Based on observations, interviews, record reviews and policy and procedure review for oxygen administration, the facility failed to ensure that two (Residents #56 and #32) of ten residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 39 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. On 4/27/21 at 10:36 AM, Resident #56 was observed lying in bed with oxygen via nasal cannula. An observation of her oxygen tank revealed the flow meter was above the maximum 5 liters (L) level for the concentrator (photographic evidence obtained). An interview was conducted with Resident #56 on 4/27/21 at 10:38 AM concerning how much oxygen she was supposed to receive. She stated, My oxygen rate should be at 6 liters/minute (L/min). A review of Resident #56's medical record noted an admission date of 5/22/20 and a diagnosis of hypoxemia, atrial fibrillation, dependence on supplemental oxygen, and chronic rhinitis. A review of the physician orders revealed, Oxygen at 6 L/min via nasal cannula to keep saturation at 92%. An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 4/28/21 at 2:30 PM concerning the oxygen order for Resident #56. She confirmed that Resident #56 had orders for 6 L/min of oxygen to maintain saturation at 92%. When asked what the oxygen concentrator was reading, she stated 6 L. When asked how she could be sure the resident was receiving 6 L/min when the concentrator's maximum flow was 5 L, she stated that when the dial was all the way at the top of the meter, then the flow was 6 L. When asked if there was a mark indicating 6 L, Employee A confirmed that there were no markings indicating the oxygen level was at 6 L. An interview was conducted with Employee B, Registered Nurse (RN)/Unit Manager on 4/28/21 at 02:39 PM concerning the oxygen order for Resident #56. She confirmed that Resident #56 had orders for 6 L/min of oxygen to maintain saturation at 92%. When asked how she ensured that the concentrator with a 5 L maximum provided the oxygen flow at 6 L as ordered, she said, When the staff dial the meter all the way up, then we assume the concentration is at 6 L. An interview was conducted with Director of Nursing (DON) on 4/29/21 at 10:45 AM concerning the oxygen order for Resident #56. She confirmed that the 5 Liter concentrator used by Resident #56 had a maximum flow of 5.5 L/min. However, the flow meter had the capability of going above the maximum level of 5.5 L, hence the resident could be receiving more oxygen. When asked how much oxygen was contained while the dial flow meter was above the 5.5 L, she stated that it could not be determined. She also added that when the dial flow meter was past the maximum level, oxygen was dispensed at a high pressure. A review of the Invacare Perfecto2 Oxygen concentrator user manual read, Do not set the flow above the RED ring. An oxygen flow greater than 5 L/min will decrease the oxygen concentration. 2. On 4/28/21 at 3:26 PM, Resident #32 was observed sitting in a recliner in her room with oxygen via nasal cannula. Her oxygen flow was set at 3 L/min. An interview was conducted with Resident #32 on 4/28/21 at 3:28 PM concerning how much oxygen she was supposed to receive. She stated, The oxygen has always been at 3 liters. An interview was conducted with Employee C, Registered Nurse (RN) on 4/28/21 at 3:45 PM. She confirmed that Resident #32's oxygen was on 3 liters and adjusted the flow to 2 liters. A review of Resident #32's medical record noted an admission date of 3/31/20 and a diagnosis of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with dependence on supplemental oxygen, congestive heart failure, and bronchiectasis. A review of the physician orders revealed, Oxygen humidified via nasal cannula at 2 L/min routine to keep saturation greater than 92%. A review of nursing progress notes for Resident #32, dated 4/27/21 at 1:31 AM, revealed continuous oxygen at 3 L/min via nasal cannula in progress. On 4/22/21 at 3:36 AM, the nursing note revealed, able to verbalize needs without difficulty, continuous oxygen at 3L/min via nasal cannula in progress, no respiratory discomfort observed. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/29/21 at 10:53 AM. She confirmed that Resident #32's was receiving the wrong oxygen flow rate and she should have been receiving 2 L/min. A review of the facility policy and procedure entitled Oxygen Administration read: To maintain basic life support to all residents when needed, oxygen available to all residents and is administered by a physician's order. Trained CNAs under the supervision of the charge nurse may switch the oxygen from portable tank to concentrator and vice- versa, adjust regulator according to the physician's order and fill humidifier bottle with distilled water. Trained CNAs will report immediately to the charge nurse any identified issues.

Based on observations, staff interview, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices with the potential to affect all of the residents in the facility. The facility failed to ensure dietary staff implemented the policy for for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen during the lunch meal service. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: On 04/28/2021 at 12:00 PM, a second observation of the lunch meal service in the kitchen was conducted. At 12:07 PM, Employee F, Dining Staff, was observed doffing her gloves to grab nectar from the refrigerator and did not wash or sanitize her hands prior to donning a new set of gloves. At 12:08 PM, Employee F grabbed a coffee cup and handed it to another employee. She doffed her gloves and did not wash her hands or put on new gloves. Employee F then grabbed a thermometer and sanitizer wipes for the thermometer and tested the food, without gloves. She then donned new gloves without washing or sanitizing her hands. During an interview with the Dining Service Director on 04/28/2021 at 12:10 PM, he was asked about staff hand hygiene for serving food on the second-floor memory care unit. He stated that staff hand washing was to be done in the sink and pointed to the sink next to the tray line. The sink was blocked and covered by the lids that cover the food on the tray line. Review of the facility policy on hand hygiene revealed it read: All direct and indirect caregivers will maintain standards for hand care that will provide an environment that limits exposure to skin integrity issues as well as infection control issues within River Garden. It is up to each health care worker, to become a model of prevention. This includes not wearing artificial nails, keeping nails trimmed and neat, wearing personal protective equipment (PPE), and washing hands when necessary. Care staff affected by this policy includes Nursing, Life Enrichment, Environmental Services, Dietary, Rehabilitative Services and any other department that provides direct care.