**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Incident of physical abuse on 8/29/24 between Resident #52 and Resident #26 A. Facility investigation The facility's investigation of the incident on 8/29/24 between Resident #52 and Resident #26 was provided by the DON on 11/19/24 at 4:01 p.m. A statement written by CNA #4 on 9/3/24 documented Resident #52 and Resident #26 were observed attempting to elope from the Bookcliff hallway on 8/29/24 at approximately 5:45 p.m. CNA #4 said the door alarm went off and she responded in an attempt to redirect Resident #52 and Resident #26. CNA #4 said Resident #26 asked for keys to leave the facility and CNA #4 told Resident #26 she did not have them. CNA #4 said Resident #26 began yelling at her and Resident #52 told Resident #26 not to yell at CNA #4. CNA #4 said Resident #26 threatened to hit Resident #52. CNA #4 said Resident #52 put her hand on the back of Resident #26's neck and said she would like to see Resident #26 try. CNA #4 said Resident #26 then attempted to uppercut Resident #52 with only her index finger connecting to Resident #26's chin. CNA #4 said Resident #52 pushed Resident #26 and Resident #26 pushed Resident #52 back in response. CNA #4 said she was able to intervene and separate Resident #52 and Resident #26. A statement written by the NHA on 8/29/24 documented observations of facility camera surveillance footage between 5:30 p.m. and 6:00 p.m. on 8/29/24. The observation documented that Resident #52 and Resident #26 were observed attempting to elope through the Bookcliff stairwell exit door. The statement documented that when a staff member approached the residents, Resident #52 went into her room briefly and then returned. The statement documented that Resident #26 was observed to be tapping Resident #52 on her chin. The statement documented Resident #52 then pinched or poked Resident #26 and Resident #26 poked Resident #52 in response. The statement documented neither resident was observed to stumble or fall. The investigation documentation included new recommendations for Resident #52's medication regimen to address her anxiety and restlessness. The investigation documented the facility updated care plans for Resident #26 and Resident #52. The facility documented that the attending physician, the NHA, the DON and the social services department were notified of the incident on 8/29/24 within two hours of the event occurrence. The facility documented that the police department and adult protective services were notified at 6:45 p.m. on 8/29/24. The state health department, veteran's affairs, and the ombudsman were also notified of the event on 8/29/24. The summary of the investigation documentation, not dated, was provided by the DON on 11/19/24 at 4:01 p.m. It read in pertinent part; Abuse is unsubstantiated. Element of bodily injury or unreasonable confinement or restraint not met. Element of fear not met for verbal abuse as both residents remain at baseline prior to incident. -However, CNA #4's statement documented that Resident #26 attempted to hit Resident #52 in an uppercut motion and the statement further documented Resident #26 and Resident #52 pushed each other. -Furthermore, the NHA documented she observed via the camera footage, that Resident #26 intended to hit Resident #52 with her hand and the NHA documented Resident #52 and Resident #26 pinched and poked each other (see NHA statement above and interview below). B. Resident #52 1. Resident status Resident #52, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included dementia, unspecified mood disorder and unspecified depression. The 9/12/24 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of five out of 15. The resident required moderate assistance with oral hygiene, dressing and toileting hygiene. The assessment documented Resident #52 was independent with all other aspects of daily mobility. The assessment documented that Resident #52 exhibited wandering behaviors on a daily basis which put her at a significant risk for her to get to a potentially dangerous place. The assessment documented that Resident #52 had exhibited physical and verbal behavioral symptoms directed towards others on one to three days during the assessment period. The assessment documented Resident #52's physical and verbal behaviors created a significant risk of causing herself physical illness or injury, significantly interfered with her care and put others at significant risk for physical injury, intruded on the safety or privacy of others and disrupted the care environment. The assessment documented that Resident #52's behaviors were getting worse. 2. Resident #52's representative interview Resident #52's representative was interviewed on 11/20/24 at 10:07 a.m. The representative said Resident #52 had severe dementia and elopement behaviors. The resident's representative said he thought Resident #52 and Resident #26 were friends. He said he had seen Resident #52 and Resident #26 arguing in the dining room, however, Resident #52 was known to argue with others around her for years even before she received her dementia diagnosis. The resident's representative said he was notified that Resident #52 and Resident #26 hit each other on 8/29/24 after trying to elope from the facility together. He said Resident #52 was not known to be physically aggressive before the event on 8/29/24. 3. Record review The elopement plan of care, initiated and revised 9/3/24, documented that Resident #52 was a high elopement risk because of her cognitive deficits. The plan of care documented the goal was for Resident #52 to be at a reduced risk of injury and elopement through the review period. The plan of care documented interventions including redirecting Resident #52 to other activities of interest when she was wandering, to keep Resident #52 within line of sight of staff members when outside of her room and to reassure Resident #52 that the animals were fed and her kids were safe. A social services quarterly note, dated 10/2/24, documented that Resident #52 was a high elopement risk and the resident needed to be within staff line of sight when outside her room. A behavior monitoring note, signed 8/30/24 by LPN #4, documented that Resident #52 and Resident #26 were observed attempting to elope on 8/29/24 after dinner. The note documented that Resident #52 punched Resident #26 in her neck. It documented that immediately thereafter, both residents were separated and placed on frequent checks. C. Resident #26 1. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included dementia, unspecified depression and anemia. The 8/22/24 significant change MDS assessment documented Resident #26 was severely cognitively impaired with a BIMS score of six out of 15. The resident required supervision with upper body dressing and oral hygiene and moderate assistance with personal hygiene. The assessment documented that Resident #26 was independent walking 50 feet, but required a helper to provide verbal cues when walking 150 feet. The assessment documented Resident #26 was independent with all other aspects of daily mobility. The assessment indicated Resident #26 experienced hallucinations and delusions but did not exhibit physical or behaviors directed towards herself or others. The assessment documented that Resident #26 exhibited wandering behaviors on one to three days during the assessment period, but the wandering behavior did not place the resident at risk of getting to a potentially dangerous place. 2. Record review The elopement plan of care, initiated 5/2/24 and revised 7/12/24, documented that Resident #26 was at a high risk of elopement because the resident would often be looking for her husband and children, and experienced increased confusion. The facility documented her elopement plan of care goal was to keep her safe through the current review period. The facility documented interventions included keeping Resident #26 within line of sight when she went upstairs to the office or visited with other residents, to offer distractions to decrease wandering behaviors, and to reassure the resident that her family was fine because Resident #26 was often confused about where she was at. A social services quarterly assessment, dated 7/17/24, documented Resident #26 did not have a history of wandering behaviors. The assessment documented Resident #26 did not have elopement precautions and Resident #26 was not at risk for elopement. -The social services quarterly assessment failed to accurately document Resident #26's wandering behaviors. An elopement assessment, dated 11/12/24, documented that Resident #26 had no history of wandering behaviors. The assessment documented Resident #26 was a moderate risk for elopement. -The elopement assessment failed to document the elopement behaviors witnessed by the facility staff on 8/29/24. D. Staff interviews Registered nurse (RN) #1 was interviewed on 11/20/21 at 9:51 a.m. RN #1 said Resident #26 and Resident #52 were both known to wander in the facility, but it was usually rare for Resident #26 to wander while it was often a daily occurrence for Resident #52 to wander. RN #1 said Resident #52 was known to help other residents and the resident would wander around to look for other residents who needed help. RN #1 said Resident #52 was easily redirected when she was observed to be wandering where she was not supposed to be. RN #1 said she had heard Resident #52 and Resident #26 hit each other a few months ago. Nursing assistant (NA) #2 was interviewed on 11/21/24 at 10:41 a.m. NA #2 said she was present in the building on 8/29/24. NA #2 said at the time, she was in the role of a student observer on the upstairs floor. NA #2 said she was not interviewed as part of the investigation between Resident #52 and Resident #26. NA #2 said she did not see anything occur that day since she was on the second floor and the event occurred on the first floor of the building. NA #2 said Resident #52 was known to wander in other resident rooms and all nursing staff knew to look out for her whenever she was moving in the building to ensure she was not going somewhere she was not supposed to. RN #2 was interviewed on 11/21/24 at 3:21 p.m. RN #2 said she heard Resident #52 and Resident #26 hit each other several months ago while trying to elope through the stairwell door. RN #2 said she was not working in the building on 8/29/24. RN #2 said when she worked downstairs she kept a close eye on both residents. RN #2 said she had not observed either Resident #52 or Resident #26 exhibit aggressive behaviors in September 2024, October 2024 or November 2024. RN #2 said care staff had to redirect Resident #52 from her wandering behaviors on a daily basis. RN #2 said she had observed Resident #26 exhibit wandering behaviors on only one occasion in the last few months. The NHA was interviewed on 11/22/24 at 11:32 a.m. The NHA said she reviewed the camera footage of the physical altercation that occurred between Resident #52 and Resident #26 on 8/29/24 but said she did not witness the original event occur. The NHA said the camera footage revealed Resident #52 approached Resident #26 from behind and placed her open hand on the back of Resident #26's neck. The NHA said she then Resident #26 brushed the chin of Resident #52. The NHA said both residents poked and pinched each other, but she could not remember when that occurred. The NHA said Resident #52 and Resident #26 were observed willfully touching each other on the camera footage. The NHA said the camera footage of the event was not available for anyone to view because the video footage had been deleted. Based on observation, record review and staff interviews, the facility failed to ensure three (#12, #26 and #52) of seven residents reviewed for abuse out of 41 sample residents was kept free from abuse. Specifically, the facility failed to: -Protect Resident #12 from physical abuse from a staff member; and, -Protect Resident #26 from verbal abuse from Resident #52. Findings include: I. Facility policy and procedure The Abuse policy, revised 9/19/24, was provided by the nursing home administrator (NHA) on 11/18/24 at 1:21 p.m. The policy read in pertinent part, It is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent mistreatment, abuse, neglect, and exploitation (MANE). The facility will take necessary precautions to prevent resident abuse by anyone including staff members, other residents, volunteers, contracted staff, family members, resident representatives, visitors, and any other individuals. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility employees and contractors will be educated on MANE during initial orientation. Existing staff will receive annual education and as needed. Training topics should include: -Types of abuse; -Prohibiting and preventing all forms of MANE; -Identifying what constitutes MANE; -Recognizing signs of MANE, such as physical or psychosocial indicators; and, -Reporting process for MANE, including injuries of unknown sources. Understanding behavioral symptoms of residents that may increase the risk of MANE such as: -Aggressive and/or catastrophic reactions of residents; -Wandering or elopement-type behaviors; -Resistance to care; -Outbursts or yelling out; and, -Difficulty in adjusting to new routines or staff. II. Allegation of physical abuse of Resident #12 from certified nurse aide (CNA) #2 A. Allegation of physical abuse on 11/11/24 The 11/11/24 alleged abuse incident report was provided by the director of nursing (DON) on 11/20/24 at 1:49 p.m. Resident #12 alleged that a male CNA (CNA #2) held/grabbed his arms during care that the resident did not want done. The resident reported the allegation to the DON and the lead CNA on 11/11/24 at 1:38 p.m. Resident #12 reported that the male CNA (CNA #2) held/grabbed his arms so another staff member could change him when he refused wanting to be checked and changed. According to the incident report, the resident was alert and oriented and immediately assessed for injury. The assessment of the resident's right hand identified Resident #12 had a small crescent moon shaped bruise on the back side between his thumb and his first finger. He had multiple red marks on his left arm that the resident said were bruises, however, the marks were consistent with various red age spots on both his arms. According to the incident report, the facility started an investigation after the allegation of the abuse. The NHA provided the 11/11/24 alleged abuse occurrence investigation packet on 11/19/24 at 4:25 p.m. According to the alleged abuse occurrence investigation, Resident #12 reported CNA #2 entered his room on 11/11/24 at 3:00 a.m. and held him down to change his brief. The alleged abuse occurrence investigation documented the alleged assailant was placed on administrative leave pending the investigation, a skin assessment was completed for Resident #12 and other staff and residents were interviewed. The 11/11/24 interview with Resident #12 documented Resident #12 reported to the DON two staff members requested to change the resident's brief. Resident #12 declined the request which prompted CNA #2 to hold the resident's arms while the other CNA changed his brief. According to the documented interview, Resident #12 was yelling out as his arms were held and his brief was changed. The 11/11/24 interview with CNA #2 documented CNA #2 said he entered Resident #12's room and the resident was yelling at him and told him to leave his room. CNA #2 said he left the room and reported the interaction to the night shift nurse. According to the documented interview, CNA #2 said he later returned to the room with CNA #3 to change Resident #12. CNA #2 reported the resident became physically and verbally aggressive. The 11/11/24 documented interview with CNA #2 further revealed CNA #2 said he grabbed Resident #12's arm to prevent him from hitting CNA #3. CNA #2 said he did not leave the room when the resident was upset because he was told by CNA #3 that Resident #12 needed to be changed on the last rounds, no matter what. The documented interview indicated CNA #2 and CNA #3 received education from the night shift nurse to leave the situation next time and report the resident's refusal to the nurse. The 11/11/24 documented interview with CNA #3 identified CNA #3 witnessed CNA #2 grab Resident #12's arms to prevent the resident from hitting her face. The 11/11/24 alleged abuse occurrence investigation packet identified four other residents and three other staff members were interviewed as part of the initial investigation. A staff interview with CNA #4 documented another resident (Resident #37) told her CNA #2 was a bit rough in his approach and felt he could benefit from some additional training. The summary of the investigation included in the 11/11/24 alleged abuse occurrence investigation packet documented Resident #12 was combative and struck CNA #3 when she was providing cares so CNA #2 held his arm back to prevent her from being hit. According to the summary, CNA #3 felt there was no malicious intent of CNA #2 with his actions, no other residents expressed fear or experienced injury from a staff member and Resident #12 had no behavioral changes after the incident. The summary of the investigation indicated the documentation following the incident did not identify Resident #12 had new bruises or injuries consistent with the allegation noted to his arms following the incident. According to the summary, the resident had a small one centimeter (cm) bruise in between his thumb and index finger where he would normally grip his wheelchair. The summary of the investigation documented the facility did not determine physical abuse occurred because there were no injuries or bruising on the resident's arms consistent with the allegation and the resident had a noted history of prejudice. According to the summary, CNA #2 was asked to return to the facility and his contract was terminated. -However, abuse occurred because CNA #2 willfully held Resident #12's arm down while CNA #3 changed the resident. B. Resident #12 1. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included mild cognitive impairment of uncertain or unknown etiology, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The 10/10/24 minimum data set (MDS) assessment documented Resident #12 had moderate cognitive impairment deficits with a brief interview for mental status (BIMS) score of 12 out of 15. He did not have inattention, disorganized thinking, hallucinations or delusions. Resident #12 used a wheelchair for mobility. According the MDS assessment, Resident #12 did not have physical or verbal behavioral symptoms directed at others or rejections of care. 2. Resident observation and interview Resident #12 was interviewed on 11/18/24 at 4:09 p.m. Resident #12 said a little over a week ago, a large male CNA (CNA #2) entered his room in the middle of the night and wanted to change Resident #12's brief and bed pad. The resident told CNA #2 he was comfortable and did not want to be changed at that time. Resident #12 said CNA #2 left the room but returned with a female CNA (CNA #3) a few minutes later. He said the CNA #3 tried to forcibly remove his underwear while CNA #2 held him down by his arms. He said both CNAs left the room after he was changed. Resident #12 said he was bruised as a result of the incident. Resident #12 pointed out small red spots on both forearms/wrists and a fading purple bruise approximately the size of a quarter, on the back side of his right hand. between his thumb and index finger. He said he had reported the incident to staff on the same day as the incident. He said he had not seen CNA #3 since the incident and had heard CNA #2 was terminated. He said he had not had any concerns with other staff. Resident #12 was interviewed a second time on 11/20/24 at 1:45 p.m. Resident #12's bruise was slightly lighter in color. He said he was not fearful of anyone. 3. Record review The cognitive impairment care plan, initiated 4/14/24, identified Resident #12 had mild cognitive impairment and needed reduced distractions during interactions. The care plan was updated on 11/11/24, after the incident, to include the following interventions: -Reminding Resident #12 he was safe in his environment; -Explaining provided tasks/care in short simple sentences; -Allowing Resident #12 time to process information and respond; -Leaving the room if Resident #12 resisted a staff provided task, making sure the resident was safe and asking a different team member to approach the resident again in a timely manner; and, -Respecting Resident #12's right to decline. The psychosocial well-being care plan, initiated 4/22/24, identified Resident #12 experienced loss of his spouse in May 2024 and loss of his home of 30 years. The care plan directed staff to allow Resident #12 time to answer questions and to verbalize his feelings, perceptions and fears and validating his concerns and feelings. The activity of daily living (ADL) care plan, initiated 10/7/24, directed staff to provide the resident with supportive care, assistance with mobility and encourage him to use the call light for assistance. According to the care plan, staff should allow Resident #12 sufficient time for dressing and undressing. -The review of progress notes and skin assessments prior to 11/11/24 did not not identify a bruise on Resident #12's hand. The 11/12/24 nurse progress note documented Resident #12's arms were assessed on 11/11/24 and 11/12/24 to ensure safety following the (11/11/24) occurrence investigation. The note identified a small crescent moon shaped bruise on his right hand between his thumb and first finger and red marks which were consistent with age spots. According to the note, there were no behavioral changes following the incident, the resident felt he was doing well and spent time with staff and family. The note documented staff would continue to monitor the red spots on his left arm. -The note did not identify the staff would continue to monitor the bruise on his hand. The 11/13/24 nurse progress note documented the nurse met with the resident on 11/13/24. According to the note, Resident #12 had no new bruising and the spots on the left arm continued to be consistent with age spots and there were no changes in shape or color. He continued to deny pain, there were no changes in his behavior and the resident felt he was doing well. -The note did not identify the staff would continue to monitor the bruise on his hand. The Personal Care: Dressing Dependent Resident training, conducted with staff on 5/14/24, was provided by the corporate consultant (CC) on 11/26/24 at 12:17 p.m. The training identified staff should never forcefully pull or tug on clothing to assist a resident while dressing because it could cause injury. -The review of the training did not identify CNA #2 or CNA #3 had attended the training. The Competency Fair staff training, conducted on 10/15/24 and 10/16/24, was provided by the CC on 11/26/24 at 12:17 p.m. The training reviewed facility policies, such as abuse training. -The review of the Competency Fair attendance sheet, identified CNA #2 and CNA #3 did not attend the training. The Emergency Response Plans staff signature sheet, dated between 1/16/24 and 11/21/24, and the facility's onboarding packet was provided by the DON on 11/22/24 at 9:34 a.m. The packet included the abuse policy and the resident rights policy. The resident rights policy identified residents had the right to be free of verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. According to the policy, the residents had the right to make choices regarding their care, including schedules, activities, healthcare providers or health care services. -The review of the Emergency Response Plans staff signature sheet revealed CNA #2 did not sign that he had received the emergency response plans and onboarding packet. C. Staff interviews The DON was interviewed on 11/20/24 at 4:10 p.m. The DON said if there was a new bruise on a resident, staff should try to determine what was the cause of the bruise. She said staff would interview the resident and notify the physician. She said the facility would make sure the resident was safe and the bruise was not caused by another person. She said the bruise would be documented in the risk management assessment. The DON said if the cause of the bruise was not known, then she would start an investigation and interview staff. The DON said the bruise on the right hand of Resident #12 was found during a skin assessment after a reported incident on 11/11/24. The DON said Resident #12 alleged, on 11/11/24, that a staff member grabbed his arms and held him. She said the resident reported the incident to her and the lead CNA. She said the CNA (CNA #2) was an agency/travel staff member. She said CNA #2 and CNA #3 were interviewed. The DON said both CNAs said Resident #12 attempted to hit CNA #3 so CNA #2 grabbed his arm to stop him. She said CNA #2 reported he grabbed the resident's left arm. The DON said the agency CNA #2 worked for was notified and CNA #2 was suspended, pending the investigation. The DON said Resident #12 did not have a bruise on his left arm. She said the bruise on the back of his right hand was in the shape of a half moon and in between his index finger and his thumb. The DON said the bruise was not identified before the 11/11/24 incident. She said she thought the bruise might have been caused by his wheelchair. She said the bruise matched up to where he would put his hand on the wheelchair. She said she was not aware of any incidents or observations which indicated that the resident injured himself from use of his wheelchair. She said it was possible the resident's bruise was caused during the 11/11/24 incident. The DON said the facility decided not to have CNA #2 return to the facility because another resident felt the CNA was rough with care. She said the term rough could be a trigger word for potential abuse. The DON said the other residents were not fearful of CNA #2 and said he was just a little rough. The social service assistant (SSA) was interviewed on 11/21/24 at 10:07 a.m. The SSA said she assisted with abuse investigations when they were reported to her. She said she was a nurse and would conduct a head to toe assessment when needed, by use of the weekly assessment form if there was a bruise that was unexplained or an allegation of abuse. The SSA said she interviewed residents anytime that there was a potential abuse allegation, including verbal and physical abuse, including a resident to resident altercation. She said if a resident was not able to answer the questions, she and the staff would make observations of their behaviors and complete an assessment for non-interviewable residents. The SSA said the social services department would report their piece of the investigation findings to the interdisciplinary team (IDT) and the NHA would make the determination if abuse was substantiated or not. The NHA was interviewed on 11/21/24 at 10:33 a.m. The NHA said she reported all allegations of abuse to the State Agency and then the social services department started the investigation with a skin assessment to check for injuries and interviews with staff. She said if a resident had a high BIMs score, they would be interviewed. She said staff should attempt to interview pertinent residents even if they had a lower BIMS score. She said if the resident was not interviewable, a non-interviewable form would be completed. The NHA said there needed to be enough information gathered to make the determination if abuse occurred. The NHA said to substantiate abuse, she needed to confirm elements of abuse occurred, such as injury and or fear, depending on what type of abuse was alleged. She said she did not determine the allegation of physical abuse towards Resident #12 was substantiated after the investigation because the resident said it was his arms that were grabbed and the bruise was found on his hand. The NHA said CNA #2 said Resident #12 kicked CNA #3 but he did not make contact with her with his hand. The NHA said Resident #12 did not indicate fear and there was no injury to his arms where he said he was grabbed. The NHA said CNA #2 was preventing the resident from striking CNA #3. She said CNA #2 was asked not to return to the facility after the incident because another resident said he was a bit rough with care. The NHA said the term rough could be a trigger word indicating potential abuse. She said the facility started an investigation when a resident alleged potential abuse. The DON was interviewed a second time on 11/21/24 at 10:54 a.m. She said CNA #2 and CNA #3 were educated by the night nurse after the incident. CNA #2 and CNA #3 were told they should have not performed ADLs after Resident #12 refused and should have informed the nurse of the refusal. The DON said both CNAs were temporary traveling staff. She said before they started working independently with the residents, they had to shadow another staff member and sign off on a packet of facility expectations and policies. She said the abuse policy was included in the packet the CNAs had to sign off on that they would have received. -However, record review revealed CNA #2 did not sign the receipt of the facility's packet that included the abuse policy. The DON was interviewed on 11/22/24 at 9:34 a.m. She confirmed CNA #2 did not sign the facility policies and expectations when he was on boarding The CC was interviewed on 11/22/24 at 12:10 p.m. The CC said the facility would make sure all temporary and current staff had reviewed and signed off on the facility policies and expectations after it was identified CNA #2 did not sign that he received the packet that included the abuse policy. The DON and the CC were interviewed together on 11/22/24 at 12:13 p.m. The CC said bruises should be monitored for 72 hours after the bruise was identified. The DON said the documentation in Resident #12's EMR did not clearly indicate the bruise to his hand was monitored. She said she recently looked at it and it was looking much better then when it was first identified on 11/11/24. The DON said Resident #12 had not made allegations towards staff before 11/11/24. The CC said restraining a resident's movement would be considered abuse. The NHA and the DON were interviewed together on 11/22/24 at 2:12 p.m. The NHA said the facility reviewed every occurrence/incident every month, including allegations of abuse and resident-to- resident altercations to identify possible trends and areas the facility needed to address. The NHA said the interdisciplinary (IDT) team tried to find the root cause of the concern, looking at what caused the incident and what could be put in place to prevent the incident from happening again. She said for resident-to-resident altercations, the team looked at interventions to help separate residents when needed and de-escalate the situation. The NHA and the DON said the facility had not looked at the lack of education provided to the temporary traveling staff. The DON said she recently requested the education the contr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure resident choices for one (#213) of two residents reviewed for activities of daily living (ADL) out of 40 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #213 per her preference. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised 6/6/24, was received from the corporate consultant (CC) on 11/22/24 at 1:33 p.m. It documented in pertinent part, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. II. Resident #213 A. Resident status Resident #213, age less than 65, was admitted on [DATE]. According to the November 2024 computerized physician order (CPO), diagnoses included paraplegia (loss of function in the lower legs), congestive heart failure,and generalized muscle weakness. According to the 11/14/24 minimum data set (MDS) assessment Resident #213 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented Resident #213 was dependent on staff for toileting, hygiene, dressing, chair and toilet transfers. The assessment did not document the amount of assistance Resident #213 needed with bathing. B. Resident interview and observations Resident #213 was interviewed on 11/19/24 at 9:35 a.m. Resident #213 said she was admitted to the facility earlier in the month and had only received one bed bath since her admission on [DATE]. Resident #213 said she hoped to receive two baths per week. Resident #213 said she was paraplegic and had no feeling below the level of her waist. Resident #213 said that she knew her care took more time and staff, since she was unable to move or control the lower half of her body. Resident #213 said she could not sense if the lower half of her body was not clean. Resident #213 said her hair was difficult to comb because it had not been washed recently. Resident #213 said she felt sad that she required extensive assistance with bathing because she perceived her extensive ADL care needs would reduce the help other residents received on her bath days. Resident #213's hair was greasy. She was attempting to comb through it, but was struggling to do so. On 11/20/24 at 9:12 a.m., the restorative registered nurse (RRN) was discussing the daily plan to get Resident #213 out of bed and into the wheelchair with another unidentified staff member. The RRN said Resident #213 required three person assistance with a hoyer lift to get her out of bed and into the wheelchair. III. Record review The ADL/mobility plan of care, initiated on 11/15/24 and revised on 11/15/24. The plan of care documented Bathing/Showering level of assistance: Independent; set-up assistance; supervision; minimal assist; extensive assist; dependent. -A review of the resident's comprehensive care plan did not reveal documentation indicating Resident #213's bathing preferences or the level of assistance Resident #213 required with bathing. The Bathing/shower preference documentation was reviewed between 11/7/24 and 11/21/24. The facility documented Resident #213 was unavailable for bathing preference discussions on 11/18/24 and bathing preference discussions were not applicable on 11/8/24, 11/11/24 and 11/15/24 (see interviews below). The facility point of care bathing documentation was reviewed for 14 days (11/7/24 to 11/21/24). It documented Resident #213 had received two baths out of four opportunities. IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 11/21/24 at 1:41 p.m. CNA #3 said it was normal for residents to receive two baths per week or by the resident's preference. CNA #3 said if a resident refused a bath the nurse would be told and the resident refusal would be documented in the electronic medical record (EMR). Registered nurse (RN) #2 was interviewed on 11/21/24 at 1:55 p.m. RN #2 said the residents received two baths per week on their chosen days unless the resident had a more specific preference. RN #2 said it was important to bathe residents to reduce infection risk and also because it felt nice to be clean. The director of nursing (DON) was interviewed on 11/22/24 at 10:27 a.m. The DON said she reviewed Resident #213's bathing documentation between 11/7/24 and 11/21/24. The DON said Resident #213 received two baths in the review period. The DON said Resident #213 did not receive enough baths. The DON said the residents should receive two baths per week or by their stated preference. The DON said Resident #213's bathing preference and assessment documentation did not make sense and should not have been documented as not applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#43 and #14) of seven residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician's orders and the resident's care plan out of 41 sample residents. Specifically, the facility failed to ensure Resident #43 and Resident #13, who were prescribed a mechanically altered diet texture, were served food in the correct form. Findings include: I. Facility policy and procedure The Therapeutics Diets policy, revised on 6/7/24, was provided by the corporate consultant (CC) on 11/21/24 at 1:33 p.m. It read in pertinent part, Each resident has a specific food and beverage preparation detailed on a tray card so accurate diets are served. Therapeutic diets are prepared and served according to written orders from the provider and are planned and served with supervision from the dietary manager (DM) or registered dietician (RD). Specific diets and textures are referenced in the diet manual with specific content and preparation. A current diet manual is available for reference to attending physicians, nursing service and dietary staff. Residents and/or their power of attorney (POA) may refuse the recommended diet. In this case the facility must provide education, provide and ask for a signature on a dietary waiver and increase monitoring at meal times. II. Facility's diet manual The Diet Manual, revised August 2015, was provided by the nursing home administrator (NHA). It read in pertinent, Dysphagia mechanically altered: This level consists of foods that are moist, soft textured and easily formed into a bolus. Meats are ground or minced no larger than one-quarter-inch pieces: they are still moist with some cohesion. This diet is a transition from the pureed textures to more solid textures. Chewing ability is required. The textures on this level are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia. Breads: Soft pancakes well moistened with syrup or sauce. Pureed bread mixes, pregelled or slurried breads that are gelled through entire thickness. Avoid all other breads. Vegetables:All soft, well-cooked vegetables should be smaller than half-an-inch and easily mashed with a fork. Avoid cooked corn and peas, broccoli, cabbage, brussels sprouts, asparagus or other fibrous non-tender or rubbery cooked vegetables. III. Facility recipes A. Salisbury steak Mechanical soft: Grind portions needed from regular prepared recipe into one eighth inch pieces. B. Garlic cheese biscuit It is recommended to serve pureed bread/biscuit or gelled bread for dysphagia diets, but if the speech language pathologist (SLP) at your facility signs and approves regular breads on an individual basis, chop regular portions. Make sure all particles are no more than half-an-inch by half-an-inch. -The facility served cooked biscuits with a slice of American cheese melted over the top (see observations below). IV. Resident #43 A. Resident status Resident #43, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician order (CPO) diagnoses included dementia, acute cough and dysphagia (difficulty swallowing). The 11/4/24 minimum data set (MDS) assessment revealed Resident #43 t had long-term and short-term memory problems and was severely cognitively impaired per staff assessment. The MDS assessment indicated Resident #43 required a mechanically altered diet. B. Record review A review of the November 2024 CPO revealed the resident had a physician's order that indicated the resident was prescribed a mechanical soft diet and was to be served his food on a lipped plate, ordered on 10/14/24. A review of Resident #43's electronic medical record (EMR) did not reveal a dietary waiver indicating the resident was able to consume regular textured food cut-up (see interview below). C. Observation The following was observed on 11/21/24 at 11:44 a.m.: Resident #43 was served a Salisbury steak and a dinner roll both were cut into bite-sized pieces. -The facility failed to serve theSalisbury steak ground and puree or gel the dinner roll as indicated on the recipe (see recipe above). V. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO diagnoses included dementia, Parkinsonism (degenerative disease that causes involuntary movements) and dysphagia. The 10/12/24 MDS assessment revealed Resident #14 t had long-term and short-term memory problems and was severely cognitively impaired per staff assessment. The MDS assessment indicated Resident #14 required a mechanically altered diet. B. Record review A review of the November 2024 CPO revealed the resident had a physician's order that indicated the resident was prescribed a mechanical soft diet and nectar thick liquids, ordered on 8/20/2020. A review of Resident #14's EMR did not indicate a dietary waiver that indicated the resident was able to consume regular textured food cut-up. The resident had a dietary waiver in place to consume thin liquids versus nectar thick (see interview below). C. Observations The following was observed on 11/21/24 at 11:44 a.m.: Resident #43 was served a regular textured Salisbury steak and a dinner roll both were cut into bite-sized pieces. -The facility failed to serve the Salisbury steak ground and puree or gel the dinner roll as indicated on the recipe (see recipe above). VI. Staff interviews Dietary aide (DA) #3 was interviewed on 11/21/24 at 11:50 a.m. DA #3 said Resident #43 and Resident #14 had waivers in place to eat regular or bite-sized textured foods. DA #3 said if a resident's plate looked like the wrong texture she would send it back to the kitchen to be fixed. DA #3 said she was unaware bread needed to be pureed or slurried on a mechanical soft diet. -However, review of the resident's EMR did not indicate dietary waivers were in place for the residents to receive regular textured food (see record review above). The cook (CK) was interviewed on 11/21/24 at 11:50 a.m. The CK said Resident #43 and Resident #14 were allowed to have bread and the Salisbury steak was the correct texture. The CK said she was unaware the bread needed to be pureed or gelled for residents who were prescribed a mechanical soft diet. The NHA, the CC and the registered dietitian (RD) were interviewed together on 11/21/24 at 12:57 p.m. The RD said the facility had not implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) program yet. She said the facility modified resident's diets based on what the SLP recommended. The NHA, the CC and the RD said they were unaware the facility's diet manual indicated the mechanically soft texture required the bread to be pureed or slurried. The RD said although the Salisbury steak was made from ground beef it should not have been formed into a steak shape and cut into bite-sized pieces. The RD said the residents should have been served ground beef with the gravy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, the facility failed to ensure facility staff used blood pressure cuffs rated for medical use. Findings include: I. Professional reference According to the [NAME] Advantage for Basic Nursing handbook, third edition, retrieved on 11/25/24 from Treas, [NAME] S., et al. [NAME] Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. [NAME] Company, 2022., Blood Pressure - Practical Knowledge, Electronic blood pressure monitors may be less accurate than those with an aneroid monitor (a manual blood pressure measuring device). To ensure accuracy, you should auscultate (listen to) a baseline blood pressure before initiating automatic monitoring. Ensure devices are rated for medical use. The width of the blood pressure cuff bladder of a properly fitting cuff will cover approximately two-thirds of the length of the upper arm for an adult, and the entire upper arm for a child. Alternative sites you can use are the forearm, thigh, or calf. However, systolic pressure may be 20 to 30 mmHg (millimeters of mercury) higher in the lower extremities than in the arms, but diastolic pressures are similar. Abnormally high or low blood pressure readings should be rechecked by the provider. II. Facility policy The Medical Equipment policy, revised 7/1/24, was provided by the corporate consultant (CC) on 11/22/24 at 1:39 p.m. It documented that all durable medical equipment (DME) to be used for resident assessment and monitoring would be deemed medically rated for use in health care facilities. III. Observations On 11/20/24 at 8:52 a.m., licensed practical nurse (LPN) #1 was observed using a Veridian Healthcare model 01-574 model wrist type blood pressure cuff to take Resident #213's blood pressure. -LPN #5 did not use a blood pressure cuff rated for medical use to obtain Resident #213's blood pressure (see professional references above and interview below). On 11/20/24 at 10:23 a.m., registered nurse (RN) #4 was observed taking Resident #33's blood pressure using a W1101L wrist type blood pressure cuff. -RN #4 did not use a blood pressure cuff rated for medical use to obtain Resident #33's blood pressure (see professional references above and interview below). IV. Record Review On 11/20/24 at 11:57 a.m., the director of nursing (DON) said (via email) that she could not find manufacturer's instructions for the W1101L wrist type blood pressure cuff or the Veridian Healthcare model 01-574 model wrist type blood pressure cuff that documented either device was rated for medical use. The DON said both blood pressure cuffs had been removed from use in the facility on 11/20/24. V. Staff interviews LPN #1 was interviewed on 11/20/24 at 8:55 a.m. LPN #1 said she enjoyed using the Veridian Healthcare model 01-574 model wrist type blood pressure cuff to obtain blood pressures on residents. LPN #1 said she did not know if the blood pressure cuff was rated for medical use. LPN #3 was interviewed on 11/21/24 at 1:17 p.m. LPN #3 said she had used both the Veridian Healthcare model 01-574 model wrist type blood pressure cuff and the W1101L wrist type blood pressure cuff to obtain resident blood pressure readings. LPN #3 said the blood pressure cuffs were stored in a protective case on each medication cart to use whenever nurses needed to. LPN #3 said she did not know if the devices were rated for medical use. The DON was interviewed on 11/22/24 at 10:27 a.m. The DON said she had obtained the blood pressure cuffs from a medical supply company but did not verify if the blood pressure cuffs were rated for medical use. The DON said she was surprised to learn the Veridian Healthcare model 01-574 model wrist type blood pressure cuff and the W1101L wrist type blood pressure cuff were not rated for medical use. The DON said it was important for the facility to use blood pressure cuffs rated for medical use to ensure residents' vital signs were accurate. The DON said residents could receive blood pressure medications when they were not needed if the facility relied on the accuracy of a non-medically rated device to obtain resident blood pressures.

Based on record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in two of three medication storage refrigerators. Specifically, the facility failed to maintain a medication refrigerator temperature log for the facility vaccine refrigerator and the medication refrigerator. Findings include: I. Professional reference According to the Centers for Disease Control (CDC), Handle with Care: Protect your Vaccine, Protect Your Patients, (revised on 3/19/24) was retrived on 11/26/24 from https://www.cdc.gov/vaccines/hcp/admin/storage/downloads/vaccine-storage-temperatures.pdf Keep your storage units and vaccines within the appropriate temperature ranges. Check and record storage unit min/ma (minimum/maximum) temperatures at the start of each workday. II. Facility policy and procedure The Medication Storage policy, revised on 1/25/24, was provided by the nursing home administrator (NHA) on 11/21/24 at 2:43 p.m. It documented in pertinent part, All drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. II. Record review The vaccine and medication refrigerator temperature log records from 10/1/24 to 11/19/24 were provided by registered nurse (RN) #1 on 11/20/24 at 2:16 p.m. Out of 50 days of documentation opportunities, vaccine refrigerator temperatures were documented on 16 of those days. Out of 50 days of documentation opportunities, medication refrigerator temperatures were documented on 24 of those days. III. Staff interviews RN #1 was interviewed on 11/20/24 at 2:16 p.m. RN #1 said the medication and vaccine refrigerator temperatures should be logged every night by night shift nurses. RN #1 said many days had not been documented in the medication and vaccine refrigerator temperature logs. RN #1 said it was important to ensure medications were safely stored at the correct temperature so they could be safely administered to residents. The director of nursing (DON) was interviewed on 11/22/24 at 10:27 a.m. The DON said that all floor nurses were responsible for recording medication refrigerator temperatures. The DON reviewed the medication and vaccine refrigerator temperature logs between 10/1/24 and 11/19/24. The DON said many days had not been documented in the temperature logs. The DON said the vaccine and medication refrigerator temperatures should be documented daily. The DON said that if these refrigerators were not monitored by staff, then medications could expire or not work correctly for residents.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to implement an effective system to identify and address multiple concerns related to quality of care, including accidents/hazards, in which the facility failed to conduct safety risk assessments for residents with transfer poles which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Facility policy The Quality Assurance Performance Improvement (QAPI) policy, updated 9/30/24, was provided by the nursing home administrator (NHA) on 11/18/24 at 1:21 p.m. The policy documented in pertinent part, It is the policy that the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life. Develop and implement appropriate plans of action to correct identified quality deficiencies. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. The QAPI plan should address the following elements: -Design and scope of the facility's QAPI program and QAA (Quality Assessment and Assurance) committee responsibilities and actions; -Policies and procedures for feedback, data collection systems, and monitoring; and, -Process addressing how the committee should conduct activities necessary to identify and correct quality deficiencies. Key components of this process include: -Tracking and measuring performance; -Establishing goals and thresholds for performance improvements; -Identifying and prioritizing quality deficiencies; -Systematically analyzing underlying causes of systemic quality deficiencies; -Developing and implementing corrective action or performance improvement activities; and, -Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. The facility takes actions aimed at performance improvement as documented in QAA committee meeting minutes and action plans. Performance/success of the actions should be monitored and documented in subsequent QAA committee or sub-committee meetings. To ensure improvements are sustained, the effectiveness of performance improvement activities should be monitored in QAA committee meetings in accordance with the QAPI plan, but no less than annually. II. Cross-referenced citations affecting quality of care identified during the facility's recertification on 11/22/24 Cross-reference F689: The facility failed to ensure the resident environment remained as free of accident hazards as possible. The facility failed to complete a safety risk assessment before placing resident transfer poles and failed to investigate after a transfer pole accident. Additional accident/hazards failures were identified related to fall prevention and smoking while wearing a nasal cannula and a turned off oxygen tank. The deficiency was cited at a K scope and severity, immediate jeopardy, pattern. Cross-reference F686: The facility failed to prevent a resident from developing a pressure ulcer and failed to ensure interventions were consistently in place to prevent the pressure ulcer from worsening. The deficiency was cited at a G scope and severity, actual harm, isolated. Cross-reference F880: The facility failed to maintain an effective water management plan. The deficiency was cited at a F scope and severity, potential for more than minimal harm, widespread. Cross-reference F600: The facility failed to protect residents from physical abuse. The deficiency was cited at a D scope and severity, potential for more than minimal harm, isolated. Cross-reference F761: The facility failed to maintain appropriate temperatures in the medication refrigerator and the vaccine refrigerator. The deficiency was cited at an E scope and severity, potential for more than minimal harm, pattern. Cross-reference F677: The facility failed to provide bathing per resident preferences. The deficiency was cited at a D scope and severity, potential for more than minimal harm, isolated. Cross-reference F908: The facility failed to use medically rated blood pressure cuffs to obtain residents blood pressures. The deficiency was cited at a D scope and severity, potential for more than minimal harm, pattern. Cross-reference F805: The facility failed to ensure residents were served food in a form designed to meet residents' needs per physician's orders. The deficiency was cited at a D scope and severity, potential for more than minimal harm, isolated. III. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 11/22/24 at 2:12 p.m. The NHA said the QAPI committee met monthly to continuously improve processes and meet standards. The NHA said all managers, the medical director, the pharmacist and the licensed social worker from a sister facility participated in the monthly QAPI meetings. The NHA said during the meetings, each manager reviewed their department reports and as a team, the committee tried to identify concerns, problem solve as a group and discuss how the facility would address the concern in attempts to resolve it. The NHA said the QAPI committee received additional insight from line staff, resident council, care conferences and morning nurse reports. The DON said each department would determine the root cause of their department concern. She said the department managers would bring their department concerns to the QAPI committee if they felt they needed to expand the discussion and analysis. The NHA said the QAPI committee created and implemented performance improvement projects/plans. She said the QAPI committee reviewed the implemented plans, made the determination if the identified concern was resolved and if the facility was able to effectively sustain system change. The NHA said if the plan did not produce a sustaining resolution to the concern, the committee would attempt to adjust the plan in efforts to resolve the concern. The DON said the QAPI committee reviewed falls monthly in the QAPI committee meeting. She said the committee looked at the number of falls in each month, whether the falls were witnessed or not, residents with multiple falls and where the falls occurred. The DON said if the facility had a resident fall several times in one month, the committee discussed the nature of the falls in an effort to gain additional insight and perspective that may not have already been identified. The DON said part of the root cause analysis was to identify if staff were properly educated and understanding why the falls happened. The DON said the process failed because the committee did not recognize what needed to be documented and not enough questions were asked to determine the full factor/cause of the falls. The NHA said the QAPI committee did not review smoking with a nasal cannula on or smoking near a turned off oxygen tank as a QAPI concern because the staff had not seen or reported to management that it was a concern. She said the resident involved in the situation was usually good about taking his oxygen off before he went outside to smoke. The DON said the QAPI committee did not review the residents' transfer poles and lack of safety assessments. The DON said the QAPI committee did not identify the assessments were not completed prior to the installation of the transfer poles. The NHA said pressure ulcers were reviewed in the QAPI committee meetings. The DON said pressure ulcers were reviewed during QAPI committee meetings. She said the team reviewed the residents who currently had pressure ulcers, identified if the pressure ulcers were improving, what treatments were being provided and received insight from the medical director on the pressure ulcers. The DON said the facility needed to work on improving documenting refusals of interventions, increasing observations of the resident and addressing concerns with the resident. The NHA said food textures were not reviewed in QAPI meetings. She said menus were reviewed but the committee had not discussed if the residents received the appropriate textured diets. The DON said diet order education with the kitchen staff had been discussed in the care concern at-risk meetings. The NHA said the registered dietitian (RD) had a weekly report of everyone with weight concerns and choking hazards. The NHA said the RD discussed any related concerns with the IDT, speech therapy and the kitchen staff and offered her recommendations. The DON said there had been a lot of confusion related to mechanical soft textures and she would like to look at new text diet texture processes and education. The DON said the use of medical grade blood pressure cuffs was not reviewed in QAPI meetings. The DON said she was not aware there was a problem with the blood pressure cuffs the facility was using. The NHA said residents' bathing preferences and choices had not been identified as a concern in QAPI meetings. She said residents did not usually address bathing preferences as a concern. She said the bathing preferences concern may have been addressed under the grievance process but the QAPI committee had not identified this as a concern. The NHA said resident-to-resident altercations were reviewed in QAPI committee meetings. She said the social services director (SSD) reviewed every occurrence identified in the previous month. The NHA said the QAPI committee discussed the occurrences to help identify trends that needed to be addressed. The NHA said the committee tried to find the root cause of the concern, looked at what caused each incident and tried to determine what could be put in place to prevent the incident from happening again. She said for resident-to-resident altercations, the team looked at interventions to help separate residents when needed and de-escalate the situations. The NHA said staff to resident physical abuse was discussed in QAPI meetings but the committee had not identified the concerns as a facility trend. The NHA and the DON said the facility had not looked at the lack of education provided to the temporary traveling staff. The DON said she recently requested the education the contract agency provided to the traveling staff. The NHA said refrigerator temperatures were reviewed in QAPI meetings, but not recently. She said in the past, audits identified concerns with consistent tracking of the temperature in the kitchen but refrigerators storing medications and vaccines had not been reviewed in QAPI committee meetings or identified as a concern. The NHA said the water management plan in relation to Legionella had not been reviewed in the QAPI meetings or identified as a concern. The NHA said the facility would look at all the identified concerns addressed and would relook at the facility's QAPI committee process, add additional audits and review how the QAPI committee analyzed facility concerns.

Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to implement an effective water management plan. Findings include: I. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 3/15/24, was retrieved on 11/26/24 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html It read in pertinent part, Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140°F (60°C). Ensure hot water in circulation does not fall below 120°F (49°C). Recirculate hot water continuously, if possible. Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113°F, 25-45°C). Legionella may grow at temperatures as low as 68°F (20°C). Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Ensure disinfectant residual is detectable throughout the potable water system. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. Consider testing for Legionella in accordance with the routine testing module of this toolkit. II. Facility policy and procedure The Legionella water management program policy was provided by the nursing home administrator (NHA) on 11/20/24 at 11:14 a.m. It documented in pertinent part, It is the policy of the Veterans Community Living Centers (VCLCs) to establish water management plans for reducing risk of legionella and other opportunistic pathogens in the facility's water systems. It is also the policy of the VCLCs to establish primary and secondary strategies for the prevention and control of legionella infections. C. Record Review The water management plan documentation was provided by the director of maintenance (DOM) on 11/20/24 at 12:43 p.m. The plan documented the facility had completed a legionella test on 7/18/24 which was negative. -The facility failed to document the flushing of dead legs and low-flow piping runs on all three hallways where residents resided. An email was received from the director of nursing (DON) on 10/22/24 at 9:54 a.m. The DON documented that seven rooms available for resident use had been vacant for seven contiguous days or more between 9/23/24 and 11/22/24. D. Staff interviews The DON and the NHA were interviewed together on 11/20/24 at 12:43 p.m. The DOM said all empty rooms in the facility had hot water run though all dead legs and low-flow piping runs of empty resident rooms in the facility every two weeks. The NHA said the facility flushed water in empty rooms every other week. The DOM and the NHA both said flushing the water every two weeks was sufficient to prevent the growth of legionella. The DOM said the facility tested for legionella annually. The infection preventionist (IP) and the DON were interviewed together on 11/22/24 at 9:03 a.m. The IP said she was not directly involved in the water management plan because that was the responsibility of the maintenance department in the facility. The IP said she thought water had to be flushed weekly to prevent the spread of waterborne pathogens such as legionella. The DON said she also thought water had to be flushed weekly in dead legs to prevent legionella growth. The IP and the DON both said they were not aware the facility practice was to flush water in dead legs and low-flow piping runs every two weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure timely physician visits for four (#9, #10, #12 and #13) of five residents reviewed for new admission physician visits out of 13 sample residents. Specifically, the facility failed to ensure the physician evaluated Resident #9, Resident #10, Resident #12 and Resident #13 within 30 days following admission to the facility. Findings include: I. Facility policy and procedure The Physician Visits and Delegation policy, revised 5/6/24, was provided by the nursing home administrator (NHA) on 6/5/24 at 1:48 p.m. It revealed in pertinent part, The physician should: -See the resident within 30 days of initial admission to the facility; -The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by the physician or physician delegate as appropriate by state law; and, -Review the resident's total program of care including medications and treatments at each visit. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized physician's order (CPO), diagnoses included heart failure, atrial fibrillation (irregular heart rhythm), edema, bladder dysfunction, pelvic pain and hypertension. The 4/30/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident had an indwelling catheter and was prescribed antidepressants and diuretic medications. B. Record review -A review of Resident #9's electronic medical record (EMR) revealed the physician did not see the resident until 4/2/24, 57 days after the resident was admitted to the facility. III. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the June 2024 CPO, diagnoses included hypertension, idiopathic progressive neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), sleep apnea and osteomyelitis. The 6/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident was prescribed opioid and antiplatelet medications. B. Record review -A review of Resident #12's EMR revealed the physician did not see the resident until 4/2/24, 47 days after the resident was admitted to the facility. IV. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia with behavioral disturbances, adjustment disorder, bipolar disorder, diabetes, hypertension and osteoarthritis. The 6/6/24 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of six out of 15. The resident was prescribed antipsychotic, antidepressant, diuretic, opioid and hypoglycemic medications. B. Record review -A review of Resident #13's EMR revealed the physician did not see the resident until 4/2/24, 47 days after the resident was admitted to the facility. V. Resident #10 Resident #10, age less than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included heart failure, atrial fibrillation, dementia, benign prostatic hyperplasia, conjunctivitis and hypertension. The 6/5/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident had an indwelling catheter and was prescribed antidepressants and anticoagulant medications. B. Record review -A review of Resident #10's EMR revealed the physician did not see the resident until 4/2/24, 42 days after the resident was admitted to the facility. VI. Staff interviews The director of nursing (DON) was interviewed on 6/6/24 at 9:02 p.m. The DON said residents should be seen timely by the physician following admission to the facility. The DON said the facility had talked to the residents' physician about the requirement to see the residents within 30 days of admission. The medical director (MD) was interviewed on 6/6/24 at 12:58 p.m. The MD said the facility had some issues in regards to the physician seeing residents within the first 30 days after admission and the frequency of physician's visits. The MD said she was working with the resident's physician to establish a more consistent schedule for physician visitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#42) of four out of 34 sample residents were kept free from physical abuse. Specifically, the facility failed to ensure effective personalized care planned behavioral interventions were in place for Resident #43, who had a history of physically abusive behaviors towards Resident #42. Findings include: I. Facility policy and procedure The Abuse policy and procedure, last reviewed on 2/21/23, was provided by the nursing home administrator (NHA) on 5/18/23 at 8:30 a.m. It read in pertinent part, Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual, or because of the number of injuries whether at a single point in time or over time. II. Incident of abuse between Resident #42 and Resident #43 Resident #42 and Resident #43 were married with Resident #43 having a history of physically abusive behaviors towards Resident #42 (see care plan below). The 5/15/23 facility's abuse investigation documented staff members observed Resident #42 sitting and visiting with Resident #43 and Resident #42 was spitting on the floor. Resident #43 told Resident #42 that was not acceptable and was observed hitting Resident #42's hand in his lap. Staff immediately separated the residents and Resident #43 was returned to the second floor, where she resided. Resident #42 remained on the first floor where he resided. Resident #42 was interviewed after the incident and did not remember the incident and did not express any fear of Resident #43. No injury was observed. The facility investigation did not indicate if the abuse was substantiated or not. -However, the abuse should be substantiated based on Resident #43 willfully hitting Resident #42. III. Resident #43 A. Resident status Resident #43, aged 84, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included dementia with other behavioral disturbance, adjustment disorder and depression. The 4/13/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. She required set up assistance for eating and was independent with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated she was not exhibiting verbal and physical behaviors towards others. B. Record review The behavioral care plan, initiated on 5/30/22 revised on 5/9/23, documented Resident #43 had a history of physically abusive behaviors towards Resident #42 and interfered in his care. It indicated that she was quick to act and unable to remember coping skills. The interventions included assist resident to develop more appropriate methods of coping and interacting with Resident #42 that will not interfere with care, encourage resident to express feelings appropriately, provide opportunity for positive interaction, intervene as necessary to protect rights and safety of others, approach in a calm manner, divert attention, remove from the situation. Remind the resident, when she brings Resident #42 upstairs to eat or go to activities, not to leave unattended and monitor Resident #42's location. -A review of Resident #43's comprehensive care plan did not reveal effective personalized behavioral interventions for monitoring and preventing resident's behavior during interactions with Resident #42 during mealtimes or activities. The care plan was not updated after the altercation on 5/15/23. A 5/15/23 social services progress note revealed the social worker spoke with the resident regarding the incident that Resident #42 was spitting on the floor and Resident #43 told him to stop that and then slapped his hand and arm that was on his lap to get his attention to stop the behavior. Resident #43 became teary and left the interview and verbalized that Resident #42 was unable to understand and reason anymore. The social worker followed up with the resident in her room regarding how dementia affected people and to reach out to staff before she became frustrated. A 5/16/23 nursing progress note revealed the Resident #43 was on visual checks every 15 minutes, secondary to striking Resident #42 on 5/15/23. The facility had daily behavior monitoring of the Resident #43's behavior towards other residents in the facility. The 4/19/23 to 5/18/23 behavior tracking form indicated no physical or verbal behaviors directed at others. -However, the resident had an altercation on 5/15/23 (see above). -A comprehensive review of the progress notes did not reveal any further documentation of the incident. C. Resident interview Resident #43 was interviewed on 5/16/23 at 1:30 p.m She was not able to recall the incident on 5/15/23 and asked why she could not be in the same room as her husband. IV. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included Alzheimers's disease, type II diabetes mellitus and chronic kidney disease. The 3/30/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. He required the extensive assistance of two people with bed mobility, transfers, dressing, toileting, personal hygiene and the limited assistance of one person with eating. B. Record review The behavior care plan, initiated 5/30/22 revised 4/25/23, indicated that Resident #42 had a history of being resistive to care and would swing at staff and Resident #43 when he did not want care, was agitated or angry. The interventions included allow the resident to be involved with treatment and care regime, give resident clear explanation of all care activities prior to when they occur and do not rush resident. -A comprehensive review of Resident #42's care plan did not reveal any additional person centered interventions after the altercation on 5/15/23. C. Resident interview Resident #42 was interviewed on 5/17/23 at 3:00 p.m. He was not able to answer questions when asked. V. Staff interviews Certified nursing assistant (CNA) #6 was interviewed on 5/18/23 at 11:01 a.m. She said Resident #43 was a social person and she observed that Resident #43 and Resident #42 were together frequently during activities and meals. CNA #6 said she had not been closely monitoring the two residents and had not observed any physically aggressive behaviors by Resident #43 during activities or mealtimes. Registered nurse (RN) #4 was interviewed on 5/18/23 at 1:15 p.m. She said she had not observed any aggressive behavior by Resident #43 towards Resident #42. She said that historically Resident #43 had slapped Resident #42. She was unable to recall the last instance of physical aggression towards Resident #42 by Resident #43. She said the residents were frequently together at activities and at mealtimes. The director of nursing (DON) was interviewed on 5/18/23 at 5:00 p.m. She said Resident #43 and Resident #42 lived on separate floors due to Resident #43's history of physical aggression towards Resident #42 and interference in care. Resident #43 and Resident #42 had been having supervised meals in the past. There had been no observed physically aggressive behavior by Resident #43 for a significant amount of time until the incident on 5/15/23. Resident #43 and #42 had been assessed to need to be in line of sight during activities and mealtimes but since the incident occurred they would need to be supervised with staff present and monitoring activities and mealtimes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss for two (#3 and #37) of seven residents reviewed for nutrition out of 34 sample residents. Specifically, the facility failed to ensure Resident #3 and #37 were provided nutritional interventions identified for their weight losss. Findings include: I. Professional reference Roigk. P. (2018) Chapter 8: Nutrition and Hydration. In K. [NAME] and J. [NAME]-[NAME] Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). [NAME] Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 5/24/23 at 9:24 a.m. According to the North American Nursing Diagnoses Association ([NAME]) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are: Body mass index (BMI)< (less than) 18.5 kg/m2, unintended weight loss> (greater than) 10% in the last 3-6 months, BMI < 20 kg/m2 and unintended weight loss>5% in the last 3-6 months, fasting period>7 days. II. Facility policy and procedure The Weight Monitoring policy and procedure, last revised on 5/18/23, was provided by the nursing home administrator (NHA) on 5/18/23 at 4:20 p.m. It read in pertinent part, It is the policy of the facility to establish weight baseline, to monitor weight loss and/or gain, and to monitor residents for significant changes in weight that may require intervention. Weights are to be taken and recorded at the same time each month to assure consistent monitoring. The scale(s) for evaluating weight should be calibrated routinely to assure equipment is working properly and that information is accurate. III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnosis included type II diabetes mellitus and vitamin B deficiency. The 2/2/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out 15. She required the extensive assistance of one person for dressing, toileting, personal hygiene, limited assistance of one person for bed mobility and transfers and was independent with eating. B. Observations On 5/17/23 at 9:19 a.m. snacks were not observed in the resident's room (as indicated in the care plan, see below). The resident was observed sitting in the lobby, the resident was observed not having or eating snacks. At 11:00 a.m. The resident was observed wheeling self in the hallway past a snack cart. The resident did not attempt to take snacks from the snack cart. At 11:30 a.m. the resident was observed sitting in the dining area. The resident was served lunch at 12:03 p.m. - a small green salad, small bowl of soup and a breadstick. She ate 40% of green salad, three spoonfuls of soup and 0% of breadstick. She was given a small container of ice cream and ate 20%. She was not offered an alternative to the meal or additional food prior to the ice cream. At 1:45 p.m. the resident was observed wheeling self around in the lobby area. The resident was observed not having or eating snacks. At 4:30 p.m. the resident was observed in the dining room. She ordered a half order of the special which consisted of mashed potatoes, roast beef and gravy and pudding. She ate approximately 30% of the scoop of mashed potatoes, 0% of roast beef and 80% of pudding. She was not offered an alternative meal or additional food. C. Record review The nutrition and weight management care plan, initiated on 10/8/2020 revised on 5/16/22, indicated resident was at a high nutritional risk with possibility of weight changes due to diabetes, cardiac fluid retention, desire to take in only minimal supplements and periods of poor appetite. It indicated the resident's ideal body weight (IBW) was 105 pounds (lbs) with a range of 95-115 lbs. Interventions included a regular diet with meats cut in half inch pieces, small portions and thin liquids.Ensure plus or supplement of choice every morning, shelf stable high calorie snacks for her room to consume, encourage resident to eat, monitor weight for significant weight changes, offer snack hydration cart twice a day between meals, record and monitor oral intake at meals and snacks between meals, review calories, protein and fluid needs as necessary. The resident's weights were documented as follows: -11/15/22 108 lbs (bath chair) -2/7/23 104.8 lbs (bath chair) -4/11/23 106.4 lbs (bath chair) -5/9/23 92.8 lbs (bath chair), and; -5/11/23 97.6 lbs (wheelchair) The 5/2/23 interdisciplinary weight team notes documented Resident #3 had a weight increase of 3% in one week, weight loss of 5% in one month, weight loss of 4.7% in three months and a loss of 6.8% in six months. It documented a recent weight loss but improved appetite with intake of 75-100% of meals. The resident declined any additional nutritional interventions but requested additional shelf stable snacks in her room. The 5/15/23 interdisciplinary weight team notes documented Resident #3 had weight loss of 2.9% in one week, weight loss of 8.4% in one month and 6.8% in three months. It documented variable oral intake with current intake of 95-100% of meals. It documented current interventions of Ensure plus once a day and snacks in her room. Recommendations were to try super cereal and bring in her favorite fast food. Current interventions included Ensure plus once a day and shelf stable snacks for room. -The resident's intake was indicated as 95-100% at meals, however based on observations (see above) she ordered a half order and she did not eat the full meal on both occasions. A comprehensive review of diet and supplementation orders revealed: -Ensure plus once a day, ordered 2/14/23. The medication administration record (MAR) revealed that she received the supplement once a day in the morning. -Regular diet ordered 1/3/19. D. Staff interviews Certified nurse assistant (CNA) #6 was interviewed on 5/18/23 at 11:14 a.m. She said Resident #3 was a picky eater and she did get offered Ensure and snacks. The registered dietitian (RD) was interviewed on 5/18/23 at 9:30 a.m. She said Resident #3 was hesitant to try snacks but liked M&M's with peanuts and cookies. She said she liked shelf stable snacks in her room that were kept at her bedside. The RD purchased snacks to keep at Resident #3's bedside. The RD was out of town for the last week and there was no plan for staff to supply the snacks at the resident's bedside while the RD was gone. It had only been recently discussed at the 5/15/23 IDT meeting to try super cereal and reassess food choices outside of what was being offered at the facility to bring resident food from outside of the facility. She said she did not have recent observations of Resident #3 at mealtimes. The director of nursing (DON) was interviewed on 5/18/23 at 5:30 p.m. She said monitoring and preventing significant weight loss was important for residents to prevent skin breakdown, keep them healthy and labs within normal limits. Weight loss triggered a review of the resident's weight by the RD and the interdisciplinary team and if they were trending downward they were monitored weekly. Weight loss monitoring was important to continue to discuss what did and did not work and the root causes. She said the goal was to see the weight trend back up. IV. Resident #37 A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease, abdominal aortic aneurysm (a swelling of the aorta) without rupture, alcohol dependence, and peripheral vascular angioplasty status with implants and grafts (a procedure to open narrow blocked arteries to improve blood flow. The 4/5/23 minimum data set (MDS) assessment revealed the resident's cognition was intact, with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 required extensive physical assistance from one staff member for locomotion off unit, dressing, toileting and personal hygiene. He required limited assistance from one staff member for bed mobility, transferring and walking in his room. He did not have a known weight loss of 5% or more in the last month prior to his admission or a 10% weight loss in the last six months. B. Resident interview Resident #37 was interviewed on 5/16/23 at 3:25 p.m. The resident said he thought he had recently lost weight but it did not bother him. He said he did not have much of an appetite. He said he usually ordered from the alternate menu because he did not like the main meal. The resident said he ordered watermelon for lunch. He said the portion sizes were large. He said there was a lot of waste because he could not eat it all at one time. Resident #37 was interviewed on 5/17/23 at 3:11 p.m. He said the facility did not have a lot of items he liked. He said they have fruit and vegetables available on the snack table. He said he likes salad but he did not like their salad because they did not have the spicy Italian dressing to put on it. He said the facility had offered him a dietary supplement but he did not want it because it was too thick and it clogged him up. Resident #37 said he preferred thinner drinks like juice, compared to supplements. He said he liked seafood but it was not offered. He said would always eat seafood. He said he understands that it could be costly but he hoped it could be offered at least once a month. Resident #37 said fish was on the menu but it was usually breaded, which he did not like. He said he would eat filets of fish that were not breaded. -Interviews with Resident #37 identified the resident was able to identify food/drink preferences that he would want to eat, potentially increasing his caloric intake. C. Record review The 3/29/23 CPO identified the resident was on a regular diet with thin liquids. The 3/29/23 CPO directed staff to weigh the resident weekly. The 3/29/23 vital record under weights identified the resident's admission weight using the standing scale was 137.2 pounds (lbs). A 3/29/23 diet communication slip was provided by the dietary manager on 5/18/23. The communication slip identified Resident #37 liked seafood, wanted small portions and did not have food dislikes. The undated diet card was provided by the dietary manager on 5/18/23. The diet card read the resident did not like chicken and liked fish, coffee, cereal, eggs and toast. The 3/30/23 nutritional assessment read the resident's ideal body weight (IBW) and adjusted IBW was 134 to 162 lbs. He currently had a body mass index (BMI) of 21.5. The assessment read weight loss had been gradual over several years. According to the assessment, the resident did not like chicken and preferred fish, coffee, eggs, bacon, cereal, and other meats. The assessment indicated the resident had unintended weight loss. The nutrition plan read to monitor weight intake status and provide preferences. The 4/3/23 dietary note read Resident #37 stated he had some weight loss prior to his admission but his appetite had been rebounding. He did not want supplements at this time (4/3/23). The 4/3/23 health status note identified Resident #37 was reviewed in the weight meeting. The note read the resident was taking meals in his room and an alternate menu was provided. He was on a regular diet. The registered dietitian recommended small portions and to cut up his meat. Additional interventions included shelf stable snacks and provide preferences. The 4/15/23 weight record identified Resident #37 weighed 131.2 lbs, indicating the resident lost six lbs and 4.37% of his body weight in just over two weeks since his 3/29/23 admission. The 4/17/23 health status note identified Resident #37 was reviewed in the weight meeting. The note read the resident weighed 131.2 lbs on 4/15/23. The resident had a 2% weight loss in a week and a 4.3% weight loss since admission [DATE]). According to the note, the resident had clothes on during his 3/29/23 admission weight and lasix upon admission for diuresis could have contributed to weight loss. The resident had been skipping meals and ate very little. Interventions included to encourage food intake and to come out of his room. The assessment read staff should also encourage intake at activities and continue to provide snacks for his room. No additional interventions were identified other than encouraging the resident to eat more and provide snacks. The intervention to offer snacks was not a new intervention as identified as a 4/3/23 intervention. -However, according to the assessment, the resident's PO (by mouth) intake identified the resident ate 50-100% of his meals. The review of progress notes and nutrition concern list (weight meeting minutes) did not identify the resident was reviewed on 4/24/23 or 5/1/23 when the resident had a weight gain (see below) however, after the weight gain, the resident's weight continued to trend down. The 4/27/23 weight record identified Resident #37 gained 4.8 lbs with a weight of 136 lbs however the 5/8/23 weight record identified the resident dropped down to 129.6 lbs. The 5/8/23 weight identified the resident lost 6.4 lbs between 4/27/23 and 5/8/23. The weight identified the resident lost a total weight of 7.6 lbs at 5.54% since 3/29/23. The 5/8/23 nutrition concern list identified Resident #37 was discussed on 5/8/23 with the weight committee. According to the minutes, the resident's intake was variable and ordered very small portions. The minutes indicated the resident stated he weight fluctuates and stays low. The minutes read they were providing him his preferences and he refused nutritional interventions. The intervention read the RD was working on coming up with alternatives such as meal and snack ideas. The 5/10/23 weight record identified Resident #37 weighed 134 lbs on 4/8/23. The resident weighed 126.2 lbs on 5/10/23 indicating a 7.8 lbs weight loss. The RD 5/15/23 weight change note read the resident weighed 126.2 lbs on 5/10/23 with a 3.8% weight loss in a week and 5.9% in a month. The note confirmed the resident had significant continued weight loss. According to the note, he had variable PO intake with small portions of a minimal selection of food items and the dietary manager would continue to work with the resident to find preferences and ways to increase intake. The resident seemed to have very little interest in food and had a prior history of 12 or more beers a day and did not have a craving for sweets. The note read acute illness may have also contributed to weight loss. The resident did not have chewing or swallowing issues and had a history of declining nutritional interventions. -Review of records did not identify acute illness since admission. The 5/15/25 health status note read the resident was reviewed at the weight meeting. He had a weight of 126.2 on 5/10/23 with a 3.8% loss in one week and 5.9% in a month. According to the note, it had been very difficult to obtain preferences or to assist in coming up with nutritional strategies or even a to go to meal in which the resident could order when he did not want the special menu items. The note read the current interventions was: -Refused nutritional interventions; -Regular texture diet with thin liquids; -The dietary manager would follow up to see if they could figure out some food preferences and a way to increase intake; and, -Notify physician's assistant (PA) of significant weight loss. The nutritional management care plan, last revised on 5/15/23 read Resident #37 was at an elevated nutritional risk due to history of poor intake and weight loss prior to admission, and medical diagnosis which could contribute to increased nutritional needs. His diagnosis included COPD and alcohol dependence. According to the care plan goal, the resident would avoid significant weight loss over the next quarter. His goal weight was 155 lb. Interventions initiated on 4/3/23 included: -Weigh at the same time of day and record weekly. -Attempt to follow consistent times/type of scale/clothing/wheelchair weighed to ensure the most accurate weights. -Notify RD, and provider of weight loss greater than 5lb; -Invite the resident to activities to provide an additional avenue for intake. -Monitor meal/fluid and snack intake. -Monitor nutrition related labs prn (as needed). -Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of dehydration and dysphagia (swallowing difficulty). -Offer snack/hydration cart bid (two times a day) between meals. -Preferences: Likes coffee, does not chicken that much, likes fish and other meats, likes bananas, cookies, and will eat all breakfast foods. -Update preferences as needed. -Review calories, protein and fluid needs prn. -Stated he wished to eat half hour after taking his morning pills. -The resident did not want to be disturbed prior to 7:30 a.m. and would take his breakfast at 8:30 a.m. The review of the care plan only identified one intervention after 4/3/23 and after a 10 lb weight loss. On 5/10/23 the intervention read: (Resident #37) was not very forthcoming of his food preferences. -No other interventions were included after the resident continued to have a weight loss. In addition, the resident was able to indicate his food preferences (see resident interview above). The weekly weight record was collected on 5/18/23 after the interview with the RD (see below). The 5/18/23 weight identified the resident had a slight gain of 1.6 lbs with a weight of 127.8 lbs. D. Staff interview The RD was interviewed on 5/18/23 at 9:00 a.m. The RD confirmed Resident #37 had lost 10 lbs since his admission between 3/29/23 and 5/10/23. She said he had orders for weekly weights and had not been weighed since 5/10/23. She said she would request staff to obtain his weight today (5/18/23). The RD said she offered him high calorie dietary supplements on 4/3/23 but he refused. He said the supplements caused him too much phlegm/thick mucus. The RD said she could not get the resident to nail down a preference to help increase his calorie intake. The RD was informed the resident said he liked juice. She said there were thinner supplements that could be flavored with juice. She said she had not discussed the thin supplements with the resident and could order them and offered it to the resident. She said she asked the dietary manager this week if she could step in and help the resident identify other interests. The RD confirmed the resident had lost six lbs by 4/15/23. She said he was discussed at the weight meeting and the intervention was to offer snacks available in his room, inform him of meal options and try to find ways to increase his appetite. She said he did not like sweets. The RD said she did not look into other potential appetite stimulates. She said would speak to the PA to determine if there were additional appetite stimulating options. The RD confirmed the resident loss of almost five lbs between 5/4/23 and 5/10/23. The RD she would continue to focus on what they could offer the resident. She said she did not remember the resident liked seafood. She said she would talk to the resident about seafood options. The RD said the facility could order him shrimp. The RD said she would order the Boost Breeze clear supplement for the resident. The dietary manager (DM) was interviewed on 5/18/23 at 10:05 a.m. The DM said she attended the weekly weight meeting. She said staff had been monitoring Resident #37's weight and was trying to see what more they could do to encourage him to eat more. She said they offered an alternate menu that he would order from. The DM said the nursing home administrator (NHA) just told her to order shrimp for Resident #37. The DM said she was aware the resident liked seafood. She said she they already offered fish on the menu. The DM was informed the resident did not like most of the fish provided because it was breaded. The DM said she talked to the resident everyday and he, just like all the other residents, said he wanted a T-bone steak. She said maybe they could add more specialty items to the menu such as a special meal or ask activities if they could pick up more specialty foods for the resident. She said the resident told her that he did not like steamed vegetables. The DM said steamed vegetables were frequently on the menu. The DM said he liked salad but usually did not eat too much of it. The DM was informed the resident said he would eat more salads if he they would offer him spicy Italian dressing. She said they did not offer that dressing as an option but they could order the spicy Italian dressing for him. She said his preferences were on his diet communication card (see above). She said he did not like most of the meals provided. She said he would eat regular meals on occasion. She said he liked the chicken fried steak. She said she spoke to him a few days ago on what he might like to eat. He said he wanted more beer. The director of nursing (DON) was interviewed on 5/18/23 at 5:29 p.m. She said the facility just ordered different kinds of Boost as on 5/18/23. She said they ordered wild berry Boost for Resident #37. The DON said new residents recently admitted to the facility were followed in the weekly weight committee for the first two to three weeks and if there was a trending weight loss. The DON said the resident would be brought back to the weight meeting if the resident continued to lose weight. She said the weight committee discussed new interventions to promote weight gain and reviewed what was working and not working. She said the committee in the weight meeting would try to identify root causes of the weight loss such as pain or medications. She said the committee would continue to monitor changes if there was little to no improvement. The DON said the resident lost a lot of weight in a short period of time. She said from a nursing standpoint, increasing his calorie intake would be great for him and it would reduce his bony prominences and skin breakdown risk. She said nursing would like him to be able to eat anything he would like and eat. She said if he ate more, he could have improved strength and might feel better. The DON said the resident was not yet identified as malnourished but increased calories could reduce his risk for malnourishment. She said nursing staff would advocate for the resident's food preferences, visit with him on food options and monitor his weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure three (#55, #35 and #32) out of 34 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Assess a Resident #55's change of condition and notify the resident's physician in a timely manner when the resident had ongoing vomiting and when the resident's abdomen was distended and tender to touch on 3/12/23; and, -Assess Resident #35 and Resident #32 vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Resident #55 A. Professional references [NAME], D. A., [NAME], S. [NAME], S. M. (August 2022). Bowel obstruction. National Library of Medicine. Stat Pearls (Internet) https://www.ncbi.nlm.nih.gov/books/NBK441975/ retrieved on 5/22/23. Commonly in small bowel obstruction (SBO), abdominal pain is described as intermittent and colicky but improves with vomiting. The vomiting in SBO tends to be more frequent, in larger volumes, and bilious (yellowish green vomit). [NAME], P. (April 2023). Intestinal Obstruction. Merck Manual Professional Version. https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/intestinal-obstruction retrieved on 5/22/23. Obstruction of the small bowel causes symptoms shortly after onset: abdominal cramps centered around the umbilicus or in the epigastrum, vomiting and, in patients with complete obstruction, obstipation (severe prolonged constipation). Patients with partial obstruction may develop diarrhea. Severe, steady pain suggests that strangulation has occurred. Sanivarapu, R. R., [NAME], G. (December 2022). Aspiration pneumonia. National Library of Medicine. Stat Pearls (Internet) https://www.ncbi.nlm.nih.gov/books/NBK470459/ retrieved on 5/22/23. The infectious pulmonary process that occurs after abnormal entry of fluids into the lower respiratory tract is termed aspiration pneumonia. The aspirated fluid can be oropharyngeal secretions or particulate matter or can also be gastric content. B. Facility policy and procedure The Change of Condition policy and procedure, reviewed on 2/1/23, was provided by the nursing home administrator (NHA) on 5/18/23 at 3:15 p.m. It revealed in pertinent part, The purpose of this policy is to ensure the (facility) promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life threatening conditions, or b. Clinical complications. C. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, dysphagia (swallowing difficulty), pain and gastroesophageal reflux disease (GERD). The 3/12/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory and daily decision making. He was dependent with the assistance of two people for transfers, toileting, personal hygiene, he required extensive assistance of two or more people with bed mobility and dressing and extensive assistance of one person for eating. D. Record review The pain care plan, initiated 2/23/23, indicated that resident was unable to verbalize pain description or pain level related to dementia progression. Interventions included monitor and document side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls and report to physician. Monitor and report any signs and symptoms of non-verbal pain changes in breathing, vocalizations, mood/behavior changes, eyes (wide open/narrow slits/shut, glazed, tearing, no focus), face (sad, crying, worried, scared, clenched teeth grimacing), body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. The 2/26/23 physician progress notes revealed a diagnosis of GERD, dysphagia, diarrhea, constipation, colon polyps, bilious vomiting with a surgical history of appendectomy (removal of appendix), colon polyp removal and cholecystectomy (removal of gallbladder). The assessment revealed the abdomen was soft and non distended, non tender and bowel sounds active. Lung assessment revealed they were clear to auscultation (listened to lung sounds with a stethoscope) without crackles or wheezes. -A review of the physician documentation revealed no further physician assessment or follow up after 2/26/23. The 3/6/23 nursing progress notes revealed at 2:31 p.m. the resident refused to get out of bed, had refused meals and medications. He was tensed and made noises throughout the shift. The 3/6/23 nursing progress notes revealed at 5:08 p.m. the resident had a large emesis (vomiting). The 3/6/23 nursing progress notes revealed at 7:07 p.m. the resident had a large emesis and acetaminophen was held. -A review of documentation revealed no further nursing assessment, including an abdominal assessment, vital signs or communication with providers. The 3/7/23 nursing progress notes revealed at 12:20 a.m. Zofran 4 milligram (mg) was given for nausea after three emesis episodes. The 3/7/23 nursing progress notes revealed at 4:54 a.m. resident at midnight had a large emesis that was observed to be yellow with small streaks of red. The resident had a second emesis that was bile colored. The resident temperature was 100.3 degrees Fahrenheit. The resident had medium watery diarrhea. Message was sent to providers and infection control was notified. The 3/7/23 at 11:27 a.m. revealed the resident had a COVID test with negative results. -A review of documentation revealed no further nursing assessment, including an abdominal assessment or if the provider returned the message. The 3/7/23 nursing progress notes revealed at 10:27 p.m. the resident remained in bed and made continuous sounds. The resident's daughter gave resident a milkshake which he vomited. A review of documentation of 3/7/23 10:27 p.m. revealed no further nursing assessment, including an abdominal assessment, vital signs or providers being notified after resident vomited at 10:27 p.m. The 3/11/23 nursing progress notes revealed at 5:16 a.m. the resident had two episodes of emesis during the night shift and would not give a verbal response to the nurse. The 3/11/23 nursing progress notes revealed at 1:41 p.m. the resident refused oral care. -A review of documentation for 3/11/23 revealed no further nursing assessment, including an abdominal assessment, vital signs or communication with providers. The 3/12/23 nursing progress notes revealed at 12:14 a.m. the resident remained in bed with increased episodes of vomitus. Head of bed elevated and making quacking noise during care. The 3/12/23 nursing progress notes revealed at 1:53 a.m. the resident was given Zofran 4 mg for nausea. The 3/12/23 nursing notes revealed at 5:11 a.m. the resident was awake and making continuous quacking sounds. The 3/12/23 nursing progress notes revealed at 6:00 a.m. it was documented that at 5:00 a.m. the resident had a moderate amount of vomit. Resident #55's vital signs were blood pressure 150/74, heart rate 108, temperature 99.0 degrees Fahrenheit, oxygen saturation 91%. -A review of documentation revealed no further nursing assessment, including an abdominal assessment or communication with providers regarding increased heart rate, low grade temperature and vomiting. The 3/12/23 nursing progress notes revealed at 9:42 a.m. the resident vomited a large amount of food particles and Synthroid (thyroid medication) was held. The 3/12/23 nursing progress notes revealed at 9:43 a.m. the resident was left in bed at this time due to feeling sick. The 3/12/23 nursing progress notes revealed at 9:55 a.m. the resident vomited a large amount of food particles and light brownish fluid. He refused oral fluids and medications. The 3/12/23 nursing progress notes revealed the resident had vomited at 11:45 a.m. The nurse assessed the resident who appeared pale with sunken eyes and was slightly agitated. Pain medication was provided. The resident then slept and then vomited a second time. The abdomen was found to be distended and tender to the touch. The nurse was unable to assess the abdomen or lung sounds due to the resident making quacking sounds. The resident exhibited muscle rigidity and abdominal guarding. The 3/12/23 nursing progress notes revealed at 1:40 p.m. the resident's vital signs were blood pressure 100/64, temperature 99.1 degrees Fahrenheit, pulse 159, and oxygen saturation of 82%. Resident's head was raised and supplemental oxygen was administered at 2 liters via nasal cannula. Binax COVID test was done with negative results. The resident had a medium putty colored bowel movement. The 3/12/23 nursing progress notes revealed at 2:00 p.m. the on-call provider and on call nurse were notified at 2:00 p.m. A voicemail was left for the resident's power of attorney (POA). The 3/12/23 nursing progress notes revealed at 3:30 p.m. the POA requested the resident be sent to the emergency department for evaluation. The 3/12/23 nursing progress notes revealed the resident was transferred at 4:10 p.m. -A comprehensive review of the 3/12/23 documentation revealed the resident began vomiting at 5:00 a.m. with a change in vital signs, the resident did not have an abdominal assessment until 11:45 a.m. where the resident's abdomen was distended and tender to touch. The resident's vital signs were not documented at 1:40 p.m. The provider was not called until 2:00 p.m. which was over two hours later and the resident did not go to the hospital until over four hours later. The 3/12/23 nursing progress notes revealed at 10:00 p.m. report by the hospital staff to nursing home staff that the resident had a small bowel obstruction on computerized tomography (CT) with likely pneumonia on chest x-ray and potential sepsis. He was admitted to the medical surgical unit for end of life care and was treated with pain medication and intravenous fluids. The bowel elimination documentation revealed: -3/5/23 at 9:49 p.m. resident was incontinent; -3/7/23 at 5:59 a.m. resident was incontinent; -3/8/23 no bowel movement was recorded; -3/9/23 no bowel movement was recorded; -3/10/23 at 9:59 p.m. resident was incontinent; -3/11/23 at 1:50 p.m. resident was incontinent; -3/12/23 at 5:59 a.m. resident was incontinent; and, -3/12/23 at 1:59 p.m. resident was incontinent. -A review of documentation revealed no documentation of quality (formed versus diarrhea) or quantity of bowel movement. A review of the March 2023 CPO revealed: -Ondansteron (Zofran) 4 milligrams (mg) by mouth every four hours as needed for nausea, ordered 1/12/23. This medication was administered on 3/7/23 at 12:20 a.m. and on 3/12/23 at 11:53 a.m. A review of the March 2023 medication administration record (MAR) pain assessment in advanced dementia scale (PAINAD) revealed -3/6/23 day shift pain level 5, evening pain level 2, and night pain level 1. -3/7/23 day shift pain level 0, evening pain level 7 and night pain level 2. -3/8/23 day shift pain level 2, evening pain level 5 and night pain level 2. -3/9/23 day shift pain level 3, evening pain level 0 and night pain level 0. -3/10/23 day shift pain level 4, evening pain level 3 and night pain level 3. -3/11/23 day shift pain level 2, evening pain level 0 and night pain level 2. -3/12/23 day shift pain level 5. -A comprehensive review of pain assessment documented an elevated pain level on 3/6/23 day shift when resident was exhibiting tensed and vocalization behaviors, 3/7/23 evening shift when resident was experiencing emesis and making continuous sounds and 3/12/23 day shift when resident was exhibiting elevated temperature, emesis, elevated pulse and decreased oxygen saturation. C. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 5/18/23 at 10:15 a.m. She said Resident #55 had been throwing up prior to being hospitalized and he had not been feeling well and was making strange quacking noises. She said physicians and nurses had talked about the quacking noises and if they were the result of the resident experiencing pain or if it was related to something else. CNA #1 was interviewed on 5/18/23 at 10:20 a.m. She said the resident had not been feeling well and had been staying in bed. He had not been eating much and had been throwing up prior to being hospitalized . Registered nurse (RN) #1 was interviewed on 5/18/23 at 10:25 a.m. She said the resident had been having an overall decline. She said she took care of the resident the day before he was hospitalized . She said he was having bowel movements but he was having instances of vomiting. She said he may have been having a pain crisis because he was making frequent quacking noises. He had been having episodes of emesis and he had normal bowel sounds. She was not aware if the providers had been notified regarding his vomiting. She said when there was a suspected change of condition, providers were notified, vital signs were monitored and for gastrointestinal symptoms an abdominal assessment should be performed. She said providers were notified for residents ' changes of condition. The director of nursing (DON) was interviewed on 5/18/23 at 5:01 p.m. She said he had been having occasional emesis the entire stay. She said that the resident made quacking noises but they had been unable to determine if it was pain related. She said providers were notified on 3/7/23 regarding the vomiting and temperature but was unable to confirm if there was an abdominal assessment, return communication or follow up with the providers. She was unable to locate documentation if the provider was notified on 3/12/23 before 2:00 p.m. She said when a resident was having symptoms of vomiting with changes in vital signs, including an elevated temperature, an abdominal assessment should be completed and the provider notified. The medical director was interviewed on 5/18/23 at 6:00 p.m. The resident exhibited during his stay at the facility was quacking vocalizations. Staff were unable to attribute the quacking noises to pain or to a tardive dyskinesia (abnormal or impaired voluntary movement) type side effect of the medications. He said when there were episodes of vomiting with a fever there should be an assessment of vital signs, abdominal assessment, monitoring for constipation and a lung assessment (to assess for aspiration). He said the provider should be notified. II. Monitoring blood pressure medication A. Professional references Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 5/25/23. It read in pertinent part, 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. Kizior, R. J., [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. B. Observations On 5/16/23 at 3:00 p.m. registered nurse (RN) #5 was observed dispensing Metoprolol 25 milligrams (mg). RN #5 checked order for parameters and was observed checking Resident #32's pulse, which was 60 beats per minute (bpm) prior to administration of medication. RN #5 was not observed checking for the resident's blood pressure prior to administration. RN #5 was observed administering Metoprolol. The physician order documented Metoprolol 25 mg twice a day. Parameters ordered to hold medication if pulse was less than 55. On 5/17/23 at 7:30 a.m. RN #4 was observed dispensing Amlodipine 5 mg. RN #4 was not observed checking for a current blood pressure or pulse prior to administration. RN #4 then administered Amlodipine medication to Resident #35. The physician order documented Amlodipine 5 mg once a day. C. Staff interviews RN #1 was interviewed on 5/18/23 at 11:45 a.m. She said before giving a blood pressure medication the residents' blood pressure and pulse should be assessed. She said if blood pressure and pulse were below baseline a reassessment should be done and physician ordered parameters should be followed. She said if there were no physician ordered parameters an assessment of the resident including a blood pressure and pulse, along with signs and symptoms of low blood pressure were done. She said a physician should be notified if the resident experienced a blood pressure less than 100-120 systolic and pulse was less than 55 bpm. The DON was interviewed on 5/18/23 at 5:22 p.m. She said blood pressure and pulse were done prior to the administration of a blood pressure medication and physician ordered parameters should be followed. If there were no physician ordered parameters, an assessment of low blood pressure which included monitoring blood pressure, pulse and monitoring for signs and symptoms should be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in one of two dining rooms. Specifically, the facility failed to ensure residents had hand hygiene before meals. Findings include: I. Facility policy and procedure The Infection Prevention and Control policy, revised 1/31/23, was provided by the facility on 5/15/23. The policy read in pertinent part: The (facility's) Infection Prevention and Control (ICP) plan shall ensure the organization develops, implements and maintains an active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risk of epidemic and epidemic infections in residence, visitors and healthcare workers, and to optimize use of resources. According to the infection control policies the facility would implement appropriate infection prevention and control measures and communicate responsibilities about preventing and controlling infection. Responsibilities would include hand hygiene to all staff residents, families and visitors. The Hand Hygiene policy, reviewed 1/19/23, was provided by the facility on 5/18/23. The policy identified hand hygiene should be performed before and after eating. II. Observations Dinner observations were conducted 5/15/23 between 4:18 p.m. and 5:10 p.m. A free standing alcohol based hand rub (ABHR) dispenser with an orange sign requesting residents to use the ABHR was on the 2nd floor dining room near the entrance. Observations identified residents who brought themselves to the dining room did not stop to use the ABHR from the dispenser. The staff assisting residents into the dining room did stop with the residents at the dispenser and provide ABHR. Observations did not identify staff provided ABHR or hand hygiene wipes for most of the residents once they sat down and prepared for their meal, or once the residents were provided their meal. Only one resident in the dining room was provided hand hygiene before he was provided total meal assistance. In room meal delivery on 5/15/23 identified some residents were not offered hand hygiene during meal service. Between 5:14 p.m. and 5:30 p.m. the residents in room [ROOM NUMBER], #209 and #216 were not offered hand hygiene before they were served their meal tray. Observations were conducted on 5/17/23 during the lunch meal service. The meal included hand held items such as bread sticks and sandwiches. Residents were not observed to be encouraged or assisted with hand hygiene in their rooms prior to the meal. Residents assisting themselves into the dining room were not observed to use the ABHR dispenser. Staff assisting residents in their wheelchairs into the dining room, did not stop and assisted residents with ABHR. Staff did not encourage residents to use ABHR when entering the dining room. Residents were not provided or assisted with hand hygiene prior to meal service in the dining room or when offered their meal. One resident was observed touching the eating surface of his spoon with his fingers prior to eating. Another resident was observed to wipe his nose with his fingers before eating his sandwich. Observations were conducted in the dining room on 5/17/23 during dinner. Only one resident assisting herself into the dining room, used the ABHR dispenser. Residents were not provided or assisted with hand hygiene in the dining room before their meal. The 5/18/23 lunch observation did not identify residents were provided hand hygiene prior to their meal. Several residents were observed eating a hamburger with their hands. III. Resident interviews Resident #34 was interviewed on 5/17/23 at approximately 3:30 p.m. He said there was ABHR available in the dining room but he usually did not think about it or pay too much attention to it. He said staff does not remind him or encourage him to do hand hygiene in the dining room or in his room. He said he would usually wash his hands after using the restroom. Resident #7 was interviewed on 5/18/23 at 3:20 p.m. He said he was aware of an ABHR dispenser in the dining room. He said he did not usually see residents using it. Resident #7 said staff pushing residents would have to stop and assist the resident they were assisting to use the ABHR dispenser. He said he personally did not like to use the ABHR. He did not like the way it smelled or how it felt. He said he would prefer hand wipes offered in the dining room. He said his hands would feel cleaner with wipes. He said hand wipes were not offered in the dining room by staff. He said he figured if staff performed hand hygiene in the dining room, that would be enough for him. Resident #33 was interviewed on 5/18/23 at 3:26 p.m. He said he did not use the ABHR dispenser in the dining room because he used a walker. He said he would have to take his hands off the walker to use the dispenser and he was afraid if he let go of the walker he might lose his balance and fall. Resident #39 was interviewed on 5/18/23 at 3:34 p.m. He said he was not aware there was a place in the dining room that he could use ABHR before meals. IV. Staff interviews The director of nursing (DON) and the infection preventionist (IP) was interviewed on 5/18/23 at 12:30 p.m. According to the DON and the IP, the IP was new to the position and the DON was overseeing the program. The DON said the best way to prevent the spread of transmission based infections was to practice appropriate infection control such as personal protection equipment and hand hygiene. The DON said staff were trained on hand hygiene during staff in-services, online training, new hire orientation and the certified nurse aide (CNA) education class. The DON said infection control practices were included in a staff education fair last fall. She said part of the training included a return demonstration of hand hygiene. The IP said she conducted infection control rounds and audits throughout the week. She said the rounds included making sure staff performed hand hygiene. She said the audits did not include resident hand hygiene at meals. The DON said staff needed to ensure residents were offered and assisted with hand hygiene after use of the restroom, before and after eating, primarily, but not limited to anytime a resident needed and wanted hand hygiene. She said ABHR was available on the walls in the hallways but staff should be offering, reminding, encouraging, assisting the residents with hand hygiene. The DON said the residents live in a shared community environment and everyone touches everything. She said hand hygiene helped protect against the spread of transmission based infections by breaking the infection chain. The DON and the IP were informed of the above observations. The DON and the IP said they would re-educate staff on the importance of resident hand hygiene and remind residents where they could perform hand hygiene. The IP said she would do in service or activity residents with a glow light that would show them the germs on the hands and surfaces. The IP said she would include resident hand hygiene with her infection control rounds. The DON said she would look into ordering hand wipes for residents to use in the dining room and change the location and color of the sign on the ABHR dispenser stand in the dining room. V. Record review The DON provided an 11/7/22 staff inservice attendance sheet with an attached hand hygiene competency validation check list and an online course completion record on 5/19/23 via email. According to the attendance sheet, staff were in service on infection control practices, including hand hygiene. The hand hygiene competency check list requested staff to perform a return demonstration of appropriate hand hygiene practices. The course completion record identified staff completed an online training course of hand hygiene between 11/19/22 and 5/19/23. VI. Facility follow-up The DON was interviewed again on 5/18/23 at 5:17 p.m. She said the facility chose to offer hand hygiene in the dining room by way of the ABHR dispenser stand in the entry of the dining room for residents because the facility thought it would be more convenient for residents to use as opposed to the ABHR on the walls. She said they wanted a convenient system so residents could have cleaner hands just before they sat down at the dining table for meal service. She said the IP conducted staff education on 5/18/23 on the importance of resident hand hygiene. She said she changed the color of the sign to bright green which reminded residents to use. She said she would periodically change the colors of the sign to help catch staff and residents' attention. The DON said she had ordered wipe packets and hand hygiene wipes for use in the dining rooms. She said she would have a staff member assigned to each meal to assist residents with hand hygiene. The DON said the activities department scheduled an activity for residents on 6/5/23 to teach residents on the importance of infection control and hand hygiene. She said the facility may include infection control presentations as a monthly resident activity. The DON said she would continue to educate staff on infection control with a focus on resident hand hygiene before meals. She said during the 5/18/23 dinner after changing the color of the sign on the ABHR dispenser, the placement of the dispenser at the entrance of the dining room, and educating staff to remind and assist residents with hand hygiene before meals, she saw residents lining up to use the ABHR before sitting down at their meal table. The DON provided the records identifying facility follow up after the hand hygiene observations were shared with the facility on 5/19/23 via email. The records included: -An 5/18/23 dining room hand hygiene audit identified staff offered hand hygiene during the 5/18/23 dinner to all residents who ate in the dining room. The audit showed that residents in the dining room were provided hand hygiene in the dining room. According to the audit, only one resident refused hand hygiene. -An outline of hand hygiene improvements the facility would make to adhere to appropriate infection control practices, to include, one to one education with staff regarding the residents' need for hand hygiene before and after meals. According to the hand hygiene improvement outline, the staff needed increased education to remind residents to perform hand hygiene before meals. -A staff attendance sheet identified staff received resident hand hygiene before and after meals education on 5/18/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure each resident was treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for one (#10) of one resident reviewed for dignity out of 21 sample residents. Specifically, the facility failed to ensure Resident #10 was positioned correctly at the dining room table and while she received care from staff during meals. Findings include: I. Facility policy and procedure The Promoting/Maintaining Resident Dignity During Mealtimes policy, dated 2/10/22, was provided by the nursing home administrator (NHA) on 2/10/21 at 5:20 p.m. The date on the policy was the same date the policy was requested from the NHA. It documented the practice of this facility was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintained or enhanced his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. It documented that all staff members involved in providing feeding assistance to residents should promote and maintain resident dignity during mealtimes. It documented staff should assist the resident with opening condiment packages, cutting necessary food items, such as ensuring each resident could see and reach their food and beverages. II. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction, dementia with behavioral disturbance, anxiety disorder, depressive episodes and dependence on her wheelchair. The 11/18/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. It documented the resident required supervision with set-up for her meals. B. Resident observations Resident #10 was initially observed on 2/8/22 at 12:14 p.m. She was petite, measuring 5 ' 3 who was seated in her wheelchair at a table in the first floor dining room. She was positioned at the table with her head below the level of the table's top. She was struggling to reach her food and drinks at this time. No staff was observed assisting the resident at this time. -At 12:20 p.m., the resident was seated at the dining room table with her head at table top level. She was having difficulty spooning her ice cream out of her dessert bowl. No staff were observed assisting the resident at this time. -At 12:33 p.m., the resident was observed rolling her wheelchair back and forth at the table in order to reach her food and drinks. She was observed hitting the top of her head on the side of the table. Certified nurse aide (CNA) #2 told the resident she was smacking her head on the table and telling the resident to be more careful. She did not ask the resident if her head was okay or assist the resident in any manner. She then walked away from the resident. Resident #10 was observed on 2/9/22 at 9:12 a.m. She was positioned at the dining room table with her forehead level with the table top. She was having difficulty reaching up to get her glass of juice. No staff was observed assisting the resident at this time. Resident #10 was observed on 2/10/22 at 8:20 a.m. She was seated at the dining room table, leaning slightly towards the left. Her forehead was at the level of the table top and the resident was having difficulty reaching her hot cocoa. She was observed from 12:20 p.m. through approximately 12:30 p.m., occasionally rolling her wheelchair back and forth at the dining room table. She was observed pulling herself forward in her wheelchair in order to reach her dinner roll. She dropped her spoon on the floor and called for CNA #3 to get her another spoon. The resident then propelled her wheelchair backwards out of the dining room. She returned to the dining room at approximately 12:23 p.m. At 12:25 p.m., CNA #3 was observed standing over the resident and was watching her eat a bite of blueberry cobbler off the table top after the resident had dropped it on the table. The CNA did not assist the resident with her dessert or try to prevent her from eating off the dirty top of the table where two other residents were also seated. Resident #10 was observed on 2/14/22 at 10:00 a.m. She was seated at her table in the dining room. Her eyes were level with the table top. She was observed struggling to reach her hot chocolate cup and to eat the oatmeal in her bowl. -At 11:10 a.m., staff was observed positioning the resident at an activity table in the common area. Her head was below the top of the table. -At 12:30 p.m., the resident was observed at the dining room table with her head below the level of the table top. C. Resident interview Resident #10 was interviewed on 2/10/22 at 8:20 a.m. She said she was seated so low at the dining room table that she sometimes hit her head on the tabletop reaching for her food. She said the facility had provided her a lower table in the past, but it had been sometime since they used it. She said she would like the lower table again for easier access to the food when eating. Resident #10 was again interviewed on 2/14/22 at 10:00 a.m. She said her positioning at the table was pretty uncomfortable. When asked if, besides the comfort level, she felt the positioning was undignified for an adult, she said, It's not really dignified, but I'm used to it. D. Record review Resident #10's care plan related to positioning, dated 2/9/22, documented the resident had limited physical mobility. The limitations were due to contractures and having sustained a previous stroke. The goal of this care plan was for the resident to remain free of complications related to immobility. The positioning schedule documented that the resident was to be up in her wheelchair for meals. III. Staff interviews The occupational therapist (OT) was interviewed on 2/10/22 at 10:35 a.m. He said the therapy department had previously attempted to use a lap tray for Resident #10 when she was dining, but the resident refused the tray. He said the table the resident always sat at had already been lowered as far as it could go. He said he did not want to give her a lower table because the more they compensate for her poor positioning, the less she would attempt to sit tall, which he felt she had the ability to do. He said the interdisciplinary team said Resident #10 had decompensated with her ability to position herself in the last week or so for some reason and he had a new screening request in to re-evaluate the resident for needing more assistance with her meals. -As of the survey's exit on 2/14/22 at 5:15 p.m., the OT had not completed his re-evaluation of the resident's assistance needs during meals. Registered nurse (RN) #6 was interviewed on 2/14/22 at 10:10 a.m. She said the dining room table was too high for Resident #10. She said the facility had another smaller-sized resident in the past and restorative therapy gave her a lap tray for her wheelchair that she could eat off of. She said Resident #10 refused to sit in a regular dining room chair and wanted to eat in her wheelchair. She said she did not know if restorative therapy had tried a lap tray for this resident, but felt she needed a smaller table because the resident had a lot of difficulty positioning herself at the table. She said she did not feel the resident was currently being positioned at the table in a dignified manner. She said the interaction with CNA #2 was poor because the staff should have stopped to ask the resident if she was okay when she hit her head on the table top and should have assessed for the resident's lethargy, having felt the resident must have fallen asleep at the table if she hit her head on the table top. The registered dietitian (RD) was interviewed on 2/14/22 at 12:30 p.m. She said she had brought Resident #10's poor positioning at the dining room table to the therapy department about a month ago. She said therapy tried a bedside table at the main table shortly before lunch was served this date and the resident did not want anything to do with that table. She said the resident's power of attorney (POA) was present and tried to encourage the resident to try the table, but the resident did not like something about the table. She said the dining table was at the lowest position already, but the resident looked like her positioning was even more slumped than she was a week and a half ago. She said she sent a message to the therapy department with her concerns, but felt the facility had to get creative with positioning for this resident. She said she and the restorative nurse brought up the possibility of using a computer table, which could be attached underneath the table and could adjust up or down for the resident. The RD said she did not feel this resident was appropriately positioned at the table because she could not even see her food and drinks at times and acknowledged this was a dignity issue for the resident. She said the resident's weight was stable despite the positioning issue. The NHA was interviewed on 2/14/22 at 3:21 p.m. She said she would have a conversation with the OT about Resident #10's physical ability to sit up straighter. She said she thought the facility needed to figure out something to make the resident more comfortable at meals. She said if the resident was uncomfortable and felt her positioning at the table was undignified, it was not okay. She said it was hard to find adaptive equipment that Resident #10 would accept because the resident did not want to be different. She said, we need to figure something out for her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide the highest practicable quality of care for one (#40) out of two residents reviewed for skin conditions or injuries out of 21 sample residents. Specifically, the facility failed to for Resident #40 ensure the resident had proper protection of her right heel wound to promote healing. Findings include: I. Professional Reference The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/2018), retrieved on 2/18/22, rehttp://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility standards The Wound Treatment Management policy, dated 1/5/22, was provided by the nursing home administrator (NHA) on 2/10/22 at 2:19 p.m. It read in pertinent part, To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with the current standards of practices and physician orders .Wound Treatment will be provided with physician orders, including the cleansing method, the type of dressing, and frequency of the dressing change. III. Resident status Resident #40, age [AGE], was admitted [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, pressure ulcer to right buttock (on admission), type two diabetes mellitus with diabetic peripheral angiopathy without gangrene, hereditary and idiopathy (neuropathy), unspecified. According to the 1/27/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of two or more persons for bed mobility, transfers, dressing, and toileting. Resident #40 required extensive assistance of one person for personal hygiene and locomotion. The MDS coded a pressure ulcer to her buttocks present on admission, her heel was not indicated. IV. Resident interview and representative interview Resident #40 was interviewed on 2/9/22 at 10:35 a.m. She said she spent a good portion of everyday in her wheelchair and out of bed. Resident #40 said she had a wound on her right foot. She said the last couple of days, her foot was feeling better since the staff provided her with a new boot to take the pressure off. The husband of Resident #40 was interviewed on 2/14/22 at 9:36 a.m. He said Resident #40 wore a foam boot at night to take off the pressure of foot when she was in bed. He said last week (2/8/22), she started wearing a different boot during the day to protect her heel. He said the new boot has seemed to help her with the pain from her heel. V. Observation and interview Resident #40's wound care was observed on 2/10/22 between 9:33 a.m. and 9:45 a.m. The wound care was conducted by the registered nurse (RN) #2. RN #2 applied Vashe cleanser on new gauze and removed the old dressing from the right heel of Resident #40. Dried yellow old skin was on the surface of the dressing. Observations of the heel identified two distinct wounds. The first wound/injury was on the posterior (back) part of her heel. The second wound/injury was located on her lower ankle. The lower ankle wound revealed black eschar in the bed. The lower heel wound was pink with granulation and did not have measurable depth. RN #2 said she did not know how the wounds developed but she confirmed they developed at the facility as originally a large wound. RN #2 said she could not identify the stages of the injury without looking at the stage chart. During the wound care with RN #2, potential contamination of the wounds were identified. RN #2 placed the new clean dressing and two tubes of Iodophor ointment directly on the seat of the resident's wheelchair before applying the treatments. The RN did not initiate hand hygiene after she removed the old dressing of the heel, doffed her old gloves and donned new gloves to cleanse and apply new dressing over the wounds (cross-reference F880 for infection control). VI. Record review The skin injury risk care plan, initiated 1/27/22 and revised on 2/10/22, read Resident #40 was at risk for potential/actual impairment to her skin integrity including MASD (moisture associated skin damage), skin tears and /or pressure injuries related to edema, fragile skin, balance issues and incontinence. The care plan identified the resident had a large fluid filled intact blister on her right heel. The care plan also identified the blister ruptured without changes in wound care. Care planned interventions implemented on 1/27/22 read: -Heel elevating boot to be worn while in bed to promote skin integrity related to edema and right heal blister. -Monitor/reposition bilateral extremities (BLE) as needed and at least every two hours while in bed to ensure heels were elevated on a pillow or cushion. -Pressure relieving/reducing mattress to protect the skin while in bed. The care plan intervention on 2/1/22, directed staff to refer to orders for the current wound treatment plan. -The care plan did not include the use of a protection boot to her right foot when the resident was not in bed. The 1/20/22 admission assessment for Resident #40 did not identify concerns with her right heel. The 1/21/22 weekly skin assessment identified Resident #40's heels were red but blanchable indicating no development of injuries/wounds to her right heel. The 1/25/22 skin/wound note read Resident #40 had a blister to her right heel. According to the note the wound nurse notified. The note did not identify the changes to the resident's care. The 1/26/22 OT treatment note read the resident was provided an updated wheelchair to allow for better bilateral lower extremity contact with the ground for self-propelling with bilateral lower extremities. Education completed on using bilateral lower extremities and bilateral upper extremities to self-propel manual wheelchair. The resident was able to use the manual wheelchair for approximately 15 feet in the room. -The OT note did not include precautions related to the 1/25/22 identification of the resident's right heel blister. The 1/26/22 at 2:13 p.m. skin/wound note read the wound nurse assessed the resident's heel and what appeared to look consistent with a blister. According to the note, the wound nurse instructed the registered nurse on dressing the site on the right heel. The note identified an application of Betadine was placed on the site. A foam heel covering was placed over and secured with hypafix. The note indicated the heel was tender to touch. The 1/26/22 skin/wound note created by the wound nurse read she was assessed to Resident #40's right foot/heel. The wound described the area of concern as a large blister measuring 4x6 centimeters (cm). The blister was fluid filled and intact. According to the note, the resident reported pain in the area with pressure and palpation. The note indicated that wound care orders were written and the registered nurse and therapy was notified. Heel elevator boots were requested to alleviate pressure while in bed. According to the note, the resident prefered to spend most of her time lying down and/or sleeping. An air mattress was put in place while lying down for pressure prevention and offloading. The 1/27/22 skin/wound note read betadine and a heel protector in place. The note described the blister as intact. According to the note, the resident helped by elevating her legs. The resident was educated to keep her legs off the floor. The 1/27/22 OT treatment note read the resident participated in the function transfer training to wheelchair from recliner. The 1/30/22 and the 1/31/22 skin/wound note read Resident #40's right heel bandage was removed, the blister was swabbed with Betadine and a new bandage was applied. According to the notes, the resident tolerated the wound care well with no pain or discomfort. The 1/31/22 OT treatment note read the resident continued to rest by lateral lower extremities off of the foot pedals and on the back of heels where she had a blister on her right lower extremity. According to the note, she had improved with self-propelling with a manual wheelchair with no foot pedals. She requires foot pedals for transport with caregivers. The note read education was provided to staff to cue the resident to rest her bilateral lower extremities on the foot pedals and not off of the pedals. The 2/1/22 skin/wound note created by the wound nurse, read the right posterior heel blister continued to be intact and fluid filled. According to the note, the blister measured 6x6 cm. Interventions continued to include a heel flotation cushion in place when the resident was lying in bed to avoid pressure to the area and continued use of an air mattress for pressure prevention and offloading. The note indicated the resident was educated by the wound nurse as well as therapy on the importance of not placing pressure on the blistered area. According to the note, the resident verbalized understanding. The note identified the resident did not receive compression to the right lateral extremity as an effort to keep the blister intact. The note indicated that therapy and the registered dietitian were aware of the wounds and were implementing necessary interventions. The wound physician was consulted for additional treatment options for the heel. The note read the physician did not recommend new interventions at that time. The review of the 2/1/22 wound measurement, according to the skin wound note, identified the blister increased in size between 1/26/22 and 2/1/22. The 2/2/22 OT treatment note read the resident was measured for the right lower extremity podus boot for heel protection during transfers for skin integrity. Education was completed with staff regarding recommendations for functional transfers. The positioning in the wheelchair interventions was completed to include foot rest adjustments. The OT note read Resident #40's blister on the right lower extremity, per wound care, was not improving. The care plan and the orders were updated to include no ambulation and weight bearing for transfers at the time of the OT note on 2/2/22. The 2/2/22 skin/wound nurse note read an Allevyn heel protector dressing was placed on the right heel and secured with tape. The note identified the heel as a blood blister. According to the note, the fluid filled area covered the entire heel. The 2/3/22 skin/wound note read the resident's right heel dressing was removed with no drainage noted on the dressing. The heel was covered with a large blister encompassing all of the heel. The heel was swabbed with Betadine and allowed to air dry. An Allevyn heel protector was applied on her heel with a sock over her foot and the heel protector. According to the note, the resident denied pain at the site. The note identified the blister bed appeared to be dry and was still intact. The 2/5/22 skin/wound note read the wound was on the bottom and up the back side of the heel. It was covered in white thick peeling skin, with a slight odor and the surrounding skin was pink in color. According to the note, the resident complained of tenderness when removing and applying the new dressing. The 2/6/22 at 2:13p.m. skin/wound note read the resident had a dressing change and treatment per orders to the right heel. The skin is whitish in color and peeled back slightly. The 2/6/22 at 9:53 p.m. read Resident #40's right heel was missing the Allevyn heel dressing and tape. According to the note, the blister appeared to have ruptured and the resident had dried blood and peeling skin above the blister. The wound bed was described as dark red with dried skin peeling around it. The review of the note identified the blister ruptured during the same time period of the missing dressing. The 2/7/22 OT treatment note read adjustments were made to the resident's wheelchair pedals to decrease pressure on the right foot and heel. The 2/7/22 skin/wound note created by the wound nurse described the right heel blister as denuded and no longer fluid-filled. The wound bed was pink with two darker areas within. The proximal darkened area measured 1.5 x 2 cm with no measurable depth. The distal darkened area measured 2.5 x 2.5 cm with no measurable depth. According to the note, the total denuded area measures 6 x 5.5 cm with partial thickness and a scant amount of blood. The note indicated the resident reported tenderness to the entire area. The 2/8/22 OT treatment note read the resident was fitted with a shield protection boot on the right low extremity to protect the blister while sitting in the wheelchair and during functional transfers. The 2/8/22 skin and wound note read changes to the right heel blister treatment were made on 2/8/22 with new orders placed. The January 2022 CPO was reviewed for Resident #40. The order summary read as follows: The 1/27/22 order read the resident was to wear a heel elevating boot while in bed to promote skin integrity related edema and right heel blister. According to the order, staff were to monitor/reposition her bilateral extremities as needed and at least every two hours while lying in bed to ensure heels are elevated on a pillow or cushion on every shift for pressure prevention and wound healing. The 1/31/22 order read to change position every two hours during the day and elevate bilateral lower extremities when available and every two hours. The order on 2/2/22 read the resident was not to be weight-bearing on her right lower extremity except for transfers and a sit to stand mechanical light. The 2/8/22 order read to apply Iodosorb Gel 0.9 % (Cadexomer Iodine) to the right heel topically one time a day for the denuded blister. The 2/8/22 order instructed staff to monitor placement of Allevyn heel dressing q (every) shift and replace and/or secure as needed on every shift. The 2/9/22 new order for wound care for the right heel denuded blister read to apply Vashe wash and allow the site to dry. Cover with Allevyn gentle border heel dressing and daily and report changes or concerns to physician and wound nurse once a day. The 2/9/22 order read the resident was to wear a heel protection boot on the right lower extremity when out of bed. The order was placed after the blister had ruptured and after two wounds under the blister were identified. VII. Interviews RN #7 was interviewed on 2/9/22 at 12:20 p.m. Resident #40 often would drag her foot when she was in her wheelchair. She said the dragging created a blister. RN #7 said the blister had opened and now caused her pain. The RN said a new boot has been placed on the right foot for protection. She said 2/9/22 was the first day she was aware of the new boot. RN #5, who was the certified wound nurse, was interviewed on 2/10/22 at 1:12 p.m. The RN said therapy witnessed one of the areas on the heel was caused by her foot pressing against the foot pedal. She said the observation prompted therapy to fit Resident #40 with the podus boot. RN #5 was interviewed again on 2/14/22 at 1:45 p.m. RN #5 said she first observed the blister on 1/26/22. She said pressure relieving interventions were put in place. She said she felt the interventions and care provided to Resident #40 was appropriate. She said she did not consider the wound to the heel as two separated wounds even though she was recording measurements to the two separate areas because both areas were on the resident's heel and were both treated the same. She said she weekly assessed the wound. The RN said the heel would have only been staged if the wound/injury was from pressure. RN #5 said the wound was caused by friction and rubbing from her foot sliding in her sock and on the ground, creating a fluid filled blister. She determined the wound was caused by friction therefore the wound was not a pressure injury; however, as identified in the above progress notes, opportunities for pressure on the right heel were present. RN #5 said the only protection over the heel when the resident was up and out of her wheelchair was a protective cup/covering over her heel until she was fitted with a new podus boot from therapy. The wound nurse identified that no additional protective measures to the heel were put in place between the time the blister was identified on 1/25/22 and 2/8/22, when the podus boot was implemented other than a thin protective cup. The occupational therapist (OT) was interviewed on 2/14/22 at 2:22 p.m. The OT said a protective boot was implemented when Resident #40 so she could bear some weight and to reduce friction on her foot. He said the resident was frequently up and was observed to take her foot on and off her foot pedal. He said she tried to adjust the pedals to be more conducive to her not having her heel resting directly on the top of the pedal. He said he placed an order for the podis boot but she had to wait for it to arrive. The boot was fitted the following week on 2/8/22. He said the resident wears the boot (since 2/8/22), when she was out of bed, in her wheelchair and during therapy. The OT said prior to the podus boot, there was no weight bearing activities till the boot arrived to protect Resident #22's heel. The director of nursing (DON) was interviewed on 2/14/22 at 4:28 p.m. The DON said the physician assistant (PA) saw the heel on 2/10/22 via telehealth. The DON said the PA did not indicate the wound was a pressure injury at that time. The DON said a wound could start out from friction and exacerbate into a pressure injury. She said a darkened area on a wound could represent a pressure injury.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to prevent the spread of infection during wound care for one (#40) of one resident with wounds, of 21 sample residents, and during the medication administration observation for one of four nurses. Specifically, the facility: -Failed to implement appropriate hand hygiene practices, glove use and sanitary conditions while providing wound care for Residents #40; and, -Failed to implement appropriate hand hygiene practices and glove use during medication administration. Findings include: I. Unsanitary wound care A. Professional standard According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/8/21, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, on 2/17/22, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) 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. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. B. Facility policy and procedure The Handwashing Procedure policy, dated September 2019, was provided by the infection control nurse (ICN) on 2/10/22 at 5:28 p.m., and included the following guidance: For effective hand hygiene in order to prevent the transmission of bacteria, germs, and infections, all staff shall use the hand-hygiene techniques in the following procedure. Clinical contact requires hand hygiene and will be completed before and after every clinical contact (e.g., medication pass, vital signs, transfer assistance, incontinence care). Employees should also perform hand hygiene before applying gloves to perform a procedure, after removing gloves, after working on a contaminated body site and then moving to a clean body site on the same resident, and after coming in contact with bodily fluids and dressings. C. Wound care observations for Resident #40 1. Right heel The right heel wound dressing change was observed on 2/10/22 at 9:32 a.m. with registered nurse (RN) #2 while the resident was in the tub room after being bathed. The following was observed: At 9:33 a.m., RN #2 performed hand hygiene with alcohol-based hand rub (ABHR) and donned a clean pair of gloves. She removed the right heel dressing that contained dead skin and serous drainage and discarded it. At 9:34 a.m., RN #2 doffed her gloves and donned a clean pair without performing hand hygiene. At 9:35 a.m., RN #2 cleansed the two wounds on the resident's heel, then doffed her gloves and performed hand hygiene with ABHR. At 9:38 a.m., RN #2 donned a clean pair of gloves and placed the clean dressing that would be applied to the wound and two tubes of ointment directly on the seat cushion of the resident's wheelchair. She did not place a clean surface down first to provide a sanitary place to set the dressing supplies. The RN applied the ointment and clean dressing to the wound and doffed her gloves. 2. Right gluteal fold/coccyx The right gluteal fold/coccyx wound dressing change was observed on 2/10/22 at 9:48 a.m. with RN #2 and the following was observed: At 9:48 a.m., RN #2 washed her hands at the sink and donned a clean pair of gloves. She assisted the bath aide to prepare the resident to stand up using the sit-to-stand lift, and touched the lift, the resident's shoulders, and sling with her gloved hands. At 9:53 a.m., RN #2 cleansed the open wound with the same-gloved hands, without changing her gloves or performing hand hygiene. At 9:57 a.m., RN #2 picked up the ointment from the wheelchair seat and applied it to the wound, then placed a clean dressing over it. She placed the two tubes of ointment back inside of the resident's personal wound care supply box with the other clean dressing supplies, without cleaning or sanitizing them. She doffed her gloves and performed hand hygiene with ABHR. 3. RN #2 interview RN #2 was interviewed on 2/10/22 at 12:30 p.m., and she said she routinely worked with Resident #40. She explained that during the dressing change for the resident's heel, she removed the old soiled dressing, doffed the gloves she was wearing, and did not perform hand hygiene prior to donning a clean pair of gloves, and she said she should have. She said when she placed the tubes of ointment directly on the seat of the wheelchair; she cross-contaminated the tubes and should have put down a clean surface to lay them on, or at least wiped them off before she put them away. She said she did not normally change the wound dressings in the tub room, but instead in the resident's room where she had a table with a surface to put her dressing change supplies on. RN #2 said she remembered she used the same gloves to assist the resident to stand up using the lift because she was nervous about the resident's strength, so she was helping her. She said she should have doffed the dirty gloves and performed hand hygiene prior to donning a clean pair of gloves and cleansing the wound. II. Hand hygiene and glove use during medication administration A. Facility policy and procedure The Medication Administration policy and procedure, dated 1/5/22, was provided by the ICN on 2/10/22 at 5:28 p.m., and included the following guidance: Medications were to be administered in a manner to prevent contamination or infection, which included perform hand hygiene prior to and following administering medications. B. Medication administration observation RN #4 was observed preparing and administering medications on 2/8/22 at 3:46 p.m. for Resident #22. RN #4 donned a pair of clean gloves without performing hand hygiene, then touched the medication cart drawer and pulled it open. She touched multiple medication blister pack cards, two boxes of dairy aide, and a container of Tiger Balm ointment, then poured Lactaid tablets, Tylenol and Tamsulosin into a soufflé cup without doffing the gloves or performing hand hygiene. With the same gloves, the RN touched the mouse for the computer, removed a drinking cup from a stack and poured water from a pitcher into the cup. She took the medications and water to the resident and administered them to him without doffing the gloves or performing hand hygiene. The RN doffed her gloves at 3:57 p.m. and did not perform hand hygiene. C. RN #4 interview RN #4 was interviewed on 2/8/22 at 4:00 p.m., and she said she had worked at the facility for approximately one and a half months. She said any time she was passing medications; she wanted to make sure she wore gloves so that she did not touch the pills. She said she did not routinely change gloves after touch drawer pulls, medication cards or other items in the medication cart, or sanitize her hands in between, and said she probably should. She said she normally wiped down her medication cart with alcohol pads prior to beginning any medication administration during her shift. III. Director of nurses (DON) interview The interim director of nurses (IDON) was interviewed on 2/10/22 at 2:51 p.m., and she said during wound care, gloves should be changed and hand hygiene should be performed before the start of the procedure, after dirty dressings were removed, after the nurse completed the dressing change, and before they touched anything else. She said a designated clean surface or bedside tray should be used to place the dressing supplies on during the wound care process in order to prevent the spread of infection. She said a wheelchair seat was not a suitable surface to place wound care supplies because it was not an easily cleanable surface and was not an acceptable practice. She said the tubes of ointment should have been sanitized prior to returning them to the storage box to prevent cross contamination. The IDON said hand hygiene should be performed routinely during medication administration including before the nurse started the process, in between each resident, and when they were finished. She added that if the nurse touched something in between those opportunities, they should perform hand hygiene at that time as well, so they did not spread germs from resident to resident. She said nurses did not typically wear gloves during medication administration.