Every finding on record at Archway Transitional Care Center

Based on staff and resident interviews, record reviews and a review of the facility's policies titled Abuse Prohibition - Reporting and Investigating and Abuse Prohibition, the facility failed to protect one Resident's (R) (R1) right to be free from sexual abuse by a resident (R2). Additionally, the facility failed to provide adequate protection for R1 while investigating the allegation of sexual abuse by R2. The facility sample size was 18.On January 12, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), and the Divisional Nurse Consultant were informed of the Immediate Jeopardy (IJ) on January 12, 2026, at 10:47 am. The noncompliance related to the IJ was identified to have existed on December 20, 2025.An Acceptable IJ removal Plan was received on January 14, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on December 31, 2025.Findings include:Review of the facility policy Abuse Prohibition with a revision date of 4/7/2025, included the definition of sexual abuse as sexual harassment, sexual coercion or sexual assault.Review of the facility policy Abuse Prohibition - Reporting and Investigating with a revision date of 12/27/2024 documented the following procedures will be followed to protect the patient from harm during the investigation: Center will respond immediately to protect the alleged victim and integrity of the investigation; Increased supervision of the alleged victim and residents; At the discretion of the Administrative staff, room or staffing changes may be implemented, if necessary, to protect the resident(s) from the alleged perpetrator.R1 was admitted to the facility on [DATE] with the following, but not limited to diagnoses: major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, muscle weakness, and contracture of right hand.Review of the admission Minimum Data Set (MDS) assessment for R1 dated 12/23/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.R2 was admitted to the facility on [DATE] with the following, but not limited to diagnoses: insomnia, major depressive disorder recurrent severe without psychotic features, history of non-suicidal self-harm, and unspecified dementia with psychotic disturbance.Review of the five-day MDS assessment for R2 dated 12/1/2025 indicated the resident had a BIMS score of 2, indicating severe cognitive impairment.Review of the Nurses' Notes for R2 dated 12/20/2025 at 8:05 pm revealed, that Licensed Practical Nurse (LPN) AA was notified by Certified Nursing Assistants (CNA) BB and CC that the resident was standing at the bedside of his roommate with his penis out of his pants and moving his hands in an upward and downward motion while standing near the roommate. The CNAs attempted to redirect the resident, but he refused to move from R1's bedside. Staff asked R2 if he needed to use the restroom. The CNAs pointed out the restroom and attempted to show him where it was, but he refused to enter the restroom. The CNAs guided R2 back to his side of the room while pulling the privacy curtain to divide the room, but the resident snatched the curtain back and sat in a chair at his roommate's (R1) bedside. When LPN AA entered the room, R2 was sitting at the roommate's bedside. LPN AA spoke to R2 about the incident and encouraged him to go to his side of the room, and he did. She asked the resident why he had taken out his private part, and he stated, I didn't do that. The LPN asked R1 whether R2 touched him, whether he pulled his covers back, and he touched the covers, or whether he had done this before. The roommate stated, No!Review of the 12/20/2025 Nurses' Notes further noted that at 8:13 pm, the Administrator and the DON were notified concerning R2 exposing himself. At 8:22 pm, the Sheriff's Department was called. At 8:57 pm, the Sheriff's deputy arrived at the facility, and a report number was given. At 8:57 pm, the Nurse Practitioner (NP) was notified and informed of the incident, who noted initiating behavior protocol and making a psychiatrist referral. At 10:27 pm, the daughter was notified of the incident.Review of the Line of Sight Observation forms from 12/20/2025 to 12/31/2025 revealed, documentation of staff monitoring R2 once every hour.Further review of R2's clinical record revealed, a 12/22/2025 progress note from a Licensed Professional Counselor (LPC) who noted the resident denied remembering any recent inappropriate behavior. The LPC noted they reviewed with the resident the need to comply with facility rules and expectations of respecting others. The resident (R2) expressed understanding. (R2 BIMS of 2)Further review of R2's clinical record revealed, a 12/23/2025 progress note from the Psychiatric NP who noted that staff reported that the resident had exhibited inappropriate sexual behavior and was redirected appropriately and had no recent history of hypersexual behaviors. She further noted that an urinalysis was ordered to rule out a urinary tract infection, and there were no other episodes since the incident. The NP recommended no change to medications and to maintain the current medication regimen. An interview on 12/29/2025 at 12:25 pm with R1 revealed, that his roommate had sat on his bed near the foot of his bed naked from the waist down with his penis in his hand. He did not know what the resident was doing with his penis. R1 stated he told him to go and motioned for him to leave. He stated he did not report the incident to anyone and did not know whether anyone saw what happened. He stated that it was the first time it had happened and that it did not bother him. He confirmed that R2 was still residing in the room with him.An interview on 12/31/2025 at 10:10 am with LPN AA revealed that a CNA came and got her to report that R2 was standing at the chest area next to R1 with his penis out, doing an up and down motion with his hands. She stated the CNAs tried to redirect R2 back to his side of the room and pull the privacy curtain between the two beds, but R2 snatched the curtain back open. When she entered the room, R2 was sitting in a chair on R1's side of the room. With much encouragement, R2 finally went back to his side of the room. She assessed R1and asked him whether R2 had touched him or pulled his covers back, to which R1 replied, no. R1 also denied R2 touching him with his private parts. She stated she called the DON and the Administrator, who instructed her to call 911, which she did. She also called the NP who ordered a psychiatrist referral. She stated that she implemented the one-hour checks and that the DON and the Administrator agreed. LPN AA stated she did not move the resident that night because no male beds were available.An interview on 12/31/2025 at 10:25 am with CNA BB revealed she was making rounds when she saw R2 walking around R1's bed with something in his hand, and he was moving his hand. She wasn't sure what she was seeing, so she called another CNA into the room, who confirmed her observation. CNA BB stated R2 was standing near R1's head with his penis in his hand, masturbating. She was not sure if R1 was awake. She and the other CNA tried to assist R2 to the restroom, but he got angry and then sat down in the chair. She asked R1 if he was ok, then went to get the nurse. She stated that both residents denied the incident. She checked on the residents every hour, and sometimes more often. They kept the door open and the privacy curtain pulled between the two beds. R2 slept in his bed all night. CNA BB stated that the next morning, she got him (R2) up and dressed, then took him out of the room.An interview on 12/30/2025 at 11:30 am with the Administrator revealed that the hourly monitoring ended on 12/29/2025. She stated she decided to monitor hourly. They did not send the resident (R2) to the emergency room (ER) because the NP did not order it; only a psychiatry referral was ordered. The Administrator stated they moved R1 to a different room on 12/29/2025.An interview on 1/6/2026 at 11:32 am with the DON revealed that the evening staff called her to report the incident. She stated the nurse explained to her everything she put in place and that she was fine with the interventions. She stated that at the time, she thought the hourly monitoring was appropriate because R2 had never had that behavior and was usually a well-mannered man. The DON further revealed that, looking back on it now and moving forward, they would be providing one-to-one supervision in a situation like that, especially since no male beds were available.

Based on interviews, record reviews, and review of the job descriptions for the Administrator and the Director of Nursing (DON), the facility Administration failed to ensure that one Resident (R) (R1) was protected from sexual abuse by a resident R2 and failed to provide adequate protection of R1 while conducting an investigation of an allegation of sexual abuse from R2. The sample size was 18.On January 12, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), and the Divisional Nurse Consultant were informed of the Immediate Jeopardy (IJ) on January 12, 2026, at 10:47 am. The noncompliance related to the IJ was identified to have existed on December 20, 2025.An Acceptable IJ removal Plan was received on January 14, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on December 31, 2025.Findings include: Review of the undataed job description for the Administrator for Inpatient Services revealed, the summary of the job description noted the Administrator was responsible for directing the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. The category of Essential Duties and Responsibilities included to operate the Nursing Center in accordance with the established guidelines of the organization and in compliance with federal, state, and local regulations. Also, assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse.Review of the undated job description for the DON for Inpatient Services revealed, the summary of the job description noted the DON was responsible for planning, organizing, developing, and directing the overall operation of our Nursing Services Department in accordance with federal, state, and local regulations governing our nursing center, and as be directed by the Administrator and/or the Medical Director, to provide appropriate care.Administration failed to maintain an environment free from sexual abuse and failed to provide adequate protection during the investigation of the alleged sexual abuse for R1.Cross-reference to F600. An interview on 12/30/2025 at 11:30 am with the Administrator revealed that hourly monitoring ended on 12/29/2025. She stated she made the decision to do hourly monitoring. They did not send the resident to the emergency room (ER) because the Nurse Practitioner (NP) did not issue an order to send the resident there. The NP only gave an order for a psychiatry referral. The Administrator stated they moved R1 to a different room on 12/29/2025.An interview on 1/6/2026 at 11:32 am with the DON revealed, that the evening staff called her to report the incident. She stated the nurse explained to her what all she had put in place and that she was fine with the interventions. The DON further stated that at the time, she believed hourly monitoring was appropriate because R2 had never exhibited that behavior and was usually a well-mannered man. She then stated that looking back on it now and moving forward, they would be doing one to one supervision in a situation like that, especially since there were no male beds available.During a subsequent interview with the Administrator and the DON on 1/6/2026 at 12:15 pm, the Administrator wanted to discuss the timeline of the incident. The Administrator summarized what happened and stated she felt as if the facility had done everything they needed to do to keep R1 safe since R2 had never had this behavior before.R1 and R2 continued to reside in the same room from the date of the incident on 12/20/2025 until the surveyor inquired to the Administrator about placement options for the aggressor (R2) on 12/29/2025. R1 was moved to a different room on 12/29/2025.

Based on staff interviews, record reviews, and a review of the facility's policy titled Abuse Prohibition-Reporting and Investigating, the facility failed to report an allegation of physical abuse to the State Survey Agency (SSA) in a timely manner involving two Residents (R) (R6 and R7) from a sample of 18 residents.Findings include: Review of a facility policy titled Abuse Prohibition - Reporting and Investigation with a revision date of 12/27/2024. Under the Reporting section of the Guidelines included all allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours.Review of the clinical record for R6 revealed a Nurse's Note dated 12/12/2025 at 7:36 pm that documented the writer was summoned to the dining room regarding an altercation between a resident and another male resident (R7). Witnesses stated that R6 walked up to R7 and started hitting him in the head. Resident was escorted back to his room for assessment. Writer assessed R6 and noted bleeding from the index finger on the right hand from previous injury. Will continue with plan of care.However, review of the Facility Incident Report Form (FRI) dated 12/13/2025 revealed, the facility documented the date and time of the incident as 12/13/2025 instead of 12/12/2025.Further review revealed the 12/19/2025 follow up report to the SSA noted the incident occurred on 12/13/2025.During an interview with the Administrator on 1/7/2026 at 11:35 am, she stated she was not sure why the FRI was reported late.

Based on observations, staff interviews, and record review, the facility failed to ensure that furniture in resident rooms and the day room on one of four halls, and in the dining room, were maintained in good repair. These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment and a diminished quality of life.Findings include: Observations on 12/9/2025 at 10:30 am on the 300 Hall revealed seven armchairs in use in resident rooms and the day room with missing and torn upholstery. Cushion material was visible on the chairs' seats, arms, and backs. Further observations revealed dressers in resident rooms had broken handles and missing drawer fronts. Observations on 12/9/2025 at 11:54 am in the dining room revealed 55 of 55 chairs in disrepair, with torn or missing upholstery and exposed or missing cushioning on the arms, seats, and backs of chairs. Four of the 55 chairs were missing arm padding/cushioning, leaving sharp metal corners exposed.Review of the email correspondence dated 9/6/2023 between the Central Division [NAME] President and the Administrator revealed a request for new furniture, including bedside tables, dressers, and overbed tables. Review of an email correspondence dated 10/1/2025 revealed a request for estimates for 12 pairs of armchair rests for replacement. A follow-up email to the Administrator provided the estimated price. Review of an email correspondence dated 10/2/2025 revealed the Administrator requested the armchair rests to be ordered. Review of an email correspondence dated 10/7/2025 revealed that a corporate representative clarified the items requested for the order, sent a Purchase Order, and the Administrator signed the order. Review of the facility records titled [Electronic System Name] Tasks in Use revealed no evidence of requests for furniture repair or inspections. During concurrent observations and an interview on 12/11/2025 at 11:55 am, the Administrator and Maintenance Supervisor confirmed the armchairs and dressers were in need of repair. The Maintenance Supervisor stated parts had been ordered and had not been delivered. He further stated that all staff could enter a work order, not the electronic notification system, and stated he had not received any work orders for the furniture. The Administrator stated the chairs with missing armrests had been removed from the building, but kept reappearing. The Administrator stated it was her expectation to have resident furnishings and dining chairs in good repair for the facility.In an interview on 12/11/25 at 2:00 pm, the Administrator stated she had spoken with the corporate office over the course of two years to request new furniture.

Based on observation, staff interviews, record review, and review of the facility's policies titled Medication Administration-General and Medication Errors, the facility failed to ensure the medication error rate was less than five percent. There were three medication administration errors with 35 opportunities for two of six residents (R) (R37 and R96) observed for a medication error rate of 8.57 percent. This deficient practice had the potential to place R37 and R96 at risk of avoidable medical complications.Findings include:Review of the facility policy titled Medication Administration-General, revised 4/15/2025, revealed the Guideline section included, Associates authorized to administer medications do so only after they have familiarized themselves with the medications. The joint responsibility of the center and the pharmacy is to facilitate accurate medication administration. Prior to medication administration, the Nurse or Certified Medication Aide (CMA): . Reads the administration directions on the MAR [Medication Administration Record] and verifies correct medication, dose, and directions for use. Checks the expiration date of the medication. Expired medications are not administered to a patient.Review of the facility policy titled Medication Errors, revised 4/15/2025, revealed the Definition section stated, Medication Error is defined as the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services.1. Review of the electronic medical record (EMR) for R37 revealed diagnoses including, but not limited to, hypertensive heart disease with heart failure, pulmonary hypertension, and unspecified dementia.Review of the Med Aid MAR for R37, dated 12/1/2025 to 12/13/2025, revealed an order dated 5/16/2025 for Anoro Ellipta 62.5 micrograms (mcg)-25 mcg/actuation powder for inhalation, one puff inhalation, one time per day for dependence on supplemental oxygen. Observation on 12/10/2025 at 9:55 am revealed Certified Medication Aide (CMA) GG, administered Anoro Ellipta powder inhaler, two puffs to R37.In an interview on 12/10/2025 at 10:10 am, CMA GG confirmed the medication Anoro Ellipta powder inhaler was not administered as ordered. CMA GG confirmed that administering two puffs instead of one puff was an error and stated it would be reported to the charge nurse.2. Review of the EMR for R96 revealed diagnoses including, but not limited to, Guillain-Barre syndrome, chronic respiratory failure, and chronic obstructive pulmonary disease.Review of the Med Aid MAR for R37, dated 12/1/2025 to 12/13/2025, revealed an order dated 9/23/2025 for loratadine 10 milligrams (mg) one tablet by mouth, one time per day for seasonal allergic rhinitis. Further observation revealed an order dated 3/3/2025 for olanzapine five mg, one tablet, disintegrating by mouth one time per day for schizophrenia. Observation on 12/11/2025 at 9:07 am revealed during medication preparation for R96, CMA II prepared loratadine 10 mg, one tablet from a container with an expiration date of 10/27/2025. The surveyor intervened, and the medication was not administered. CMA II confirmed they were preparing to administer the loratadine to R96, and this would have been a medication error. Continued observation revealed CMA II administered an olanzapine five mg oral disintegrating tablet, by mouth to R96, and did not instruct the resident to allow the medication to dissolve in his mouth. R96 swallowed the medication without allowing it to dissolve. In an interview on 12/11/2025 at 9:12 am, CMA II confirmed the olanzapine five mg disintegrating tablet was not administered as ordered. CMA II confirmed the medication was given by oral ingestion and confirmed it should have been allowed to dissolve in the resident's mouth. In an interview on 12/11/2025 at 9:33 am, Charge Nurse Licensed Practical Nurse (LPN) BB and Unit Manager Registered Nurse (RN) HH confirmed the administration route for olanzapine was incorrect, and the date for the loratadine had expired. Medication error protocols were initiated at this time.

Based on staff interview, record review, and review of the facility policy titled Abuse Prohibition-Reporting and Investigating, the facility failed to ensure that an allegation of abuse was reported to the state survey agency for one resident (R) (R8) from a total sample of nine residents. Findings include: Review of the facility policy titled Abuse Prohibition-Reporting and Investigating, review date 12/27/2024, revealed the policy included that all allegations of abuse must be reported immediately, but no later than two hours. The Administrator or designee will notify the Complaint Investigation Intake and Referral Unit of the incident and the pending investigation. Review of R8's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, paranoid schizophrenia, generalized anxiety disorder, and hallucinations. Review of the 5/16/2025 Quarterly Minimum Data Set (MDS) assessment revealed that R8 was assessed as being cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3 out of 15. Further review of R8's clinical record revealed a 4/3/2025 Event-Initial Note that documented R8 sustained a fall in her room and laceration to the lips and inner mouth with moderate bleeding. The actions taken following the fall included R8 being sent to the hospital emergency room. Review of nurses' notes revealed R8 was hospitalized from [DATE] through 4/5/2025 and returned to the facility. Review of R8's hospital emergency department provider notes, dated 4/3/2025, revealed that R8 alleged she was raped six weeks prior at the facility. R8 named the perpetrator as R9. Review of the 4/3/2025 genitourinary exam findings revealed no abnormalities documented. Review of hospital case management notes, dated 4/5/2025, revealed that R8 alleged that she was raped by R9 multiple times. Further review of the case management notes revealed that law enforcement was notified, along with R8's family and Registered Nurse (RN) AA at the facility. However, there was no evidence that the facility reported R8's allegation of rape to the State Survey Agency. During an interview on 6/9/2025 at 1:15 pm, the Director of Nursing (DON) confirmed that the facility did not submit an initial report to the State Survey Agency (SSA) for R8's rape allegation. During an interview on 6/12/2025 at 3:05 pm, RN AA confirmed she spoke with the hospital case manager on 4/5/2025 and was made aware of R8's rape allegation. RN AA stated she told the hospital case manager that R8 had made allegations in the past, and they had been looked into, but that R8 had not made any allegations prior to her going to the hospital on 4/3/2025. RN AA stated that she notified the DON and Administrator via text message on 4/5/2025. RN AA stated that on the following Monday, 4/7/2025, the allegation was discussed in the facility staff's morning meeting, and it was decided that it was not a true reportable to the SSA, and RN AA went ahead and made a note of the call from 4/5/2025.

Based on observations, staff interviews, and a review of the facility policy titled, Storage Areas, the facility failed to ensure the dumpster area was maintained in sanitary conditions. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms. The facility census was 89 residents. Findings include: A review of the facility policy titled, Storage Areas, dated 12/29/2023, revealed the section titled Dumpster included, Area should be free of trash and debris. Containers should be kept in good condition and covered. Observations on 8/23/2024 at 8:45 am of the facility dumpster area with the Dietary Manager (DM) revealed two of the three dumpster lids were badly damaged and did not allow a secure closure. Further observation revealed broken pallet pieces and large pallets covered with dirt and debris on the ground between two of the dumpsters. During an interview on 8/23/2024 at 10:00 am, the Maintenance Director and DM confirmed the observations. The Maintenance Director reported their vendors deliver supplies, on pallets, to the facility every Tuesday and the last delivery was on 8/20/2024. He further stated the Housekeeping Staff usually unloaded the delivery truck and should place the pallets in the dumpsters. The Maintenance Director stated he would have the dumpsters replaced. In an interview on 8/24/2024 at 11:10 am, the Housekeeper Supervisor reported being unaware that her staff was assigned to place the pallets in the dumpster. In an interview on 8/25/2024 at 11:13 am, the Administrator reported she planned to have all staff monitor the dumpster area for cleanliness and trash. She reported being unaware of the lids being badly dented and that staff were leaving broken pallets on the ground. She stated that her expectation was for staff to maintain the dumpster in a sanitary manner. She further stated that all staff were responsible for reporting damages and any concerns about the dumpster area not being maintained in a sanitary manner.

Based on observations, staff interviews, record review, and review of the facility policy titled, Use of Oxygen Therapy, the facility failed to ensure one of 14 residents (R) (R27) receiving oxygen (O2) therapy was administered O2 in accordance with the physician order. The deficient practice had the potential to place R27 at risk of respiratory complications. Findings include: A review of the facility's policy titled Use of Oxygen Therapy, dated 7/1/2024, revealed the section titled Guideline included, Physician's order for oxygen should be obtained and include oxygen with liter flow as ordered. A review of R27's clinical record revealed a diagnosis of chronic obstructive pulmonary disease (COPD), unspecified. A review of R27's Physician Order Form revealed an order dated 10/2/2023 for O2 via a nasal cannula (NC) at two liters per minute (LPM) as needed for SOB (shortness of breath) or wheezing. Observations on 8/23/2024 at 1:30 pm and 8/24/2024 at 2:00 pm revealed R27 lying in bed receiving O2 via a NC at 2.5 LPM instead of 2.0 LPM. During observation and interview on 8/25/2024 at 11:45 am, the Administrator and Director of Nursing (DON) confirmed R27 was receiving O2 at 2.5 LPM instead of 2.0 LPM. The DON stated her expectation was for O2 to be administered per the physician's order. The Administrator reported staff will receive education on following physician's orders for O2.

Based on observations, staff interviews, and a review of the facilities policies titled, Labeling and Dating Guidelines, Skilled Nursing Services Food Preparation and Distribution, Ready 365 Best Practice Standard of the Week: Thawing, and Skilled Inpatient Services Cleaning and Sanitizing the facility failed to label and date food in the walk-in freezer; failed to properly store stack pans to prevent wet-nesting; failed to properly thaw frozen food items to prevent foodborne illness; and failed to hold food items on the steam table above 135 degrees. The facility census was 77 with 73 residents consuming an oral diet. These failures had the potential of causing bacterial growth associated with foodborne illness. Findings include: 1. Review of the policy titled Labeling and Dating Guidelines revealed upon opening, all items should have an open date and a use by date. Observation on 2/24/2023 at 9:03 a.m. of the walk-in freezer revealed an opened bag of breaded squash with no label or date. Interview on 2/24/2023 at 9:30 a.m. the Certified Dietary Manager (CDM) confirmed that the opened bag of breaded squash did not have a label or date. The CDM expects staff to label and date opened items before storing in freezer. 2. Observation on 2/24/2023 at 9:10 a.m. of the pot and pan storage rack revealed multiple stacks of steam table pans of various shapes and sizes. A stack of four smaller rectangle shaped steam table pans were turned over and the second pan from the top, the inside was wet and had yellow orange food debris. The bottom of the pan third in the stack had food debris that was light tan in color. Interview on 2/24/2023 at 9:10 a.m. with the CDM confirmed that the steam table pan was wet inside and had food debris and confirmed that the bottom of the other pan had food debris. The CDM expects staff to stack pans dry and clean on the rack. Interview on 2/26/2023 at 11:40 a.m., the CDM stated that they do not have a specific policy regarding storage of pots and pans. 3. Review of the policy titled Skilled Nursing Services Food Preparation and Distribution revealed thawing methods, submerged under running water at a temperature no greater that 70 degrees. Review of the policy titled Ready 365 Best Practice Standard of the Week: Thawing revealed running water, fully submerge food under running, drinkable water at 70 degrees or below; the flow of the water must be strong enough to wash loose food bits into the drain. The container must be able to hold water in a manner that is consistently surrounding the food item and allowing fresh water to circulate. Observation on 2/24/2023 at 9:12 a.m., inside of the food preparation sink revealed three clear plastic vacuumed sealed bags containing a frozen meat product. The bags were set directly on the bottom of the sink, and cold water was running only touching the top corner of one bag of meat. The three bags of meat were not submerged in water with the cold water running into the container for thawing. Interview on 2/24/2023 at 9:12 a.m., the CDM revealed that she thought just having the running water on top of the frozen bags was sufficient for thawing the meat. The CDM was not aware that when thawing foods with running water the food items need to be submerged in the water and have the water flowing freely from the vessel containing the food item. 4. Review of the policy titled Skilled Inpatient Services Cleaning and Sanitizing revealed three-compartment sinks, and manufacturer guidelines should be followed. Review of the Eco Lab Product Specification Document for Multi Quat Sanitizer revealed to allow equipment to drain thoroughly and air dry. Observation on 2/25/2023 at 11:30 a.m. of Dietary Aide CC using the three-compartment sink revealed Dietary Aide CC was using a cloth towel to dry the inside of two small square steam table pans after the pans were in the sanitizing solution. Dietary Aide CC was also observed wiping dry the inside of a square shaped steam table pan. Continued observation revealed the facility was using Eco Lab Quat Sanitizing solution in the three-compartment sink. Interview on 2/25/2023 at 11:30 a.m. with Dietary Aide CC revealed that she was drying the inside of the steam table pans to make sure that they were dry inside. Interview on 2/25/2023 at 11:30 a.m. with the CDM revealed that she expects staff to let pans air dry and not wipe with a towel. 5. Review of the policy titled Skilled Nursing Services Food Preparation and Distribution revealed: tray line hot foods should be held at or greater than 135 degrees. Tray line temperatures were completed on 2/25/2023 at 12:40 p.m., Dietary Aide AA assisted with taking temperatures using the facility's calibrated thermometer. The chopped Philly steak meat had a temperature of 105 degrees, cooked cabbaged had a temperature of 106 degrees, and cooked white rice had a temperature of 105 degrees. Interview on 2/25/2023 at 12:40 p.m. with Dietary Aide AA confirmed that the temperatures of the chopped Philly steak meat, cooked cabbage, and cooked white rice were below 135 degrees. Dietary Aide AA revealed that foods on the steam table should be 135 degrees or higher. Continued interview with Dietary Aide AA revealed that the cooked cabbage is for residents receiving a mechanical soft chopped diet and renal diet. The Dietary Aide AA stated that the rice was for only renal diets and there is only one resident receiving a renal diet. Interview on 2/25/2023 at 12:45 p.m. with the CDM revealed that food items on the steam table should be 135 degrees or higher. The CDM stated that the residents on 200, 300, and 400 halls still needed to be served lunch meals and the items will be reheated.

Based on observations and staff interviews the facility failed to ensure the area behind the dumpsters was properly maintained and free from debris. This failure had the potential to attract pests and transfer microorganisms. Findings include: Observation on 2/25/2023 at 8:40 a.m. of the dumpster area revealed that the facility had three medium sized dumpsters located on the side of the building. The area behind the dumpsters had a wire fence separating the facility campus from a residential home. Between the dumpsters and the wire fence was brush. Continued observation revealed that the area behind the dumpsters in the brush on the ground were multiple Styrofoam cups, two-eight ounce cups, and two-12 ounce cups. The area also had three Styrofoam take-out containers. Further observation revealed paper cloth like trash items that were scattered in the area. Interview on 2/25/2023 at 8:40 a.m. the Certified Dietary Manager (CDM) confirmed that there were multiple trash items on the ground behind the dumpsters. The CDM stated that housekeeping is responsible for the area around the dumpsters. Interview on 2/26/2023 at 8:50 a.m. with Housekeeper BB revealed that housekeeping is responsible for the area around the dumpsters for cleanliness. The Housekeeper BB stated that it is not a daily task that is performed, and only cleans the outside when directed by their supervisor. Interview and observation on 2/26/2023 at 11:50 a.m. with the Administrator of the dumpster area revealed that housekeeping is responsible for the area around the dumpsters. The Administrator revealed that they are currently searching for a new housekeeping supervisor and the Maintenance Director has been appointed interim. The Administrator confirmed that there was trash on the ground behind the dumpsters and revealed that the trash should have been pick-up.

Based on observations, interviews, and review of facility policy titled Medication Administration -General, the facility failed to ensure the proper disposal of expired medication for a centrally located medication storage room and four of five medication carts. Findings include: Observation of medication storage room on 9/1/21 at 1:50 p.m. revealed the following medications to be expired: calcium with vitamin D 500 milligrams (mg) 60 tabs (six bottles) expired 10/2020 and one of the six expired 7/2019; vitamin B-12 1000 mcg (micrograms) 130 tab (two bottles) expired 1/2021, aspirin [MEDICATION(S)] coated 325 mg 100 tabs expired 10/2020; [MEDICATION(S)] (HCL) 25 mg 24 capsules expired 6/2021, [MEDICATION(S)] (children's) stuffy nose and chest congestion 4 fluid ounces (two bottles) expired 10/2020; mineral oil lubricant [MEDICATION(S)] 16 fluid ounces (two bottles) expired 5/2021, cough syrup 473 milliliters (ml) expired 8/2021, super strength cranberry 450 mg 60 soft gels expired 6/2020, [MEDICATION(S)] liquid 473 ml (stool softener) (three bottles) expired 6/2021, and antacid (calcium [MEDICATION(S)]) 750 mg 80 chewable tablets expired 8/2021. All medication expiration dates were confirmed by Licensed Practical Nurse (LPN) AA at the time of observation. Observation of the medication cart for the 400 Hall on 9/1/21 at 1:55 p.m. revealed the following medications were expired during observation: [MEDICATION(S)] liquid (stool Softener) 473 ml expired 6/2021. The expired medication was confirmed by LPN BB at the time of observation. Observation of the medication cart for the 300 Hall on 9/1/21 at 2:05 p.m. revealed the following medications were expired during observation: [MEDICATION(S)] 30 capsules expired 3/2021, cough syrup 473 ml expired 8/2021, [MEDICATION(S)] syrup 473 ml expired 10/2020, and [MEDICATION(S)] stuffy nose and cold 4 fluid ounces expired 5/2020. All expired medications were confirmed by LPN CC at the time of observation. Observation of the medication cart for the 200 Hall (cart one) on 9/1/21 at 2:15 p.m. revealed the following medications were expired during observation: [MEDICATION(S)] liquid 473 ml expired 6/2021, and [MEDICATION(S)] sulfate [MEDICATION(S)] 473 ml expired 8/2021. Observation of medication cart for the 200 Hall (cart two) revealed the following medications were expired during observation: [MEDICATION(S)] sulfate [MEDICATION(S)] 473 ml expired 8/2021. All expired medications were confirmed by LPN DD at the time of observation. Interview on 9/1/21 at 2:44 p.m. with the DON (Director of Nursing) revealed the expectation is that every nurse should be checking stock medications weekly and before administering medications to residents. The staff member over the central supply medication storage and ordering works Friday, Saturday, and Sunday and was supposed to be checking the medication regularly for expiration dates. Interview on 9/1/21 at 2:55 p.m. with the Administrator revealed that the previous central supply staff member has resigned, and the expectation is that all medication that is expired is to be discarded. Review of facility policy title Medication Administration - General dated 2019 revealed under Guidelines: prior to medication administration: check expiration date of the medication. Under no circumstances should an expired medication be administered to a patient.

Based on record review, review of the facility policy titled Abuse Prohibition, and staff interview, the facility failed to report resident-to-resident abuse involving three residents (R) (#1, R#2, and R#3) reviewed for abuse. Findings include: Review of the facility policy titled Abuse Prohibition updated February 2020 revealed: 2. Identification of possible abuse, neglect, or exploitation d. identification of coverage and responsibility. Patients in our center will not be subjected to abuse by anyone (including but not limited to: . other residents.) Any person observing any abuse, ., must immediately report it the Administrator . The policy does not include information related to reporting to the State Survey Agency. R#1 had an Admission Minimum Data Set (MDS) dated [DATE] documenting a Brief Interview of Mental Status (BIMS) score of 9, indicating mild cognitive impairment. Section E - Behaviors revealed delusions, physical and verbal behaviors, puts others at risk for injury, intrudes on others privacy, disrupts care/living environment, and wanders. R#1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#2 had an Annual MDS dated [DATE] documenting a BIMS score of 15 indicating no cognitive impairment. Section E - Behaviors revealed no behaviors. R#2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#3 had a Quarterly MDS dated [DATE] documenting a BIMS score of 3, indicating severe cognitive impairment. Section E - Behaviors revealed rejection of care. R#3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse's Note dated 3/13/21 revealed R#2 came to the nurse's desk and stated R#1 attacked her. Staff escorted R#1 out of the room and assessed R#2 finding no injuries. Review of Nurse's Note dated 3/26/21 revealed R#3 approached R#2 in the hallway, grabbed her by the hair and slapped her in the face. R#2 then threw a glass of water at R#3. There is no evidence that the incidents were reported to the State Survey Agency. Interview on 4/7/21 at 1:04 p.m. with the Administrator and Assistant Director of Nursing (ADON) confirmed neither incident was reported to the State Survey Agency. They did not deem the incident to be abuse because R#1 and R#3 have these behaviors but there was no intent. There were no concerns identified with the actions of the facility related to resident care, in response to the resident-to-resident abuse.

Based on observation, interview, and review of the facility's COVID-19 Infection Control Policy, the facility failed to ensure the infection prevention program was maintained when one Certified Nursing Assistant (CNA) DD failed to wear a face shield while escorting a Resident (R#1) in the COVID-19 isolation hall (200 Hall). The failure to wear the required Personal Protective Equipment (PPE) increased the risk of exposure and/or infection for staff. The census was 81. Findings include: During a facility tour on 8/6/20 at 10:20 a.m., CNA DD was observed walking in the COVID-19 isolation hall (200 Hall), with a N95 face mask in place, but without the protection of a face shield. CNA DD was escorting R#1, who was wearing a face mask, from the area of room [ROOM NUMBER] through the double doors, where face shields were mandatory, beyond room [ROOM NUMBER]. R#1 was walking behind CNA DD with his right hand on CNA DD's left shoulder. On 8/6/20 at 10:42 a.m., CNA DD was observed outside room [ROOM NUMBER] talking with CNA EE and CNA FF. CNA DD was not wearing a face shield. CNA EE and CNA FF were donning face masks and face shields. An interview with CNA DD on 8/6/20 at 10:42 a.m., indicated the facility required facility staff to don a face mask and face shield while in the facility, except when eating. CNA DD revealed the face shield was left over there, pointing in the direction of the 200 Hall nurses' station. An interview with CNA EE on 8/6/20 at 10:45 a.m., indicated the facility began requiring face shields over face masks about a week before, and staff were required to wear both mask and face shield at all times in the facility. An interview with CNA FF on 8/6/20 at 10:46 a.m. revealed staff were required to wear both face mask and face shield while in the facility. An interview with the Director of Nursing (DON) on 8/6/20 at 10:55 a.m., indicated facility staff were required to wear face shields over masks at all times throughout the facility and that CNA DD should have a face shield on when in the facility. An interview with the Infection Control Nurse on 8/6/20 at 11:50 a.m., indicated the facility implemented a program that required all staff to begin wearing face shields on 7/27/20, and CNA DD should have been wearing a face shield while on the 200 Hall. The facility's COVID-19 Infection Control Policy, most recently revised on 7/24/20, was provided by the Administrator on 8/6/20 at 12:40 p.m. The policy indicated, .Personal Protective Equipment (PPE) .4. Universal use of face shields or goggles for all HCP (Health Care Providers) should be used per guidance of CDC A review of the Centers for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 7/15/20, indicated, HCP should, Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters On 8/6/20 at 2:31 p.m., the Infection Control Nurse provided a notification she had provided to all employees through an in-service which stated, ATTENTION ALL (facility name deleted) EMPLOYEES: We will start wearing face shields on July 27, 2020. You will have to wear one with your N95 mask. Do not go behind the double doors without your face mask and shield' (sic) You must change it when going from a COVID positive to a negative room. Pass the word on.

Based on observation, interview, record review, and review of the facility's policy entitled Skilled Inpatient Services Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne), the facility failed to ensure an effective Infection Prevention and Control Program (IPCP) was maintained to prevent or reduce the spread of COVID-19 to residents and staff which resulted in immediate jeopardy. Specifically, the facility failed to ensure Certified Nursing Assistant (CNA) #1 followed the facility's policy for use of Personal Pertective Equipment (PPE), did not wear the same PPE used for a resident who was COVID positive (Resident #1) for resident's who were not identified as COVID-19 positive (Resident #'s 2 and 3) and failed to ensure CNA #1 wore eye protection when providing care, according to facility policy. The failure to change PPE between residents and wear appropriate eye protection increased the risk of cross contamination and spread of COVID-19. In addtion, the facility failed to ensure five (5) residents (Resident #'s 6, 7, 8, 9 and 10) who were eating in the 100-Hall dining room were encouraged to maintain social distancing requirements when seated at small dining room tables. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to 480.80 Infection Control. On 06/03/20 at 6:10 p.m., the Administrator and the Director of Nursing (DON) were notified that an Immediate Jeopardy existed. The facility presented an acceptable removal plan for the Immediate Jeopardy 06/04/20 at 12:40 p.m The removal plan indicated all facility staff had been educated not to reuse/wear PPE from a COVID-19 positive room to a 14-day quarantined room. The removal plan was validated through observations and interviews, which revealed all on duty staff had been educated. The facility was notified that the Immediate Jeopardy was removed on 06/04/20 at 1:25 p.m. and that they remained out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) at F880. The findings include: 1.Review of the facility's undated policy entitled, Skilled Inpatient Services Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne), revealed it was the policy of the facility to use transmission-based precautions for residents who have infections or communicable diseases that may necessitate the use of barriers in addition to those used for standard precautions. The policy revealed for residents with suspected or proven [DIAGNOSES REDACTED], avian influenza or pandemic influenza, refer to the following websites for the most current recommendations at the time: www.cdc.gov/[DIAGNOSES REDACTED]; www.cdc.gov/flu/avain/; www.pandemicflu.gov. Airborne precautions are used by the facility for residents known or suspected to be infected with infectious agents' transmitted resident-to-resident by the airborne route. For airborne precautions wear a fit-tested NIOSH-approved 95 or higher respirator for respiratory protection when entering the room of a resident. Further review of the policy revealed for the condition of Severe Acute Respiratory Syndrome ([DIAGNOSES REDACTED]) airborne precautions preferred .N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosol-generating procedures . Observations on 06/03/20 at 1:12 p.m., on the 300 Hall, revealed CNA #1 picked up a blue gown lying on a bedside table outside Resident #2's room. Continued observation revealed the CNA donned (put on) the gown, N95 mask, and gloves, and then entered Resident #1's room, where signage on the door indicated the resident was on airborne isolation precautions. The CNA did not don a face shield or goggles prior to entering Resident #1's room. The PPE signage on Resident #1's door indicated required PPE included gown, mask/respirator, goggles or face shield, and gloves were to be worn when entering the room. Continuous observation revealed at 1:20 p.m., CNA #1 exited Resident #1's room, doffed (removed) the gown and placed it back on the bedside table, with the other gowns outside of Resident #1's room. This potentially cross contaminated all of the PPE on the table; and increased exposure risk to residents and staff because the PPE should have been removed, and appropriately discarded in a biohazard receptacle prior to exiting the room. Interview on 06/03/20 at 1:21 p.m., with CNA #1 revealed she placed the gown that she wore in Resident #1's room on the bedside table because she would use the same gown all of her shift, for all three rooms. The CNA stated Resident #1 was a COVID-19 positive room and two rooms next to Resident #1(Resident #'s 2 and 3) were 14-day quarantine rooms because the residents had gone to the hospital and returned. Continued interview with CNA #1 revealed the resident in room .(Resident #1's room) .was the only resident who was positive for COVID-19 in the facility. The CNA stated the other two rooms were residents who were on 14-day quarantine. When asked why she did not wear a face shield or googles into the COVID-19 positive room, CNA #1 stated, I think it is optional. Another observation of CNA #1 on 06/03/20 at 2:38 p.m., on the 300-Hall, revealed the CNA picked up a gown from the bedside table (the same gown she used while she provided care to COVID-19 positive Resident #1), she donned the gown, gloves, and N95 mask. Continued observation revealed CNA #1 knocked and entered Resident #2's doorway. Resident #2 was on droplet precautions for a 14-day quarantine, and was currently being seen by the therapy department, so the CNA doffed the PPE and placed the gown back on the bedside table outside the room. Interview with CNA #1 immediately following this observation, confirmed the gown she used was the same exact gown she had used when in the COVID-19 positive room of Resident #1. The CNA stated she had used this same gown for her shift, for all three rooms. Interview on 06/03/20 at 2:45 p.m., with the Infection Control Nurse (ICN) revealed when a staff person enters a COVID-19 room, they should always have on either a face shield or goggles. Continued interview with the ICN revealed the CNA should not have worn the same gown from a positive COVID-19 room to a 14-day quarantine room that may have a COVID-19 negative resident. The ICN stated wearing the same gown could have cross contaminated the 14-day quarantine room from the positive (COVID-19) room. Interview on 06/03/20 at 3:01 p.m., with the Administrator revealed it was her expectation when going into a COVID-19 positive room, that staff would wear goggles or a face shield to reduce the risk of contracting COVID-19. Continued interview with the Administrator revealed staff could not go into a COVID-19 positive room and then wear the same gown (PPE) when caring for other residents in different isolation situations (14-day quarantine). The Administrator stated gowns should be discarded after coming out of the COVID-19 positive room. Interview on 06/04/20 at 11:30 a.m., with the Director of Nursing (DON) revealed it was her expectation that facility staff would have worn a face shield or goggles before going into the COVID-19 positive room. The DON stated it was her expectation CNA #1 should not have gone into the COVID positive room, and then into a 14-day quarantine room, in the same PPE, because of cross contamination and putting the resident (who was presumed negative) at increased exposure risk. The faclilty presented an acceptable removal plan for the Immediate Jeopardy 06/04/20 at 12:40 PM that read, F880 Infection Prevention and Control 1) Certified Nursing Assistant #1 identified in the survey has been educated conceming the proper use of Personal Protect Equipment and lsolation Precaution for Resident on Standard Precautions/Use of PPE and Transmission Based precautions (Contact, Enhanced Barrier Precautions, Droplet and Airbome) precautions. Certified Nursing Assistant #l identified during the survey has been educated by the RN InfectionPrevention/education coordinator on 6-3-20 conceming donning and doffing personal protective equipment for Standard Precautionfuse of PPE and Transmission Based precautions (Contact, Enhanced Barrier Precautions, Droplet, and Airbome). An assessment of Resident #'s 3 and 2 was performed, and was found to have no changes in vital signs, physical appearance, or presence of signs and symptoms of infection by Licensed Practical Nurse (LPN) charge nurse on 06/3/20 at 2:00 p.m. Resident #'s 3 and 2 responsible parties and physicians were notified of possible exposure. The Assistant Director of Nursing (ADON) notified the Medical Director on 06/4//20 at 8:31 a.m. and the DON notified the families on 06/4/20 at 8:45 a.m. New orders to implement COVID-I9 nasopharyngeal testing were obtained to monitor for infection by the ADON on 06/4/20 at 8:50 a.m. The residents will continue to receive a comprehensive nursing assessment three times per day to monitor for any changes in baseline condition or signs and symptoms of infection for a minimum of 14 days. The l4 day quarantine will start over again as of 6/3/20. 2) All Patients have the potential to be affected. 3) The Skilled Inpatient Service Standard Precaution/Use of PPE and Transmission Based precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) policy has been reviewed by the Director of Nurses, Administrator, Infection Prevention Nurse and Regional Nurse on 6-3-20 and no changes were made to this policy. The Administrator, DON and Infection Prevention Nurse pulled infection control policies and procedure and educational resources in order to reeducate and complete a competency checkoff for all staff for their understanding and compliance. An Ad- Hoc Quality Assurance Performance Improvement meeting was called on 6/4/20 with the Medical Director, Administrator, DON, ADON and the Infection prevention nurse to discuss recommendations for Standard Precautionruse of PPE and Transmission Based precautions (Contact, Enhanced Barrier Precautions, Droplet, Airbome). All Administrative department heads Health Information Manager, Financial Conholler and Assistant, Social Service Director, Activity Director and Assistants, Admission Coordinator, Resident Assessment Instrument (RAI) coordinalor, Registered Nurse (RN) Wound Nurse, Director of Nurses, Assistant Director ofNunes, Resident Care Coordinator (RCC), CNA, LPNs, RN, Housekeeping, Maintenance and Maintenance Assistant, dietary were trained by the education nurse, ADON or DON on what is considered standard precaution, transmission base precaution and correct use of PPE. The DON, ADON, RCC or RN Education Nurse will audit that the long term care staff that enters and exits isolation room for the proper use of correct PPE and the correct type of PPE according to the type of isolation precaution posted on the door. This audit will be listed on the Quality Improvement Data Collection Grid. Following this initial 100 percent audit of the actively working associates on re-education and training of staff on Standard Precaution/Use of PPE and Transmission Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) , the Director of Nursing or RN IC/Education nurse will complete a weekly audit of 1:l RN DON: 1:l RN ADON I:1, 1:1 RN Charge Nurse, l3:13 LPN charge nurses, 1:l Weekend RN supervisors, 1 LPN Resident Care Coordinator Nurse, I : I RN Wound Care Coordinator, I : I LPN Admission coordinator and 1 : I LPN Minimum Data Set Coordinator nurses, l: I RN Edu,Infection Control Nurse, T:7 Housekeepers 8:8 Dietary, 2:2 Maintenance,8:8 Administrative Department Head, 4:4 Therapy Staff correctly donning and doffing PPE for Transmission Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airbome) in isolation areas using a check utilizing the PPE check off sheet developed by the DPH, and will audit/assess competency of the RNs, LPNs, CNAs, Dietary, Therapy, Administrative staff and Housekeepers use of Standard Precaution/Use of PPE and Transmission Based Precautions(Contact, Enhanced Barrier Precautions, Droplet, Airbome x 4 weeks. Out of 83 staff, 76 staff have been in-serviced and checkoff for compliance based on DPH proper use of PPE for Transmission Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airbome) and all staff and agency will be educated prior to the beginning oftheir shift for compliance. 4) l:l (one of one) RN DON: l:1 RN/ADON1:1, l:l RN Charge Nurse, 13:13 LPN charge nurses, 1:l Weekend RN supervisors, I LPN Resident Care Coordinator Nurse, l:l RN Wound Care Coordinator, l:1 LPN Admission coordinator and 1:1 LPN Minimum Data Set Coordinator nurses, 1:l RN Edu/Infection Control Nurse, T:THousekeepers 8:8 Dietary,2:2 Maintenance,8:8 Administrative Depatment Head,4:4 Therapy Staff were educated on 6/4/20 by the Director of Nursing, Assistant Director ofNurses, or Education Nurse on Standard Precaution/Use of PPE and Transmission Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airbome, what constitutes a changing PPE or re-use of PPE. Any RN, LPN, CNA, Administrative staff, Maintenance, therapy, dietary or housekeeping associates on FMLA will be educated upon their return to work. New RN, LPN, CNA, Administrative staff, Maintenance, therapy, dietary and agency associates'hired will be educated on Standard Precaution/Use ofPPE and Transmission Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airbome) during their orientation period, annually, at the beginning ofthe shift and as needed for compliance by either the charge nurse on duty, RCC, IC Nurse, DON or ADON. 5) Observations and findings of corrective actions will be forwarded by Director of Nurses for review of an evaluation ofeffectiveness to the Quality Assurance/Performance Improvement Committee monthly and as needed. Revisions and or updates will be made as indicated by QAPI committee which is led the Administrator every month for 2. Observation on 06/03/20 at 1:05 p.m. of the 100-Hall day room revealed Resident #'s 6 and 7 sitting at the same small table, less than six feet apart, wiping their hands of food crumbs, and touching each other's arms, and neither resident was wearing a mask. Continued observation revealed Resident #'s 8 and 9 sitting at a different small table, less than six feet apart, with one resident wearing a mask incorrectly on her forehead, and the other resident with no mask on. Interview on 06/03/20 at 2:23 p.m., with CNA #2 revealed the four residents (Resident #'s 6, 7, 8, and 9) at two different tables were still in the small dining room from lunch. The CNA stated she had just removed the residents' plates right before (surveyor) came into the room. CNA #2 stated there were two residents who ate at one table independently (#'s 6 and 7) and at the other table were three residents (#'s 8, 9, and 10); two of which (Resident #'s 9 and 10), were feeders (needed assistance). Continued interview with CNA #2 revealed she was told by the facility staff all feeders were to eat in the small dining room. When asked if the residents who were at the two tables were all six feet apart to practice social distancing, CNA #2 stated, no. Interview on 06/03/20 at 2:45 p.m., with the ICN revealed communal dining should not have been happening. The ICN stated some residents still came to the small dining rooms; but should not be because they are violating the six-foot social distancing recommendations. Interview on 06/03/20 at 3:01 p.m., with the Administrator revealed it was her expectation that residents would have eaten in their rooms, and not in a communal dining situation. The Administrator stated there should not be communal dining because of the increased risk of getting and spreading COVID-19. The Administrator also stated with communal dining, the facility could not practice social distancing of six feet. A policy was requested regarding communal dining during COVID-19, but none was provided prior to exiting the survey. Interview on 06/04/20 at 11:30 a.m., with the DON revealed it was her expectation the facility staff would not have provided communal dining, because the residents were not six feet apart and someone could sneeze and spread [MEDICAL CONDITION] if they were infected.

Based on observation, resident, and staff interviews, the facility failed to post notice of the availability of the State survey results so that residents (R) and/or visitors were aware of its location for four of four days of the survey. The facility census was 81 residents. Findings include: During an interview on 10/2/18 at 10:00 a.m. about the facility's Resident Council, five of five residents in the meeting stated that they did not know where the State inspection results were located, and that this was something they would be interested in reviewing. R A and R B each reported that they would review the survey book if they knew where it was located. They further reported that they do not think they are allowed to leave their unit as the doors are locked. Tour of units on 10/3/18 at 10:50 a.m. revealed that survey results were not found. Tour of front lobby sitting area on 10/3/18 at 11 a.m. revealed survey book located in front lobby sitting area. Interview on 10/3/18 at 4:10 p.m. with Activities Director and Social Services Director (SSD). Activities Director reported that residents are informed of where the survey book is located during resident council meetings. SSD reported that residents are brought up to the front daily by family members and staff. SSD also reported that residents can request to come to the front lobby area without telling staff why they want to come up front. Interview with Administrator on 10/3/18 at 4:15 p.m. who reported that she has a second survey book that is located in her office. She further reported that the doors must remain locked to ensure the safety of the residents and if residents want to see the book staff can bring them up to look at the book. The Administrator acknowledged that with the doors being locked residents would not be able to access the survey book without having to ask for assistance. Interview on 10/4/18 11:09 a.m. family of R C reported not being aware of where the survey book is located. Interview on 10/4/18 at 12:24 p.m. with family of R D who reported not being aware of the location of the survey book. Interview on 10/4/18 at 12:43 p.m. with the Guardian for R E who denied being aware of where the survey book is located and has not seen signs posted regarding this. Interview on 10/4/18 at 1:15 p.m. with family of R F who reported that not being aware of where the survey results book is located.

Based on observation, review of records, and staff and resident interview, it was revealed that the facility failed to consider and provide for the individuality of its residents when it provided inappropriate eating utensils to most of the residents in an attempt to address the behavioral needs of just one resident during meals on two of four halls. The facility's census was 81 residents. Findings include: On 10/1/18 at 12:10 p.m. during service of the lunch meal which consisted of barbecued chicken breast, greens, roasted red potatoes, roll, and pie, 10 residents were observed seated at five tables in the main dining room off the 100 hall, and each were observed to receive only one item of flatware - a metal spoon - with which to eat the meal. No other flatware was provided and some residents (those receiving a meal of regular texture) were observed struggling to cut some food items (like the chicken breast) with this only item of flatware. On 10/1/18 at 12:41 p.m., 8 residents were observed eating lunch at three tables in the small dining room on the locked unit of the 100 hall. All residents in this dining room were observed to be provided with a plastic spoon, and no other flatware, with which to consume their meals. Two residents - one in room [ROOM NUMBER] and the other in room [ROOM NUMBER] - were served in their rooms. The resident in room [ROOM NUMBER] was assisted by a certified nursing assistant (CNA). The residents eating in their rooms were also provided with a plastic spoon for consuming their meals. On 10/2/18 at 12:28 p.m. during observation of the lunch meal consisting of Swiss steaks, mashed potatoes, steamed broccoli, a roll, and pudding in the dining room on the 200 hall, 14 of 15 residents were served with plastic flatware in cellophane packets such as those served at a picnic or a fast food restaurant. The15th resident - Resident (R) #5 was served with metal flatware which included a spoon, fork, and knife. During an interview on 10/2/18 at 12:30 p.m. with CNA EE, it was revealed that residents in the facility are served with plastic flatware because of concerns that they might poke themselves or others with metal flatware. On 10/2/18 12:36 p.m., during observation of the lunch meal in the main dining room of the 100 hall, it was again revealed that all the residents were provided with a metal spoon as the only flatware. During an interview on 10/2/18 at 12:46 p.m. with member of the kitchen staff AA, it was revealed that residents in the main dining room of the 100 hall were provided with only a metal spoon for eating meals because of concerns that they might use other flatware in an appropriate manner. AA said (but could not remember the exact details, including when the incident occurred) there was an incident wherein one resident attempted to stab another resident with an eating utensil. After said incident, the regional dietitian had informed the kitchen staff that the residents on the 100 hall were to be provided with only a spoon with which to eat their meals. During an interview on 10/3/18 at 12:20 p.m. with the Food Service Director, it was revealed that residents on the 100 and 200 halls are served only with metal spoons or plastic flatware because of safety concerns. He said that in the past, some of the residents had attempted to stab at each other with the metal forks. The dietary manager said the facility had no policy or procedures for this practice. The staff were simply aware that they needed to follow this practice. During an interview on 10/3/18 at 2:10 p.m. with CNA BB, it was revealed that she had worked at the facility for several months, and from observation, she was aware that most of the residents on all the hallways were routinely served with plastic utensils or with a spoon only. She was told that the facility was concerned that the behaviors of some residents limited the type of flatware/utensils they are provided with for eating. However, this CNA knew not every resident in the building had behaviors and she did not believe it was fair to those without behaviors to not have proper utensils with which to eat their meals. CNA BB said she felt the kitchen staff simply found it to be more convenient to have the residents in the facility use plastic utensils or only provides metal spoons because it gave them less clean up to do. On 10/3/18 at 5:41 p.m. during the dinner meal in the main dining room on 100 hallway 10 residents were observed eating dinner with complete sets of metal flatware - spoons, forks, and knives. On 10/3/18 at 5:44 p.m., observation of the small dining room on the 100-hall revealed two residents finishing the dinner meal. Each was using a full set of metal flatware. On 10/3/18 at 5:50 p.m., 9 residents were observed in the dining room of the 200 hall, and all were noted to be using full sets of metal flatware. Residents eating in their rooms on the 200 hall were also observed to be eating their dinner meal with metal flatware sets which included forks, knives, and spoons. During an interview on 10/3/18 at 5:52 p.m., CNA CC confirmed that the residents on the 200 hall were served with metal flatware at that meal, but said they were usually served with plastic flatware because of their behaviors. The CNA admitted never witnessing any of the residents attempting to harm another resident with their flatware, but had observed the residents on the 100 hall go at each other and one of them had attempted to a stab a member of staff with a fork. On 10/4/18 at 7:52 a.m. during observation of the breakfast meal in the small dining room on the 100 hall, five residents were seen eating eggs, ground meat or bacon, and hash browns. Three of these residents were eating on their own using metal flatware - forks, knives, spoons. Two residents receiving assistance from staff had plastic spoons only. Three residents were observed eating in their rooms; two had only a plastic spoon; and one of these residents was receiving assistance with eating his meal. On 10/4/18 at 8:09 a.m., 10 residents were observed eating breakfast in the dining room on the 200 Hall. All, including R#5, and R#59 were observed to be using metal flatware sets - spoons, knives, forks. During an interview on 10/4/18 at 09:20 a.m. with R#5, it was revealed that she was always served with metal flatware and this without asking. However, she had noticed the other residents in her dining room being served with plastic flatware and some of these residents appeared to have difficulties with the plastic. R#5 said some of the residents with tremors appear to find it difficult to use the plastic ware because the handles on these items are too short to be properly grasped. She recalls an incident in which one of the plastic utensils/flatware had broken off in the mouth of one of the residents. She said the staff had to assist with extricating the plastic from between that resident's teeth. During an interview on 10/4/18 at 9:29 a.m., R#59 said his nerves are so bad that he finds it difficult to pick up the plastic flatware with which most of his meals are served. They know the silver ones are the ones I have to have; it helps me to have that heavy ware. However, he went on to say that one day he is served with the silver ones and the next day the plastic ones. They know it makes me mad, but they do it anyway. Review of the records for R#59 revealed an Occupational Therapy (OT) certification of 7/19/18 which documented that the resident had demonstrated difficulties in scooping food from plate and gripping silver utensils. The OT discharge summary of 9/14/18 revealed the resident had: performed self-feeding task using raised inner edge plate and built up utensils independently. Review of the care plan records for R#59 revealed a plan of care for nutrition which was updated on 10/1/18 to document that the resident's needed a weighted spoon and fork. During an interview on 10/4/18 at 1:15 p.m. the Regional Dietician said he did not give authorization for the dietary staff at the facility to provide anything other than regular flatware for the residents to use at mealtimes. Due to concerns related to dignity, all residents should be served with regular flatware. If for some reason, a resident needed to use an alternative form of flatware/silverware, that resident would be care planned for that need and the staff would discuss the best way to implement this exception. During a follow-up interview on 10/4/18 at 1:22 p.m. with the Food Service Director, he reiterated that the residents eating meals with spoons only or plastic flatware was a measure implemented because some of the residents had behaviors. He (the food service director), not the regional dietitian, had put this in place as a temporary measure after one resident on the 200 hall had attempted to use his flatware as a weapon. That resident was care planned for using alternative flatware, but since the resident wanders around the dietary manager said he felt it would be in the best interest of the other residents if regular flatware were not available on the hallways for the resident with behaviors to use as a weapon against the other residents. The dietary manager said he did not remember when this measure was first implemented, but said that this had not been in place for very long.

Based on record review, review of policy Advance Directives, and staff interviews, the facility failed to provide a Physician's signature and a concurring Physician's signature for an Allow Natural Death (AND) order for one Resident (R#13) and failed to provide written documentation for one of three Residents (R#45) reviewed. Findings include: 1. Record review for R#13 revealed an AND order which was signed on 9/11/18 by daughter and on 9/12/18 by a Physician. However, there was no concurring physician signature, or any documentation found in the chart indicating R#13 daughter was the healthcare agent. Review of the Quarterly Mininum Data Set ((MDS) dated [DATE] the resident was assessed with [REDACTED]. An iInterview on 10/3/18 at 10:50 a.m. with the Social Services Director (SSD) who reported that if a resident does not have decision making capacity and spouse signs the AND order then two physician signatures would be needed. SSD further reported that anytime a Physician order [REDACTED]. Review of Resident # 13 medical record in electronic record system did not reflect an Advanced Directive nor any documentation that Resident # 13 daughter is the health care agent. SSD reported that she and the Admission's Coordinator work together to assure that Advance Directives and orders are carried out per residents wishes. On 10/3/18 at 11:42 a.m. the SSD provided a copy of the Allow Natural Death (A.N.D.) Request for R #13. Review of the policy titled, Advanced Directives last reviewed/revised (MONTH) (YEAR) revealed that during the admission or preadmission process or shortly thereafter, residents are asked if they have an Advanced Directive and encouraged to provide the facility with a copy if there is one. If the resident has not executed an Advanced Directive, the facility will inform the resident/family of the right to establish one. Written and verbal information is given to the resident on the subject during admission/preadmission, and an Advanced Directive Checklist form is completed and filed with the resident's record. This form indicates that written information was provided and whether the resident requested further information or had an Advanced Directive. Review of the clinical records revealed Resident (R) #45 was admitted since 10/12/17. A further review of the clinical records revealed no documentation indicating whether written or verbal information was provided to the resident during the admission/preadmission process about Advanced Directives or the right to establish one. On 10/03/18 at 5:21 p.m., an interview with the Admission Coordinator revealed that upon admission, she has the resident/family indicate if they have an advanced directive or if they would like to have information about Advanced Directives. If the resident and/or family say the resident has an Advanced Directive, they are asked to provide a copy for the resident's records. After searching the clinical records for R #45, the Admission Coordinator could not provide evidence of an Advanced Directive documentation was filed on his behalf.

Based on record review and staff interview, the facility failed to complete a discharge documents that included a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of the resident's medications upon discharge for one resident (#80) from a sample of 43 residents. Findings include: Review of the clinical records revealed Resident (R)#80 was admitted to the facility on [DATE] and discharged home on[DATE]. A further review of the records revealed a note from the Social Services Director (SSD) on 7/17/18 documenting that the resident would discharge home with family on day 21. On 7/25/18, the SSD documented that a referral was made to home health, and on 8/6/18 the SSD documented that the resident was discharged home. A review of the discharge records for R#80 revealed a Discharge Summary that was partially completed by social work and signed by the physician. However, nursing, nutritional services, activity, and therapy sections on the summary were not completed. A further review of the discharge records for R#80 revealed a Discharge Instructions that were not completed. This information covered current status, diet, and discharge medications. During an interview on 10/3/18 at 5:31 p.m. with the SSD, it was revealed that the Discharge Summary which includes a recapitulation of the resident's stay is supposed completed in its entirety upon the discharge of a resident. Social services completes part, and the other disciplines such as nursing completes other parts. The SSD said she was not sure why the entire summary was not completed in this instance because the resident's discharge went according to plan. During an interview on 10/3/18 at 5:58 p.m. with Registered Nurse (RN) DD, it was revealed that the nurses are responsible for filling out part of the discharge paperwork required when a resident is discharged . This includes the education that was provided to the resident/family, the discharge instructions, and a transfer form. Two copies of these discharge documents are printed and signed by the resident/responsible party. One signed copy is given to the resident, and the other is scanned and becomes part of the resident's clinical records. During an interview on 10/4/18 at 11:15 a.m. with the Director of Nursing (DON), it was revealed when a resident is discharged , the nurse fills out a Discharge Instructions for Care form which delineates any follow-ups, discharge medications, and the current status of the resident. The nurse also fills out a Transfer Form if the resident is not being picked up by family. All disciplines, including nursing, social services, activity, therapy, etc., fill out the Interdisciplinary Discharge Summary which includes the Recapitulation Summary. The Discharge Instruction and the Discharge Summary is printed out and signed by the resident/family. Copies of the signed forms are given to the resident and other copies are kept by the facility to be scanned and entered into the resident's record. During a follow-up interview with the DON on 10/04/18 at 1:02 p.m. it was revealed that the facility had no policy/guidelines for discharges.

Based on observation, staff interviews, and the review of facility records, the facility failed to ensure that one (1) resident (#1) remain inside of a locked unit by assuring that all doors were secured to prevent an elopement and safety on one (1) of four (4) halls. Findings include: Review of the Admission Minimum Data Set (MDS) for Resident #1 (R#1) dated 1/12/17 revealed the resident was assessed for delusions, physical and verbal behaviors toward others and wandering. Review of the re-admission MDS dated [DATE] the resident was assessed with [REDACTED]. Review of the care plan for R#1 date 11/27/17 and updated on 2/27/18 related to wandering included interventions to: observed the residents location to ensure safety, Observe wandering behaviors during the night time hours. R#1 eloped from the facility on 2/4/18 and was found walking in the middle of the street, near the facility, by a passerby and a Certified Nursing Assistant (CNA) who was coming to work around 6:30 a.m. An interview with CNA BB on 2/12/18 at 11:35 a.m. revealed that on her way to work on 2/4/18 that she found R#1 walking in the street near the facility. She stopped, in an attempt to protect the resident, and called Dietary staff person BB to report that R#1 was outside the building. CNA BB revealed that she had brought the resident back to faciity, with police officer who had been called by the passerby. An interview with Dietary staff JJ on 2/12/18 at 11:40 a.m. confirmed that CNA BB had contacted him on 2/4/18 and he was asked to let the nurse on the 300 hall (where R#1 resided) which he did. Interview on 2/12/18 at 6:02 p.m with the Nurse Supervisor MM revealed that she was notified at about 6:40 a.m. that R#1 had gotten out of the facility. She revealed that R#1 had went out the 300 Hall door. She revealed that the only staff that can go in or out of that door is the Security Guard KK and the Maintenance Director LL. She revealed a head count was done and confirming that R#1 was missing. She revealed that the Police was there (near the end of the employee parking lot) with the CNA BB and R#1. Review of written statement from security guard on 2/13/18 indicated that on (MONTH) 4, (YEAR) around about 6 a.m. he entered from outside the 300 Hall and he returned to main entrance front desk.

Based on observation, staff interviews, and the facility records, the facility failed to ensure that one (1) resident (#1) remain inside of a locked unit by assuring that all doors were secured to prevent an elopement and safety on one (1) of four (4) halls. Findings include: Observation on 2/12/18 at 9:30 a.m. revealed that the facility is a locked facility that requires all doors to be locked at all times. Interview on 2/12/18 at 11:35 a.m. with Certified Nurse Assistant BB revealed that on her way to work on 2/4/18 at 6:45 a.m. she found R#1 walking in the street about one to two blocks from the facility. Interview on 2/12/18 at 11:40 a.m. with Dietary Staff JJ revealed that he was called by CNA BB and told to notify the nurses of the 300 Hall that R#1 was outside which he did. Interview on 2/12/18 at 3:21 p.m. with the Complainant revealed that R#1 stepped out into the road in front of their car across from the facility at about 6:30 a.m.and that they followed her her down the road until staff came and got the resident. Interview on 2/12/18 at 5:36 p.m. with Security guard KK revealed that he did not know that the resident was missing until the next day. He revealed that he did not know that the nurses did not have the codes to the doors. He revealed that he checked the doors every hour and they were all locked. He revealed that he only enter the facility through the front door. He revealed that the staff could not use the 300 Hall doors. Interview on 2/12/18 at 6:02 p.m with the Nurse Supervisor MM revealed that she was notified at about 6:40 a.m. that R#1 had got out of the facility. She revealed that R#1 had went out the 300 Hall door. She revealed that the only staff that can go in or out of that door is the Security Guard KK and the Maintenance Director LL. She revealed a head count was done and which confirmed that R#1 was missing. She revealed that a car was at the end of the employee parking lot, across the street from the facility, and that the Police were there with the CNA BB and R#1. Interview on 2/13/18 at 11:40 a.m. with CNA RR revealed that she last saw R#1 sitting at the nurse station at about 6:20 a.m. She revealed that she saw the security guard come through the door on the 300 Hall, where R#1 went out. She revealed that at 6:50 a.m a call came in that R#1 was outside the building in the street. She revealed that the staff can not go out of the doorway of the 300 hall because the Security guard is the only one that has the code. She revealed that the 300 Hall exit door is directly in front of the street where the resident was found. She revealed that all doors were checked and that they were locked at this time. Review of the Facility Security Agreement dated 2/12/18 indicated that the Security Guard are to make security rounds inside and out side of building, as well as, on all halls of building. The agreement further indicated that security guards are to make rounds every hour. Review of the Security Office Daily Log dated 2/3/18 indicated tour of the interior and exterior from 2300, 0001, 0100, 0200, 0300, 0400, 0500, 0600, and 0700 were all secured. Review of written statement from security guard on 2/13/18 indicated that on (MONTH) 4, (YEAR) around about 6 a.m. he entered from outside the 300 Hall and he returned to main entrance front desk.