MOUNT ST FRANCIS NURSING CENTER

A complaint survey, prompted by #CO34337 was conducted on 11/30/23. Two deficiencies were cited.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one of three floors. Specifically, the facility failed to:-Ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms;-Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure shared equipment was properly disinfected between use;-Ensure staff followed proper hand hygiene procedures when moving from task to task; and,-Provide accurate isolation precautions, including isolation signage and assure the resident doors remained closed. Findings include:I. Ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms. A. Professional referenceThe Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 12/11/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r2 revealed in part, "Healthcare personnel who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face)."The Centers for Disease Control (CDC) use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID-19, updated 6/3/20, retrieved on 12/13/23 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf revealed in part, "Donning (putting on the gear): Identify and gather the proper PPE to don. Perform hand hygiene using hand sanitizer. Put on an isolation gown. Put on N95 filtering respirator or higher (use a facemask if a respirator is not available. Put on a face shield or goggles. Put on gloves. Healthcare worker can now enter patient's room." "Doffing (taking off the gear): Remove gloves. Remove gown. Healthcare worker can now exit patient's room. Perform hand hygiene. Remove face shield or goggles. Remove and discard respirator (or face mask if used). Perform hand hygiene after removing the respirator or facemask." B. Facility policyThe Transmission Based Precautions policy, reviewed 11/3/22, was provided by the nursing home administrator (NHA) on 11/30/23 at 3:00 p.m. It revealed in pertinent part, "Transmission-based precautions would be used by all staff that have contact with residents and/or their environment. Transmission based precautions would be used when caring for residents who were documented or suspected to have communicable disease or infections that can be transmitted to others. Droplet precautions would be implemented in addition to standard precautions for an individual documented or suspected to be infected with microorganism transmitted by droplets that can be generated by the individual coughing, sneezing, talking or by the performance of procedures. Illness that required droplet precautions included COVID-19."In addition to standard precautions, a face mask and eye protection are required to enter a COVID-19 quarantine or isolation precaution resident room. C. ObservationsOn 11/30/23 at 10:15 a.m., two unidentified staff members walked out of a resident room #306. The resident had COVID-19. One staff member left the room still wearing a gown that had been worn in the resident's room.. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. At 10:35 a.m., an unidentified staff member walked into room #307 wearing a surgical mask, gown and gloves. The resident had COVID-19. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The staff member did not put on eye protection before entering the room. At 10:40 a.m. an identified female staff member walked out of room #303. The resident had COVID-19. The resident had COVID-19. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The female staff member did not change her surgical mask upon exiting the room. At 10:43 a.m., an unidentified housekeeping staff member walked into room #330 and room #331, which were adjoining rooms, with a vacuum. One resident had COVID-19. He was wearing a surgical mask. There was a sign that contact precautions were required and a bin inside the resident's room with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The housekeeping staff member did not don (put on) any other PPE prior to entering the rooms. At 10:48 a.m., the unit manager walked into room adjoining room #330 and room #331. One resident had COVID-19. There was a sign that contact precautions were required and a bin inside the resident's room with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unit manager did not don any PPE prior to entering the rooms. At 10:48 a.m. the unidentified housekeeping staff member walked out of room #330 and room #331 with the vacuum. -The housekeeping staff member did not change his surgical mask upon exiting the rooms. At 11:16 a.m., an unidentified male staff member walked out of room #312. The resident had COVID-19. There was a sign on the wall next to the resident's door that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The male staff member exited the room still wearing the gown he had worn while in the resident's room. At 11:31 am., an unidentified dietary aide walked into room #332 and room #333 to ask for room #332's lunch order. One of the residents had COVID-19. She was wearing a surgical mask. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The dietary aide did not don any other PPE prior to entering the room.-The dietary aide did not change her surgical mask when she left the room. She proceeded to enter room #334 without changing her surgical mask. At 11:34 a.m., the dietary aide left room #334. The resident had COVID-19. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room.-The dietary aide did not change her surgical mask upon exiting the room. At 11:43 a.m., an unidentified staff member went into room #304. The resident had COVID-19. She was wearing a surgical mask. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unidentified staff member did not don any other PPE prior to entering the room. -The staff member did not change her surgical mask upon exiting the room. At 11:45 a.m., an unidentified staff member went into room #305. The resident had COVID-19. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unidentified staff member did not don any other PPE prior to entering the room. -The staff member did not change her surgical mask upon exiting the room. At 11:51 a.m., an unidentified staff member came out of room #311 with a surgical mask and an N95 mask over the surgical mask. The resident had COVID-19. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The staff member did not change her surgical mask upon exiting the room. At 12:12 p.m., an unidentified staff member entered room #328. The resident had COVID-19. She was wearing a surgical mask. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unidentified staff member did not don any other PPE prior to entering the room. -The staff member did not change her surgical mask upon exiting the room. D. InterviewsThe director of nursing (DON) was interviewed on 11/30/23 at 4:49 p.m. The DON said for PPE use staff should follow the CDC guidelines for PPE. The DON said that PPE, such as surgical masks, could be changed at the staff members' discretion. She said the facility was considering keeping N95 respirator masks for each staff member in a plastic bag for reuse. -However, the CDC guidelines for donning and doffing was provided to the DON during the interview. The doffing section (when staff should remove PPE) was reviewed with the DON and NHA where the guideline documented to remove and discard respirator or facemask. II. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before meals A. Professional referenceAccording to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 12/13/23 from: https://www.cdc.gov/handhygiene/providers/guideline.html (2020), it read in pertinent part, "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves was not enough to prevent the transmission of pathogens in a healthcare settings)."B. Facility policyThe Transmission Based Precautions policy, reviewed 11/3/22, was provided by the NHA on 11/30/23 at 3:00 p.m. -The policy did not discuss when hand hygiene should be offered to residents. C. ObservationsThe lunch meal tray pass was observed on 11/30/23 from 11:41 a.m. to 12:18 p.m. The following observations were made:At 11:43 a.m., an unidentified female staff member went into room #304. -She did not offer hand hygiene to the resident. At 11:45 a.m., the same female staff member went into room #305. -She did not offer hand hygiene to the resident. At 11:51 a.m., an unidentified female staff member delivered the resident's lunch meal in room #311. -The tray did not have hand wipes or sanitizer to offer to the resident. At 11:53 a.m., the same female staff member delivered the resident's lunch meal in room #312. The tray did not have hand wipes or sanitizer to offer to the resident. D. Interview The DON was interviewed on 11/30/23 at 4:49 p.m. The DON said staff should offer hand hygiene to residents before and after eating food, after going to the bathroom and if their hands visibly looked dirty. III. Ensure shared equipment was properly disinfected between use A. Facility policy The Transmission Based Precautions policy, reviewed 11/3/22, was provided by NHA on 11/30/23 at 3:00 p.m. -The policy did not discuss when shared equipment should be cleaned. B. Observation On 11/30/23 at 10:43 a.m., an unidentified housekeeping staff member walked into room #330 and room #331 with a vacuum. One resident in the adjoining rooms had COVID-19. There was a sign that contact precautions were required. The staff member left the room at 10:48 a.m. with the vacuum. He placed the vacuum on the housekeeping cart. -He did not disinfect the vacuum after use, despite the fact that it had been used in a Covid-19 positive room. C. Interview The DON was interviewed on 11/30/23 at 4:49 p.m. The DON said shared equipment among residents should be cleaned after each use. IV. Provide accurate isolation precautions, including isolation signage and assure the resident doors remained closedA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 pandemic, retrieved on 12/12/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in part,"Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed."B. Facility Policy The Transmission Based Precautions policy, reviewed 11/3/22, was provided by the NHA on 11/30/23 at 3:00 p.m. It read in pertinent part, "For droplet precautions, the door to the room should remain closed at all times unless fall risk or other resident concerns are included in the care plan." C. Observation On 11/30/23 at 10:15 a.m., the third floor was observed. The following resident rooms had bins outside the doors to hold PPE: room #303, room #304, room #324, room #328, room #330 and room #331. -There were no signs indicating residents were on isolation precautions outside of the rooms with PPE bins until 10:32 a.m. when the unit nurse manager (UNM) placed the signs for several COVID-19 positive rooms. Room #311 had a sign for isolation precautions and the sign had a hand written notice that said to keep the door open. At 10:35 a.m., the following COVID-19 positive rooms had their doors open: room #307, room #335 and room #336. At 10:43 a.m., room #324 and room #325, which was an adjoining room, had their doors open. One resident was COVID-19 positive. At 11:06 a.m., room #332 and room #333, which was an adjoining room, had their doors open. One resident was COVID-19 positive. At 11:16 a.m., room #311's door was slightly open and room #307's door was open. Both rooms were COVID-19 positive rooms. At 11:27 a.m., room #328's door was open. The resident was COVID-19 positive. At 11:32 a.m., room #334's door was open. The resident was COVID-19 positive. At 11:41 a.m., room #307's door was open. The resident was COVID-19 positive. At 11:51 a.m., room #311's door was slightly open. The resident was COVID-19 positive. At 12:14 p.m, room #328's door was open. The resident was COVID-19 positive. D. Interviews The UNM for the third floor was interviewed on 11/30/23 at 10:42 a.m. She said that any room that had a bin outside of the room meant that the resident had COVID-19. The DON and NHA were interviewed together on 11/30/23 at 4:49 p.m. The DON said that the infection preventionist was responsible for placing signs on the door of rooms that required isolation precautions. She said that right now it was the charge nurse who would be responsible for placing signs on the resident's room door. She said that the door should be closed for any room where isolation precautions were required. She said some doors of COVID-19 positive residents were kept open if the resident was a fall risk. She did not have a way to differentiate between the COVID-19 positive rooms that should be kept open because the resident was a fall risk versus the COVID-19 negative residents rooms whose doors were open. The NHA said that the facility did not have an effective process in place to ensure staff was aware which Covid-19 positive resident room doors should be closed and which doors should remain open.

Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional referencesThe Centers for Disease Control and Prevention (CDC), Interim Infection Prevention andControl Recommendations for Healthcare Personnel During the Coronavirus Disease 2019(COVID-19) Pandemic, updated 5/8/23 and retrieved on 12/11/23, from:https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html read in pertinent part, "Nursing homes should assign one or more individuals with training in infection prevention and control (IPC) to provide on-site management of the IPC program. This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment."II. Facility policy and procedureThe Transmission Based Precautions policy, reviewed 11/3/22, was provided by the nursing home administrator (NHA) on 11/30/23 at 3:00 p.m. It revealed, that an ICP was not included in their policy. III. Record reviewA request was made for the ICP's infection control certificate on 11/30/23 at 1:00 p.m. The director of nursing (DON) said she had yet to complete the courses to obtain the infection control certificate (see interview below). On 11/30/23 at 2:38 p.m., the DON provided certificates of completion for seven of the 24 modules required to obtain the infection control certificate. IV. Staff interviewsThe vice president of ambulatory services (VPAS) was interviewed on 11/30/23 at 2:10 p.m. She said they did not have an ICP and they had not had one for three weeks. The DON and another staff member were training on 11/30/23. She said that the facility was under the same corporation as their local hospital. The facility used the hospital's infection control preventionist while they worked on hiring a designated ICP for the facility. The corporate occupational health department supported their infection prevention and control program. The nursing home administrator (NHA) was interviewed on 11/30/23 at 2:19 p.m. She said the ICP quit three weeks prior to the survey and the job was posted. She said the staff developer was being cross trained and the DON had started the infection control certificate.

A revisit survey was completed on 11/27/23 for all previous deficiencies cited on 8/17/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO33663 was conducted on 10/3/23. No deficiencies were cited.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility's general characteristics. This facility is a three-story, Type II (111) structure with a garden level basement and a penthouse. The residents use the basement for the beauty shop and the massage room. The basement and the penthouse contain offices and support facilities. The structure shares a two-hour fire rated wall and a horizontal exit (one each level) with an adjacent convent building. The kitchen is located in the convent building. The facility contains a complete fire sprinkler system. This facility was inspected September 01, 2023 for compliance with the requirements of the 2012 edition of NFPA 101, the Life Safety Code, Chapter 19 for Existing Health Care Occupancies, the 2012 edition of NFPA 99, Healthcare Facilities Code, and other publications as referenced. The facility will meet these requirements when the following deficiencies are corrected.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:Elevator fire barrier does not finish at ceiling (1st floor/2nd floor)NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: Generator Battery Monthly Battery Conductance - No Paperwork Available at time of inspection facility recognized the need to create log for these inspections monthly Generator Monthly load test - No Paperwork Available at time of inspection facility recognized the need to create log for these inspections monthly Generator Transfer Switch - No Paperwork Available at time of inspection facility recognized the need to create log for these inspections monthly8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

A recertification survey with Incidents #33066 and #32215 was completed from 8/14/23 to 8/17/23. Ten deficiencies were cited.

An Emergency Preparedness survey was conducted from 8/14/23 to 8/17/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to ensure one (#36) out of 48 sample residents had the right to receive visitors of their choosing at the time of their choosing. Specifically, the facility failed to ensure Resident #36 was able to visit with a visitor of her choice. Findings include:I. Facility policies and proceduresThe Resident Rights policy and procedure, undated, was provided by the director of health information management (DHIM) on 8/17/23 at 4:30 p.m. In pertinent part it read: "under federal and state laws you have the following rights and responsibilities. Your rights and responsibilities may be assigned and delegated to your guardian, conservator, or other legal surrogate consistent with state law. To the extent possible, we will encourage and assist you with your exercise of your rights and responsibilities, as long as you do not interfere with the rights of other residents. We will not engage in interference, coercion, discrimination, or reprisal when you exercise your rights and responsibilities. We will inform you of your rights during your stay in our facility and we will notify you of any changes made to these rights. You have the right to choose activities schedules and healthcare consistent with your interests, assessments and plan of care. You have the right to participate in social, religious, and community activities that do not interfere with the rights of other residents. "II. Resident #36 A. Resident statusResident #36, age 63, was admitted on 12/22/20. According to the August 2023 computerized physician orders (CPO), diagnoses included pain in the left shoulder, abnormal posture, lymphedema (swelling due to build-up of lymph fluid in the body), not elsewhere classified, major depressive disorder, recurrent, moderate and generalized anxiety disorder. The 6/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident was independent with transfers, walking in the room, dressing, toileting and personal hygiene. She was always continent of the bowel and bladder. B. Resident interviewThe resident was interviewed on 8/16/23 at 2:15 p.m. She said she was denied a visit with her friend who was a former employee, who wanted to take her out to lunch. The NHA told her that the visitor was not allowed to be in the facility. The resident said she felt sad and no longer had control of her life and her choices which made her feel trapped. C. Record reviewThe resident's rights were reviewed on 8/16/23 at 4:30 p.m. the resident's rights revealed the resident had the right to visit privately outside the facility with anyone of their choice. III. Staff interviewsThe nursing home administrator (NHA) was interviewed on 8/16/23 at 3:45 p.m. She said she made a mistake by telling the resident that the former employee was not allowed to visit with her. She should have been more clear that although the facility's policy did not allow former employees entrance into the nursing home the resident could have still gone to lunch with the former employee as long as they met in the parking lot of the facility. The director of nursing (DON) was interviewed on 8/17/23 at 4:54 p.m. She said residents had the right to make their own choices. Residents could visit with whoever they want and the facility needs to observe the resident's rights.

Based on record review and staff interviews, the facility failed to ensure five (#2, #4, #7, #27 and #43) of six residents reviewed for abuse out of 48 sample residents were kept free from abuse. Specifically, the facility failed to ensure Residents #2, #4, #7, #27 and #43 were kept free from abuse by Resident #92. Findings include:I. Facility policyThe Abuse and Neglect policy, revised 6/6/23, was provided by the director of health information management (DHIM) on 8/16/23 at 9:15 a.m. The policy revealed in pertinent part: "Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff, residents, volunteers, consultants, family members or legal guardians, friends, or any other individuals. "Observations and/or allegations of abuse, neglect or mistreatment must be immediately reported to the Administer/Designee to ensure safety of those involved, for thorough investigation of the occurrence, and meet the reporting guidelines established by regulation. "During an investigation, the alleged assailant(s) will not be present in the facility. Employees will be suspended immediately until the investigation is completed. If familyor visitors are suspected, they will not be present during the investigation. If anotherresident was involved, they would be separated and monitored."II. Resident-to-resident altercation involving Resident #7 and Resident #92 on 6/9/23A. Altercation The 6/9/23 progress note revealed Resident #7 grabbed Resident # 92's pants to stop her from entering her room. Resident #92 slapped Resident #7 on the hand. B. Resident #921. Resident statusResident #92, age above 65, was admitted on 5/7/22. According to the August 2023 computerized physicians orders (CPO), the diagnoses included unspecified dementia severe with anxiety, severe agitation, severe with other behavioral disturbances, anxiety disorder and major depressive disorder. The 5/21/23 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). She had short and long term memory problems. She was short tempered and easily annoyed. She required supervision with transfers, walking in room and corridor, locomotion on and off the unit, dressing and personal hygiene. She was independent with bed mobility, toilet use and eating. She had no behaviors and did not reject care. No antipsychotics were received. 2. Record reviewThe mood care plan, initiated 5/8/22 and revised 8/15/23, documented the resident had a history of anxiety and restlessness. She wandered aimlessly into other resident's rooms and went through their belongings. She may become combative with staff and residents at times. The interventions included:-Please knock, introduce yourself, and explain the purpose of your visit;-Encourage resident to tell staff her needs/wants;-Encourage the resident to participate in activities;-Monitor resident for depressive symptoms;-Attempt non-pharmacological interventions as able;-Notify physician of change in mood;-Track residents anxiety;-Review residents medication for efficacy and /or possible decreases; and,-When the resident wanders into another resident's room, walk with her to redirect to her room. The dementia care plan, initiated 5/8/22, documented the resident's dementia was progressing and often wandered into other resident's rooms. She was at risk for being injured or verbally abused by other residents. She may become combative and agitated when she interacted with other residents or staff. The interventions included:-Please knock, introduce yourself, and explain the purpose of your visit;-Please listen to what she has to say;-Provide encouragement and validation as needed;-Provide cues and reminders as needed;-Encourage resident to make her needs/wants known;-Encourage her to attend activity groups that interest her;-Notify physician of changes in her cognition to rule out acute medical issues;-Include her power of attorney (POA) in decision-making;-Redirect her with her favorite foods when able; and-Loud noises could be irritating to her, attempt to keep her in a quiet environment. The aggressive behavior care plan, initiated 7/31/23 and revised 8/15/23, documented the resident had incidents of aggressive behaviors towards other residents. The interventions included:-She had been provided a 24 hour sitter; -She received a 30 day notice for alternate placement;-Monitor and document her aggressive behaviors;-Notify physician of her aggressive behaviors;-Provide one-to-one social services visits;-Provide one to one life enrichment visits;-Assure that there is no medical reason for her aggressive behaviors; and,-Administer medications as ordered.-Resident #92 was involved in five resident to resident altercations in two months.-According to the progress notes, the resident continued to wander into other resident rooms daily. Cross-reference F744 for dementia care and services due to facility implementing personalized interventions for Resident #92's behaviors that caused resident-to-resident altercations. C. Resident #71. Resident statusResident #7, age above 65, was admitted on 9/27/22 and discharged on 7/27/23. According to the August 2023 CPO, the diagnoses included Parkinson's disease, dementia, age related osteoporosis and macular degeneration (blurred vision). The 6/1/23 MDS assessment revealed the resident was unable to conduct the BIMS assessment. She had short and long term memory problems. She was moderately impaired with her cognitive skills for daily decision making and required supervision. She had no behaviors and did not reject care. She required extensive assistance with locomotion on and off the unit, dressing, toilet use and personal hygiene. She required limited assistance with transfers, walking in the room and corridor and eating. She required supervision with bed mobility. 2. Record review The mood care plan, initiated 12/2/22 and revised 7/10/23, documented she often misunderstood the intentions of others trying to care for her. Interventions included:-Please knock, attempt to get her attention prior to entering her room;-Use the translator device or a translator to find out her needs;-Anticipate her needs;-Be patient with her as she may have trouble understanding; and,-Her vision was poor which may add to her confusion. The dementia care plan, initiated 9/27/22 and revised 7/10/23, documented the resident had dementia with behavioral disturbance, disorder of the brain, and Parkinson's. Interventions included:-Please knock and/or flip on the light switch to announce your presence;-Encourage her to make her needs known by using communication cards;-Provide visual cues as able;-Monitor her mental status for increased signs of cognitive loss;-Notify her physician of changes in cognition to rule out acute medical issues;-Include my POA in decision making;-Provide Korean interpreter as able; and,-Utilize the communication sheet hanging in her room. The resident had no further altercations. III. Resident-to-resident altercation involving Resident #4 and Resident #92 on 7/6/23A. AltercationThe 7/6/23 progress note revealed Resident #92 was wandering in and out of other resident's rooms despite frequent redirection. Resident #92 was observed leaving Resident #4's room. Resident #4 was crying and stated Resident #92 had thrown things at her and hit her in the head. There were no injuries. B. Resident #41. Resident statusResident #4, age above 65, was admitted on 12/22/22. According to the August 2023 CPO, the diagnoses included non-Hodgkin's lymphoma (cancer), essential hypertension (high blood pressure), legal blindness and history of falling. The 6/28/23 MDS assessment revealed, the resident had moderate cognitive impairment with aBIMS score of nine out of 15. She had no behaviors and did not reject care. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. She required supervision with eating. She used a walker and a wheelchair. 2. Record reviewThe mood care plan, initiated 1/9/23 and revised 7/5/23, documented the resident was adjusting to the facility and denied depression. She had shown tearfulness, verbal aggression, and other behavioral symptoms directed at others. Interventions included:-Please knock, introduce yourself, and explain the purpose of your visit;-Monitor her for alterations in mood and/or behavioral symptoms;-Attempt non-medication interventions;-Offer one-to-one visits;-Offer validation and reassurance;-Encourage her to participate in activities of her interest;-Include her family in information; and, -Notify physician in changes of mood and behavior. 3. Resident interviewResident #4 was interviewed on 8/15/23 at 11:14 a.m. She said Resident #92 entered her room and threw her kleenex box at her. She said she then used the kleenex box to hit her on the hands and head. She said she was hard of hearing and legally blind. She said when Resident #92 entered her room she would point at the wall and her words did not make sense. She said she was unable to figure out what she wanted. She said she was not afraid of her, but did not want her in her room. IV. Resident to resident altercation involving Resident #2 and Resident #92 on 7/30/23A. AltercationThe 7/31/23 progress note at 1:56 p.m. revealed a certified nurse aide (CNA) reported Resident #92 entered Resident #2's room and hit her three times in the head. There were no injuries. B. Resident #21. Resident statusResident #2, age above 65, was admitted on 12/5/17. According to the August 2023 CPO, the diagnoses included dementia, traumatic brain injury, abnormal posture, dependence on a wheelchair, mood disorder, insomnia and history of falling. The 5/9/22 MDS assessment revealed the resident had severe cognitive impairment with a brief BIMS score of five out of 15. She had behavioral symptoms not directed at others. She did not reject care. She required extensive assistance with bed mobility, transfers, locomotion off the unit, gressing, eating, toilet use and personal hygiene. She required supervision with locomotion on the unit. She used a wheelchair. 2. Record reviewThe mood care plan, initiated 3/15/18 and revised 5/18/23, revealed the resident had a history of traumatic brain injury and was intellectually challenged. She was childlike in her behaviors and abilities. Interventions included:-Please introduce yourself to her so she will know who you are;-Please encourage her to go activities;-Please make sure she goes to musical performances;-Listen to her when she talks and validate and reassure her as needed;-Include my POA in decision making;-Monitor her for in mood and/or behavior;-Notify physician in changes of mood state/behavior and rule out acute medical conditions; and,-Encourage her to visit with her family and go on outings in the community. V. Resident to resident altercation involving Resident #27 and Resident #92 on 7/30/23A. AltercationThe 7/30/23 progress note revealed Resident #92 saw Resident #27 walking with her walker. Resident #92 approached her, punched Resident #27 in the stomach and told her to hurry up. B. Resident #271. Resident statusResident #27, age above 65, was admitted on 2/7/22. According to the August 2023 CPO, the diagnoses included unspecified dementia, difficulty in walking, history of falling, anxiety disorder, muscle weakness, major depressive disorder, dependence on supplemental oxygen and bipolar disease. The 5/30/23 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She had disorganized thinking, but did not reject care. She required supervision with locomotion on and off the unit, dressing and personal hygiene. She required extensive assistance with toileting. She was independent with bed mobility, transfers, walking in the room and corridor and eating. She used a walker. She received an antipsychotic, an antianxiety, an antidepressant and a diuretic daily. 2. Record reviewThe mood care plan, initiated 2/22/22 and revised 6/7/23, revealed she had unspecified bipolar mood disorder. Her depression depended on what was going on in her life. Interventions included:-Please knock, introduce yourself, and explain the purpose of your visit;-Encourage her to participate in group activities;-When the weather was nice, encourage her to help take care of the plants on the patio;-Encourage her to take care of the plants in her room;-The psychiatrist will manage her medications;-She will participate in mental health therapy; -Track her behaviors related to medications and diagnosis;-Monitor for suicidal ideation;-Notify her physician/psychiatrist of changes in mood state and rule out acute medical issues;-Administer her medications as ordered; and,-Review her medications through the psychotropic medication committee. VI. Resident to resident altercation involving Resident #43 and Resident #92 on 7/31/23A. AltercationThe 7/31/23 progress note revealed a visitor reported Resident #92 kicked Resident #43 unprovoked. No injuries were noted and Resident #43 did not remember the incident. Residents were immediately separated. B. Resident #43 1. Resident statusResident #43, age above 65, was admitted on 1/30/23. According to the August 2023 CPO, the diagnoses included unspecified dementia, cognitive communication deficit, anxiety disorder and history of falling. The 5/9/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. He had no behaviors and did not reject care. He required extensive assistance with toilet use and personal hygiene. He required limited assistance with bed mobility, transfers, and dressing. He required supervision with locomotion on and off the unit. He was independent with eating. He used a walker and a wheelchair. 2. Record reviewThe mood care plan, initiated 2/7/23 and revised 8/14/23, revealed the resident had a diagnosis of anxiety disorder. Interventions included:-Knock and introduce yourself and reason for the visit;-Encourage him to make his needs known to staff;-Encourage him to stay busy with independent activities and group activities;-Monitor for signs and symptoms of anxiety;-Attempt non-pharmaceutical interventions; and,-Notify physician to rule out acute medical issues or conditions. VII. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/16/23 at 2:03 p.m. She said Resident #92 got violently aggressive hitting staff and residents. She said the nursing staff had a training meeting with management to discuss interventions, who to report abuse to and how to handle aggressive situations. She said all the staff discussed which interventions worked and which ones did not. She said since Resident #92 had a one-to-one sitter since 7/31/23; she seemed calmer. Registered nurse (RN) #1 was interviewed on 8/16/23 at 2:11 p.m. She said Resident #92 was violent with staff, family members and her peers. She said she had been involved in many resident-to-resident altercations and required one-to-one supervision to keep others safe. The DHIM was interviewed on 8/17/23 at 11:46 a.m. She said after the 7/6/23 altercation, Resident #92 had a part time one-to-one sitter while awake or active. She said as the weeks went on with no altercations and decreased aggression, the one-to-one sitter became as needed. She said because of the two altercations on 7/30/23, the facility hired a one-to-one sitter 24 hours a day indefinitely. The medical director was interviewed on 817/23 at 12:11 p.m. He said Resident #92 had very aggressive behavior. He said after many failed interventions, he consulted with the psychiatrist for the appropriate medication and care. He said he then started her onan anti-anxiety, an antipsychotic, an antidepressant and had aromatherapy. He said the facility was trying to find a facility to discharge her to that was a better fit. The nursing home administrator was interviewed on 8/17/23 at 1:30 p.m. She said Resident #92 was moved to a private room from her shared room on 8/11/23. She said with the two altercations on 7/30/23, Resident #92 had a one-to-one sitter that was as needed. She said the resident used the bathroom which was shared and exited through the shared door of her neighbor. She said the sitter allowed her privacy in the bathroom and was unaware she had exited through the other door. She then had the two altercations with two different individuals. She said the second door between the two rooms for the bathroom was now kept locked. She said the resident in the neighboring room required extensive assistance by two staff to toilet and the staff would unlock her bathroom door when she needed to use it. She said with the 7/31/23 altercation the one-to-one sitter had called off and the resident was then placed on every fifteen minute checks. Within the fifteen minutes she assaulted Resident #43. She said the facility put a plan in place on 7/31/23 to have a one-to-one sitter 24 hours a day indefinitely with a back up sitter if there was a call off. She said Resident #92 needed a smaller, quieter environment and the facility was looking for placement for her. She said the family was given a 30 day notice to discharge, but the family was appealing the notice. She said the facility was doing everything in their power to keep other residents safe. She said Resident #92 had not had any further altercations after implementing the sitter 24 hours a day.

Based on record review and interviews, the facility failed to provide two (#86 and #45) of two residents out of 48 sample residents with the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, the facility failed to:-Ensure resident #86 received showers according to her preferences; and, -Ensure resident #45 was provided with a functional system to meet her communication needs. Finding include: I. Activities of daily living-showering and bathing preferencesA. Facility policy and procedureThe Resident Bath Preference policy and procedure, reviewed 7/30/2020, was provided by the director of health information management (DHIM) on 8/17/23 at 4:35 p.m. It read in pertinent part, " (Facility name) ) shall honor the resident's bathing preferences. As new residents move into the Neighborhood, their bath preference will be established and the bath schedule revised to reflect their choice. At the time of each bath the resident will be asked what their preference is and it will be honored as able."B. Resident #861. Resident statusResident #86, age 68, was admitted on 6/28/21. According to the August 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, unspecified and schizoaffective disorder. The 6/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. The resident required supervision for showers and setup help only with transfers, walking in the room, dressing, toileting and personal hygiene. She was always continent of the bowel and bladder. 2. Resident interviewThe resident was interviewed on 8/16/23 at 2:25 p.m. She said she felt uncared for by staff because she wanted to receive two showers per week, however, the facility only provided her with one shower per week and it bothered her and made her feel sad. 3. Record reviewThe resident's care plan was reviewed on 8/16/23 at 4:25 p.m. The care plan revealed the resident preferred to receive a shower or bath twice per week no specific days were indicated. The resident's shower log for the last three months (6/4/23 through 8/15/23) was reviewed on 8/16/23 at 4:30 p.m. The shower log revealed the resident had received 56% of her showers (nine out of 16 showers). 4. InterviewsCertified nurse aide (CNA) #8 was interviewed on 8/17/23 at 2:08 p.m. CNA #8 said when there was a call off or the facility was short staffed by CNAs the shower aides would work the floor as CNAs and therefore some resident showers got missed when that happened. The nursing home administrator (NHA) was interviewed on 8/17/23 at 3:15 p.m. She said the issue stemmed from shower aides being pulled to the floor at times of need or when the facility was short staffed and moving forward the matter would be corrected and residents would receive their showers according to their preferences. The director of nurses (DON) was interviewed on 8/17/23 at 4:54 p.m. The DON said the facility would make an attempt to provide residents with showers according to their preferences, if the facility has enough staff to do so. In the case a resident missed their shower, as soon as staffing permits, the facility would host a make up day and all residents would be offered showers on a first come first serve basis. The DON did not provide an answer as to why the make up day was not provided to Resident #86 for her missed shower days for the past three months. II. Activities of daily living-communicationA. Facility policy and procedureThe Communication policy and procedure, updated 2/1/23, was provided by the DHIM on 8/17/23 at 4:35 p.m. It read in pertinent part, "(Facility name) will communicate with residents who do not speak English to facilitate care and quality of life. Staff will utilize pocket talkers that are located on each med cart. Native speakers either staff, friends/family, or volunteers. The iPad with the live translation app. Storyboards/picture boards and Google translate."B. Resident #451. Resident statusResident #45, age 86, was admitted on 10/25/16. According to the August 2023 CPO, diagnoses included unspecified dementia, moderate, with mood disturbance, chronic kidney disease, atrial fibrillation, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral, primary open-angle glaucoma, bilateral, mild stage and chronic diastolic (congestive) heart failure. The 6/20/23 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score nine out of 15. The resident was primarily independent with transfers, walking in the room, dressing, toileting and personal hygiene. The resident only required setup help for bathing. She was always continent of the bowel and bladder. The MDS indicated the resident's preferred language was English and the resident did not require an interpreter.-However, the resident did not understand English well (see interview below). 2. Resident InterviewThe resident was interviewed on 8/14/23 at 10:29 a.m. She said when staff talked to her she did not understand them because she did not understand English well and she preferred having a translator that spoke Tagalog. Because the resident did not understand the staff she laughed at them. The resident said she felt that she did not do things at the facility or talk to anybody (staff and residents) effectively because staff did not provide language assistance. The resident said she did not understand any reading material and or activities provided to her at the facility, therefore she watched television that was in English or Spanish and that was difficult for her to understand but she did her best to understand. She said she always complained to staff however staff were never able to respond to her. The resident said she felt sad because nobody understood her and she did not know why staff tried to communicate with her in Spanish. 3. Record reviewThe resident's face sheet was reviewed on 8/14/23 at 12:00 p.m. The face sheet revealed the resident's preferred language was Tagalog. The resident's care plan was reviewed on 8/14/23 at 12:30 p.m. The care plan revealed "the resident can speak several languages but never learned to read. The resident can speakEnglish,but needed to be reminded. If you ask me a direct question about my needs, I will tell you. Otherwise, I don't initiate making my needs known. My hearing is slightly impaired without amplification, I may have difficulty in some environments and because of the language barrier, I may need information repeated. I also have some word finding difficulty, but I am usually understood, and I usually understand others." -No interventions were listed to ensure the language line was utilized and or any communication assistance to ensure the resident was able to convey her needs and or for the resident to understand staff. E. InterviewsRegistered nurse (RN) #3 was interviewed on 8/16/23 at 1:52 p.m. She said the resident was Filipino and spoke some English, however, there was a Filipino staff that helped communicate with the resident; however, if the staff was not present or available then the staff would speak to the resident in English but at times RN #3 did not understand the resident and was uncertain if the resident understood her. RN #3 said she did not know why some staff spoke Spanish to the resident because the resident would not understand. RN #3 said the facility had translation resources available for use, however, she never used it and she did not know how to use the device and that the device did not work right. CNA #7 was interviewed on 8/16/23 at 1:59 p.m. CNA #7 said she tried to find staff that speak Tagalog to speak to the resident to make sure the resident understood her and she understood the resident because the resident only spoke and understood a little bit of English. If staff did not speak the resident's language then CNA #7 would obtain the translator and was what staff should have done in the first place. CNA #7 said the resident should have a picture book to help her communicate with staff as other residents in the building had them and it was a helpful resource. CNA #8 was interviewed on 8/16/23 at 2:07 p.m. She said the resident spoke a little bit of English, however she used Spanish as well to communicate with the resident since that was the resident's native language, however, sometimes the resident did not understand her. In the instance the resident and CNA #8 did not understand each other CNA #8 would find Spanish speaking staff to translate for the resident. CNA #8 said she was not sure if the facility had translation services in place and therefore never used them. The minimum data set (MDS) coordinator was interviewed on 8/17/23 at 10:06 a.m. She said the resident's native language was Gaelic, however, after further review of the resident's MDS assessment she said the resident's native language was English and then said she spoke Tagalog as well. The MDS coordinator completed the MDS in English with the resident because the resident spoke and understood simple English. The social services director (SSD) was interviewed on 8/17/23 at 10:39 a.m. She said the resident's native language was Tagalog and the resident understood basic English but for more complex conversations or questions the resident would need an interpreter. Staff should use an interpreter whenever they spoke to the resident especially if they did not understand the resident. The SSD said a good idea would be for social services staff to be part of orientation especially when a resident was admitted with English as a second language to ensure staff knew the resources they have available to them.

Based on observations, record review and interviews, the facility failed to ensure one (#158) residents out of two who required respiratory care received the care consistent with professional standards of practice out of 48 sample residents. Specifically, the facility failed to for Resident #158:-Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine;-Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #158's CPAP;-Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of the CPAP; and,-Ensure staff was properly trained to use the CPAP sanitizing chamber. Cross-reference to F726 failure to train nursing staff on the care and use of the CPAP.Findings include:I. Facility policies and proceduresThe CPAP/BiPAP Non-Invasive Ventilation policy, revised 12/21/21, was provided by the director of health information management (DHIM) on 8/15/23 at 3:18 p.m. The policy revealed in parts: "The CPAP provides respiratory support for residents to promote adequate sleep to improve energy levels and heart health for those diagnosed with obstructive sleep apnea (OSA)."A physician's order must specify the type of mask needed, if supplemental oxygen was to be used, equipment settings, when to use the equipment, and if humidification was appropriate. "Follow manufacturers instructions for:-daily cleaning of the mask or nasal pillows; -routine cleaning of the machine's chamber, tubing and straps as applicable; and,-replacement of supplies as needed."The care plan would include:-physician's orders and indication for use (to include equipment settings); -assessment of the resident's respiratory status as needed;-Monitor response to CPAP therapy; and,-when to use the equipment and humidification as appropriate."Documentation would include:-type of equipment and settings;-date and time CPAP was administered; and,-any intolerance or complications, actions taken, and resident's reaction as needed." II. Manufacturer recommendationsAccording to https://cpapx.com/, retrieved 8/23/23, it read in pertinent part," after initial set up, the sanitizing chamber cleans the mask, headgear, tubing and humidifier chambers quickly and conveniently without disassembly. Upon awakening, place the mask with headgear into the cleaning chamber. The lid should be left on the unit securely for at least two hours after the initial cleaning cycle for proper sanitation." III. Resident #158A. Resident statusResident #158, age above 80, was admitted on 8/2/23. According to the August 2023 computerized physician orders (CPO), the diagnoses included acute kidney failure, obstructive sleep apnea, morbid obesity, hypertension (high blood pressure) and specified heart block. The 8/4/23 MDS assessment revealed, the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He had no behaviors and did not reject care. His functional abilities had not been assessed. -The use of the CPAP was not triggered/coded on the MDS assessment under section O.B. Resident interviewThe resident was interviewed on 8/14/23 at 12:14 p.m. He said he always took the CPAP mask off when he woke up and placed it over the machine on the nightstand. He said he did not know when the tubing was last changed or when the machine had last been cleaned. C. ObservationsThe CPAP was observed on 8/14/23, 8/15/23 and 8/16/23 on the resident's night stand next to the bed. The CPAP mask and tubing was laying over the CPAP machine and not stored in a plastic bag to avoid contamination of the mask. D. Record reviewThe August 2023 CPO did not include any orders related to the CPAP settings, cleaning, disinfecting, or storage. There was no care plan initiated for the use of the CPAP. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed 8/16/23 at 2:03 p.m. She said the nurse was responsible for the storage and care of the CPAP. She said she did not know how the CPAP should have been stored. She said Resident #158 kept the CPAP next to his bed on the nightstand and the mask and tubing hung over the machine. She said the morning shift cleaned it once a week, but did not know what it was cleaned with. Registered nurse (RN) #1 was interviewed on 8/16/23 at 2:11 p.m. She said all CPAP machines should have a physician's order and care planned. She said it was kept at bedside and stored in the sanitizing chamber compartment. She observed Resident #158's CPAP machine and acknowledged the mask and tubing laying over the CPAP machine. She said it should have been stored in the sanitizing machine. She attempted to store the mask and tubing into the sanitizer. However, she did not know how to use the machine. The resident showed her how to place the mask and tubing into the sanitizer and explained to her that it could not be opened for three hours. He said the green light would indicate when it could be opened and used. RN #1 siad the staff should have had training on how to sanitize and clean the CPAP as well as the settings. She said when she admitted the resident, she should have called the respiratory company to assess the CPAP and its settings. The nursing home administrator (NHA) was interviewed on 8/17/23 at 3:10 p.m. She said all CPAP use should have a physician's order, identified on the MDS assessment and have a care plan. She said nursing should have been trained on the CPAP machine and the sanitizing machine.

Based on observations, interview and record review, the facility failed to ensure nursing staff were able to demonstrate competence in skills and techniques necessary to care for residents who required the use of a continuous positive airway pressure (CPAP) machine as identified in the resident assessment. Specifically, the facility failed to provide training to the nurses on the cleaning, sanitizing and storage of CPAP machines. Cross-reference to F695 respiratory care. Findings include:I. Facility policy and procedureThe Employee Training policy updated 7/25/19, was provided by the director of health information management (DHIM) on 8/17/23 at 5:43 p.m. The policy revealed in pertinent part:"It is the policy to ensure all staff are well trained and competent employees need to replenish their knowledge and acquire new skills to do their jobs better. This would benefit both the employees and the residents who are served."The staff development coordinator or department managers will develop training checklists and competencies to cover all aspects of an employees job description and expectations for performance and will ensure that all staff meet the establishments requirements to perform their duties. Training and competencies will be added as new issues are identified, with new regulations or new equipment are utilized."II. ObservationsRegistered nurse (RN) #1 was observed entering room 201. She said the CPAP mask and tubing was not stored properly. She attempted to store the CPAP mask and tubing into the sanitizing machine and was stopped by the resident. She did not know how to use the machine. The resident showed her how to place the mask and tubing into the sanitizer and explained to her that it could not be opened for three hours. He said the green light would indicate when it could be opened and used. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed 8/16/23 at 2:03 p.m. She said the nurse was responsible for the storage and care of the CPAP. She said she did not know how the CPAP should have been stored. The resident kept the CPAP next to his bed on the nightstand and the mask and tubing hung over the machine. She said the morning shift cleaned it once a week, but did not know what it was cleaned with. RN #1 was interviewed on 8/16/23 at 2:11 p.m. She said the nursing staff should have had training on how to sanitize and clean the CPAP as well as the settings. She said when the resident admitted, she should have called the respiratory company to assess the CPAP and its settings. The nursing home administrator (NHA) was interviewed on 8/17/23 at 3:10 p.m. She said all CPAP use should have a physician's order, identified in the minimum data set assessment and have a care plan. She said the nursing staff should have been trained on the CPAP machine and the sanitizing machine.

Based on record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for dementia care of 48 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #92 to prevent resident-to-resident altercations and address repeated behavioral issues which created an environment where abuse persisted. Findings include:I. Facility policy and procedureThe Dementia Care policy, revised 11/2/22, was provided by the the director of health information management (DHIM) on 8/16/23 at 9:15 a.m. The policy revealed in pertinent part: "Proving care that is focused on what each resident needs to maintain dignity and a positive sense of self. Tailoring personal care approaches, meal service, and activities to the individual by paying close attention to past life history, as well as current functional and cognitive level."II. Resident census and conditionsThe 8/14/23 resident census and conditions documented 59 residents who had a diagnosis of dementia. The facility census was 104 residents. III. Resident #92A. Resident statusResident #92, age above 65, was admitted on 5/7/22. According to the August 2023 computerized physicians orders (CPO), the diagnoses included unspecified dementia severe with anxiety, severe agitation, severe with other behavioral disturbances, anxiety disorder and major depressive disorder. The 5/21/23 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status (BIMS). She had short and long term memory problems. She was short tempered and easily annoyed. She required supervision with transfers, walking in room and corridor, locomotion on and off the unit, dressing and personal hygiene. She was independent with bed mobility, toilet use and eating. She had no behaviors and did not reject care. No antipsychotics were received. B. Record reviewThe mood care plan, initiated 5/8/22 and revised 8/15/23, documented the resident had a history of anxiety and restlessness. She wandered aimlessly into other resident's rooms and went through their belongings. She may become combative with staff and residents at times. The interventions included:-Please knock, introduce yourself, and explain the purpose of your visit;-Encourage resident to tell staff her needs/wants;-Encourage the resident to participate in activities;-Monitor resident for depressive symptoms;-Attempt non-pharmacological interventions as able;-Notify physician of change in mood;-Track residents anxiety;-Review residents medication for efficacy and /or possible decreases; and,-When the resident wanders into another resident's room, walk with her to redirect to her room. The dementia care plan, initiated 5/8/22, documented the resident's dementia was progressing and often wandered into other resident's rooms. She was at risk for being injured or verbally abused by other residents. She may become combative and agitated when she interacted with other residents or staff. The interventions included:-Please knock, introduce yourself, and explain the purpose of your visit;-Please listen to what she has to say;-Provide encouragement and validation as needed;-Provide cues and reminders as needed;-Encourage resident to make her needs/wants known;-Encourage her to attend activity groups that interest her;-Notify physician of changes in her cognition to rule out acute medical issues;-Include her power of attorney (POA) in decision-making;-Redirect her with her favorite foods when able; and-Loud noises could be irritating to her, attempt to keep her in a quiet environment. The aggressive behavior care plan, initiated 7/31/23 and revised 8/15/23, documented the resident had incidents of aggressive behaviors towards other residents. The interventions included:-She had been provided a 24 hour sitter; -She received a 30 day notice for alternate placement;-Monitor and document her aggressive behaviors;-Notify physician of her aggressive behaviors;-Provide one-to-one social services visits;-Provide one-to-one life enrichment visits;-Assure that there is no medical reason for her aggressive behaviors; and,-Administer medications as ordered. Resident #92 was involved in five resident to resident altercations in two months, where she was the aggressor. The preceding factor to most of the altercations was the resident wandered into another resident's room or space. According to the June 2023 to August 2023 progress notes the resident continued to wander into other resident rooms daily.-The facility failed to prevent and identify why the resident continued to wander into other resident rooms and failed to prevent the residents from abuse. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/16/23 at 2:03 p.m. She said Resident #92 got violently aggressive hitting staff and residents. She said the nursing staff had a training meeting with management to discuss interventions, who to report abuse to, and how to handle aggressive situations. She said all the staff discussed which interventions worked and which ones did not. She said since Resident #92 had a one-to-one sitter since 7/31/23, she seemed calmer. Registered nurse (RN) #1 was interviewed on 8/16/23 at 2:11 p.m. She said Resident #92 was violent with staff, family members and her peers. She said she had been involved in many resident to resident altercations and required one-to-one supervision to keep others safe. The DHIM was interviewed on 8/17/23 at 11:46 a.m. She said after the 7/6/23 altercation, Resident #92 had a part time one-to-one sitter while awake or active. She said as the weeks went on with no altercations and decreased aggression, the one to one sitter became as needed. She said because of the two altercations on 7/30/23, the facility hired a one-to-one sitter twenty four hours a day indefinitely. The medical director was interviewed on 817/23 at 12:11 p.m. He said Resident #92 had very aggressive behavior. He said after many failed interventions, he consulted with the psychiatrist for the appropriate medication and care. He said she was then started her on an anti-anxiety, an antipsychotic, an antidepressant, and aromatherapy. He said the facility was trying to find a facility to discharge her to that was a better fit. The nursing home administrator was interviewed on 8/17/23 at 1:30 p.m. She said Resident #92 was moved to a private room from her shared room on 8/11/23. She said the two altercations on 7/30/23, Resident #92 had a one-to-one sitter. She said the resident used the bathroom, which was shared and exited through the shared door of her neighbor. She said the sitter allowed her privacy in the bathroom and was unaware she had exited through the other door. She then had the two altercations with two different individuals. She said the second door between the two rooms for the bathroom was now kept locked. She said the resident in the neighboring room who required extensive assistance by two staff to toilet and the staff would unlock her bathroom door when she needed to use it. She said with the 7/31/23 altercation the one-to-one sitter had called off and the resident was then placed on every 15 minute checks. Within the 15 minutes she assaulted Resident #43. She said the facility then put in place a plan to have a one-to-one sitter 24 hours a day indefinitely with a back up sitter if there was a call off. She said Resident #92 needed a smaller, quieter environment and the facility was looking for placement for her. She said the family was given a 30 day notice to discharge, but the family was appealing the notice. She said the facility was doing everything in their power to keep others safe. She said Resident #92 had not had any further altercations since the one-to-one sitter had been implemented 24 hoursa day.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance and temperature. Findings include:I. Resident interviewsResident #45 was interviewed on 8/14/23 at 10:51 a.m. Resident #45 said the rice was always hard. Resident #45 said she had complained but they had not fixed the concern or had offered an alternate food choice. Resident #5 was interviewed on 8/14/23 at 12:09 p.m. Resident #5 said the evening meal was not palatable. For an alternative they always give you peanut butter and jelly, yogurt or ice cream. Resident #50 was interviewed on 8/14/23 at 3:40 p.m. Resident #50 said sometimes the food was served cold, eggs especially. The hot plate worked too well and ended up toasting the bottom piece of bread until it was very hard. Resident #54 was interviewed on 8/14/23 at 3:24 p.m. Resident #54 said the food was horrible and bland. It did not have any spice. The resident group interview was held with four residents (#103, #69, #36 and #64) on 8/15/23 at 1:57 p.m. Several residents had concerns with food palatability. The residents said the pork was tough and the vegetables were too soft. Resident #71 was interviewed on 8/17/23 at 10:57 a.m. Resident #71 said she did not like the dinner meal, she had to discard the bread and the green beans were tough and she could not chew them. Resident #71 said if they had offered a different choice for dinner she would have ordered that instead. Resident #71 said she was unable to eat most of the mealResident #209 was interviewed on 8/17/23 at 11:10 a.m. Resident #209 said she had a mechanically soft hamburger which was ground up meat, with french fries and soup. Resident #209 said she ate the hamburger but the french fries were cold and she did not like the soup because it was watery and bland. Resident #91 was interviewed on 8/17/23 at 11:22 a.m. Resident #91 said she did not eat bread or cheese. Resident #91 said she ate the tuna out of the sandwich and left the rest. Resident #91 said she did not like the meal and would have liked a substitute. Resident #45 was interviewed on 8/17/23 at 11:32 a.m. Resident #45 said she liked to eat her rice and soup together at a meal but the soup did not taste good and she was unable to eat it. Resident #54 was interviewed on 8/14/23 at 3:24 p.m. Resident #54 said the food was horrible. She said she did not eat the food other than eating the soup for lunch and dinner. II. Food Committee MinutesReview of the Food Committee Minutes from 5/2023 to 8/2/23 revealed the following concerns about the palatability of food:-The minutes from May 2023 (no date) revealed the soups were salty, greasy, bland and too thin. The broccoli was overcooked.-The minutes from 6/7/23 revealed the soup was salty, food over seasoned, three bean salad was mashed up and used relish, broccoli overcooked, green beans too long and they served too many carbs (such as bread, rice, potatoes). -The minutes from 7/5/23 revealed that some of the meat was difficult to chew, they served mashed potatoes too much, the meats were repetitive and melon and mandarin oranges were served too often.-The minutes from 8/2/23 revealed one resident was being served items she was allergic to, the french fries were always cold and another resident did not eat the soup because of the food combinations in them. The resident said the soups tasted like they were made with leftovers. IV. Test trayA test tray was evaluated on 8/16/23 at 6:30 p.m. by two surveyors. The meal was the alternate choice of chicken fingers, pasta salad, french fries, broccoli soup and watermelon. The test tray was received after the last resident was served on the South unit. The temperatures were as follows: -The chicken fingers were 119 degrees F. The chicken fingers were warm to the palate, crunchy, overcooked and difficult to eat. -The french fries were 107 degrees F. The french fries were warm to the palate and hard.-The pasta salad was bland and had little taste. The pasta salad was served in a four ounce disposable plastic container. -The broccoli soup was warm to the palate, the consistency was thin and bland in taste and the broccoli was scant. The watermelon for dessert was fresh and tasty. -No condiments were served with the chicken. During the meal service, only a few residents received ketchup, but otherwise no condiments. V. Staff interviewsThe culinary supervisor (CS) and the nutrition services supervisor (NSS) were interviewed on 8/17/23 at 4:13 p.m. The NSS said that she had heard of complaints on the meal in regards to being served cold. The NSS said if a meal was served to a resident cold then it needed to be reheated outside of the kitchen or discarded and a new hot meal should have been served to the resident. The CS said the facility had a food committee which was held monthly. He said that it was a forum to help with the food concerns. He said there had been some turnover in the kitchen and they were working on the palatability of the food. The CS said that the soup was made in the kitchen. The CS said that he did not taste the broccoli cheese soup. He said the food should be tasted to ensure palatability.

Based on observations, record review and interviews; the facility failed to provide each resident with a nourishing, well balanced diet that meets his or her nutritional and special dietary needs, taking into consideration the allegations and preferences of each resident for four (#71, #209, #91 and #53) out of 48 sample residents. Specifically, the facility failed to ensure Residents #71, #209, #91 and #53 were provided food that accommodated their food dislikes and preferences. Findings include:I. Resident interviews, observations and record reviewA. Resident #711. ObservationOn 8/16/23 at approximately 6:00 p.m., an unidentified certified nurse aide (CNA) approached the kitchen window and said Resident #71 requested an alternate vegetable because she did not like nor could chew the green beans. Dietary aide (DA) #2 said she was unable to give Resident #71 a different vegetable because there was no alternative to the green beans. 2. Record reviewResident #71's food selection ticket revealed the resident had no dislikes but had a regular mechanically soft diet. B. Resident #531. Record reviewResident #53's food selection ticket revealed the resident disliked fish and had a regular pureed diet. 2. ObservationAt 5:40 p.m. Resident #53's meal ticket documented she did not like fish and required a pureed meal. The resident was served a pureed tuna melt sandwich. DA #2 was interviewed and said they only had fish for Resident #53. DA#2 said the last time Resident #53 was served fish, she ate it. Resident #53 did not receive soup. At 6:11 p.m. Resident #53 had not eaten and a CNA went to assist Resident #53 as requested by the nursing home administrator (NHA). The CNA did not attempt to reheat the food nor obtain a new meal from the kitchen for Resident #53. The resident consumed less than 15% of her meal. C. Resident #2091. Observation and record reviewOn 8/16/23 at approximately 5:30 p.m. Resident #209 was served the tuna melt sandwich, her ticket read she did not like fish. 2. Resident interviewResident #209 was interviewed on 8/17/23 at 11:10 a.m. Resident #209 said she was initially given a tuna melt for dinner. Resident #209 said she did not like fish. Resident #209 said the staff did not offer a substitute and Resident #209 had to request an alternate food choice. Resident #209 said she had a mechanically soft hamburger which was ground up meat, with french fries and soup. D. Resident #911. Record reviewOn 8/16/23 at approximately 6:00 p.m. Resident #91 was served the tuna melt sandwich, her ticket read she did not eat cheese or bread. 2. Resident interviewResident #91 was interviewed on 8/17/23 at 11:22 a.m. Resident #91 said she did not eat bread or cheese. Resident #91 said she ate the tuna out of the sandwich and left the rest. Resident #91 said she would have preferred an alternative to the tuna melt but was not offered one. She said she would prefer to have eggs as an alternative at all meals but they had denied her that alternative for lunch and dinner. II. Food committee minutesReview of the Food Committee Minutes from May 2023 to 8/2/23 revealed the following concerns about the palatability of food:-The minutes from May 2023 (no date) revealed almond milk was substituted for lactose free milk. The sugar substitute was Splenda.-The minutes from 6/7/23 revealed the kitchen was starting to do lighter foods during the dinner meal.-The minutes from 7/5/23 revealed they substituted baked sweet potato instead of mashed potatoes. They substituted berries for melon.-The minutes from 8/2/23 revealed one resident was being served items she was allergic to and another resident revealed he kept getting food from his dislike list. III. Additional observationsDuring dinner observation in the first floor dining room on 8/16/23 from 5:20 p.m. to 6:25 p.m. revealed the following:-During meal service only a handful of tickets were completed with resident meal choices for dinner. The majority of tickets did not have check marks or highlighted food choices for the resident's dinner.-Resident #81 required a mechanically soft diet and was served chicken strips by DA #2. The resident had requested the alternative meal of chicken strips. However, the tray line did not have the mechanical soft chicken strips, so the resident had to wait for his meal until it could be prepared. The resident requested soup, however, it was not served. IV. Staff interviewsDA #3 was interviewed on 8/16/23 at 2:23 p.m. DA #3 said the resident would let the DA know they preferred an alternate food choice when the DA took their meal order. The DA would write the resident's alternate choices on the meal ticket. When served, if the resident did not receive the alternate food choice or did not want what they ordered, the DA should call the kitchen for an alternate food choice and it would be brought up for the resident. DA #1 was interviewed on 8/16/23 at 3:43 p.m. DA #1 said he visited each resident on the third floor daily between 2:00 to 4:00 p.m. and took the resident orders for the following day. Each resident had an individualized ticket which included the menu, the resident's diet, dislikes and preferences. The resident's orders were written on their ticket along with any alternate food choices. DA #1 said the residents were asked daily about their dislikes and preferences. If a resident's preferences changed it was put into the system and the tickets were updated. The tickets were updated weekly with the menu and printed out daily. DA #2 was interviewed on 8/16/23 at 5:43 p.m. during meal service. DA #2 said if the resident's meal ticket did not have any check marks on it indicated the resident got the regular meal. The nutrition services supervisor (NSS) was interviewed on 8/17/23 at 4:13 p.m. The NSS said when Resident #53 pureed meal included something she disliked the kitchen should have been called for an alternate pureed meal for the Resident #53. The NSS said when Resident #53's meal sat for 30 minutes prior to being eaten, the meal should have been heated up outside of the kitchen or discarded and replaced with hot food from the kitchen. The NSS said DA staff should have not given Resident #81 regular chicken strips and should have been given a mechanically soft food choice. The NSS said the DA staff needed to be trained again. The NSS said the DA #2 did not take the resident's orders for the dinner meal on 8/16/23. Therefore, the majority of the tickets were not marked with the resident's meal choices. The meal tickets should identify what meal choice the residents requested along with any alternate meal choices. The NSS said when Resident #71 requested an alternate vegetable, DA #2 should have called the kitchen for an alternate vegetable. The NSS said the DAs should offer the residents soup if it was not marked on the resident's ticket. If the resident refused the soup, then an alternate food choice should have been offered.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner to prevent food-borne illness. Specifically, the facility failed to ensure: -Holding temperatures were appropriate;-Moisture was not between stacked pans;-Appropriate sanitation of utensils, lids and thermometers; and,-Appropriate sanitation of food coolers on resident floors. Findings include:I. Holding temperatures A. Professional referenceThe Food and Drug Administration (FDA) Food Code (2019) p. 441, "When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated. It is especially effective in reducing the numbers of Clostridium perfringens (C. perfringens) that may grow in meat, poultry, or gravy if these products were improperly cooled. Vegetative cells of C. perfringens can cause foodborne illness when they grow to high numbers. Highly resistant C. perfringens spores will survive cooking and hot holding. If food is abused by being held at improper holding temperatures or improperly cooled, spores can germinate to become rapidly multiplying vegetative cells."The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; "The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control."B. ObservationsObservations of the dinner meal in the first floor kitchen and dining area were conducted on 8/16/23 from 5:20 p.m. to 6:25 p.m.-At 5:20 p.m. dietary aide (DA) #2 took the temperatures of the tuna melt sandwiches. The tuna melt sandwiches were in a large pan stacked four high. The temperature was 111.3 degrees Fahrenheit (F).-At 5:20 p.m. DA #2 took the temperature of the chicken tenders which were in a small eighth sized pan. The temperature was 119 degrees F. -At 5:20 p.m. DA #2 took the temperature of the french fries which were in a small eighth sized pan. The temperature was 107 degrees F. -Between 5:30 and 6:25 p.m. DA #2 served the tuna melt, chicken tenders and french fries to the resident's without re-heating them to 165 degrees F. -At 5:53 p.m. DA #2 reheated food a resident's family brought into the kitchen from the outside. DA #2 did not know that to prevent food borne illnesses the proper temperature to reheat the food was to 165 degrees F and DA #2 reheated the food to 141 degrees F. DA #2 then reheated the food to 175 degrees F with prompting from the nursing home administrator (NHA) and attempted to serve it but was stopped by the NHA as it was soup. DA #2 said soup should not be served at any higher than 160 degrees F to avoid burns.-The tomato soup was served in individual bowls. The soup was sitting with no mechanism to keep it at the appropriate temperature from 5:20 p.m. until it was served at approximately 6:00 p.m.-The food temperatures at the end of the meal were chicken tenders at 119 degrees F, the broccoli cheese soup at 127 degrees F and french fries at 107 degrees F. C. Record ReviewThe menus for cream of broccoli soup and chicken tenders were received on 8/17/23 from the nursing home administrator (NHA) at 11:45 a.m. The menu for the cream of broccoli soup revealed the soup must maintain a minimum temperature of 135 degrees F or 140 degrees F during the entire service period. The product should be kept covered whenever possible. The menu for chicken tenders revealed at the completion of cooking, the internal temperature must reach 165 degrees F for 15 seconds. The finished product must maintain a minimum temperature of 135 or 140 degrees F during the entire service period. The product should be kept covered whenever possible. The temperature of the unserved product should be taken and recorded every 30 minutes. D. InterviewsThe nutrition services supervisor (NSS) was interviewed on 8/17/23 at 4:13 p.m. The NSS said the temperature on the steam table should be between 140-165 degrees F with the lowest temperature being 135 degrees F. The NSS said DA #2 should have either put the food in the microwave or had the main kitchen reheat the food before serving it to the residents. II. Moisture in pansA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; "Unless used immediately after sanitization, all equipment and utensils shall be air-dried. Towel drying shall not be permitted. Utensils that have been air-dried may be polished with cloths which are maintained clean and dry."B. ObservationsOn 8/16/23 at 2:12 p.m. moisture was observed between pans stacked seven high for quarter size pans,13 high for quarter size pans and stacked four high for eighth size pans. On 8/17/23 at 4:01 p.m. with the culinary manager (CM) moisture was observed between pans stacked six high for quarter size pans. C. Staff interviewsThe CM was interviewed on 8/17/23 4:01 p.m. The CM said the pans should not have moisture between them and should be air dried to ensure bacteria did not grow. He took the pan and placed it on a table to be air dried. III. Inappropriate sanitation of utensils, lids and thermometers. A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised January 2019, read in pertinent part, "equipment food -contact surfaces and utensils shall be clean to sight and touch."Equipment food -contact surfaces and utensils shall be cleaned:(1) before each use with a different type of raw animal food such as beef, fish, lamb, pork, or poultry;(2) Each time there is a change from working with raw foods to working with ready-to-eat foods;(3) Between uses with raw fruits and vegetables and with time/temperature control for safety food;(4) Before using or storing a food temperature measuring device; and(5) At any time during the operation when contamination may have occurred."B. ObservationsOn 8/16/23 the following observations were made during the evening meal on the first floor kitchen and dining room between 5:20 p.m. and 6:25 p.m.-At the beginning of service, DA #2 dropped the soup lid into the soup, took it out and rinsed it in the sink and placed it back on the soup container.-During service, DA #2 used a cutting knife to cut oranges and then rinsed it off in the handwashing sink to be used again. She placed it directly onto the counter, where she had placed the food temperature notebook. -DA #2 did not clean the thermometer prior to placing the thermometer in the bowl of soup. The thermometer did not have a cover. C. InterviewsThe NSS was interviewed on 8/17/23 at 4:13 p.m. The NSS said when DA #2 dropped the soup lid into the soup DA #2 should have gone down to the kitchen to have it washed and sanitized in the dishwasher. When DA #2 needed a clean knife, DA #2 should have put that knife aside and gotten a clean knife or had it washed and sanitized in the dishwasher. When DA #2 took the temperature of the soup, she should have used a clean wipe to wash the thermometer prior to putting it into the soup. It should have been cleaned after the temperature was taken and a cover should have been placed on the thermometer. V. Inappropriate sanitation of food coolers on resident floorsA. Facility policyThe Cleaning Hydration Ice and Snack Care, dated January 2015, was received on 8/17/23 at 2:43 p.m. from the NHAThe policy reads in pertinent part "Hydration ice and snack carts are scheduled to be cleaned daily by 10:30 a.m. by a certified nurse aide (CNA) and again by passing snacks by 3:30 p.m. This will be logged every time in the appropriate log book."Clean the inside of the ice container. Remove ice and water, discard in the sink in the galley. Use appropriate sanitizer with a clean rag on the inside of the ice container. Wipe the inside of the ice container with a clean rag and clear water."B. ObservationsOn 8/17/23 the ice container on the third floor was observed at 3:46 p.m. the cooler was on a cart in the corner of the dining room. C. InterviewsCNA #10 was interviewed on 8/17/23 at 3:23 p.m. CNA #10 said he thought the coolers were cleaned by the janitorial staff. CNA #10 said he sometimes washed the coolers if they did not look clean. CNA #10 said he washed them out with a clean cloth and dawn dishwashing liquid and dried them inside and out with a clean cloth from the supply closet. CNA #11 was interviewed on 8/17/23 at 3:27 p.m. CNA #11 said she did not know who cleaned the cooler on the floor. The NSS was interviewed on 8/17/23 at 4:13 p.m. The NSS said that she was not familiar with the cleaning of the hydration ice chest, but she thought they were washed in the kitchen, but not sure if in the dishwasher or three compartment sink.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to:-Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails);-Ensure surface disinfectant times were followed; and, -Ensure staff engaged in hand hygiene between providing care to two residents. Finding include: I. Housekeeping failuresA. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 821/23 revealed in pertinent part: "High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment." The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 8/21/23 read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include:-bedrails-IV (intravenous) poles-sink handles-bedside tables-counters-edges of privacy curtains-patient monitoring equipment (keyboards, control panels)-call bells-door knobs"Proceed From Cleaner To DirtierProceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include:-During terminal cleaning, clean low-touch surfaces before high-touch surfaces.-Clean patient areas (patient zones) before patient toilets.-Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone.-Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. Facility policy and procedureThe Housekeeping Services policy and procedure, undated, was provided by the director of health information management (DHIM) on 8/17/23 at 4:35 p.m. It read in pertinent part, "It is the policy of the facility that the workplace will be maintained in s sanitary,orderly and safe condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. It is the purpose to provide standard operation procedures for a clean, safe and sanitary environment for residents."1. Doorknobs, handrails, bath rails, sink handles, and surfaces will be cleaned at least once daily and more often as needed, especially important during an outbreak. 2. Cleaning of walls, curtains, blinds, will be done when dust/soil is visible and placed on a terminal cleaning program. 3. Daily damp high dusting will be done to minimize aerosolization of dust particles. 4. Upholstered furniture or cloth furniture should be vacuumed routinely to reduce dust and allergens (unless resident is immunocompromised with preexisting lung condition ( asthma. In the case of immunized residents, minimizing the use of upholstered furniture is recommended). 5. Privacy curtains should be changed when visibly dirty and should be laundered or disinfected with an Environmental Protection Agency (EPA)-registered disinfectant per the curtain and disinfectant manufacturer's instructions."Regular cleaning and dusting of housekeeping surfaces with soap and water is sufficient for general housekeeping surfaces. "Cleaning and disinfecting schedules include: High Touch Surfaces -Beds -Bed rails -Bedside table -Call button -Call button in the bathroom -Chair -Closet handles -Door handles -Handrails -Ledges -Light cords -Light switch -Soap dispenser and sink -Telephone -Telephone cord -Toilet -TV remote -Trash can -Walls -Wheel chairs -Window blinds and window sills." C. Manufacturer recommendations The disinfectant in the facility was identified as:Waxie Solsta 200 General Purpose CleanerThe product label was reviewed which read in pertinent part, "Select appropriate dispensing mode, bottle or bucket fill, press button and fill. Sweep, dust mop or vacuum floors to remove loose dirt prior to cleaning. Use an auto scrubber or swing machine with light cleaning (white or red) pads, machine brushes, or WAXIE Fast Glide Mopping System for daily floor cleaning. Apply solution to floor. Allow dwell time. Agitate and pick up soiled solution. It may be necessary depending on soil load to double scrub the surface. Rinse the surface thoroughly after cleaning. Use unheated tap water. For surfaces other than floors, apply with a WAXIE yellow microfiber cleaning cloth, bottle with course or foam-type trigger sprayer. Agitate and/or wipe clean as needed. No rinsing is required. Use unheated tap water."Purell Healthcare Surface Disinfectant SprayThe product label was reviewed which read in pertinent part, "Formulated for convenience and ease-of-use, Purell Healthcare Surface Disinfectant Spray has powerful germ-kill on the surfaces people touch most - yet is gentle enough to use around sensitive patients. Designed to accelerate the germ-killing power of alcohol, the patented fragrance-free formulation disinfects without harsh chemicals. It's mild around staff and patients and provides a better overall experience. This powerful formulation has the EPA's lowest allowable toxicity rating and delivers the fastest overall disinfection time of any Design for the Environment (DfE) product. Compatible with both hard and soft surfaces, it eliminates 99.9 percent of viruses and bacteria on surfaces - including norovirus, MRSA (Methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant enterococci), and human coronavirus in 30 seconds with no rinse required."D. ObservationsOn 8/17/23 housekeeper (HSKP) #1 was continuously observed cleaning rooms #101, #102, #104, #133, #134 and #135 from 10:20 a.m. to 12:00 p.m. HSKP #1 wiped the surfaces in each room with a cloth that she sprayed with the cleaning product (not a disinfectant) and then diluted the cleaning product by rinsing the cloth with water. HSKP #1 wiped surfaces in each room (sink, mirror and toilet) for five seconds per surface. The surface disinfectant was not used and therefore all surfaces in the room were not disinfected. The call lights, light switches, door handles, handrails and bathroom call lights in each room were not disinfected (see above per CDC guidelines). E. Staff interviewsHSKP #1 was interviewed on 8/17/23 at 12:05 p.m. HSKP #1 said she did not disinfect any areas in the room because she only used a surface cleaning product. HSKP #1 said she did not clean or disinfect any high touch areas in all rooms. The director of housekeeping (DOH) was interviewed on 8/17/23 at 1:05 p.m. The DOH said rooms should be cleaned top down, dirtiest to cleanest. All high frequency touch areas in the room should be disinfected daily. The DOH said surface disinfectant times should be adhered to ensure surfaces were properly disinfected and based on the deficient practice identified she needed to provide training to all housekeeping staff that covered correct resident room cleaning procedures, use of cleaning products versus disinfectant products, surface disinfectant times and high frequency touch areas. The infection preventionist (IP) was interviewed on 8/17/23 at 1:36 p.m. The IP said surface disinfectant times should be adhered to be effective in killing germs, viruses and bacteria. The IP said if the surface disinfectant time was not adhered to then a surface would not be clean or disinfected, which could lead to potential infection. High frequency touch areas should be disinfected. Cleaning agents do not disinfect surfaces but just shine them and a disinfectant would kill the bacteria and germs on a surface. II. Staff hand hygiene failures A. Facility policy and procedureThe Infection Control policy, revised 2023, was provided by the nursing home administrator on 8/17/23. It read in pertinent part, "alcohol based hand sanitizer should be used prior to and after touching a resident or the resident's immediate environment." B. Observations On 8/14/23 at 12:04 p.m., in the second floor dining room, an unidentified certified nurse aide (CNA) sat between two residents and assisted Resident #56 by using spoon, then turned to Resident #68 and used both her hands to adjust the resident's oxygen tubing on her nose. The CNA then picked up utensil and returned to using the utensil to offer food to Resident #56 without performing hand hygiene. At 12:17 p.m. the CNA continued to assist Resident #56 and Resident #68 with their meals and used both hands to assist both residents without performing hand hygiene between residents. On 8/15/23 at 11:48 a.m, the CNA picked up a utensil for Resident #56 and offered the resident food. After Resident #56 took a bite of food, the CNA then turned toward Resident #68 and with same hand picked up that resident's utensil (which Resident #68 had previously held) and offered food to the Resident #68. The CNA then used same hand to pick up utensil and offer food again to Resident #56. She did not perform hand hygiene between assisting the two residents. At 11:58 a.m., the CNA continued to use Resident #56 and Resident #68's utensils without performing hand hygiene and continued to use the same hand for both residents. At 12:03 p.m, the CNA used Resident #56's fork and offered food to her, then picked up Resident #68's fork to provide food to her (Resident #68 had previously held the fork). The CNA did not use hand hygiene between resident contacts. On 8/16/23 at 12:05 p.m. the CNA used napkin as a clothing protector and applied to Resident #2 and Resident #17. The CNA did not perform hand hygiene between resident contacts. At 12:10 p.m., an unidentified CNA used a fork to provide food to Resident #2, then turned to Resident #65 and took fork that the resident was holding and used fork to assist Resident #65 with eating. The CNA then picked up a coffee mug to offer sip of coffee to Resident #2. The CNA then used a fork to pick up food and offer to Resident #2. The CNA then used same hand (left) to pick up Resident #65's fork, after Resident #65 was holding it. The CNA failed to perform hand hygiene between resident contacts. C. Staff interviewsThe IP was interviewed on 8/17/23 at 1:36 p.m. The IP said staff should engage in hand hygiene to prevent the spread of infection and if someone had visibly soiled hands they should wash their hands with soap and water. Staff should not assist two residents with their meal at the same time. Staff should ensure they sanitize between residents and wear gloves. CNA #4 was interviewed on 8/17/23 at 1:55 p.m. The CNA said if he had to assist two residents with their meals at the same time, he would prepare both residents' trays first. He would then use a hand sanitizer between assisting residents. He would use the hand sanitizer which was provided at the table. Licenced practical nurse (LPN) # 1 was interviewed on 8/17/23 at 2:15 p.m. The LPN said there should always be one staff per resident when assisting with a meal, but if she had to assist two residents at the same time, she would make sure that she did not cross contaminate by using hand sanitizer between residents.