Every finding on record at Country View Living

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the freezer on 12/9/25 at 9:40 AM revealed the following:1. (2) plastic bags of okra, no label or date, not in original box. 2. (3) plastic bags of frozen chicken strips, no label or date, not in original box. Observation of the freezer on 12/10/25 at 11:00 am revealed the following: 1. (2) plastic bags of okra, no label or date, not in original box. 2. (3) plastic bags of frozen chicken strips, no label or date, not in original box. In an interview and a walk through with the DM on 12/10/25 at 11:20 AM, the DM stated she expected the kitchen staff to label and date all food items as they were used or taken out of the box. The DM stated she had done spot checks on a weekly basis. When asked who trained the staff on labeling and dating foods, she stated she had trained the staff on labeling and dating the food. The DM stated the consequences of not labeling and dating foods would be food borne illnesses could make residents sick. Record Review of the policy titled Food Storage dated April 2021, documented: Food must be stored in properly covered containers with a date and label identifying the food item. Foods may remain in the [NAME] box as long as content and date are easily visible on the box. Any food removed from the [NAME] box must be labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #38) of 15 residents reviewed for respiratory care. -Resident #38 was not receiving oxygen at the correct dose. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings included:Record review of Resident #38's face sheet dated 12/10/2025 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease(airway inflammation and difficulty breathing), Obstructive Sleep Apnea(a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), Chronic Respiratory failure with hypoxia(low oxygen levels in the blood), dependence on supplemental oxygen(needs extra oxygen to breathe adequately) and need for assistance with personal care. Record review of Resident #38's Significant Change MDS completed 10/07/2025 listed her with a BIMS of 15 indicating her cognition was intact. Resident #38 was listed as receiving oxygen therapy while a resident.Record review of Resident #38's care plan revealed the following revision for oxygen on 10/03/2025 reflected Resident #38 had altered respiratory status related to COPD with an intervention for supplemental oxygen via nasal cannula to maintain saturation at 92% and above, not to exceed 4 liters. Record review of Resident #38's order summary reports revealed the following active orders: Oxygen via nasal cannula at 4L/min continuously related to Chronic Obstructive Pulmonary Disease dated 02/07/2025.Record review of Resident #38's vitals from 09/11/2025 through 12/10/2025 revealed oxygen saturation was above 92% via n/c.During an observation on 12/09/2025 at 10:08 AM Resident #38 was sitting in her wheelchair and was wearing oxygen via nasal cannula at 2L/min Resident #38 stated she wears her oxygen continuously and believed her supplemental oxygen was supposed to be at 2-3lpm. Resident #38 felt she was getting enough oxygen and had no concerns. During an observation on 12/10/2025 at 10:27 AM Resident #38 was in her room watching television while sitting in her wheelchair and was utilizing oxygen at 2L/min. During an interview on 12/10/2025 at 10:35 AM LVN B (the skilled staff member responsible for Resident #38 this shift) checked Resident #38's oxygen and verified that the current dose being administered was 2L/min. LVN B then reviewed Resident #38's physician orders and noted Resident #38 was ordered to receive oxygen at 4L/min. LVN stated Resident #38's orders were wrong, and the orders should be 2L/min and stated the physician and changed it from 4L/min to 2L/min and it must not have been changed in the system. LVN B stated the 2 liters she was receiving was correct and did not believe there was a negative outcome for not following the physician's order. During an interview on 12/10/2025 at 2:17 PM the DON reported that staff were not following the physician's order per the record. The DON stated Resident #38's oxygen order should have been 2-4L/min rather than 4L/min. The DON stated she had contacted the physician, and the order would be changed to reflect 2-4L/min. The DON stated she and the floor nurses were responsible for ensuring correct dosages were administered and acknowledged that because the physician's order stated 4L/min, the discrepancy would have been addressed. The DON stated that failure to administer the correct oxygen dose could have resulted in harm to the resident. Record review of the facility provided policy titled, Oxygen Administration updated April 2025, reflected the following: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 (Resident #38) of 15 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #38 for the use of CPAP therapy on her significant change of condition MDS assessment completed 10/07/2025. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings included: Record review of Resident #38's face sheet printed 12/10/2025 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), cardiomegaly (enlargement of the heart), and emphysema (a chronic lung condition where the tiny air sacs (alveoli) in the lungs become permanently damaged and enlarged, making it hard to breathe and exhale air). Resident #38's last MDS was a significant change of condition assessment completed 10/07/2025 listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring setup/clean-up assistance from staff with her activities of daily living. Section O - Special Treatments, Procedures, and Programs G1. Non-invasive Mechanical Ventilator BiPAP/CPAP - Resident #38 was not listed as having this therapy While a Resident. Record review of Resident #38's care plan with admission date of 09/03/2024 revealed the following: Problem: Resident #38 has altered respiratory status/difficulty breathing r/t COPD (a group of lung diseases that block airflow and make it difficult to breath) . CPAP. Date initiated: 9/10/2024. Record review of the clinical record for Resident #38 revealed an Order Summary Report with active orders as of 12/10/2025 with the following order:- BiPAP machine at night and PRN setting: in 12, out 7, rate 12, O2-50% as needed related to DYSPNEA (difficulty breathing), UNSPECIFIED (R06.00) Active 02/07/2025. During an observation and interview on 12/09/2025 at 10:08 AM Resident #38 was observed with a CPAP/BiPAP machine on her bedside table. Resident #38 reported she used the machine nightly and the care and staff were good. During an interview on 12/11/2025 at 9:30 AM MDS Coordinator B reviewed Resident #38 Significant Change of Condition MDS completed 10/07/2025 and stated, We did this (the Significant Change of Condition MDS) because she (Resident #38) came off of hospice and no I did not address her use of CPAP therapy. MDS Coordinator B reported the CPAP therapy should have been addressed, she (MDS Coordinator B) had completed the MDS assessment, and she did not know why the CPAP therapy was missing. MDS Coordinator B reported if the CPAP was not addressed on the MDS then the staff could miss administering the therapy if they review the MDS and the residents might not get their care. MDS Coordinator B reported the facility follows the RAI manual for any policy related issues with the MDS assessment. During an interview on 12/11/2025 at 9:38 AM the DON reported if an MDS was not completed accurately then it was an issue. The DON reported the MDS should accurately reflect the residents' condition or an adverse reaction could occur because the MDS was not correct for the residents care. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 (RAI Manual) revealed the following: SECTION O: SPECIAL TREATMENTS, PROCEDURES, ANDPROGRAMS Coding Instructions for Column b. While a ResidentCheck all treatments, procedures, and programs that the resident received or performed afteradmission/entry or reentry to the facility and within the last 14 days. If no treatments,procedures or programs were received by, performed on, or participated in by the residentwithin the last 14 days or since admission/entry or reentry, check Z, None of the above. O0110G1, Non-invasive Mechanical VentilatorCode any type of CPAP or BiPAP respiratory support devices that prevent airways from closingby delivering slightly pressurized air through a mask or other device continuously or viaelectronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables theindividual to support their own spontaneous respiration by providing enough pressure whenthe individual inhales to keep their airways open, unlike ventilators that breathe for theindividual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here.This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device.

Based on interview and record review the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #38) of 25 residents reviewed for advanced directives. Resident #38 had a DNR in her record that was signed incorrectly by the witnesses. The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.Findings included: Record review of Resident #38's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), cardiomegaly (enlargement of the heart), and emphysema (a chronic lung condition where the tiny air sacs (alveoli) in the lungs become permanently damaged and enlarged, making it hard to breathe and exhale air). Resident #38 was as a DNR in the section Advance Directives. Resident #38's last MDS was a significant change of condition assessment completed [DATE] listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring setup/clean-up assistance from staff with her activities of daily living. Resident #38's care plan with admission date of [DATE] revealed the following: Problem:Resident has an order for Do Not Resuscitate. Date initiated: [DATE]. Record review of the clinical record for Resident #38 revealed an Order Summary printed [DATE] with the following order: DNR Active - Revision Date: [DATE]. Record review of the clinical record for Resident #38 revealed a DNR dated [DATE] (signed by the physician) with the following:Section - Two Witnesses: Both witness #1 and witness #2 did not date when they signed the document. During an interview on [DATE] at 10:26 AM LVN A (the nurse responsible for Resident #38 this shift) reported that all residents have their code status listed on the front/first page of their electronic chart, and they have a code book on the unit that lists all residents' code status. LVN A reviewed Resident #38 electronic chart and printed code status and stated, Resident #38 is a DNR so we would not do CPR if she had no heartbeat or was not breathing. LVN A reported she would notify management if Resident #38 was to code (found with no heartbeat of was not breathing). When asked to review Resident #38's DNR form listed in Resident #38's electronic record, LVN A reported both witnesses did not date their signatures therefore the DNR form was not valid. LVN A stated, we would start CPR on her if she coded now. LVN A reported if the DNR was not completed correctly it was not considered valid and would affect the resident care, and the facility would not follow the residents' wishes. During an interview on [DATE] at 9:34 AM the DON reported she had been made aware Resident #38 had the date missing from two signatures on her DNR form. The DON reported she and her staff do a complete audit of all DNR's every 6 months and they check for the proper signatures and just missed the dates. The DON reported if the DNR was incorrect then the process will be done wrong for the residents, because you do not have a legal paper. Record review of the facility provided policy titled Advanced Directives updated [DATE], revealed the following: Policy Statement: Advanced Directives will be respected in accordance with state law and facility policy. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, revised [DATE] revealed the following:-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals

Based on observation, , and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure staff wore a hair restraint while working in the kitchen. B. Ensure stored food was properlycontained and sealed to air after use. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 9/23/24 at 9:20 am the following items in the freezer were observed unsecured and open to air. 1. a box of frozen churro sticks, 2. a brown bag of frozen french fries, not in the original box, 3. a box of frozen cobbler crust dough sheets, 4. a box of frozen fried eggs An observation on 9/24/24 at 11:00 am revealed the same issues in the freezer with no corrections. An observation on 9/25/24 at 1:20 pm revealed FS A was in the cleaning preparation area cleaning the steam table with no hairnet covering her hair. FS A stated she had just forgotten to put it on her hair.She stated she had been trained to wear her hair net at all times in the kitchen. She stated the consequences of her not having a hair net on could cause food borne illness to the residents. In an observation and interview on 9/25/24 at 1:30 pm the Food Service Superviser (FSS) stated she did observe the FS A without a hairnet on at the same time this writer did. She stated she had trained kitchen staff on the use of hairnets and expected all staff to wear hairnets at all times in the kitchen. Observations of the freezer with the FSS revealed the same boxes of frozed foods were still unsecured and open to air. The FSS stated she expected all staff to secure and store all foods propperly and stated all staff had been trained on how to store foods. She stated cross contamination and food borne illness could be a consequence of not securing foods in the freezer. Record review of the facility's policy titled 'Food Safety' dated April, 2021, documented opened packaged food or leftover food is to be tightly wrapped and / or covered in clean air tight containers, labeled dated and stored properly. Record review of the facility policy titled 'Dietary Services Personnel Guidelines' dated March 2021 documented hair must be covered with a hairnet at all times.

Based on interviews and record review, it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 2 of 15 residents reviewed for clinical records (Resident #18 And Resident #20) in that: 1. The facility failed to ensure Resident #18's oxygen therapy was documented in her care plan. 2. The facility failed to ensure the correct interventions were documented in Resident #20's care plan relating to his hydration and cardiovascular health. The facility's failure placed residents requiring care at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care. Findings included: Record review of Resident #18's face sheet dated 09/24/24 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease, personal history of Covid 19, chronic obstructive pulmonary disease and hypertensive heart disease with heart failure. Record review of Resident #18's Annual MDS assessment dated [DATE] reflected Resident #18 had a BIMS score of 00 out of 15 indicating she had severe cognitive impairment. The MDS Assessment revealed she received oxygen therapy. Record review of Resident #18's revised care plan dated 08/30/2024 did not have any documentation related to oxygen therapy. Record review of Resident #18's active physician orders revealed resident may use oxygen @ 2 liters per nasal canula as needed for shortness of breath. Record review of Resident #20's face sheet dated 09/24/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] had diagnoses that included but not limited to type 2 diabetes, mellitus without complications, chronic kidney disease and congestive heart failure. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 had a BIMS score of 15 out of 15 indicating his cognition was intact. Record review of Resident #20's care plan dated 08/02/2024 revealed Resident #20 had cardiovascular status related to hyperlipidemia with interventions of fluid restrictions of 1.5 liters each day-date initiated on 05/03/2024. Record review of Resident #20's physician orders dated 05/03/2024 revealed an order for fluid restriction 1.5 liters each day discontinued on 09/06/2024. In an interview and observation on 09/24/2024 at 8:42 AM, Resident #20 stated he liked to drink milk, and he was able to have milk and juice in his personal refrigerator. Observation of Resident #20's personal refrigerator revealed several cartons of milk and juice in refrigerator. In an observation on 09/24/2024 at 2:40 PM, Resident #18 was sleeping in her bed, oxygen tank in room, Resident #18 was not utilizing the oxygen. In an interview on 09/25/2024 at 9:07 AM, RN B was looking at Resident #20's active orders and could not find any orders for fluid restriction. RN B found the discontinued orders for fluid restriction dated 09/06/2024. RN B stated the MDSC was responsible for ensuring accuracy of records and stated a possible negative outcome for not having accurate records could cause a resident's care not to be effective. In an interview on 09/25/2024 at 9:39 AM, the MDSC stated she and the DON were responsible for ensuring resident records were accurate. The MDSC stated she was not sure how she missed putting the information for oxygen therapy in Resident #18's care plan. The MDSC stated a possible negative outcome for not having accurate records could impact a resident's quality of care. In an interview on 09/25/2024 at 9:51 AM , the DON stated she was responsible for monitoring accuracy of documentation. The DON stated a possible negative outcome for not having accurate records could cause residents to be at risk for something bad to happen. Record review of Charting and Documentation policy revised on July 2017 revealed the following: .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings included: Observation of the kitchen food prep activities on 8/10/23 from 10:45 a.m. to 11:15 p.m. revealed the following: At 10:40 a.m., Cook A was observed in the kitchen preparing purees for the lunch meal on 8/10/23. While preparing the pureed meals Cook A did not change her gloves during the activity. Cook A washed hands and applied gloves to her hands. Cook A walked to the oven, opened the oven doors, and took out a pan of beef casserole. Cook A closed the oven doors. Cook A set the pan onto the counter, removed the foil covering, picked up a scoop and scooped the required amount of casserole into a blender container. Cook A then placed the foil covering back over the casserole pan, opened the door to the oven and placed the casserole back in the oven. Cook A removed the pan of vegetables from the oven. Cook A closed the oven doors, removed the foil from the vegetable pan and scooped vegetables into a blender container. Cook A replaced the foil on the vegetables and placed the pan of vegetables back into the oven. Cook A closed the oven doors and took both blender containers to the blending machine across the kitchen. Cook A got 2 serving pans and 2 scoops from the shelf and brought them to the prep table. Cook A blended the meat casserole touching the lid, blender controls and the prep table while blending the puree. Cook A picked up the blending container from the base with her gloved hands and set the blender container on the counter. Cook A blended the vegetables and then picked up each blender container and poured the blended meat casserole into the serving pan and covered the pan with foil. Cook A then poured the vegetables into the serving pan and covered the pan with foil. Cook A then opened the bread wrapper and pulled a slice of bread from the wrapper and tore the bread into pieces with her gloved hands and put the bread into a 3rd blender container. Cook A then reached into the bread wrapper with her gloved hands and pulled 4 slices of bread from the wrapper and tore the bread with her hands and placed the torn bread into the blender. Cook A picked up a carton of milk opened the container with her gloved hands and poured the milk into the blender. Cook A picked up another container of milk and dropped it on the floor. Cook A walked to the cooler, removed a carton of milk, and brought the milk to the prep table, opened the carton with her hands and poured milk into the blender. Cook A picked up a small container of honey and poured the honey into the blender. Cook A did not make any attempts to change her gloves or wash her hands. In an interview on 8/10/23 at 11:10 AM, Cook A was asked if she realized she touched the bread and various kitchen surfaces while pureeing and had not changed her gloves or washed her hands while pureeing the lunch foods. Cook A stated Yes, I should not have touched the bread without washing my hands first and changing my gloves. Cook A stated she was trained on proper food handling and use of tongs when touching food. She stated touching foods with contaminated gloves can cause food borne illnesses to the residents. Cook A stated she was just nervous. In an interview on 8/11/23 at 9:30 AM, the DM was asked about handwashing, the use of gloves and tongs. The DM stated She shouldn't be touching the food. The DM stated tongs should be used to touch the bread and gloves should be changed between tasks. The DM stated she trusts Cook A's work. Cook A knows to change gloves between tasks and use tongs to touch food. The DM stated the consequences of touching food with contaminated gloves was the spread of bacteria and pathogens contaminate the food the residents eat. The residents could get sick from contaminated food. The DM stated Cook A was just nervous. Record Review of the facility's policies titled Preparation of Food with a date of April 2021, documented: ' Bare hands should never touch food directly. Gloves or serving utensils should be used to handle all foods. Record Review of the facility policy titled Handwashing with a date of April 2021, revealed: Employees are to wash hands between handling of dirty and clean equipment, dishes, utensils, and food. After touching objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces; between handling cooked and uncooked food; The use of gloves or the use of hand sanitizer does not replace handwashing.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA B) of 6 staff observed for resident care. -CNA B did not wash her hands between glove changes while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 08-10-2023 at 10:47 AM when performing incontinent care CNA B cleaned the residents vaginal and peri area, changed her gloves, assisted to roll the resident to her side, cleaned the resident's rectal area, changed her gloves, then placed a new brief on the resident. CNA B did not wash her hands or use ABHR between glove changes. During an interview on 08-10-2023 at 10:56 AM CNA B reported that she should have washed her hands each time she changed her gloves and that she should have washed her hands because she touched the resident each time that she provided care. CNA B reported that by not washing her hands between glove changes she could place the resident at risk of developing germs or bacteria and that could result in an infection. During an interview on 08-10-2023 at 03:48 PM when questioned about expected employee handwashing the Administrator reported that was the responsibility of the nursing department to ensure that handwashing was taken care of and that this surveyor would need to ask that department for guidance. During an interview on 08-11-2023 at 08:48 AM the DON verified that she was responsible for training staff on proper handwashing. The DON reported that staff are to wash their hands when they are visibly soiled otherwise, they can use ABHR between glove changes. The DON reported that staff are to use ABHR and change gloves between each portion of the incontinent care and especially between the dirty portion and clean portion of the incontinent care such as prior to placing a new brief. The DON reported that if handwashing is not followed properly during incontinent care, then residents will be placed at risk for infection and cross-contamination. Record review of the competency assessment titled Perineal Care completed by CNA B on 4-25-2023 revealed the following: Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the residents skin condition. f. After washing genital area, turn to the side, then washes rectal area moving from front to back . j. Remove gloves and perform hand hygiene Record review of the competency assessment titled Hand Hygiene completed by CNA B on 4-25-2023 revealed the following: Objectives: 1. To prevent transmission of infections agents by performing hand hygiene 2. To protect the resident/patient from infectious agents. Record review of the facility provided policy titled Handwashing/Hand Hygiene revised August 2015 revealed the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water in the following situations. h. Before moving from a contaminated body site to a clean body site during resident care. i. After contact with a resident's intact skin. m. After removing gloves. 9. Th use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves 4. Hold and remove glove in the gloved hand and remove the other glove by rolling it down the hand and folding it in the first glove 5. Perform hand hygiene.

Based on observation, interview, and record review, it was determined the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 of 2 medication carts. 3 insulin medications in the 200-Hall medication cart were not marked with the date they were opened and accessed and/or a discard by date. 1 insulin medication in the 200-Hall medication cart was marked with an open date of 4-11-2022, still in use 73 days after opening. 2 insulin medications in the 200-Hall medication cart had no identifying information of which resident they were being used for. The facility's failure to ensure medications were labeled in accordance with currently accepted professional principles could place residents receiving medication at risk for administration of medication that are ineffective resulting in exacerbation of the disease being treated or the introduction of infection from contamination. Findings include: During an observation and interview on 06/23/22 at 12:24 PM of the 200-Hall medication cart with staff member RN D present the following was noted: Resident #30-Humulog Insulin given per sliding scale with an access dated of 4-11-2022. RN D verified that she had administered 2 units from this bottle per Resident #30 sliding scale orders prior to lunch from this bottle, the bottle was almost empty, and it was for a blood sugar of 222mg/dl. During continued observation and interview on 06/23/22 at 12:24 PM RN D verified that Resident #30's [MEDICATION(S)] insulin bottle had no open/access date or dated of discard. RN D verified that she had given Resident #30 30units per Resident #30's scheduled dose this AM from the unmarked [MEDICATION(S)] bottle. During continued interview on 06/23/22 at 12:24 PM RN D verified that both of Resident #30's insulin bottles were not marked correctly and when questioned as to why the insulin bottles were not marked RN D stated, I don't know on these, I didn't access them. When questions if they should be marked with the access date RN D stated, Yes sir. When questioned when an insulin should be discarded after it is opened RN D stated, I want to say 90 days. During continued observation on 06/23/22 at 12:24 PM of the 200-Hall medication cart with staff member RN D present the following was noted: Resident #19 had a [MEDICATION(S)] insulin pen that had been accessed and a [MEDICATION(S)] Insulin Pen that had been accessed. RN D verified that the [MEDICATION(S)] pen was nearly full and the [MEDICATION(S)] pen had approximately 65 units remaining. RN D also verified that both pens had no resident identifying information and that both insulin pens had no open/access date or dated of discard. When questioned if a staff member unfamiliar with the resident was ordered to administer the unidentified insulin would it be safe practice RN D stated, There is no way to tell which resident it would go to. When questioned as to the consequences of not marking insulin with the access date the RN D stated, The insulin will not be effective, and the residents blood sugars would be high. During an interview on 06/23/22 at 12:14 PM the DON reported that insulins should be discarded 28 days after they are accessed. When presented with the insulin that was accessed 4-11-22 the DON stated, This should have been discarded. The DON verified the bottle was almost empty. The DON verified Resident #30's [MEDICATION(S)] was not marked with an access date. The DON verified that both of Resident #19's insulin pens were not marked with open/access dates or dates of discard and had no resident identifying information. When questioned if she was not familiar with Resident #19 would she be able to give him the insulin safely the DON stated, No, I would not know who to give it to. When questioned as to the consequences of not marking insulin with the access date the DON stated, The insulin will not be effective. Record review of the facility provided policy titled Administering Medications revised December 2021, revealed: Policy Interpretation and Implementation 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 14. Insulin pens will be clearly labeled with the resident named or other identifying information. Prior to administering insulin with an insulin pen, the nurse will verify that the correct pen is used for that resident. Record review of the facility provided policy titled Labeling of Medication Containers revised April 2007, revealed: Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current stated and federal regulations. Policy Interpretation and Implantation: 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name b. The prescribing physician's name c. The name, address, and telephone number of the issuing pharmacy . f. Date the medication was dispensed .

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 1of 1 kitchens reviewed for food storage. The facility failed to ensure stored food was properly labeled, dated, and stored. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation on 06/21/2022 at 9:20 AM on initial kitchen rounds revealed the following: 1 re-sealable clear storage bag containing food item, unlabeled, and not in original packaging in the walk-in refrigerator. In an interview on 06/21/202 at 9:20 AM, the DM said the unlabeled storage bag should have been labeled. In an interview on 06/21/2022 at 10:00 AM, the DM stated that the LD had conducted a review of the Kitchen on 06/20/2022. Observation on 06/22/2022 at 11:35 AM, on follow up kitchen rounds revealed the following: 1 re-sealable clear storage bag containing food item, unlabeled, and not in original packaging sitting on the prep table across from the walk-in refrigerator. In an interview on 06/22/2022 at 11:35 AM, the DM identified the food item as small potatoes and said that the food item should not have been out on the table and should have been labeled. The DM said the consequence of improper food handling could be a food-borne illness. Record Review of the Dietary Consulting Report Month: June 2022, signed by LD, revealed 8. Proper dates/labels on foods checked category Needs Improvement. Record Review of the facility's policy titled Food Storage - Refrigerated and Frozen Foods from the Dietary Services Policy and Procedure Manual dated April 2021, documented: PROCEDURE: 6. Food must be stored in properly covered container with a date and label identifying what is in the container. Foods may remain in the [NAME] box as long as content and date are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated and used or discarded before the expiration date B. Ensure general cleanliness was maintained C. Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. D. Ensure dented cans were not placed in the general use food storage area. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: Observations on 3/15/21 beginning at 9:40 AM of the upright front freezer revealed: 1. 1 box of frozen meat patties, open to air 2. 1 box of frozen catfish, open to air Observations on 3/15/21 beginning at 9:42 AM of walk-in refrigerator revealed: 1. 1 package of shredded cheese, open to air, unlabeled, and dated 12/30/20. 2. 1 package of swiss cheese, unopened, undated, with use-by date of 12/25/20. 3. 1 piece of a muffin found on top of package of swiss cheese. 4. 1 muffin upside down with missing piece found on top rack behind bread. Observations on 3/15/21 beginning at 9:55 AM of the pantry revealed: 1. 1 can of pumpkin, dented, dated 12/11/20 2. 1 can of sliced peaches, dented, undated 3. 1 can of Campbell's Chicken Noodle Soup, dented, dated 2/12/20 4. 1 bag of dry cereal, no label, not in original box An observation on 3/16/21 at 7:14 AM revealed FSW H was observed touching heat keeping base, plate, shell-less boiled egg, sausage, scoop, biscuit, knife, scoop, heat keeping cover, and meal ticket with gloved hands. An observation on 3/16/21 at 7:18 AM revealed FSW H was observed touching 2 heat keeping base, 2 plates, 2 shell-less boiled eggs, tongs, 2 biscuits, knife, scoop, 2 heat keeping covers and 2 meal tickets with same gloved hands. In an interview on 3/16/21 at 7:21 AM, FSW H was asked if she realized she touched various surfaces on serving line and picked up the boiled eggs, sausage, and biscuits with her dirty gloved hands. FSW H stated, we always wear gloves and touch food like this. In an interview on 3/16/21 at 7:29 AM, DM was asked about FSW's wearing the same gloves to touch various surfaces and food. DM stated, it's normal for them to use the same gloves. DM stated, staff should be changing gloves before touching food or using tongs. In an interview on 3/16/21 at 8:02 AM, DM was asked where dented cans were kept. DM stated, I have a place in my office that's for all of the dented cans to go. In an interview on 3/17/21 at 8:44 AM, DM was asked how often the walk-in refrigerator and freezer were cleaned. DM stated, they are cleaned every weekend. Record Review of the facility's policy titled Production, Purchasing, Storage- Food and Supply Storage dated 08/18, documented the following: Dry storage: date and rotate items. Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit. Post a sign so items will not be used. Refrigerated storage: date and rotate items. Discard food past the use-by-date. Frozen storage: Wrap food tightly to prevent cross contamination. Record Review of the facility's policy titled Production, Purchasing, Storage- Actions in Response to Deviant Temperatures dated 8/18, documented the following: The use-by date is the last date that a food can be consumed.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 12 (Resident #4, #5, #6, #14, #16, #19, #21, #27, #40, #41, #50, and #52) of 13 residents reviewed for comprehensive care plans. - The facility failed to update the comprehensive person-centered care plans to address resident's needs after MDS assessments. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #4 Record review of Resident #4's undated face sheet revealed an [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's MDS assessments revealed a 5-26-2020 entry, a 6-4-2020 admission, 9-2-2020 quarterly, 11-30-2020 quarterly, and a 2-26-2021 quarterly MDS assessment completed. The most recent MDS, the 2-26-2021 quarterly listed the resident with a BIMS that was not evaluated due to the resident is rarely/never understood and she has a functionality of requiring one-person assistance with all activities Record review of Resident #4's Comprehensive Care Plan revealed a date of initiated 5-31-2020 with review date of 6-11-2020. There were no further reviews. Resident #5 Record review of Resident #5's undated face sheet revealed an [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's MDS assessments revealed an entry 3-10-2020, an admission 3-17-2020, a quarterly 6-10-2020, a quarterly 9-8-2020, a quarterly 12-2-2020, and an annual assessment 3-1-2021. The most recent MDS, the 3-1-2021 annual listed the resident with a BIMS of 8 indicating she is moderately cognitively impaired, and she has a functionality of requiring one-person assistance with all activities Record review of Resident #5's Comprehensive Care Plan revealed a date of initiated 4-19-2020 with review date of 7-18-2020. There were no further reviews. Resident # 6 Record review of Resident #6's undated face sheet revealed that Resident # 6 was an [AGE] year-old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's MDS assessments revealed that she had a quarterly assessment dated [DATE], a discharge with return anticipated assessment dated [DATE], an entry assessment dated [DATE], an admission 5-day assessment dated [DATE], and an annual assessment dated [DATE]. The most recent MDS assessment, the annual assessment dated [DATE], indicated that the resident was not able to participate in a BIMS score assessment due to being rarely/never understood. Record review of Resident #6's comprehensive care plan revealed that the resident's comprehensive care plan was last reviewed and/or revised on 12/17/2020. Resident # 14 Record review of Resident #14's undated face sheet revealed that Resident # 14 was a [AGE] year-old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #14's MDS assessments revealed that she had a quarterly assessment dated [DATE], a discharge with return anticipated assessment dated [DATE], an entry assessment darted 01/09/2021, and a quarterly assessment dated [DATE]. The most recent MDS assessment, a quarterly assessment dated [DATE], indicated that Resident # 14 had a BIMS score of 03 out of 15, indicating severe cognitive impairment. Record review of Resident #14's comprehensive care plan revealed that the resident's comprehensive care plan was last reviewed and/or revised on 12/17/2020. Resident #16 Record review of Resident #16's undated face sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's MDS assessments revealed a quarterly 2-29-2020, an annual 5-11-2020, a quarterly 8-11-2020, a quarterly 10-17-2020, a quarterly 11-13-2020, a discharge 12-18-2020, an entry 12-28-2020, and an annual assessment 1-4-2021, The most recent MDS assessment, the annual assessment dated [DATE], indicated that Resident #16 had a BIMS score of 13 indicating she is cognitively intact and she has a functionality of requiring one-person assistance with all activities. Record review of Resident #16's Comprehensive Care Plan revealed that the resident's comprehensive care plan was reviewed and/or revised 4-16-2020 (6 weeks after the 2-29-2020 MDS), no review after the 5-11-2020 MDS, no review after the 10-17-2020 MDS, and no review after the 11-13-2020 MDS. Resident #19 Record review of Resident # 19's undated face sheet revealed a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #19's MDS assessment revealed a quarterly 1-22-2020, a quarterly 2-26-2020, an annual 5-12-2020, quarterly 6-18-2020, a quarterly 9-17-2020, a discharge 12-21-2020, an entry 12-31-2020, and a quarterly assessment 1-7-2021. The most recent MDS assessment, the quarterly assessment dated [DATE], indicated that Resident #19 had a BIMS score of 7 indicating he is severely cognitively impaired, and he has a functionality of requiring two-person assistance with most activities. Record review of Resident #19's Comprehensive Care Plan revealed that the resident's comprehensive care plan was reviewed and/or revised on 12/17/2020. There were no further reviews. Resident # 21 Record review of Resident # 21's undated face sheet revealed that Resident # 21 was an [AGE] year-old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 21's MDS assessments revealed that she had a quarterly assessment dated [DATE], a quarterly assessment dated [DATE], a discharge with return anticipated assessment dated [DATE], an entry assessment dated [DATE], a discharge with return anticipated assessment dated [DATE], an entry assessment dated [DATE], and an annual assessment dated [DATE]. The most recent MDS assessment, an annual assessment dated [DATE], indicated that Resident # 21 had a BIMS score of 14 out of 15, indicating no cognitive impairment. Record review of Resident # 21's comprehensive care plan revealed that the resident's comprehensive care plan was last reviewed and/or revised on 08/05/2020. Resident # 27 Record review of Resident # 27's undated face sheet revealed that Resident # 27 was an [AGE] year-old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 27's MDS assessments revealed that she had a quarterly assessment dated [DATE], a quarterly assessment dated [DATE], a discharge with return anticipated assessment dated [DATE], an entry assessment dated [DATE], and an annual assessment dated [DATE]. The most recent MDS assessment, an annual assessment dated [DATE], indicated that Resident # 27 had a BIMS score of 03 out of 15, indicating severe cognitive impairment. Record review of Resident # 27's comprehensive care plan revealed that the resident's comprehensive care plan was last reviewed and/or revised on 10/29/2020. Resident #40 Record review of Resident # 40's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #40's MDS assessments revealed an entry 1-20-2020, an admission 1-27-2020, a quarterly 4-22-2020, a quarterly 7-17-2020, a discharge 7-24-2020, an entry 8-7-2020, a significant change of condition 8-18-20, a quarterly 11-17-2020, and a quarterly 2-16-2021. The most recent MDS, the 2-16-2021 quarterly listed the resident with a BIMS that was not evaluated due to the resident is rarely/never understood and he has a functionality of requiring two-person assistance with all activities Record review of Resident # 40's Comprehensive Care Plan revealed that the resident's comprehensive care plan was initiated on 1-25-2020 and was reviewed and/or revised on 5-6-2020 and 9-2-2020. There were no further reviews. Resident #41 Record review of Resident # 41's undated face sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #41's MDS assessments revealed an entry 6-17-2020, admission 6-29-2020, a quarterly 7-16-2020, a quarterly 8-20-2020, a quarterly 11-20-2020, and an annual assessment 2-21-2021. The most recent MDS, the 2-21-2021 annual listed the resident with a BIMS of 13 indicating she is cognitively intact, and she has a functionality of requiring one-person assistance with all activities Record review of Resident #41's Comprehensive Care Plan revealed that the resident's comprehensive care plan was initiated 6-17-2020 and was reviewed and/or revised on 7-8-2020 and 10-7-2020. There were no further reviews Resident # 50 Record review of Resident # 50's undated face sheet revealed that Resident # 50 was an [AGE] year-old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 50's MDS assessments revealed that she had an annual assessment dated [DATE], a quarterly assessment dated [DATE], a discharge with return anticipated assessment dated [DATE], an entry assessment dated [DATE], a quarterly assessment dated [DATE], a quarterly assessment dated [DATE], and an annual assessment dated [DATE]. The most recent MDS assessment, an annual assessment dated [DATE], indicated that Resident # 50 had a BIMS score of 07 out of 15, indicating severe cognitive impairment. Record review of Resident # 50's comprehensive care plan revealed that the resident's comprehensive care plan was last reviewed and/or revised on 04/08/2020. Resident #52 Record review of Resident # 52's undated face sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #52's MDS assessments revealed an entry 3-2-2020, an admission 3-9-2020, a quarterly 6-2-2020, a quarterly 8-26-2020, a quarterly 11-23-2020, and an annual assessment 2-23-2021. The most recent MDS, the 2-23-2021 annual listed the resident with a BIMS of 1 indicating she is moderately cognitively impaired, and she has a functionality of requiring one-person assistance with all activities. Record review of Resident #52's comprehensive care plan revealed that the resident's comprehensive care plan was initiated on 3-27-2020 with the reviewed and/or revised on 6-25-2020. There were no further reviews During an interview on 03/17/21 at 09:01 AM with the DON (in person) and the MDS coordinator (by telephone), the DON confirmed that Resident #16 had an annual MDS done 01/04/2021 and Resident #16's care plan was reviewed last on 08/05/2020. The DON confirmed that care plans should be updated and reviewed after each MDS assessment. This was confirmed by the MDS coordinator. When questioned the DON stated, If the care plans are not up to date then the resident is at risk of not receiving proper care which can result in the resident no getting the care that's needed. The DON and the MDS coordinator both confirmed that multiple staff are currently responsible for updating the care plans to include the DON and the MDS coordinator but due to resent staff turnovers and multiple changes currently going on in the facility per the DON, It has just been missed. During an interview on 03/17/21 at 10:44 AM with the ADM, she reported she could not find any evidence that the care plans for the 12 listed residents have been reviewed and /or revised. The ADM confirmed that the care plans should have been reviewed and revised and that the facility should have evidence of such revisions. Record review of facility provided policy titled. Care Plans, Comprehensive Person-Centered revised December 2016, revealed the following: Policy Interpretation and Implementation 2. The care pan interventions are derived form a thorough analysis of the information gathered as part of the comprehensive assessment. 12. The comprehensive, person-centered care plan is developed within fourteen (14) days of the completion of the required comprehensive assessment (MDS). 14, The Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 out of 5 staff members (CNA C and LVN F), 3 of 14 Residents (Resident # 4, Resident # 19, and Resident # 46), and 1 out of 1 visitors (Individual E) reviewed for infection control and prevention. - LVN F did not change gloves or perform hand hygiene after cleaning the wound of Resident # 4 and before handling clean wound dressing supplies and placing them on the resident's wound per facility policy. - CNA C did not change gloves or perform hand hygiene after wiping the buttocks and rectum of Resident # 19 and handling his soiled brief; and before handling his clean brief, bed sheet and blanket, and shirt per facility policy. - Individual E was visiting with Resident # 46 as an essential caregiver and did not wear a mask or any PPE per facility policy. Resident # 46 was not wearing a mask during visits. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: Resident # 4 Record review of Resident # 4's face sheet, not dated, revealed that Resident # 4 was an [AGE] year-old female admitted to the facility initially on 05/26/2020 with [DIAGNOSES REDACTED]. Record review of Resident # 4's comprehensive care plan revealed the following identified problem: Venous stasis ulcer of left inner ankle, venous stasis ulcer of right outer ankle. During an observation on 03/16/2021 at 1:38 PM LVN F performed wound care for a wound on the right outer ankle of Resident # 4. LVN F, while wearing gloves, cleaned the wound and dried it using gauze pads. LVN F, without changing gloves or performing hand hygiene, then handled a clean xeroform dressing and placed it on the resident's wound. During an interview on 03/16/2021 at 1:40 PM, LVN F was asked if he should have changed gloves before handling the clean dressing and securing it over the resident's wound. LVN F replied, No I should have changed my gloves before I put on the new dressing. When asked about the potential consequences of his actions, LVN F replied, It could contaminate the wound. During an interview on 03/17/2021 at 9:08 AM, ADON was asked if staff performing wound care are expected to change gloves and perform hand hygiene after cleaning a wound and before applying a clean dressing. ADON replied, Yes, they should change their gloves before that put on a new dressing. We have reviewed that process with LVN F and he understands he should change his gloves and wash his hands frequently. Resident # 19 Record review of Resident # 19's face sheet, not dated, revealed that the resident was a [AGE] year-old male admitted to the facility initially on 06/05/2019 with [DIAGNOSES REDACTED]. Record review of Resident # 19's quarterly MDS assessment dated [DATE] revealed in section H that he had an indwelling catheter and was frequently incontinent of bowel. Section I of the MDS indicated that he had a history of [REDACTED]. During an observation on 03/16/2021 at 9:37 AM, CNA C performed catheter and incontinent care on Resident # 19. During the observation CNA C, while wearing gloves, wiped the buttocks and rectal area of Resident # 19, removed the resident's soiled brief, handled a clean brief and placed it on the resident, and repositioned the resident in bed. While repositioning the resident in bed, CNA C touched the resident's bed sheet, blanket, and shirt. CNA C conducted all these actions without having changed gloves or performing hand hygiene. During an interview on 03/16/2021 at 10:51 AM CNA C reported that she felt as though she should change gloves after cleaning a resident and removing a dirty brief but before touching a clean brief and other objects. CNA C claimed she was taught by the facility not to change gloves between handling a dirty and clean brief. CNA C stated, I do it the way I was taught, and I was taught not to change gloves between dirty and clean briefs. During an interview on 03/16/2021 at 1:37 PM CNA D reported that changing gloves and hand hygiene must be done before handling clean objects after having handled dirty things such as wiping a resident during incontinent care or handling a dirty brief. CNA D reported that the facility trained her to do so and reported that the reason for such actions is so they don't get infections. During an interview on 03/17/2021 at 9:08 AM, DON reported that staff performing catheter and/or incontinent care are expected to change gloves and perform hand hygiene before handling clean objects after they have handled soiled objects. Resident # 46 Record review of Resident # 46's face sheet, not dated, revealed that the resident was an [AGE] year-old male initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of facility provided document titled Sign-In for Infection Control and Prevention Class, dated 09/22/2020, intended for family and visitors, revealed that Individual E had received infection control training from the facility related to being a visitor. Record review of facility provided document titled Isolation Mask Competency Checklist, dated 09/22/2020, revealed that Individual E had signed the document indicated she was trained on properly wearing a mask while in the facility. The content of the document revealed in part: Placing and wearing isolation mask technique 5. Keep mask on at all times especially when coughing or sneezing. Remember to cough or sneeze into elbow. During an observation and interview on 03/15/2021 at 10:20 AM, Resident # 46 was in his room sitting in a recliner and Individual E was sitting in another recliner in the room beside him. Neither Resident # 46 or Individual E were wearing a mask or face covering of any kind. Individual E reported that she was visiting the resident and occasionally volunteered at the facility. During an observation and interview on 03/16/2021 at 9:11 AM, Resident # 46 was sitting in a recliner in his room and Individual E was standing in the room beside. Individual E was facing the resident and within 3 feet of him. Individual E reported that she was visiting the resident and was asked if she is supposed to be wearing a mask. Individual E replied, Not in here I don't but if I leave this room, yes. During an interview on 03/16/2021 at 9:19 AM, LVN A reported that Individual E visits Resident # 46 as an essential caregiver and occasionally volunteers at the facility to play the piano. LVN A reported that Individual E was currently in the building in the capacity of an essential caregiver visitor for Resident # 46. LVN A reported that Individual E is supposed to wear a mask in the building, but when asked if that included while she is in the room of Resident # 46, LVN A claimed that she was not sure if Individual E had to wear a mask in that room or not. During an interview on 03/16/2021 at 9:24 AM, RN B reported that essential caregivers and visitors must wear a mask the whole time that are in the building. When asked if Individual E should be wearing a mask while in Resident # 46's room with him, RN B replied, Yes. During an observation on 03/16/2021 at 9:37 AM of the front door of the facility, there was a sign on the door that read, MASKS REQUIRED. During an interview with ADM and DON on 03/16/2021 at 10:56 AM, Don reported that Individual E enters the facility as an activity volunteer and as a visitor for Resident # 46. Don reported that Individual E is an essential caregiver visitor for Resident # 46. Don stated that Individual E is supposed to wear a mask in the facility all the time. ADM reported that Individual E went through the essential caregiver training regarding PPE which includes wearing a mask throughout visits. Record review of facility provided policy titled Handwashing/Hand Hygiene, dated August 2015, revealed in part: Policy Interpretation and Implementation 7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin j. After contact with blood or body fluids; k. After handling used dressing, contaminated equipment, etc.; Record review of guidance document by the CDC titled Hand Hygiene in Healthcare Settings, dated 01/30/2020, and accessed from https://www.cdc.gov/handhygiene/providers/guideline.html, revealed in part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately after touching a patient Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Record review of facility provided policy titled Standard Precautions, dated December 2007, revealed in part: Standard precautions include the following practices: 1. Hand Hygiene d. Wash hands after removing gloves (see below) 2. Gloves e. Change gloves, as necessary, during care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Record review of facility provided policy titled Country View Living Visitation Policy, not dated, revealed in part: Essential Caregiver Visits Visitation Rules 1. The resident will wear a facemask or face covering (if tolerated) throughout the visit. 6. The visitor will wear a facemask or face covering over both the mouth and nose throughout the visit. Visitation Process/Scheduling for Essential Designated Care Givers 5. Assign staff for visitation watch/check-in, sanitation 7. Monitor for compliance with visitation Record review of guidance document by CDC titled Infection Control for Nursing Homes, dated 11/20/2020 and accessed from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed, in part: Implement source control measures: Visitors, if permitted into the facility, should wear a cloth face covering while in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 out of 3 Residents (Resident #19) reviewed for incontinent and catheter care. - CNA C did not change gloves or perform hand hygiene after wiping the buttocks and rectum of Resident #19 and handling his soiled brief; and before handling his clean brief, bed sheet and blanket, and shirt per facility policy. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections and contracting urinary tract infections. Findings include: Record review of Resident #19's face sheet, not dated, revealed that the resident was a [AGE] year-old male admitted to the facility initially on 06/05/2019 with [DIAGNOSES REDACTED]. Record review of Resident #19's quarterly MDS assessment dated [DATE] revealed in section H that he had an indwelling catheter and was frequently incontinent of bowel. Section I of the MDS indicated that he had a history of [REDACTED]. During an observation on 03/16/2021 at 9:37 AM, CNA C performed catheter and incontinent care on Resident #19. During the observation CNA C, while wearing gloves, wiped the buttocks and rectal area of Resident #19, removed the resident's soiled brief, handled a clean brief and placed it on the resident, and repositioned the resident in bed. While repositioning the resident in bed, CNA C touched the resident's bed sheet, blanket, and shirt. CNA C conducted all these actions without having changed gloves or performing hand hygiene. During an interview on 03/16/2021 at 10:51 AM CNA C reported that she felt as though she should change gloves after cleaning a resident and removing a dirty brief but before touching a clean brief and other objects. CNA C claimed she was taught by the facility not to change gloves between handling a dirty and clean brief. CNA C stated, I do it the way I was taught, and I was taught not to change gloves between dirty and clean briefs. During an interview on 03/16/2021 at 1:37 PM CNA D reported that changing gloves and hand hygiene must be done before handling clean objects after having handled dirty things such as wiping a resident during incontinent care or handling a dirty brief. CNA D reported that the facility trained her to do so and reported that the reason for such actions is so they don't get infections. During an interview on 03/17/2021 at 9:08 AM, DON reported that staff performing catheter and/or incontinent care are expected to change gloves and perform hand hygiene before handling clean objects after they have handled soiled objects. Record review of facility provided policy titled Catheter Care, Urinary, dated September 2014, revealed in part: Steps in Procedure 5. Put on gloves 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. 8. Pour wash water down the commode. Flush the commode. 9. Place soiled linen into designated container. 10. Put on clean gloves. 11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. 12. Provide privacy. 13. With nondominated hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. 14. Assess the urethral meatus. 15. For a female resident . 16. For a male resident male: Use a washcloth with warm water and soap to cleanse around the meatus. 17. Use clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 18. Secure catheter utilizing a leg band. 19. Check drainage tubing and bag to ensure that the catheter is draining properly. 20. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry hands thoroughly. 21. Reposition the bed covers. Make resident comfortable. Record review of facility provided policy titled Handwashing/Hand Hygiene, dated August 2015, revealed in part: Policy Interpretation and Implementation 7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin j. After contact with blood or body fluids; k. After handling used dressing, contaminated equipment, etc.; Record review of guidance document by the CDC titled Hand Hygiene in Healthcare Settings, dated 01/30/2020, and accessed from https://www.cdc.gov/handhygiene/providers/guideline.html, revealed in part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately after touching a patient Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Record review of facility provided policy titled Standard Precautions, dated December 2007, revealed in part: Standard precautions include the following practices: 1. Hand Hygiene d. Wash hands after removing gloves (see below) 2. Gloves e. Change gloves, as necessary, during care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 3 Residents (Resident # 19) reviewed for incontinent and catheter care. The facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 out of 3 nurse aides (CNA C) reviewed for skills competency. - CNA C did not change gloves or perform hand hygiene after wiping the buttocks and rectum of Resident #19 and handling his soiled brief; and before handling his clean brief, bed sheet and blanket, and shirt per facility policy. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing exposure accidents, hazards, and communicable diseases and infections. Findings include: Record review of Resident #19's face sheet, not dated, revealed that the resident was a [AGE] year-old male admitted to the facility initially on 06/05/2019 with [DIAGNOSES REDACTED]. Record review of Resident #19's quarterly MDS assessment dated [DATE] revealed in section H that he had an indwelling catheter and was frequently incontinent of bowel. Section I of the MDS indicated that he had a history of [REDACTED]. Record review of Resident #19's comprehensive care plan revealed the following identified problems: (Resident # 19) does have an indwelling catheter at this time. (Resident # 19) has an indwelling catheter. During an observation on 03/16/2021 at 9:37 AM, CNA C performed catheter and incontinent care on Resident #19. During the observation CNA C, while wearing gloves, wiped the buttocks and rectal area of Resident #19, removed the resident's soiled brief, handled a clean brief and placed it on the resident, and repositioned the resident in bed. While repositioning the resident in bed, CNA C touched the resident's bed sheet, blanket, and shirt. CNA C conducted all these actions without having changed gloves or performing hand hygiene. During an interview on 03/16/2021 at 10:51 AM CNA C reported that she felt as though she should change gloves after cleaning a resident and removing a dirty brief but before touching a clean brief and other objects. CNA C claimed she was taught by the facility not to change gloves between handling a dirty and clean brief. CNA C stated, I do it the way I was taught, and I was taught not to change gloves between dirty and clean briefs. During an interview on 03/16/2021 at 1:37 PM CNA D reported that changing gloves and hand hygiene must be done before handling clean objects after having handled dirty things such as wiping a resident during incontinent care or handling a dirty brief. CNA D reported that the facility trained her to do so and reported that the reason for such actions is so they don't get infections. During an interview on 03/17/2021 at 9:08 AM, DON reported that staff performing catheter and/or incontinent care are expected to change gloves and perform hand hygiene before handling clean objects after they have handled soiled objects. Record review of facility provide training record for CNA C revealed that the employee received and completed the following trainings: basics of hand hygiene on 12/16/2020, assisting with activities of daily living on 06/13/2020, hand hygiene the basics on 06/17/2020, infection control and prevention 06/22/2020, infection control essentials on 06/29/2020 and 09/08/2020, perineal and catheter care on 06/23/2020, and personal protective equipment on 08/08/2020. Record review of facility provided policy titled Catheter Care, Urinary, dated September 2014, revealed in part: Steps in Procedure 5. Put on gloves 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. 8. Pour wash water down the commode. Flush the commode. 9. Place soiled linen into designated container. 10. Put on clean gloves. 11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. 12. Provide privacy. 13. With nondominated hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. 14. Assess the urethral meatus. 15. For a female resident . 16. For a male resident male: Use a washcloth with warm water and soap to cleanse around the meatus. 17. Use clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 18. Secure catheter utilizing a leg band. 19. Check drainage tubing and bag to ensure that the catheter is draining properly. 20. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry hands thoroughly. 21. Reposition the bed covers. Make resident comfortable. Record review of facility provided policy titled Handwashing/Hand Hygiene, dated August 2015, revealed in part: Policy Interpretation and Implementation 7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin j. After contact with blood or body fluids; k. After handling used dressing, contaminated equipment, etc.; Record review of guidance document by the CDC titled Hand Hygiene in Healthcare Settings, dated 01/30/2020, and accessed from https://www.cdc.gov/handhygiene/providers/guideline.html, revealed in part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately after touching a patient Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Record review of facility provided policy titled Standard Precautions, dated December 2007, revealed in part: Standard precautions include the following practices: 1. Hand Hygiene d. Wash hands after removing gloves (see below) 2. Gloves e. Change gloves, as necessary, during care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.

Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. - LVN A did not alert the facility that she had a family member living in the same house test positive for COVID-19 - LVN A did not answer the screening sheet correctly when asked if she had come in close contact with a person who was COVID positive. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: Record review of facility screening sheets reflected in part: On 8-27-2020, 8-30-2020, 8-31-2020, 9-2-2020, 9-4-2020, and 9-5-2020, LVN A answered the last column of the questionnaire, Exposure to facilities with confirmed COVID-19 cases (Y/N), no on all dates. During an interview with ADM on 9-14-2020 at 1:45 PM, she confirmed that the LVN was exposed to three family members who were COVID positive in August of 2020. ADM was asked if she knew that the LVN A was exposed to COVID before LVN A tested positive. ADM stated that she was not aware that LVN A had been exposed to COVID until she tested positive for COVID on 9-4-2020. ADM stated that she then asked LVN how she thought that she had got COVID and LVN told her that her granddaughter, daughter and husband had all tested positive. ADM stated that she then asked LVN why she did not alert the facility to known exposure, LVN replied that her husband's doctor said that he was ok to work so she assumed that she was too. ADM stated that LVN A's husband does not work in healthcare. ADM was then asked if she had provided education to all staff about reporting in to the facility if exposed to COVID. ADM stated that she had done education with all staff and that LVN A was receiving a write up as soon as she was back at work. During a phone interview with LVN A on 9-14-2020 at 2:14 PM, she confirmed that her granddaughter, daughter and husband had all tested positive for COVID. She stated that her granddaughter tested positive on 8-11-2020. LVN A stated that she alerted the facility after her granddaughter and daughter tested positive and was told that as long as she was having no signs or symptoms she was ok to work. LVN A did not remember who had told her that she could return to work. LVN A stated that she spoke with DON about her husband testing positive for COVID and was told that as long as she had no symptoms she was ok to work. She stated that she was tested on [DATE] as a part of the facility wide testing, and then received her results on 9-5-2020 while she was at work. She confirmed that she left the facility immediately. During an interview with DON on 9-14-2020 at 2:24 PM, she was asked if LVN A called her and told her that her husband was COVID positive. DON stated she did not recall ever receiving a phone call from LVN A telling her that her husband had tested positive, nor any other family member. During an interview with ADM on 9-14-2020 at 2:54 PM, ADM was asked if it was her expectation that staff members who have family members test positive for COVID answer yes to this question. She responded that it was her expectation that staff members who come in close contact with anyone who is COVID positive to answer yes to that question. Record review of facility investigation sheet titled Positive Employers Root Cause Analysis, not dated, reflected in part: LVN A, Day LVN - Positive test on 9-4-2020 - Employee last worked 9-5-2020. She was tested with the facility wide testing. No symptoms or signs of COVID-19. Employee was sent home immediately of learning of her test results. She was asked if she knew where she may have contracted COVID-19. Employee stated that he granddaughter tested positive on 8-10, her daughter tested positive on 8-13, and her husband tested positive on 8-24. She stated that Dr. Rohm told her husband that he probably had it already for a while ant here was no need to quarantine and to just return to work immediately. She stated that she thought because he was cleared to work she was too. She stated that she did not tell anyone at (facility) that her husband was positive. Record review of facility provided policy titled COVID-19 Testing, not dated, reflected in part: Employee Testing - Will notify Administrator or Director of Nursing with any questions, regarding concerns about COVID-19. If a temp or an answer of yes on the questionnaire, employee will don a facemask and exit the facility and notify charge nurse via phone. If they suspect illness or exposure, employee is to call prior to entering building. Record review of facility provided policy titled Infection Control, dated 1-20-2013, reflected in part: POLICY: - Employees exposed, or believed to have been exposed, to any communicable diseases shall report the incident promptly to their immediate supervisor and /or the Infection Control Practitioner RESPONSIBILITIES: - The employee has the responsibility for promptly reporting exposure to communicable disease incident to his/her immediate supervisor Record review of an in service titled: COVID-19 Illness Reporting and Memo dated 4-28-2020, revealed the LVN A received training on facility policy titled infection Control listed above. Record review of Nursing Facility COVID-19 Response Emergency Rule, not dated, reflected in part: (c) A nursing facility must screen all residents, staff, and people who come to the facility for the following criteria: (4) contact in the last 14 days, unless to provide critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED].