**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were free from abuse for one (#26) of two residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to protect Resident #22 from sexual abuse by Resident #26. Findings include: I. Facility policy and procedure The Abuse Non-Tolerance policy, dated October 2022, was provided by the nursing home administrator (NHA) on 3/18/24. It read in pertinent part, Residents and clients must be free from abuse by anyone, including associates, other residents or clients, consultants or volunteers, family members or legal guardians, friends or other individuals. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Capacity and consent: Residents and clients have the right to engage in consensual sexual activity. However, if the community has reason to suspect that a resident may not have the capacity to consent to sexual activity, the community must take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity. Protection of the person who may have been a victim of abuse: -Changing caregiver assignments; -Restricting visitors; -Frequent monitoring of the resident; -Relocating the resident to a more visible area; -Utilizing a companion or sitter to stay with the resident; and, -Have the resident leave the community as appropriate and if desired with friends or family. II. Facility investigation The facility investigation, dated 2/5/24, documented the following information in pertinent part, (Resident #22) and (Resident #26) were sharing transportation to church. (Resident #22) reports that they were holding hands in church and it was consensual. On the bus ride back to the community, they were also holding hands. (Resident #22) reports that she let go and when she did (Resident #26) did not remove his hand from her person and that his hand lingered on her clothing over her breast. She did not say anything and he removed his hand. (Resident #22) reported the incident to a nurse after returning to the community. Nurse provided information to DON (director of nursing) and Social Worker via email, which was read the following day just prior to submission of report. (Resident #22) denies feeling unsafe with (Resident #26), and states 'we are friends, he is a boob man, he's not aggressive.' (Resident #22) would like to continue to share the bus to church on Sundays. No physical redness, bruising. Resident is relaxed in body language and denies feeling unsafe. No physical harm, (Resident #22) did not provide consent, also wishes to continue to have interactions with alleged assailant (Resident #26). Every 30 minute observations of alleged assailant (Resident #26). Behavior monitoring updated in treatment administration record (TAR) to be more individualized to (Resident #26) specific behaviors of concern. Continue observation monitoring when resident is out of room. Additional education provided to nursing staff regarding behaviors, interventions and documentation. Place next to male or out of reach of females when possible during activities and transportation. Consider alternative living arrangement. Resident and POA (power of attorney), notified of concern regarding pattern of behavior and inability to retain education or control impulses secondary to TBI (traumatic brain injury). Social services will assist family in looking for alternate living options. If the behaviors continue (Resident #26) may be facing involuntary discharge. Review of the State Agency portal revealed the facility reported the incident on 2/5/24. III. Resident #26 (assailant) A. Resident status Resident #26, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included personal history of traumatic brain injury, hemiplegia (paralysis), unspecified, affecting left non-dominant side, mild cognitive impairment, psychophysiologic insomnia, personality change due to known physiological condition and other sexual dysfunction not due to a substance or known physiological condition. The 1/29/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score 14 out of 15. No behaviors were documented. He required set-up assistance with toileting, moderate assistance with bathing and maximal assistance with lower body dressing. He was independent with transfers. B. Resident interview Resident #26 was interviewed on 3/17/24 at 4:42 p.m. Resident #26 said he had lived at the facility for four years. He said he stayed in his room most of the time and kept himself busy watching movies on his television (TV) and computer, reading and writing emails and people could visit with him if they wanted. He said he did not want to leave his room because he was accused of touching a female resident. He said when he was in his twenties, he spent many years living and working in Brazil as a model. He said he wrote a book about that time but it was not published yet. C. Record review A review of Resident #26's comprehensive care plan, initiated 1/30/2020, revealed the resident had a diagnosis of a traumatic brain injury (TBI) and had impulse control issues. The resident had hypersexuality and watched pornography at times. Interventions included: Be aware of any behaviors that put the resident or others at risk and report this to the DON , nurse manager or social service director (SSD), initiated 5/4/2020; If the resident was inappropriate in anyway staff was to directly tell him in the moment that what he was doing was not alright; If the resident was confused, staff was to tell him what behaviors were appropriate, if the resident was masturbating in front of others, staff was to tell him it was not an appropriate time to do that, and allow him to have some privacy in his room, initiated 1/30/2020; If the resident was out of his room, staff was to supervise him so he did not put himself and others at risk, if the resident's zipper was down and he was exposing himself, staff were to let him know and either take him back to his room or ask him to return to his room, initiated 11/16/2020; the resident required two certified nurse aides (CNAs) to provide personal care and bathing at all times; If the resident made inappropriate sexual comments or began to masturbate while being showered, staff was to tell him to stop and tell him it was inappropriate, initiated 6/12/23; The resident was to be placed/encouraged to sit next to males or out of reach of females during events or during transportation, initiated 2/9/24. -The care plan did not address the need for the resident to have close staff supervision when Resident #26 was outside of his room. The life enrichment (activities) care plan, initiated 2/4/2020, revealed Resident #26 shared interest in going out to church services on Sundays. All arrangements were made to help with transportation, initiated: 9/13/21. \ -The care plan failed to address appropriate supervision when Resident #26 was outside of the facility. Review of Resident #26's electronic medical record (EMR) revealed the following progress notes: On 9/13/23, a nurse documented in pertinent part, Resident was seen touching another resident in an inappropriate manner. Resident was made aware that his behavior was inappropriate and separated from other resident. Physician assistant and DON informed. Orders received to increase resident's Sertraline (antidepressant) in order to control his behaviors. On 9/13/23, a physician documented in pertinent part, Hemiparesis, left. Due to TBI. Wheelchair dependent. Cognitive and neurobehavioral dysfunction following brain injury. Cognitive and behavioral problems with executive dysfunction, impaired decision-making, disinhibition, lack of safety awareness, impulsivity, irritability, and inappropriate sexual behaviors. He tends to have unrealistic expectations, and poor insight into the limitations of his impairments. Inappropriate behaviors involving female residents, risk of harm, will increase Zoloft (antidepressant) to 75 mg (milligrams) qd (daily). On 9/20/23, a nurse documented in pertinent part, CNA reported that resident was behaving in a way that was sexually inappropriate. She stated that he was in his doorway with his penis in his hands while the housekeepers were mopping. Resident was told to go into his room and not to expose himself in the hallway. On 10/24/23, a social worker documented in pertinent part, Resident #26 is a long term care resident who resides in a private room in the (name) neighborhood at the (facility). Resident #26 experienced a TBI as a young adult. His only daughter, (name), lives in (town). Resident #26 does not engage in many activities or socialization, preferring to stay in his room and watch TV. His room is covered in pictures of himself pre-TBI and family members. Occasionally he will attend an activity, especially if it involves food. Resident #26 has also attended a photography activity before, which he enjoyed. Even if he does not want to attend many group activities, Resident #26 enjoys it if you stop by him and engage in conversation 1:1 (one-on-one). He enjoys listening to stories about others' lives, and telling you about his life. He has written a book about his life, and sometimes asks for help in getting it published. [NAME] can sometimes make inappropriate sexual comments, if this happens it is important to tell him that it was inappropriate. Resident #26 enjoys attending church services at the Christian church on Sundays when there is a driver available. On 2/5/24, the DON documented in pertinent part, Interview with Resident #26 regarding allegation of sexual misconduct by another resident. (Name of social worker), LSW (licensed social worker) present. Resident #26 acknowledges that he was holding hands with another resident, denies touching breast or lingering hand states 'I didn't do that .she's old .On the bus? I was here and she was over there. We were closer at church.' On 2/9/24, the DON documented in pertinent part, Spoke with resident regarding the investigation of sexual misconduct. (Name of social worker), LSW present. Resident #26 reports that as he has considered our previous conversation. He recalls when Resident #22 removed her hand and his remained on her body and said 'but her (breasts) are huge, they're down to here, so what am I supposed to do, plus she never said anything, she could've moved my hand.' The vulnerability of the surrounding population, likelihood of cognitive impairment and inability to know other individuals medical history was reviewed. Resident informed of requirement and importance of not touching other residents. Discussed an established pattern of behavior and need to seek alternate living arrangement if the behaviors persist. Resident said 'I won't, these people are all old around here, I don't get off touching old ladies.' Resident acknowledges his understanding. Resident is aware of notification to POA (power of attorney). -Despite the facility's awareness of Resident #26's hypersexual behaviors and history of inappropriately touching a female resident, the facility allowed the resident to travel next to a female resident in a van (see facility investigation above). -The facility failed to protect Resident #22 from being inappropriately touched by Resident #26. IV. Resident #22 (victim) A. Resident status Resident #22, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, post-traumatic stress disorder, alcohol dependence with alcohol-induced persisting dementia and major depressive disorder. The 1/21/24 MDS assessment revealed the resident had intact cognition with a BIMS score of 13 out of 15. The resident had no hallucinations, delusions or behaviors. She had a range of motion impairment on one side of both the upper and lower extremity. She required substantial/maximal assistance with toileting, bathing and dressing and partial/moderate assistance with transfers. B. Resident interview Resident #22 was interviewed on 3/20/24 at 12:42 p.m. Resident #22 said she had experienced inappropriate touching in the past. She said one evening Resident #26 was sitting at the computer desk on her unit when she went down to use the computer. She said he moved over and let her use the computer and started telling her about his time in Brazil and how he loved the women there because they did not wear shirts and the men could touch and kiss the women's breasts. She said when she was finished on the computer she bent over causing her breast to fall with gravity and Resident #26 touched her right breast. She said she told him this isn't Brazil and we aren't going to be doing that. She said she did not wear a bra. She said she was not afraid of Resident #26 and did not feel uncomfortable around him because she knew how to take care of herself. She said after the computer incident, Resident #26 was banned from going down to her unit and was even banned from being around her for a while. C. Record review A review of Resident #22's comprehensive care plan, initiated 6/20/19, revealed the resident had impaired cognitive function/dementia or impaired thought processes. She did not have safety awareness and was often impulsive. Interventions included: Reminding the resident of goals she had set such as not over eating and focusing on keeping her weight low, providing gentle reminders if staff saw her doing anything unsafe or making poor decisions, providing the resident with simple instructions and reminders when needed and staff was to remember, due to the resident's cognitive impairments, she would l often have the same conversation over again. The mood care plan, initiated on 6/20/19, revealed the resident struggled with alcohol addiction in the past and used alcohol to treat her depression and get to sleep. The resident would overeat because she thought it would make her feel better and she was often down which would present as irregular sleep patterns, irritability and overeating. The resident saw a therapist but due to her dementia, insight work was sometimes difficult. Interventions included: Arranging for psychological consultation and follow up as indicated, assisting the resident with developing/providing her with a program of activities that was meaningful and of interest, Encouraging and providing opportunities for exercise and physical activity, discussing with the resident, her family and caregivers any concerns, fears or issues regarding health or other subjects as they occur, encouraging the resident to express her feelings and giving her time to talk., avoiding challenging her behavior as she did not respond well and showing the resident care and gentleness. -The care plan failed to address Resident #22's vulnerability and risks for being a victim of sexual abuse. -Review of Resident #22's EMR did not reveal documentation that she was inappropriately touched by Resident #26. V. Staff interviews The SSD was interviewed on 3/18/24 at 11:25 a.m. The SSD said Resident #26 was sexually and verbally inappropriate towards staff and would ask for sexual favors. She said the resident was observed by staff placing his hand on a female resident's leg while she was playing piano. The residents were immediately separated. She said the facility investigated an incident when a female resident reported that Resident #26 touched her breast while on a bus trip to church on 2/4/24. She said the female resident was not upset or afraid of Resident #26, she said the residents were still friends. She said Resident #26 was always accompanied/supervised by staff when he wished to leave his room and join any group activities. Certified nurse aide (CNA) #5 was interviewed on 3/19/24 at 9:30 a.m. CNA #5 said she was aware of Resident #26 being sexually inappropriate towards staff. She said the resident's behaviors were documented in the care plan. She said she had not experienced any inappropriate situations with Resident #26. She said she worked mostly night shifts and the resident was always respectful when she was assisting him with activities of daily living (ADL). Licensed practical nurse (LPN) #2 was interviewed on 3/19/24 at 9:36 a.m. LPN #2 said she was aware of Resident #26's inappropriate sexual behaviors towards staff and female residents. She said she witnessed the incident when Resident #26 placed his hand on a female resident's leg. She said staff immediately separated both residents. She said she was aware of Resident #26 exposing his lower body parts to some staff, mostly housekeepers as the housekeeping closet was across the hall from the resident's room. She said Resident #26 was easy to redirect. She said once a staff member observed his inappropriate behavior, the resident would apologize. VI. Facility follow-up Resident #26's care plan was updated on 3/20/24 (during the survey) to include the following intervention: I enjoy attending church on Sundays. Please place me in my w/c (wheelchair) out of reach of any other residents when riding the bus.

Based on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to follow accepted standards of practice for medication administration by pre-pouring medications prior to confirming the resident was ready and available for medication administration. Findings include: I. Professional references Nursing rights of medication administration, updated on 9/5/22, was retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 3/22/24 at 9:00 a.m. It read in pertinent part: 'Right time'-administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. Long Term Care Nursing: Medication Pass, updated on 1/24/24, was retrieved from https://ceufast.com/course/long-term-care-nursing-medication-pass on 3/22/24. It read in pertinent part: Medication errors are serious and can cause resident harm or even death. It is human nature to want to simplify things when there is much to be done. In an attempt to do this, sometimes shortcuts are made. However, this is not good practice. Especially when it comes to medications. Do not take shortcuts. More specifically, do not, under any circumstances, try to pre-pour medications to save time. Pre-pouring medications are against regulations. In addition, it increases the risk of making mistakes. II. Facility policy and procedure The Medication Storage policy, version one 2024, was provided by the director of nursing (DON) on 3/21/24 at 8:49 a.m. It read in the pertinent part, Medications are administered at the time they are prepared. Medications are not pre-poured. III. Observations On 3/19/24 at 8:36 a.m., the medication pass on the Mountainside unit was observed with the registered nurse (RN) #1. At 9:06 a.m., RN #1 prepared medications for Resident #44. RN #1 walked to the resident's room and found the resident was not in her room. RN #1 returned to the medication cart, wrote the resident's name on the medication cup and put it in the top drawer. RN #1 began preparing medications for the next resident. -RN #1 did not destroy the dispensed medications. -The dispensed medications were not administered to the resident until 10:14 a.m., over an hour after RN #1 prepared them. At 9:11 a.m., RN #1 prepared medications for Resident #50. She dispensed four of the ordered medications into a medication cup for the resident and then stopped. She put the medication cup in the top drawer of the medication cart and locked the cart. RN #1 did not label the medication cup with the resident' sname. She left the medication cart and went to another resident's room to finish flushing a foley catheter. -RN #1 did not destroy the dispensed medications. At 9:27 a.m., RN #1 returned to the medication cart, removed the medication cup for Resident #50 and continued to dispense the remaining medications. At 9:30 a.m. RN #1 took the medication cup to the resident's room and the resident was asleep. She returned to the medication cart, placed the medication cup back in the top drawer and began preparing medications for the next resident. -RN #1 did not destroy the dispensed medications. -The dispensed medications were not administered to the resident until 10:26 a.m., almost an hour after RN #1 prepared them. IV. Staff interviews RN #1 was interviewed on 3/19/24 at 9:11 a.m. RN #1 said she realized she was not supposed to put dispensed medications in the top drawer of the medication cart but she did not know what she should have done because she needed to flush a foley catheter. The DON was interviewed on 3/20/24 at 1:05 p.m. The DON said storing dispensed medications in a medication cup in the top drawer of the medication cart was not safe practice and was not permitted in the facility. The DON said the nurse should have destroyed the medications and dispensed them again when the resident was ready for administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#7 and #49) of four residents out of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility failed to: -Ensure Resident #7's portable oxygen concentrator was turned on while she was out of the building at an appointment; and, -Ensure Resident #49 was assisted with removing her cervical collar (c-collar) during meal times. Findings include: I. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic respiratory failure (shortness of breath) and chronic obstructive pulmonary disease (COPD) ( airflow blockage and breathing related problems). The 2/1/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with transferring, dressing and personal hygiene. B. Resident observation and interviews On 3/19/24 at 9:21 a.m., Resident #7 returned to the facility from an outside appointment. She said she left the building at 8:15 a.m. via facility transportation for the appointment but when she arrived at the appointment was told she did not have an appointment scheduled. The dial of Resident #7's portable oxygen tank was positioned on zero. Resident #7 said she received 2 liters per minute (LPM) of oxygen. She said she was unable to tell if oxygen was flowing through the nasal cannula. At 9:25 a.m. licensed practical nurse (LPN) #1 approached Resident #7 and asked about the appointment. LPN #1 said Resident #7 required 2 LPM of oxygen. LPN #1 turned the dial on the portable oxygen tank to 2 LPM. LPN #1 said Resident #7 had cold hands and proceeded to warm Resident #7's hands up using friction from her own hands prior to placing a pulse oximeter (a non-invasive device which measures the level of oxygen in the blood) on Resident #7's finger. The pulse oximeter indicated Resident #7 had an oxygen saturation level (SpO2) of 87 percent (%). After being on 2 LPM of oxygen for just under two minutes, Resident #7's SpO2 increased to 92%. LPN#1 said the certified nurse aides (CNA) were supposed to ensure the resident's portable oxygen tank was turned on once she was positioned in her wheelchair. She said the CNAs must have forgotten to turn the oxygen tank on before Resident #7 left for her appointment. C. Record review The March 2024 CPO revealed the following physician's order: -Oxygen 2 LPM via nasal cannula (NC) every day and 3 LPM via NC every night. Check pulse oximeter on day and evening shift, ordered 9/11/23. The oxygen therapy care plan,initiated on 6/20/19, revealed Resident #7 utilized oxygen. Pertinent interventions included monitoring for signs and symptoms of respiratory distress and the oxygen flow rate was 2 LPM at night. -The care plan failed to include an oxygen flow rate for day time use. -The care plan failed to reflect the correct oxygen flow rate of 3 LPM at night. The 3/19/24 progress note (during the survey) revealed nursing staff had spoken to the CNA who had assisted Resident #7 out of bed. The CNA told the nursing staff she turned the portable oxygen tank off to fill it and must have forgotten to turn it back on. D. Facility follow up On 3/19/24 at 10:30 a.m. (during the survey), the director of nursing (DON) began providing facility staff education on portable oxygen tank expectations. The education revealed in pertinent parts: When a resident requires supplemental oxygen, please ensure the following: nasal cannula is in their nose, portable oxygen is set to their ordered amount, tank has enough oxygen in it to provide resident with their needed amount for the needed time before a refill is needed. When transferring residents between surfaces please ensure oxygen tubing is hooked up to the appropriate source and the source is turned on to ordered flow rate. The DON also provided written follow up revealing in pertinent: An audit was conducted of all residents with portable tanks on their wheelchairs to ensure that portable oxygen tanks were turned on to the appropriate amount. No additional issues were noted. an education was provided to nursing team members working on 3/19/24, including team members who were working with the above noted resident. Nursing team members not working on 3/19/24 will also be educated. An audit was created for the nursing leadership team (or designees) to monitor random residents from each neighborhood two times per week. This audit will be brought to the community's GO (QAPI) meeting and reported to ensure substantial compliance. -However, the facility's corrective actions began after the concern with the portable oxygen tank was brought to the facility's attention. II. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the March 2024 CPO, diagnoses included fracture of the neck and muscle weakness. The 2/20/24 minimum data set MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance with bathing, dressing, toileting, limited assistance with personal hygiene and set up / clean up for eating. B. Resident observation and interview On 3/17/24 at 5:00 p.m., Resident #49 was sitting in the main dining room at a table eating soup. The resident was wearing a cervical collar (c-collar) ( a collar used to support and limit movement of neck and head). Resident #49 had awkward movements while eating as she had to bring the eating utensil to eye level and then to her mouth while eating. Resident #49 was interviewed on 3/18/24 at 9:00 a.m. Resident #49 was sitting in her wheelchair in her room eating breakfast with the c-collar on. The resident said she was at the facility receiving therapy after she fell at home in January 2024. She said she fractured her right hip and her neck. Resident #49 said she was doing better than when she first admitted to the facility and was told the c-collar could be removed during meals. Resident #49 said she was unsure who was allowed to remove the c-collar and thought only certain staff were trained on this because only some of the staff would offer to remove the c-collar during meals. Resident #49 said the c-collar was uncomfortable and made eating difficult. She said eating foods containing a lot of liquid, such as yogurt, soup or hot and cold cereals, presented the most difficulty with spilling. Resident #49 said if she could not stab food with her fork or the food did not stick to her spoon she usually spilled food on herself Resident #49's c-collar had multiple small dark circular stains on the padding where her chin was resting. On 3/18/24 a 12:09 p.m., Resident #49 was sitting in her room eating lunch wearing the c-collar. Resident #49 was interviewed again on 3/19/24 at 9:20 a.m. Resident #49 was sitting in her wheelchair in her room eating breakfast wearing the c-collar. She said staff had not offered to remove the c-collar while she was eating. On 3/19/24 at 1:00 p.m., LPN #1 was assisting Resident #49 in her room with a scheduled treatment. LPN #1 said the c-collar could be removed by any nurse or CNA and should be removed at meals. She said the c-collar was removed and reapplied by two velcro straps. LPN #1 said Resident #49 could adjust the velcro on her own if she wanted to. Resident #49 said she was unaware she could do this and did not think she had enough strength in her arms after therapy to adjust the c-collar on her own. On 3/20/24 at 12:15 p.m., Resident #49 was sitting up in her wheelchair in her room eating lunch without her c-collar on. She said someone offered to remove the c-collar while she was eating. On 3/21/24 at 9:30 a.m. Resident #49 was sitting in her wheelchair in her room eating breakfast wearing the c-collar again. The breakfast consisted of fruit mixed with yogurt. She said staff had not offered to remove the c-collar while she was eating. C. Record review -Review of Resident #49's comprehensive care plan, initiated 2/12/24, did not reveal a care plan focus for the resident's c-collar. The March 2024 CPO revealed the following physician's order: -Every day and night shift keep the c-collar in place at all times except when eating, ordered 2/26/24. C. Additional interviews CNA #3 was interviewed on 3/20/24 at 10:00 a.m. CNA #3 said Resident #49's c-collar could be removed when she was eating. She said CNAs could assist the resident with removing the c-collar. CNA #3 said she assisted Resident #49 if she asked for help and offered to help the resident remove the collar sometimes. CNA #4 was interviewed on 3/20/24 at 10:00 a.m. CNA #4 said Resident #49's c-collar could be removed while she was eating. She said CNAs and nurses could assist the resident with removing the c-collar. She said she offered to assist the resident remove the c-collar when she worked with her. The DON and LPN #1 were interviewed on 3/20/24 at 10:20 a.m. LPN #1 said she observed Resident #49 eating that morning (3/20/24) without her c-collar. LPN #1 said she was unsure if the resident had her c-collar removed for all meals. The DON said the physician's order would be clarified to instruct staff to assist Resident #49 with removing the collar at all meals. D. Facility follow up On 3/20/24, the DON began providing staff education it read in pertinent: Please assist Resident #49 to remove her neck brace at meals. It is difficult for her to feed herself with it on and she may not remember every time to ask. On 3/20/24, the March 2024 CPO revealed the revised order: Please encourage and assist me to wear my c-collar when I am not eating and assist me to remove at meals, if I decline please educate me on reasons and benefits. -However, the facility's corrective actions began after the concern with Resident #49's c-collar was brought to the facility's attention. -The facility failed to include updating the care plan to include the c-collar as part of facility follow up.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator. Findings include: I. Observations On 3/18/24 at 11:09 a.m., the medication refrigerator was observed with the registered nurse liaison (RNL). A vial of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) was in a storage box. -The storage box was not permanently affixed to the inside of the refrigerator. II. Staff interviews The RNL was interviewed on 3/18/24 at 11:11 a.m. The RNL said she was new to the facility and still in training. She said she was not aware that controlled medications were required to be in a permanently affixed locked compartment in the refrigerator. She said she understood anyone with access to the refrigerator could just take the controlled medication boxes out of the refrigerator. The director of nursing (DON) was interviewed on 3/20/24 at 1:10 p.m. The DON said she was not aware that refrigerated controlled medications were required to be in a permanently affixed locked compartment, however, the maintenance department had attached the storage box to the inside of the refrigerator (during the survey).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to treat one (#27) of two residents reviewed for dignity of 39 sample residents with respect and dignity and provide care for the resident in a manner that enhanced her quality of life. Specifically, the facility failed to: -Assist Resident #27 with dining while being seated at the resident's eye level; and -Interact with Resident #27 while assisting the resident with dining. Findings include: I. Facility policy and procedure The Dignity and Respect policy, revised 10/11/18, revealed the purpose of the policy was to identify ways staff would maintain residents' dignity while providing care. Staff should display respect for residents when speaking with, caring for or talking about them, as constant affirmation of their individuality and dignity as human beings. The Feeding Assistance checklist, dated September 2019, documented staff assisting residents with dining should always treat residents with dignity and respect. Staff should sit at the same level as the resident and within the resident's line of vision. Staff should converse with the resident, if able, and should not talk to others while assisting the resident. II. Resident #27 status Resident #27, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included Alzheimer's disease, unspecified severe protein-calorie malnutrition, major depression and anxiety disorder. The 8/28/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) cognition score, but documented the resident had both short-term and long-term memory deficits. The resident required supervision of one for eating. The MDS dated [DATE], which was in progress, documented the resident required limited assistance of one of eating. III. Resident observations Resident #27 was observed during dinner in the Pondside dining room on 10/28/19 at 5:27 p.m. The resident was seated in her high-backed wheelchair and was positioned at a table for residents who required assistance with their meals. The resident was being assisted with her meal by certified nurse aide (CNA) #3 and the CNA was observed to be standing over Resident #27 while assisting the resident. -At 5:31 p.m., Resident #27 was observed to give CNA #3 a somewhat angry look and refused the bite that the CNA was offering the resident. -At 5:32 p.m., CNA #3 was observed to be interacting with other staff rather than interacting with Resident #27, until 5:36 p.m. CNA #3 had the resident's food on a spoon during the four-minute observation. -At 5:36 p.m., CNA #3 was observed standing with her left hand on her hip while feeding Resident #27. She was observed to smile at the resident, but not to verbally interact with the resident. The CNA kept offering Resident #27 repeated spoonfuls of food and not speaking to the resident. -At 5:38 p.m., CNA #3 continued to stand over Resident #27 while offering the resident drinks out of a sippy cup. There were two other staff members seated at this assist table who were assisting other residents at the residents' eye level. Resident #27 was observed at her table in the Pondside dining room on 10/29/19 at 5:33 p.m. CNA #3 was again assisting Resident #27 with her meal. During this observation, the CNA was seated on a high wooden counter stool, which placed the CNA above the resident's line of sight. The CNA said she had been working in the facility since the end of July 2019. IV. Staff interviews CNA #6 was interviewed on 10/30/19 at 12:29 p.m. She said Resident #27 should be positioned at a 90-degree angle with staff seated on her left side in order to have staff visible to the resident. She said staff should not be standing over a resident while assisting them with their meals. CNA #8 was interviewed on 10/30/19 at 1:55 p.m. She said staff should be seated next to the resident, at the resident's eye level, when assisting them with their meals. She said it was not appropriate to stand over a resident while helping them eat their meal. She said it was also not appropriate to sit on a high counter stool and be elevated above the resident while assisting them. CNA #7 was interviewed on 10/30/19 at 2:14 p.m. She said, when assisting a resident with their meal, staff should sit beside the resident eye-to-eye so the resident could see the staff. She said staff should never stand over a resident when assisting with their meal. She said having staff seated on a high counter stool would not be appropriate either. CNA #2 was interviewed on 10/30/19 at 2:18 p.m. She said, when assisting a resident with their meal, staff should face the resident as directly as they could while continuing to maintain direct eye contact. She said it would overpower the resident if staff were above them. She said staff should not stand or sit on a tall counter chair when assisting residents with their meals. Licensed practical nurse (LPN) #1 was interviewed on 10/30/19 at 2:21 p.m. He said, when assisting a resident with their meal, staff should position themselves on the side of the resident that gave the resident the most comfort and feeling of independence. He said staff should be seated at the same level as the resident or staff would assert dominance over the resident, which would be disconcerting to them. He said it was not appropriate for staff to stand over a resident while assisting them with their meal. He said the counter stools would be too high for an average sized CNA to assist residents at an appropriate height and that would be a dignity issue for the residents. Social services coordinator (SSC) #1 was interviewed on 10/30/19 at 4:25 p.m. She said staff should be seated next to the resident and verbally interacting with the resident while assisting a resident with their meal. She said the above observations constituted a dignity issue and a perfect chance for staff education about how to interact with residents who required assistance with their meals. The interim director of nursing (DON) was interviewed on 10/30/19 at 4:32 p.m. She said staff should sit next to a resident when assisting with their meals, while communicating with and verbally engaging the resident. She said she also observed the interaction between Resident #27 and CNA #3 the evening of 10/28/19. She said she felt CNA #3 was inappropriately positioned to assist Resident #27 with her meal and asked CNA #3 to stop bopping around and sit down. She said the CNA's response to that request was to tell the interim DON that she did not like that rule, and she did not sit down. She said she notified CNA #3's supervisor and said she was disappointed in CNA #3's response to her request. The corporate nurse consultant (CNC) was interviewed on 10/30/19 at 5:59 p.m. She said she essentially felt the same about the observations of CNA #3's assistance with Resident 27's meals on 10/28/19 and 10/29/19 as the interim DON felt. CNA #3 was unavailable for an interview regarding dining assistance, in that she was not scheduled to work on either 10/30/19 or 10/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to administer medications according to professional standards of quality for two (#39 and #30) of 11 residents reviewed for medication administration of 39 sample residents. Specifically, the facility failed to ensure: -Resident #39's and Resident #30's medications were not left at the bedside; -Residents #39 and #30 were evaluated and assessed to self-administer their own medications in a timely manner; and -Physician orders were in place in a timely manner that allowed Residents #39 and #30 to self-administer their own medications. Findings include: I. Facility policy and procedure The corporate nurse consultant (CNC) provided the Safe Medication Preparation policy and procedure, dated 2017, on 10/31/19 at 12:05 p.m. It documented prior to administering medications, a physical assessment should be performed that would reveal physical findings for any indications or contraindications for medication therapy. Be sure to assess the resident's sensory, motor, and cognitive functions. By assessing the resident's level of knowledge, you determine the need for teaching. Complete appropriate assessments, which may include vital signs, laboratory data, and the nature and severity of symptoms. Nursing interventions focus on safe and effective drug administration. This includes careful medication preparation, accurate and timely administration, and patient education. Follow the six rights of medication administration (right person, right route, right dose, right time, right medication, and right documentation). Stay with the resident until the medication is taken. Provide help as necessary. Do not leave medication at the bedside without a health care provider's order. II. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, Alzheimer's disease, opioid dependence, noncompliance with other medical treatment and regimen, and gastro-esophageal reflux disease (GERD). The 9/17/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Mood symptoms present included feeling down, depressed or hopeless, feeling tired or having little energy, and moving or speaking so slowly that other people could have noticed occurred once during the lookback period. Behaviors of psychosis that were present included delusions. She required extensive assistance with bed mobility, dressing, and personal hygiene, and supervision with eating. B. Observation and resident interview On 10/29/19 at 10:21 a.m., Resident #39 was lying in bed in her room and there was an empty paper soufflé medication cup and a plastic soufflé cup with multiple pills in it sitting on her bedside table. Licensed practical nurse (LPN) #1 entered the room at 10:22 a.m., and explained the resident preferred he left the medications at her bedside so she could take them at her own pace. He turned to leave the room and stated, Make sure she takes her pills. After LPN #1 left the room, Resident #39 said, They usually leave them next to the bedside. They are not supposed to, but (LPN #1) knows me. She said the medications were routinely left on her bedside table by the nursing staff and she confirmed one of the pills in the plastic soufflé cup was a narcotic. She explained she was slow in taking her pills and liked to have a little bit of rest time in between taking each medication. She said most of the time she did not have any problems swallowing them, but sometimes the broken potassium tablet would scratch down my food pipe and I definitely have to wait for a little bit in between pills. There were seven pills in the plastic medication cup and she swallowed them all together at 10:26 a.m. C. LPN #1 interviews LPN #1 was interviewed on 10/29/19 at 10:40 a.m., and he confirmed he routinely worked with Resident #39. He said he usually left her morning medications at her bedside for her to take at her leisure. He said if he stayed in her room during the medication pass and waited for her to take the pills, She will just talk and talk and I've been stuck in there for 30 minutes before. He stated, I just have to walk away or else I would be in there forever. He confirmed he routinely left her medications at her bedside and would go back into her room later and check on her to make sure she had taken them. LPN #1 was interviewed a second time on 10/29/19 at 5:28 p.m. He confirmed there were seven pills in the soufflé cup at the resident's bedside that morning and identified them as the following: Lexapro (antidepressant), gabapentin (anticonvulsant), Zantac (antiulcer), spironolactone (diuretic), Percocet (opioid analgesic) and two torsemide (diuretic). He said Resident #39 also received a potassium pill in the mornings, which he would break in half and place it in a separate paper soufflé cup, which she would normally take first. He said he was currently responsible for 30 residents and said if he stayed in Resident #39's room and waited for her to take her pills, I would be in there for 30 minutes, and I do not have that amount of time in my day. D. Record review The care plan, initiated 6/25/19 and not revised since, identified the resident had impaired cognitive function/dementia or impaired thought processes and needed verbal and visual cues to help with recall, orientation and tasks of daily life. She required approaches that would maximize her involvement in daily decision-making and activity by limiting her choices, using cueing, task segmentation, written lists, and instructions. She should be cued, reoriented and supervised as needed. She had been diagnosed with dementia with behavioral disturbances and her speech was clear though often nonsensical or not related to questions being asked. She knew her name and at times her caregivers, but was not aware of where she was or her situation. The care plan, initiated 6/20/19 and not revised since, identified the resident was at potential nutrition and hydration risk related to a history of swallowing difficulty and use of diuretics. The approaches documented she had complained of difficulty swallowing in the past and should be monitored for signs and symptoms of aspiration, and allowed to drink and eat at her own pace. The Monthly Nursing Observations assessment, dated 10/25/19, documented the resident's orientation included short- and long-term memory impairment and impaired decision-making ability. The CPO for October 2019 included the medications listed above, but did not include an order that the resident could administer her own medications. The clinical record was reviewed in its entirety and there was no assessment for self-administration of medications present. On 10/30/19, the director of nurses (DON) and CNC were asked to provide the most recent assessment for self-administration of medications for Resident #39. A Medication Self-Administration Safety Screen, dated 10/30/19 (same day), was provided. It included the following instructions: Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. The form provided space for up to 10 different medications to be listed, and each should include the provider's order, the reason for use, and the side effects. Under the space for medication #1, the form listed see orders, and the remaining nine medications were void of documentation. The evaluation revealed the resident was completely capable of correctly reading medication labels, and could correctly state the time, frequency, and dosage for the medications to be taken. However, she required assistance opening containers and correctly stating what each medication was used for. The section on the form titled Approvals, was void of documentation as to whether or not the resident agreed to the terms and policies for self-administration, but was dated 10/30/19. The section on the form titled, Physician, documented the resident may self-administer medications unsupervised once prepared by staff and may be left at the bedside with the resident. The physician's order was dated 10/30/19. Registered nurse (RN) #1 completed the form. A progress note dated 10/30/19 was written by a physician's assistant that read, May leave pills at bedside with resident once prepared by staff. On 10/31/19 at 10:00 a.m., the MDS coordinator provided a list of residents in the facility that included their BIMS scores and who were independently able to ambulate or propel themselves in their wheelchairs. There were a total of three residents who were severely impaired and five residents who were moderately impaired but were able to navigate independently. E. Additional staff interviews Certified nurse aide (CNA) #12 was interviewed on 10/31/19 at 10:00 a.m., and she confirmed she routinely worked with resident #39. She said she was confused at times, and other times she was able to have a good conversation with her. The CNA said she saw her medications left at her bedside every morning and stated, Because she likes to take her time taking them. RN #1 was interviewed on 10/30/19 at 6:05 p.m., and she confirmed she was the nurse who completed the medication self-administration assessment for Resident #39 earlier that day. She said she received no training or guidance on how to complete the form or do the assessment, and had never completed one before. She said she did not speak to Resident #39 personally, but rather, she interviewed LPN #1 instead. She said the assessment needed to re-done and would clarify with the DON who should complete it. The DON and CNC were interviewed on 10/31/19 at 10:50 a.m. The CNC confirmed if a resident was deemed safe to administer their own medications, there should be an order from their provider stating that. The DON said Resident #39's mental clarity varied, and on some days, she was very clear and on other days, she was a little less clear. She explained the resident often refused to keep her oxygen on, so when she woke up in the mornings she was more confused. They were not aware of any swallowing difficulties Resident #39 had and were unable to speak to the impaired decision-making ability, memory impairment, and dementia with impaired thought processes care plans. The CNC said the self-administration of medication assessment was used as a guide for staff to make a recommendation and decide as a team to allow it or not. She said the assessment that was performed for Resident #39 revealed she was okay to be unsupervised and then they obtained an order to support that. She confirmed Resident #39 had not had any previous self-administration of medication assessments performed prior to the one completed 10/30/19, and explained the facility staff were not doing those assessments, but instead would follow a physician's order to allow the resident to self-administer the medications if appropriate. The CNC said if medications were left at a resident's bedside, the safety of the other residents in the facility would be ensured because on the following medication round, the nurse would determine if the medication had been consumed. She said if they had reports that residents were in the habit of hoarding or keeping pills or not taking them appropriately, that would cause a reassessment. III. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the October 2019 CPO, diagnoses included bipolar disorder, patient's noncompliance with other medical treatment and regimen, and anxiety disorder. According to the most recent MDS assessment completed 9/2/19, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident experienced delusions and exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, cursing at others, screaming at others). B. Observation During medication pass with LPN #1 on 10/29/19 at 3:19 p.m., the nurse was observed taking medications into Resident #30's room, including oxybutynin (medication for overactive bladder), oxycodone (opioid narcotic), and Risperdal (antipsychotic). LPN #1 handed the medications to the resident along with a cup of pudding and left the resident's room. The nurse did not stay with the resident to ensure the medications were taken. C. Record review The resident medication self-administration safety screen, completed 10/30/19 (during survey and after medication pass observation), showed the resident was capable of self-administering medications. However, the screen was not completed prior to allowing the resident to administer her own medications. The CPO showed an order added 10/30/19 (during survey and after medication pass observation) which read resident may have medications at bedside. However, the order was not obtained prior to leaving the medications at the resident's bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#36) of one resident reviewed for bathing and grooming received the necessary assistance with activities of daily living (ADLs) of 39 sample residents. Specifically, the facility failed to ensure Resident #36 received timely assistance with eye and facial cleanliness. Findings include: I. Facility policy and procedure The Resident Observations policy and procedure, dated July 2018, was provided by the corporate nurse consultant (CNC) on 10/31/19 at 12:05 p.m. It listed the expectations for residents' grooming and cleanliness, which included the following: staff were to check to ensure their skin was clean and there was not food on their face or hands, their hair was combed and clean, their eyes were not matted, and their mouth did not contain debris or odor. II. Resident #36 status Resident #36, age [AGE], was admitted [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included macular degeneration, changes in skin texture, contracture of her hand, Alzheimer's disease, and dementia without behavioral disturbance. The 9/16/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with dressing, eating, and personal hygiene, and was totally dependent for bed mobility, toilet use, and transfers. She had functional limitation in range of motion in both of her upper and lower extremities bilaterally. III. Observations On 10/29/19 at 9:19 a.m., Resident #36 was sitting in her wheelchair in the sunroom in the Mountainside neighborhood. She was awake and alert and was watching TV. There was a string of drool, approximately three inches long, coming out the left side of her mouth. Her eyes were soiled with thick crusted debris accumulation on both the upper and lower lashes, and there were dried brown food stains on her chin and around the corners of her mouth. On 10/30/19 at 10:00 a.m., Resident #36 was sitting in her wheelchair in the sunroom picking at the left side of her head with her left index finger. The skin on her eyebrows was dry and flaking off in pieces and there was thick crusted tan debris accumulation on her upper and lower eyelashes. There was brown, dried debris on her chin. There was a large accumulation of white dandruff flakes on the sling behind her head. On 10/30/19 at 12:03 p.m., Resident #36 was returned to the Mountainside neighborhood by a community life staff member and was placed at a dining table. Her eyes and eyelashes remained crusted with tan debris. CNA #10 fed the resident her lunch without offering to wash her hands or her face. On 10/31/19 at 8:57 a.m., Resident #36 was sitting in her wheelchair in the Mountainside sunroom. She had dry, crusted tan debris on her upper and lower eyelashes bilaterally. IV. Record review The care plan, initiated 6/26/19 and not revised since, identified an ADL self-care performance deficit related to her disease process and contractures. The approaches documented she was dependent on staff for bathing, showering, personal hygiene and oral care. The bathing records were reviewed from 8/1/19 through 10/31/19 and documented the following: -8/10/19 = bathed (10 days since last bathed) -8/24/19 = bathed (10 days since last bathed) -10/3/19 = bathed (five days since last bathed) -10/10/19 = bathed (five days since last bathed) -10/30/19 = bathed (seven days since last bathed) The documentation did not include any refusals of care by the resident. V. Staff interviews CNA #11 was interviewed on 10/31/19 at 8:57 a.m., and she confirmed she routinely worked with Resident #36. She said it was not unusual to see sleepies in her eyes and on her eyelashes in the mornings and stated, In the mornings we need to really wipe them out. CNA #12 was interviewed on 10/31/19 at 10:00 a.m., and she confirmed she routinely worked with Resident #36. She said the resident was totally dependent on staff for all of her ADL needs because she was unable to provide them herself. She said after residents ate their meals, they would have their hands sprayed with hand sanitizer or a wet towel would be used to wipe their hands and face if needed. She said she provided routine morning ADL care for Resident #36 that included combing her hair and washing her face, and she had not noticed flaky skin on her scalp or dandruff. She said the resident refused care sometimes, but if they waited for a few minutes and re-approached her, she was agreeable. The CNA confirmed she had noticed Resident #36's eyelashes to be crusted with debris and said she used a wet paper towel with warm water to clean them. Registered nurse (RN) #4 was interviewed on 10/31/19 at 10:28 a.m., and she confirmed she routinely worked with Resident #36. She said she had noticed crusted debris in the resident's eyes in the past and said she did not have an eye infection. She stated, I think she just needs her face washed. The director of nurses (DON) and CNC were interviewed on 10/31/19 at 10:50 a.m. The DON said the routine morning ADL care provided to residents who were unable to provide it for themselves included changing into clean clothes, washing their face, brushing their teeth, getting anything out of their eyes, provide toileting, and allowing them to pick what they wanted to wear. She said if a resident had food or debris on their face after a meal, the staff should address it by taking them into their room and using a washcloth to clean them up. She said Resident #36 did not have an eye infection and she had not noticed the crusted debris in her eyes or excessive flaking dandruff. She said she would talk to the resident's nurse for more details and look in the chart. The DON and CNC said residents should be clean and well groomed.

Based on record review, observations, and interviews, the facility failed to ensure infection control standards of practice for three (#15, #5 and #13) of three residents reviewed for blood glucose monitoring of 34 sample residents. Specifically, the facility failed to: -Properly disinfect and store personal blood glucose monitoring devices after use for Residents #15, #5, and #13; -Dispose of contaminated materials properly after blood glucose testing; and -Wear appropriate personal protective equipment (PPE) while performing blood glucose testing. Findings include: I. Facility policy and procedure According to the Blood Sugar Glucometer Testing policy, revised December 2018, provided by corporate nurse consultant (CNC) on 10/31/19 at 8:30 a.m., staff were to provide privacy, apply gloves, and clean the glucometer with disinfectant wipes (or manufacturer's recommendations) after each use. II. Observations During medication pass with licensed practical nurse (LPN) #1 on 10/29/19 at 3:30 p.m., the LPN was observed performing a blood sugar test on Resident #13. Upon completion the LPN returned the blood glucose monitoring (BGM) device to the carrying pouch while wearing contaminated gloves and set the pouch on the counter at the nursing station. The BGM device was returned to the storage cabinet without being disinfected after use. The LPN was also observed to walk across the resident hallway with a contaminated glove on, carrying the lancet device, and disposed of the lancet in the sharps container on the medication cart. During medication pass with LPN #1 on 10/30/19 at 3:29 p.m., the LPN was observed performing a fingerstick blood glucose test on Resident #15. After completion of the test the LPN was observed returning the BGM device to the carrying pouch with contaminated gloves and returned the pouch to a storage cabinet at the nursing station without disinfecting the device. The LPN was also observed wearing a contaminated glove while holding the lancet device in the hallway and disposed of it in the sharps container on the medication cart. During medication pass with LPN #1 on 10/30/19 at 4:00 p.m., the LPN was observed performing a fingerstick blood glucose test on Resident #5. After the completion of the blood glucose test the LPN was observed returning the BGM device to the carrying pouch with contaminated gloves and placing the pouch on the medication cart at the nursing station without disinfecting the device after use. LPN #1 was observed walking in the resident hallway with a contaminated glove holding the lancet device to dispose of it at the sharps container on the medication cart. Registered nurse (RN) #4 was observed performing a blood glucose fingerstick test on an unknown resident while in the Pondside resident dining room on 10/30/19 at 4:40 p.m. The RN was observed not wearing gloves while performing the fingerstick blood glucose test. III. Record review Skills checklists for blood sugar glucometer testing for LPN #1 and RN #4 were provided by the facility. On 11/21/18 LPN #1 completed the skills checklist which included to disinfect the glucometer with disinfectant wipes after each use. RN #4 completed her skills checklist on 9/1/19, which included to apply gloves while performing the test. According to the manufacturer's instructions for the BGM device provided by the facility, to disinfect your meter, clean the meter with a validated disinfecting wipe or other EPA registered wipe. IV. Interviews LPN #1 was interviewed on 10/30/19 at 5:17 p.m. He said all nurses were to disinfect the BGM devices after each use using a disinfectant wipe, then document they were disinfected in the electronic medical record. He said his process was to disinfect them in the morning, but some residents had several blood glucose tests a day so he would clean at the end of the day and not after each use. He said it was ok for staff to walk in the hallway with contaminated gloves and materials as long as it was with only one glove. He said there were sharps containers in each resident's restroom and he would probably start using those. RN #4 was interviewed on 10/31/19 at 10:22 a.m. She said nurses were to clean BGM devices before and after every use. She also said nurses should be wearing gloves during BGM tests, and she should have had gloves on while performing the observed BGM test on the unknown resident. The CNC and director of nursing (DON) were interviewed on 10/31/19 at 10:09 a.m. The DON said nurses should be disinfecting the BGM devices before and after use with a disinfectant wipe. She said nurses should wear gloves while performing a BGM test. She said nurses should dispose of contaminated materials in the nearest sharps container, and staff should not walk through residential areas or hallways with dirty gloves or contaminated materials.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility production kitchen. Specifically, the facility failed to minimize the risk for potential foodborne illness in an at risk population. The facility failed to ensure: -Appropriate hand washing; -Safe storage of cold foods; and -Food and non-food contact surfaces were maintained in a clean and sanitary manner. Findings include: I. Hand hygiene A. Professional references According to the Food and Drug Administration (FDA) Food Code (2017), pp. 48-50, foodservice staff shall use the following handwashing procedures: -Rinse under clean, running warm water; -Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; -Rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails and creating friction on the surfaces of the hands and arms fingertips, and areas between the fingers; -Thoroughly rinse under clean, running warm water; and -Immediately follow the cleaning procedure with thorough drying using individual disposable towels, a continuous towel system that supplies the user with a clean towel, or a heated-air hand drying device. The FDA Food Code (2017) pp. 49-50, detailed the following instances when foodservice staff should wash their hands: -Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and -After engaging in other activities that contaminate the hands. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised January 2019 was provided by the nursing home administrator (NHA) on 10/30/19. The policy revealed all associates associated with food handling shall wash their hands at the following times: -Before handling clean utensils, dishes or equipment; -After handling soiled silverware or utensils; -After touching hair, skin or clothing; and -After any other activity that may contaminate the hands. C. Observations The initial tour of the kitchen was on 10/28/19 from 2:05 p.m. through 2:35 p.m. The observations included: -The paper towel dispenser above the handwashing sink adjacent to the food preparation sink did not have paper towels and there was no trash receptacle near the sink; and -The paper towel dispenser above the handwashing sink adjacent to the electric slicer was inoperable and there was no trash receptacle. The paper towel dispenser was not marked as out of service on repeat observations on 10/29, 10/30 and 10/31/19 respectively. Food service utility (FSU) #1 worker was observed on 10/29/19 at approximately 4:00 p.m. He entered the kitchen through the rear entry door and removed his hat with his right hand and scratched his head with his left hand. He entered the dish room and pulled a clean rack of dishes from the dish washing machine. He did not wash his hands after they were contaminated or before he handled clean kitchenware. FSU worker #2 was observed in the dishwashing room on 10/31/19 at approximately 10:00 a.m. He loaded two racks of soiled plates and utensils on the dirty side of the dish machine and slid one into the dishwashing machine. He moved to the clean-side drain board and removed clean cups and other utensils and placed them on a rolling utility cart. He did not wash his hands between touching soiled and clean kitchenware. II. Safe cold food storage A. Facility policy and procedure The Cold Storage Temperatures policy and procedure, revised January 2019, was provided by the NHA on 10/30/19. The policy read in pertinent part: -Each refrigerated storage unit shall have an independent thermometer in addition to a built in thermometer; and -The temperature of each unit shall be recorded and initialed each morning at opening and in the evening at closing on the monthly refrigerator/freezer log sheet. B. Observations The initial tour of the kitchen was on 10/28/19 from 2:05 p.m. through 2:35 p.m. On the wall to the right of the walk-in refrigerator there was an incomplete temperature recording log. There were no internal thermometers in the compact freezer next to the deep fat fryer or within the reach-in refrigerator next to the serving line. On 10/30/19 at approximately 4:00 p.m. there was an uncovered and unlabeled three gallon container of marinara sauce in the walk-in refrigerator. There was a defrosted ice-paddle partially submerged in the red sauce and the outside of the container was warm to the touch. The dining services manager (DSM) checked the temperature with his thermometer and it read 71 degrees Fahrenheit (F). He said he did not know when it had been placed in the refrigerator and he placed it in the dish washing room to be discarded. C. Record review The Kitchen Coolers and Freezer temperature logs for September 2019 and October 2019 were provided by the DSM on 10/28/19 at 2:23 p.m. The month of September had no recorded temperatures for 11 out of 30 days. The month of October 2019 temperature log had last recorded data on the morning of 10/15/19 and only two out of a possible 27 evening temperatures recorded. III. Clean and sanitary work surfaces A. Professional reference According to the Food Code 2017 Recommendations of the United States Public Health Service Food and Drug Administration, page 149: Non-food contact surfaces of equipment should be kept free of dirt, food residue and other debris. Food contact surfaces should be clean to sight and touch. B. Facility policy and procedures The Cleaning of Food and Non-Food Contact Surfaces policy and procedure was provided by the NHA on 10/30/19. The policy revealed utensils and equipment used to serve potentially hazardous foods (PHF) were cleaned and sanitized after each use and non-food contact surfaces of equipment shall be cleaned as often as necessary to keep the equipment free of dust, dirt, food particles and other debris. C. Observations The initial tour of the kitchen was on 10/28/19 from 2:05 p.m. through 2:35 p.m. The observations included: -There was a large plastic bin beneath the top shelf of a rolling stainless steel table at the end of the long rectangular food preparation table. Along the interior sides and bottom of the bin there were large pieces of dried food, white and yellow food splatter and dried brown-colored liquid stains; -The inside of the utensil drawer on the right-sided end of the service table had chunks of food debris and a blackish-brown dust and greasy grime build up along the inside edges and corners; -The tops of the bulk sugar and flour containers stored beneath the drainboard of the three compartment sink had loose pieces of food debris and food splatter. These observations were repeated on 10/29, 10/30 and 10/31/19 respectively. -The floor behind and beneath the rolling bulk food containers had black build up of grime, multiple pieces of paper, a wadded up paper towel and loose food debris. The electric slicer was observed on 10/29/19 at approximately 3:00 p.m. The slicer was covered with a large plastic bag. There was build-up of dried meat between the slicer blade and blade sharpening tool mounted on the slicer. The slicer tray beneath had dried pieces of brown food in multiple areas. D. Record review The facility Kitchen Cleaning List was provided by the DSM on 10/31/19. There were no cleaning log sheets from 9/29/19 through 10/19/19. E. Staff interview The DSM was interviewed on 10/31/19 at approximately 10:30 a.m. He said staff should wash their hands before they touched any clean utensils. He said ongoing education would be provided to all food service associates related to proper hand washing. He said the automatic paper towel dispenser should be tagged out of service and there should be a covered trash receptacle at each hand washing sink. He said there had been a lapse in procedures for ensuring appropriate cold food storage. He said he had purchased additional internal thermometers and re-educated staff on temperature controls and the facility policy for recording cold storage unit temperatures. He said the cleaning schedule had not been followed until the most recent days. He said he and the executive chef would direct overdue and current cleaning responsibilities immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure one (#17) of one resident reviewed for dignity of 35 sample residents was treated with respect and dignity. Specifically, the facility failed to: -Assess needs and provide dignified care while Resident #17 was visibly upset; -Verbally interact with Resident #17 while providing care; and -Provide dignified care to Resident #17 by honoring the resident's request to be transferred to a recliner. Findings include: I. Facility policy and procedure The Dignity and Respect policy, dated 10/28/13 and revised 10/11/18, provided by the director of nursing (DON) on 11/15/18 at 11:30 a.m., read in pertinent part, Our staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. II. Resident #17 status Resident #17, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2018 computerized physician orders (CPO), diagnoses included disorders of psychological development, generalized anxiety disorder, delusional disorders, unspecified psychosis, moderate intellectual disabilities, altered mental state, psychotic disorder and other specified depressive episodes. The 9/5/18 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) cognition score of three out of 15. She required extensive assistance for dressing, personal hygiene, mobility, transfers and toilet use. According to the mood evaluation, the resident felt down/depressed/hopeless and had sleep and appetite disturbances. III. Observations On 11/12/18 at approximately 2:05 p.m., Resident #17 was observed seated in her wheelchair near the nurses' station on the Mountainside neighborhood. She had a milkshake on a rolling bedside table within reach of her wheelchair. She was tearful and calling out for assistance. Two nurses and one certified nurse aide (CNA) were observed approximately 10 feet away from the resident giving change of shift information to each other. Resident #17 remained tearful and continued to softly call out, but no staff responded to the resident or attempted to interact with her or reassure her. Resident #17's needs were pointed out to these staff at 2:23 p.m., 18 minutes after the resident was first observed crying. The nurse going off duty said Resident #17 cry all the time over nothing. On 11/14/18 at 11:25 a.m., Resident #17 was being transferred from the recliner in the Mountainside common area to her room by CNA #7 and the nurse practitioner (NP). CNA #7 brought the wrong size lift belt, and said he could not find the smaller one. The NP and CNA #7 attempted to use the lift belt, but it was too large and the NP asked CNA #7 to go find the smaller belt. CNA #7 returned with a smaller belt about three minutes later, but was rough with cares when changing the belt and was inattentive to the resident when transferring her in the Sara lift. CNA #7 was observed trying to rip the larger belt from beneath Resident #17, rather than gently moving the resident's arms and asking her to lean forward in order to safely replace the lift belt with the smaller belt in a dignified manner. CNA #7 provided no verbal interaction with the resident during this transfer and spoke with the NP instead of the resident. The CNA did not assist Resident #17 with placing her feet securely on the Sara lift and the CNA began moving the lift when the resident's feet were not firmly in place. The CNA was unable to buckle the straps onto the resident's feet and the NP had to perform this task. After transferring the resident from the common area recliner into her wheelchair, the CNA was looking away from the resident as he moved the larger unused lift belt to the top of the Sara lift, and hit Resident #17 in the head with the lift belt, causing the resident to duck and wince. During a continuous observation on 11/15/18 from 9:18 a.m. to 10:37 a.m., Resident #17 was observed seated by herself in the Creekside neighborhood common area in her wheelchair. She was in front of the television, but the television was not turned on. Resident #17 said she had been waiting for someone to assist her into a recliner for some time, but no one had come yet. - At 9:32 a.m., there were now three residents, including Resident #17, in the common area and the television had just been turned on when the other two residents arrived. Resident #17 continued to be seated in her wheelchair and now had a rolling bedside table next to her with a sippy cup of water and a box of Kleenex. She had not been transferred to the recliner, as she had requested. Registered nurse (RN) #7, CNA #10 and CNA #2 were nearby, but were not observed interacting with Resident #17 or the other two female residents seated in the common area. - At 9:38 a.m., CNA #1 was observed stepping into the common area to take a personal phone call, but did not interact with any of the three residents. - At 9:44 a.m., an unidentified CNA went into the common area to assist one of the other two residents, but did not stop to interact with Resident #17 or ask her if she needed anything. - At 9:51 a.m., another resident was observed being taken into the common area of the Creekside neighborhood by another unidentified CNA and again, the CNA was not observed interacting with Resident #17 or the other two residents already seated in this area. - At 10:37 a.m., it was pointed out to CNA #2 that Resident #17 looked agitated and probably needed something. CNA #2 checked on Resident #17, who had been calling out and crying about no one helping her into her recliner. CNA #2 asked Resident #17 why she was crying and the resident told her she had been waiting for assistance into her recliner. CNA #2 told the resident they would not be able to put her in the recliner because they were beginning to get the residents ready for lunch. The resident asked if they would be using the lift and CNA #2 acknowledged that they would. CNA #2 asked the resident if she wanted some juice and Resident #17 said she did. The observation revealed no staff responded to Resident #17's needs for an hour and a half, and her initial request to be assisted into a recliner was never honored. Observations and record review (below) revealed staff failed to consistently implement the approaches in Resident #17's care plans. IV. Record review The care plan, initiated 3/25/15 and revised 10/8/18, identified Resident #17 had a developmental delay and had lived with family members all of her life. The memory and communication care plan, initiated 3/25/18 and revised 9/18/18, documented the resident's speech could be a little garbled and became more unclear when she was anxious. Her voice was soft and staff may need to get close to hear her. The resident was able to make her needs known, but please orient her as part of staff's conversation with the resident when providing care. The mood and psychotropic medications care plan, initiated 3/25/18 and revised 9/18/18, read the resident's goal was to remain calm and at ease. Approaches included to reassure the resident that she was okay and remind her that staff were there to help care for her. The resident could occasionally become anxious and when this occurred, she started to speak faster and have quick movements. When she became anxious, staff were to validate the resident's feelings by providing 1:1 attention and redirect her. The resident often became teary when she was upset. Root beer, ice cream, peanut butter and jelly sandwiches and chocolate usually calmed the resident down. V. Staff interviews The nursing home administrator (NHA) and DON were interviewed together on 11/15/18 at 1:46 p.m. The DON said the above observations with Resident #17 all constituted dignity issues, which she said were odd and out of the norm. The NHA said he spoke with social services coordinator #1 to provide immediate training and education for CNA #7.

Based on record review and interviews, the facility failed to inform two (#500 and #46) of three residents reviewed for beneficiary notices of 35 sample residents in a timely manner of changes in their services covered by Medicare. Specifically, the residents were not provided notice of Medicare provider non-coverage, including all required information, in a timely manner. Findings include: I. Standard The Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Provider Non-Coverage (Form CMS-10123) letters (also called Non-Coverage letters, Expedited Appeal Notice (ABN), or a Generic Notice) are provided to residents receiving Skilled Nursing Facility (SNF) services funded through Medicare benefits. Non-Coverage letters document residents and/or their legal representatives received written notification that discontinuation of Medicare coverage was imminent. II. Facility policy and procedure The director of nursing (DON) said on 11/14/18 at 12:45 p.m. the facility did not have a policy regarding Medicare coverage and liability notices. She provided an instruction sheet requiring the notification forms should include the resident's name, identification number, type of coverage and effective date. III. Resident #500 A. Record review The CMS form 10123, dated 7/24/18, read Resident #500 had been discharged from Medicare part A services on 7/24/18, as the resident had met her Medicare rehabilitation goals. The resident's benefit days were not exhausted. The form was signed by the resident on 7/24/18. This form was not provided to the resident with at least 48-hour notice. The form did not specify what Medicare services were ending, did not include an estimated cost of services if the resident chose to receive the services, or provide the resident with an option of appealing this decision. B. Interview The social services coordinator (SSC) #1 was interviewed on 11/13/18 at 1:12 p.m. After researching Resident #500's discharge, SSC #1 said the resident was receiving physical therapy, occupational therapy and speech therapy. She said she spoke with Resident #500's daughter a few days prior to discharge about the discharge recommendations, but had nothing documented that she went over this form with either the resident or her daughter with at least 48 hours of notice prior to discontinuation of services on 7/23/18. SSC #1 acknowledged the form did not include an estimated cost of services if the resident chose to continue these services, nor did the form include a choice if the resident wanted to appeal this decision. IV. Resident #46 A. Record review The CMS form 10123, dated 11/2/18, read Resident #46 had been discharged from Medicare part A services on 11/2/18, as the resident asked to be discharged by 4:00 p.m. on 11/2/18 so a family member could transport him home. He waived his 48-hour notice. However, the form did not specify what services were ending; that portion of the form was left blank. The form did not include an estimated cost of the unidentified services if the resident chose to receive the services, nor did the form provide the resident with an option to appeal. B. Interviews SSC #1 was interviewed on 11/13/18 at 1:12 p.m. She said even though the resident waived his 48-hour notice to receive this form, the form was incomplete and did not include all required components for full disclosure. SSC #1 was interviewed on 11/13/18 at 1:12 p.m. She said last year, she was told by someone, whom she could not initially recall, not to put the specific Medicare covered services on the forms and to just document Medicare A services for everything. SSC #1 was interviewed a second time on 11/13/18 at 4:50 p.m. She said, according to the facility's administrative services manager, it was the corporate management company who informed the facility they did not have to specify exactly what types of services were being covered on these forms. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 11/4/18 at 12:46 p.m. They both said the facility had no specific policy related to beneficiary notices, other than an undated information sheet from their computerized system (see facility policy and procedures section above). The NHA and DON acknowledged there were some omissions on the above notices for Residents #500 and #46. The NHA said he clarified with their organizational management company that the specific services should be included on the form, and that the forms should be provided with at least 48 hours notice prior to the discontinuation of services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the accuracy of minimum data set (MDS) assessments regarding personal alarms for two (#43 and #51) of two residents reviewed for personal alarms of 35 sample residents. Specifically, Residents #43 and #51 had personal alarms but their MDS assessments documented alarms were not used. Findings include: I. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2018 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia with Lewy bodies, unspecified dementia with behavioral disturbances and other specified anxiety disorders. The 10/25/18 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. Restraints and personal alarms were documented as not used. B. Record review Review of the resident's fall prevention care plan, initiated 7/20/18, revealed the first approach listed, added 10/17/18, was pressure alarm in place while in bed and in chair. A revision on 11/1/18 read the resident had three falls this quarter, all while self transferring. He stated during care conference that he doesn ' t like to ask for help or wait for someone to come. He was encouraged to use the call light at all times. Pressure alarms in place. Review of the November 2018 CPO revealed no physician order for personal alarms. C. Observations and resident interview Observations from 11/12/18 through 11/15/18 revealed a beeping noise near the nurses' station with a three-note musical sound in between. A resident number flashed on a white computer screen near the medication cart each time the beeps sounded. The resident was not observed with a tab alarm on his chair or bed. However, nursing staff interviews revealed the resident had pressure alarms on his chair pad and bed which were covered when the resident was sitting or lying down. Resident #43 was interviewed on the afternoon of 11/13/18 and indicated he was not aware of the personal alarms and didn't hear any sounds from them. D. Staff interviews The MDS coordinator was interviewed on 11/13/18 at approximately 11:15 a.m. She said she wasn't aware Resident #43 had pressure alarms because they had been working on personal alarm reduction and there was no physician order for it. Certified nurse aide (CNA) #7 was interviewed on 11/14/18 at 2:15 p.m. He said the resident had a personal alarm pad in his chair and in bed. The CNA described it as an alarming pad that goes off at the nurses' station if he gets up or anything. The CNA said there was a little white box at the nurse station and a number that flashes on the screen so the nurse knew which resident to check on. The CNA said the alarm didn't sound anywhere else, and on the Pondside neighborhood there were two residents with personal alarms. CNA #8 was interviewed on 11/14/18 at 2:45 p.m. CNA #8 said, I've heard him pull on his tab alarm a few times and they've gone off and he hasn't really responded. He's just kind of confused when they're going off. I tell him it's to keep him from falling and he understands. It doesn't go off very often. II. Resident #51 A. Resident status Resident #51, age [AGE], was admitted on [DATE] with diagnoses including Alzheimer's disease and dementia per MDS assessment. The 10/18/18 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. Restraints and personal alarms were noted as not used. B. Observations The resident was not observed with a tab alarm on her chair or bed during observations conducted 11/12 through 11/15/18. However, interviews with nursing staff and family revealed the resident had pressure alarms in her chair and bed, which were covered when the resident was sitting or lying down. C. Record review The resident's fall prevention care plan listed personal alarms as the first approach. There was no physician order for personal alarms for Resident #51. D. Interviews The resident's daughter/representative was interviewed on 11/13/18 at 10:00 a.m. She said the resident had fallen and since then she wanted her to have a tab alarm. CNA #7 was interviewed on 11/14/18 at 2:30 p.m. The CNA said Resident #31 had a chair alarm and a bed alarm for fall precautions, which sounded at the nurses' station. CNA #8 was interviewed on 11/14/18 at 2:55 p.m. The CNA said Resident #31's fall precautions included a tab and pressure alarms to her chair and bed. The director of nursing (DON) and nurse manager (NM) were interviewed on 11/15/18 at 1:15 p.m. The DON said they had a process improvement project to remove personal alarms, had removed eight, and do not want to put new alarms on people if not necessary but it has been a successful process improvement project. The DON said they eliminated tab alarms first because they're connected to the body and loud. Pressure alarms are not noticeable to a resident, just a notification to us. The DON acknowledged the MDS assessments were inaccurate regarding use of personal alarms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide person-centered dementia care services to one (#43) of two residents reviewed for dementia with antipsychotics and dementia care services of 35 sample residents. Specifically, Resident #43 had diagnoses of dementia with Lewy bodies and dementia with behavioral disturbance, but no psychiatric diagnoses. Resident #43 was administered antipsychotic medications and personal alarms were applied to his wheelchair and bed. However, the facility failed to comprehensively assess, develop and implement person-centered, non-pharmaceutical interventions for dementia care to enhance Resident #43's highest practicable quality of life and well-being. Findings include: I. Facility policy and procedure The Behavioral Management Dementia-Clinical Protocol, dated 10/28/13 and revised 10/10/18, was provided by the director of nursing (DON) on 11/15/18 at 11:30 a.m. The DON said the facility did not have a dementia care policy, and said the behavioral management policy was the current protocol for dementia care. The protocol included the staff and physician would identify a plan to maximize remaining function and quality of life for residents diagnosed with dementia. II. Resident status Resident #43, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2018 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia with Lewy bodies, unspecified dementia with behavioral disturbances and other specified anxiety disorders. The 10/25/18 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The mood interview revealed he had little interest or pleasure in doing things; felt down, depressed or hopeless; felt tired or had little energy; felt bad about himself or that he had let his family down; and moved or spoke so slowly it was noticeable to others. No behavioral symptoms were exhibited. The resident needed limited to extensive assistance with most activities of daily living (ADLs), and used a walker or wheelchair for ambulation assistance. He took antipsychotic and antidepressant medication daily. III. Observations The resident was observed on the afternoon of 11/12/18, and throughout the day on 11/13, 11/14 and 11/15/18. He used a wheelchair to ambulate, and spent most of his time in his room watching television or lying down on his bed, and at meals in the dining room. He ate very slowly, and although staff members spoke with him, he was not observed interacting with his tablemates during meals. When out of his room he was at appointments and attended a scenic drive outing activity. When interviewed, his voice was quiet and his responses were slow but clear and appropriate. He said he was receiving good care, had no problems or side effects from his medications, and had no complaints or concerns. He said he had dogs all his life but was unable to care for a dog in his current setting. No dog visits to the resident's room or neighborhood were observed. IV. Record review A. Medications November 2018 CPOs revealed the resident received the following pertinent scheduled medications: -Amantadine HCI (dopamine promoter and antiviral) for Parkinson's disease, 100 mg (milligrams) three times daily (TID); -Nuplazid (antipsychotic) for Parkinson's disease, 17 mg, two tabs once daily; -Seroquel (antipsychotic) for unspecified dementia with behavioral disturbance, 25 mg, one tab once daily at 8:00 a.m., and two tabs each evening at 9:00 p.m.; -Celexa (antidepressant) for other specified anxiety disorders, 20 mg once daily; -Aricept (enzyme blocker used to treat confusion) for dementia with Lew bodies, 10 mg each evening; -Sinemet (anti-Parkinson agent) 25-100 mg two tabs five times per day at 5:00 a.m., 8:00 a.m., 12:00 p.m., 3:00 p.m. and 6:00 p.m. -Sinemet CR extended release 50-200 mg one tab once an evening at 9:00 p.m. -Mirtazapine (antidepressant) for other specified anxiety disorders, 15 mg each evening. B. Psychotropic medication review The pharmacist's drug regimen reviews for Resident #43 were completed monthly since his admission, with no documentation of recommendations. The facility's 10/13/18 Psychotropic Medications Report was provided by the DON on 11/14/18 at 7:45 a.m. The report showed Resident #43's medication start dates, side effects, initial care plan completion and daily behavior notes sections were blank. A gradual dose reduction (GDR) was planned for January 2019, seven months after the resident's admission. D. Behavior monitoring documentation Resident #43's behavior monitoring charting on the treatment administration records (TARs), from July through November 2018 (11/13/18) revealed behaviors and side effects were being monitored, but no non-pharmacological interventions were listed. There was no evidence of behavioral symptoms or medication side effects, as evidenced by Xs, 0s or dashes with nurse initials. E. Neurology progress notes The DON provided a progress note on 11/14/18 at 3:09 p.m. from a neurologist visit before the resident's admission to the facility, on 4/16/18. The document revealed the resident was seen for follow-up for advanced idiopathic Parkinson's disease, he continued on carbidopa levodopa (Sinemet), and does take both Seroquel and neoplasm. The family is aware of the risk of QT prolongation, risk of cardiac death and stroke in this patient using these medications. He overall has very advanced disease with significant dementia balance and postural instability. Marked hypophonia, dysarthria and fairly significant cognitive deficits were noted. The neurologist noted with regard to the resident's visual hallucinations, the plan was to continue with (illegible medication) and Seroquel, and stop the amantadine, which may help with the hallucinations as well. He is going to taper off this drug over the course of 2 weeks. The resident was to return in about 4 months (around 8/16/2018). However, Resident #43 was currently taking amantadine (see medications list above), and there was no evidence of a follow-up neurologist visit during or after August 2018. E. Care plans The memory/communication care plan, initiated 8/16/18, identified the resident had experienced a decline since being diagnosed with Parkinson's and dementia. The care plan included: I love people and having relationships with them. Offer me opportunities to joke around and get to know staff and residents. Although the resident had been in the facility for five months, there was not an updated, detailed, person-centered care plan regarding memory and communication. 2. The psychotropic drug use care plan, initiated 7/20/18, identified anxiety and dementia with distressed behaviors, with the goal for the lowest therapeutic dose for control of symptoms. Nursing approaches included always assess for and provide non-pharmacological interventions such as one-on-one interaction, distraction, singing, talking and listening to music, and remember to document the effectiveness of the interventions used. Although the resident took multiple psychotropic medications with potential side effects and interactions, there was insufficient detail to guide nursing staff in monitoring for side effects. There was no documentation in the care plan regarding a follow-up visit with the neurologist (see progress notes above). 3. The resident's activities care plan, initiated 7/20/18 and revised 11/1/18, documented the resident loved Corvettes and enjoyed gardening. The care plan included: I also really enjoy it outside during nice days and can spend time outside by myself. Assist if needed. I also am very interested in the news and watch the news on TV throughout the day; provide me with the daily paper. Encourage me to be out of my room to enjoy the company of residents and staff on my neighborhood. Assist me in finding ways to meet my needs as I continue to settle in . I also enjoy sitting out on the courtyard and can do this independently. The care plan did not include a person-centered plan for winter activities if the resident was unable to go outside. The care plan did not address assistance and supervision needs for regarding potential safety concerns considering the resident's risk for falls. 4. The 7/20/18 fall prevention care plan's first approach, added 10/17/18, was pressure alarm in place while in bed and in chair. Other approaches were fall mat when in bed, hourly rounding, assess and treat for postural/orthostatic hypotension, increased staff supervision with intensity based on resident need. A revision on 11/1/18 read the resident had three falls this quarter, all while self transferring. He stated during care conference that he doesn ' t like to ask for help or wait for someone to come. He was encouraged to use the call light at all times. Pressure alarms in place. The care plan did not direct staff to respond immediately to the resident's call light, how to ensure he was safe when outdoors, and how to anticipate his needs and provide other non-alarm methods to ensure he was safe and his needs were met. F. Interdisciplinary team notes IDT notes revealed the facility staff were aware of the following regarding Resident #43: On 7/20/18, during a meeting with the resident and his family shortly after his admission, Resident #43's family was told the facility did not have enough staff to take Resident #43 outside, which the family stated was what he enjoyed most. The family responded they were comfortable with Resident #43 going out on his own, and using the doorbell when he was ready to re-enter the facility. On 10/25/18, during his quarterly assessment interviews, Resident #43 was able to repeat three words, needed some cueing for memory, and expressed many challenges regarding the mood section (see MDS above). He said this was due to his disease and how he could not do things he wanted. He said therapy was the only thing that helped. He said some days he had great energy and the next none at all, which was frustrating. He said visits from his family really helped. Resident #43 used his call light often and attempted to self transfer if not answered immediately (cross reference F725 sufficient staffing and F919 resident call light system). On 10/26/18 the resident had an unwitnessed fall, and said he willingly slid off the side of the bed and sat on the floor. On 11/1/18 during a care conference meeting, the group reviewed that Resident #43 did not want to move rooms, and reviewed he was not being kicked out, which he worried about and needed reassurance. The resident had two falls and said they were not actual falls, he was trying to get out of bed on his own. Resident #43 was enjoying going outside, loved animals, kids and gardening. He enjoyed chocolate milk shakes and would like them to be offered every once in a while, and he was told salmon was available on the anytime menu. On 11/10/18 the resident had an unwitnessed fall at 6:50 a.m. He used his call light to alert staff he was sitting on the floor, and said he didn't fall, he slid off the bed because he wanted to get himself up. G. Staff training documentation Review of staff training for the past 12 months revealed no evidence of dementia care training. H. Facility assessment Review of the facility assessment revealed no comprehensive assessment, plan or staff training requirements for dementia care or for residents with dementia who received antipsychotic medications. V. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 11/14/18 at 2:15 p.m. Regarding dementia care interventions, CNA #7 could not recall what Resident #43 enjoyed, but said Resident #43 was invited to all activities. Sometimes he feels like going, sometimes not. For fall prevention, CNA #7 said Resident #43 had a pad in his chair, pad in bed and a fall mat. The alarming pad goes off at the nurses' station if he gets up or anything. CNA #8 was interviewed on 11/14/18 at 2:45 p.m. Regarding dementia care interventions, CNA #8 said Resident #43 enjoyed going out for walks, talking, puzzles, and had seen the MDS coordinator bring her dog in to visit. CNA #8 said regarding fall prevention, About two months ago I started noticing he'd be able to stand at the bar but he'd start slumping down. I recommended two-person transfers to be safe, and use a gait belt for sure, and two CNAs when working with him. I try to use his walker as much as possible too. I've heard him pull on his tab alarm a few times and they've gone off and he hasn't really responded, he's just kind of confused when they're going off. I tell him it's to keep him from falling and he understands. It doesn't go off very often. CNA #8 said insufficient staffing made it difficult to spend individual time with residents. The MDS coordinator was interviewed on 11/13/18 at approximately 11:15 a.m. She said the resident was admitted on all these meds and his POA doesn't want them changed because he had a failed GDR at his previous facility and he's now stable. She said she would try to locate documentation regarding this and a non-pharmacological care plan related to dementia care. She said the pharmacist had reviewed the resident's medications monthly and documented nothing additional in the chart. She said Resident #43 was discussed during the psychoactive med meetings. Social services coordinator #1 was interviewed on 11/15/18 at 12:00 p.m. She said she felt Resident #43 was content and doing well on his medications. She said his primary desire when he moved from a different facility was to have a private room. She said Resident #43 likes animals and they have several visiting. He also likes outdoors and gardening. She said he hadn't felt like going outside since it had gotten cold out, but said sometimes they bundled up residents and took them out if they liked. She acknowledged they had not provided a dementia care training, but they had developed training that would be provided soon. The DON and nurse manager were interviewed on 11/15/18 at 1:15 p.m. Regarding non-pharmacological dementia care interventions for Resident #43, the DON said the resident was happy with his care at the facility. He's out at meals, chooses to be in and out of his room depending on his own preference, and can make his needs and choices known. The DON said Resident #43 attended activities and outings when offered, always participated in monthly parties and when offered an activity he wanted to participate. She said the resident and his family were very happy with his care and he did not need to be supervised one-on-one when outdoors because they had a doorbell that many residents utilized to go outside independently. The DON said she did not understand the documentation in the resident's chart regarding insufficient staffing to take the resident outside, and said she disagreed with it. Until the cold he was out quite a bit sitting in that little patio area. Regarding the resident's ability to go outdoors independently and the use of personal alarms, the DON said, He's chosen multiple times to sit on the floor, so we want to know that he's on the floor. Regarding the facility's lack of a dementia care policy and staff training, the DON said, We understand dementia care training is a need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#9) of five residents reviewed for medications of 35 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure documentation related to Resident #9's level of psychosis was consistent between the diagnosis list, minimum data set (MDS), computerized physician orders (CPOs), progress notes and care plan; and -Consistently document Resident #9's reaction to psychotropic medications, including effectiveness, potential side effects and any non-pharmacological interventions attempted in lieu of psychotropic use. Findings include: I. Professional reference According to the [NAME] Nursing Drug Handbook (2019), page 437, Lexapro is classified as an anti-depressant used for the treatment of depressive disorders and generalized anxiety disorder. Seroquel (page 976) is classified as a second-generation (atypical) anti-psychotic with an off-label use for the treatment of psychosis and agitation related to Alzheimer's dementia. There was a black-box warning that elderly people with dementia-related psychosis are at increased risk for death. II. Facility policy and procedure The Medication Review Committee policy, dated 10/28/13 and revised 10/10/18, provided by the director of nursing (DON) on 11/15/18 at 11:30 a.m. read, The facility shall establish a medication review committee, including a registered nurse, the consulting pharmacist, medical advisor and social services, to assist in the formulation of broad profession policies and procedures relating to pharmaceutical service in the facility. The Pharmacy-Behavior Monitoring policy, dated 10/28/13 and revised 10/10/18, provided by the DON on 11/15/18 at 11:30 a.m., read the purpose of this policy was to provide quantitative documentation of specific problem behaviors exhibited by a particular resident to be used to evaluate which interventions would most benefit that particular resident. It read, All residents on anti-psychotic medications for treatment of problem behaviors associated with an organic mental syndrome (including dementia) will be monitored. Monitoring would be done on individual treatment sheets in the electronic medication administration record (EMAR) and specific behaviors would be determined by observations from family, nursing staff and physician. If a behavior was present, the nurse would document in the matrix, including date, time, details of behaviors and attempted interventions and results. Whenever possible, attempts would be made to modify problem behaviors by non-pharmacologic methods. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the November 2018 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, anxiety disorder, other specified depressive episodes and Alzheimer's disease. The 8/8/18 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) cognition score of eight out of 15. The resident displayed little interest or pleasure in things; felt down, depressed and hopeless; displayed movement difficulties; and was tired or had little energy. The resident displayed no symptoms of psychosis or delusions. No behavioral symptoms were documented. The resident received anti-psychotic and anti-depressant medications daily. B. Record review 1. Care plans The care plan dated 9/26/17 and revised 9/16/18 read the resident was on psychotropic medications related to diagnosed depression. The resident received an antidepressant for depression and Seroquel for dementia with psychosis. Staff were directed to always assess the resident for symptoms of depression and provide non-pharmacological interventions such as 1:1 interaction, distractions and listening to music.Staff were to consult with pharmacy and the medical director to consider a dosage reduction when clinically appropriate. The care plan failed to include target behaviors for the use of Seroquel. The care plan did not match the 8/8/18 MDS assessment, which documented the resident displayed no symptoms of psychosis or delusions. 2. Physician orders The November 2018 CPO documented the resident received the following medications: - Lexapro, 10 mg QD (every day) for the behaviors of isolation, tearfulness, stating being sad and less interest in activities. This anti-depressant medication was ordered on 3/14/18. - Seroquel, 25 mg QHS (at hour of sleep) for the behaviors of hallucinations, tearfulness, yelling out, severe anxiety and inability to redirect. This anti-psychotic medication was ordered on 9/18/18. 3. Treatment administration records (TARs) The September 2018 TAR showed the resident was prescribed Lexapro and was being monitored for the behaviors of isolation, tearfulness, stating being sad and having less interest in activities. The resident had one unspecified documented behavior for the use of Lexapro on 9/17/18. The September 2018 TAR showed the resident was prescribed Seroquel and was being monitored for the behaviors of hallucinations, tearfulness, yelling out, severe anxiety and inability to redirect. The resident had three behaviors relating to anxiety/agitation and exit seeking on 9/11/18, one behavior of paranoia on 9/12/18, one behavior of screaming out in her sleep on 9/18/18 and two behaviors of not sleeping on 9/22/18. The October 2018 TAR showed for the use of Lexapro, the resident displayed four behaviors of being very confused on 10/5/18 and one behavior on 10/12/18 relating to less interest in activities due to pain. The October 2018 TAR showed for the use of Seroquel, the resident displayed one behavior of unrelieved pain on 10/12/18, one behavior of some confusion and shouting out this a.m. on 10/14/18, one behavior of yelling out on 10/18/18 and one behavior of being very confused and agitated and slightly combative with staff as evidenced by the resident refusing to go to bed and throwing a cup of water at staff. The TAR for November 2018 showed no behaviors as of 11/15/18 for the use of Lexapro or Seroquel. 4. Progress notes The interdisciplinary progress note dated 10/31/18 at 8:30 p.m. read, Resident very confused and agitated, slightly combative with staff and refuses to go to bed. Threw cup of water at staff, stating 'I can't find my bracelets, I don't want her (referring to CNA) helping me.' Repeated attempts to calm (resident's name). She transferred into bed with RN assistance and for a short time screamed out 'Help .Help.' After approximately 20 minutes, she went to sleep . There were no corresponding progress notes for Resident #9's behaviors on 9/17/18, 9/22/18, or 10/5/18 other than the resident was very confused, on 10/12/18 other than comments about unrelieved pain, on 10/14/18 other than confusion, and no progress note on 10/18/18 regarding behavioral symptoms. C. Staff interviews The DON was interviewed on 11/14/18 at approximately 12:30 p.m. She said the procedure for behavior monitoring for psychotropic medications was to chart each shift for every psychotropic medication prescribed. She said she would expect to see a detailed progress note if the behavior was out of the ordinary; and if a behavior was noted on the TAR, there should be a corresponding progress note. She said outcomes, potential side effects, medication effectiveness, and the non-pharmacological interventions attempted should be documented somewhere. The DON was interviewed a second time on 11/14/18 at approximately 3:00 p.m. She said the nurses had completed progress notes regarding the resident's behaviors and use of psychotropic medications most days, but failed to document anything on the resident's behaviors on 9/17/18, 9/22/18, 10/5/18 and 10/18/18. The nursing home administrator (NHA) was interviewed on 11/15/18 at 12:50 p.m. He said he understood there were some areas of deficiency with charting on all the requirements for tracking psychotropic medications and effectiveness. He said part of the problem was the computerized system was cumbersome to use. The NHA and DON were interviewed together on 11/15/18 at 1:46 p.m. They said their action plan included a new computer system that they hoped to implement by April 2019. They planned to train nursing staff on thoughtful documentation, and ensure nurses were documenting on any attempted non-pharmacological interventions and effectiveness. They said there was room for improvement with their psychotropic medication documentation. They said they would be spot-checking psychotropic medication documentation during their daily stand-up meetings. The DON said the facility had been working on psychotropics on a regular basis. The pharmacist consultant was interviewed by telephone on 11/20/18 at 1:45 p.m. He said his minimal expectation for monitoring behaviors for residents who were prescribed psychotropic medications would be for the facility to track specific behaviors, assess for potential side effects, document effectiveness and attempt non-pharmacological interventions. He said the facility needed to tighten up their documentation better. He said, in relation to the level of psychosis exhibited for Resident #9, Something must have fallen through the cracks between the resident ' s behavior and the completion of the MDS . maybe it was a coding error. The pharmacist said Resident #9 did display psychotic behaviors. He said despite the issues with documentation regarding behavior monitoring, the facility was headed in the right direction.

Based on record review, observations and interviews, the facility failed to ensure infection control standards of practice for one (#8) of five residents reviewed for blood glucose monitoring of 35 sample residents. Specifically, the facility failed to properly disinfect and store blood glucose monitoring devices after use for Resident #8. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (2017) Injection Safety, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (11/20/18), blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. II. Facility policy and procedure According to the Blood Sugar Monitoring policy, last revised on 10/11/18, provided by the director of nursing (DON) on 11/14/18 at 1:57 p.m., blood glucose monitoring machines were to be disinfected with an EPA regulated disinfectant after each use to prevent cross contamination. III. Manufacturer's instructions According to the facility's blood glucose monitoring device manufacturer's instructions, provided by the DON on 11/14/18 at 1:57 p.m., cleaning and disinfecting your meter was very important in the prevention of infection disease. Cleaning allowed for subsequent disinfection to ensure germ and disease causing agents were destroyed on the meter device surface. IV. Observations Licensed practical nurse (LPN) #2 was observed on 11/14/18 at 9:49 a.m. performing a fingerstick glucose test on Resident #8. The blood glucose monitoring device was stored in a cardboard box inside a caddie carrying container along with other needed supplies such as alcohol prep pads, lancets, and band aids. The LPN was observed bringing the entire caddie storage container into the resident's room and set it upon a bedside table. The LPN prepped the device and the resident's finger for the fingerstick with an alcohol prep pad. The LPN then applied the lancet and discharged the device to draw blood for the test. The LPN then applied the blood to the test strip, which was attached to the blood glucose monitoring device. After the machine read the results, the LPN, with the same gloves he had been wearing to perform the test, returned the blood glucose monitoring device to the cardboard box inside the caddie carrying storage container. The LPN was not observed disinfecting the surface of the device with an approved disinfectant wipe prior to returning the device to the storage box, and returned the device back to the nursing station. LPN #2 stated that there was only one blood glucose monitoring device for that station, and that the other two nursing stations also only had one device for their residents. V. Interviews The infection control nurse and nurse manager (NM) were interviewed on 11/14/18 at 3:00 p.m. The staff members confirmed that after each use the nurses should have been cleaning the device with an approved wipe as per both the facility policy and manufacturer's instructions. The staff members stated education was needed for LPN #2 for infection control and cross contamination practices, and would be provided. The staff members stated that they would get individual glucometers for each resident that day (11/14/18 during survey), and update the policy to reflect the changes as well as provide staff training on those changes. The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the proper infection control policy for blood glucose was to clean with an approved disinfectant wipe after each use, and that the caddie carrying container should not be going into residents' rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide oxygen services as prescribed by the physician. Specifically, the facility failed to ensure oxygen therapy was administered as ordered by the physician for four (#2, #12, #13 and #35) of four residents reviewed for oxygen therapy of 35 sample residents. Findings include: I. Facility policy and procedure The Oxygen Therapy Monitoring policy, revised 10/11/18, provided by the director of nursing (DON) on 11/14/18 at 1:57 p.m., stated in purpose that oxygen therapy was considered a vital treatment, and monitoring its correct usage was the responsibility of all nursing staff. The policy statement read that regularly scheduled checks of each oxygen dependent resident would be done to ensure that residents were receiving the correct liter flow, attached to an adequate supply source, and had a nasal cannula or mask in place and all tubing intact. Compliance with these expectations would be monitored by the nursing manager and any pattern of errors would be addressed. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. The computerized physician orders (CPO) provided by the minimum data set (MDS) coordinator on 11/14/18 at 6:00 p.m. included diagnoses of pneumonia of unspecified organism, unspecified acute bronchitis, unspecified asthma, and unspecified anemia. The most recent minimum data set (MDS) assessment completed 8/1/18, included a brief interview for mental status (BIMS) score of 15 of 15 indicating a cognitively intact status. MDS diagnoses included asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease. The resident was listed as receiving oxygen therapy while a resident. B. Observations -On 11/12/18 at 1:59 p.m. Resident #2 was observed in her room on the in room stationary oxygen concentrator set at 3.5 liters per minute (LPM). The resident stated that her setting should be set at 2.5 liters. -On 11/13/18 at 1:12 p.m. the resident was observed on 3.5 LPM on her stationary concentrator in her room. -On 11/14/18 at 1:12 p.m. while doing wound care with the wound care nurse practitioner (NP) the resident was observed on her in room stationary concentrator set at 3.5 LPM. This flow rate was confirmed with the NP. -On 11/15/18 at 11:19 a.m. the resident was observed on 3.5 LPM on her in room stationary concentrator; this flow rate was confirmed with registered nurse (RN) #4. RN #4 stated it was the responsibility of the nurses to check and confirm oxygen flow rates every shift. C. Record Review The physician order report's oxygen administration order, entered 7/2/18 with an open ended end date, for resident #2 read for oxygen at 2.5 LPM nasal cannula at all times. The care plan initiated on 5/8/18 for the problem of oxygen therapy included an approach to administer oxygen at 2.5 LPM via nasal cannula at all times per physician orders. Point of care history charting for the order to administer oxygen at 2.5 LPM via nasal cannula indicated that from 11/12/18 through 11/14/18 (during survey) the resident was being documented as receiving 2.5 LPM despite the observations of 3.5 LPM listed prior. D. Interviews The DON and nurse manager (NM) were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the resident should be on 2.5 LPM as ordered by the physician and that the resident was on the wrong oxygen flow settings. The DON and NM both confirmed that nursing staff had been entering wrong LPM documentation in the point of care history documentation for oxygen administration. III. Resident #13 A. Resident status Resident #13, age [AGE], was originally admitted [DATE] with the most recent return admission on [DATE]. CPOs included the diagnoses of dependence on supplemental oxygen, anemia, and unspecified chronic ischemic heart disease. The most recent MDS assessment completed on 8/30/18, included a BIMS score of two of 15 indicating severe cognitive impairment. The resident was listed as receiving oxygen therapy while a resident, and diagnoses included asthma, COPD, or chronic lung disease. B. Observations -On 11/12/18 at 2:39 p.m. the resident was observed in the activities area in her wheelchair not wearing her nasal cannula. The resident was holding the oxygen tubing in her hand. -On 11/13/18 at 8:23 a.m. the resident was observed on her in room stationary concentrator at 2.5 LPM resting in bed. -On 11/14/18 at 8:34 a.m. the resident was observed on her in room stationary concentrator set at 2.5 LPM while asleep in bed. At 3:06 p.m. the resident was observed in the hallway on her portable oxygen device set at 2.5 LPM, the setting was confirmed with RN # 2. RN #2 was unaware why the oxygen was set at 2.5 liters despite confirming the order for 3 LPM. At this same time the stationary in room concentrator was observed as well, and was also confirmed to be still set at 2.5 LPM. The RN was unsure of why both the stationary in room and portable devices were both set to 2.5 LPM and acknowledged that both were wrong in comparison of the order flow rate of 3 LPM. -On 11/15/18 at 9:11 a.m. the resident was again observed on 2.5 LPM on the in room stationary concentrator while resting in bed. C. Record review The physician orders report had a start date of 7/2/19 with no ending date, and read for oxygen to be administered at 3 LPM via nasal cannula. The care plan for oxygen therapy was last edited on 4/30/18. The care plan read to administer oxygen at 3 LPM via nasal cannula. Point of care history charting for the order to administer oxygen at 3 LPM via nasal cannula indicated that from 11/12/18 through 11/15/18 (during survey) the resident was being documented as receiving 3 LPM despite the observations of 2.5 LPM listed prior. D. Interviews The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the resident should be on 3 LPM as ordered by the physician and that the resident was on the wrong oxygen flow settings. The DON and NM both confirmed that nursing staff had been entering wrong LPM documentation in the point of care history documentation for oxygen administration. IV. Resident #12 A. Resident status Resident #12, age [AGE], was originally admitted on [DATE] with the latest return admission on [DATE]. The resident face sheet diagnoses included chronic respiratory failure with hypoxia, hypoxemia, and myocardial infarction. The most current MDS assessment dated [DATE] listed a BIMS score of 13 out of 15 indicating a cognitively intact mental status. MDS diagnoses included respiratory failure, depression, and dementia. The resident was identified as receiving oxygen therapy while a resident. B. Observations -On 11/13/18 at 9:14 a.m. the resident was observed on his in room concentrator at 5.5 LPM; the resident was unsure of his correct oxygen settings. -On 11/13/18 at 12:03 p.m. the resident was observed in the hallway reading the paper while sitting in the sun. The flow rate on his portable oxygen device was set to 6 LPM. -On 11/13/18 at 3:05 p.m. the resident was observed in bed on 6 LPM from his portable oxygen device hanging off his wheelchair. The oxygen device gauge was reading low and in the red indicating it was nearly empty. This was confirmed with RN #4 who switched the resident to the in room stationary condenser and set the flow rate at 5 LPM. The RN confirmed that there would have been no alarms if the portable oxygen device ran empty or if the resident's oxygen saturation would have fallen below normal limits due to the device running out of oxygen. C. Record review The computerized physician orders read for oxygen to be set at 5 LPM via nasal cannula continuously. The care plan last edited on 8/2/18 read to administer the resident's oxygen at 5 LPM via nasal cannula continuously. Point of care history reports for the order to administer oxygen at 5 LPM via nasal cannula indicated that from 11/12/18 through 11/15/18 (during survey) the resident was documented as receiving 5 LPM. D. Interview The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the resident should be on 5 LPM as ordered by the physician and that the resident was on the wrong oxygen flow settings during listed observations. The DON and NM both confirmed that nursing staff had been entering wrong LPM documentation in the point of care history documentation for oxygen administration. The DON confirmed that it was the nurse's responsibility to confirm both flow rates and the tank capacity during hourly rounding, and that it is the CNA's responsibility for filling portable oxygen devices. V. Resident #35 A. Resident status Resident #35, age [AGE], was originally admitted [DATE] with the most recent return admission on [DATE]. The CPO listed diagnoses of chronic obstructive pulmonary disease with acute exacerbation, unspecified atherosclerosis, and chronic respiratory failure with hypoxia. According to the most recent MDS assessment on 9/27/18 the resident had a BIMS score of five out of 15 indicating severe cognitive impairment. MDS diagnoses included heart failure, asthma, COPD, or chronic lung disease. B. Observations -On 11/13/18 at 08:36 a.m. the resident was observed in bed not wearing her nasal cannula for oxygen administration; the stationary in room oxygen concentrator was set to 4.5 LPM. LPN #2 stated that the resident regularly removed her oxygen and was unsure how long the resident was without her oxygen. -On 11/13/18 at 3:25 p.m. the resident was observed in bed with her nasal cannula falling off and not secured properly. -On 11/14/18 at 12:25 p.m. the resident was observed not wearing her nasal cannula. -On 11/14/18 at 1:28 p.m. the resident was again observed not wearing her nasal cannula. C. Record review The November 2018 CPO read for oxygen via nasal cannula 4 LPM in daytime and 5 LPM at night for every shift day, evening, and night. The care plan was initiated for the problem of oxygen therapy on 8/3/17. The approach of administering oxygen via nasal cannula at 4 LPM in the daytime and 5 LPM at night via nasal cannula as ordered was last edited on 4/24/18. Another approach -- listed as I often remove my oxygen tubing and forget to replace it. Please ensure my nasal cannula is in place each time we meet -- was created on 11/14/18 (during survey). A nursing progress note by LPN #2 on 8/5/18 at 4:45 p.m. read in pertinent part that the resident was on oxygen via nasal cannula which the resident frequently took off causing some changes in mental status that resumed to normal when the resident put oxygen back on. D. Interview The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members stated that it was the nursing staff's responsibility to be ensuring that residents were both wearing oxygen and that oxygen flow rates were set to the prescribed rates, and that this should have been done upon hourly rounding. The DON and NM stated that per the care plan wording of ensure my nasal cannula is in place each time we meet was in reference and would be done during the hourly rounding. The DON acknowledged that nursing staff had identified and documented the resident did get more confused when removing her oxygen and that her confusion improved when the oxygen was reapplied. The DON and NM both agreed that changes in mental status such as an increased level of confusion was an early sign of hypoxia. The DON also stated that the care plan interventions for this resident to ensure she was receiving her oxygen administration were effective. The DON and NM stated that a new process was initiated in the last two weeks in response to identified issues with ensuring oxygen flow rates. They said it was now the nurse's responsibility to verify oxygen flow rates for all residents receiving oxygen therapy in the facility, and that these checks should be done hourly. The DON stated that there was no policy for nurses to titrate oxygen flow rates either up or down, and that all changes to a resident's oxygen flow rate required a physician order. The DON and NM stated that there was no reason for any resident's oxygen settings to have deviated from the prescribed oxygen settings. The DON and NM both stated that the new process initiated two weeks ago of having the nurses ensure oxygen flow rates were consistent with the prescribed flow rates during hourly rounding, had not been effective.

Based on resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 17 (#1, #2, #3, #9, #16, #22, #24, #25, #28, #31, #35, #41, #44, #47, #50, #51, #52) of 35 sample residents. Resident and staff interviews revealed the facility failed to consistently provide adequate nursing staff resulting in delayed call light response, assistance with activities of daily living, assistance to and from the toilet, and prolonged wait times before and after meals in the dining room. Findings include: Cross-reference F550 failure to provide care with dignity and respect, F695 failure to provide oxygen therapy as ordered, F744 failure to provide person-centered dementia care, F802 sufficient dietary support personnel, and F919 failure to answer call lights in a timely manner. I. Facility policy and procedure The Staffing policy and procedure, last revised 10/10/18, was provided by the director of nurses (DON) after survey exit on 11/19/18. The policy included clinical staffing would be based on census and acuity and may be adjusted up or down as needed to provide sufficient staffing. The day and evening shifts would include three licensed nurses and six certified nurse aides (CNAs); the night shift would include two licensed nurses and three CNAs. The DON, nurse manager, and minimum data set (MDS) coordinator would cover shifts that could not be replaced by regular staff members. An additional float CNA would be added when acuity required it, and all efforts should be made by the manager on call to replace call-ins to maintain the above staffing levels. II. Record review A. According to the Resident Census and Conditions of Residents report, signed by MDS coordinator on 11/12/18, the resident census was 52 and the following care needs were identified: -42 residents needed assist of one or two staff for dressing -23 residents needed assist of one or two staff for bathing -35 residents needed assist of one or two staff and nine were dependent for transfers -31 residents were occasionally or frequently incontinent of bladder -Six were bedfast all or most of the time -28 residents had dementia or Alzheimer's disease -25 received respiratory treatment -Five residents had pressure ulcers B. Resident council meeting minutes The Neighborhood Council Minutes were reviewed from 1/2018 through 10/2018 and revealed the following comments: -One resident said the nurses seem very stretched. (2/8/18) -One resident said she likes the transportation she receives to groups, but sometimes feels stranded afterwards as it can take a while to get back. (4/12/18) -Some residents felt it seemed as though the nursing department was short on staffing . they agreed it was around change of shift and meal times . the Ombudsman asked residents if their call buttons were answered in a timely manner, some said they wait at times . (8/9/18) -One resident commented that the nurse staffing seems short lately on both shifts. He said they do a great job, but need more help. One resident added that they are having a CNA class currently, so that should help with staffing . One resident asked about the traveling nurses we have lately . (9/13/18) -(DON) announced that it had been a group effort to come to the decision to use Creekside dining as the new Community Life Room for activity groups . This will start this Monday the 15th . One resident asked about now only having one nurse on each neighborhood. (DON) explained the medication nurses has shrunk to one medication nurse manager. (10/11/18) III. Resident and family interviews A. Resident group interview A resident group interview was conducted on 11/13/18 at 1:00 p.m. with eight residents who, per facility and assessment, were interviewable and four of whom regularly attended resident council meetings. Several of the residents said the facility did not have sufficient nursing staff to ensure they did not have to wait too long for the care and services they required. B. Resident and family interviews Residents who, per facility assessment were interviewable, made the following comments regarding nursing staffing. Resident #35 was interviewed on 11/12/18 at 12:59 p.m. She said CNAs in the facility needed training, and they were short staffed on Sundays and the midnight shift. Resident #3 interviewed on 11/13/18 at 12:19 p.m. She said that due to insufficient staff, she had been left on the toilet for an hour or longer just a few weeks ago. She said, by the time she got off the toilet, her bottom was numb. She was interviewed a second time on 11/12/18 at 1:17 p.m. She said approximately one week prior, the battery in her call light was not working and it had to be replaced. She said after the battery was replaced, her call lights were answered more timely. On 11/13/18 at 10:12 a.m., the resident said she felt there were times when the facility needed more CNAs and nurses on the floor. Resident #2 was interviewed on 11/12/18 at 1:24 p.m. She said the facility never had enough staff in the morning and would only have one CNA working when they were supposed to have two in each neighborhood during the 6:00 a.m. to 2:00 p.m. shift. She stated, They take 20 minutes to answer the call light. Resident #52 was interviewed on 11/12/18 at 1:30 p.m. She said she felt the facility did not have enough nurses or CNAs working to get to all the residents needs quick enough. Resident #25 was interviewed on 11/12/18 at 1:43 p.m. She said the facility could use more CNAs, more training for the CNAs, and the facility was short on staffing during the night shift. She said she had lengthy call light response times in the past and had not made it to the bathroom in time on one occasion. She said recently the battery in her call light was not functioning properly and needed to be replaced. Resident #41 was interviewed on 11/12/18 at 1:49 p.m. She said the facility was always short on CNAs, especially at night, when there was one person on duty for two hallways, and that did not work out very well. She said when she was in the bathroom and needed help, sometimes she ended up waiting for long periods and her legs got sore and would go to sleep while she was sitting on the toilet waiting. She said this had been brought up in resident council in the past, and it was usually during the night shift. Resident #47 was interviewed on 11/12/18 at 1:57 p.m. She said the facility need more nursing staff to help her lie down in a timely manner. She said it was an issue on all days and all shifts. She said she had waited up to three hours for assistance, from the time she originally asked for help, for staff to come and assist her to bed. Resident #28 was interviewed on 11/12/18 at 1:59 p.m., and she said staffing was a problem. She said she had to wait too long for the bathroom at night and That's not good. She said she had talked to the facility staff in the past about the concern during her care conferences and was told they would ensure they came in to her room at eight p.m. in the evenings and get her ready for bed. She said one of her worries was having a fall and the call light response time has been a problem. She explained her neighborhood had only one CNA after 10:00 p.m., and they had many people to take care of. She estimated one nurse and one CNA were responsible for caring for over 20 residents. She stated, It's a problem about twice a week; they come eventually but sometimes that's too late. She asked, What if you fall and can't reach the call light and they don't come, then what? There you are on the floor for hours again. She said it concerned her because the night prior, a CNA went to get her a bandage and never came back. She said one night, a couple weeks ago, she had wet her pajamas and could not reach a dry adult incontinence brief and stated, There I was. It was a long time. She said she pushed the call light and no one responded and she finally took off the wet pajamas herself. She said a nurse checked on her later and she told him she had been incontinent of urine, and he told her she should have used the call light to ask for help. She clarified she had pushed the call light but no one responded. She said the facility used a lot of traveling nursing staff who stayed for a month or two, and thought more would stay if it were not so expensive to live in the area. Resident #9 was interviewed on 11/12/18 at 2:04 p.m. She said staff did not come when she rang her call light and this had happened on more than one occasion. Resident #24 was interviewed on 11/12/18 at 2:43 p.m. She said the call light response was very slow and she had waited for over an hour for help with incontinence care at times, mostly during the night shift. She said when that happened to her, It feels like (expletive). Resident #51's daughter was interviewed on 11/12/18 at 3:10 p.m., and she said the resident had waited 15 to 30 minutes for call light response. She said her mother required two staff members for assistance to use the bathroom, and she had a fall on 9/2/18. She said two Wednesdays ago, there was one CNA for the 2:00 p.m. to 10:00 p.m. shift, which was not enough. She stated, Twice now I've been with Mom, watched it and timed it, and personally went down to get someone at the nurses' station. She said meal wait times could be an hour, and it was a 15-minute wait for soup, then another wait for the meal, and then another wait for the dessert. She said there was usually one person serving every single tray, and if the staff did not know the resident, It's a struggle. She said recently she waited for lunch from 11:30 a.m. to 1:00 p.m. before she was served. Resident #51's daughter was interviewed a second time on 11/13/18 at 10:08 a.m. She said the facility staff left her mother on the toilet, unattended, and that made the family concerned. She said the resident had sciatic pain from sitting for 15 to 30 minutes about a week ago during the weekend. Resident #22 was interviewed on 11/12/18 at 3:56 p.m. She said she felt the facility was short staffed and the staff told her every other day that there was not enough staff working. Resident #1 was interviewed on 11/13/18 at 9:19 a.m. He said sometimes after he pushed his call light he had to wait as long as an hour for help when they got busy. He said it usually occurred during the day shift and stated, It doesn't do any good to say anything. Resident #16 was interviewed on 11/13/18 at 1:14 p.m. She said sometimes her medications were given to her late, 30-40 minutes after they were due. She said the facility had a lot of nursing turnover and some new nurses who were there for 60-day intervals, and they were not used to the residents' medications. Resident #31 was interviewed on 11/13/18 at 1:20 p.m. He said the facility seemed to have a lot of nursing turnover and they were understaffed at times. Resident #44 was interviewed on 11/13/18 at 2:14 p.m. He said the facility was short of staff and would sometimes rush when providing him cares. He said it was most noticeable during the evenings between 6:00 p.m. to 7:00 p.m. when they were putting residents to bed and more people needed help. Resident #50 was interviewed on 11/13/18 at 2:20 p.m. He said the staff who were currently working in the facility were stretched out too thin. He said there were too many people to take care of with too many issues to take care of at the same time. He said 8:00 p.m. - 9:00 p.m. was when he noticed it was the worst, when they were trying to get everyone to bed. IV. Observations On 11/13/18 at 9:00 p.m., the Pond Side neighborhood was short staffed, with one nurse and one CNA working, rather than the routinely scheduled two CNAs. There was a dietary staff member working in the kitchenette and the majority of the resident room doors were closed. On 11/13/18 at 9:06 p.m., the Creek Side neighborhood was short staffed, with one nurse and one CNA working, rather than the routinely scheduled two CNAs. Resident #11 was observed sitting in her wheelchair calling out and said, Is anyone going to give me a push? I wish someone would come and give me a push. At 9:08 p.m., registered nurse (RN) #1 propelled the resident into the TV room and the resident stated, I want to go to my bedroom. The RN said she would be able to go to her room as soon as she located a staff member to help her, and then left the resident in the TV room. At 9:12 p.m., a CNA propelled the resident into her room. On 11/14/18 at 12:21 p.m., arrangements had been made with the nurse practitioner (NP) to observe Resident #35's wounds. However, the NP said the observation would not be able to be completed at that time because there was not enough staff to help. The wound observation was completed at 1:25 p.m., when assistance was available. On 11/14/18 at 12:45 p.m., Resident #2's wounds were observed with the NP. There were no CNAs available to assist, so the unit secretary (who was also a CNA) was asked to help. The call light messaging system was observed from the Mountain Side neighborhood dining room on 11/14/19. The following messages were noted: - 2:57 p.m.: Try 6 for Bed 41 - 3:25 p.m.: Try 12 for Bed 41 - 3:51 p.m.: Try 7 for Bed 33, Try 5 for Bed 41 and Try 6 for Bed 33 On 11/15/18 at 10:44 a.m., there was a Try 4 for Bed 41. This message changed to Try 5 for Bed 41 at 10:46 a.m. (Cross-reference F919 call light system) On 11/15/18 at 10:44 a.m., there were no nursing staffing observed on Mountainside neighborhood until 11:52 a.m. V. Additional record review The Daily Staffing Reports were reviewed from 9/1/18 through 11/14/18 and revealed the facility was unable to locate the reports for 10/17/18 through 10/22/18, 10/24/18 through 10/30/18 and nine days in November. The staffing sheets revealed the following nursing shortages: -September: 22 days were short CNA staff, 14 days they were short on more than one shift -October: Eight days were short CNA staff, three days they were short on more than one shift -November: one day were short CNA staff VI. Staff interviews The nurse manager (NM) was interviewed on 11/13/18 at 12:54 p.m., and she confirmed she was responsible for scheduling the nursing staff. She explained they used a nurse scheduling software that allowed staff to sign up for shifts as needed. She said the desired staffing numbers for the facility's three neighborhoods included the following: -6:00 a.m. to 2:00 p.m., three licensed nurses and six CNAs -2:00 p.m. to 10:00 p.m., three licensed nurses and six CNAs -10:00 p.m. to 6:00 a.m., three licensed nurses and six CNAs The NM said it was acceptable for a staff member to float back and forth among the units. She said at night, starting at 10:00 p.m., there were two nurses and three CNAs, so there was one staff member in each neighborhood at all times. If there was a call out, the person calling off had to notify the nurse manager, and then the nurse manager called around to find a replacement. She said nurses had worked as CNAs in the past, and started using agency nurses in April 2018. She said they were trying to get away from using agency nurses but had not been able to. She said the local area was very transient due to the ski season and they had had multiple staff members leave. She said they had nursing staff who worked per diem and liked to pick up extra shifts when needed. She said when agency nurses and CNAs were first hired, they had a 12-hour training shift. After that, if they were not comfortable, they could get more and stated, But no one has ever needed additional training. She said the facility also required nurses to complete competencies that included tube feedings, abuse, skin assessments, hand hygiene, shift report, infection control, writing a telephone order, proper body mechanics, and medication administration before they were released on their own. CNA #9 was interviewed on 11/13/18 at 9:03 p.m. She said facility staffing depended on the day, but that the facility was having trouble retaining CNAs especially. She said maybe working as a CNA was not the job they expected. She said staffing had been a problem for months and it was not getting better. She said she picked up an extra shift at least every other week due to call offs. She said she had worked short-handed approximately 50% of the time. CNA #6 was interviewed on 11/13/18 at 9:46 p.m. She said she had been working in the facility for the past eight weeks as a traveling CNA and that she picked up three extra shifts just last week. She said they often worked short-handed and often had to go find help from a nurse during these times. She said she was training another traveling CNA that evening, which was slowing things down even further. She said she felt the facility could use another CNA on the Pondside neighborhood. RN #5 was interviewed on 11/13/18 at 9:12 p.m. She said the facility was not fully staffed the night she was interviewed. She said the facility had used traveling CNAs recently, but thought those CNAs were on vacation at the time. She said the facility was short one CNA on Mountainside neighborhood that evening and since she had CNA duties to perform herself, she was a bit behind schedule with passing medications and other nursing duties. She said the facility was very short of CNAs working presently. She said there were many jobs in the area, but not many workers for those positions. She said lack of CNAs affected the residents negatively, as their dinners and baths were rushed. She said the CNAs attempted to make up missed baths or showers during the night shift. She said the facility used to have a dedicated bath aide prior to the CNA shortage, but that they would not have a bath aide again until the facility was fully staffed with CNAs. She said the facility did not call the employees; they posted the opening they were short staffed and employees signed up to work. She said she signed up for extra work about three times per month. She said the night shift should have three CNAs working in the building; one per neighborhood. She said approximately three times per month, there were only two CNAs in the building from 6:00 p.m. to 10:00 p.m. She said being down one CNA during this time was very problematic due to residents finishing their meals and getting ready for bed at this time. She said that shortage of CNAs delayed residents' cares. She said showers were either postponed or turned into bed baths and that this had been happening more often the past two weeks. She said 50% of the CNAs had been newly hired within the past year. She said the longest call light she had seen going off without being answered was a Try 6. She said she thought every Try was five minutes, so a Try 6 should have been 30 minutes. She said Resident #12 had told her earlier that night that his call light had been going off for an hour. RN #1 was interviewed on 11/13/18 at 9:13 p.m., and said she worked per diem at the facility, and had picked up a four hour gap that evening shift on the Creek Side neighborhood. She said she routinely worked with one or two CNAs with her, and if there was not a second CNA, I step up and do more CNA stuff. She explained the Pond Side neighborhood where she was working had six out of 17 residents who needed to be transferred with mechanical lifts and explained those required two staff members. She said the CNA who was currently working in the neighborhood with her was an agency staff member. RN #1 was interrupted and had to go sign in a delivery of medications at the front desk. When she returned, she said she had a concern with the dining service and did not think there was enough dietary staff to get the meals served in a timely manner. She said she would prefer the residents seated at the same table received their meals all at the same time, versus how it currently was being served, when one resident was getting their soup and another was already eating their dessert. (Cross-reference F802 dietary staffing) RN #3 was interviewed on 11/13/18 at 9:32 p.m. She said the Pond Side neighborhood was currently staffed with one CNA, rather than the two routinely scheduled CNAs. She said she was busy and they were usually putting people to bed at that time of the evening and she was carrying a CNA IPod for call light notifications. She said she and the CNA were currently responsible for 19 residents, five of whom required mechanical lifts for transfers, which required two staff members. She said when that happened they tried to plan it out and rotate through the residents, prioritizing by their needs. She explained the call light system was initiated when the resident first pushed the call button for help, and that alert was sent to the CNAs working in the neighborhood. That occured every two minutes, and she called them Try one, try two, and try three. She said try four would be eight minutes after the call light was initially pushed, and would then notify every nurse working in every neighborhood as well as all of the CNAs. She stated, Try nine is considered an unanswered call and that goes to (the nursing home administrator/NHA) and (DON), and said, That is when it would drop off. CNA #3 was interviewed on 11/13/18 at 9:46 p.m. Shesaid she had worked night shift at the facility for two and a half years. She said sometimes the CNA staffing was a little short, and confirmed she was working short staffed that night on the Pond Side neighborhood, without one CNA. She said she was normally called to work extra shifts three to four times each month and had worked short-handed four times in a six-month period. She said if she needed help during her shift, she would just walk to another neighborhood and ask for it. CNA #4 was interviewed on 11/13/18 at 10:00 p.m. She said she worked for an agency and that was her first night working at the facility. She was being oriented by another agency CNA traveler and said they were teamed up so she could learn the routine. She said she had not completed any classroom orientation specific to the facility prior to starting and was not aware if she had any competencies to complete prior to working on her own. The DON was interviewed on 11/14/18 at 3:14 p.m. She said the call light system's functionality was the Try nine's, meaning the call lights did get dropped after nine 'tries,' which sent notification to staff every two minutes until it was answered, for a total of 18 minutes. After the 18 minutes, the call was not responded to, and stopped alarming. She said when this process was brought to her attention the day prior, the functionality had been increased to 100 tries, or 200 minutes. The DON and NM were interviewed on 11/15/18 at 12:28 p.m. The DON confirmed the facility was currently utilizing one agency licensed practical nurse and five CNAs. She said their community was unique in that it was rural and they had very few nurse and CNA applicants. She said they had a high cost of living, which affected the ability for people to live in their town and work. She said the town's population was small and they had the competition of the hospital there as well. The DON said the facility was currently providing CNA classes in-house and they were trying hard to recruit them and retain them when they did their training there. She said the facility recently hired a recruitment and retention staff member to begin actively recruiting CNAs. She said they were trying to think as creatively as possible to recruit nursing staff and wanted to limit their use of agency staff. She said she saw it as a benefit for current agency CNAs to orient new agency CNAs when they start working at the facility, because they knew what the differences were in each community and had worked in multiple areas. The DON confirmed two staff members were required to assist all residents when a mechanical lift was used. She said there were currently three residents in Pond Side, six in Creek Side, and four or five in Mountain Side who required a mechanical lift. She said there was currently one resident in both Pond Side and Creek Side who did not get out of bed. The DON and NM said they felt the facility had enough staff available to meet the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review, the facility failed to employ sufficient dietary support staff to carry out the functions of the food and nutrition services department in two of two facility dining rooms. Specifically, insufficient numbers of adequately trained food and nutrition staff contributed to prolonged wait times for meals and overall decreased resident satisfaction with dining. Findings include: I. Food production and service The facility had one production kitchen and two functioning serving kitchens. There was a serving kitchen with adjacent dining area in the Pondside and Mountainside neighborhoods. Meals for the neighborhood dining rooms and for in-room dining were prepared in the production kitchen and transported to the neighborhoods for service to residents. Certified nursing aides (CNAs) took orders and delivered trays for in-room meals. There was one dietary server assigned to each neighborhood kitchen and dining area. Meal times were breakfast 8:00 a.m., lunch 12:00 p.m. and supper 5:00 p.m. II. Resident interviews Interviews with residents who, per facility assessment were cognitively intact and interviewable, revealed the following comments. Resident #22 was interviewed on 11/12/18 at 3:56 p.m. She said she ordered a room tray and often received cold pancakes in the mornings. She said the facility had fancy-sounding names for food and she was often uncertain what she was ordering. She said the staff who she ordered the meals from could not tell her what some of the dishes were. Resident #28 was interviewed on 11/13/18 at 9:45 a.m. Regarding food service, Resident #28 said, A lot of times the food is cold; they don't have enough people to work in the kitchen. A lot of times the CNAs help serve depending on who's here. Last night I got there just a tiny bit after 5:00 p.m. and didn't leave till 6:30 because I never got my main dish. I was the last one served for some reason. The resident said staff usually brought menu items from the kitchen far away to our little kitchen. If they ran out of food, they had to call the main kitchen and get them to prepare it, then staff had to go get it. Not a very good system I don't think. She said residents could order eggs any style, hot dogs, hamburgers, etc. from the anytime menu if they didn't like the main menu items. But then you have to sit and wait for it because they have to send down to (the main kitchen) to get it. I don't know how they could design a worse system. III. Family member interview Resident #51's family member was interviewed on 11/12/18 at 3:10 p.m. She said, Meal wait times can be an hour: 15 minutes in between soup, meal and dessert service. Because the middle kitchen is closed. There is usually one person serving every single tray. If they don't know the resident it's a struggle. One lunch (Resident #51) waited from 11:30 a.m. to 12:55 or 1:00 p.m. IV. Dining observations A. Dinner on 11/12/18 Continuous dinner service observations on 11/12/18, from 5:00 to 5:50 p.m., revealed the following: Residents were seated in the dining room at 5:00 p.m. Two long tables and one short table were available in the dining room: the long bar table in front of the kitchen, a long table in the center of the dining room, and directly behind it a three-top assistance table against the wall. -At 5:27 p.m. a nurse served a room tray. Resident orders were being taken. Two or three residents were eating cauliflower-cheese soup, but some declined soup when offered. One resident at the bar table, who had soup, was just served his entree. Glasses of water were on the tables, and hot beverages were now being served. -At 5:29 p.m. only one resident at the bar table by the kitchen had been served. Two other residents were sitting at the bar table with him but not yet served. The other residents had not been served. -At 5:31 p.m. the same resident at the bar table was served a second plate of food. At 5:32 p.m. the second resident at the bar table (Resident #48) was served his plate. At 5:33 p.m., a staff person wheeled a resident into the dining room and took the resident's order. Two of the three residents at the bar table were eating their meals, but the third resident still had no entrée. -At 5:37 p.m. Resident #41, who was sitting at the head of the long table, was served her entrée. The six other residents at her table had drinks but no food. At 5:40 p.m., the third resident at the bar table was served, 11 minutes after the first resident was served. -At 5:41 p.m., the resident to the right of Resident #41 was served her plate. Five others at the table were not yet served. At 5:46 p.m., a third resident at the long table was served. Four residents at the table were still without food and waiting. At 5:47 p.m., the resident who was brought in later was served her soup. The male resident at the far end of the table (opposite Resident #41) was served a bowl of soup. -At 5:50 p.m., a fourth male resident wheeled up to the bar table, and the first resident was served at the three-top table at the far wall behind the long table. Dinner was scheduled for 5:00 p.m., and most residents had been waiting in the dining room since then, but several residents had still not been served at 5:50 p.m., some of whom sat at the same table with those who were already eating their meals. B. Dinner on 11/13/18 Continuous dinner service observations on 11/13/18, from 5:00 to 5:51 p.m., revealed the following: -At 5:32 p.m., residents had been in the dining room since 5:00 p.m. The three residents at the bar table were eating together. Only two residents at the long table had been served their entrée and the rest were waiting. One resident was still eating her soup. The male resident at the end of the table was served his meal, picked up his adaptive fork and was slowly trying to pick up a bite of food. -At 5:41 p.m., Resident #41, at the opposite end of the long table, said to her tablemates, I don't think I'm going to get any food anyway. -At 5:42 p.m., a nurse delivered a room tray to Resident #51. -At 5:49 p.m., Resident #41 and her three remaining tablemates were served their entrees after at least a 49-minute wait. The residents at the assist table still had not been served. C. Lunch on 11/14/18 Continuous observations from 12:15 to 12:40 p.m. on 11/14/18 revealed the following: -At 12:15 p.m., four entrees were delivered to residents at the long table. All three residents at the bar table had been served. Resident #28 just seated herself at the long table. Six other residents at the long table were not yet served and were waiting. -At 12:17 p.m., Resident #43 was wheeled up to the bar table by staff to join the three who were already eating. Resident #41 at the head of the long table was served her entrée. -At 12:22 p.m., Resident #51's and Resident #106 at the long table were served. Resident #43 was eating soup at the bar table with his three tablemates who were eating their entrees. -At 12:23 p.m., Resident #28 at the long table was served her entrée. -At 12:26 p.m., the last resident at the long table was served her meal, 11 minutes after the first resident at the same table was served. A CNA asked all the residents if they needed anything. -At 12:27 p.m., Resident #17 at the small assist table was served by kitchen staff. Two of the three residents at the assist table had no food yet. A CNA said they were getting soup now, and added, We always start with soup. -At 12:34 p.m., Resident #17 was slowly eating soup with an adaptive spoon. Her two tablemates and everyone else in the dining room had been served and were eating something. -At 12:36 p.m., CNA #7 stood over Resident #17, placed a straw in a cup and held it to her mouth, then walked away toward the kitchen, saying tomato soup was all she wanted to eat for lunch that day. -At 12:40 p.m., CNA #7 was asking Resident #17 if she was done, and asking other residents at the assist table if they were done, although they had only been served a few minutes before. Residents at the long table were not served together. Residents at the assist table were served last and were asked if they were finished after seven minutes. V. Record review Facility assessment The facility assessment, last updated 10/21/18, indicated 38 of 51 residents would be considered to require assistance of one to two staff or fully dependent on staff for eating. B. Resident council meeting minutes The Neighborhood Council Minutes were reviewed from 1/2018 through 10/2018 and revealed the following comments and discussions: 1/11/18: One resident said she was consistently hearing just a moment please from both servers and nursing staff in the dining room. 3/8/18: One resident said he was told individual packets of salad dressing or steak sauce were not available in the neighborhoods. The food service director responded those items were available and the servers had to go to the main kitchen to get them. 6/14/18: The culinary director suggested residents order their evening meal at lunch when ordering a la carte so they would not have to wait so long at the evening meal. -One resident said ordering that far in advance was difficult due to last minute changes from dietary. -One resident said if the item is broadcast on the television screen it should be available at meal time. -Two residents said they had very long waits for meals. One had waited over 45 minutes and the other over an hour before saying forget it it ' s too late. 9/13/18: One resident said she had to wait a long time for dinner sometimes. One resident asked if the cooks were well trained or do they just take anyone. 10/11/18: Residents were informed there would be no menu modifications while the culinary director was away to keep it stable. -The DON announced the Creekside dining area was going to become the new Community Life room for group activities. C. Dining service handbook The [NAME] Community Living (MCL) Dining Handbook, undated, was provided by the registered dietitian (RD) on 11/15/18 at 1:44 p.m. She said this was the training tool used throughout the past summer at monthly department meetings and new employees were given a copy. Steps for quality table service included (pp.7-9): -Greeting each resident within two minutes of being seated; -Deliver beverages immediately, serving females first; -Clear dishes after everyone has finished the first course; and, -Detailed instructions for which side of the resident and with which hand meal courses and beverages are served and cleared. VI. Staff interviews CNA #6 was interviewed on 11/13/18 at 9:46 p.m. She said it was her opinion that the dietary department should serve the room trays first due to resident's food getting cold. She said, in the past eight weeks she had worked in the facility, she had had several complaints of this nature from the residents. Server #4 was interviewed on 11/14/18 at approximately 8:25 a.m. She said she was always busy and often has worked double shifts. She said there were times she felt like she needed help but the residents understand and do not hold it against her. She said it was not uncommon for meals from the kitchen to take over 30 minutes, especially at lunch. The interim food service director (FSD) and registered dietitian (RD) were interviewed on 11/15/18 at 11:05 a.m. and the findings above discussed. They said the facility tried to give everyone five star service, so all staff knew the proper way to serve, although different team members worked and organized differently. They said it could be overwhelming for some staff, and some were just more efficient naturally. They said there was one server assigned to each neighborhood. Residents should have their order taken in 10 minutes or less and some items could take up to 30 minutes with preparation and travel time. They said in-room meals were last to be served unless the dining room was slow and the server had time. They said items ordered from the a la carte menu were phoned to the kitchen by the neighborhood server and delivered to the neighborhoods when ready. They said resident meals phoned in were put in line behind any orders ahead from the assisted living and bistro. They said tablet computers had been ordered to communicate directly with the kitchen. They said there were no dietary staff reassigned to Mountainside or Pondside as an additional server. They said the position of a runner was created to help facilitate prompt service by decreasing the travel time back and forth to the production kitchen. They said there was one person in the position who was scheduled five days per week. They said there was no part-time runner position and staff would let them know when help was needed. The RD said they offered staff training, but one on one training was something they would like to do. It needs to be a more scheduled training we can work on. They said they were taking orders a table at a time, and if one resident sat at a table later, it could affect meal service times, depending on the day and the meal. They said they attempted to accommodate resident needs, but the size of the kitchen was a challenge. The director of nursing (DON) was interviewed on 11/15/18 at approximately 12:30 p.m. She said nine to 12 residents were now served from the other two neighborhood kitchens. She said she felt meal service times had decreased. She said 20 minutes would be a reasonable wait for a meal unless it was an item requiring longer preparation time. She said wait times greater than 20 minutes for on-menu items were excessive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the resident's call light system was functioning in its entirety. Specifically, the facility failed to ensure call light requests for assistance were not dismissed prior to the resident receiving the help they needed. Cross-reference F725 sufficient nursing staff Findings include: I. Professional standard According to [NAME], [NAME], Stockert, and Hall (copyright 2017), Fundamentals of Nursing (ninth edition), page 390: Nurses are responsible for making a patient's bedside safe. Explain and demonstrate to patients how to use the call light or intercom system and always place the call device close to the patient at the conclusion of every nurse-patient interaction. Respond quickly to call lights. II. Facility layout The facility had three neighborhoods with one long hallway that connected all three: Mountain Side, Creek Side, and Pond Side. The resident call light system alerted staff by sending notifications to IPods carried by the certified nurse aides (CNA) and licensed nursing staff. In addition, each neighborhood had an electronic digital display that would light up with the resident's room number, whether it was the main room or bathroom where the assistance was needed, and the number of tries that had occurred since the resident first pushed the call button. III. Resident interviews Resident #3 was interviewed on 11/12/18 at 1:17 p.m. She said approximately one week prior, the battery in her call light was not working and it had to be replaced. She said after the battery was replaced, her call lights were answered more timely. Resident #25 was interviewed on 11/12/18 at 1:43 p.m. She said she had lengthy call light response times in the past and had not made it to the bathroom in time on one occasion. She said recently the battery in her call light was not functioning properly and needed to be replaced. Resident #28 was interviewed on 11/12/18 at 1:59 p.m., and she said she had to wait too long for the bathroom at night and That's not good. She said one of her worries was having a fall and the call light response time has been a problem. She stated, It's a problem about twice a week; they come eventually but sometimes that's too late. She asked, What if you fall and can't reach the call light and they don't come, then what? There you are on the floor for hours again. She said it concerned her because the night prior, a CNA went to get her a bandage and never came back. She said one night, a couple weeks ago, she had wet her pajamas and could not reach a dry adult incontinence brief and stated, There I was. It was a long time. She said she pushed the call light and no one responded and she finally took off the wet pajamas herself. She said a nurse checked on her later and she told him she had been incontinent of urine, and he told her she should have used the call light to ask for help. She clarified she had pushed the call light but no one responded. Resident #1 was interviewed on 11/13/18 at 9:19 a.m. He said sometimes after he pushed his call light he had to wait as long as an hour for help when they got busy. He said it usually occurred during the day shift and stated, It doesn't do any good to say anything. Resident #51's daughter was interviewed on 11/12/18 at 3:10 p.m., and she said the resident had waited 15-30 minutes for a call light response. She stated, Twice now I've been with Mom, watched it and timed it, and personally went down to get someone at the nurses' station. IV. Record review The call light history and response time was reviewed for the following residents from 9/1/18 through 11/14/18, and the following was documented: 1. The call light history and response time was reviewed for Resident #25 from 9/1/18 through 11/14/18, and the following dates revealed the call light was pushed and the alert was never responded to: -9/1/18 at 1:30 and 6:44 a.m.,9/2/18 at 4:56 p.m.,9/5/18 at 6:25 p.m.,9/8/18 at 5:15 and 5:34 a.m.,9/9/18 at 6:28 a.m., 9/12/18 at 3:26 p.m., 9/13/18 at 6:24 a.m., 9/18/18 at 6:57 a.m.and 4:24 p.m., -9/21/18 at 6:21 a.m., 9/22/18 at 5:09 a.m., 9/26/18 at 6:41 p.m., 9/27/18 at 7:04 p.m., 10/1/18 at 9:27 p.m., 10/3/18 at 3:56 p.m., 10/16/18 at 6:25 a.m., 10/29/18 at 6:25 and 6:45 a.m., 10/31/18 at 6:53 a.m. 2. The call light history and response time was reviewed for Resident #28 from 9/1/18 through 11/14/18, and the following dates revealed the call light was pushed and the alert was never responded to: -9/1/18 at 8:14 p.m. and 9:31 p.m., 9/4/18 at 7:31 a.m., 9/8/18 at 11:33 a.m., 9/10/18 at 10:31 p.m., 9/12/18 at 10:51 p.m., 9/13/18 at 11:13 p.m., 9/18/18 at 1:30 a.m., 9/21/18 at 2:13 a.m., 9/23/18 at 5:04 a.m., 8:35 a.m., 9:55 p.m., and 11:14 p.m., 9/26/18 at 12:07 a.m., 9/28/18 at 7:53 a.m., 9/30/18 at 11:23 a.m. and 11:32 a.m., 10/1/18 at 11:22 a.m., 10/5/18 at 1:39 a.m., 10/6/18 at 3:54 a.m., 10/12/18 at 11:13 a.m., 10/13/18 at 7:30 a.m., 10/14/18 at 9:35 a.m., 10/16/18 at 9:29 a.m., 10/17/18 at 8:10 a.m., 2:10 p.m., and 10:46 p.m., 10/22/18 at 8:46 p.m., and 9:30 p.m., and 11/3/18 at 8:56 p.m. 3.The call light history and response time was reviewed for Resident #1 from 9/1/18 through 11/14/18, and the following date revealed the call light was pushed and the alert was never responded to: -10/6/18 at 7:02 a.m. 4. The call light history and response time was reviewed for Resident #51 from 9/1/18 through 11/14/18, and the following dates revealed the call light was pushed and the alert was never responded to: -9/1/18 at 6:54 a.m. and 10:19 a.m., 9/2/18 at 12:37 p.m., 9/4/18 at 1:49 p.m., 9/7/18 at 8:59 p.m, 9/9/18 at 4:28 a.m., 9/10/18 at 5:08 a.m., 9/12/18 at 2:24 p.m. and 4:08 p.m., 9/13/18 at 3:53 p.m., 9/17/18 at 5:57 p.m., 9/21/18 at 6:38 p.m., 9/22/18 at 9:23 a.m., 9/23/18 at 7:12 p.m., 9/24/18 at 11:44 a.m., 9/30/18 at 10:45 a.m., 10/13/18 at 10:11 a.m., 10/16/18 at 4:57 p.m., 10/26/18 at 5:47 p.m. and 6:11 p.m., 10/28/18 at 4:04 p.m., and 11/1/18 at 2:42 p.m. 5. The call light history and response time was reviewed for Resident #3 from 9/1/18 through 11/14/18, and the following date revealed the call light was pushed and the alert was never responded to: -9/10/18 at 4:21 p.m. V. Staff interviews: RN #1 was interviewed on 11/13/18 at 9:13 p.m., and said if a call light was pulled out of the wall it might not alarm. She said earlier that day, she entered room [ROOM NUMBER] and noticed the call light was not connected to the wall, was lying on the floor, and was not alarming. She plugged the call light back into the wall and instructed the resident to walk out to the nurses' station if that happened again and she did not receive a response to her call light. RN #3 was interviewed on 11/13/18 at 9:32 p.m. and said she was carrying a CNA IPod for call light notifications because they were short one CNA on her neighborhood. She explained the call light system was initiated when the resident first pushed the call button for help, and that alert was sent to the CNAs working in the neighborhood. That occurred every two minutes, and she called them Try one, try two, and try three. She said try four would be eight minutes after the call light was initially pushed, and then the system would then notify every nurse working in every neighborhood as well as all of the CNAs. The RN was asked if the call light ever timed out after a certain number of tries and she stated, Try nine is considered an unanswered call and that goes to (nursing home administrator/NHA) and (DON), and said, That is when it would drop off. RN #5 was interviewed on 11/13/18 at 10:27 p.m., and she confirmed she was the charge nurse working that night. She said she could not confirm that call lights were dropped after try nine without assistance being provided. She said she thought it was try six when an actual phone call occurred to the NHA, so they tried very hard to answer them before it got to that. The information technologist (IT) was interviewed on 11/15/18 at 8:46 a.m. He said there was a bed call light and bathroom call light in each resident's room. If they needed assistance, they pressed the button, or pulled the string if they were in the bathroom, and that sent a signal out to a wallboard and to a portable IPod device that signaled to the CNA that a resident in room X needed assistance. The CNA would go and help the resident and pressed the reset button when they were finished, and then the process started all over again. He said there were groupings of emails set up for notification when the call lights were alarming for a certain amount of time with no response. He explained the notifications were Level 1, Level 2, and Level 3, which escalated to include more staff were notified the longer the alarm remained unanswered. He said Level 1 alerted the CNAs working in the particular neighborhood where the call light was initiated. Level 2 escalated to all CNAs and nurses in the building who were working the floor. Then Level 3 went out to all of them again, including the director of nurses (DON) and nurse manager (NM). The IT said he was occasionally made aware of call lights not functioning properly by staff or residents, which could be made through a work order, email, phone call, or verbal requests. He said he performed random audits and do call light testing in all of the rooms. If he saw a call light not operating correctly, or a cord that was frayed, or if he was pressing it and nothing was happening, he would replace them. He said it was rare for the call light to be pushed and not send an alarm, but they were mechanical devices and required troubleshooting. He said more often than not, it was user error and they were working the way they should be. He said he was not aware of the call light in room [ROOM NUMBER] not alarming when it was pulled out of the wall and clarified that when they were removed from the wall, it triggered a spring to be released that would then set off the call light. He looked at his most recent call light audit for room [ROOM NUMBER], dated 10/31/18, and said he had changed the bed cord at that time, and would investigate further. The IT said the call light system included a way to look at the battery life remaining in the wall-mounted units and stated, But personally, I don't trust it. He said checking the batteries was not currently on a routine schedule, but he knew the facility had changed every call light battery within the whole system within the past year. He explained if a resident pressed the call light more often, the battery would wear down faster. The DON was interviewed on 11/14/18 at 3:14 p.m. She said she had not been aware that the call lights dropped off after try nine until the night before, when she received a phone call from RN #5. She said she had a conversation with the IT that morning and had been told in the past that this was the company's functionality, the try nines. She said the functionality had been increased that morning to 100, which was equivalent to 200 minutes. Meaning, if the call light alert was tried every two minutes for 100 times, it would take 200 minutes before the call light would drop off. She said they were happy with the increase and the change had already been made on the nursing staff's IPods, which is what they received the call light notifications on. She confirmed the facility did not currently have a system in place to routinely check the call light batteries and said their maintenance director and IT would change them if they were notified to do so. She said in the event a call light was not functioning properly, they had bells they could provide to the residents to use in the meantime, and the call light could be changed out very quickly. The DON said if a call light was pulled out of the wall, she did not know if it would alarm and keep alarming or not. She said the nursing staff did hourly rounding in their assigned zones, and if for some reason, a call light was broken, she felt it would be identified quickly. She said sometimes the CNAs or nurses entered a resident's room to answer a call light and forgot to reset it. She said in the past when a resident or family complained of a lack of timeliness answering the call lights, they had a video surveillance system in the building they could review. She said she would check that camera system based on that complaint to explain to the family staff had been in the resident's room. She said the longest wait time she was aware of was 21 minutes, and said that was a long time, however, that is a rarity. She said she trusted the staff and thought they just forgot to turn the call lights off. VI. Additional observations On 11/14/18 at 3:35 p.m., the DON entered room [ROOM NUMBER] and pulled the call light out of the wall. It initiated a call light notification through the system properly. At 3:40 p.m., the DON tested the call light in room [ROOM NUMBER], and it initiated the call light system appropriately. VII. Facility follow up The DON provided additional documentation via email on 11/19/18 at 3:02 p.m. She said their video footage was deleted regularly based on the volume allowed per camera, and the systems rebooted sporadically. She said Resident #1's room did not have video footage until 9/12/18 when she had requested the camera be relocated so she could see the nurses' station, which also gave access to his room. In addition, Resident #25's room did not currently have video access to view her room, but she would ask for a camera angle to be relocated so she could view her room in the future. The additional documentation did not address the video footage for Resident #25, Resident #28, or Resident #51.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility kitchen and one of three resident dining room refrigerators. Specifically, the facility failed to minimize potential risks for foodborne illness in a highly susceptible population as evidenced by: -Inadequate hand washing; -Insufficient sanitation of work surfaces; and -Failure to monitor, identify and correct improper refrigerator temperatures in the Creekside dining area. Findings include: I. Inappropriate hand hygiene A. Professional references According to the Food and Drug Administration (FDA) 2017 Food Code pp. 48-50: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils. In addition hands shall be washed: - After handling soiled utensils or equipment; - During food preparation as often as necessary to remove soil and contamination; - After engaging in other activities that contaminate the hands; and - Before donning gloves to initiate a task that involves working with food. The following cleaning procedures shall be used: -Rinse under clean, running warm water; -Apply hand washing soap; -Thoroughly rinse under clean, running warm water; and -Immediately follow the cleaning procedure with thorough drying of the cleaned hands. B. Facility policy and procedures The Hand Hygiene policy revised 1/18, provided by the director of nursing (DON) on 11/14/18 at approximately 4:00 p.m., read in pertinent part: All associates involved in the handling of food shall wash their hands with soap and water at the following times: -Before handling food or clean utensils, dishes or equipment -Before putting on gloves -After handling soiled utensils -After removing gloves. In addition, procedures for effective hand washing stipulated hand washing sinks and supplies should be easily accessible, include a covered trash receptacle, and provide hot water at 100 degrees Fahrenheit (F) within one minute. C. Observations On 11/12/18 at approximately 12:30 p.m. there was no trash can near the hand washing sink located to the right of the food preparation table. A dietary staff member moved a table-height, uncovered trash container being used for food waste during preparation to the side of the hand sink to discard paper towels. approximately 20 feet which was used on the other side of the preparation table to the side of the hand washing sink. On subsequent visits to the kitchen on 11/12/18, 11/13/18, 11/14/18 and 11/15/18 there was no trash receptacle near the hand washing sink to the right of the preparation table. On 11/14/18 at approximately 12:24 p.m., [NAME] #3 was observed loading soiled utensils into the dish machine. He was wearing green, elbow-length dishwashing gloves. He removed the green dishwashing gloves which were covering a pair of clear single-use gloves, and removed clean utensils from the dish room. He returned to the dishroom, donned the green dishwashing gloves over the single-use gloves and continued to wash dishes. On 11/15/18 at 8:05 a.m, the soap dispenser above the hand washing sink to the right of the preparation table did not dispense soap. On 11/15/18 at 8:08 a.m., [NAME] #2 approached the hand washing sink to the right of the food preparation table he pushed the bar of the dispenser and no soap was dispensed. He rubbed his hands beneath the water and dried them with a paper towel. On 11/15/18 at 8:18 a.m., Server #3 pressed the dispense bar of the soap dispenser and no soap was dispensed. She retrieved a refill container of a blue colored soap and refilled the soap dispenser with a container of blue colored antimicrobial hand washing soap. She held her hands under running water for approximately two minutes, and said the water did not get warm. She then used the hand washing sink at the far left of the cooks line. On 11/15/18 at 8:55 a.m. the hand washing sink water was 61 degrees F after two minutes. D. Staff interviews Server #3 was interviewed on 8/15/18 at approximately 8:20 a.m. She said she changed the soap dispenser because it was empty and all dietary staff should know where to find the soap and how to refill the dispenser. She said the water felt really cold and it would not warm up. Cook #3 was interviewed on 11/15/18 at approximately 9:30 a.m. He said he wore the green dishwashing gloves to prevent the clear single-use gloves from getting dirty. He said he had not received kitchen sanitation training. The interim food service director (FSD) was interviewed on 11/15/18 at 8:59 a.m. She said the water in the hand washing sink was too cold and she would put in a work order. The interim FSD and registered dietitian (RD) were interviewed jointly on 11/15/18 at 11:05 a.m. They said dietary staff should wash their hands anytime they changed gloves. They said dishwashing gloves should not be worn over other gloves. They said maintenance was working to fix the mixing valve for hot water and the sink would be taken out of service until hot water was restored. The FSD said a foot operated trash can would be found to place near the hand washing sink. II. Failure to adequately sanitize kitchenware and equipment A. Professional references 1. According to the Food Code 2017 Recommendations of the United States Public Health Service Food and Drug Administration, page 149: Non-food contact surfaces of equipment should be kept free of dirt, food residue and other debris. Food contact surfaces should be clean to sight and touch. 2. According to the Colorado Retail Food Establishment Rules and Regulations (effective 3/1/13), page 67: Equipment food-contact surfaces and utensils shall be clean to sight and touch. Utensils and food-contact surfaces of equipment shall be cleaned and sanitized at any time during the operation when contamination may have occurred; and after final use each day. 3. According to the Colorado Retail Food Establishment Rules and Regulations (effective 3/1/13) pg. 36: Cloths used for wiping food spills or cleaning on food-contact surfaces shall be cleaned and rinsed frequently. These cloths should be held between uses in a clean, chemical sanitizer solution at the proper concentration. B. Facility policy and procedures 1. The Sanitizing Food Contact Surfaces policy and procedure, revised January 2018, provided by the DON on 11/14/18 at 5:25 p.m., read each work area shall be equipped with sanitizing solution. Quaternary ammonia sanitizing solution used in red buckets must be between 200 to 400 parts per million (ppm). 2. The Cleaning of Food and Non-food Contact Surfaces policy, revised January 2017, provided by the DON on 11/14/18 at 5:25 p.m. read in part: All in-use wiping cloths must be kept in sanitizing solution between uses regardless of their intended use. C. Observations During the initial tour of the kitchen on 11/12/18 from 12:30 p.m. to 1:05 p.m., there was an inverted red sanitizing bucket and a wet cloth in the sink directly across from the preparation table. A dietary staff member used the cloth to wipe the preparation table. He placed the cloth back in the sink basin and placed two white cutting boards on the table. He did not sanitize the table and the cloth was not stored in a sanitizing solution. On 11/14/18 at 12:24 p.m. [NAME] #3 was cutting melon and pineapple at the food preparation table. He removed a cloth from a red sanitizing bucket and wiped fruit juice from around the cutting board and the blade of the knife. He continued to cut fruit with the soiled and non-sanitary knife. On 11/15/18 at 9:20 a.m, the interim FSD used a test strip from a white cylinder-shaped container stored above the preparation sink. She verified the solution had been prepared and checked with the same strips by [NAME] #4 at approximately 9:10 a.m. She said the strip read 200 parts per million (ppm) of sanitizer. -The strip container read, Antimicrobial Fruit and Vegetable Treatment Test Strip and had a color coded chart of eight colors ranging from royal blue to pale green. Each color indicated the amount of water in relation to the product expressed as a ratio. D. Staff interviews Cook #4 was interviewed on 11/15/18 at approximately 9:20 a.m. He said the green color on the strip container indicated the sanitizer solution concentration and he typically used these strips. Cook #1 was interviewed on 11/15/18 at approximately 9:30 a.m. He said he used the same container of strips earlier in the morning to check the sanitizer solution and maybe the color was off because it needed to be changed. The RD and interim FSD were interviewed on 11/15/18 at 11:05 a.m. They provided the content and roster of an in-service done that morning will all dietary staff on site. They said all staff must know what chemicals were used to sanitize and now to ensure the concentration is at the appropriate concentration. III. Failure to ensure cold foods stored at appropriate temperatures A. Professional references According to the Food and Drug Administration (FDA) website, www.fsis.usda.gov, downloadable document, Refrigeration and Food Safety, last modified 1/23/15, bacteria grow most rapidly in the range of temperatures between 40 and 140 degrees F, the Danger Zone. A refrigerator set at 40 °F or below will protect most foods. B. Observations On 11/13/18 at 2:40 p.m and 5:53 p.m., the South (Creekside) dining room below-counter refrigerator thermometer read 50 degrees F. The refrigerator contents included pudding, yogurt, applesauce, milk, and juice. On 11/14/18 at the Creekside room refrigerator temperature was 45 degrees F. On 11/15/18, at approximately 11:55 a.m., the temperature of the Creekside refrigerator was 48 degrees F. C. Record review The facility Refrigeration Temperature Record sheets, last revised February 2017, stipulated the standards of a minimum refrigerator temperature of 34 degrees F and a maximum temperature of 41 degrees F. All entries were to be initialed by the staff person who recorded the temperature with a notation of the corrective action taken for any reading outside the standard range. Creekside refrigerator temperature logs provided by the RD on 11/15/18 at approximately 3:00 p.m. revealed the notation previous log destroyed by water written diagonally across the top one-third of the form. There were no entries 11/1/18 through 11/11/18. The dates 11/12/18 through 11/14/18 had p.m. readings only. D. Staff interviews and facility follow-up The interim FSD and RD were interviewed on 11/15/18 at 11:05 a.m. They said the refrigerator in the Creekside dining area remained in use despite the area being utilized for activities. They said they were not aware of any refrigerator temperatures above 40 degrees F. They said they would evaluate the Creekside refrigerator and provide follow-up. A text message from the RD on 1/15/18 at 12:48 p.m., stated the contents of the Creekside refrigerator had been discarded and the refrigerator was now cooling properly.