Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were labeled and stored properly according to professional standards in two of five locked cabinets in resident rooms. Specifically, the facility failed to ensure medications were labeled with the date they were opened. Findings include: I. Professional reference According to the manufacturer Astra Zeneca, Symbicort Medication Guide (June 2024), retrieved on 8/19/24 from https://den8dhaj6zs0e.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/a4b62ab8-1314-4583-91b4-294ec239f790/a4b62ab8-1314-4583-91b4-294ec239f790_pi_med_guide_rendition__c.pdf, Throw away Symbicort when the counter reaches zero or three months after you take Symbicort out of its foil pouch, whichever comes first. According to the manufacturer NovoNordisk, Storage and Travel with Tresiba (June 2024), retrieved on 8/19/24 from https://www.mynovoinsulin.com/insulin-products/tresiba/how-to-take-tresiba/flextouch-storage.html, Storage after use - dispose after eight weeks, even if there is insulin left in the pen or vial and the expiration date has not passed. According to the manufacturer NovoNordisk, Taking Novolog-Insulin Aspart (March 2023), retrieved on 8/19/24 from https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, Storage after use - keep at room temperature or refrigerated up to 28 days. Dispose after 28 days, even if there is insulin left in the pen or vial. II. Facility policy and procedure The Storage and Expiration Dating of Medications and Biologicals policy, revised August 2024, was provided by the director of nursing (DON) on 8/15/24 at 2:45 p.m. The policy read in pertinent part, Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (example vial, bottle, inhaler) when the medication has a shortened expiration date once opened. III. Observations and interviews On 8/14/24 at 1:58 p.m., the medication storage cabinet in Resident #17's room was observed with licensed practical nurse (LPN) #2. The following was observed: -An opened Tresiba Flex Touch U-100 insulin pen was not labeled with the date it was opened for use. -An opened Novolog U-100 insulin pen was not labeled with the date it was opened for use. LPN #2 said the insulin pens should have been labeled when opened. LPN #2 said she did not know what the facility policy said about the storage of insulin pens. LPN #2 said she would check with the staff from the previous shift to find out if they knew when the insulin pens were opened. -LPN #2 did not remove the insulin pens from Resident #17's medication storage cabinet. On 8/15/24 at 10:27 a.m., the medication storage cabinet in Resident #4's room was observed with LPN #1. The following was observed: -An opened Symbicort 160 microgram (mcg)/4.5 mcg inhaler was not labeled with the date it was opened for use. LPN #1 said inhalers should be labeled with a date the medication was opened. LPN #1 said she did not know if inhalers could be used until the manufacturer expiration date after they were opened. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 8/13/24 at 2:00 p.m. RN #2 said the residents' medications were stored in the residents' rooms in locked cabinets. She said the facility did not have medication carts. The DON was interviewed on 8/14/24 at 2:15 p.m. The DON said insulin pens should be labeled with the date they were opened and staff should know how long the pens could be opened before they needed to be discarded. The DON said the Tresiba and Novolog insulin pens needed to be discarded and she would immediately discard the insulin pens and replace them with new pens which would be labeled with the date they were opened. The DON said she planned to check all staff competencies and confirm appropriate education had been provided. The DON said that insulin could be less effective if not discarded by the recommended disposal date. The DON was interviewed a second time on 8/15/24 at 11:04 a.m. She said inhalers should be labeled with the date they were opened. The DON said staff should check manufacturers' instructions for information about when inhalers needed to be discarded when opened. The DON said inhalers could be less effective if used beyond the recommended disposal date. V. Facility follow-up On 8/14/24 at 2:48 p.m, the DON provided a staff education document titled Insulin Pen Storage/Dating. The education contained three staff signatures and was dated 8/14/24 (during the survey). The education content included adding the date opened to medication vials when put in use and expiration dates of medications after opening. The document included reference to a second document provided without a title which described storage information specific to Tresiba and Novolog. The document revealed Tresiba should be discarded eight weeks after opening and Novolog Flex Pens should be discarded 28 days after opening. The DON said the information was posted in Resident #17's medication storage cabinet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to accommodate the needs of one (#22) of three residents reviewed for dining services, out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #22 had a table that was adjusted to a height and distance from the resident's person that accommodated positioning and range of motion needs in order to be able to see drinks and food on the plate and in the bowls; and to be able to reach and eat the food served without additional struggle and fatigue; and, -Resident #22 had accessible dishes such as a mug with a handle that accommodated the resident being able to self-feed food items such as soup, as recommended by speech, occupational and physical therapy assessment (see therapy recommendations below). Findings include: I. Facility policy A request was made, during the survey on 3/16/23, for the facility's policy on accommodation of needs and feeding assistance for a dependent resident. The nursing home administrator (NHA) said the facility did not have a specific policy for incontinence care; in lieu of a dedicated policy, the facility used [NAME] nursing procedures as a guide for care. The NHA provided copies of pages from the [NAME] manual. The resource was undated, and documented in pertinent part: There is growing evidence that a balanced diet along with either health promoting behavior contributes to longevity . -Position food on the plate so that if there is visual neglect or impairment, the patient is best able to see the food served. II. Resident #22 A. Resident status Resident #22, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified protein calorie malnutrition, dementia, contractures (a permanent tightening/stiffness of the muscles) of the left hand, dysphagia (swallowing difficulties) and muscle weakness. The 2/28/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15 and no psychosis or aggressive behaviors. The resident was totally dependent on staff for bed mobility/positioning, and extensive assistance with eating. The resident had functional limitations of the upper extremities (shoulder, elbow, wrist, hand) on one side and required the use of a specialized wheelchair for mobility and positioning. The resident was able to eat independently if set up appropriately but was dependent on staff to perform oral hygiene. The resident had no dental concern. B. Observations On 3/13/23, Resident #22 was observed from 12:00 p.m. to 1:05 p.m., during the lunchtime meal; observations as follows: -At 12:00 p.m. staff delivered Resident #22's lunch. The resident was served a turkey sandwich, French fries, peaches, a carton of milk, a can of cola, and a juice or ice tea drink. The staff set the resident's food on a bedside table that was already in place in front of the resident then opened the drinks and uncovered the food. Staff did not announce the food items served to the resident, but did tell the resident lunch was served. The resident nodded and the staff walked away. Resident #22 was seated in a specialized manual wheelchair in front of a rolling bedside table tray. The resident was seated up right but was unable to sit up straight. The resident head was tilted forward with the chin bent downward towards the chest. The resident was unable to lift her head up straight and had limited range of mention to move her head (see therapy notes below). The height of the table tray was even with the resident's eyes and the resident was unable to look down on the dishes/food on the table. The resident was unable to lift her head any higher and once the food was set in front of the resident on the table the resident remained still and continued looking downwards. The resident made no effort to eat. -From 12:02 p.m., until 12:25 p.m., no staff approached Resident #22 to encourage or assist the resident with the meal. The resident made no attempts to eat any of the meal. The resident did reach up and over the table to reach a can of coke and took a few sips. The can was placed directly in front of the meal and was directly in front of the resident. -At 12:26 p.m., a staff approached Resident #22 to ask if the resident was done with the meal. The resident shook her head no. The staff offered to cut up the sandwich the resident declined and acknowledged she was still hungry. Staff did not rearrange the resident did her or adjust or lower the height of the table and walked away after earning the resident was hungry. -At 12:47 p.m., a staff approached Resident #22 to ask how the meal was and lowered the bedside table to its lowest possible height and moved the table closer to the resident. Once the table was repositioned Resident #22 immediately reached out to pick up the turkey sandwich and started to eat. The resident still had a bit of a struggle to lift her arm up and over the table to reach food but ate all of the sandwich and fries on the plate without needing assistance or prompting. Although the resident at a slow pace; engagement with food and eating progressed at a steady pace. On 3/15/23, Resident #22 was observed from 11:58 p.m. to 1:07 p.m., during the lunchtime meal; observations as follows: -At 12:02 p.m., staff delivered a lunch tray to Resident #22. Staff uncovered the resident food and set the plates on the table but did not tell the resident what was served; did not adjust the table height; or move the table close to the resident. Resident #22 was seated in front of a rolling bedside table; the table was positioned at the resident's nose level and approximately 10 inches above the resident's lap and was approximately six inches from the resident. This enabled the resident to see food on the flat plates on the table but not the food inside of the bowls. The resident was served a tuna salad sandwich, a bowl of soup, a bowl of Jell-O, a carton of milk, a can of cola and a glass of juice or ice tea. The resident was able to reach the sandwich, as it was on the plate directly in front of her. The resident ate the entire sandwich. The resident had to extend the reach of the right arm, up and over the table, to reach the bowl of Jell-O that was off to the left side of the table on the far left of the plate. The resident ate a few bites of Jell-O then stopped. The resident did not eat any of the soup that was out of vision, because the resident was positioned towards the left side of the table and was not able to turn her head far enough to see the right side of the table. The bowl of soup was off to the right side of the table placed at the back of the table. -During the observation, staff did not offer to adjust the resident plates or the height or distance of the resident table to facilitate eating. Staff did not check to see if the resident liked the Jell-O and soup or if the resident wanted alternative food items when she did not eat the soup or Jell-O. -At 12:29 p.m., after eating the entire sandwich Resident #22 stopped eating. -At 12:59 p.m., staff approached Resident #22 and removed the plates for the table in front of the resident. Staff did not inquire when the resident had not eaten all of the food; attempt to move uneaten foods closer to the resident; or to see if the resident wanted an alternative option for uneaten food. On 3/16/23, Resident #22 was observed from 11:56 p.m. to 1:05 p.m., during the lunchtime meal; observations as follows: -Resident #22 was observed sitting in front of the bedside table. The table was lowered to a level even to the tip of the resident's nose. The resident's head was tilted forward with her chin angled down toward her chest. The resident did not (or could not) raise her head up to look at the food that was served. -The resident was served a sandwich and soup. Staff set up the resident meal, told the resident what each plate and bowl contained and moved the table close to the resident. The resident was able to reach and eat the entire sandwich but struggled with eating soup due to the height of the table and the resident's ability to reach up to the table and spoon up the soup. The resident only ate a couple of spoons of soup. -No staff offered the resident assistance to adjust the table position, to rearrange the resident's dishes or asked if the resident wanted an alternative for the uneaten soup. C. Resident interview Resident #22 was interviewed on 3/16/23 at 2:10 p.m. Resident #22 was interested in eating but acknowledged she could not always see the food on the table and sometimes could not reach food easily. D. Record review Speech language discharge summary-treatment plan goals and progress notes documented Resident #22 required physical assistance with proper/safe positioning in bed or wheelchair for meals. -Staff educated for proper position and safe swallow strategies. -Self-feeding with moderate assistance. Resident was able to take bites without assistance but fatigued quickly. Forward flexion of head and neck may have been a limiting factor in self- feeding. -Resident demonstrated selective intake behaviors if not encouraged to eat a variety of foods served -Resident #22 tended to eat sweets, fruits and soup (clear broth). -Staff educated (including floor clinical manager, nurses and certified nurse aids) regarding the importance of the resident being out of bed for meals at least on time a day for cueing for self-feeding in order to minimize risk of malnutrition as well as to maximize safety with oral intake due to the resident being diagnosed with mild oral pharyngeal dysphagia. Functional Status: The resident requires a straw for functional oral hydration intake due to being unable to lilt her head backwards because of a severe stiff neck. The resident's general head and neck position is hanging down forward. The Resident tolerated a mechanical soft chopped diet with only selective dishes such as a half inch cut up cucumbers and cantaloupe. Food avoidance noted when served food larger than one half inch in diameter the resident complained they were too big. Resident #22 needed food cut into manageable size pieces because the resident was unable to use the left hand for cutting food due to severe contracture. -Resident #22 required dining modification to promote a program that manages contractures in the left hand and maximizes ability for self-feeding. Occupational therapy progress note documented: -Resident dines in the main dining room for lunch. Occupational therapist noted the height of the table is restrictive for the resident's comfort with self-feeding. Resident agreeable to trial bedside adjustable table for meal. Resident reports improved ability to reach food and utensils with modification. Resident #22 primarily ate finger food items but was able to hold a cup to drink soup. -Functional maintenance program completed and restorative aid verbalizes understanding of modifications made (for resident dining). Continue to recommend lower table surface for increased accessibility to food and drink items. Bedside table available dining room and executive team was looking into long term options to provide optimal dining experience. The comprehensive care plan, dated 8/22/22, last reviewed 2/22/23, revealed the resident had specialized care needs for dining, eating and swallowing. The care plan documented in pertinent part: -Resident #22 needed limited assistance, defined as a meal set up only and in another section, the care plan documented the resident needing assistance eating. -Nutritional approaches included encouragement to consume the meal. -The comprehensive care plan did not include speech and occupational assessment that the resident did better with finger hand held foods or with the recommendations to provide a table at the appropriate height or to provide the resident with a cup to drink rather than spoon in food items such as soup. III. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 2:55 p.m. RN #2 said there was a list posted at the nurses station listing all resident nutritional and feeding assistance needs. Nursing staff should make sure the resident was positioned correctly to facilitate swallowing and ability to reach and eat food without risk of choking. If the resident's table was not accommodating the resident's ability to eat independently. Staff could provide an adjustable bedside table for the resident to be able to reach and eat their food. Certified nurse aide (CNA) #3 was interviewed on 3/16/23 at 4:22 p.m. CNA #3 said there was a listing of residents who needed feeding assistance and the type of assistance needed. The nurse would provide a report if any resident needs changed and give instruction of the changes. If a resident was not positioned properly to facilitate eating, staff were expected to reposition the resident so the resident was sitting up as straight as possible and close enough to the table to see and reach food items. If the resident had an adjustable table, the table could be moved closer to the resident and adjusted downward so the resident was able to reach their food. CNA #5 was interviewed on 3/16/23 at 4:35 p.m. CNA #5 was familiar with the resident's eating needs due to regularly wiring with the residents. If there were any new residents, the nurse and the registered dietitian would hold a staff huddle (meeting) and give report on the new resident's needs. If a resident was too far from the table or the table was too high for the resident to reach the food staff should position the resident to make sure they were squared up close to the table. For residents with a specialized wheelchair staff would need to adjust the chair down so that they could fit under the table and be able to reach their food. The director of nursing (DON) was interviewed on 3/16/23 at 5:06 p.m. The DON said staff should offer meal assistance and or encourage eating to any resident who required assistance or was not eating. The DON said each resident had a care plan for nutrition and eating where eating and nutritional needs were documented. Care plans were maintained in a resident specific binder in the nurses station and all nursing staff had access to the care plan. The DON said Resident #22 ate in the dining room at an adjustable table. Staff should adjust the table in the low position and close enough to the resident so the Resident #22 could reach and eat all served foods. Staff should continually round during the meal, identify resident struggles while eating and offer assistance as needed to facilitate successful eating. The DON said Resident #22 was unable to reposition to sit up straight due to limited range of motion with her upper extremities-arms, hands and shoulder; as well as with the head and neck. The DON said the CNAs and nursing staff had been using the adjustable bedside table for the resident's meals and was unaware of any challenges the resident may have had with the table height; but would look into it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to provide services for one (#36) of four residents reviewed out of 25 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #36's vital signs, specifically the resident's blood pressure, was monitored prior to the administration of a blood pressure medication. Finding include: I. Professional reference According to Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from:https://www.ncbi.nlm.nih.gov/books/NBK532906 on 3/20/2023. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. According to Kizior, R. J., [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. II. Resident #36 A. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included atherosclerotic heart disease (plaque formation in the arteries that supply the heart) and atrial fibrillation. The 2/23/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. The resident required limited assistance of one person for transfers, dressing, personal hygiene, toileting and was independent with bed mobility and eating. B. Observations On 3/15/23 at 9:00 a.m. registered nurse (RN ) #1 was observed dispensing and administering Metoprolol 25 milligrams (mg) toResident #36. RN #1 did not assess the resident vital signs including the resident's blood pressure; check the order for blood pressure parameters; or review the resident's record for the resident's most recent vital signs prior toadministering the Metoprolol medication to Resident #36. C. Record review The March 2023 CPO documented a physician order of Metoprolol tartrate 25 mg, give twice a day for paroxysmal atrial fibrillation ordered on 2/28/2023. The CPO did not document any vital signs parameters for when to hold the Metoprolol medication or when to notify the physician of irregular vital sign results. The March 2023 medication and treatment administration record (MAR/TAR) did not document how often the resident's vital signs should be checked. The February 2023 and March 2023 vital signs summary revealed Resident #36's blood pressure and pulse were only assessed on 2/17/23, 2/21/23, 2/23/23, 3/3/23, 3/8/23 and 3/12/23 and not daily at the time the resident was given the prescribed Metoprolol tablets. III. Staff interviews RN #1 was interviewed on 3/15/23 at 9:05 a.m. She reviewed the Metoprolol physician's order and said there were no parameters ordered. She confirmed she did not obtain the resident's vital signs prior to administering the Metoprolol medication. She said she did not know when the resident's vital signs were last taken. She said the residents vital signs were taken once a week and up to once a month. RN #2 was interviewed on 3/16/23 at 10:00 a.m. She said for residents that were on a blood pressure medication that blood pressure should be taken once a shift prior to administration. She said they would follow the physician ordered parameters. If there were no ordered parameters and the systolic was less than 100 or if the blood pressure was trending downward, they would hold the medication and notify the physician and obtain parameters. The director of nursing (DON) was interviewed on 3/16/23 at 5:05 p.m. She said when a resident was on a blood pressure medication they would follow the physician ordered parameters. She said when there were no parameters the nurse would document and monitor for signs of hypotension and notify the physician if there was a concern. She said that vital signs should be taken prior to the administration of a blood pressure medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#34) of one sample residents for incontinence care and one (#16) of five sample residents for eating assistance out of 25 sample residents. Specifically, the facility failed to ensure -Resident #34 was provided incontinence care in a timely manner; and, -Resident #16 was provided eating assistance in a timely and consistent manner. Findings include: I. Incontinent care A. Professional reference According to [NAME] C., Ratnana I., [NAME] S., et al. (July 12, 2020). Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve. Cureus: 12(7): e9161. National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7419143/ on 3/20/23. Besides the financial ramifications, urinary incontinence (UI) increases the risk for physical problems such as skin breakdown, for example, perineal dermatitis, skin maceration and pressure ulcers. Residents who are incontinent are also at risk for developing urinary tract infections (UTI's ) that not only exacerbate incontinence but also represent a major source of sepsis in the elderly. Incontinent elderly persons are more likely to fall, either because of the sense of urgency to reach the toilet or because of slipping on a floor wet with urine. B. Facility policy A request was made for the facility's policy on incontinence care for dependent residents. The nursing home administrator (NHA) said the facility did not have a specific policy for incontinence care; in lieu of a dedicated policy, the facility used Lippincott procedures as a guide for care. The NHA provided copies of pages from the [NAME] manual; the resource was undated, and documented in pertinent part: Institute other interventions such as: a. Bladder retraining-progressive lengthening or shortening of voiding intervals to restore the normal patterns of voiding after a period of immobility or catheterization. b. Scheduled toileting-using a fixed toileting schedule to prevent episodes for patients with urge or functional incontinence, c. Habit training-involves using a viable toileting schedule based on the patient's pattern of voiding, also incorporates positive reinforcement, d. Prompted voiding-includes regular prompts to void every 1 to 2 hours with positive reinforcement. C. Resident #34 1. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included syncope (fainting) with collapse, multiple left side rib fractures, liver laceration and cognitive communication deficit. The 2/9/23 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance of one person with bed mobility, transfers, dressing, toileting, personal hygiene and supervision with set up for eating. The MDS indicated the resident was continent of bowel but had frequent urinary incontinence. A toileting program trial was not attempted during this assessment. 2. Observations On 3/13/23 at 12:00 p.m. Resident #34 was observed sitting in the dining room seated at a table with other residents. Three staff were present delivering and assisting the resident in the dining room with the meal. Resident #34 smelled strongly of urine during lunch time observation. Resident was not checked or changed during the meal. During a continuous observation on 3/15/23 beginning at 10:00 a.m. and ending at 2:40 p.m., Resident #34 was observed. At 10:00 a.m., Resident #34 was observed sitting at a table in the dining room eating breakfast. At 11:25 a.m., certified nursing assistant (CNA) #1 was observed giving Resident #34 a glass of water and after the CNA transferred the resident from the dining room chair into a wheelchair. CNA #1 then transported Resident #34 to her room and transferred the resident in a recliner. -The resident was not checked for incontinence or provided incontinent care. At 12:05 p.m., CNA #1 transferred the resident from the recliner to a wheelchair and transported the resident to the dining area for lunch. -The resident was not checked for incontinence or provided incontinent care At 1:15 p.m., an unidentified activity staff person wheeled the resident from the dining room to the common area where music was being played. At 2:40 p.m., CNA #2 wheeled Resident #34 to the bathroom. CNA #2 removed the brief from the resident. The resident's incontinence brief was wet and soiled with urine slightly yellow in color and had a mild odor of urine. The incontinence brief when held was moderately heavy but not completely saturated. -Resident #34 had not been changed or toileted in over four hours. C. Record review The continence care plan, initiated on 2/6/23, documented the resident needed the assistance of nursing staff for toileting. The interventions included assisting resident to pull up or down garments, cleansing the perineal area properly and managing protective garments and continence products. The fall care plan, initiated on 2/6/23, documented the resident needed the assistance of nursing staff to help maintain and improve current level of self performance with ADL's . The interventions included anticipating and checking frequently for resident's need to use the bathroom. A review of Resident #34's comprehensive care plan did not reveal person centered approaches to incontinence care. Personalized interventions, such as habit retraining and an individualized toileting schedule, were not identified. D. Staff interviews Certified nurse assistant (CNA) #3 was interviewed on 3/15/23 at 9:15 a.m. CNA #3 said residents were checked for incontinence every two hours and offered toileting at that time.The nursing staff would toilet or change residents when the residents got up in the morning and after meals. When the resident smelled of urine, the nursing staff changed and offered the residents toileting in the moment. The director of nursing (DON) was interviewed on 3/15/23 at 5:10 p.m. The DON said the nursing staff would identify the residents voiding patterns and then develop an individualized toileting schedule for the resident. The individualized toileting program was care planned. If voiding patterns were not identified, the routine schedule was to check and change the resident every two hours while awake. Residents that smelled strongly of urine were to be checked and changed. The DON acknowledged that a resident who presented with the smell of urine should be taken to the bathroom and not left to eat their meal while soiled with bodily fluid and smelling of urine. II. Eating assistance A. Facility policy On 3/16/23, a request was made for the facility's policy on eating assistance for dependent residents. The nursing home administrator (NHA) said the facility did not have a specific policy for eating assistance; in lieu of a dedicated policy, the facility used Lippincott procedures as a guide for care. The NHA provided pages from the [NAME] manual. The resource was undated, and documented in pertinent part: There is growing evidence that a balanced diet along with either health promoting behavior contributes to longevity . In large facility settings, environment factors may influence food enjoyment. Encourage socialization when eating . If possible, encourage five to six small meals per day rather than three large meals. B. Resident #16 1. Resident status Resident #16, over the age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), Alzheimer's disease, vascular dementia, dysphagia (difficulty swallowing), and major depression. The 1/7/23 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had unclear speech; was usually able to make self-understand; and sometimes understood others in conversation if communication was simple and direct. The resident needed limited assistance from one staff member to eat meals; where the staff member provided guided maneuvering of limbs or other non-weight bearing assistance. Additionally the resident needed supervision throughout the meal where the helper was to provide verbal cues or touching/steading assistance while the resident ate. 2. Observations On 3/13/23 from 12:00 p.m. to 1:05 p.m., Resident #16 was observed sitting at a large dining room table with several other residents. Staff delivered Resident #16's meal uncovered the food and walked away to deliver other resident meal trays. Resident #16 sat looking at the food for approximately five minutes but did to eat any of the meal. -At 12:07 p.m., certified nurse aide (CNA) #8 sat between Resident #16 and Resident #31. The CNA said facing forward and not facing either resident. The CNA spooned food to each resident extending reach across the resident's torso with a backwards wrist movement. The staff did not communicate with either resident during the meal. -CNA #8 did not socialize with Resident #16 during the meal and did not tell the resident what she was eating. On 3/15/23 from 11:58 p.m. to 1:07 p.m., Resident #16 was observed sitting at a large dining room table with several other residents. -At 12:08 p.m., staff delivered Resident #16's meal and walked away. Resident #16 said at the table looking at her food but did not eat any of the meal. -At 12:17 p.m., Resident #16 still had not made any attempt to eat her meal and no staff sat with the resident to assist with eating. -At 12:22 p.m., CNA #3 sat with Resident #16 to assist the resident to eat but kept stopping to assist other residents with their meals. The resident spooned up three spoons of soup. -At 12:25 p.m., CNA #3 left the table to assist another resident with their meal. As soon at the CNA left the resident, Resident #16 stopped eating. -At 12:36 p.m., CNA #1 approached Resident #16 and asked the resident how the tuna sandwich was; Resident #16 said I don't like it. The CNA said you should eat your sandwich. Then the CNA offered Resident #16 a spoon of soup; Resident #16 said I don't think I like it. CNA #1 said the soup is a nice color, you like orange, eat your soup. The CNA walked away. The resident did not eat any more of the meal. -At 12:55 p.m., a CNA approved Resident #16's table; the CNA did not ask the resident about the meal or if Resident #16 had enough to eat. No staff offered Resident #16 and alternate meal option when the resident said she did not like the meal and did not eat any more than three bites of soup. On 3/16/23, from 11:56 p.m. to 1:05 p.m., Resident #16 was observed sitting at a large dining room table with several other residents. -At 12:03 p.m., the lunch meal was set out in front of Resident #16. No staff sat to assist the resident with the meal and the resident did not initiate eating. The resident sat rocking back and forth in a manual wheelchair. -At 12:50 p.m., a staff member handed the resident a drink; the resident took a sip and placed the cup back on the table. The resident then closed her eyes and appeared to be dozing. -At 1:05 p.m., a staff approached Resident #16 and picked up the lunch plates. No staff assisted Resident #16 to each lunch. 3. Record review The comprehensive care plan documented a care focus for dining and eating assistance, initiated on 1/11/23. The care focus documented the resident needed daily eating assistance where staff were to provide standby assistance and encouragement to improve dining self-performance. The interventions included providing the resident set up assistance and supervision throughout the meal. -The resident comprehensive care plan and MDS assessment did not match in reflecting the type of assistance the resident needed to consume a meal. The MDS assessment indicated the resident needed guided maneuvering of limbs or other non-weight bearing assistance; the care plan did not document staff providing eating assistance. 4. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 2:55 p.m. RN #2 said there was a list posted at the nurses station listing all resident nutritional and eating assistance needs. RN #2 said staff should follow the resident's care plan and provide eating assistance as written in the care plan. CNA #3 was interviewed on 3/16/23 at 9:15 a.m. CNA #3 said the facility posted the names of residents who needed eating assistance at the nurses station. The posting also documents the type of assistance each resident on the list needed. CNA #3 said Resident #16 could eat foods on her own but usually needed prompting to eat meals. Sometimes staff had to assist Resident #16 in order to get her to eat the meal. CNA #5 was interviewed on 3/16/23 at 4:35 p.m. CNA #5 said she had worked for the facility for several years and knew the resident's needs; including eating needs. The registered dietitian would notify the nursing staff of any changes in the resident's assistance needs. If a resident needed eating assistance staff were to sit with the resident and assist one resident at a time. The director of nursing (DON) was interviewed on 3/16/23 at 5:06 p.m. The DON said staff should offer meal assistance and or encourage eating to any resident who required assistance or was not eating. The DON said each resident had a care plan for nutrition and eating where eating and nutritional needs were documented. Care plans were maintained in a resident specific binder in the nurses station and all nursing staff had access to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to to keep residents safe from accident hazards related to safe transfers for one (#24) of two residents reviewed out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #24 receive safe transfer assistance from staff during transfers from wheelchair to the bed; -Staff used the recommended gait belt while assisting Resident #24 to make a safe transfer; and, -Update the Resident #24's care plan after the resident was reassessed following a fall during a staff assisted transfer. Findings include: I. Facility policies: The Lifting,Transfer and Bed Mobility policy originated in November 2012 was received from the nursing home administrator (NHA) on 3/16/23 at 5:53 p.m. a.m. It read in pertinent part:The purpose of this policy is to identify and assess the guests/ residents in the (Continuing Care) program that require mobility assistance to eliminate unnecessary manual repositioning and lifting resulting in potential injury or increased pain/discomfort to guest/resident. Each resident will be assessed by a nurse upon admission and readmission to determine the need for continuing services and change of condition. The gait belt will be used for residents who can contribute a moderate effort (50%) or more to the transfer and can follow simple commands in the transfer process but still requires physical guidance or support by the direct care giver. Refer to the policy Gait Belt for Transfers for specific procedures pertaining to use of the gait belt (see below). -Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and education will be provided on an as needed basis. The Gait Belts for Transfers and Ambulation policy originated in November 2012 was received from the NHA on 3/16/23 at 5:53 p.m. It read in pertinent part: Purpose/scope:To provide staff with detailed information regarding safe and proper usage of the gait belt during recent transfers and ambulation. Procedure: Gait belts are used by staff to improve the safety and decrease the risk of injury to residents and staff while assisting the residents with transfers or ambulation. -The gait belt will be utilized for guests/residents who can contribute at least 50 percent or more to the transfer effort and can follow simple commands but still requires physical guidance or support from the direct care staff. The need for a gait belt will be documented on a resident's care plan. II. Resident #24 A. Resident Status Resident #24 age [AGE], was admitted to the facility on [DATE]. According to the March 2023 computerized physicians orders (CPO) diagnosis included a personal history of stroke, type two diabetes, muscle weakness, and abnormalities of gait and mobility. The 1/3/23 minimum data set (MDS) indicated the resident had intact cognition evidenced by a brief interview of mental status score (BIMS) of 12 out of 15. The resident required two person weight bearing assistance with transfers and bed mobility. The resident did not walk around his room or the unit; and had no history of walking since he had been at the facility. The resident manipulated his wheelchair adequately around the unit. B. Resident interview Resident #24 was interviewed on 3/13/23 at 10:30 a.m. Resident #24 said he had a stroke that affected his left arm causing constant pain. Resident #24 said CNA #4 caused his fall because the CNA did not use a gait belt when assisting him with a transfer. Resident #24 said that was the first time he fell since he was admitted to the facility. Resident #24 was interviewed on 3/15/23 at 11:09 a.m. Resident #24 said he experienced a fall on 3/8/23 and was sent out to hospital per his wife's request. Resident #24 said he did not have any major injuries from the fall, but did have some bruises and head pain. Resident #24 said he remembered that he did not have the gait belt on and he bumped his head against the wall when he fell but was unable to remember any details of the fall. The resident was most concerned that CNA #4 did not place the gait belt on him during the transfer. The resident said he knew how to use the transfer pole and felt confident using it because he had one when he lived at home; no one from the facility trained him how to use it. The resident said he felt confident using the grab bar. He said he had no training from the staff on how to do this. Resident #24 said he was agreeable using the gait belt during a transfer, however not all of the staff would put the gait belt on him. Resident #24 said he needed staff to put a gait belt on him for transfers so they could help him be safe in case his leg buckled or in case he lost his balance. C. Record review The comprehensive care plan initiated on 1/3/23, revealed the resident was at risk for falls and needed extensive assistance from staff when transferring from surface to surface. -The transfer functional status care focus initiated 1/3/23, documented the resident required one staff to assist with transfers. Staff were to stand on the resident's left side; the transfer pole was to be on the right side of the resident and the surface he resident was transferring during the procedure. The assisting staff was to remind Resident #24 to move slowly through the transfer. Additionally, because resident #24 was unable to use the right arm, staff was to provide the resident under arm support and use a gait belt on the resident while assisting the resident to transfer. -The falls care focus initiated 1/3/23 documented the resident wanted to maintain current level of self-performance of activities of daily living and not experience decline in functional abilities due to fall risk. Care plan approaches included: staff to assist with re-positioning; therapy to educate staff on the correct way to complete transfer and provide instruction in room for reference. Physical therapy progress notes-dated 2/7/2023; documented: Resident #24 presented for skilled physical therapy for transfer training after admission. The resident had by this date participated in 11 physical therapy sessions with a plan of care focused on transfer training (training for both patient and staff) and endurance exercises. The resident's transfers fluctuated in technique from staff member to staff member. The physical therapist (PT) educated the staff on a consistent transfer method for bed mobility, sit to stand and stand pivot transfers. The PT discharged the resident from therapy once safe transfer training had been accomplished. Therapy goal: Resident will perform supine to sit transfer using transfer pole and minimal assist to demonstrate improved independence with function mobility. A nurse's note dated 3/8/23 documented the resident injuries following the 3/8/23 fall included two bruises to the back of the right shoulder and an abrasion to the resident's left pinky finger. The hospital visit report dated 3/8/23, documented that the resident received a computerized tomography (CT) scan of the head and cervical spine. The findings of the test revealed no hemorrhage or mass of the brain. There was no acute fracture of any bones in the brain and no brain bleed. Staff education for resident transfers provided to staff during a staff huddle (shift report update) on 3/8/23, read in part: Falls/change of condition: director of nursing (DON) reviewed all fall interventions with staff on shift. Fall interventions for Resident #24, read in pertinent part: -Bed mobility and morning transfers: Put gait belt on, have one staff member support under Resident #24's left arm ( after asking permission, put your forearm under [the resident ' s] armpit) and have other [NAME] member support at the gait belt. Resident #24 reaches to the transfer pole with his right hand. Resident #24 counts to three, then both staff members work with Resident #24 while he stands up. One staff member removes old brief and shorts, other staff members supports Resident #24 while he stands. Assist Resident #24 with pivoting into the wheelchair. -Evening transfers: Bring wheelchair alongside bed so Resistant #24 can reach the transfer pole. Put a gait belt on Resident #24. Have one staff member support under Resident #24's left arm . and have OTHER staff member support at the gait belt. Resident #24 reaches to the transfer pole with his right hand. Resident #24 counts to three, then both staff members work with Resident #24 while he stands up. Support Resident #24 while he pivots to the edge of the bed. Assist with bringing his legs up and into bed while he lays down. Physician's note dated 3/10/23 documented the resident was seen for follow up after a visit to the emergency room. Assessment: Fall subsequent encounter. Treatment: Fall while being transferred into bed; hit head; patient without evidence of injury other than two abrasions on the posterior left shoulder. Incident report form dated 3/15/23 revealed the resident fell during a staff assisted transfer. The note read in pertinent part: On 3/8/23 at 6:10 a.m. Resident #24 had a witnessed fall during a staff assisted transfer into bed. The CNA (CNA#4) who had been assisting the resident with transferring notified the floor nurse to report the fall. The resident was found laying on the floor, at bedside on his left arm with his head turned sideways against the wall and feet under the bed without shorts or brief pulled up. The resident had sandals and socks on; the resident's oxygen (nasal cannula tubing) was not on. The resident was screaming at the CNA that she dropped him and he hated the facility . -Upon assessment the resident complained of neck; back; left hip and (left) arm pain. The resident was very upset, and unable to calm. The fire department emergency medical services (EMS) arrived to assess Resident #24. The EMS applied a cervical collar to Resident #24 and transported the resident to the hospital for further assessment due hitting his head in the fall. -Conclusion of the investigation: the resident fell in a staff assisted transfer when the resident's leg buckled and the resident let go of the transfer pole; the resident fell forward and hit his head on the floor. -Steps taken to prevent recurrence (actions): All current interventions are active and in place. Additional interventions include non-skid strips added by transfer pole. Therapy order obtained to re-evaluate the transfer pole and to provide staff training. The investigation revealed the fall, during a staff assisted transfer, involved an assistive device handrail/grab bar but not the use of a gait belt assistive device (see above). -The care plan was not updated to include new interventions. Fall Reassessment dated [DATE] revealed Resident #24 had one fall prior to 3/8/23, on 10/22/22. Root cause of falls was related to a history of Falls unsteady gait, use of assistive devices, loss of limb movement, unsafe transfers, use of opioids, partial and full dependence on activities of daily living (ADL), performance, pain and medical diagnosis. -Care plan approaches: No self transfer attempts. Staff will assist the resident with repositioning. Therapy to educate the staff on the correct way to complete transfers and provide instructions in room for transfers. -Assistive devices: low bed, call pendant, wheelchair, and gait belt. -New care plan approaches: Restorative program for maintaining function; personal trainer; physical therapy to complete direct training to staff for proper transfer pole and transfers; non-skid strips placed by recliner and by resident's bed; wearing proper footwear for transfers (not described). The resident's care plan was not updated with all newly implemented care approaches/ interventions. IV. Staff interviews CNA #6 was interviewed on 3/15/23 at 11:14 a.m. CNA #6 said she had worked with Resident #24 and was familiar with the resident. CNA #6 said Resident #24's left arm was weak so the CNAs needed to provide extra support while assisting the resident to get the resident up. Sometimes it took one CNA and sometimes it took two CNAs to help the resident out of bed; a gait belt should always be used to help steady the resident. CNA #6 did not know the resident had any memory issues. The physical therapist (PT) was interviewed on 3/16/23 at 10:30 a.m. The PT said transfer training for Resident #24 and the staff was ongoing. The PT said Resident #24 did not like the gait belt, however, the staff should try their best to encourage the resident to wear the gait belt when transferring. The director of nursing (DON) was interviewed on 3/16/23 at 10:30 a.m. the DON said the CNA who was assisting the resident on 3/8/23 when he fell should have asked for help from the nurse on duty to persuade the resident to wear the gait belt since he had been refusing. The DON acknowledge that Resident #24 had a physician's orders indicated Resident #24 should be wearing the gait belt for all transfers and the gait belt should be applied before the resident stood up from the bed; and there should be two staff available to help the resident transfer. This would increase the resident's safety when transferring. CNA #7 was interviewed on 3/16/23 at 10:55 a.m. CNA #7 said it usually took two staff to transfer Resident #24 with a gait belt. CNA #7 said some days the resident was able to transfer with one staff person and the gait belt. CNA #7 said she did not know that the resident had memory loss. CNA # 5 was interviewed on 3/16/23 at 4:14 p.m. CNA #5 said Resident #24 agreed to use the gait belt to transfer if staff approached him politely and used manners. CNA #5 said most of the time it just took one CNA with the gait belt to assist the resident with a transfer. CNA #5 said it took two staff to get him out of bed this morning but she gave him a shower today and his wife was in the room as a standby assistant. CNA#5 said the proper way to use a gait belt was to make sure it was snug but not tight and not too loose; staff should be able to get only two fingers in between the resident's body and the gait belt. The restorative aide (RA) #1 was interviewed on 3/16/23 at 4:55 p.m. The RT said all residents had to be evaluated to use the transfer pole and had to demonstrate safe use of the transfer pole while in the therapy room before the pole could be installed in the resident's room. The RT said Resident #24 had a transfer pole in his room since she could remember. The RT said she was not sure if Resident #24 had been evaluated prior to the transfer pole being installed.

Based on observations, record review, and staff interviews, the facility failed to ensure food items were served, stored, and prepared under sanitary conditions, to prevent the potential cross contamination of food-borne illness to food served to residents, in one of two dining rooms and in one of one kitchen. Specifically, the facility failed to ensure: -The main kitchen and food preparation area were maintained in a sanitary manner; -Resident meals were served in a sanitary manner; -Ready to eat foods served to residents were not handled by staff with bare, unwashed, hands; and, -Staff preformed proper hand hygiene in-between assisting one resident to the other with eating, setting up residents meals, and performing other care tasks for residents. Findings include: I. Kitchen sanitation A. Professional Reference According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 3/23/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view 6-501.12 Cleaning, Frequency and Restrictions: Physical facilities shall be cleaned as often as necessary to keep them clean. Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. 6-201.16 Wall and Ceiling Coverings and Coatings: Wall and ceiling covering materials shall be attached so that they are easily cleanable except in areas used only for dry storage, concrete, porous blocks, or bricks used for indoor wall construction shall be finished and sealed to provide a smooth, nonabsorbent, easily cleanable surface. 5-502.12 Receptacles or Vehicles: Refuse, recyclables, and returnables shall be removed from the premises by way of portable receptacles that are constructed and maintained according to law; or a transport vehicle that is constructed, maintained,and operated according to law. 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered inside the food establishment if the receptacles and units contain food residue and are not in continuous use; or after they are filled; and with tight-fitting lids or doors if kept outside the food establishment. 5-501.15 Outside Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors,or covers. Receptacles and waste handling units for refuse and recyclables shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad under the unit. B. Facility policy The Redbook Sanitation Checklist policy, revised 10/18/18, was received from the nursing home administrator (NHA) on 3/16/23 at 5:30 p.m. It read in pertinent part: The purpose of this policy is to ensure assigned cleaning tasks are completed daily prior to the closing of each shift. A comprehensive closing and opening checklist to ensure all assigned cleaning duties are completed. The closing/opening manager will assign specific tasks to the relevant person in each area.The kitchen and services will be inspected and documented in the Kitchen Red Book. Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and medication will be provided on an as needed basis determined by the employees supervisor. C. Observations The initial kitchen walkthrough was conducted on 3/13/23 at 9:15 a.m. revealed: -The inside lid of the ice machine contained a white substance that was dried to the lid; -The floor in the walk-in freezer had a translucent yellowish slimy film on the floor; -The oil in the deep fryer contained burned floating particles and the oil was dark in color and had an odor; -The juice machine drip tray had fallen off the machine; the part of the machine that the drip connected to had a layer of deep blackened matter. Additionally, there was fresh bright red juice dried on the narrow ledge that was intended to be held in the drip tray; -The counter surface underneath the juice machine had spilled dried justice on the surface; -The surface under the coffee machine had a large amount of spilled, dried coffee, and an excess of coffee had spilled onto the floor in front of the coffee machine; -None of the trash cans in the kitchen were covered with lids; -The mop sink contained a blackish brown substance on the surface and cracked in the corners and the wall behind the sink had dried drips and splashes; -The walls throughout the kitchen had several dried brown drips of liquid on the surface; -The floors was heavily soiled with food debris (bread, lettuce and other unidentified food items) under cabinets and throughout the kitchen; and, -The outside dumpster lid was open and there was trash on the ground outside the dumpster. On 3/16/23 at 2:05 p.m., a second kitchen walkthrough revealed: -The walls throughout the kitchen were soiled with dried drips of a translucent brown substance; -The mop stationary sink was heavily soiled with a reddish brown substance particularly in the basin and along the top edge. The floor around the sink was soiled with black marks. The mop handle where the mop head connected was heavily soiled with a black substance. The inside of the yellow mop bucket was heavily soiled with a black film. The water pipe going into the sink was heavily soiled with a brownish black film; -The stainless steel dish counter next to the dishwasher was heavily soiled with dried white droplets and the wall behind the counter and beside the dishwasher was heavily soiled with dried splatters of food and other unidentified matter; -The recycle bin was full of large empty cans. The receptacle was overflowing and there were two empty cans and two empty gallon milk jugs that did not fit into the container on the floor beside the receptacle. Kitchen staff were working on preparing the dinner meal; -Unused coffee filters were observed out of their packaging in a box that also contained bananas. The coffee filters were soiled with brown colored dust and other substance particles. In addition, there was also an opened bag containing coffee filters that were also soiled with brown dust and debris; -All stainless steel appliances and cabinets were streaked with dried white smudges and splatters and dust in the cracks at the ledges and seams of the units; -A dietary aide (DA) entered the kitchen and entered the food preparation area without a hair net on. The dietary manager asked the DA a number of times to put a hair net on, the staff argued back that she was only passing through the kitchen. After several exchanges, the DA complained and put on a hairnet. In addition, the other conditions observed on 3/13/23 at 9:15 a.m. were not addressed and remained the same (see above). D. Staff interviews The assistant director of dining (ADD) was interviewed on 3/16/23 at 1:00 p.m. The ADD said management would hold an inservice with kitchen staff to discuss kitchen sanitation expectations. The ADD said he would stay in close contact with the dining service manager to assist with keeping the staff on track with kitchen sanitation. The sous chef (SC) was interviewed on 3/16/23 at 1:30 p.m. The SC said he would check the kitchen and dining area for sanitary conditions every shift every day; and initiate a new checklist for sanitation procedures in the kitchen and dining areas. The SC said the fryer was cleaned weekly or as needed. E. Facility follow-up On 3/16/23 at 3:00 p.m., observations of the kitchen revealed: -The facility called the vendor and requested a new juice machine; the machine was replaced; and, -The stainless steel tables and refrigerator doors were wiped down, the deep fryer had been cleaned out. The rest of the observed sanitation concerns had not yet been addressed.II. Resident dining services A. Professional reference According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 3/23/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view \ Persons who are more likely than other people in the general population to experience foodborne disease because they are .older adults; and they obtain food at a facility that provides services such as nursing home. -Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: Poor personal hygiene. -The Food Code addresses controls for risk factors and further establishes five (5) key public health interventions to protect consumer health. Specifically, these interventions are: demonstration of knowledge, employee health controls, controlling hands as a vehicle of contamination. B. Facility policy and procedure The Food Handling policy, revised May 2012, was provided by the nursing home administration (NHA) on 3/16/23 at 5:30 p.m., it read in pertinent part: Purpose: To ensure the prevention of food borne illness. Policy: High standards of sanitation will be maintained and practiced in all community food preparation and service areas. - Continuing care staff are trained regarding general sanitation theory, use and cleaning of equipment, personal hygiene. C. Observations On 3/13/23 from 12:00 p.m. to 1:05 p.m., lunch service was observed: -At 12:05 p.m., certified nurse aide (CNA) preformed hand hygiene and assisted Resident #14 with lunch. CNA #9 handed Resident #7 the silverware from the resident plate. Resident #7 took the spoon and ate the food off the spoon. CNA #9 then handed the resident her cup to drink. -CNA #9 then walked over to Resident #7 and without performing hand hygiene CNA #9 started assisting Resident #7 with eating. -At 12:24 p.m., CNA #9 stood by Resident #39 and without any hand hygiene picked up Resident #39's spoon and assisted the resident with a couple bits of soup; then picked up the resident's cup and prompted the resident to drink. The resident took the cup and drank some liquid and handed it back to CNA #9. CNA #9 set the cup on the table and walked back to Resident #7 and without hand hygiene, CNA #9 assisted Resident #7 eat some soup with a spoon. -At 12:11 p.m. CNA #8 sat down to assist Resident #16 and #31. CNA #8 was assisting both residents simultaneously; one bite to Resident #16 then one bite to Resident #31 and so on. CNA #8 used the same hand to hold the spoons for each resident with the same hand and did not perform hand hygiene in-between assisting each resident with eating. -At 12:40 p.m. CNA #2 approached the resident eating lunch at the table; CNA #2 reached behind Resident #16 and grasped the resident pants waistband and assisted the resident to reposition in the chair. -CNA #2 then without performing hand hygiene assisted CNA #9 to reposition Resident #31. -CNA #9 stopped assisting Resident #31 and #16 to assist CNA #9 in repositioning Resident #31. The CNAs grasped Resident #31's pants at the waistband to reposition the resident. CNA #9 went back to assisting Resident #31 and Resident #16 without performing hand hygiene. -CNA #2 walked over to the other end of the table to prompt the resident to eat and rearranged the resident's dishes closer to their reach. The CNA did not perform hand hygiene between assisting Resident #16 and #31 and helping other residents with their meals. -CNA # 2 then sat next to Resident #7 to assist the resident with eating via a spoon. CNA #2 still had not performed any hand hygiene. On 3/15/23 from 11:58 a.m. to 1:07 p.m., lunch service was observed: -At 12:08 p.m. activities assistant (AA) brought two bananas to the table and offered one banana to a resident. When the resident accepted the AA opened the banana and with bare unwashed hands, the AA broke the banana into small manageable pieces and set the banana pieces on the resident's plate. The resident ate the broken up banana. -The AA then peeled the second banana and with bare unwashed hands broke it in half and walked around the table offering it to residents. Two residents accepted each of the halves of the peeled banana. -At 12:22 p.m., after assisting a different resident to eat her meal, CNA # 3 sat next to Resident #16 to feed the resident a couple spoons of soup. In-between the spoons of soup CNA #3 stopped assisting Resident #16 to assist Resident #31's clothing protector, then went back to assisting Resident #16 with her soup. The CNA did not perform hand hygiene in-between assisting the three different residents. -At 12:24 p.m., CNA #1 assisted Resident #39 lunch, then with bare unwashed hands cut up Resident #30's sandwich. The CNA used an unwashed bare hand to hold the sandwich while cutting it up. On 3/16/23 from 11:56 a.m. to 1:05 p.m., lunch service was observed: -At 12:28 p.m., CNA #3 was assisting Resident #39 with lunch via spoon and assisting the resident hold a cup while the resident drank. CNA #3 stopped assisting Resident #39 to help another resident rearrange plates of food for better reach and get a better grasp on her silverware. CNA #3 then retried to assist Resident #39 to eat. CNA #3 did not perform any hand hygiene between assisting the two residents. -At 12:32 p.m., CNA #5 was holding Resident #39's hands, when another resident asked for hot coffee. The resident still had some coffee in her cup; CNA #5 left Resident #39 to pick up the other resident's coffee mug and reheated it in the microwave. CNA #5 then took the cup back to the resident. CNA #5 did not perform hand hygiene in between holding Resident #39's hands and touching the other residents. D. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 2:55 p.m. RN #2 said staff should wash their hands prior to providing eating assistance to a resident. If the staff was transitioning to assisting a different resident with their meal, the staff should perform hand hygiene between working with one resident to another. CNA #3 was interviewed on 3/16/23 at 4:22 p.m. CNA #3 said when assisting a resident with eating finger foods or ready to eat foods, staff should perform hand hygiene before handling the resident food and perform hand hygiene after assisting the resident before assisting another resident. When assisting two residents at once staff needed to perform hand hygiene before sitting down to assist the residents. It was ok to give one resident a bite using their utensils and then give the other resident a bite using that resident's utensils. Once staff were done assisting both residents the staff needed to perform hand hygiene. CNA #5 was interviewed on 3/16/23 at 4:35 p.m. CNA #5 said when assisting a resident with finger foods or ready to eat foods, staff should put on gloves or cut up the food so the resident could feed themselves. Staff should perform hand hygiene prior to assisting a resident with their meal and before handling resident dishes and utensils. The director of nursing (DON) was interviewed on 3/16/23 at 5:06 p.m. The DON said staff should wash their hands prior to assisting a resident and in between assisting two residents with any care including eating assistance. If staff need to touch ready to eat foods, staff should wash their hands first and put on gloves; the preferred method would be for staff to use a utensil to hold the food while cutting and fork the food pieces to assist the resident with eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to develop and maintain an infection prevention and 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: -Encourage and/or provide residents with protective masks when in common areas to prevent the spread of COVID-19 on two of two units; -Ensure proper hand hygiene after glove use; -Ensure bedpan equipment was properly contained; and, -Ensure proper handling of linen. Findings include: I. Facility policies The Infection Prevention and Control policy, revised May 2021, was provided by the director of nursing (DON) on 12/14/21 at 3:28 p.m. It read, in pertinent part, The infection preventionist will collaborate with members of the campus infection prevention committee/subcommittee members to .Monitor to ensure established infection prevention and control standards, policies and practices are consistently executed by staff and residents/patients. -Provide education and training, such as, preventing the transmission of infectious diseases, hazardous material management, food safety & sanitation, blood borne and water borne pathogens, emerging infectious diseases, and emergency preparedness program and other education and training as needed. The Hand Hygiene policy, revised March 2020, was provided by the DON on 12/15/21 at 4:54 p.m. It read, in pertinent part, When to perform some form of hand hygiene (at a minimum) .Before putting on (donning) and after removing (taking off) PPE (personal protective equipment), including gloves. II. Failure to encourage and provide residents with protective masks A. Observations and interviews On 12/8/21 at 9:15 a.m. several residents were observed in the dining room having breakfast. Staff were observed bringing residents to the dining area, the residents did not have masks on. -At 10:00 a.m. staff were observed providing activities to several residents who stayed in the dining room. Staff did not offer resident protective masks during the activity. -At 12:27 p.m. Resident #20 was assisted by staff from the main hallway into the dining room, after a couple of minutes he asked a staff member to take him to his room. Resident #20 did not have on a protective mask. -At 12:29 p.m. Resident #20 was interviewed. He said he came from the salon and just received a haircut and the staff member assisted him in the dining room because it was time to have lunch. On 12/13/21 at 8:35 a.m. staff were observed transporting Resident #4 and #19 to the dining room without protective masks on. -At 8:58 a.m. certified nurse assistant (CNA) #1 assisted Resident #5 out of bed and to the dining room. CNA #1 did not encourage Resident #5 to wear a protective mask. There was signage posted in the resident's room which read, Are you leaving your room? You must wear a mask. -At 9:19 a.m. the hospice CNA was observed assisting a resident down the hallway without a protective mask. -At 10:10 a.m. CNA #1 assisted Resident #33 out of her room to the dining room. Resident #33 did not have a protective mask on. -At 10:12 a.m. CNA #1 was interviewed. She said she was supposed to offer Resident #33 to wear a mask, but she often refused and would remove it. She said she was nervous and forgot to offer Resident #5 a protective mask before she brought her out of her room to the dining room. On 12/14/21 at 9:06 a.m. Resident #3 was observed in a common area in her wheelchair. She was not wearing a protective mask. She said she was confused and needed help to make a phone call. An unidentified housekeeper asked if she needed help. She did not offer a protective mask to the resident. -At 9:06 a.m. Resident # 23 was assisted by physical therapy to walk in the hallway near the dining room. She was not wearing a protective mask. The therapist did not offer the resident a protective mask. B. Staff interviews The nursing home administrator (NHA) and DON were interviewed on 12/9/21 at 5:29 p.m. They said they were tracking their COVID-19 outbreak (only staff no residents) and it was from the outside community. The NHA said the staff had continued to follow guidance to ensure they did not spread COVID-19 to the residents by wearing N95 masks and protective eyewear. They said the outbreak initially started with only one resident who was found positive for COVID-19 on 11/4/21 which they believe was contracted from a compassionate visit as the resident was on hospice, and the first positive staff member was on 11/4/21; however they were not connected because the staff member did not work with that resident. They said several residents had refused to wear protective masks, they would remove them and leave them hanging around and several did not know how to apply them or remove them. They acknowledged protective masks were beneficial to prevent the spread of COVID-19. They said to ensure resident safety they should have continued to encourage residents to wear protective masks and planned to re-educate staff to offer and encourage masks. III. Failure to ensure proper hand hygiene after glove use A. Observation and interview On 12/13/21 at 8:38 a.m. CNA #1 was observed providing care to Resident #5. She performed hand hygiene and donned gloves. After she unfastened the residents brief she wiped the resident's peri-area (in the front area) with a wet wipe then she doffed her gloves and donned new gloves. She did not perform hand hygiene. She rolled the resident on her right side and then wiped her buttocks with a wet wipe and placed a clean brief under the resident's buttocks. She doffed her gloves and donned new gloves. She did not perform hand hygiene. She fastened the resident's brief and rolled the resident to either side to pull up the resident's pants. She doffed her gloves and performed hand hygiene. -At 8:59 a.m. CNA #1 was interviewed. She said she knew she was supposed to perform hand hygiene after she removed her gloves, but she was nervous and forgot. B. Staff interviews The NHA and DON were interviewed on 12/13/21 at 4:38 p.m. The DON said staff were trained on when to perform hand hygiene, including after glove use. She said they planned to re-educate staff. IV. Failure to ensure bedpan equipment was properly contained and proper handling of linen A. Observation and interview Housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER] on 12/13/21 at 10:15 a.m. There were three used bedpans (they had white film surrounding the pan) on the floor. After she cleaned the bathroom and the toilet from top to bottom, she placed the bedpans on top of the toilet. She then swept and mopped the resident's bathroom floor. She doffed her gloves, performed hand hygiene and donned clean gloves and continued to clean the rest of the resident's room. After she was finished, she placed the bedpans back on the bathroom floor. She doffed her gloves, performed hand hygiene, went to the laundry closet and grabbed clean towels (face towel and hand towel). She placed them under her arm and carried them to the room and placed them in the resident's bathroom. She exited the room, performed hand hygiene and moved to the next room. -At 10:52 a.m. HSK #1 was interviewed, she said she did not know where the bed pans belonged or if they needed to be placed in a bag. She said she just left them on the floor for the CNAs to take care of. She said she did know she should not place linen up against her clothing. -At 11:45 a.m. during wound observation the bedpans were still observed on the bathroom floor. -At 4:28 p.m. the bedpans were observed on the resident's bathroom floor with CNA #2. He said the bedpans should be placed in a plastic bag after use. He said he was going to throw them away and obtain a clean bedpan for the resident and place in a bag in the resident's bathroom. B. Staff interviews The NHA and DON were interviewed on 12/13/21 at 4:38 p.m. The DON said she expected all staff to ensure bedpans were bagged. She said bedpans could be easily rinsed/wiped and placed in a bag after use. She said typically all staff were instructed on how to transport linen and they should not hold them against their body or under their arm next to their clothing. She said she would provide education. V. Staff interviews The staff development coordinator (SDC) was interviewed on 12/13/21 at 12:53 p.m. She said she provided orientation education related to infection control as well as education regarding hand hygiene (spot check) with return demonstration. She provided documentation of hand hygiene and returned demonstration. Two to five staff completed the training monthly from January 2021 to December 2021. In addition, education included proper use of PPE, peri-care, catheter care and droplet precautions. The NHA and DON were interviewed a second time on 12/13/21 at 4:50 p.m. The NHA and DON said they had previously offered and encouraged residents to wear their masks when they were under quarantine or isolation; they had more luck getting residents to comply with the regulation when they were on quarantine. They said staff were encouraged to offer residents protective masks and signage and masks were in resident rooms and at the nurse's station as a reminder. They acknowledged all breaks in infection control identified above and would re-educate. VI. Facility COVID-19 status The director of nurses (DON) was interviewed on 12/8/21 at 9:30 a.m. She said they had zero COVID-19 positive residents and three COVID-19 positive staff who had not returned to work. She said there were no presumptive positive COVID-19 residents and all staff and resident tests from 12/7/21 were pending for COVID-19. On 12/14/21 all staff and all residents test results for 12/7/21 and 12/10/21 were negative for COVID-19.