**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#44 and #16) of seven residents reviewed for unnecessary medications out of 18 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident # 44 was assessed by the interdisciplinary team (IDT) prior to implementation of a psychotropic medication treatment and appropriate non-pharmacological interventions were initiated; -Ensure Resident #16's psychoactive medication, an antidepressant, was not increased without evidence and documentation of change of behaviors or attempts of non-pharmacological interventions, and, -Resident # 16's hours of sleep were documented for hypnotic medication use. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 1/10/24 at 8:02 a.m. and read in parts: Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Consideration of the use of any psychotropic medications is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. When determining whether to initiate, modify, or discontinue medication therapy, the IDT (interdisciplinary team) conducts an evaluation of the resident. II. Resident # 44 A. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician order (CPO) diagnoses included dementia, history of urinary tract infections and type 2 diabetes mellitus. The 1/2/24 minimum data set (MDS) assessment revealed resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. Section E revealed presence of hallucinations and delusions, physical and verbal behavioral symptoms directed towards others occurred in one to three days. Rejection of care and wandering occurred in one to three days. B. Resident observations Resident #44 was observed on 1/8/24 throughout the day. She was wearing a dark coat and was carrying a purse. She was walking up and down the hallways throughout the facility and occasionally rested in the television room next to the nurses' station. She was invited to participate in the afternoon activities, however she did not stay. On 1/10/24 at approximately 9:30 a.m. the resident was observed walking on the 300 hall. She was dressed in a dark coat and was carrying a purse. She appeared upset and agitated. She said she did not know where she was and would like to go home. C. Record review Physician orders: -Seroquel oral tablet 25 mg (Quetiapine Fumarate) (antipsychotic medication), give one tablet by mouth three times a day related to unspecified dementia, mild, without behavioral disturbance. Start date 1/4/24 -Melatonin oral tablet 10 mg (Melatonin) (supplement used for insomnia), give one tablet by mouth at bedtime for insomnia. Start date12/28/23 Care plan: The comprehensive care plan review revealed the following: -(Resident) takes psychotropic medications r/t (related to) dementia with behaviors. Interventions included: Administer medications as indicated by physician orders. Consult with pharmacist/physician for gradual dose reduction if appropriate. Monitor for and report to physician adverse effects of antipsychotic medication use (drowsiness, dizziness, restlessness, weight gain, dry mouth, constipation, nausea/vomiting, blurred vision, low blood pressure, uncontrolled movements/tics/tremors, seizures, increased risk for falls). Review with resident/family/responsible person the risks vs. benefits of psychotropic medication use. Care plan was initiated on 1/7/24 -(Resident) has impaired cognitive function r/t (related to) diagnosis of dementia (dated 9/12/23). Interventions included: Encourage resident to participate in daily decision making with daily activities. Keep resident's routine as consistent as possible to avoid anxiety and frustration. Notify nurse, physician of any significant change in (Resident's) baseline cognitive status. Reassure (Resident) of safety. Redirect as needed. -The resident's care plan did not include non-pharmacological interventions for the psychotropic medication Seroquel. -The resident's care plan did not include the use of Melatonin for insomnia. Interdisciplinary notes: On 11/11/23 a nurse documented: Resident was found standing outside the door of her room crying stating 'no one likes me, no one wants me' . RN (registered nurse) provided therapeutic listening and reassurance, given cup of tea and encouraged to socialize. Then she wandered around the unit, and required encouragement to return to her room to change into pajamas. Resident's roommate voiced complaints that resident was talking loudly to self in her room. When RN arrived, resident was sleeping sitting upright in bed. RN closed room window as (resident) seems bothered by the cold. Will pass on to dayshift that new room assignment may not be best fit. On 11/15/23 a nurse documented: This resident has been up wondering the hallways t/o the noc (throughout the night). Resident will sleep for two hours and then get back up. When approached by this RN, resident states 'I just can't sleep'. On 11/17/23 a nurse documented: Resident appears to be having more issues during the night. At the beginning of the shift resident was wondering the halls but not really communicating what she was looking for, commenting she was waiting on the baby, or looking for a coat she had misplaced. Resident was then standing in the hall in front of her room being very weepy making comments that she only wanted to be nice to people. Reassured resident that all was well and encouraged her to go to bed. Later in the evening she was assisted to bed by staff and has been asleep since that time. On 12/26/23 a nurse documented: Resident redirected to stay in room several times per hour due to isolation precautions. Encouraged to wear mask when out of the room. Resident forgetful and becomes anxious, confused, and agitated. Redirected and reiterated that resident is safe and shown location of room through day. Call light within reach and resident encouraged to use as needed. On 1/1/24 a nurse documented: Resident continues to be very upset, agitated towards staff. Also continues to go into other rooms frequently upsetting other residents. Very difficult to redirect. Will not stay in her room, getting very little sleep. On 1/3/24 a nurse documented: Resident attempted to hit CNA (certified nurse aide) while being redirected out of another resident's room. Resident walking up and down the hallway shouting 'cheaters' Resident not easily redirectable at this time. Encouraged adequate space while ensuring safety. On 1/4/24 a nurse documented: Resident was arguing with another resident this evening and the altercation almost became physical. Nursing staff intervened prior to this occurring. Resident not easily redirectable. Resident was noted to be very agitated, yelling, wandering, and aggressive with other residents and staff at the beginning of this shift. Resident was walking up and down the hallway in the eve on January 3rd, 2024, and was calling staff 'liars'. Nursing staff encouraged space while ensuring safety of all residents and staff. Resident was assisted to change into pajamas and into bed at 2130 (9:30 p.m.). Resident still lying in bed resting. Call light and personal items are within reach. On 1/6/24 a nurse documented: Resident noted with verbal outbursts and verbal aggression toward staff. Pacing and upset about 'missing the bus to Texas', positive reinforcement and redirection provided but resident responds angrily and walks away. Resident allowed space and frequent visual checks continue. Staff will continue to provide a safe and hazard free environment. D. Staff interviews The medical director (MD) was interviewed on 1/8/24 at 10:35 a.m. He said the antipsychotic medication Seroquel was prescribed for dementia with behaviors. He said the nursing staff told him the resident was verbally and physically aggressive towards staff and occasionally with other residents. He said he did not consider a lower dose for the resident. He said the medication had six hours half-life and the nursing staff observed significant positive changes in resident's behaviors. The director of nursing (DON), the social service director (SSD) and the activities director (AD) were interviewed on 1/9/24 at 5:00 p.m. The DON said it was the facility policy the interdisciplinary team (IDT) should review and assess a resident's behaviors prior to asking physician for a drug, especially an antipsychotic medication. She said the nurses were frequently reminded not call the physician and ask for a psychotropic medication. The SSD said there were no non-pharmacological interventions implemented for resident increased behaviors and there was no care plan for it. She said the resident was moved to different rooms three times in the past two months and that could have triggered increased of confusion and behaviors. The AD said Resident #44 was always invited to the group activities however she would not stay long. RN #1 was interviewed on 1/9/24 at 5:30 p.m. She said Resident #44's behaviors increased during her isolation due to COVID-19 diagnosis. She would not stay in her isolation room and would not wear a facemask. She began being aggressive towards staff. RN#1 said after the COVID-19 isolation was over, the resident returned to her previous room and became more confused. She said the resident was wandering to other residents' rooms and was not easily redirectable. She said she notified the MD of Resident #44's behaviors and he prescribed the antipsychotic medication. III. Resident #16 A. Resident status Resident # 16, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician order (CPO) diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD), insomnia, major depressive disorder and anxiety. The 12/5/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. She had no identified behaviors or rejections of care. The mood interview PHQ-9 (the nine questions of patient health questionnaire objectifies degree of depression severity) score was two out of 27 which indicated no depression. She was administered high risk medications included an antidepressant, hypnotic and anticoagulant. B. Resident interview Resident #16 was interviewed on 1/10/24 at 9:55 a.m. She said she was not aware her antidepressant was increased a week ago. She said she usually went to bed and fell asleep around 10:30 p.m. woke up one time to go to the bathroom and slept the rest of the night. C. Record review Physician orders: -Citalopram Hydrobromide, oral tablet 10 mg (Citalopram Hydrobromide) (antidepressant known as selective serotonin reuptake inhibitors). Give one tablet by mouth one time a day related to major depressive disorder. Start date 12/5/23. End date 1/2/24. -Citalopram Hydrobromide, oral tablet 20 mg (Citalopram Hydrobromide). Give one tablet by mouth one time a day related to major depressive disorder and anxiety disorder. Start date 1/3/24. -Temazepam oral capsule 15 mg (Temazepam) (Benzodiazepine used to treat severe insomnia). Give 15 mg by mouth at bedtime for insomnia. Start date11/22/23. Care plan The comprehensive care plan review revealed the following: -There was no care plan for the antidepressant medication in resident's record. -There was no care plan for the hypnotic medication in resident's record -There was no care plan for non-pharmacological interventions for the above medications. Review of the resident's electronic record revealed there were no behavior notes identifying any behaviors. The January 2024 CPO identified the medication Citalopram Hydrobromide for depression and anxiety was increased on 1/3/24 from 10 mg to 20 mg every day (qd). -The facility failed to have evidence of increased behaviors and attempts at non-pharmacological interventions prior to the increase of Citalopram Hydrobromide from 10 mg to 20 mg. Interdisciplinary notes On 12/5/23 a nurse documented: Citalopram 10mg started for increased anxiety. No unusual behaviors noted with no adverse reactions. On 1/2/24 a nurse documented: MD in house to see resident. Resident verbalizing increase in anxiety. New orders obtained to change Citalopram to 20mg PO QD. Orders noted and carried out. Resident made aware. D. Staff interviews The DON and MDS coordinator (MDSC) were interviewed on 1/10/24 at 8:35 a.m. The MDSC said the resident's care plan was not finished timely. She said the resident's care plan did not address the insomnia and antidepressant medications. She said there were no non-pharmacological approaches for the above medications in the resident's care plan. The DON was interviewed on 1/10/24 at 9:40 a.m. She said the resident was admitted on Tomazepam from the hospital. She said there were no hours of sleep documented. She said she was not aware the resident's antidepressant was increased and IDT did not review change in behaviors or increase in depression.

Based on observations and interviews the facility failed to ensure one of one medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised February 2023, was provided by the director of nursing (DON) on 1/9/24 at 1:00 p.m. It read in pertinent part, Controlled substances (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. II. Observations On 1/8/24 at 10:33 a.m. the medication refrigerator was observed with registered nurse (RN) #1. There were two controlled medication locked boxes in the refrigerator not permanently affixed to the refrigerator and they contained liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) and liquid morphine (pain medication). III. Staff interviews RN #1 was interviewed on 1/8/24 at 10:36 a.m. She said she was not aware that the controlled medication box in the refrigerator should be permanently affixed to the refrigerator. She said she now knew that anyone with access to the refrigerator could just take the boxes of controlled medications out of the refrigerator. The director of nursing (DON) was interviewed on 1/9/24 at 1:14 p.m. The DON said she was not aware of the requirement that the controlled medication boxes should be permanently affixed to the refrigerators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure four (#11, #12, #21 and #46) out of 18 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure blood pressure medication was ordered with administration parameters for Residents #11, #12, #21 and #46. Findings include: I. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 1/19/24. 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 [NAME], R.G., [NAME], R.J. (2022). Calcium Channel Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK482473/ retrieved on 1/19/24. Calcium channel antagonists, also known as calcium channel blockers (CCBs), have been widely used for many indications. This cardiovascular drug class is one of the leading causes of drug-related fatalities. Patients require close monitoring. The improvement of their symptoms of angina or maintenance of their blood pressure is an indication of efficacy (effectiveness for the desired result). Hypotension (low blood pressure) may be profound and life-threatening. Many factors may affect the severity of overdose, including the calcium-channel antagonist dose, the formulation, ingestion with other cardioactive medications such as beta-blockers, the patient's age, and comorbidities. These medications may also be life-threatening with as little as one tablet in small pediatric patients. Kiziior, R. J., [NAME], K. J. (2023). Lisinopril. [NAME] Nursing Drug Handbook. Elsevier. P. 704. Obtain blood pressure, apical pulse immediately before each dose in addition to regular monitoring (be alert to fluctuations). According to [NAME], L.L, [NAME], P, [NAME] K (2023) Hydrochlorothiazide. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK430766/ retrieved on 1/9/24. Hydrochlorothiazide is a medication to treat hypertension and peripheral edema. Blood pressure should be closely monitored to ensure patients on hydrochlorothiazide treatment achieve and maintain their target blood pressure, minimizing the risk of adverse effects associated with high or low blood pressure. II. Resident #11 A review of the December 2023 computerized physician orders (CPO) revealed: -Metoprolol Tartrate Oral Tablet 25 milligrams (mg). Give 0.5 tablet by mouth twice daily, started 11/29/23. A review of the December 2023 medication administration record (MAR) revealed: -Metoprolol was administered on 12/4/23, 12/11/23 and 12/15/23 when the resident's blood pressure was low with normal blood pressure being 120/80. A review of the December 2023 blood pressure summary showed Resident #11 had a blood pressure of 85/44 on 12/4/23, a blood pressure of 85/54 on 12/11/23 and a blood pressure of 70/38 on 12/15/23. II. Resident #12 A review of the December 2023 CPO revealed: -Lisinopril Oral Tablet 20mg. Give one tablet by mouth one time a day related to essential primary hypertension, started 11/2/23. A review of the December 2023 MAR revealed: -Lisinopril was given on 11/24/23, 11/30/23 and12/26/23. A review of the November 2023 and December 2023 blood pressure summary showed Resident #12 had a blood pressure of 84/56 on 11/24/23, a blood pressure of 89/57 on 11/30/23 and a blood pressure of 78/53 on 12/26/23. III. Resident #21 A review of the December 2023 CPO revealed: -Hydrchlorithiazide (HCTZ) Oral Tablet 12.5 mg. Give one tablet by mouth three times daily related to essential primary hypertension. A review of the October 2023 medication administration record (MAR) revealed the HCTZ medication was administered consistently according to the order. A review of the October 2023 medication regimen review from the pharmacist revealed the resident had a diastolic blood pressure of less than 60, six times during the previous 30 days and the medication was administered. The pharmacist recommended either eliminating the medication or adding hold parameters in order to lessen the potential fall risk associated with hypotension (low blood pressure), drug to drug interactions and side effects. IV. Resident #46 A review of the November 2023 CPO revealed: -Amlodipine Besylate Oral Tablet five mg. Give one tablet by mouth one time a day related to essential primary hypertension, date started 11/2/23 and was discontinued on 11/13/23. A review of the November 2023 MAR revealed amlodipine was given on 11/5/23. -A review of the November 2023 blood pressure summary showed Resident #46 had a blood pressure of 87/56 on 11/5/23. V. Interviews Registered nurse (RN) #1 was interviewed on 1/8/24 at 10:57 a.m. She said there were no standing orders for acceptable blood pressure ranges for residents on blood pressure medications. She said she used her own judgment when determining if the medication should be administered. She said the certified nurse aides with medication authority (CNA/MA) only took the resident's blood pressure when necessary as ordered by the physician. She said in most cases, the blood pressure was only ordered to be checked once daily. CNA/MA #1 was interviewed on 1/8/24 at 11:01 a.m. He said he checked residents' blood pressure if he was requested to and reported the results to the nurse on duty. The director of nursing (DON) was interviewed on 1/9/24 at 1:32 p.m. She said she was aware there were not currently any orders that directed staff on when it was appropriate to hold blood pressure medications. She said the CNA/MAs and nursing staff were to use good judgment and withhold medications when appropriate.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure reheated food reached the appropriate temperature; and, -Ensure beard nets were worn in the kitchen. Findings include: I. Reheated food 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. Reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (Retrieved 1/10/24) B. Observations Cook #1 was asked on 1/7/24 at 11:52 a.m. to reheat soup that was brought by the family. The cook placed the soup in the microwave for less than two minutes. He did not rotate or stir the soup, did not take the temperature of the soup and did not allow the soup to stand covered for two minutes. Dietary aide (DA) #2 was asked on 1/9/24 at 11:12 a.m. to reheat a cinnamon roll that was in a paper bag. DA #2 placed the cinnamon roll in the original packaging in the microwave for less than two minutes. She did not take the temperature of the cinnamon roll. She did not rotate the cinnamon roll, did not take the temperature of the cinnamon roll and did not allow the cinnamon roll to stand covered for two minutes. C. Staff interviews The corporate dietary manager was interviewed on 1/9/24 at 3:20 p.m. She said cooks should be the only ones who reheat food. She preferred outside food to be sealed and in its original packaging. She said that any food that is reheated should be tested with a thermometer to ensure the food reached 165 degrees Fahrenheit. D. Facility follow-up The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. training was provided to kitchen staff that food should be reheated to reach 165 degrees Fahrenheit. II. Hair restraints 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. Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn effectively keep their hair from contacting exposed food. (Retrieved 1/22/24) B. Observations Cook #1 and an unidentified dietary aide were observed on 1/9/24 at 11:01 a.m. Both staff were continuously observed during the lunch meal on 1/9/24 from 11:01 a.m. until 11:48 a.m. Both staff had a beard that was less than one inch. They both did not have a beard net worn to prevent their hair from contacting exposed food. C. Staff interviews The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. She said any dietary staff that entered the kitchen should have worn hair coverings that covered body hair including beards. She said she would talk to the kitchen staff who have beards to wear hair coverings. D. Facility follow-up The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. She provided documentation training was provided to all kitchen staff to wear hair coverings including beard nets.

Based on interviews and record review, the facility failed to investigate allegations of abuse for two (#17 and #45) out of 25 sample residents. Specifically, the facility failed to investigate abuse allegations against a staff member brought forward by Resident #17 and Resident #45. Cross-reference F600 for abuse. Findings include: I. Facility policy and procedure The Resident Safety policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 9/14/22 at 5:50 p.m. documented in part, it was the policy of the facility to maintain a work and living environment that was professional and free from threat and/or occurrence of harassment, abuse, (verbal, mental, or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Making reasonable efforts to provide a safe environment for the residents was one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relations with residents makes ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Reporting suspected or reported violations: Any suspected, observed or reported violation of this resident safety policy would be reported to the supervisor on duty immediately. The supervisor on duty shall report any suspected violations of this resident safety policy immediately to the administrator and to the director of nursing or their designee as soon as practicable. Procedure for investigation: -The quality assurance manager and/or supervisor on duty will assess the resident and document the date, time, and location of the reported or suspected incident. -The supervisor would ensure that the resident was protected from harm during the investigation. -An incident report would be completed. -An employee suspected of violation of the resident safety policy may be suspended pending the results of the investigation. -The quality assurance manager and/or supervisor on duty would attempt to interview the resident as well as all nursing, housekeeping, laundry, dietary, activity, social service staff, any visitors or others who may have knowledge of the occurrence or who may had been in the vicinity at the time the incident happened. The quality assurance manager and/or supervisor on duty would prepare a written summary of each interview. II. Resident #17 Resident #17 was interviewed on 9/12/2022 at 2:47 p.m. He said a certified nurse aide (CNA) at the facility was mean to him purposefully (referring to CNA #3). Resident #17 said he had reported the CNA purposefully pushing on his legs and her name calling to a registered nurse (RN) at the facility a couple months ago, and nothing came of it because he later found out the RN was friends with the CNA. He said he continued to report these issues to staff and finally a few weeks ago the director of nursing (DON) came down to talk to him, and he thought that was about three weeks ago. He said he expressed his concerns to the DON at that time about the staff member and reported the issues with her pushing on his legs purposefully (cross-reference F600). III. Resident #45 Resident #45 was interviewed on 9/14/22 at 8:15 a.m. She said she did not like certified nurse aide (CNA) #3 because she was mean and rough (no specifics were given by the resident but she was tearful during the interview). She said she felt it did feel like abuse and she was afraid of the staff member. She said she had reported these concerns to the director of nursing (DON) and nursing home administrator (NHA) previously but nothing had been done about it (cross-reference F600). IV. Record review A nursing progress note for Resident #17 by licensed practical nurse (LPN) #2 dated 7/10/22 at 3:30 a.m. read, Resident continues this evening to swear at staff, call staff names. Calls for assistance and is noted to immediately yell at staff, verbalize multiple complaints regarding his positioning, as well as all departments in the facility. States he expects his call light to be answered immediately, resident non receptive to any form of waiting. He has made multiple accusations this evening, he is advised to discuss these with administration, he follows this suggestion with comment that he has been in touch with his attorney and speaks to his attorney every Monday regarding his complaints. Staff has been instructed to provide care for this resident with 2 staff members present at all times. A Complaint & Concern form dated 8/24/22 completed by the DON under nature of concern showed Resident #17 stated he was unhappy with care from a night shift CNA. Resident stated the staff member did not speak to him while providing care. He also stated the CNA did not help assist him with changing his hearing aids. The resident chose not to state the name of the CNA. Under response on the form the suspected CNA was moved to day shift per the CNA's request and for observation. The CNA was instructed to not enter Resident #17's room without another staff member. This change was made in early September and dated 9/1/22. -The Complaint & Concern form did not include information about the staff member pushing on his legs or calling him names. A Complaint & Concern form dated 9/9/22 completed by the NHA for Resident #45 showed the nature of the concern as Resident #45 reported CNA #3 was impatient and gruff. She stated stated she did not like CNA #3, and CNA #3 had walked into her room and shut off her call light without addressing the residents' needs. Under the response and action taken it was noted the staff member was educated and encouraged to slow down and approve the resident with a gentle voice and manner, and communicate and approach the resident with additional aid (staff member) if needed. An Educational Forms document dated 9/9/22 showed CNA #3 was given a verbal warning for a resident stating she was impatient and gruff. The staff member verbalized understanding of resident dignity and was given a handout. A statement by Resident #45 provided by the facility on 9/14/22 at 8:47 a.m. showed Resident #45 stated she did not know she was afraid of the staff member until this morning, and she never expressed it. The CNA was mean and it was her personality. The resident signed the statement. V. Interviews The DON and NHA were initially interviewed on 9/14/22 at 8:45 a.m. The DON said Resident #17 had reported to her some concerns about a CNA. The resident had not given her a name, but she was able to identify the staff member as CNA #3. She said the concerns were initially brought to her sometime in August 2022, and Resident #17 had reported the issues of CNA #3 pushing on his legs. She said she did not know if the staff member had been doing it on purpose or not. She said she did not complete an investigation at the time about it (cross-reference F600). She said the staff member was moved to day shift on 9/1/22 for more supervision and was not moved earlier because of staffing issues in the facility. She said it was not reported to her the staff member had called the resident cry baby or any other verbal issues. The DON and NHA said they felt for Resident #45 the concerns brought forward to them from the resident did not meet the level of abuse, so an investigation was not done. Both staff acknowledged they felt it was the way and tone of the CNA when she spoke to the resident. They said the resident had not reported she was afraid of the staff member until it was brought to their attention during the survey. The NHA said it was not ok for staff not to be cordial with residents. They said they had interviewed some nurses about the CNA and they decided again the staff member should provide care in pairs with another staff member for Resident #45. Both staff acknowledged they did not interview other residents about CNA #3, but said Resident #17 and #45 had come forward with concerns about the staff member and no investigation had been done (cross-reference F600). LPN #2 was interviewed on 9/15/22 at 2:00 p.m. She said she was fairly certain the accusations being made from her note in July 2022 were about CNA #3. She said she knew it was about a CNA because if it were her she would have said in her note that it was about her, but that she did not name other staff in her notes. She said she thought it was about CNA #3 pushing on his legs purposefully, and she did not recall any verbal abuse accusations. She said she would have told whoever was coming on the next morning the resident was making accusations and she trusted they would follow up with administration as they were not on during the night and it was a Sunday night. She said she did not follow up with administration herself and notify them about the accusations from Resident #17, and she was unaware if an investigation was done. She said she was at fault and dropped the ball. She said she should have notified administration herself as that was the process at the facility. She said she did not remember who she asked to forward the allegation to administration the next morning, and she put her trust in them that it would be done and it was not. The DON and NHA were interviewed on 9/15/22 at 7:30 p.m. The NHA said if the facility received an allegation she would immediately make sure the resident was safe. She would suspend the staff member pending an investigation. She said they would follow the reporting process with occurrences and notify law enforcement and the ombudsman. She said she would sometimes interview residents about the allegations first and right away because it was fresh in their minds. She said she would interview other residents as well to ensure the abuse was not spreading. She said the staff were educated to let her know immediately about allegations even if they were not sure it met the criteria of abuse as she would rather know about it than not. She said the LPN #2 should have let them know right away about the allegations from July 2022 and an investigation should have been done right away. She said an investigation had been done into CNA #3 during the survey and she had substantiated verbal abuse for that staff member and she was pursuing termination of CNA #3 (cross-reference F600). The NHA and DON both acknowledged if LPN #2 had come forward with her concerns in July 2022 the substantiated verbal abuse for Resident's #17 and #45 could have been possibly mitigated, and the importance of conducting investigations was to prevent and stop further abuse. The DON said an investigation was not done in August 2022 when she spoke to Resident #17. It was only reported to her on the grievance form that CNA #3 was rude and did not speak to him when she performed care. She said he had called her the roughest CNA, but he did not report the issues with her pushing on his legs at that time. -There was conflicting information provided by the DON interviews of the time of when she made aware of the staff member allegedly purposely pushing on Resident #17's legs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan for four (#14, #18, #24 and #39) of 12 out of 25 sample residents for services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to: -Develop a comprehensive, person-centered care plan to effectively address multiple falls and psychotropic medications for Resident #39; -Continue to provide updated care planned fall interventions for Resident #14 after his multiple falls; -Develop a comprehensive, person-centered care plan to effectively address multiple falls and weight loss for Resident #18; and, -Develop a person-centered care plan for multiple falls, restorative services and activities needs for Resident #24. Findings include: I. Facility policy and procedure The Resident Care Planning and admission policy, undated, was provided by the minimum data set coordinator (MDSC) on 9/15/22 at 6:11 p.m. The policy read, in pertinent part, Each resident has a resident care plan that is current, individualized, and consistent with the medical regimen. The plan of care is initiated within 24 hours after admission to fully develop within 7 days following resident arrival at the facility. Following interdisciplinary team conferences, which occurs 7 days after every 90 days thereafter, the nurse coordinates the resident care plan for all disciplines by updating goals and actions that were discussed. Action or nursing intervention is specific and related to each stated short-term goal. Times and actions are stated so that caregivers new to the resident can carry out care with complete continuity. II Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPOs), the resident's diagnoses included dementia with and without behavioral disturbances, and macular degeneration. According to the 8/23/22 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for a mental status score of three out of 15. He required extensive assistance of more than two staff for transferring and toileting. He needed extensive assistance of one staff for bed mobility, dressing and personal hygiene. Resident #39 needed limited assistance from one person with locomotion on and off the unit. According to the MDS assessment, he had shortness of breath with exertion such as walking and transferring. The MDS assessment indicated the resident has had more than two falls since his admission to the facility. B. Record review The review of the September 2022 care plan for Resident #39 did not identify the resident at risk for falls, had history of falls, or had interventions specifically initiated to prevent future falls. The mobility care plan, initiated on 8/23/22, identified Resident #39 had a decline in mobility and needed a wheelchair and was referred to physical therapy. -The care plan did not identify the resident required extensive assistance of more than two staff for transferring and toileting, as indicated by the 8/23/22 MDS assessment. The review of Resident #39's fall documentation 7/1/22 and 9/10/22 identified Resident #39 had nine falls between 7/1/22 and 9/10/22 without injury. According to incident reports, post fall assessments, and post-incident action reports, interventions were needed to prevent future falls. The identified interventions were not communicated on Resident #39's above care plan. The care plan did not direct staff to ensure Resident #39: -Wore lace-up shoes instead of slip-on shoes; -Needed a greater level of assistance with activities of daily living (ADLs); -Had his call light in reach; -Had a tab alarm/pressure alarm in place; -Was educated and reminded to lock his breaks to before transferring; -Had close monitoring, including providing the resident assistance to common area for additional monitoring; -Had frequent rounding; -A bed alarm to alert staff of unsafe transfers; and, -A fall mat. The 8/29/22 CPO identified Resident #39 had an order for a Risperdal (an antipsychotic medication) 0.5 milligrams tablet by mouth every night. The September 2022 medication administration record (MAR) indicated Resident #39 was receiving Risperdal. -The review of the comprehensive care plan for Resident #39 did not identify the resident had a care plan for psychotropic medication including Risperdal. C. Staff interview The therapy service director (TSD), also identified as certified occupational therapy assistant (COTA) was interviewed on 9/14/22 at 10:22 a.m. She said falls were discussed with the interdisciplinary (IDT) team and she received therapy referrals from the team. The TSD said Resident #39 was originally referred to therapies due to his reduction in mobility and had multiple falls. She said Resident #39 was discontinued from physical therapy in August 2022. The MDSC was interviewed on 9/15/22 at 5:04 p.m. The MDSC said all residents at risk for falling, history of falling, issues with mobility, in physical therapy, and new medications such as psychotropics, should have a fall care plan. She said fall care plans should include assistive devices implemented, instructions how to monitor the resident and any other preventive interventions to limit potential future falls. The MDSC said she conducted a 90 day look back of the resident's medical record and interviewed staff, when completing an MDS assessment and determined interventions to add on the resident's care plan.The interventions would also be added to the care plan after a resident falls and reviewed by the interdisciplinary team. She said the fall committee met once a week. The MDSC reviewed the care plan for Resident #39. The MSDC confirmed Resident #39 did not have a fall care plan with interventions to prevent falls other than the resident needed a wheelchair for mobility. The MSDC confirmed Resident #39 need for extensive assistance of more than two persons physical assistance for transferring and toileting should have also been included on his care plan. She said Resident #39 should have had a fall care plan with updated interventions to prevent further falls and potential injury. She acknowledged the care plan was a care directive and said the care plan was part of the staff communication process to identify resident needs. The MDSC said she would complete a full review of residents' care plans. Certified nurse aide (CNA) #1 was interviewed on 9/15/22 at 5:31 p.m. The CNA said Resident #39 needed two person max assistance with transfers from his bed to his wheelchair. She said he just needed limited assistance toileting because he used the wall mounted bar in the bathroom. The CNA said his transfer and toileting needs were not communicated to her. She said she just identified what he needed based on routinely working with him. The social service director (SSD) was interviewed on 9/15/22 at 2:25 p.m. She reviewed the care plan and confirmed Resident #39 did not have a care plan for Resperdal but should have a care plan. She said she would create a care plan pertaining to his Resiperal use and related dementia and behavior interventions. D. Facility follow-up The SSD provided an updated dementia care plan for Resident #39 on 9/15/22 at 3:49 p.m. The care plan identified the resident had a diagnosis of dementia with behaviors and took Risperdal. According to the care plan, interventions initiated on 9/15/22 included: -Monitor and document target behaviors every shift; -Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician; -Divert or redirect attention if he becomes physically aggressive, provide one to one visits, offer snacks/fluids and provide verbal cues/reminders to not be physically aggressive; -Encourage family support and visits; and, -When offering assistance approach [NAME] in a comment or by calling him by name. III. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the resident's diagnoses included hemiplegia following a cerebral infarction (stroke) affecting left non-dominant side, insomnia, bipolar disorder, and schizoaffective disorder. According to the MDS assessment, the resident had moderate cognitive impairment with a brief interview for a mental status score of 12 out of 15. He required limited assistance of one person with bed mobility, dressing, toileting, personal hygiene, locomotion, and transfers. B. Record review The review of the fall care plan, initiated 7/9/2020, identified Resident #14 was at risk for falls. -The care plan did not indicate the resident had a history of falls, or a history of falls with injury. -The care plan did not identify new interventions after each fall to prevent future falls. The care plan for falls included the following initiated interventions on 7/9/2020: -Refer to physical therapy (PT) for evaluation if indicated; and, -Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. The fall care plan did not identify new interventions until 7/8/22, two weeks after the resident had a fall on 6/25/22 after a cardiovascular incident resulting in a hematoma (clotted blood). Falls between 7/9/22 and 9/9/22 did not result in an injury. Interventions added to the care plan on 7/8/22 included: -Use of a wheelchair for long distance or ability related to a recent decline; -Use of a tab alarm well in share related to impulsive behavior of standing up and it risk for fall; -Reminder to ask staff for assistance with ambulation; and, -Assist with one staff member for ambulation. -The fall care plan did not identify additional interventions even though the resident continued to have seven more falls between 7/9/22 and 9/9/22. The review of Resident #14's fall documentation identified Resident #14 had seven falls between 6/25/22 and 9/10/22.According to incident reports, post fall assessments, and post-incident action reports, interventions were needed to prevent future falls. The identified interventions were not communicated on Resident #14's above care plan. The care plan did not direct staff to ensure Resident #14: -Continue PT and occupational therapy (OT); -Room was clutter free; -Bed in lowest position; -Had his call light in reach; -Had pressure alarm in place; -Was educated on safety; -Frequent visual checks; -Had routine toileting; -Was monitored and provided encouragement to remain in a public area; and, -Had a fall mat. C. Staff interviews The TSD was interviewed on 9/14/22 at 10:22 a.m. She said Resident #14 was referred to therapy related to his change in gait and function and he had an increase in falls. She said therapy worked with caregivers/staff on transfer and mobility safety. She said he was not currently receiving therapy services. The MDSC was interviewed on 9/15/22 at 5:04 p.m. She said Resident #14 was challenging because he was impulsive, very independent and continued to fall. She acknowledged he should have had new interventions added to the care plan to help prevent future falls. The MDSC said Resident #14 would be reviewed in the upcoming IDT meeting to review his past falls and determine what interventions were working for Resident #14 and what intervention could be added to his care plan. IV. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included Parkinson's disease, dementia without behavioral disturbance, adult failure to thrive and history of falling. The 7/15/22 MDS assessment documented he was cognitively intact with a BIMS score of 12 out of 15, no behavioral symptoms and no rejection of care. He needed extensive assistance with activities of daily living except eating and personal hygiene, and used a wheelchair for ambulation. He had two or more falls since the last assessment, one with injury. He had significant weight loss and was not on a weight loss regimen. His 4/15/22 admission MDS documented he weighed 147 pounds, and his 7/15/22 MDS documented he weighed 117 pounds. B. Resident interview Resident #18 was interviewed on 9/12/22 at 4:30 p.m., and on 9/15/22 at 10:15 a.m. He said he had lost a lot of weight and was down to skin and bones, but he was gaining some of his weight and strength back, with good food and plenty of snacks. He acknowledged he had several falls, and said he did not like the personal alarms but was told they were necessary. He said he preferred to get up when he wanted to get up without a damn alarm going off. He indicated he was able to disengage the alarm, and said they had not really gotten his permission to administer personal alarms. C. Record review 1. Failure to develop a comprehensive, person-centered care plan regarding falls and use of personal alarms Resident #18's CPO listed a clip alarm for bed, wheelchair, recliner and bathroom check for placement every shift for poor safety awareness (ordered 4/4/22). Resident #18 had 10 falls within five months according to nursing progress notes. His first fall occurred within an hour of his 4/4/22 admission to the facility. He was admitted on [DATE] at 6:02 p.m. with abrasions to his right elbow, abrasions and bruises to both hands and forearms, and soreness from broken ribs resulting from falls at home prior to admission. -On 4/4/22 at 7:01 p.m. he was found on the floor in the bathroom with an abrasion to his knee. -On 4/8/22 at 5:16 p.m. he was found on the floor beside his bed and fall mat with rib pain from prior falls at home. -On 4/14/22 at 4:20 a.m. he was found on the floor of his room bleeding from previous injuries and rib pain. -On 4/15/22 at 6:04 p.m. he had been found kneeling on his floor mat twice during the shift, with rib pain and an abrasion to his knee from a previous injury. -On 5/11/22 at 3:00 p.m. he was found on the bathroom floor with an abrasion and bleeding to his upper arm and his wrist was swollen and tender to touch. -On 5/16/22 at 2:53 a.m. he was found on the floor with his pillow repeatedly, having rolled out of bed, and was kept out at the nurses' station in line of sight. -On 6/11/22 at 9:46 p.m. he was found on the floor next to his bed with no injuries. -On 6/25/22 at 4:46 p.m. staff had transferred him from bed to wheelchair, and when she turned her back he attempted to stand up unassisted and slid to the floor. He was assisted back into his chair by a registered nurse (RN) and CNA and did not suffer any injuries. -On 8/5/22 at 6:45 a.m. he was found on the bathroom floor and suffered a skin tear to his elbow. He was taken to the common area for monitoring. -On 8/30/22 at 1:54 p.m. he fell forward out of his wheelchair onto the floor in the common area by the nurses' station. He had previously been observed sleeping in his wheelchair. He had a small area of redness to his right temple. -After each fall, nursing staff documented that either a low bed, fall mat or personal alarm, or all the above, were in place. However, the care plan was not developed until 4/15/22 after the resident's third fall, and the only revision dated 8/2/22 read, Uses a Tab alarm while in the chair. According to the CPO and nursing notes, personal alarms had been in place since the resident's admission on [DATE]. The care plan identified poor safety awareness and frequent falls, but did not include the dates or circumstances of the resident's falls. New interventions were not documented in the care plan after each fall. -Fall investigations and risk assessments were requested but were not provided. -The personal alarm was not care planned as a potential restraint. The resident was typically found after each fall, indicating the personal alarm did not prevent or reduce falls. 2. Failure to develop a comprehensive care plan regarding weight loss and nutritional needs The September 2022 CPO listed a nutritional supplement, 120 ml three times daily for dietary supplement (ordered 6/27/22). The most recent registered dietitian note, dated 9/13/22, documented the resident ate 75-100% on average with some assistance, adaptive silverware and a plate guard. He was gaining weight, from 116.8 pounds on 7/7/22 to 124.4 pounds on 8/1/22 to 130.8 pounds on 8/26/22, but was below his regular weight range of 139-169 pounds and had abnormal labs. His BMI (body mass index) was at the low end of normal at 19.8. The plan was to continue supplements, continue to offer snacks between meals, and encourage and monitor meal and fluid intakes. Review of weights since admission revealed Resident #18 had lost 11.26% of his body weight since admission and although he was gaining weight, he had not gained back to his admission weight (see MDS assessments above). The dietary care plan goal was for Resident #18 to eat, drink and not be hungry. There were three interventions, initiated on 4/7/22 and not revised, as follows: Monitor and record all meals, snacks and fluid intakes daily; weigh weekly for four weeks, then monthly if stable, notify physician of weight changes of 5% in 30 days or 10% in 180 days; regular diet with nectar thick liquids and a regular texture, with chopped meats as needed for self-feeding. -Although the facility had implemented measures to address the resident's weight loss, there was not a corresponding nutritional care plan to identify actual weight loss and the specific interventions provided for Resident #18. D. Staff interviews The MSDC was interviewed on 9/15/22 at 5:30 p.m. She said he did have a dietary care plan, but should have a weight loss care plan to include the current interventions he was given every day. Regarding falls, she said her thought was to add the fall mat, low bed, more frequent checks than they currently did just to check in, because he hardly ever used his call light. She said his care plan would definitely be reviewed and updated, and she suspected they would be doing away with personal alarms after the survey was completed. V. Resident #24 Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included Parkinson's disease, dementia, depression and chronic pain syndrome. The 7/27/22 MDS assessment documented severe cognitive impairment with a BIMS score of three out of 15. She had no behavioral symptoms and no rejection of care. She needed extensive assistance with most ADLs, used a wheelchair for ambulation, and had range of motion limitations to her lower extremities. She had not had any falls since the prior assessment. B. Observations Resident #24 was observed throughout the survey, from 9/12 through 9/15/22, spending most of her time sitting in her wheelchair in the common areas or in her room alone. There was a tab alarm on the back of her wheelchair and she had a wander guard. She was typically not engaged in activities, and often had her head down with her eyes closed. On 9/13/22 at 12:02 p.m. and 12:13 p.m. she set off the alarm at the door leading from the common area into the therapy gym. Staff assisted her away from the door and back into the common area both times. C. Record review 1. Eight falls within six months, most unwitnessed Resident #24 had eight falls within the past six months as follows according to nursing notes and fall investigations: -On 2/15/22 at 2:14 p.m. she was resting in bed then lowered herself to her floor mattress and scooted on her bottom towards the entry of her bedroom door. No injuries. -On 3/20/22 at 2:11 a.m. she lowered herself to the mattress on her floor twice tonight. Nursing staff assisted the resident back to bed. No injuries voiced or noted. Will monitor frequently throughout the night. -On 6/26/22 at 9:31 p.m. she was found on the fall mat at the side of her bed lying on her left side and both lower extremities under the bed. She had removed her pants, brief and socks, and her wheelchair was seven -10 feet away from the resident. She had a skin tear to her right pinky toe nail bed. It was not documented when she was last checked on. -On 6/27/22 at 7:51 p.m. she was found by another resident lying on the floor in her room near her wheelchair flat on her back, no fall mat in place. Staff to ensure safety measures are in place: fall mat, low bed, tab alarm, and refer to physical therapy. This fall was not documented in nursing notes. -On 7/6/22 at 3:50 a.m. she was found on the floor in her room beside her floor mat during 4:00 a.m. incontinence care rounds. The call light was on and the resident was soiled. She was assisted to the bathroom and back to bed. It was not documented when she was last checked on by staff. -On 8/15/22 at 1:35 p.m. she was found lying on the bathroom floor on her back, brief and pants removed with incontinence of stool, appears to have attempted to transfer self on the toilet, states that the back of her right head, right elbow and big right toe hurt, bruising starting to form to right elbow. Tab alarm was on resident at time of fall to alert staff of her getting out of the wheelchair by herself. It was not documented when she was last checked on by staff. -On 8/22/22 at 12:54 a.m. she was found having slid herself out of bed and onto the mattress next to the bed per her own admission. She was assisted back into her bed which had been and remained in low position, call light in reach. No injuries. -On 9/9/22 she was found on the bathroom floor. Safety measures continue: low bed, fall mat, tab alarm to alert staff of unsafe transfers, staff to encourage resident to remain in common area for observation, offer routine toileting (per a 9/12/22 fall investigation). This fall was not documented in nursing notes. -Although Resident #24 had a tab alarm, she was typically found on the floor after falls, indicating the tab alarm did not help to reduce or prevent falls. 2. Failure to develop comprehensive, person-centered care plans to engage the resident to prevent falls and improve quality of life Her care plan, initiated 8/1/19 and revised on 12/10/21, identified risk for falls related to poor decision making, cognitive decline and unsteady gait/mobility. Interventions included call light within reach, encourage call light use, properly fitting non-skid footwear, clutter-free environment, mattress on floor when in bed, assist with transfers as she is not strong enough to transfer herself and ambulates throughout the facility by propelling her wheelchair. Her activities care plan, initiated on 8/12/19 and not revised, identified minimal participation in activities. She would occasionally attend exercise group activities depending on her mood. Interventions included assess her response and modify as needed, remind and assist to activities, create activity plan based on resident preferences, and post activity calendar in her room. -There was no restorative nursing or range of motion care plan or intervention, although the resident had limited range of motion. She was also referred by therapy to restorative services on 7/26/22 which was noted by the occupational therapist as not available at this facility but staff are encouraged to include resident in facility exercises and activities. -A care plan regarding personal alarms could not be found. -There was no care plan for actual falls and no care plan updates after falls over the past six months. -A person-centered activities care plan to incorporate resident engagement to prevent falls was not developed. Moreover, review of activity participation records revealed the resident went for days or weeks without any documented activities from 3/21/22 to current. Her activity participation was documented as reminiscing, family and friend visits, beauty shop (once), aromatherapy (once) and music (once). Exercise activity participation was not documented at all. D. Staff interview The MSDC was interviewed on 9/15/22 at 5:43 p.m. She said Resident #24 did participate in exercise group twice a week, either actively or passively. All these things could be incorporated into her care plan. She said she would follow up and update her care plan accordingly. We'll probably get rid of tab alarms and continue to look at restorative and activities to help try to prevent falls. VI. Additional staff interviews The nursing home administrator (NHA) and the director of nursing (DON) was interviewed on 9/15/22 at 7:39 p.m. They said the MDSC had been pulled in a lot of different directions, impacting care plan development and needed more support. The DON said the IDT would start and complete fall care plan interventions in the IDT meetings.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of one medication storage rooms and one of two medication storage carts. Specifically, the facility failed to ensure proper date of opening for a multi use tuberculin vial and an insulin pen. Findings include: I. Manufacturer instructions Manufacturer instructions for Aplisol (tuberculin) solution retrieved 9/21/2022 from https://www.fda.gov/files/vaccines%2C%20blood%20%26%20biologics/published/Package-Insert---Aplisol.pdf, showed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Manufacturer instructions for Lantus insulin pens retrieved 9/21/2022 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021081s072lbl.pdf, showed pens should be discarded 28 days after opening. II. Facility policy and procedure The Storage of medications policy, revised April 2007, provided by the nursing home administrator (NHA) on 9/19/2022 at 2:00 p.m. read the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. III. Observations The medication storage refrigerator was inspected with licensed practical nurse (LPN) #3 on 9/14/22 at 2:00 p.m. Inside the medication refrigerator an open bottle of Aplisol tuberculin solution was observed to be unlabeled with a date of open. LPN #3's medication cart was inspected and inside was an in use Lantus insulin pen with no open date labeled. IV. Interviews LPN #3 was interviewed on 9/14/22 at 2:00 p.m. She said both the tuberculin solution and insulin pens were supposed to be labeled. She said she had no idea how long the tuberculin solution was in the refrigerator as it was not labeled. She says she believed both were good for 30 days after opening but she was not sure. She said both medications were supposed to be labeled with the day of opening. She said both medications were discarded since she did not know the open date. The DON was interviewed on 9/15/22 at 7:30 p.m. She said both insulin pens and tuberculin solutions were to be labeled with the date of open and discarded she thought 30 days after opening or according to the manufacturer's instructions.

Based on interviews and record review, the facility failed to take timely action to follow up on grievances of the resident council group. Specifically, residents who regularly participated in resident council said facility staff did not take action on their grievances involving: -Residents who did not receive adequate staff supervision and dignified treatment, and repeatedly set off alarms and wandered into other residents' rooms; and, -Food quality and palatability, snacks and dining room concerns/choices. Residents said nothing ever gets done in resident council, and the concerns they brought forward were unresolved and ongoing. Residents further stated the concerns they discussed in resident council were not documented in the minutes. Findings include: I. Facility policies The undated Resident Council policy, provided by the facility on 9/15/22, included the following: All residents had the right to a quality of life supportive of independent expression, decision making and independence of action. Staff and residents would work together to attempt to resolve any issues/problems within 60 days. The resident council format included that minutes would be taken to include if issues had been resolved or action was being taken, who was involved, what action was being taken, and ask for comments and concerns. The undated Grievance Procedure policy, provided by the facility on 9/15/22, included the following: Ensure prompt resolution of all grievances regarding resident rights. The grievance official shall be responsible for the timely follow up (5 days) of the corrective action to ensure resolution of the recorded concern and the satisfaction of corrective action. The staff designee shall make contact with the complainant 14 days after the date of initial complaint to ensure full satisfaction with corrective measures. II. Resident council minutes Review of resident council minutes for the past six months revealed: On 3/30/22, seven facility staff and 10 residents attended. The previous month's minutes were read and approved. Concerns about the dietary (department) voiced by residents were: coffee is cold, food is cold, the cooks were not reading the tickets, and the posted chalkboard menus were difficult to read. The staff's documented response was that kitchen staff were being retrained in their positions and white chalk was being used on the chalkboard menus for readability. -No other resident concerns were documented in the minutes. -There was no documented discussion of resident rights. On 4/27/22, seven staff and four residents attended. The previous minutes were read and approved. There was no documentation of action taken on the previous resident concerns. Concerns about dietary voiced by residents were: food is served cold and the kitchen staff were not asking residents what they would like to eat. Staff's documented response was new staff training. Residents voiced that nursing staff were slow to respond to call lights. The staff response was more staff were hired to fix the problem. -Repeated dietary concerns from the previous month were documented, but there was no evidence of discussion about the lack of action taken and resolution. On 5/25/22, seven staff and eight residents attended. The previous minutes were read and approved. Concerns about dietary were voiced that food was cold for room trays. The staff response was that kitchen staff had hustled to get room trays out faster to solve the cold food problem. On 6/29/22, seven staff and four residents attended. The residents voiced concerns again about cold food, said the meat was too tough to chew, and they would like smaller portions as there was too much wasted food. Staff responded that the dietary director had a meeting with staff. On 7/27/22, seven staff and four residents attended. Residents said the meat was too tough to eat. The resolution was the dietary director stopped ordering the pork chops. On 8/31/22, seven staff and three residents attended. Residents said they would like more snacks, cornbread without sugar, cornbread browned, and bacon in the beans. One resident said he would like bottled water as he did not like the filtered water in the facility. The staff response was they would purchase water for the resident who requested it. Plans for resolution of the other dietary concerns were not discussed. -There was no evidence of grievances generated as a result of resident council discussions, and no evidence that staff discussed resolutions to resolve ongoing dietary concerns voiced by resident council. III. Resident group interview Residents #4, #6 and #23, including the resident council president and two residents who regularly attended, and were cognitively intact and interviewable, were interviewed on 9/13/22 at 2:30 p.m. When asked if the facility considered the views of the resident group and acted promptly upon grievances and concerns, they responded, No. When asked if a rationale was provided when the facility was unable to make changes as requested, they said, No. They did not know how to file a grievance. They said, Nothing ever gets done and that resolutions to the concerns they brought up during resident council were always ongoing. The residents said they sometimes felt like inmates because the door alarms were set off so frequently by confused residents who tried to elope. They said some certified nurse aides (CNAs) were not well trained and thought they had to make people do things, by saying to confused residents, No, you can't do that and the residents did not understand because they think they have to leave and there's really no place for them to go, but they're always testing the doors. They just want someone to walk around with them. They named Residents #3, #7, #22 and#43. They said these residents wandered into other residents' rooms including theirs and you have to get them out. They said it was disturbing and disgusting to them at times, and that was why they had stop signs on their doors. They described examples where a resident urinated in their laundry basket, another resident dropped trash into their laundry basket, and a third resident entered their room and said she was going to take a nap in their roommate's bed and proceeded to do so. They said they did not feel that staff adequately supervised and engaged confused residents in activities to prevent them from encroaching on the privacy and rights of other residents. The residents said there were unresolved food concerns, that food choices and food palatability were a problem. The corn bread was still a problem in that it had a sweet taste they did not like, foods were served that did not go well together, there was no bacon in the beans as requested, and the food was sometimes served cold. A resident said he saw his food sitting in the kitchen window for 10-15 minutes before being served to him, and it was cold. There was too much food waste and requests for small portions were not honored. They said sufficient flavorful, substantial snacks of their choice were not provided, dinner was served early and from 4:00 p.m. until the next morning is a long time to go on soup and a sandwich. They said dinner was only served until 5:00 p.m. and that's it, and then the dining room was closed. They said several days could go by where there were no drinks, no sodas, no juices, the fridge will just be empty. They had requested specific snacks that were not provided, such as V8 juice, Oreos and Fig Newtons. IV. Nursing home administrator follow-up The nursing home administrator (NHA) was interviewed on the afternoon of 9/13 and 9/15/22. She said she was not previously aware of some of the above resident concerns, but she was aware of resident concerns involving food, snacks and dining room issues. She said she would follow up with the residents regarding their concerns, would follow up to engage wandering residents so they did not violate other residents' rights, and would establish a food committee to help with resolving food and dining room concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to effectively address the treatment and service needs of three (#16, #39 and #22) of five residents reviewed for dementia care of 25 sample residents. Specifically, the facility failed to: -Provide dementia care and services to ensure Resident #39 was provided an appropriate level of meal assistance while promoting a dignified meal experience. -Provide dementia care and services to provide for resident needs and address repeated incidents of resident-to-resident aggression and abuse for Resident #16; and, -Provide dementia care and services for Resident #22. Findings include: I. Facility policy The Dementia-Clinical Care policy, March 2015, was provided by the nursing home administrator (NHA) on 9/19/22 via email. The policy read in pertinent part: For individuals with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. The facility will strive to optimize familiarity through consistent staff resident assignments. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. The IDT will identify and document the residents condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation. Progressive or persistent worsening of symptoms and increased need for staff support will be reported to the IDT. II. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the resident's diagnoses included dementia with and without behavioral disturbances, and macular degeneration. According to the 8/23/22 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for a mental status score of three out of 15. Resident #39 required limited assistance from one person with eating. B. Observations Resident #39 was observed on 9/12/22 at 4:08 p.m. during the dinner meal. The resident's meal was placed in front of him. He picked up his fork in right hand. He proceeded to gently poke the napkin with prongs of the fork multiple times before he made his way to find the plate. After looking down at his meal for several moments, the resident was able to take a small bite of food using his fork. The resident lifted a large slice of tortilla with his fork to his mouth. Resident #39 took a bite of the tip of the tortilla but did not chew through it. The resident sat at the table for over a minute with a large slice of tortilla hanging from his mouth with multiple staff walking past the resident. The staff did not offer to assist Resident #39 in cutting up the tortilla. After a minute, the resident was able to chew through the tortilla hanging on his mouth and the remainder of the tortilla dropped down to the plate. On 9/13/22 at 3:59 p.m. Resident #39 was assisted to his dining table. The resident was awake and alert. -At 4:27 p.m. the resident still was not served his meal. Most of the other residents in the dining room were already served. The resident fell asleep at the table. -At 4:32 p.m. Resident #39 was served. The dietary aide woke the resident up, poured his can of soda and pointed to the resident's utensils wrapped in a napkin. The resident looked at his plate and closed his eyes, opening his eyes a few moments later to look around the room. -At 4:37 p.m. Resident #39 struggled to retrieve his fork from his folded napkin. Once the fork was free from the napkin, he attempted to lift the butter knife with the fork. The resident then poked at the napkin with the fork, holding the fork upside down. The resident was not offered assistance. After a few minutes focusing on the napkin, the resident moved the fork to the plate and proceeded to feed himself. Throughout the meal the resident stopped eating and looked at the plate and then would slowly start eating again. C. Resident interview A group interview was conducted on 9/13/22 at 3:12 p.m. with three residents (#4,#6, and #23) the facility assessed and deemed as alert, oriented, and interviewable. The sample group represented resident experience living in the facility. The residents expressed concerns with the delay in meal service and assistance. Members of the group said they have seen Resident #39 go hungry. They said Resident #39 had use of only one hand and fed himself. They said he would be served his meal but could not yell when he needed help. The residents said sometimes Resident #39 would have to sit and wait to be served while everyone else was eating. According to one of the group interview members, Resident #39 had told him he wanted speech therapy. An exit interview on 9/15/22 at approximately 8:40 p.m. was conducted with two residents. A general overview of the survey findings were reviewed with the residents. The findings did not disclose resident names or resident details. One resident during the interview stated that he hoped for the facility to provide more meal assistance for Resident #39. D. Record review The 2/25/2020 long term stay care plan identified Resident #39 ate his in the dining room. The care plan directed staff to offer the resident snacks between meals, provide a regular diet, and monitor and record intake. The care plan did not identify what type of meal assistance the resident required. The 8/31/22 nutrition evaluation under recommendations identified that staff should continue to encourage good meal intakes, encourage snacks of choice and encourage good fluid intakes with and in between meals and continue to monitor. The evaluation did identify recommendations to provide Resident #39 assistance with his meals. The review of September 2022 care plan for Resident #39 identified the resident required assistance with bed mobility, ambulation, bathing, hand hygiene, and toileting assistance, however, the care plan did not identify the Resident #39 needed limited assistance from one staff member with eating as indicated by the 8/23/22 MDS assessment. The MDS activities of daily living (ADL) question log also known as smart charting between 7/24/22 and 9/15/22, under Eating-ADL Self Performance. The log indicated the resident primarily required supervision and limited assistance with eating. The Eating-ADL Support Provided indicated the resident primarily received no set up or physical help from staff or received set help only. On 8/1/22, the resident was identified to need extensive assist and received one person's physical assistance. On 8/15/22, the resident was identified to need limited assistance and received one person's physical assistance. -The review of the resident's medical record did not identify the resident had current or recent weight loss. E. Staff interviews The activity director (AD) was interviewed on 9/15/22 at 2:50 p.m. She said she and other staff had seen a recent change in Resident #39 and staff were still trying to figure out what would work best for him. The AD said during the IDT team meetings, it was discussed that Resident #39 has had a noticeable decline. She said they noticed when he ate, he would stop eating and then would have difficulty to start eating again. She said interventions have not been implemented because staff were still trying to figure out what was going on. Licenced practical nurse (LPN) #1 was interviewed on 9/15/22 at 4:15 p.m. She said Resident #39 had a steady decline over the last couple of weeks. She said she was not aware of changes in the resident's eating. She said he needed to set up assistance and then could feed himself. The LPN said the resident needed to have his utensils and his drinks set out for him. The minimum data set coordinator (MDSC) was interviewed on 9/15/22 at 4:23 p.m. She said when she completed the MDS assessment and coded a resident required limited assistance with one person physical assistance because she determined a resident needed partial assistance with eating and/or not safe eating on his own. She said a staff member should be physically present during the meal offering supervision, guidance, cueing and physical assistance as needed. The MDSC reviewed the 8/23/22 MDS assessment for Resident #39 and confirmed she identified and coded the resident needing the higher level of assistance of limited physical assistance. She said she reviewed the smart charting, observed Resident #39 at meals and interviewed staff to determine he needed more assistance than supervision, or supervision with set up. She said he sometimes needed more cueing and support during his meals. The MDSC said changes in resident ADL care needs as eating would be discussed with the IDT team. She said changes in care level would usually be communicated on the 24 hour report, the communication board and face-to-face communication at time when the need was identified. She said she did not know who she informed of the changes. The MDSC said the changes in meal assistance should have also been discussed in the weekly nutrition at risk (NAR) meetings and documented in the progress notes. The MDSC reviewed the progress notes and said Resident #39 was not discussed in the past 30 days. The MDSC said he has not had weight loss but he should have been discussed in NAR because of the change in meal assistance needed. The MDSC said the high level of meal assistance needed should have been on the care plan. The MDSC reviewed the care plan and identified he did not have a care plan conveying to staff the level of meal assistance he currently needed. She said she would review him in the next NAR meeting, update the care plan and refer him to physical and occupational therapy. Certified nurse aide (CNA) #1 was interviewed on 9/15/22 at 5:31 p.m. The CNA said Resident #39 usually needed meals to be set up but was not aware of any other meal assistance needed. She said sometimes he gets confused with his fork and spoon. She said he needs some cueing and handing him his coffee cup handle. She said he did not receive any other assistance with meals. The CNA said sometimes he would just look at his food. The NHA and the director of nursing (DON) were interviewed on 9/15/22 at 7:35 p.m. They said the IDT team discussed the changing needs of Resident #39 during the week of the survey. They said they discussed referring the resident to speech therapy. They said the staff needed to provide Resident #39 with cueing during meals and they would provide staff education. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included dementia with behavioral disturbance, restlessness and agitation, generalized anxiety disorder and brain stem stroke syndrome. The 7/11/22 minimum data set (MDS) assessment documented severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15 and delirium symptoms involving inattention. No behavioral symptoms were documented. She needed extensive assistance with most activities of daily living (ADLs) and used a wheelchair for ambulation. B. Record review revealed failures in provision of dementia care and services September 2022 physician orders documented Resident #16 took antidepressant and antipsychotic medications. Review of facility investigative reports revealed Resident #16 was involved in all six resident-to-resident abusive incidents over the past eight months, which occurred on 1/31, 4/11, 5/2, 6/5 and 7/19/22. Nursing progress notes reviewed for the same time period revealed Resident #16 was frequently verbally and physically abusive to staff, and needed line of sight monitoring by staff to prevent altercations from other residents. Only three activity notes were found in the progress notes: on 3/16, 3/17 and 4/1/22, regarding her enjoyment of the St. Patrick's Day party, social events and movies, and live music. Resident #16's most recent activities assessment, dated 7/11/22, identified she was a retired teacher. Her activity interests included socialization, one-on-ones (visits), hobbies, exercise and sports, religious/spiritual, television, movies, and musical activities. Her preferred activity time was late afternoon two to three times per week. Activity participation records reviewed for the previous six months revealed Resident #16 was frequently not engaged in activities. Documented activities were reminisce, family and friend visits, nail care (one time on 3/16/22), beauty shop (one time on 8/15/22) and outside visiting (one time on 8/12/22). There were large gaps of days or weeks between documented activities. She participated in five activities during March, none in April, four in May, two in June, three in July, six in August, and none in September 2022. The care plan for verbally (and occasionally physically) aggressive behavior, initiated on 7/19/21 and not revised, listed the following interventions: talk in calm voice when behavior is disruptive, remove from public area when behavior is disruptive and unacceptable, reinforce unacceptability of verbal abuse, praise for demonstrating desired behavior, monitor and document target behaviors, elicit family input for best approaches to resident, do not argue with resident, discuss options for appropriate channeling of anger, assist in selection of appropriate coping mechanisms, administer behavior medications as ordered by physician, provide diversional activities (magazines, offer cold drink, etc.). The care plan for activities, initiated on 9/18/19 and not revised, listed the following interventions: assess resident's response to new activity plan, modify as needed; remind when activities are scheduled; assist to preferred activities; provide environment that respects privacy; create activity plan based on resident preferences; a monthly calendar is placed in her room. -The care plans were not person-centered, were not updated following abusive incidents, did not identify triggers or specific methods to engage the resident to avoid or quickly diffuse potentially abusive situations, and did not include keeping the resident within line of sight in order to intervene before she became abusive to other residents. (Cross-reference F600, freedom from resident-to-resident abuse) C. Staff interview The NHA and DON were interviewed on 9/15/22 at 8:00 p.m. They said they would develop comprehensive plans and interventions to engage Resident #16 to meet her dementia care, behavioral and quality of life needs, and protect other residents' safety and quality of life. III. Resident #22 A. Resident status Resident #22, age [AGE], was admitted on [DATE]. September 2022 CPO diagnoses included dementia with behavioral disturbance and anxiety disorder. The 7/22/22 MDS assessment documented severe dementia with a BIMS score of three out of 15 and no behavioral symptoms. She needed limited assistance with most ADLs and used a wheelchair or walker for ambulation. B. Record review revealed failures in provision of dementia care and services September 2022 physician orders documented Resident #22 took antidepressant and antipsychotic medications. Review of facility investigative reports revealed Resident #22 was involved in two resident-to-resident abusive incidents over the past eight months, both with Resident #16, on 4/11/22 and 7/19/22. Nursing progress notes revealed Resident #22 frequently disturbed other residents by wandering into their rooms, had loud verbal outbursts, exhibited verbal and physical aggression, tried to provide care for other residents, perseverated on looking for her dog, argued with other residents, attempted to hit other residents, and was difficult to redirect. A few activity notes were included in the progress notes regarding enjoying the St Patrick's Day party on 3/17/22, enjoying bingo and social events on 3/16/22, live music on 4/1/22, socializing well with other residents on 5/31/22, at the round table with others watching television on 6/6/22, two movies and socialization with snacks on 7/15/22, socializing with others and looking at magazines on 7/30/22, snacks with TV and coloring on 8/13/22, and enjoying the luau on 8/26/22. Her most recent activities assessment on 3/9/22 identified her activity interests as socialization activities and one-on-ones in the late afternoon. The activity participation records, reviewed for the past six months, documented she attended reminisce, visits with family and friends, had outside visits twice and beauty shop once. There were large gaps of days or weeks between activities. She was documented to participate in activities five times in April, five times in May, 10 times in June, four times in July, eight times in August, and none in September 2022. Resident #22's behavioral care plan, initiated 7/20/22 and not revised, included exactly the same title and interventions as Resident #16's (see above) and was not person-centered. No revisions, trigger identifications or specific methods to diffuse aggressive situations were included in the care plan. Her dementia care plan, initiated 1/17/22 and not revised, listed the following interventions: monitor and document behaviors; divert or redirect attention; provide one-on-one; offer snacks/fluids; approach warmly and positively; encourage family visits and support; approach in a calm manner, calling her by name; encourage her to attend activities of choice; speak to her in clear concise sentences and allow for her to answer; do not hurry or rush. -No activities care plan could be found. C. Staff interviews CNA #2 was interviewed on 9/15/22 at 2:00 p.m. and said they tried to keep Residents #16 and #22 apart and redirected or engaged in something more interesting than arguing or being aggressive, which tended to happen more in the evenings. CNA #1 was interviewed on 9/15/22 at 5:10 p.m. and said they had enough staff to provide the necessary ADL care for residents, but not to engage with the residents, spend time with them, anticipate their needs to address behavioral symptoms The NHA and DON were interviewed on 9/15/22 at 8:00 p.m. They said they would develop comprehensive plans and interventions to engage Resident #16 to meet her dementia care, behavioral and quality of life needs, and protect other residents' safety and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper infection control practices for one of one dining rooms and one of one laundry rooms. Specifically, the facility failed to ensure: -Residents were offered hand hygiene prior to meals; and, -Proper personal protective equipment (PPE) was utilized in the laundry room. Findings include: I. Facility policy and procedures The Infection Control policy, no date of inception or revision, provided by the infection and control preventionist (IP) on [DATE] at 12:00 p.m. read, there was an active facility wide infection control program with effective measure to control and prevent infections acquired or brought in the facility from the community or other health care facilities. There was a practical system for reporting, evaluating, and maintaining records of infections among residents, including assignment of responsibility for ongoing collection and analysis of data and required follow up. II. Hand hygiene A. Observations Dinner meal service was observed on 9/12-[DATE] at 4:00 p.m. The dining room was divided into residents who required assistance with meals and residents who did not. The residents on the side who did not require assistance were not offered hand hygiene prior to their meals. On [DATE] at 2:08 p.m a bottle of hand sanitizer on a resident dining room table upon entry on the non-assistance side of the dining room was expired as of [DATE]. B. Interviews Dietary aides (DA) #3 and #4 were interviewed on [DATE] at 4:40 p.m. Both staff acknowledged that it was up to the certified nurse aides to assist residents with hand hygiene, and it was just their responsibility to ensure hand sanitizer was available on the table. The IP was interviewed on [DATE] at 11:00 a.m. She said hand sanitizer was on all resident dining tables and all staff should be offering and encouraging residents to use it prior to all meals and this was important to prevent cross contamination. The director of nursing (DON) was interviewed on [DATE] at 7:30 p.m. She said all residents were to be offered hand hygiene upon entering the dining room by any staff member. She said hand sanitizer should be on everything at the dining room table and utilized. III. Laundry room A. Observations The laundry room was inspected with the housekeeping director (HKD) on [DATE] at 2:18 p.m The HKD demonstrated the process of which laundry was handled from start to finish. She demonstrated the process for sorting soiled laundry intake and said only gloves were worn by staff when sorting soiled laundry. She said aprons or additional PPE were not needed and only work for things like COVID rooms soiled laundry. B. Interviews The IP was interviewed on [DATE] at 11:00 a.m. She said laundry staff should be wearing gloves, aprons, and a mask when sorting any and all soiled laundry. She said this was important to prevent cross contamination. The DON was interviewed on [DATE] at 7:30 p.m. She said laundry staff should be wearing gowns, gloves, and potentially goggles as well when sorting soiled laundry.

Based on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Prevent potential cross contamination during meal preparation; -Demonstrate appropriate use of gloves during the meal service; -Ensure cold food items were stored and served at proper temperature to prevent potential food-borne illnesses; and, -Ensure food surfaces were properly sanitized. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) https://www.cdc.gov/handwashing/handwashing-kitchen.html, dated 7/18/22, retrieved on 9/19/22, read in pertinent part: Handwashing is one of the most important things you can do to prevent food poisoning when preparing food for yourself or loved ones. Your hands can spread germs in the kitchen. Some of these germs, like salmonella, can make you very sick. Washing your hands frequently with soap and water is an easy way to prevent germs from spreading around your kitchen and to other foods. According the CDC, handwashing was especially important during some key times when germs could spread easily: -Before, during, and after preparing any food. -After handling uncooked meat, poultry, seafood, flour, or eggs. -Before and after using gloves to prevent germs from spreading to your food and your hands. -Before eating. -After touching garbage. -After wiping counters or cleaning other surfaces with chemicals. -After touching pets, pet food, or pet treats. -After coughing, sneezing, or blowing your nose. According to CDC guidance, Handwashing: Clean Hands Save Lives, https://www.cdc.gov/handwashing/campaign.html, dated 11/19/2020, retrieved on 9/19/22 read in part Germs are everywhere. Make handwashing with soap and water a healthy habit. - Everything you touch has germs that stay on your hands. -Your hands carry germs you can't see. -Handwashing can help prevent one (1) in five (5) respiratory illnesses. Additional CDC guidance for food safety, retrieved from https://www.cdc.gov/foodsafety/people-at-risk-food-poisoning.html, dated 1/24/19, retrieved on 9/19/22, read in part: Anyone can get food poisoning, but certain groups of people are more likely to get sick and to have a more serious illness. Their bodies' ability to fight germs and sickness is not as effective for a variety of reasons. Adults aged 65 and older have a higher risk because as people age, their immune systems and organs don't recognize and get rid of harmful germs as well as they once did. Nearly half of people aged 65 and older who have a lab-confirmed foodborne illness from salmonella, campylobacter, listeria or E. coli are hospitalized . People with weakened immune systems due to diabetes, liver or kidney disease, alcoholism, and HIV/AIDS; or receiving chemotherapy or radiation therapy cannot fight germs and sickness as effectively. For example, people on dialysis are 50 times more likely to get a listeria infection. II. Facility policy The following food policies were provided by the facility on 9/15/22: The Dietary Department Infection Control policy, undated, read in part: Proper procedures are followed at all times in order to prevent the spread of infection. Proper techniques are employed to prevent the possibility of cross-contamination and foodborne illnesses including: washing hands with germicidal soap before preparing Foods, eating, after smoking, after using the restroom, after working with potentially hazardous food, and at any other time hands becomes contaminated in any way. The Sanitary Condition of Dietary Department policy, undated, read in part: Sanitary conditions are maintained at all times in the Dietary Department. All surfaces used for the preparation of food are sanitized before the beginning of the preparation of food, between using the surface for the preparation of raw cooked food in order to prevent cross-contamination and after preparation is complete. The Food Temperature policy, undated, read in part: Foods are prepared and served at proper temperature in order to assure the safety of the residents. Potentially hazardous foods are kept at an internal temperature of 45 degrees F (Fahrenheit) or below or at an internal temperature of 140 degrees F or above during display and service. The Food Preparation and Service policy, undated, read in part: Equipment is provided and procedures established to maintain food at a proper temperature during storage and service. III. Observations On 9/12/22 at 2:10 p.m. during the initial kitchen tour, a sanitized cleaning bucket was observed in the kitchen. [NAME] #1 was unsure if he was to use the chlorine test strips or the quat test strips. [NAME] #1 decided on the chlorine test strips and tested the sanitized water with chlorine test strips. The test strip indicated the solution measured at 10 parts per million (ppm). -However, the cook used the wrong testing strip, he should have used the quat test strips to test the solution (see the corporate regional dietary consultant interview). According to the cook the solution was used to clean kitchen food surfaces. He said the buckets were changed out once per shift. The dinner service in the kitchen was observed between 3:20 p.m. and 4:45 p.m. -At 3:32 p.m. DA #1 pulled out a tray of plated pre-cut key lime pie slices out of the refrigerator and placed them on a cart to be included as the resident dinner dessert item. The slices were not covered or placed on or in a cooling surface to maintain a temperature appropriate for cold food items. -At 3:34 p.m. cook #2 took the temperatures for the hot food items. [NAME] #2 did not take the temperature to the pre-cut key lime pie slices. The cook said the dietary manager (DM) usually obtained the food temperatures before service. He said he has not taken the food temperatures for over a year. -At 3:42 p.m. cook #2 adjusted the back of his shirt with his gloved hands. He did not doff his gloves and perform hand hygiene. -At 3:45 p.m. cook #2 placed his right gloved hand in his apron pocket slightly pulling out a white cloth while touching his left gloved hand of his face mask. He did not doff his gloves and perform hand hygiene. -At 3:46 p.m. cook #2 left the steamline and walked to the back of the kitchen. He retrieved an open plastic water bottle out of the refrigerator with his gloved hands. He returned to the steamline. [NAME] #2 pulled his mask below his nose and mouth with his gloved hands and drank the remainder of the water in the bottle. [NAME] #2 pulled up his mask with his gloved hands and threw the empty bottle away. He did not doff his gloves and perform hand hygiene. -At 3:48 p.m. cook #2 patted the regional dietary consultant on his back and returned to the steamline. He proceeded to plate resident meals. He did not doff his gloves and perform hand hygiene prior to plating the meals. -At 3:49 p.m. cook #2 plated the resident first meal and DA #1 took the plated meal, beverages and a slice of key lime pie on a food tray. The DA expedited the meal out the kitchen service window. -At 3:52 p.m. cook #2 wiped his hands on the back pants. He did not doff his gloves and perform hand hygiene prior to plating the meals. -At 3:55 p.m. DA #1 retrieved a second tray of key lime pies from the refrigerator. As she placed the tray on the cart, her arm touched the surfaces of one of the pies. She wiped her elbow off with gloved hands, pulled her mask under her nose and mouth, walked to the other side of the kitchen and threw the pie slice away. She pulled the mask back over her nose and mouth with her gloved hands and returned to the service line. She did not doff her gloves and perform hand hygiene -At 3:56 p.m. DA #1placed two pie slices on resident trays, with her gloved thumb in the center of the eating surface of the pie plates. -At 3:59 p.m. cook #2 left the steam line and walked to the back of the kitchen. He retrieved a plastic bottle of water out of the refrigerator with his gloved hands. He returned to the steamline, pulled his mask below his nose and mouth with his gloved hands and took a sip of the water. He pulled his mask back up with his gloved hand and returned to plating food. He did not doff his gloves and perform hand hygiene. -At 4:01 p.m. cook #2 adjusted his mask with his gloved hands without performing hand hygiene. -At 4:03 p.m. cook #2 pulled his mask down with his gloved hands and took another drink of water from his water bottle. He pulled his mask back up. The corporate regional dietary consultant (CRDC) directed cook #2 to doff his gloves and perform hand hygiene. -At 4:07 p.m. DA #1 placed her gloved right hand on the wall as she spoke to the DM. -At 4:09 p.m. DA #1 touched her eye glasses with right hand then placed her gloved hand on the meal tray stack. She did not doff her gloves or perform hand hygiene. -At 4:13 p.m. DA #1 placed her right hand over the drinking surface of a filled juice glass and placed the glass on a resident meal tray. -At 4:15 p.m. DA #1 placed a plated guard over a plate of food. -At 4:17 p.m. cook #2 pulled the back of his shirt down with his gloved hands as he plated a meal. -At 4:43 p.m. a test tray was plated and prepared for sampling. -At 4:46 p.m. the key lime pie slice temperature was collected. The pie's internal temperature was 50 degrees Fahrenheit (F.) The pie temperature was above 45 degrees F. On 9/15/22 at 10:45 a.m. a red sanitizer bucket filled with sanitized water was on the counter in the dining room. The DM said the sanitizer was used to wipe down the resident dining room tables. The DM said he did not know when the water was last changed. The CRDC dipped the hydro quat strip on the bucket of water. The strip did not change in color, indicating a very low amount of sanitizer solution. The CRDC said the sanitizer did not show registered at appropriate levels and instructed the bucket to be changed with new sanitized water. IV. Staff interview The dietary director (DM), the CRDC and cook #2 introduced themself on 9/14/22 at 3:20 p.m. The DM said he recently was promoted to the position as dietary manager and was a cook prior to the promotion. The DM said he had been the facility's DM for less than a week. The CRDC said the facility was new to the corporation and he was providing consultation and would establish a regional dietary consultant for the facility. Cook #2 said he had been a cook for the past 10 years. Cook #2 was interviewed on 9/14/22 at 4:20 p.m. The cook said he was trained annually on hand hygiene and he should change gloves anytime he was handling food, after doffing gloves and anytime he touched contaminated surfaces. DA #1 was interviewed on 9/14/22 at 4:25 p.m The DA said she should change gloves anytime she stepped away from the service line and anytime she touched non-food surfaces. According to DA #1, surfaces such as the wall or her mask were items she should have changed her gloves and performed hand hygiene after touching. The DM was interviewed on 9/15/22 at 10:01 a.m. The DM said the facility did not log when they changed the sanitizer buckets. He said the buckets should be changed every two to three hours or less if the water was cloudy. The above infection control concerns during the meal were shared with the DM and the CRDC. The CRDC confirmed he also observed breaks in infection control during the 5/19/22 dinner observations. The key lime pie temperature on the test tray was shared with the DM and the CRDC. The CRDC said cold food could not rise above 41 degrees F because of the risk of bacterial growth. He said they should have not had a cold food tray sit for long periods at a time till served. He said the dietary department would be changing the way they handled cold food and for now would have the DA retrieve the desserts out of the refrigerated one at a time and serve immediately. The CRDC said cook #1 should have used the hydrion quaternary test strips not the chlorine test strips to test the red bucket on 9/12/22. He said the chlorine strips were to test the dishwasher. He said the sanitized solution in the read bucket should have registered at 200 ppm for adequate sanitation levels. The DM and CRDC said he would provide education with staff immediately to address the identified concerns. The CRDC said on 9/19/22 he would do an in-depth inservice with the dietary department on infection control procedures using the new corporation's training packets. According to the DM and CRDC, infection control practices would change.

Based on record review and interviews, the facility failed to develop and implement effective quality assurance/process improvement (QAPI) action plans to identify and address quality deficiencies regarding resident rights and resident care. Specifically, the facility failed to correct recurring deficiencies related to abuse, investigations, accident hazards, and infection control. Findings include: I. Record review Cross-reference F600 abuse: the facility failed to protect residents' rights to be free from abuse by staff and other residents. Cross-reference F610 investigations: the facility failed to investigate allegations of abuse and protect residents from further abuse during and after the investigations. Cross-reference F689 accident hazards regarding elopement: the facility failed to ensure residents were safe from elopement at immediate jeopardy level, with potential for serious injury or death. Cross-reference F880 infection control: the facility failed to maintain an effective infection control program to prevent the potential spread of infection. The above deficiencies were repeated deficiencies cited during the prior recertification survey ending on 6/10/21. F689 was previously cited related to other accident hazards including falls, smoking safety and call light accessibility for residents at risk for falls. II. Staff interview The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 9/15/22 at 8:15 p.m. They said their QAPI program was working on action plans for wandering/elopement, falls, weight loss, abuse, conducting thorough investigations, any resident concerns brought to their attention, food and vaccinations. They said they needed something better in place to keep problems from occurring and reoccurring, and said their current process improvement was not effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Fall prevention A. Facility policy and procedure related to falls The Accident/Incident report policy, revised 3/13/14, was provided by the nursing home administrator (NHA) on 6/9/21 at 1:28 p.m. It documented an accident/incident report should be completed for all accidents or incidents where there is injury or the potential to result in injury. The report should then be sent to the nursing office. Documentation should be completed in clinical notes, which included an accurate description of the accident/incident. It documented the facility should have developed and implemented an individualized plan as part of the care plan and should evaluate and update the resident's care plan. The policy documented that an incident was defined as any happening, which was not consistent with the routine operation of the long-term care facility, that did not result in bodily injury or property damage. It documented an accident was defined as any happening, which was not consistent with the routine operation of the long-term care facility, that resulted in bodily injury other than abuse. It documented the charge nurse was responsible for ensuring the legibility and completeness of all accident/incident reports. It documented that all accident/incidents should be reported to the physician and family as soon as possible. B. Facility fall program A Falling Star Program Description and Residents Identified on the Program, dated , was provided on 6/10/21 at 2:50 p.m. by the medical record director. According to the description, a resident was placed on the falling star program after they fell. A star is placed next to the resident room number, on the call light. A star is also placed on the doorway of the residents room and a gold table would be applied to the walker or wheelchair handles. The star and the gold tape alerted staff that the resident was at risk of falling and knew to quickly answer the call light before the resident fell. Resident #1 and #5 were identified to be placed on the falling star program. C. Resident #5 1. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the June 2021 CPO, diagnoses included fracture of neck of the right femur, after care following joint replacement surgery, history of falling, muscle weakness, abnormalities of the gait and mobility, and unspecified osteoarthritis. According to the 2/25/21 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of seven out of 15, which indicated her cognition was severely impaired. The MDS identified Resident #5 required limited physical assistance of one person for locomotion, transfers, bed mobility, toileting, dressing and hygiene. Resident #5 used a wheelchair for mobility. The MDS indicated the resident had a history of falls without injury. 2. Resident record The 4/2/21, the 5/1/21, and 6/1/21 high fall risk assessment identified the as a high fall risk. According to the assessment, staff should have implemented high risk fall prevention interventions. -The assessment did not identify new recommended interventions on each assessment. The resident incident report packet was reviewed for fall on 4/11/21 at 7:05 a.m. The resident was not injured at the time of the fall. The incident packet read Resident #5 had an unwitnessed fall to the floor. According to the report, the resident attempted to self transfer herself out of the bed. At the time of the fall, her call light was in reach and the bed was at its lowest position. The identified fall prevention intervention to prevent future was to have the call light within reach of the resident, the bed at the lowest position and remind the resident to use her call light bell if she wanted to transfer out of her bed. -The intervention did not attempt to identify the need associated with the reason the resident attempted to get out of bed and how those needs could be anticipated. The incident packet did identify how reminders to the call bell would be consistently effective to a resident with severe cognitive impairment. The 4/11/21 fall incident investigation was completed on 4/20/21. The investigation read Resident was noted on the floor sitting up on the floor next to her bed. Resident stated she was trying to get out of bed. Call light was within reach and was not on. Interventions is a falling star program, frequent checks and will have a therapy screen for possible eval (evaluation) and treat (treatment). The 6/3/21 resident incident report packet was reviewed for a fall on 6/3/21 at 1:09 p.m. According to the incident report, the resident transferred herself out of her wheelchair to self ambulate to push the wheelchair from behind. The resident tripped over her shoes and fell to the floor. The resident had an abrasion to her right knee and redness to her right hip. According to the report packet, the resident was currently receiving therapy services. The incident investigation read Resident #5 fell in the entry of her room. The investigation indicated the resident was wearing shoes, the area was well lit and without clutter. According to the investigation, the resident fell because she was without assistance. The 6/3/21 registered nurse progress note read the resident reported pain to her right hip and her right ankle. Her ankle was swollen and had some abnormality to her pelvic area. The resident was transferred to the hospital. The facility was notified the resident had a fractured hip. The 6/6/21 progress not read the resident was discharged from the hospital with a right hip fracture. The fall care plan, last reviewed on 11/26/2019, read the resident was at risk for falls. According to the care plan, Resident #5 self transfer to her wheelchair. Interventions included to provide stand by assistance for ambulation. -The care plan did not identify the resident's two recent falls on 4/11/21 and 6/1/21. The care plan did not identify new interventions to prevent the occurrence of future falls after the two falls. The care plan did not identify the resident was on the falling star program. The behavior care plan was initiated on 5/6/21. According to the care plan, it was a goal for the resident to be more compliant with allowance to assist her with her daily needs. Interventions included educating and reeducating the resident on the importance of staff assistance and the possible problems that could occur if she did not have their assistance. The cognition care plan, reviewed 12/12/19, read the resident had an impaired thought process related to short term and long term cognitive loss. According to the care plan, staff should keep the call bell within easy reach and encourage the resident to use it. The care plan indicated staff would answer promptly. 3. Observations On 6/9/21 at 8:56 a.m. the call bell to the room of Resident #5 was on and sounding. -At 8:59 a.m. the roommate of Resident #5 exited the room and said the call light had been on for a while. She said her roommate might need assistance. The resident walked down the hall towards the staff. -At 9:00 a.m. Resident #5 was observed in the bathroom with the door open. The resident was attempting to stand up. The resident was encouraged to wait for staff. The resident sat back down on the toilet, her call light continued to sound. -At 9:03 a.m. certified nursing assistant (CNA) #2 passed her room, she did not check to see if the resident needed assistance. -At 9:04 a.m. housekeeper (HK) #2 passed her room twice, she did not check to see if the resident needed assistance. -At 9:05 a.m. registered nurse (RN) #2 entered the resident's room to answer the call light. -At 9:19 a.m. RN #2 exited the room. The RN said she assisted her off the toilet and helped her clean up. She said the resident needed to return to the bathroom because she was having difficulty with her bowels. The RN said Resident #5 was returned to the bathroom. The RN said she had her call bell with her in the bathroom. Between 9:19 a.m. and 9:45 a.m., Resident #5 was in the bathroom alone. -At 9:49 a.m the call light turned on. Resident #5's roommate told CNA #2 the call light was on as she stood in the hallway. The CNA did not acknowledge the resident and she passed the room, entering into another room. HK #2 entered and exited the room across from Resident #5's room. Neither staff member answered the call light of Resident #5. -At 9:50 a.m. CNA #9 entered the resident room and told the Resident #5 that she would get the nurse. The CNA exited the room. The resident was left alone in the bathroom. -At 9:54 a.m. CNA #9 walked passed the room of Resident #5 with CNA #2. CNA #5 told CNA #2 that the resident requested something for her bowels. The resident remained alone in the bathroom. -At 9:55 a.m. the roommate of Resident #5 said the resident was still alone in the bathroom. -At 9:57 a.m. CNA #10 entered the room of Resident #5 and looked in on the resident and then left her alone in the bathroom. CNA #10 exited the room and entered another resident's room. -At 10:00 a.m the dietary aide refreshed the resident's water. The resident remained alone in the bathroom. -At 10:11 a.m. CNA #2 passed the resident's room, she did not check on the resident as she remained alone in the bathroom. -At 10:17 a.m. the resident turned the call light on. CNA #4 entered the room and assisted the resident. -At 10:19 a.m. Resident #5 was observed in her wheelchair in her room. She did not have gold tape on the handles of her wheelchair. She did not have a star next to her name next to her door. She did not have identifying markers to inform staff that she was a high fall risk and was on a falling star program (indicated in the facility policy above). On 6/10/21 at 2:54 p.m. observations revealed the resident still did not have tape on the resident's handles or a star next to the residents room. 4. Staff interviews RN #2 was interviewed on 6/9/21 at 9:19 a.m. RN #2 said Resident #5 returned to the facility from the hospital on 6/6/21. RN #2 said the resident was attempting to self transfer and broke her hip when she fell. The RN said the resident had the ability to bear weight but she should have staff assistance. She said the resident was reminded to use the call light but has an impaired memory. She said all staff were responsible to answer call lights. HK #2 was interviewed on 6/9/21 at 9:32 a.m. with a translator. She said she was trained to answer call lights when she saw one on. She said she could usually help them but she could get a nurse to assist the resident. CNA #4 was interviewed on 6/9/21 at 9:38 a.m. She said residents who have fallen or at high risk for falling have a star next to their name by the door, gold or yellow tape on the handles of their wheelchair and sometimes will have a chair alarm. CNA #4 said these residents should be checked on through the shift. They should have shoes on, a floor mat by their bed, non-skid strips by their bed. She said the residents need assistance to transfer and toilet and should never be left alone in the bathroom or they could fall. CNA/MA #1 was interviewed on 6/9/21 at 10:59 a.m. He said residents that were at high risk for falls should be frequently checked on in their rooms and their call flights should always be within their reach. He said those residents were usually encouraged to use the toilet every two hours and should never be left alone in the bathroom.The CNA/MA said gold tape on the wheelchairs and gold stars by their name in front of their room was how staff knew a resident was a high fall risk. CNA/MA #1 walked down the hallway identifying residents who had a high fall risk. The CNA/MA identified residents that were no longer a high fall risk but still had stars by their door. The CNA/MA also identified residents that were a high fall risk with a recent fall that did not have a star by their name. He said Resident #5 just returned to the facility after she fell and broke her hip. He said she did not have tape on her wheelchair or a star by her name but should because she was a very high risk for falls. The corporate consultant (CC) and the director of nursing (DON) was interviewed on 6/10/21 at 12:34 p.m. The CC confirmed high fall risk residents were identified by the falling star gold tape and star by their name. The DON said high fall risk residents should have care planned fall interventions including the identification that the resident was on the fall program. She said they should never be left alone in the bathroom. Both the DON and the CC said all staff should answer call lights. Licensed practical nurse (LPN) #1 was interviewed on 6/10/21 at 2:44 p.m. She said she ensured high fall risk residents were frequently monitored. She said she knew who was a high fall risk because it would be discussed in the nurse report and their names were on a board in the medication room. The nurse was asked who her high fall risk residents were in her hallway that she frequently monitored. The LPN said she could not remember the residents off hand. The LPN walked down the hall reading the names of residents with the visually identifiable gold stars. The LPN said she needed to look and the stars to see who were the high fall risk residents. The nursing home administrator, the CC and the DON were interviewed on 6/10/21 at 5:56 p.m. They said fall prevention started with identifying those residents at risk for falls through fall assessments. The residents with a high fall risk were then placed on a falling star program. The team said falls are reviewed in an interdisciplinary (IDT) meeting to review potential causes of the fall and they discussed interventions to help prevent falls. The interventions were then implemented and care planned. They said markers such as the gold star and tape, provided a visual cue to staff to keep their eyes on all the high risk residents. The CC said the DON was responsible for the communication to staff about the falling star program and adding the gold stars to the names and gold tape on handles. She said the DON just started that week and the former DON stepped down at the end of May 2021. The NHA said they were scheduled to have an IDT review of falls but rescheduled to the following week. The CC acknowledged fall review should occur shortly after the fall occurred to ensure all interventions were in place. The DON and CC said there was a lapse in time that updates to the fall star program could have been missed. The CC said Resident #5 should have staff assistance to transfer. She said she helped the resident the day of the interview and ensured she stayed with her as the resident used the bathroom. The CC said the resident had poor safety awareness. She said Resident #5 should not have been left alone in the bathroom because of her high risk and recent hip fracture. The CC said Resident #5 was a high fall prior to her most recent fall and should have had the identifying markers and falling star care plan already in place. The 6/9/21 observations were reviewed with the management team. They said all staff should have answered the call lights and Resident #5 should have not been left alone in the bathroom. The DON and the CC said they would reassess residents for high risk and update the fall star program and interventions. D. Resident #1 1. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the June 2021 CPO, diagnoses included anxiety, unspecified dementia with behavioral disturbance, and depressive episodes According to the 2/19/21 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of five out of 15, which indicated her cognition was severely impaired. The MDS identified Resident #1 required extensive physical assistance of two or more persons for bed mobility. According to the MDS the resident required extensive physical assistance of one person for locomotion, transfers, toileting, dressing and personal hygiene. The MDS indicated the resident had a history of falls without injury. 2. Observations On 6/9/21 at 10:37 a.m. the Resident #1 was observed attempting to self transfer from her wheelchair into her bed. Her chair alarm sounded and the CNA entered her room and assisted her back in her wheelchair into the common area. -At 2:05 p.m. Resident #1 was observed in her bed. She was tearful, her face red and she pulled on the call bell cord with one hand and pushed the top of the call bell handle. The call bell handle was missing a button to notify staff that she needed assistance. Resident #1 said she can ' t as she continued to attempt to push down where a button should have been. The resident said she needed help. -At 2:08 p.m. CNA #10 was notified the resident required assistance. The CNA entered the room and identified the call bell the resident had in her hand was not working. She acknowledged a second call bell was within the resident's reach but it was clipped to the side of the bed and not visible to the resident. The CNA stayed with the resident to provide the requested care. -At 5:20 p.m. The call bell was observed to be replaced and and visually accessible to Resident #1. 3. Resident record The care plan for falls, reviewed on 11/13/2020, read the resident had a history of falling and used a motion alarm. -The care plan did not include ensuring the resident had a working and accessible call bell within line of sight. The cognition care plan, reviewed on 11/13/2020, read to keep the call bell within easy reach. According to the care plan, staff would remind and encourage Resident #1 to use it and staff would answer it promptly. The care plan for anxiety, last reviewed on 11/15/2020, read to ensure her anxiety did not interfere with her functional abilities. According to the care plan, staff needed to determine her source of anxiety. The 6/1/21 fall risk assessment read the resident had a high risk for falls, had a fall within the last three months and had an impaired gait. According to the fall risk assessment, staff should implement high fall prevention interventions. The review of the 2021 fall incident reports revealed the resident fell on 1/9/21, 2/6/21, 2/18/21 and 4/7/21. 4. Staff interviews CNA #10 was interviewed on 6/9/21 at 2:10 p.m. She said the resident would have difficulty looking for the second working call bell. She said call bells provided to the residents should be in working order. She said she did not know the call bell she attempted to use was not identified by staff not to be in working order. She said the call bell clearly was missing the red button. She said the resident had limited mobility and the bell should have been placed within her reach. CNA #10 said the resident became easily anxious and wanted someone to sit with her so she tried using her call bell for reassurance. The corporate maintenance director (CMD) was interviewed on 6/9/21 at 2:32 p.m. The CMD said call bells should be checked routinely to ensure that they were operational and accessible. He said monthly rounds of the call bells would be identified on the maintenance TELS program. The CMD observed Resident #1's call bells. He acknowledged that the resident had two call bells within her reach but the first call bell was missing a button and the second call bell was attached to the side of the bed. The CMD said the call bell would not have been in the line of sight of a resident who was lying down in bed. The CMD said he would correct the problem immediately. He said he would have to replace the broken bell and have the MTD complete a full building audit to ensure all call bells were in good working order. The maintenance director (MTD) was interviewed on 6/9/21 at 2:58 p.m. He said he did a call bell audit last week but was was not sure if he looked the call bells for Resident #1. He said he did not document his weekly rounds or what rooms he would have reviewed. He said the monthly audit on the TELS program would not show what rooms were reviewed. The CMD was interviewed again on 6/9/21 at 3:31 p.m. He said the call bell audit for every room was completed. He said all occupied resident rooms had accessible and operational call bells. He said he was not sure how the call bell was missed between nursing staff and call bell audits. The CMD said he was not sure how long the call bell was not functioning properly. The corporate consultant (CC) was interviewed on 6/10/21 at 12:05 p.m. She said there were multiple opportunities for staff to identify if a call light was not working properly. She said the MTD completed weekly and monthly rounds in resident rooms. She said the nursing staff could have noticed the call light was not working and filled out a maintenance request or informed their supervisor. The CC said management received notice if a call bell was not working but the system but there were opportunities where a call bell in need of repair could go unnoticed. She said staff should have been able to identify a red button missing on a call bell when it was provided to her. The CC said Resident #1 was a high risk for falls, has had a history of falls and could quickly become anxious. She said Resident #1 could hyperventilate when she was anxious. The CC said it was crucial for Resident #1 to have a working call bell. The CC said she started a management round program to include a daily check of call lights after she heard of the call bell concern in the room of Resident #1. She said she would incorporate a check off sheet to ensure compliance and as a reminder of what management should look for when completing the rounds. 5. Facility follow up A 6/9/21 Maintenance call light audit response outline was provided by the CMD on 6/10/21 at 8:01 a.m. According to the outline, a audit was completed after Resident #1's room was identified call bell was not operational. The call bell was replaced and tested. During the audit, it was found that a second room that was not occupied had a missing call bell due to a 6/7/21 room painting. The bell was replaced and tested. A guardian angel room round check off sheet was provided by the CC on 6/10/21 at 12:58 p.m. The check off sheet included to check if the call bells were accessible and in working order. Based on observations, record review and interviews, the facility failed to ensure three ( #5, #1 and #19) of six residents reviewed for accidents of 26 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to: -Ensure Resident #19, a smoker who required the use of oxygen, did not have his oxygen concentrator (turned off) on while smoking; -Complete a smoking assessment for this Resident #19; -Implement fall prevention interventions for Resident #5, with a history of falls and a recent hip fracture; and, -Ensure all provided call bells were operational and in the line of sight of a high fall risk resident, Resident #1. Findings include: I. Inadequate supervision related to resident smoking A. Facility policy and procedure The Smoking-COVID 19 policy, which was undated, was provided by the NHA on 6/9/21 at 1:28 p.m. It documented residents would be permitted to engage in smoking activities in designated outdoor areas after being assessed to determine the level of supervision required. It documented that all smoking would be supervised to ensure residents are removing face masks appropriately prior to smoking and that social distancing would be maintained; however, independent smoking may be allowed upon appropriate return demonstration by resident and nursing assessment of resident. It documented residents requiring the use of oxygen may not enter the designated smoking areas at any time unless all oxygen equipment had been removed. B. Resident #19 1. Resident status Resident #19, age [AGE], was originally admitted on [DATE]. He was discharged to the hospital on 4/6/21 and returned to the facility on 4/29/21. According to the June 2021 computerized physician orders (CPO), diagnoses included hemiplegia, chronic obstructive pulmonary disease (COPD), depressive episodes, anxiety disorder and dependence on supplemental oxygen. According to the minimum data set (MDS) assessment dated [DATE], Resident #19 was severely impaired with daily decision making with a brief interview for mental status (BIMS) score of five out 15. It documented the resident displayed no type of behavioral issues or rejection of care. It documented the resident required supervision and set up for eating. He needed limited assistance for bed mobility, transfers, ambulating in his wheelchair, toileting, personal hygiene and bathing. Section O documented the resident was receiving oxygen therapy, both prior and while residing in the facility as a resident. 2. Resident #19 observations Resident #19 was observed on 6/8/21 at 11:39 a.m., going outside to smoke for the third time that morning, according to various facility staff. Resident #19 was observed by two surveyors upon exiting the building on 6/8/21 at approximately 6:18 p.m. He was sitting in the designated smoking area on the front porch of the facility. He visibly had a lit cigarette in his left hand and his hand was resting on his left leg. He had an oxygen nasal cannula in his nose that was connected to a portable oxygen tank. The resident was alert and oriented; he was approached and asked if he was smoking with oxygen on. He said that they had turned off his oxygen. He said the social services director (SSD) had brought him outside. One surveyor went inside to get staff assistance while the second surveyor stayed with the resident. The resident said that sometimes he pulled his nasal cannula down out of his nose when he smoked, but that his oxygen was always turned off. The first surveyor returned with the activity director (AD). The AD looked at the oxygen tank and confirmed it was turned to 0 (off). The AD said she did not know anything about Resident #19 coming outside to smoke. The resident still had the nasal cannula on his face. The AD said she would let the NHA know right away and then she went back inside. After approximately two minutes, no staff came back outside to check on Resident #19. The second surveyor went in to find the NHA. The NHA said that the AD had just told her what had happened. The NHA came back outside to check on the resident and his tank. She looked at the tank and saw it was at zero. She then disconnected the tubing from the tank and removed the tank from his wheelchair. She said typically, before the resident came outside, his oxygen was taken off and the tank was left just inside the doorway. She said she would find out which staff member helped the resident outside and provide additional education to them. On 6/9/21 at 3:53 p.m., Resident #19 was observed returning from smoking outside. He handed certified nurse aide (CNA) #4 back his lighter when he returned it to the nurse's office and CNA #4 returned the resident's oxygen concentrator after she reattached his oxygen tubing to the concentrator. The following was observed related to resident's smoking on 6/9/21: -At 4:50 p.m., Resident #19 was observed waiting in the hall outside the nurse's office to get his 5:00 p.m. cigarettes. -At 5:00 p.m., the door to the nurse's office opened and Resident #19 propelled his wheelchair to the door of the nurse's office to get his cigarettes. Staff were busy with paperwork at this time. -At 5:09 p.m., RN #2 was observed taking Resident #19's oxygen concentrator off his wheelchair and detaching the oxygen tubing. She kept this oxygen equipment in the nurse's office. She then assisted the resident outside to the designated smoking area, handed him a cigarette and lit it for him, keeping the lighter. There was a red line designating the smoking area, which was approximately 12 feet by 12 feet. There was posted signage for no smoking past the red line. There was a fire blanket stored in a fireproof container, mounted to the patio wall, as well as two smoking receptacles and two trash cans in the smoking area. 3. Record review a. Progress notes Resident #19's progress notes were reviewed from 3/31/21 through 6/10/21: -There was no progress note documented for the observations of inappropriate smoking the evening of 6/8/21. -There were no progress notes at all documented during this time frame related to Resident #19 smoking. b. Care plans The care plan dated 5/6/21 documented the resident was receiving oxygen therapy related to a diagnosis of COPD. There were no interventions that addressed issues related to smoking. The care plan dated 5/6/21 documented Resident #19 had the potential for injury/burns related to smoking. He was an unsupervised smoker. The intervention was for the resident to have no injuries related to smoking and would continue to follow the smoking rules set for all residents. Interventions included the resident being given cigarettes when requested. It documented, as the resident was a safe smoker, he could smoke when he wanted. It documented the oxygen tank/cannula would be removed from Resident #19's chair prior to going out of the facility to smoke. The oxygen tank would be kept inside the facility. It documented cigarettes and lighters would remain in the lock box behind the nurse's station or locked in the medication room per facility policy. It documented nursing staff would perform a formal smoking assessment quarterly and as needed. It documented staff should remind and assist Resident #19 to remove oxygen and leave in the facility while on smoking break. c. Smoking assessments The smoking assessment, completed by RN #2 on 6/9/21 at 8:06 a.m. documented Resident #19 was aware of the facility's smoking area, but was unable to get there independently. It documented Resident #19 required modified independence with daily life decisions in new situations only. The resident had lower extremity limitations with range of motion, but was able to grasp and hold smoking materials without difficulty. It documented his vision was impaired, but he was able to call for emergency assistance if needed. It documented the resident was ordered continuous oxygen at 2 liters per minute via nasal cannula. It documented Resident #19 sustained no previous smoking accidents or incidents. He displayed no burn masks on his clothing. It documented the resident did remove his oxygen tubing and left his oxygen out of the smoking area. The resident displayed no tremors while smoking and was able to light his own cigarette safely. It documented the resident had never fallen asleep while smoking and could extinguish his cigarette completely. It documented Resident #19 followed the facility's smoking policy independently and could return smoking materials to the appropriate storage area. The assessment documented the interdisciplinary team's smoking recommendation that the resident was safe to smoke unsupervised at this time. It documented smoking restrictions and care have been planned. It documented Resident #19 was informed of the smoking policy and restrictions on 6/9/21, which the resident signed. -There was no smoking assessment completed for Resident #19 prior to 6/8/21. d. Physician orders The June 2021 CPO was reviewed and the following orders were documented: 4/29/21: Room air oxygen saturation levels once per shift and document, report change on oxygen saturation level of 4 percentage point from baseline or a drop to 88%. -There was no official order for oxygen use seen in the resident's chart. 4. Post activities to correct deficient practice The resident incident report, which was undated and unsigned, was provided by the DON on 6/10/21 at 11:28 a.m. She said she just created that report. It documented the occurrence happened on 6/8/21 at 1:37 p.m. and the [TRUNCATED]

Based on interviews and record review, the facility failed to timely and thoroughly investigate alleged violations of physical and sexual abuse for four (#10, #16, #20, #200) of seven residents out of 26 sample residents. Specifically, the facility failed to: -Timely and thoroughly investigate resident-to-resident physical abuse between Resident #10 and #20 and Resident #10 and #200, and -Timely and thoroughly investigatethe sexual abuse by Resident #10 towards Resident #16, Findings include: I. Facility policy and procedure The Resident Safety policy, undated, was provided by the nursing home administrator (NHA) on 6/7/21 a 7:44 p.m. the policy documented in pertinent part, It is the policy of our facility to maintain a work and living environment that is free from threat and/or occurrence of harassment, abuse (verbal, mental or sexual), neglect. Residents must not be subjected to abuse by anyone. Including, but not limited to facility staff, other residents. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault; Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. Procedure for investigation: The quality assurance manager and/or the supervisor on duty will assess the resident (including the size, location, etc. of any injury), and document the date time and location of the reported or suspected incident; -The supervisor will ensure that the resident is protected from harm during the investigation; -An incident report will be completed; -The quality assurance manager and/or supervisor on duty will attempt to interview the resident as well as all nursing, housekeeping, laundry, dietary, activity, social service staff, any visitors or others who may have knowledge of the occurrence or who may have been in the vicinity at the time the incident happened. The quality assurance manager and/or supervisor on duty will prepare a written summary of each interview; -The investigation will be conducted following the suggested procedures and measures in the most current Health Facilities and Emergency Medical Services division occurrence reporting manual and/or the federal reporting requirement for nursing facilities. Response to the investigation: Upon completion of the investigation, a written summary will be prepared by the administrator or designee; -The administrator or designee will be the custodian of all documents generated during the course of the quality assurance (QA) investigation; -These documents will be identified as QA documents and will be reviewed by the quality assurance committee for re-evaluation of the policies and procedures and for any needed revision to the same policies and procedures if warranted to prevent further occurrences. The Accident/Incident Report policy, undated, was provided by the NHA on 6/7/21 at 7:44 p.m. It documented in part, The Accident/Incident Report is completed for all allegations of resident-to-resident altercations; -An incident report needs to be completed for each resident involved; -An investigation will be initiated within 24 hours of the discovery of an allegation of abuse. Investigation and findings must be documented and submitted to the long-term care facility ' s medical staff for review. II. Record review A. Resident #10 and #200 Review of an investigation folder provided by the NHA revealed the only information found for this incident was a handwritten note with no date but a time of 9:22 a.m. The handwritten note documented in part that the OT (occupational therapist) witnessed Resident #200 swinging at Resident #10 in the front living room. Camera footage was reviewed at 9:32 a.m. which revealed that Resident #200 approached Resident #10 and began swinging at him. The author of the note was unknown. The only additional information attached to the written note was a face sheet for both of the residents and a business card from a police investigator. There was no further written evidence the victim and the assailant were interviewed. There was no written evidence other residents or staff were interviewed. There was no incident report found or provided as per the facility policy above. The NHA confirmed on 6/10/21 that this abuse allegation was reported to the State agency portal on 3/17/21. B. Resident #10 and #20 Review of the investigation folder revealed a typed letter dated 4/7/21 which explained the incident between Resident #10 and #20. The letter documented in part, Resident #10 yelled at and called Resident #20 a curse word in Spanish. Resident #20 then went over to Resident #10 and pushed him knocking him over and then Resident #20 fell on top of him. This information was verified by a review of the video camera (see NHA interview below). There was no further written evidence the victim and the assailant were interviewed. There was no written evidence other residents or staff were interviewed. There was no incident report found or provided as per the facility policy above. C. Resident #10 and #16 Review of the investigation folder revealed two hand written notes. One note, dated 5/24 (no year, however; this occurred in the current year 2021) documented Resident #16 was interviewed and she did not appear to have recollection of the incident that occurred on 5/22 with Resident #10. The resident was asked if she felt safe and she stated she always felt safe. There was no further written evidence found in the folder Resident #10 was interviewed. There was no further evidence other residents or staff were interviewed. On 6/10/21 at 5:30 p.m. the NHA provided a printed, typed letter that documented in part a certified nurse aide (CNA) witnessed Resident #10 reaching for Resident #16 ' s hand and then touching her breast over her clothes. The CNA redirected Resident #10 and immediately separated the residents. Resident #16 verbalized that she did not want Resident #10 to do that. The nurse on duty stated Resident #16 was upset and emotional support was provided to her. This document contained evidence that Resident #10 was interviewed on 5/24/21. The letter documented in part, when asked why the resident did what he did, he only shrugged his shoulders.The NHA discussed boundaries and not physically touching any residents and keeping his hands to himself. Although this incident was witnessed by the CNA, the facility failed to conduct a thorough investigation to ensure other residents were not affected by the actions of Resident #10. Cross reference F600 Free From Abuse and Neglect. The NHA confirmed on 6/10/21 this abuse allegation was reported to the State agency portal on 5/24/21. III. Staff interview The NHA was interviewed on 6/10/21 at 5:00 p.m. regarding all three incidents above. She stated that Resident #10 was currently out of the facility and Resident #200 had been discharged . She said that as soon as she received the notification of the alleged abuse incidents she did follow up with staff and the residents involved and then directly placed all the information into the State agency reporting portal. She said she had viewed camera footage of the incidents between Resident #10 and #200 and also with Resident #20. She said she felt if she had to do both (keep documentation in the folders) and placing information in the portal, was doing double work. She said because she put the investigation into the portal right away she did not know she had to have any other written documentation in the folders to show she had completed a thorough investigation. She said she did not have any incident reports for the above incidents, only her written and typed notes. She also confirmed she did not have any further interviews with staff or residents other than what was in the folder provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in five of five halls and in one of one dining room. Specifically, the facility failed to: -Ensure staff donned appropriate personal protective equipment (PPE) when entering rooms designated on isolation with droplet precautions; -Ensure resident hand hygiene was conducted before meals; -Ensure nurses donned gloves to apply a transdermal medication patch; -Consistently offer and encourage resident mask use; and, -Ensure proper waste management soiled PPE used in isolated rooms for COVID-19 precautions. Findings include: I. Professional reference The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html. on 6/16/21 included the following recommendations for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. The CDC Post Vaccination Considerations, updated 5/13/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/post-vaccine-considerations-residents.html on 6/10/21. The CDC considerations read in pertinent part: Because information is currently lacking on vaccine effectiveness in the general population; the resultant reduction in disease, severity, or transmission; or the duration of protection, residents and healthcare personnel should continue to follow all current infection prevention and control recommendations to protect themselves and others from SARS-CoV-2 infection, regardless of their vaccination status. II. Facility policy and procedure The COVID-19 Employee Education policy, undated, was provided by the nursing home administrator (NHA) on 6/18/21 via email. The policy read in part: Staff is educated on signs and symptoms of COVID-19, facility infection control prevention and use of PPE (personal protective equipment) All staff are trained on proper personal protective equipment. For routine care of residents, a mask is required for all staff. For positive or suspected COVID-19 residents, staff is educated on the use of N-95 masks, gowns, gloves, eye protection, hair and foot protection. Staff is instructed on how to appropriately don and doff PPE to prevent contamination Staff is educated on proper hand hygiene based on best practices. Staff is educated on how to clean/sanitize before and after shared medical equipment and areas. III. PPE worn and discarded appropriately 1. PPE A. Resident mask use Throughout the survey from 6/7/21 to 6/10/21, residents were observed not to be consistently offered or encouraged to wear a mask. The below observations were examples of what was routinely demonstrated pertaining to resident mask use. On 6/9/21 between 12:55 p.m. and 1:05 p.m. five residents were gathered by the activity director (AD) and CNAs for a group interview. The residents were not encouraged to wear a mask. Four of the five residents attended the small group without a mask. One resident wore a mask. -At 1:08 p.m. a female resident encouraged a masked resident to remove his mask. She told him that he did not need it. Observations were conducted on 6/9/21 between 10:21 a.m. and 11:00 a.m. in the common area between three resident hallways. -At 10:21 a.m. three residents were observed sitting in the common area tables. One resident was observed to wear a mask. Magazines were laid out on the table. The AD walked in out of the area during portions of the observation period without offering or encouraging mask use. -At 10:42 a.m. The mask of the third resident hung on her ear. The mask did not cover her nose and month. Two residents remained in the common area unmasked. Another resident sat in the hallway near the other residents. He did not wear a mask. Certified nurse aides (CNAs) and members of management were observed to walk past the residents. The residents were not offered or encouraged mask use or to properly secure the fallen mask of one of the residents. -At 10:50 a.m. staff proceeded to assist some of the residents in the dining room. Staff did not encourage mask use or assist in the proper placement of a fallen mask still hanging off the ear of the resident. -Between 10:42 a.m. and 10:56 a.m. a resident sat in the hallway across from the common area. Her mask rested below her nose and mouth. Staff including members of management who walked past her without assisting with proper mask placement. -Between 10:42 a.m. and 10:58 a.m. two ambulatory residents were observed walking down the hallways together and interacting with staff; they were not encouraged to wear masks. -Between 10:42 a.m. and 10:56 a.m. a resident sat in the hallway across from the common area. Her mask rested below her nose and mouth. Staff including members of management walked past her without assisting with proper mask placement. B. N95 use On 6/8/21 at 8:30 a.m. a PPE cart was observed next to the entrance of room [ROOM NUMBER]. Taped to the cart was sign directing the staff to wear an N95 mask, gown, gloves, and protective eyewear to enter the room. -At 8:36 a.m. CNA #7 prepared to enter the isolated resident room [ROOM NUMBER]. The resident who resided in the room was on droplet precautions for a new admission to the facility. The CNA performed hand hygiene, donned personal protective equipment (PPE) of gloves, a face shield and gown. She entered room [ROOM NUMBER]. The CNA did not change her surgical mask to a N95 as the sign instructed staff to wear to enter the room. -At 8:44 a.m. CNA #7 was observed exiting the isolated resident room [ROOM NUMBER].The resident who resided in the room was on droplet precautions for a new admission to the facility. The CNA did not wear an N95 mask. She doffed her gown, gloves and removed her face shield. She kept her surgical mask on and performed hand hygiene. -At 9:05 p.m. CNA #8 was observed to exit room [ROOM NUMBER]. She did not wear an N95 in the isolation room. C. PPE waste disposal 1. Observations On 6/8/21 at 8:35 p.m. observations were made from the doorway of room [ROOM NUMBER] (a designated isolation room). There was a basket with discarded isolation gowns piled high and overflowing and touching the floor. There was no lid on the basket to contain the potentially contaminated gowns. On 6/8/21 at 4:13 p.m. The PPE was observed piled in a small container on the floor on the entrance of room [ROOM NUMBER]. The PPE overflowed the edges of the small container and draped onto the floor of the doorway. The PPE was piled high above the edge of the backside of the container up against the wall approximately a foot taller than the sides of the container. -At 4:34 p.m. the MDS coordinator (MDSC) doffed PPE in the overflowing container. -At 4:37 p.m. the MDSC again doffed her PPE in the container, adding to the pile of PPE used in an isolated room on droplet precautions for potential COVID-19. 2. Administrative interview The infection preventionist (IP) was interviewed on 6/9/21 at 4:00 p.m. She said that the reusable isolation gowns, once removed in the room, were placed in the dirty clothes basket. She said they did not have isolation bins (with lids). She said the basket should not have gowns overflowing and staff should be bagging them and taking them to the laundry. 3. Facility follow-up On 6/10/21 at 7:45 p.m. the corporate consultant (CC) said that the facility had purchased biohazard bins to be used for the isolation rooms when needed. She said in the meantime the facility had purchased regular household trash bins with lids. She also presented an action plan to begin on 6/14/21 to address the issues identified during the survey regarding infection control. The action plan documented in part that staff would be re-educated on the proper disposal of PPE in resident rooms, proper PPE use in isolation rooms, proper PPE for isolation versus common areas and masking of residents. D. Protective eyewear On 6/8/21 at 4:31 p.m. the MDS coordinator (MDSC), prepared to enter an isolated resident room [ROOM NUMBER]. The resident who resided in the room was on droplet precautions for a new admission to the facility. The MDSC performed hand hygiene, donned PPE of gloves, a gown, and a N95 mask and entered the room. The MDSC did not don eye protection. The MDSC attempted to conduct a COVID-19 test on the resident. The MDSC exited the room and doffed her PPE. -At 4:36 p.m. MDSC returned to the entrance of room [ROOM NUMBER]. She removed her goggles on her head and placed them on a PPE cart outside of the room and donned gloves and a gown and a N95 mask. The MDSC entered the room without eye protection and handed the resident a soda. She doffed her PPE, exited the room, performed hand hygiene and returned her goggles on to her head. IV. Resident interviews On 6/10/21 at 9:24 a.m. a male resident was interviewed in the dining room. He said the staff did not encourage him to wear a mask. He said he has not had to wear a mask since December 2020 when he was vaccinated. He said he was told that he did not need to wear a mask outside of his room because he had the vaccine. On 6/10/21 at 10:13 a.m. Resident #13, said residents a couple of weeks ago were told by staff that residents did not need to wear a mask if they were vaccinated. On 6/10/21 at 3:01 p.m. Resident #21 said that he has not had to wear a mask until a couple of days prior to the interview. He said staff had just started to tell him to put it on. V. Staff interview The NHA was interviewed on 6/8/21 at 8:42 a.m. The NHA confirmed new admissions were placed on isolation. She said full PPE was required to enter the rooms on COVID-19 precautions. She said staff needed to remove their surgical mask and don an N95. CNA #3 was interviewed on 6/8/21 at 3:48 p.m. CNA #3 said staff was trained to wear full PPE in isolated rooms for new admissions. She said staff needed to wear gloves, gown, eye protection and an N95. The MDSC was interviewed on 6/8/21 at 4:48 p.m. She said she wore eye protection for some direct care tasks in non-isolated rooms but did not have to wear eye protection in isolation rooms if the county level were low for COVID-19. -However, according to RN #1 interview (see below) eye protection was required. CNA #8 was interviewed on 6/8/21 at 9:10 p.m. She said staff did not have to wear an N95 in an isolated room on COVID-19 precautions if they were fully vaccinated. RN #1 was interviewed on 6/8/21 at 9:23 p.m. She identified herself as the infection control preventionist. The RN said residents newly admitted to the facility were placed in isolation for COVID-19 precautions and monitoring. She said all staff who enter rooms on COVID-19 isolation precautions needed to wear full PPE including N95 masks and goggles or face shields regardless of vaccination status. The COVID-19 status of the county did not change PPE precautions in the isolation rooms, including the use of eye protection. The facility chief executive officer (CEO) was interviewed on 6/9/21 at 4:55 p.m. According to the CEO, the facility has not had an outbreak of COVID-19 and continued to focus on infection control. She said staff should continue to wear full PPE in isolation rooms under COVID precautions including a face shield or goggle and an N95. The CEO said she would like to see staff continue to offer and encourage residents to wear a mask when they were outside of their room. She said residents should also be encouraged to perform hand hygiene before meals. She said the staff has been trained on infection control. The CEO recognized and acknowledged it was a difficult year for the staff and was proud of all their efforts. CNA #9 was interviewed on 6/10/21 at 10:15 a.m. CNA #9 said staff should encourage and offer residents to wear a mask regardless of their vaccination status. The director of nursing (DON), the corporate consultant (CC), and the NHA were interviewed on 6/10/21 at 7:10 p.m. The above observations and interviews were shared regarding infection control practices. The CC said residents and staff needed to continue to wear the appropriate PPE, regardless of vaccination status. The CC said N95 and face shields needed to be worn at all times in an isolated room for new admissions. The NHA said she became aware of the need to provide a larger and lidded waste receptacle for soiled PPE in isolation rooms. She said the small boxes have now been replaced to appropriately contain the PPE after use in an isolation room. The DON said the soiled PPE in isolated rooms were potentially contaminated and were at risk for shedding transmission based viruses and infections and should have not been overflowing and openly exposed in the room doorways. The CC said some residents have resisted wearing masks. She said staff however, should continue to educate and encourage resident mask use. The CC said they would be more proactive in the resident mask reminders. She said they would look at why to re approach the topic of masks including find incentives and new ways to offer education on mask use. According to the CC and the DON, there seemed to be staff and resident confusion of when and what PPE should be used with all the changes to the guidelines over the past months. They said they would provide facility wide education. The CC reiterated that the facility took infection control very seriously and would make the necessary changes. VI. Record review Removing PPE Droplet Precautions competency checklist was provided by the NHA on 6/18/21 via email. The checklist reviewed the staff's ability to perform hand hygiene and don and doff PPE. Staff were observed on the proper use of the PPE and hand hygiene. The checklist noted hand hygiene should be performed between steps if hands become contaminated and immediately after removing all PPE. According to the checklist, the outside of the gloves were contaminated. VII. Failure to offer residents hand hygiene prior to eating A. Facility policy and procedures The Hand-washing policy, which was undated, was provided by the nursing home administrator (NHA) on 6/7/21. It documented proper hand-washing techniques were used for the prevention of transmission of infectious diseases. It documented that all dining table settings should have hand sanitizing wipes available for resident use to promote choice in regards to hand hygiene during all meals including breakfast, lunch and dinner. It documented facility staff would encourage residents to utilize the hand sanitizing wipes to prevent infection. B. Room tray observations On 6/7/21 at 4:27 p.m., certified nurse aide (CNA) #7 was observed delivering a resident room tray. She was not observed offering the resident hand hygiene of any type prior to the resident eating his dinner. An individual hand sanitizing packet was not observed on the resident's s room tray when it was delivered (as indicated in the NHA interview, see below). The following was observed on the 500 hall, the rehabilitation isolation hall, on 6/8/21 between 5:00 p.m. and 5:15 p.m.: -CNA #7 delivered the dinner tray to the resident in room [ROOM NUMBER]. She asked the resident if they needed help to sit up on the couch, but failed to offer an opportunity for hand hygiene prior to the resident eating her meal. There was not an individual hand sanitizing packet observed on the room tray. -CNA #7 delivered a room tray to room [ROOM NUMBER]. She did not offer the resident hand hygiene prior to eating their meal. C. Outer dining room observation/staff interview On 6/8/21 at 4:05 p.m., dietary aide (DA) #1 was observed passing a dinner tray to a male resident seated in the outer dining room. She was not observed offering the resident any type of hand hygiene prior to eating. The DA said CNAs passed the resident's room trays and the DAs passed the resident trays in the dining rooms. D. Main dining room observations The main dining room was continuously observed on 6/8/21 from 4:10 p.m. through 4:45 p.m. The following was observed: -At 4:15 p.m.,a female resident was not offered hand hygiene when the director of nursing (DON) initially brought her into the dining room. -At 4:20 p.m., CNA #5 was observed performing her own hand hygiene between residents, but failed to offer hand hygiene to a resident when she delivered their food prior to the resident eating. -At 4:29 p.m., the NHA was observed serving a male resident his dinner without offering hand hygiene to the resident prior to eating. -At 4:31 p.m., DA #1 was observed serving a female resident her dinner without offering hand hygiene prior to eating. -At 4:32 p.m., DA #1 was observed serving another resident without offering hand hygiene prior to eating. -At 4:40 p.m., DA #1 was observed serving a male and female resident at the same table their dinners without offering hand hygiene to either resident prior to their eating. -At 4:45 p.m., DA #1 was observed serving a resident their dinner without offering hand hygiene. E. Staff interviews Registered nurse (RN) #1 was interviewed on 6/9/21 at 4:00 p.m. She said residents should be offered hand hygiene when they receive their activities of daily living care, when their hands are visibly soiled, anytime they went to the bathroom and before and after meals. DA #1 was interviewed on 6/10/21 at 11:24 a.m. She said she was very new to the facility and had only been working in the kitchen for a few days. She said she was trained by one of her peers, who did not educate her about ensuring residents practiced some type of hand hygiene prior to eating. She said the facility did have some individual wet wipes that were occasionally used, but not consistently. She said she would encourage the residents to practice hand hygiene prior to eating when she remembered, which she admitted was not all of the time. She said she understood the importance of this practice due to COVID-19. The dining room hostess (DRH) was interviewed on 6/10/21 at 11:26 a.m. She said she had worked in the facility for one month and had never been educated about providing hand hygiene to residents prior to their meals. The NHA, DON and the corporate consultant (CC) were interviewed together on 6/10/21. They said hand hygiene should be offered and provided to the residents before and after meals and after toileting. They said some residents wash their hands in their rooms with soap and water prior to coming down to the dining room. -However, residents who then propel their wheelchairs or roll their walkers down to the dining room and what surfaces the residents touch that actually or potentially infect the resident's hands with dirt and germs. They acknowledged the risk of contaminated hands after the resident left their room for the dining room due to propelling their wheelchair or walker. They acknowledged hand hygiene was not being offered to residents prior to eating on a consistent basis based on observations (see above). The NHA said there were individual wet wipes in the dining room. She said the dietary staff did not always remember to place those wipes on the table or encourage residents to practice hand hygiene prior to eating. The DON said she understood residents could get everything and anything (referring to infections) if the facility did not practice hand hygiene consistently prior to the residents eating their meals. IX. Facility COVID-19 status The facility chief executive officer (CEO) was interviewed on 6/9/21 at 4:55 p.m. The CEO said the facility had no positive cases of COVID-19. She said the facility had not had an occurrence or outbreak of COVID-19. VII. Medication pass A. Observation and interviews On 6/9/21 at 8:50 a.m. a medication observation was conducted with licensed practical nurse (LPN) #2. She did not don gloves prior to applying a medicated transdermal patch to the resident ' s mid back. She prepared the Lidocaine (a local anesthetic) transdermal patch for application by cutting open the sealed package. She then went to the resident, explained she had his patch and then he turned to his side. With her bare hands she untucked his shirt and then his undershirt. She then removed the patch from the packaging, removed the protective backing from the patch and applied it, medicated side down, on his mid back. LPN #1 was interviewed on 6/9/21 at 8:59 a.m. She said she did not know if she should have put gloves on prior to applying the Lidocaine patch. She said she would find out. At 9:30 a.m. a medication observation was conducted with certified nurse aide with medication authority (CNA) #2. She did not don gloves prior to applying a medicated transdermal patch to the resident ' s lower back. She prepared the Lidocaine transdermal patch for application by cutting open the sealed package. She then went to the resident, explained she had her patch and then she turned to her side. With her bare hands she assisted the resident to pull up her top. She then removed the patch from the packaging, removed the protective backing from the patch and applied it, medicated side down, on her lower back. CNA #2 was interviewed immediately after the above observation. She said as far as she knew she did not think she had to wear gloves to apply the Lidocaine patches. She said by not wearing the gloves there was a potential for cross-contamination. B. Administrative interview The director of nursing (DON) was interviewed on 6/10/21 at 8:15 p.m. She said gloves must be worn at all times when handling and administering medicated patches due to the medication potentially absorbing through the nurses hands. She said there was also a potential for cross contamination.