed the resident reported she was nauseous and did not feel good. The progress note documented the physician was called and an anti-nausea medication was requested. The progress note documented the facility was waiting for a response. The 11/27/23 progress note documented at 10:41 p.m. revealed the resident did not feel well today and was vomiting and nauseous. The 11/28/23 communication with physician progress note documented at 2:39 p.m. revealed the physician ordered Imodium as needed for Norovirus. -The facility failed to notify the physician and the IP when the resident first had gastrointestinal symptoms. C. Staff interviews The IP was interviewed on 1/8/24 at 3:11 p.m. The IP said Resident #17 had gastrointestinal symptoms on 11/25 and 11/26/23. The IP said the licensed nurses failed to inform her or the physician that Resident #17 had nausea and vomiting until 11/27/23. The IP said Resident #17 typically was very active throughout the entire facility. The IP said when she returned to work on 11/27/23 after the weekend, she was notified that Resident #17 had nausea and vomiting. The IP said the licensed nurses should have notified her sooner. The IP said when she found out about Resident #17 having nausea and vomiting on 11/27/23, two other residents had already developed symptoms and tested positive for norovirus on 11/27/23. The IP said norovirus spread through the facility and 31 residents contracted the virus. The IP said the nurses should have notified her of Resident #17's symptoms sooner, so the resident could have been placed on isolation to prevent the spread of the disease and she could have consulted with the medical director sooner to get further direction. The IP was interviewed again on 1/9/24 at 10:12 a.m. She conducted education regarding personal protective equipment (PPE) and the importance of reporting signs and symptoms of norovirus to the IP and the physician timely. The IP said the education was given verbally and she did not document the education she provided to the staff. Registered nurse (RN) #3 was interviewed on 1/9/24 at 1:07 p.m. RN #3 said if a resident had nausea, vomiting or diarrhea more than once she would report it to the IP and the physician to get further guidance. RN #3 said the nurse stations had an infection control surveillance form to fill out that would prompt the nurse to notify the IP and the physician.

Based on observations, interviews, record review, and review of facility policy, the facility failed to maintain a medication error rate of 5% or less. There were two errors out of 34 opportunities, which resulted in a 5.88% medication error rate for two (Resident #19 and Resident #21) of three residents observed for medication administration. Findings included: A review of the policy titled, Medication: Administration including Scheduling and Medication Aides last reviewed/revised 08/24/2022, indicated Purpose: To administer medications correctly and in a timely manner. The policy further indicated, Medications are administered to the resident according to the Six Rights. Furthermore, the policy revealed, Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation. 1. A review of Resident #21's Order Summary Report (physician orders) revealed an order dated 02/03/2022 that directed staff to administer 5 milligrams (mg) of Zyrtec to the resident by mouth one time a day for allergic rhinitis. During an observation of medication administration on 09/20/2022 at 6:59 AM, Registered Nurse (RN) #1 prepared and administered 10 mg (twice the ordered dose) of Zyrtec to Resident #21. During an interview on 09/20/2022 at 1:20 PM, RN #1 reviewed Resident #21's physician order for Zyrtec and stated the resident was ordered to receive 5 mg of Zyrtec by mouth one time a day. 2. During an observation of medication administration on 09/20/2022 at 7:29 AM, RN #1 applied Biofreeze to Resident #19's lower back. A review of Resident #19's Order Summary Report revealed the resident did not have a physician's order for the application of Biofreeze to the lower back. The resident had an order dated 10/20/2020 for Icy Hot Cream to be applied to the right thigh/hip every 12 hours as needed for pain and a physician's order dated 06/09/2022 for a lidocaine patch 4% to be applied to the resident's lower back as needed for pain daily. In an interview on 09/20/2022 at 1:24 PM, RN #1 stated Resident #19 was ordered Icy Hot Cream; however, the physician's order needed to be switched to Biofreeze since the facility no longer had Icy Hot Cream in stock. Per RN #1, the facility had not had Icy Hot Cream in stock for a couple of months. RN #1 stated orders should be followed as written by the physician. During an interview on 09/21/2022 at 9:17 AM, the Director of Nursing indicated staff were expected to follow the rights of medication administration and to verify physician orders prior to medication administration to avoid errors. In an interview on 09/21/2022 at 9:18 AM, the Administrator revealed it was expected for staff to follow the rights of medication administration to avoid errors and to look at the medication administration record and physician orders to make sure everything matched before a medication was administered.