**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to provide two (Residents #82 and #62) of four residents with diagnoses of a serious mental illness (SMI) with Level II preadmission screening and resident review (PASRR) screenings as required, from a total survey sample of 34 residents. The findings include: 1. A review of Resident #82's medical record revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, unspecified dementia, bipolar disorder, insomnia, other specified depressive episodes, and Pseudobulbar affect. A review of her annual minimum data set (MDS) assessment, dated 6/10/24, revealed that in Section A1500, the resident had not been evaluated by Level II PASRR and had no serious mental illness (SMI) or intellectual disability (ID). Section I of the assessment indicated a diagnosis of non-Alzheimer's dementia, anxiety disorder, depression, bipolar disease, and Pseudobulbar affect. The resident received antipsychotic, antianxiety, and antidepressant medications during the look-back period. A review of the resident's physician's orders revealed the following: Resident received Abilify 5 mg (milligrams), take 0.5 tablet at bedtime for diagnosis: Bipolar Disorder (4/2/24) Ativan (antianxiety medication) 0.5 mg by mouth, Indication: yelling out (4/16/24) Nudexta 20 - 10 mg by mouth twice daily, Indication: Pseudobulbar affect (11/13/23) Remeron 15 mg by mouth, give 7.5 mg daily for decreased appetite (6/27/24) Further review of the resident's record revealed a Level 1 PASRR dated 6/9/20, completed by the acute care hospital prior to the resident's nursing home admission. This PASRR triggered a Level II PASRR for serious mental illness. A Level II PASRR was unavailable in the resident's electronic medical record (EMR). On 8/13/24 at 12:36 PM, an interview was conducted with the Regional Nurse Consultant (RNC) who was providing documents unavailable in the EMR to the surveyor. She was asked to review Resident #82's Level 1 PASRR results to verify that the Level 1 PASRR triggered a Level II PASRR. She was asked to provide the Level II PASRR that was indicated by the Level 1 PASRR dated 6/9/20. She provided the Resident Review (RR) evaluation request, completed by the acute care hospital on 6/9/20. She said she did not know why a Level II PASRR was not completed at that time; it was prior to her employment with the company. A review of the facility's policy titled PASARR, 2001 MED-PASS, Inc. (Revised March 2019, reviewed 08/2021, 06/2023, 01/2024) revealed: 1b. If the Level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASSAR representative for the Level II (evaluation and determination) screening process. 2. A review of Resident #62's medical record on 8/13/24 at 11:04 AM, revealed diagnoses of dementia and major depressive disorder dated 10/13/21, that were not identified on the resident's PASRR dated 2/3/18. A review of Resident #62's medicalrecord revealed an readmission date of 12/16/22 and an initial admission date of 2/16/18. Her diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, other specified anxiety disorders, paranoid schizophrenia, and insomnia. Resident #62's active physician's orders included Buspirone 10 mg (milligrams) for anxiety two times daily at 6:00 AM and 6:00 PM, started on 5/23/23; Citalopram 10 mg via gastric tube once a day at 6:00 AM for depression, starting on 5/11/23; and Seroquel (quetiapine - antipsychotic) 25 mg via gastric tube at bedtime at 9:00 PM for depression, started on 6/13/24. A review of the MDS assessment, dated 7/12/24, revealed that the resident was readmitted from an acute care hospital. Section A1550 related to PASRR was blank. The resident's brief interview for mental status (BIMS) was completed by staff and indicated that the resident's cognitive skills for daily decision-making were moderately impaired - decisions poor, cues/supervision required. An interview was conducted with the Social Services Director (SSD) on 8/15/24 at 12:09 PM. She stated nursing assisted her with completing the resident assessments to identify a history of depression. Assessments were completed as needed and quarterly. If signs of depression were identified, the resident would be referred to the psychiatric team. A resident identified as having a newly evident or possible mental disorders (MD), ID, or related condition after admission, would be assessed to ensure they had a disorder. Residents found to have a disorder were reported and referred to determine whether a PASRR Level II was needed. The SSD stated she was responsible for ensuring that a referral was sent to the appropriate state-designated authority. An interview was conducted with the Director of Nursing (DON) on 8/15/24 at 12:25 PM. She stated the facility's process for identifying residents with a possible MD, ID, or related condition prior to admission, was to consult with the Interdisciplinary Team and refer to psychiatric services for evaluation. Residents with newly evident or possible serious mental conditions, after admission to the facility, hospital documentation as well as observations for signs or symptoms related to behaviors were reviewed and evaluated. If issues or concerns were identified, the physician was contacted and a psychiatric consult and review of medications was completed. The SSD completed the PASRR and worked with the Administrator to refer the resident to the appropriate state-designated authority. The process was to collaborate with the Interdisciplinary Team, stabilize the resident, and/or [NAME] Act the resident, if necessary, to ensure other residents were kept safe. When she was asked if a PASRR Level II was required for Resident #62, the DON confirmed that Resident #62 required a PASRR Level II screening. A review of the facility's policy and procedure titled PASARR (revised date 03/2019), revealed: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. the facility conducts a level l PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. if the level l screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level ll (evaluation and determination) screening process. 1. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. 2. The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs. And whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy and procedure review, the facility failed to ensure a refund was issued to the resident or resident representative within 30 days from the resident's date of discharge from the facility for three (Residents #1, #5, and #6) of six residents sampled for refunds. The findings include: 1. Review of Resident #1's records revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 3/25/24. Review of Resident #1's refund request form dated 4/9/2024 revealed the facility had not refunded the total amount due to the resident. (Photographic evidence obtained) 2. Review of Resident #5's records revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 9/13/23. Review of Resident #5's refund request form dated 1/11/2024 revealed the facility issued a refund to the resident on 3/26/24. (Photographic evidence obtained) 3. Review of Resident #6's records revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 3/2/24. Review of Resident #6's refund request form dated 3/4/24 revealed the facility had not issued a refund to the resident. (Photographic evidence obtained) During an interview on 5/20/24 at 2:18 pm with the Business Office Manager (BOM), she reviewed the refund requests received from 12/23 to the present date (5/20/24). The BOM stated some of the refunds had not been issued or were issued past the required time. When asked why the refunds were issued past the due date or not at all, she replied, I cannot provide an answer for that. She confirmed the refund for Resident #1 was requested on 4/9/2024 and the total refund had not been issued. Resident #1's refund was being paid in increments at the family's request. The BOM stated the family had been dealing directly with their corporate office and therefore she could not provide any additional information. She stated the facility's corporate office is responsible for issuing the actual checks for requested refunds. She puts in the request for the full refund amount; however, she was not sure how corporate issued the actual refunds. When asked about the refund checks for Residents #5 and #6, she stated she would have to contact corporate for additional information. On 5/20/24 at 3:08 pm, a follow up interview was conducted with the BOM regarding Residents #5 and #6's refund. She confirmed that Resident #5's refund was dated on 3/26/24, which was more than 30 days past the resident's discharge date . The BOM was not able to explain why Resident #5's refund was issued after the 30-day timeframe. The BOM explained the refund for Resident #6 was requested on 3/4/2024, however, the refund had not been issued. She said she would have to contact corporate for additional information. On 5/20/24 at 3:57 pm, the BOM provided a copy of the refund check for Resident #6 dated 5/12/2024. However, she confirmed the check had not been mailed yet, but was going to be mailed on 5/20/2024. On 5/21/24 at 10:37 am, a phone interview was conducted with the Corporate Controller, Employee A. He stated the refund requests are made at the facility and the corporate office is responsible for issuing the refund checks. He confirmed the refund for Resident #6 was issued after the 30-day timeframe which was an oversight. He confirmed the refund for Resident #1 was being sent in installments. He stated initially the check was issued for the full amount however, it had to be canceled due to fraudulent activity, not related to the requestor. He stated the facility wasn't able to retrieve the check and are awaiting a refund from their bank. He stated they are sending the refund in installments while they are awaiting resolution. Review of the facility's policy on Refunds, version 1.2 (H5MAPL0722) revealed: 2. Within thirty (30) days of a resident's discharge or death, the facility will refund the resident's personal funds and provide a final accounting of those funds to the resident, the resident's representative or to the resident's estate, as applicable. (Photographic evidence obtained) .

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #33) of 45 residents receiving respiratory care, from a total of 27 sampled residents, had a care plan in place for oxygen as ordered. The findings include: During a tour of the facility on 08/08/22 at 2:03 pm, Resident #33's oxygen concentrator was observed in her room at bedside. A closer observation revealed the concentrator was set to administer oxygen at 1.5 liters per minute (L/min). Resident #33 was observed wearing the nasal cannula and receiving oxygen at 1.5 L/min (Photographic evidence obtained of concentrator setting) On 08/09/22 at 11:21am, another observation of Resident #33's oxygen concentrator, revealed it was set to administer oxygen at 1.5 L/min. (Photographic evidence obtained) A review of Resident #33's medical record revealed an admission date of 05/24/22 and diagnoses including acute respiratory failure with hypoxia, major depressive disorder, anxiety disorder, and pneumonia. Physician's orders revealed that on 05/24/22, she was ordered oxygen at 3 L/min via nasal cannula continuously every shift, morning and night and change oxygen tubing every Sunday and as needed. On 05/25/22, an order was written to document shortness of breath (SOB) when lying flat, SOB at rest, and SOB with exertion. Head of Bed (HOB) was to be elevated every shift, starting in the morning at 7:00 am. (Photographic evidence obtained) Resident #33's July 2022 and August 2022 Medication Administration Records (MARs) revealed that oxygen was to be set with a flow rate of 3 L/min via nasal cannula continuously. Nursing initials indicated the oxygen had been provided per the order. (Photographic evidence obtained) Resident #33's vital signs for July 2022 revealed that her oxygen saturation was between 92 and 98 percent. Her vital signs for August 2022 revealed her oxygen saturation ran between 96 and 98 percent. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/31/2022, revealed the resident had a brief interview for mental status (BIMS) score of 99, indicating the resident was unable to complete the interview. She required extensive assistance for bed mobility and she was totally dependent for eating. Resident #33 was documented as receiving oxygen therapy. A review of her active care plan revealed no care plan addressing her oxygen therapy. Further review of the resident's medical record revealed a Progress Note dated 07/07/22 at 6:47am, which read, Respirations even and unlabored, no SOB, oxygen saturation at 93 percent on 3 L/min of oxygen. Further review revealed a Nursing Note on 07/10/2022 at 11:11am, revealing, The resident continues oxygen at 3 L/min for diagnosis of acute respiratory failure, HOB elevated to facilitate breathing, and becomes shortness of breath with exertion-rest periods provided. Orders in place for weekly change of oxygen tubing. During an interview on 08/11/22 at 10:40 am, Employee B confirmed Resident #33 was receiving oxygen at 3 L/min. Employee B also confirmed Resident #33's order dated 05/24/2022 for oxygen to be administered at a flow rate of 3 L/min. She stated Resident #33 was receiving oxygen for shortness of breath. During an interview on 08/11/22 at 10:44 am, Employee A confirmed that nurses were responsible for reviewing oxygen orders each shift, each day. She confirmed that there was no care plan for oxygen administration and that the MDS Coordinators were responsible for reviewing and updating care plans quarterly and on an annual basis. During an interview on 08/11/22 at 10:49 am, Employee C confirmed Resident #33's order, dated 05/24/2022, for oxygen to be administered at a flow rate of 3 L/min. Employee C reviewed the progress notes for Resident #33. She identified that Resident #33's progress notes for August 2022 did not identify her as receiving oxygen. Resident #33's progress notes revealed that her oxygen saturation must be above 90 percent. Employee C stated Resident #33 had two orders for oxygen, and she would call the physician to clarify what Resident #33's oxygen order should be. Employee C confirmed that care plans were reviewed quarterly or as needed and Resident #33 had no care plan for oxygen. During an interview on 08/11/22 at 12:50 pm, the Director of Nursing (DON) confirmed that care plans were updated when there were changes to the resident's care, or when orders were discontinued. The facility reviewed physicians' orders and updated care plans daily or as changes occurred. A review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered (Revised December 2016 and November 2020), revealed, The comprehensive, person-centered care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. .

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, and facility policy review, the facility had a medication error rate greater than 5%. The error rate was calculated based on 33 observations, in which there were a total of two errors observed. This resulted in an error rate of 6.06% involving one (Resident #64) of five residents observed. The findings include: On 08/09/22 at 4:00pm, Employee G was observed preparing and administering medications for Resident #64. The four medications prepared included: Keppra 100 mg/ml (milligrams per milliliter): give 10ml via gastric tube twice a day for seizures Metformin 850 mg: give 850mg via gastric tube twice a day for type 2 diabetes Senna Plus 8.6-50 mg: give one tablet via gastric tube twice a day for bowel regimen Vimpat 50 mg: give one tablet gastric tube twice a day for seizures While preparing the medications, Employee G was observed crushing the Metformin tablet, the Senna Plus tablet and the Vimpat tablet. She placed them all together in one cup, mixed them with water, and aspirated them into a syringe. While administering the medications, Employee G was observed administering the liquid Keppra. She flushed with approximately 5 cc (cubic centimeters) of water, then she administered the mixture of the three remaining medications via gastric tube. This observation resulted in two medication errors, which were confirmed by facility policy, medical record review, and staff interview. On 08/10/22 at 1:10 pm, during an interview with Employee F, she was asked if the expectation during medication pass for a resident with an enteral feeding tube was to give each medication separately with a water flush between each medication. She stated, Yes, that's what the policy, unless there's a special order from the doctor that states otherwise. A review of the Physician's Orders for Resident #64 revealed the following order: 2/14/22: Gastric tube order: Flush gastric tube with 30 cc tap water before and after meds. Flush with 5 cc tap water between meds. A review of the facility's policy for Administering Medications through an Enteral Tube (revised [DATE],) revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 3. Administer each mediation separately and flush between medications. Steps in the procedure: 10. Administer each medication separately. 13. If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During tour on 02/17/21 at 2:30 PM, observed Resident #57 lying in bed with a hand splint on the left hand. Resident was having persistent tremors on the hand and had to hold it down with the right hand to slow the movement. On 02/17/21 at 2:45 PM, Resident # 57 was asked what happened to the hand and if it was usual for the tremors. Resident stated the tremors started after she fell in the shower. She added that she was trying to transfer to the shower chair and while trying to reach the grab bars she missed them and fell. Resident #57 mentioned that she used her left arm to break the fall. When asked if she was alone, she stated, No, Employee H, Certified nursing assistant (CNA) was with me. When asked when the fall happened, she said she could not remember the exact date, she stated that the Employee H would remember, but it about two weeks ago. Resident also mentioned that employee G, Licensed Practical nurse (LPN) was called and assisted Employee H, CNA, to pick up the resident from the floor and put her in the shower chair. Resident #57 added that at the time of the fall she did not feel as if she was really injured, but a few hours later she started feeling pain and the left wrist was swollen and discolored. She notified Employee H LPN and another nurse that worked on night shift. Review of Resident #57 medical record revealed that she was admitted to the facility on [DATE]. Resident's Diagnoses include but not limited to : difficult walking, anxiety disorder, altered mental status , chronic pain, cardiovascular accident (CVA) and hypertension (HTN).Quarterly minimum data set (MDS) dated [DATE] indicated that resident had a brief interview of mental status( BIMS) of 15 out of 15 possible points indicating that resident was cognitively intact. Resident was assisted to require supervision for bed mobility, transfer, toilet use and bathing. She also required limited assistance with dressing. Physician orders revealed orders for clonazepam 0.5 Milligrams (Mg) twice a day (BID), hydralazine 25 mg BID and Lopressor 50mg once a day (QD). These medications increased resident's risks for fall. Upon admission, Resident #57 was care planned for risk for falls due to CVA with hemiparesis, HTN ,care plan was updated on 02/02/21 after resident sustained a fall. Self-care deficit related to CVA with hemiparesis, HTN, depression and insomnia causing risk for falls with focus goal for resident to participate in activities of daily living (ADL) and complete all task with staff assistance. Further record review revealed a nursing progress note dated 02/02/21 at 07: 17 PM resident complained to the writer of having left wrist pain. When asked what happened resident stated, I had fallen yesterday but I did not tell anyone, and I used my left hand to break the fall. Today I am having a pain in this left wrist. Resident stated that she slipped on a plastic bag and slid on the floor. Left wrist does not show any swelling and is cool to touch. As needed (PRN) pain medication given. Physician informed. New order for x ray. Physician progress note dated 02/03/2021 at 05:01 PM, evaluation today for follow up Xray results with non-displaced fracture and management of recent fall. Plan: follow up with orthopedic as soon as possible (ASAP). Another interview was conducted with Resident#57 on 02/18/21 at 3:55 PM, resident was asked if she had another fall in her room that she put herself in bed and had not reported. Resident stated, no. She added, needed help getting up as she had left side weakness. Resident confirmed that the only fall she had at the facility was the one she had in the shower room. When asked if she had been seen by the Orthopedic doctor she answered, yes. She mentioned she was given the splint she had on and was asked to limit weight bearing activities with the left hand until next appointment. In an interview on 02/18/21 at 04:31 PM, ADON was asked if the resident had been seen by the Orthopedic doctor, she stated, no, she added that she would check with the Scheduler when resident was scheduled to go to the appointment. ADON was shown the orthopedic referral form added 02/05/21 with orders for: Splint applied no weight bearing or lifting left lower extremity. She stated that she was not aware resident had gone for the appointment. She confirmed that the new orders were not added to the careplan. Review of the facility policy and procedure titled Fall and Fall risk , managing revised 05/2020. Monitoring subsequent falls and fall risk: 1.The staff will monitor and document each resident's response to intervention intended to reduce falling or risk of falling. 2.If interventions have been successful in preventing falling , staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. 3.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help staff reconsider possible causes that may not previously be identified. 4.The staff and/ or physician will document the basis for conclusion that specific irreversible risk factors exist that continue to present risk for falling or injury due to falls. 3. Clinical record review revealed that Resident #315 was admitted at the facility on 02/12/21. Diagnosis include but not limited to dementia and altered mental status. Physician orders review revealed that resident had prescription for: Ativan, Benadryl, and Haldol (ABH) gel 0.5 Milliliters (ml) apply to inner wrist Three times a day (TID) as needed( PRN) for anxiety ordered on 02/17/21. Lorazepam (Ativan) 2 milligrams per milliliter mg/ML, administer 1 mg intramuscular (IM) injection every 8 hours as needed for severe agitation ordered on 02/12/21. Both medications had no end date. During an interview on 02/18/21 at 12:14 PM, DON confirmed that both medications did not have a stop date. She mentioned that the nurse that took the order was also supposed to add behavior monitoring. She confirmed that behavior monitoring, and side effects were not being done. She mentioned that she would call the physician for order clarification. Review of the facility policy and procedure titled Antipsychotic Medication use, revised on December 2016. Policy interpretation and implementation: 13. Resident will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless health the healthcare practitioner has evaluated the resident for appropriateness of that medication. 16. The staff will observe, document and report to the attending physician and consultant psychiatrist information regarding the effectiveness of any interventions including antipsychotic medication. 4. A review of Resident #14's medical record revealed the Resident was admitted to the facility on [DATE] with Left femur fracture, Schizophrenia, Delusions, Lack of coordination, Dementia, Tremors, Tardive Dyskinesia and Abnormal Posture. A review of the Resident #14's current physician orders revealed the order to apply Dycem (a nonskid pad) to be used under the seat cushion to prevent sliding, with an order date of 11/23/20. A review of Resident #14's ongoing fall prevention care plan revealed the resident was not care planned for the Dycem assistive device. The resident was identified with a problem of falls related to decreased cognition due to aging, previous fall with fracture and diagnosis of schizophrenia. The care plan was last revised on 2/12/21. An interview on 2/18/21 at 10:50 AM, with Employee B, Therapy Assistant was asked to check if Resident #14 had a Dycem under her seat cushion and she stated, No. I checked under her seat. I did not see the Dycem for her also. I will make sure she gets one. Interview with the Director of Nursing (DON) on 2/18/21 at 3:20 PM, confirmed the fall prevention care plan had not been developed or revised to include the Dycem assistive device for Resident #14. A review of Resident #150's medical record revealed the Resident was admitted to the facility on [DATE] with Metabolic Encephalopathy and Coronavirus Disease 2019 (COVID-19). (5) A review of the Resident #150 's medical records including physician orders revealed an active order Resident to have Azithromycin 500 milligram (an antibiotic medication to treat infection) by mouth daily for COVID-19 acute respiratory infection. The Azithromycin antibiotic was started on 2/2/21 and the stop date was 2/7/21. A review of Resident #150's ongoing care plan revealed the resident was not care planned for the antibiotic medication therapy. A review of the Resident #150's current Medication Administration Record (MAR) dated 2/2021, revealed she did not receive her oral antibiotic on 2/4/21 due to the medication not available. In an interview with the Director of Nursing (DON) on 02/17/21 at 4:01 PM, the DON verified the antibiotic medication was not given to Resident #150 on 2/4/21 because the medication was not available. The DON also verified the care plan had not been revised to reflect the antibiotic therapy. Based on observations, staff interview, clinical record review and facility policy and procedure review, the facility failed to develop and implement the person-centered care plan for 5 residents in a total sample of 64 residents. (1) Resident #147 did not have a care plan for a prescribed cervical collar or a pressure reducing device for her heels applied. (2) Resident #57 did not have a care plan for prescribed hand splint. (3) Resident #315 care plan for antipsychotic medication side effects monitoring was not implemented. (4) Resident #14 care plan did not address the resident's need for assistive device while seated in the wheelchair. (5) Resident #150 with no care plan for antibiotic medication therapy The findings include: 1. Resident #147 was observed on 02/14/21 at 12:25 PM. She was lying in bed with her eyes closed. No cervical (C-Collar) was observed to be applied to her neck. Her heels were not floated on a pillow or cushion but were resting directly on the mattress. She did not arouse when her name was called. She appeared to grimace in pain and moan. Resident #147 was observed on 02/15/21 from 12:35 PM until 1:35 PM. She was lying in bed with her eyes closed. No C-Collar was observed to be applied to her neck. Her heels were not floated on a pillow or cushion but were resting directly on the mattress. The resident was moaning in pain. A staff member delivered her lunch tray and left the room. Employee R, CNA entered the room at 1:00 PM and woke the resident. The resident cried out in pain. The CNA then proceeded to raise the head of the bed. While doing so, the resident continued to cry out in pain even louder. The CNA did not stop and ask the resident any questions, she just continued to elevate the head of the bed. The CNA attempted to feed the resident and she cried out in pain every time she moved. The CNA did not apply the resident's prescribed C-collar or float her heels. Resident #147 was observed on 02/16/2021 at 9:33 AM. She was lying in bed with her covers on. When the covers were pulled back it revealed the resident's heels were not floated. She was not wearing the prescribed C-Collar around her neck. The resident was moaning in pain. She did not open her eyes or respond to her name being called. Resident #147 was observed on 02/17/21 at 10:30 AM. She was seated in her wheelchair the day room area near the nurse's station. She was moaning in pain. The resident did not have on her prescribed C-collar applied. The resident did not open her eyes, look around or interact with anyone. During an interview on 02/17/21 at 10:31 AM with Employee P, RN she stated that the resident takes her C-collar off. She went to the resident's room and looked for it. She opened all the drawers and closets and could not find it. She asked Employee S, CNA if she knew where it was. The CNA stated she did not know where it was. The nurse, then stated that it probably went to the laundry this morning. She stated, I know because I took it off of her this morning and laid it on the bed. Resident #147 was observed on 02/18/2021 at 12:22 PM. She was lying in bed with covers on. When the covers were removed over feet, the resident's heels were not floated on a pillow or pressure reducing device. During an interview on 02/18/2021 at 12:25 PM with Employee H, CNA she stated she has worked with Resident #145 since she was admitted . She was asked if the Resident #145's heels were floated. She donned gloves and pulled the covers back over the resident's legs exposing the resident's feet. There was no pressure reducing device or pillow under the resident's heels. The CNA looked around the room, and in the closet and stated that she did not see any boots or pillow for floating her heels. She stated she might have to take one of the pillows from under the resident's head to put under her heels. She then did so. The resident cried out in pain. The CNA told her she was sorry and then put the pillow under her feet. The resident cried out in pain again. She stated the resident has declined since she has had the COVID-19 virus. She used to talk much more, usually about her husband. She stated that the C-Collar that was on the resident today is new. The one she had before was a white hard plastic one. This one is soft. She didn't work with the resident yesterday and this is the first time she's seen this C-Collar on the resident. Review of the clinical record for Resident #147 revealed the physician's order report read: admitted : 10/30/2020. DOB: [DATE]. DX include: 2019 COVID acute respiratory disease, urinary tract infection, prosthetic heart valve, transient cerebral ischemic attack, nonrheumatic aortic stenosis, sick sinus syndrome, fracture of cervical vertebra, diverticulosis of small intestine without perforation or abscess without bleeding, dysphagia, abnormalities of gait, end stage renal disease, need for assistance with personal care, presence of cardiac pacemaker, sleep apnea, anemia, hypothyroidism, hypo-osmolality and hyponatremia and hypertension (Copy obtained). Review of the physician's orders dated for February 2021 revealed orders that read: Start date 11/02/2020-End date is open ended. Patient to wear C collar at all times. Start date 11/07/2020-End date is open ended. Float heels on pillow when in bed (Copy obtained). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #147 was assessed for cognitive impairment using the Brief Interview of Mental Status tool and scored 03 out of a possible 15 indicating moderate to severe cognitive impairment. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting, and personal hygiene. She required extensive assistance of two people for transfers. She required total dependence of one person for bathing. She was not steady, only able to stabilize with human assistance for transfers. She had no impairment in her upper or lower extremities. She uses a wheelchair as a mobility device. She was assessed as having a fracture of the musculoskeletal system. She did not receive scheduled pain medications. She received as needed pain medication. She did not receive non-medication interventions for pain. She was assessed as experiencing pain rarely. Her score of 03 out of a possible 10 indicated low pain (Photographic evidence obtained). Review of the Care Plan for Resident #147 revealed the resident focus areas included: Risk of aspiration. Poor by mouth intake causing risk of weight loss. Psychosocial wellbeing, pain, behavioral symptoms, skin integrity, falls, Activities of Daily Living (ADL) functional, and nutritional status. Approaches under the ADL focus area included C-collar will be placed at all times as ordered and float heels on pillows when in bed as ordered. The Pain focus area include use of devices for positioning for comfort (Copy obtained). Review of nursing notes from admission through 02/18/2021 revealed Resident #147 has a fracture of her cervical spine. She is to wear a C-collar neck brace for fracture of the spine. The nursing note dated 02/07/2021 read: resident calm on trip back but started crying out to not let anyone hurt her once the gurney was off the bus. Resident not wearing C-collar. During an interview on 02/18/2021 at 1:30 PM with Resident #147's physician, he stated he was aware that Resident #147 is in pain. He saw her earlier today. She has declined a lot since having the COVID-19 virus. He confirmed that the resident was to wear the C-collar and have her heels floated while in bed. During an interview with the Director of Nursing (DON) 02/18/21 at 06:12 PM, she stated the resident has a fracture of the cervical vertebra and the C-Collar is for stabilization of the neck. When the neck is stabilized it reduces the pain the resident might feel when there is a fracture of the cervical vertebra. She was unaware that Resident #147 did not have the C-collar on at all times as prescribed. She confirmed that if the resident has an order to float the heels it was to prevent pressure ulcers and should be followed. During an interview with Employee Q, MDS Coordinator on 02/18/21 at 06:25 PM, she stated that the application of Resident #147's C-Collar was an approach for pain management as a supportive device in her care plan. The C-collar was also an approach for activities of daily living and rehabilitation potential. Review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered read: Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident (Copy obtained). Review of the facility policy and procedure entitled Plan of Care read: The plan of care shall be used by staff in the provision of treatment and services and will be available to staff personnel who have responsibility for providing care or services to the resident. Policy Interpretation and Implementation 1. Completed plans of care are maintained in the Electronic Health Record (EHR). 3. Staff is to follow each resident's plan of care, medication and treatment as ordered by the physician (Copy obtained).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On February 18, 2021 at 10:00 AM, observed Resident #141 lying in his bed, awake. Surveyor asked him how he was doing today, he stated, great, I just had my shower, and I'm folding some clothes. Surveyor asked him if she could see his intravenous (IV) bag, which was hanging on a pole on his right side at head of bed. He said yes. Vancomycin dose from last night hanging (completed and not currently attached to resident's IV line). He stated, That's last night's dose, I get that twice a day, so I'll be getting another dose this morning. Writer asked him which arm his IV line was in, he showed me his right arm. I observed a purple peripherally inserted central catheter (PICC) IV line which was uncovered and exposed. Writer asked him where the dressing for his IV was. He looked and stated, oh, I don't know, it must have come off during my shower, I didn't notice. He looked under his arm, and there was no dressing observed in his bed. Surveyor observed the PICC line IV to be in his right arm at the anticubital area. Surveyor did not observe any blood on his arm or at the IV site. Surveyor then went outside the resident's room and asked the nurse caring for Resident #141 (Employee D) if she knew there was no dressing covering his PICC line. She stated, no, she didn't know that, and she would check the resident and then call the doctor right now to let him know. Surveyor went back to see Resident #141 in his room [ROOM NUMBER] minutes later. Surveyor observed a 2x2 border gauze dressing where his PICC line IV was, and asked him what happened. He stated the IV had come out too far and the nurse had to remove it. In an interview on 02/18/21 at 11:15am with Employee F assigned to care for Resident #141 today, Surveyor asked her if she had given Resident #141 a shower this morning. No, I didn't. (Employee B) did, she's a therapist, gave him a shower. Surveyor asked employee F if she had seen Resident #141 or checked on him today, prior to him getting a shower this morning. She stated, I did see him earlier, I'll say about 7:30 this morning. I then asked her if she noticed if he had a dressing over his PICC line IV on his right arm. She replied, I can't say, because he had a shirt on, and that was covering his arms. But he was sitting up in bed, and he was fine, he said he was good and didn't have any complaints. In an interview on February 18, 2021 at 11:30 AM with Employee B, Surveyor asked her if she had given Resident #141 a shower this morning. She replied, Yes, I did. Around 9:30 this morning. Surveyor then asked her if she had noticed if there was a dressing covering his PICC line IV when she took him to the shower room. She replied, Yes, there was. Surveyor then asked her if she covered the dressing with anything prior to his shower. She replied, Yes, I used a plastic bag to cover the dressing. The tape was kind of loose on the dressing, so I made sure to cover it well. Surveyor then asked her if the dressing was still there when she returned him to his room, after his shower. She stated, I think so, um, I'm not sure, I think it was still there. I know the tape around it was a little loose before his shower. But now that you are asking me and I'm thinking about it, I'm not sure if the dressing was there when I brought him back. Surveyor then asked her if she was the nurse caring for Resident #141 know that the tape on the PICC line IV dressing was loose. She stated no. Surveyor asked her if you had noticed the dressing wasn't there, what would you have done? I would have let the nurse know that he needs a new dressing. In an interview on February 18, 2021 at 11:40AM with Employee E, Surveyor asked him if he had made a call to the physician in regards to Resident #141 and his PICC line IV dressing. Yes, I texted his physician. She gave me an order to discontinue the line and increase fluids. Surveyor then asked if she give any directive on his antibiotics. He stated, No, I'll text her back and see what she wants to do for that. Approximately five minutes later, Employee E stated to me, she had him confused with another resident. She texted back to have a new PICC line placed and to continue the two IV antibiotics through [DATE], as previously ordered. Surveyor then asked if the resident would have to go out to have the PICC line placed. He stated, No, we have Access IV come to the facility and place it. On February 18, 2021 at 5:30 PM in a second interview with Resident #141, I asked him how his right arm was. He stated, it's ok, doesn't hurt. Observed a 2x2 border gauze over the former IV area on his right arm. Surveyor asked him, tell me what happened when the nurse came in to look at it this morning, after I had seen the dressing was off. He stated, Well, she came in and looked at it. She said 'this doesn't feel right, this isn't good any more' and then she pulled it out. Then later, they had the guy come in from the IV place and he put a new one in my other arm. A record review of the facilities policy titled Peripheral IV Dressing Changes (revised April 2016) stated: Purpose: The purpose of this procedure is to prevent catheter related infections associated with contaminated, loosened or soiled catheter site dressings. General Guidelines: 2. Change the dressing if it becomes damp, loosened, or visible soiled and at least every 5-7 days. Reporting: 1. Notify physician, supervisor, and/or oncoming shift of any complications/interventions that were done. 2. Report other information in accordance with facility policy or professional standards of practice. A clinical record review for resident #141 revealed a care plan with problem start date 2/17/2021: Category: Antibiotic Therapy Focus: (resident #141) has an active bacteremia infection and is receiving antibiotic therapy with risk for fevers, sepsis. SOB and/or congestion. Short term goal (target date: 3/10/2021) (resident #141) will demonstrate complete recovery from infection within the next 30 days. Approach: Dressing change to IV site per orders as ordered. Observe IV site for swelling, redness, patency, leaking around site, pain, coolness. Neck Braces and Cervical Collars Treat Common Neck Pain Causes Whiplash and abnormal cervical lordosis, such as text neck, are common, yet are very different neck disorders. Neck Bracing as Part of Nonsurgical Treatment. Several nonsurgical or conservative treatment options may help manage and reduce your neck pain-and, fortunately, spine surgery is rarely necessary. A cervical brace or collar may be part of a conservative treatment plan that includes medications (over-the-counter, prescription), physical therapy, massage, and/or acupuncture. The treatment plan your doctor recommends is based on the outcome of a physical and neurological examination, x-rays and/or other imaging tests, and severity of symptoms-together, all confirm your diagnosis. Treatment goals often include neck stabilization, pain management, advance healing and early mobilization. The type of brace prescribed is based on the diagnosis and treatment goals. Soft collars are flexible and offer the greatest range of motion, while rigid braces provide more cervical stabilization. The term stabilization is used to refer to immobilizing the head and neck to limit or prevent motion, which also serves to support the head and reduce weight off the cervical spine. If your doctor prescribes a brace, it's imperative to follow his or her instructions for how to wear the brace. Wearing the brace exactly as prescribed will ensure it eases your pain while reducing the risk of adverse effects from overuse. Written by [NAME], MD https://www.spineuniverse.com/treatments/bracing/neck-braces-cervical-collars-treat-common-neck-pain-causes Recovering from a broken neck. Treatment. Cervical braces. Doctors may treat a minor compression fracture in one vertebra with a cervical or neck brace. A person may need to wear the brace for several weeks or months. They may also need pain medicine, either prescription or over-the-counter (OTC). Symptoms. Often, a broken neck will cause severe pain and tenderness in the neck immediately after an accident or fall. Other symptoms include: Cervical braces. Doctors may treat a minor compression fracture in one vertebra with a cervical or neck brace. A person may need to wear the brace for several weeks or months. They may also need pain medicine, either prescription or over-the-counter (OTC). Wear a neck brace or cervical collar precisely as instructed by the doctor. This may include wearing it all the time, including when sleeping. Take pain relief medicines as prescribed by a doctor. Do not take more than they recommend. If the pain is not under control, call a doctor. Medically reviewed by [NAME], M.D. - Written by [NAME] Berry on April 6, 2020. https://www.medicalnewstoday.com/articles/broken-neck Based on observation, staff interview, clinical record review and facility policy and procedure review, the facility failed to ensure the resident received care in accordance with professional standards of practice for two (Resident #141 and Resident #147) residents out of a total of 64 sampled residents. Lack of treatment can cause worsening of condition, health complications and inhibits the resident from reaching his/her highest practicable level of well being. The findings include: 1. Resident #147 was observed on 02/14/2021 at 12:25 PM. She was lying in bed with her eyes closed. No cervical (C-Collar) was observed to be applied to her neck. Her heels were not floated on a pillow or cushion but were resting directly on the mattress. She did not arouse when her name was called. She appeared to grimace in pain and moan. Resident #147 was observed on 02/15/2021 from 12:35 PM until 1:35 PM. She was lying in bed with her eyes closed. No C-Collar was observed to be applied to her neck. Her heels were not floated on a pillow or cushion but were resting directly on the mattress. The resident was moaning in pain. A staff member delivered her lunch tray and left the room. Employee R, CNA entered the room at 1:00 PM and woke the resident. The resident cried out in pain. The CNA then proceeded to raise the head of the bed. While doing so the resident continued to cry out in pain even louder. The CNA did not stop and ask the resident any questions, she just continued to elevate the head of the bed. The CNA attempted to feed the resident and she cried out in pain every time she moved. The resident raised her right hand between bites but then opened her mouth to accept the food. The CNA did not apply the resident's prescribed C-collar or float her heels. During an interview on 02/15/2021 at 1:25 PM with Employee R, she stated that Resident #147 was not herself today. She does not usually cry out in pain like she did today. She stated, It's not like her. Resident #147 was observed on 02/16/2021 at 9:33 AM. She was lying in bed with her covers on. When the covers were pulled back, it revealed the resident's heels were not floated. She was not wearing the prescribed C-Collar around her neck. The resident was moaning in pain. She did not open her eyes or respond to her name being called. Resident #147 was observed on 02/17/2021 at 10:30 AM. She was seated in her wheelchair the day room area near the nurse's station. She was moaning in pain. The resident did not have on her prescribed C-collar applied. The resident did not open her eyes, look around or interact with anyone. During an interview on 02/17/2021 at 10:31 AM with Employee P, RN she stated that the resident takes her C-collar off. She went to the resident's room and looked for it. She opened all the drawers and closets and could not find it. She asked Employee S, CNA if she knew where it was. The CNA stated she did not know where it was. The nurse, then stated that it probably went to the laundry this morning. She stated, I know because I took it off of her this morning and laid it on the bed. Review of the Medication Administration Record for Resident #147 dated from 02/01/2021 through 02/18/2021 revealed the resident received Oxycodone 5mg tablet by mouth every 12 hours as needed on: 02/05/2021 at 5:56 PM that was considered effective 02/06/2021 at 8:57 PM that was considered effective 02/15/2021 at 12:40 AM that was considered effective 02/16/2021 at 11:42 AM that was considered effective 02/17/2021 at 9:14 AM that was considered not effective 02/18/2021 at 5:34 AM that was considered not effective Review of the clinical record for Resident #147 revealed the physician's order report read: admitted : 10/30/2020. DOB: [DATE]. DX include: 2019 COVID acute respiratory disease, urinary tract infection, prosthetic heart valve, transient cerebral ischemic attack, nonrheumatic aortic stenosis, sick sinus syndrome, fracture of cervical vertebra, diverticulosis of small intestine without perforation or abscess without bleeding, dysphagia, abnormalities of gait, end stage renal disease, need for assistance with personal care, presence of cardiac pacemaker, sleep apnea, anemia, hypothyroidism, hypo-osmolality and hyponatremia and hypertension (Copy obtained). Review of the physician's orders dated for February 2021 revealed orders that read: Start dated 10/30/2020-End date is open ended. Pain management consult. Start Date 10/31/2020-end date is open ended. Pain Management consult with [Pain Management physician] for non-acute pain. Start date 01/28/2021-End date open ended. Oxycodone-Schedule II tablet. 5 mg. 1 tablet oral every 12 hours as needed for non-acute pain. Start date 11/02/2020-End date is open ended. Patient to wear C collar at all times. Start date 11/07/2020-End date is open ended. Float heels on pillow when in bed. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #147 was assessed for cognitive impairment using the Brief Interview of Mental Status tool and scored 03 out of a possible 15 indicating moderate to severe cognitive impairment. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting, and personal hygiene. She required extensive assistance of two people for transfers. She required total dependence of one person for bathing. She was not steady, only able to stabilize with human assistance for transfers. She had no impairment in her upper or lower extremities. She uses a wheelchair as a mobility device. She was assessed as having a fracture of the musculoskeletal system. She did not receive scheduled pain medications. She received as needed pain medication. She did not receive non-medication interventions for pain. She was assessed as experiencing pain rarely. Her score of 03 out of a possible 10 indicated low pain (Photographic evidence obtained). During an interview on 02/18/2021 at 12:25 PM with Employee H, CNA, she stated she has worked with Resident #147 since she was admitted . She was asked if Resident #147's heels were floated. She donned gloves and pulled the covers back over the resident's legs exposing the resident's feet. There was no pressure reducing device or pillow under the resident's heels. The CNA looked around the room, and in the closet, and stated that she did not see any boots or pillow for floating her heels. She stated she might have to take one of the pillows from under the resident's head to put under her heels. She then did so. The resident cried out in pain. The CNA told her she was sorry and then put the pillow under her feet. The resident cried out in pain again. She stated the resident has declined since she has had the COVID-19 virus. She used to talk much more, usually about her husband. She stated that the C-Collar that was on the resident today is new. The one she had before was a white hard plastic one. This one is soft. She didn't work with the resident yesterday and this is the first time she's seen this C-Collar on the resident. Employee H was observed to feed Resident #147. The resident cried out in pain during the meal. She raised her right hand as if to indicate being fed caused her pain. She did not verbalize what she was feeling. She did eat the food presented to her but moaned in pain while eating. During an interview on 02/18/2021 at 12:45 PM with Employee P, she stated that resident has declined since having the COVID-19 virus. She is prescribed Oxycodone 5mg every 12 hours as needed for pain. She stated the resident is in a lot of pain. She did not think the medication was effective. She does not have an order for any other pain medication. She does not know why the physician has not made the order a scheduled dose rather than an as needed dose. She did not think the resident could ask for pain medication anymore. She has declined recently. She will make a referral to pain management. She talked to the resident's physician about her this morning and he told her to make the referral. She then produced the referral form and started to fill it out. She was not sure when the pain management physician would be in the building next. During an interview on 02/18/2021 at 1:30 PM with Resident #147's physician, he stated he was aware that Resident #147 was in pain. He saw her earlier today. She has declined a lot since having the COVID-19 virus. He instructed Employee P to refer her to a pain management consultant. He did not want to give her much more pain medications without her being followed by pain management. He did not offer a rational for prescribing the pain medication as an as needed dose rather than a scheduled dose. He confirmed that the resident was to wear the C-collar and have her heels floated. During an interview with the Director of Nursing (DON) 02/18/2021 at 06:12 PM, she stated the resident has a fracture of the cervical vertebra and the C-Collar was for stabilization of the neck. When the neck is stabilized it reduces the pain the resident might feel when there is a fracture of the cervical vertebra. She was unaware that Resident #147 did not have the C-collar on at all times as prescribed. She confirmed that if the resident has an order to float the heels it was to prevent pressure ulcers. She was not aware that the resident's heels were not floated when she was in bed as ordered. During an interview with Employee Q, MDS Coordinator, on 02/18/2021 at 06:25 PM, she stated that the application of Resident #147's C-Collar was an approach for pain management as a supportive device in her care plan. The C-collar is also an approach for activities of daily living and rehabilitation potential. Resident #147 was observed on 02/18/2021 at 6:30 PM. She was lying in her bed with her eyes shut. She was crying out in pain. She did not respond to her name being called. She did not appear to be aware of her surroundings. During an interview with Employee P on 02/18/2021 at 6:35 PM, she was asked if the pain management consultant physician had been to the facility to assess Resident #147. She stated no, they had not come yet, and she had not heard from them. She stated she would call them. Review of the facility policy and procedure entitled Pain Assessment and Management read in part: Purpose The purpose of this procedure are to help the staff identify pain in the resident , and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sourced of pain; g. Monitoring for effectiveness of interventions; and h. Modifying approaches as necessary. 5 Conduct a comprehensive pain assessment whenever there is a significant change in condition and when there is an onset of new pain or worsening of existing pain. Recognizing Pain. 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc. d. Behavior such as resisting care, decreased participation in usual activities e. Limitations in her level of activity due to the presence of pain. Assessing Pain: 3. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. 2 Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including Musculoskeletal Conditions (4) Fractures. Defining Goals and Appropriate Interventions: 2. Pain management interventions shall reflect the sources, types, and severity of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that one resident reviewed for a fall (Resident #57) and two residents reviewed for application of non-skid pad assistive devices (Residents #14 and #20) received necessary care and documented on the care plan to prevent an accident from occurring. The findings include: 1. During the tour on 02/17/21 at 2:30pm, Resident #57 was observed lying in bed with a hand splint on the left hand. Resident was having persistent tremors on the hand and had to hold it down with the right hand to slow the movement. On 02/17/21 at 2:45 PM, Resident #57 was asked what happened to the hand and if it was usual for the tremors. Resident stated the tremors started after she fell in the shower. She added that she was trying to transfer to the shower chair and while trying to reach the grab bars, she missed them and fell. The resident mentioned that she used her left arm to break the fall. When asked if she was alone, she stated, No, (Employee H, Certified Nursing Assistant (CNA)) was with me. When asked when the fall happened, she said she could not remember the exact date, and she stated that Employee H would remember, but it was about two weeks ago. Resident also mentioned that Employee G, Licensed Practical Nurse (LPN) was called and assisted Employee H pick up the resident from the floor and put her in the shower chair. The resident added that at the time of the fall, she did not feel as if she was really injured, but a few hours later, she started feeling pain and the left wrist was swollen and discolored. She notified Employee H and another nurse that worked on night shift. Review of Resident #57's medical record revealed that she was admitted to the facility on [DATE]. Resident's diagnoses included but not limited to difficult walking, anxiety disorder, altered mental status, chronic pain, cardiovascular accident (CVA), and hypertension (HTN). Quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points, indicating the resident was cognitively intact. Resident was assisted to require supervision for bed mobility, transfer, toilet use, and bathing. She also required limited assistance with dressing. Physician orders revealed orders for Clonazepam 0.5 Milligrams (Mg) twice a day (BID), Hydralazine 25 mg BID, and Lopressor 50mg once a day (QD). These medications increased resident's risks for fall. Upon admission, Resident 57 was care planned for risk for falls due to CVA with hemiparesis, HTN, and the care plan was updated on 02/02/21 after resident sustained a fall. Self-care deficit related to CVA with hemiparesis, HTN, depression, and insomnia causing risk for falls with focus goal for resident to participate in activities of daily living (ADL) and complete all task with staff assistance. Further record review revealed a nursing progress note, dated 02/02/21, at 07:17 PM. The resident complained to the writer of having left wrist pain. When asked what happened, resident stated, I had fallen yesterday, but I did not tell anyone, and I used my left hand to break the fall. Today, I am having a pain in this left wrist. Resident stated that she slipped on a plastic bag and slid on the floor. Left wrist does not show any swelling and is cool to touch. As needed (PRN) pain medication given. Physician informed. New orders for x-ray. Physician progress note dated 02/03/2021 at 05:01 PM, evaluation today for follow up X-ray results with non-displaced fracture and management of recent fall. Plan: follow up with orthopedic as soon as possible (ASAP). Another interview was conducted with Resident # 57 on 02/18/21 at 3:55 PM. The resident was asked if she had another fall in her room when she put herself in bed and had not reported. Resident stated, 'no', and she added she needed help getting up as she had left side weakness. Resident confirmed that the only fall she had at the facility was the one she had in the shower room. When asked if she had been seen by the Orthopedic doctor, she answered, 'yes'. She mentioned being given the splint that she had on and was asked to limit weight bearing activities with the left hand until next appointment. During an interview on 02/18/21 at 04:15 PM, the Director of Nursing (DON) was asked to clarify the nursing progress note dated 02/20/21 regarding Resident # 57's fall. She stated she was the Interim, and was not the DON at the time of the fall. She added that she would check with the Assistant Director of Nursing (ADON), if there was any note or incident report. In an interview on 02/18/21 at 04:31 pm, the ADON stated that after receiving the X-ray for Resident #57, she initiated the investigation. She stated that the resident said she had put something on the floor and when she was walking, she slipped and fell. She added the resident picked herself up from the floor and did not notify anyone. The ADON added that the resident was alert and oriented to person, place, and time (AAOx3), and could not understand why she did not report it after it happened. She also mentioned the resident was seen by therapy and a splint was put on for pain management awaiting orthopedic appointment. When asked if there was any incident report completed, she said, No incident report was done since the fall was unwitnessed. When asked if the resident had been seen by the orthopedic doctor, she stated 'no', and she added that she would check with the Scheduler when resident was scheduled to go to the appointment. The ADON was shown the orthopedic referral form, added 02/05/21 with orders for Splint applied, no weight bearing or lifting left lower extremity. She stated that she was not aware resident had gone for the appointment. During an interview on 02/18/21 at 05:30, Resident #57 was asked to explain to the DON what happen to her left hand. Resident said, I was in the shower and while trying to reach the grab bar, I missed it and fell. I used my left hand to break the fall. Resident was asked by the DON if she was alone in the shower, and she stated Employee H was watching her. She added that she had gotten out of the Covid unit and the new shower was not familiar to her, and therefore needed more help than just watching. The DON asked the resident if she assisted herself up to the shower chair. The resident stated that Employee H, CNA and Employee G, LPN helped her back in the shower chair. She mentioned that she did not feel pain at the time and wanted to get the shower so bad. The DON asked the resident if there was something the facility could have done differently, and the resident said, At the time of the fall, I did not feel as if it was that bad, but then the hand started swelling and was bruised a couple hours after. I notified Employee G, LPN and another nurse that worked that night and they did not seem to do anything. I also do not know why the CNAs think I can do everything by myself while I need assistance. Resident continued, I just come from the COVID unit and was not familiar with the bathroom in the new unit, therefore, I needed more help. DON apologized to the resident and stated that she would follow up. In an interview on 02/18/21 at 5:50 PM, the DON was asked for the investigation of the fall. She stated she was not aware of it. She mentioned that she would check with the Administrator. During an interview on 02/18/21 at 6:00 PM, the Administrator confirmed the facility did not have any adverse incidents from November 2020 to the time of survey. Phone interview was conducted with Employee H, CNA on 02/18/21 at 6:10 PM. She stated that sometime in the beginning of February, she was assisting Resident #57 with a shower. While in the shower room, the resident tried to use grab bars to stand, resident became weak, and she lowered her to the floor. She added that she called Employee G, LPN to assist her. Nurse assessed resident for injuries and at the time, there were none observed. Nurse assisted her to lift the resident into the shower chair to resume care. She stated the resident did not complain of pain. During an interview with Employee G, LPN on 02/18/21 at 06:20 PM, she was asked if she was the nurse on duty during Resident 57's fall. She stated, 'yes'. She added that she was called to the shower room by Employee H, CNA. Upon getting to the shower room, she found the resident on the floor. She said that Employee H stated the resident slid down while reaching the grab bar, and she assisted her onto the floor. Nurse added that she assessed the resident and no injuries noted. She mentioned the resident wanted to get off the floor and was getting upset, so she assisted Employee H to put resident into the shower chair. Employee H was then asked what time of the day the fall happened and she stated it was in the morning around 10:00am. When asked the time her shift ended, Employee H stated she could not remember, but per facility policy, she was supposed to clock out by 3:30 PM. When asked if the resident had any swelling or bruising on her left wrist before end of her shift, she stated that she could not remember as resident never complained of pain. Employee H was asked if she went back to reassess the resident throughout the shift, she stated, 'no'. She was then asked if she was familiar with the facility policy on falls, she stated, 'yes'. She said that post fall, nurses were supposed to assess resident for injuries, notify physician and get any new orders, notify family, and document. When asked if she had done that, she stated 'no'. When asked about the progress note dated 02/02/21, she stated that she was not the one that wrote the note. She added the nurse who wrote the note was the one she gave the report to after Resident #57 sustained the fall in the bathroom. Review was conducted of the facility policy and procedure titled Fall and Fall Risk, Managing revised 05/2020. Monitoring subsequent falls and fall risk: 1. The staff will monitor and document each resident's response to intervention intended to reduce falling or risk of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help staff reconsider possible causes that may not previously be identified. 4. The staff and/ or physician will document the basis for conclusion that specific irreversible risk factors exist that continue to present risk for falling or injury due to falls. Review of the policy and procedure titled Abuse Prevention Program, revised 7/2020: Policy interpretation and implementation. 6. Identify and assess all possible incidents of abuse; neglect, mistreatment, and, exploitation of our residents including suspicious bruising , abrasions, lacerations, and any injury of unknown origin; and events of resident altercations. 7. Thoroughly investigate and document which will include, but not limited to: a. Name of the resident(s) b. Date and time of incident (if known) c. Circumstances of the incident d. Location of the incident (if known) e. Names of the witnesses (if any) f. Name of the person(s) alleged to have committed the act with license number(s)( if identified/provided/know) 12. The facility utilized the following definitions in relation to the Abuse Prevention Program: Neglect: Neglect if the failure of the facility , its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The administrator is responsible for the overall implementation of the policies and procedures that prohibit abuse neglect, involuntary seclusion: mistreatment of residents, exploitation, and misappropriation of resident property. The facility has a designated Abuse Coordinator. 2. A review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with left femur fracture, Schizophrenia, Delusions, Lack of Coordination, Dementia, Tremors, Tardive Dyskinesia, and Abnormal Posture. A review of Resident #14's current physician orders revealed the order to apply Dycem (a non-skid pad) to be used under the seat cushion to prevent sliding, with an order date of 11/23/20. A review of Resident #14's Care Plan revealed the resident was identified with a problem of falls related to decreased cognition due to aging, previous fall with fracture, and diagnosis of schizophrenia. Resident had the potential for injury from history of falls with an intervention to keep a side rail up when in bed and floor mats times two. The care plan was revised on 2/12/21 and did not include the intervention to apply Dycem (a non-skid pad material) under seat cushion. An interview was conducted on 2/18/21 at 10:50 AM with Employee B, Therapy Assistant who was asked to check if Resident #14 had a Dycem under her seat cushion. She stated, No. I checked under her seat. I did not see the Dycem for her also. I will make sure she gets one. Interview was conducted with the Director of Rehabilitation on 2/18/21 at 12:10 PM, and she verified Resident #14 and Resident #20 did not have the Dycem under their seat cushions to prevent sliding. She also verified the facility had not followed the physician's orders for the Dycem and stated, The residents now have on the Dycem and I will provide staff in-service for the use of Dycem. 3. A review of the resident's medical record revealed Resident #20 was admitted to the facility on [DATE] with Vascular Dementia, Anxiety, Schizophrenia, Dysphagia, Diabetes, Muscle Weakness, and Ataxia. A review of the resident's current physician orders revealed the order to apply Dycem (a nonskid pad) to be used under the seat cushion to prevent sliding, with an order date of 12/2/20. A review of the resident's Care Plan revealed the resident was identified with a problem of falls related to impaired mobility and poor safety awareness. Resident had the potential for injury from a history of falls with an intervention to apply Dycem (a non-skid pad material) under seat cushion in the resident's wheelchair to prevent sliding. The care plan was revised and dated 12/2/20. An observation conducted on 2/18/21 at 10:15 AM revealed Resident #20 was sitting in a wheelchair in the short-term care unit hallway, and was not in a good sitting position. The resident was leaning towards the back of her wheelchair and did not look comfortable. She was observed to be sliding down on the wheelchair. During an interview on 2/18/21 at 10:15 am, Employee B, Therapy Assistant was asked to look at Resident #20, and she immediately assisted the resident back to a sitting up position. She stated Resident #20 was sliding down in the wheelchair. When asked if Resident #20 had a Dycem under her seat cushion to prevent the sliding, she stated, No. I don't see one, but I will make sure she gets one from our rehab department. An interview with the resident's assigned nurse, Employee C, Licensed Practical Nurse (LPN), on 2/18/21 at 10:30 AM, confirmed Resident #20 and Resident #14 had an order for the Dycem. She stated, The CNA is supposed to put the Dycem. I don't normally put them on their chair. An interview with the resident's assigned Nursing Assistant, Employee F, on 2/18/21 at 10:40 AM, confirmed Resident #20's Dycem pad was not placed under her seat cushion. She stated, I know what the Dycem looks like. It's a pad for the chair. She doesn't have one. I haven't seen it in weeks. Therapy is supposed to put it on her chair. I haven't done it. They keep the Dycem in the gym. When asked about Resident #14's Dycem, she stated, Resident #14 also doesn't have one. I haven't seen one for her chair. It's not in her room. I don't know if she gets one. Therapy would know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Clinical record review revealed that Resident #315 was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia and altered mental status. Physician order review revealed the resident had prescriptions for Ativan, Benadryl, and Haldol (ABH) gel 0.5 Milliliters (ml) apply to inner wrist three times a day (TID) as needed (PRN) for anxiety, ordered on 02/17/21. Lorazepam (Ativan) 2 milligrams per milliliter mg/ML, administer 1 mg intramuscular (IM) injection every 8 hours as needed for severe agitation ordered on 02/12/21. Both medications had no end date. During an interview on 02/18/21 at 12:14 PM, the DON confirmed that both anti-psychotic medications for Resident #315 did not have a stop date. She mentioned that the nurse that took the order was also supposed to add behavior monitoring. She confirmed that behavior monitoring, and side effects were not being done. She mentioned that she would call the physician for order clarification. Review of the facility policy and procedure titled Antipsychotic Medication use, revised on December 2016. Policy interpretation and implementation: 13. Resident will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless health the healthcare practitioner has evaluated the resident for appropriateness of that medication. 16. The staff will observe, document and report to the attending physician and consultant psychiatrist information regarding the effectiveness of any interventions including antipsychotic medication. 18. Nursing staff shall monitor for and report any of the following side effects and the adverse consequences of the antipsychotic medication to the attending physician and consultant psychiatrist a. General/ anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation. b. Cardiovascular: orthostatic hypotension, arrhythmias. metabolic: increased in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke, or transient ischemic attack (TIA) Based on record review and interview, the facility failed to ensure as-needed (PRN) orders for anti-anxiety drugs were limited to 14 days, except when extended by the physician beyond 14 days with documented rationale in the resident's medical record for 2 of 33 sampled residents (Resident #5 and Resident #315). The findings include: 1. A review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with Dementia. A review of Resident #5's current physician orders revealed the order to give Ativan (a prescription tranquilizing medication) 0.5 milligram daily, as needed (PRN), for Anxiety with an order date of 1/29/21 to 2/28/21. Interview with the Director of Nursing (DON) on 2/18/21 at 3:20 PM confirmed the PRN Ativan order for Resident #5 was beyond 14 days without documented rationale from the physician. She stated, I just spoke with the physician about this and she ordered to discontinue the PRN Ativan. Resident #5 does not need it.

Based on resident observations, record review, and interviews with staff and residents, the facility failed to ensure accurate documentation concerning the medical record for Resident #141. The findings include: On February 18, 2021 at 10:00 am, Resident #141 was observed lying in bed, awake. When asked how he was doing that day, he stated, Great, I just had my shower, and I'm folding some clothes. I asked him which arm his intravenous (IV) line was in, and he showed me his right arm. I observed a purple peripherally inserted central catheter (PICC) IV line, which was uncovered and exposed, in his right antecubital area of his arm. There was no blood noted on his arm. I asked him where was the dressing for his IV. He looked and stated, Oh, I don't know, it must have come off during my shower, I didn't notice. I excused myself and went out into the hallway to ask his nurse (Employee D) if she was aware that Resident #141 had no dressing covering his PICC IV line. She stated, 'no', and said she'd go look at it. On February 18, 2021 at 5:20 pm, a clinical record review of Resident #141 revealed a nurse's note entered on February 18, 2021 at 11:44am, written by Employee E which stated: Resident pulled midline from RUE. During a second interview with Resident #141 on February 18, 2021 at 5:30 pm, the resident was observed with a 2x2 bandage covering the area on his right arm where his IV had been, and he had a new IV in his left arm. Surveyor asked him if he remembered her from this morning, and he stated, Yes, it's nice to see you again. Thanks for noticing my IV dressing was off. I got a new one in my other arm, and now my meds are back on schedule. Surveyor asked him if he removed the IV line in his right arm after we spoke this morning. He stated, No, I didn't take it out. That nurse from this morning came in after you left, and she looked it. She said, 'This doesn't feel right, this isn't good anymore' and she pulled it out of my arm. She said they'd get a new one started, and they had an IV guy come in and he put this one in (gestured to left arm IV). When she pulled it out, I was surprised at how long it was, I didn't know that (he gestured to show me the length of the IV line with two hands). During an interview with Employee E on February 18, 2021 at 5:40 pm, Surveyor asked him if they had been able to figure out what happened with Resident #141's IV line that morning. He stated, I think maybe it came out when he got back to his room from his shower, maybe when he was putting his shirt on. Surveyor stated Did you enter a note in his medical chart today that stated 'resident pulled midline from RUE'? He stated, Yes, but I didn't mean he pulled it out intentionally. Surveyor asked him, Did you mean to imply that the resident is the person who pulled it out? He replied Um, yes, I guess so. But not on purpose. Surveyor asked him if the nurse caring for Resident #141 (Employee D) had told him the resident had pulled his IV line out himself. He stated, 'no.' Surveyor asked him if Resident #141 had told him he pulled the IV line out himself. He stated 'no'.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to maintain an Infection Control Program designed to help prevent the spread of infection by failing to ensure facility staff followed procedures implemented to reduce the spread of infection from 2 of 2 facility residents placed on transmission based precautions (Residents #159 and #260). The findings include: On 02/18/21 at 9:45 AM, Employee O, CNA was observed exiting the room for Residents #159 and #260. The room was marked with signage inidcating it was an isolation room, and had a plastic bin with personal protective equipment (PPE) near the door. She stopped in the hallway to speak with the Speech Therapist (ST). After speaking to the ST, she re-entered the residents' room. She did not stop to don PPE prior to entering the isolation room. During an interview with Employee O, CNA at 10:46 AM, she confirmed the room was designated as an isolation room. She stated the two residents in the room were positive for Clostridium difficile (C-diff). She initially stated she did not need to wear the PPE because she only returned to put something in the room and that she was not going to be providing personal care to either of the residents. When asked about the facility policy regarding the proper use of PPE for isolation rooms, she stated she should have had the PPE on prior to going into the room. Review of the clinical records for Residents #159 and #260 revealed both had a current physician's order for contact precautions related to C-diff (Copies obtained). During an interview with Employee E, LPN, Unit Manager, at 10:55 AM, he confirmed that Employee O should have worn the PPE prior to entering the isolation room. Review of the facility policy and procedure entitled 'Personal Protective Equipment Recommendations Clostridium difficile toolkit for long-term care facilities'. PPE is worn to prevent: Resident to resident, health care provider -to-resident and resident -to health care provider exposer to and possible colonization or infection with community-and health care -associated infectious agents including multi-drug resistant organisms (MDRO) and occupational exposer to bloodborne pathogens. PPE should be readily available on all nursing units at all times. All health care providers who may have resident contact or work in resident care areas should be periodically observed for compliance with the PPE policy. Put ON in this order: 1. Wash or gel hands 2. Gown 3. Mask (if needed) 4. Eye cover (if needed) 5. Gloves (Copy obtained). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A clinical record review for Resident #141 revealed several doses of his scheduled intravenous (IV) medicine were not administered. The Medication Administration Record (MAR) showed that Ceftriaxone 2 grams once daily (start date January 22, 2021, end date February 28, 2021) were signed off as dose not given, dose not available on January 23, 24, 25, 26, 30, and 31, 2021, and February 2 and 6, 2021. Further review of the MAR showed that Resident #141 had an order for Vancomycin 1,000mg twice a day intravenous (start date January 23, 2021, end date February 7, 2021) which showed the doses on January 23, 2021 (9:00am) February 1, 2021 (9:00am and 9:00pm), February 2, 2021 (9:00am) and February 5, 2021 (9:00am dose) was signed off as dose not given, dose not available. The doses for this same order were not signed out on the MAR for January 26, 2021 (9:00am dose) and February 4, 2021 (9:00am dose). Review of the clinical nurses notes for Resident #141 did not show any notations that the physician or the pharmacy was advised of these missing IV antibiotic doses. Review of the physician orders for Resident #141 did not show any physician orders for these missed IV antibiotic doses to be extended, made up, or replaced. There were no physician orders found in the resident's medical record to indicate that the physician addressed these missed IV antibiotic medication doses. In an interview with the Director of Nurses (DON) on February 18, 2021 at 5:30pm, Surveyor asked her if she could explain to me why these IV antibiotic doses for Resident #141 were not given, and why the doses were not secured from their ADM or delivered by pharmacy. Surveyor also asked her if she could tell me why two of the doses were not signed out on the MAR. She was unable to tell the writer why these IV antibiotic doses were missed, and two doses not signed out. She stated, Let me try to find out; however, she was unable to provide any information regarding the missing IV antibiotic doses prior to survey exit. A review of the facility policy titled Automated Dispensing Machine for First Dose and Emergency Medications (dated April 2017) stated: Policy: The facility may use automated dispensing machines (ADM) (e.g., Pyxis, Cubex) for first dose and emergency medications, where permitted by regulation or law. Procedures: F. Upon receipt of a new medication order, facility staff should obtain the total number of doses necessary to cover the period of time from the administration of the first dose until it is expected to become available from the pharmacy. K. Replenishment of medications in the ADM is scheduled so that no medication supply is exhausted. A review of the facility policy titled Medication Administration- General Guidelines (dated April 2017) states: Policy: The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. 11. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication is removed from the night box/emergency kit. 6.) If a dose of a regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. Based on record review and interview, the facility failed to provide medications as ordered by the physician, to meet the needs of each resident. This involved two of 64 sampled residents (Residents #150 and #141). Resident #150 did not receive oral antibiotic and steroid medications for COVID-19 (Coronavirus Disease 2019) infection on one day out of six days, due to the medication not available. Resident #141 also did not receive antibiotic medication, as ordered by the physician. The findings include: 1. A review of the Resident #150's medical record revealed the resident was admitted to the facility on [DATE] with Metabolic Encephalopathy. A review of Resident #150's medical records, including physician orders, revealed an active order for the resident to have Azithromycin 500 milligram (an antibiotic medication to treat infection), and Dexamethasone (a steroid medication) 6 milligram by mouth daily for Coronavirus Disease 2019 (COVID-19) acute respiratory infection. The Azithromycin antibiotic was started on 2/2/21 and the stop date was 2/7/21. The Dexamethasone medication was started on 2/2/21 and the end date was 2/13/21. A review of the Resident #150's current Medication Administration Record (MAR), dated 2/2021, revealed she did not receive her oral antibiotic and steroid medication on 2/4/21 due to the medication not available. In an interview with the Director of Nursing (DON) on 02/17/21 at 4:01 PM, the DON verified the antibiotic and steroid medications were not given to Resident #150 on 2/4/21 because both medications were not available. The DON stated, The nurse was waiting for the medication to be delivered from the pharmacy on 2/4/21 and she never gave both medications that day. The DON stated the expectation was to call the physician if the medication was not available. The DON stated, The nurse said she called the physician, but she did not document it.

Based on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff implemented the facility policy for the proper procedures for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen when staff failed to change gloves when they became contaminated, and to wash their hands between glove changes 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 02/14/2021 at 11:27 AM, the initial kitchen tour was conducted. The stand mixer was observed to be covered with a large sheet of plastic. The plastic was removed, and the mixer was observed to have encrusted food debris on the mixing arm. Paint was peeling off of the mixing arm into the mixing bowl. The undercarriage of the mixer head was splattered with stuck-on food debris (Photographic evidence obtained). The Certified Dietary Manager (CDM) confirmed the mixer had been cleaned and is stored with the plastic covering after it is cleaned. He stated the mixer is old and he needs to replace it. The CDM was asked to test the dish machine. He stated the dish machine was a low temperature machine and uses chlorine bleach as the sanitizer. He pulled the door open and pushed a dish rack with a tray into the machine. When the door shut, the machine automatically started the wash cycle. The temperature gauge registered 92' F during the wash cycle and 98'F during the rinse cycle. When asked what the temperature was supposed to get to during each cycle, he stated it usually gets to 120'F. He stated the dish machine has to be run at least three times to get the temperature up to 120'F. He ran it again and the wash cycle temperature reached 98'F. The rinse cycle reached 98'F. He ran it a third time and the wash cycle got to 110'F and the rinse cycle reached 111'F. He ran the machine two more times and the temperature for the wash cycle and rinse cycle did not reach 120'F. He stated he would ask the Maintenance Director to adjust the hot water setting for the dish room to get the temperature up. When asked what the manufacturer's specifications are for the type of machine the facility was using, he pointed to the label on the wall and it read 120'F for both the wash cycle and the rinse cycle. He looked on the machine and could not find any information about the specific manufacturer's instructions about the operation of the machine. The floors under the storage and preparation tables throughout the kitchen and the walls behind the ware washing sinks were observed to have a buildup of dirt and grime. The food warmer had a buildup of grease, dirt and food debris on the handles and the front of the equipment (Photographic evidence obtained). On 02/17/21 at 11:35 AM, a second observation of the kitchen was conducted. Eight dietary staff members were observed preparing the lunch meal service and tray line. At 1:20 pm, the dish machine was run two times, and the wash and rinse cycles did not reach 120'F. On third time, the wash and rinse cycle both reached 120'F and stayed at that temperature. The Dietary Technician Registered (DTR), the CDM, and Employee M were present in the dish room. The CDM stated that he had the Maintenance Director turn the heat up for the water and he thinks that made a difference. The DTR stated that she was having a meeting with corporate level staff on Monday to discuss plans to renovate the dish room. She has all the equipment purchased (including a new dish machine) and it will all be replaced. Employee M put a digital thermometer in the water basin and took the temperature of water coming out of the machine. It read 129'F. She stated that in the morning, she has to drain the machine and let hot water run into it before dishes are run through. She was asked if the dish room staff understood the steps necessary to make the water hot enough. She stated she had trained them. She stated she would put a sign on the machine instructing the staff to run hot water in the machine before washing. At 11:45 AM, the stand mixer was observed to have a large sheet of plastic covering it. The plastic was removed, and the mixer was observed to have food stuck to the mechanical arm and under carriage. The mixing bowl had debris in the bottom. The CDM stated the mixer had been cleaned. The mechanical arm was observed to still be rusted and paint had chipped off into the bowl. During an interview with the DTR at 11:49 am, she stated the mixer had been cleaned. This Surveyor indicated food still stuck to the under carriage of the mechanical arm and in the bowl. She acknowledged the food debris, rust, and chipping paint (Photographic evidence obtained). The CDM acknowledged the mixer was not clean at 11:58 am. At 11:55 AM, the food slicer was observed to be covered with a large sheet of plastic. The slicer was uncovered and observed. It had been cleaned and reassembled. Food debris was stuck to the underside of the blade assembly and the handle of the feed carriage. (Photographic evidence obtained). The tray line for the lunch meal service was observed from 12:00 pm until 1:25 pm. At 12:40 PM, Employee L adjusted her face mask with her gloved hand and did not leave the tray line to discard her contaminated glove, wash her hands, and don new gloves. At 12:42 PM, Employee M adjusted her glasses with the side of her gloved hands. She did not stop to discard her contaminated gloves, wash her hands, and don new gloves. At 12:48 PM, Employee M took a set of keys out of her pocket and handed them to another staff member. She did not stop to discard her contaminated gloves, wash her hands, and don new gloves. At 12:49 PM, Employee M adjusted her glasses with the side of her gloved hands. She did not stop to discard her contaminated gloves, wash her hands, and don new gloves. At 12:50 PM, Employee K wiped his hands on his apron and did not stop to wash his hands. At 12:52 PM, Employee L adjusted her face mask with her gloved hand and did not leave the tray line to discard her contaminated glove, wash her hands, and don new gloves. At 01:00 PM, Employee L adjusted her face mask with her gloved hand and did not leave the tray line to discard her contaminated glove, wash her hands, and don new gloves. At 01:00 PM, Employee K wiped his hands on his apron and did not stop to wash his hands. At 01:04 PM, the CDM left the tray line with his gloved hands opened the walk-in cooler door, went inside, came back out and returned to the tray line, and continued to set up trays and handle the carts. He did not stop to discard his contaminated gloves, wash his hands, and don new gloves. At 01:07 PM, Employee L adjusted her face mask with her gloved hand and did not leave the tray line to discard her contaminated glove, wash her hands, and don new gloves. At 01:10 PM, Employee K left the tray line, went to the walk-in cooler, touched the handle of the door, went in, and came back out. He returned to the tray line and continued to plate food without washing his hands. At 1:10 PM, the CDM left the tray line with his gloved hands, opened the door into the dining room and pushed a tray cart out of the kitchen, he went into the dining room and when he returned, he did not discard his gloves and wash his hands. He continued to put trays on the tray carts. At 01:11 PM, Employee N went to the walk in cooler, opened the door with her gloved hands, went inside, came back out and returned to her position setting up food trays without changing her contaminated gloves and washing her hands. At 01:15 PM, Employee K left the tray line, washed the food processing equipment, did not allow it to air dry, went to the cook line, assembled the food processor, processed a hamburger patty, microwaved the pureed food, returned to the tray line, plated the food, and continued to plate food without washing his hands. Review of the facility policy and procedure entitled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed it read: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 6. Employees must wash their hands: a. after personal body functions; c. whenever entering or re-entering the kitchen; f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and or h. after engaging in other activities that contaminate hands. 10. Gloves are considered single-use items and must be discarded after completing the task for which that are used. The use of disposable gloves does not substitute for proper handwashing (Copy obtained). Review of the facility policy and procedure entitled Sanitation revealed it read: 1. All kitchens, kitchen areas and dining areas shall be kept clean. 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and or chemical sanitizing solutions. 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) a. Wash temperature (120'F). 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulatio and washed according to manual or dishwashing procedures (Copy obtained). Review of the facility's Dish Machine Owner's Manual revealed it read: Water Requirements: Required minimum temperature: 120'F (49'C). Recommended temperature: 140'F (60'C). The supply water to the dish machine should be 140'F. Once the proper water level is established, check the temperature of the water (it should be minimum 120'F, recommended 140'F, 49/60'C) (Copy obtained). .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in a safe operating condition. The findings include: On 02/14/2021 at 11:27 AM, the initial kitchen tour was conducted. The stand mixer was observed to be covered with a large sheet of plastic. The plastic was removed, and the mixer was observed to have encrusted food debris on the mixing arm. Paint was peeling off the mixing arm into the mixing bowl. The undercarriage of the mixer head was splattered with stuck on food debris (Photographic evidence obtained). The Certified Dietary Manager (CDM) confirmed the mixer had been cleaned and is stored with the plastic covering after it is cleaned. He stated the mixer is old and he needs to replace it. The CDM was asked to test the dish machine. He stated the dish machine was a low temperature machine and used chlorine bleach as the sanitizer. He pulled the door open and pushed a dish rack with a tray into the machine. When the door shut, the machine automatically started the wash cycle. The temperature gauge registered 92' F during the wash cycle and 98'F during the rinse cycle. When asked what the temperature was supposed to get to during each cycle, he stated it usually gets to 120'F. He stated the dish machine has to be run at least three times to get the temperature up to 120'F. He ran it again and the wash cycle temperature reached 98'F. The rinse cycle reached 98'F. He ran it a third time and the wash cycle got to 110'F and the rinse cycle reached 111'F. He ran the machine two more times and the temperature for the wash cycle and rinse cycle did not reach 120'F. He stated he would ask the maintenance director to adjust the hot water setting for the dish room to get the temperature up. When asked what the manufacturer's specifications are for the type of machine the facility was using, he pointed to the label on the wall and it read 120'F for both the wash cycle and the rinse cycle. He looked on the machine and could not find any information about the specific manufacturer's instructions about the operation of the machine. On 02/17/21 at 11:35 AM, a second observation of the kitchen was conducted. At 1:20 pm, the dish machine was run two times and wash and rinse cycle did not reach 120'F. On third time, the wash and rinse cycle both reached 120'F and stayed at that temperature. The Dietary Technician Registered (DTR), the CDM, and Employee M were present in the dish room. The CDM stated that he had the Maintenance Director turn the heat up for the water and he thinks that made a difference. The DTR stated that she was having a meeting with corporate level staff on Monday to discuss plans to renovate the dish room. She has all the equipment purchased (including a new dish machine) and it will all be replaced. Employee M put a digital thermometer in the water basin and took the temperature of water coming out of the machine. It read 129'F. She stated that in the morning, she has to drain the machine and let hot water run into it before dishes are run through. She was asked if the dish room staff understood the steps necessary to make the water hot enough. She stated she had trained them. She stated she would put a sign on the machine instructing the staff to run hot water in the machine before washing. At 11:45 AM, the stand mixer was observed to have a large sheet of plastic covering it. The plastic was removed, and the mixer was observed to have food stuck to the mechanical arm and under carriage. The mixing bowl had debris in the bottom. The CDM stated the mixer had been cleaned. The mechanical arm was observed to still be rusted and paint had chipped off into the bowl. During an interview with the DTR at 11:49 am, she stated the mixer had been cleaned. This Surveyor indicated food still stuck to the under carriage of the mechanical arm and in the bowl. She acknowledged the food debris, rust, and chipping paint (Photographic evidence obtained). The CDM acknowledged the mixer was not clean at 11:58 am. Review of the facility policy and procedure entitled Sanitation revealed it read: 1. All kitchens, kitchen areas and dining areas shall be kept clean. 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and or chemical sanitizing solutions. 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) a. Wash temperature (120'F). 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulatio and washed according to manual or dishwashing procedures (Copy obtained). Review of the facility Dish Machine Owner's Manual revealed it read: Water Requirements: Required minimum temperature: 120'F (49'C). Recommended temperature: 140'F (60'C). The supply water to the dish machine should be 140'F. Once the proper water level is established, check the temperature of the water (it should be minimum 120'F, recommended 140'F, 49/60'C) (Copy obtained).