Every finding on record at Derry Center for Rehabilitation and Healthcare

Based on observation, interview, and review, the facility failed to provide comfortable and safe temperature levels over several weeks in the main lobby and resident rooms in a facility initially certified in 2003. (Resident identifiers are #1, #2, #3, and #4).Findings include:Observation on 8/26/26 at approximately 11:30 a.m. of the lobby revealed a large portable air conditioner unit powered on. The temperature was set at 64 degrees Fahrenheit and the air conditioning unit indicted the in the room was 75 degrees Fahrenheit. The air was damp and humid, with a noticeable musty odor. The lights were dimmed low and it appeared dark. There were four residents in wheelchairs watching television.Interview on 8/26/26 at approximately 11:50 a.m. with Resident #3 revealed that Resident #3 felt the temperature in the main lobby was uncomfortably warm. He/she stated that the air conditioning had been broken for months and the portable air conditioning unit that the facility was using in the main lobby did nothing to help the warm temperatures. The temperature got worse throughout the day and by the late afternoon it was unbearable.Interview on 8/26/26 at approximately 12:00 p.m. with Resident #1 revealed that they felt it was uncomfortably hot in the main lobby where the large television was located. He/she found it difficult to watch television or engage with other residents. Resident #1 stated that their room was very warm and he/she had purchased a fan which had helped. Resident #1 was not offered an air conditioner for his/her room. Interview further revealed that this had been going on for a few months and the facility was doing nothing about it. He/she stated We have been forced to live like this all summer.Interview on 8/26/26 at approximately 12:30 p.m. with Resident #2's Durable Power of Attorney revealed that Resident #2's room was located near the main lobby. They visited Resident #2 every day and over the last few months, the temperature in Resident #'2's room was uncomfortably warm many days. Interview further revealed that they were not offered a fan or an air conditioner for their room.Interview on 8/26/26 at approximately 12:00 p.m. with Resident #4 revealed that the facility's air conditioning unit was not working for the last two months and Resident #4 was not offered an air conditioning unit for his/her room to help with the uncomfortably hot temperature.Interview on 8/26/26 at approximately 11:45 a.m. with Staff A (Maintenance Director) revealed that the facility's air conditioning unit in the lobby had not worked since early July 2026. The facility had rented a portable air conditioner unit. The facility did not have service scheduled to repair or replace the air conditioning unit. The air temperature in the lobby and several rooms located off the lobby were taken at 2:00 p.m. daily. Staff A stated that if the temperature was above 81 degrees Fahrenheit, the resident was offered a fan or a portable air conditioning unit, for their room or brought to a cooling zone which were designated in the dining room or conference room. Staff A stated they did not consistently take temperatures in July 2026. Review on 8/26/26 of the facility air temperature logs from August 2026 revealed the temperatures were over 81 degrees Fahrenheit on the following dates:On 8/6/26, the air temperature in rooms #30, and #32 were 82 degrees Fahrenheit and rooms #31 was 83 degrees Fahrenheit.On 8/7/26, the air temperature in the lobby was 82 degrees Fahrenheit.On 8/10/26, the air temperature in rooms #17 was 82 degrees Fahrenheit and the lobby was 82 degrees Fahrenheit.On 8/11/26, the air temperature in rooms #1, #2, and the lobby were 83 degrees Fahrenheit and rooms #3 and #30 were 82 degrees Fahrenheit.On 8/14/26, the air temperature in rooms #1 and #17 and the lobby was 83 degrees Fahrenheit.On 8/17/26, the air temperature in room # 31 was 82 degrees Fahrenheit.On 8/18/26, the air temperature in rooms #1, #18, and #19 were 82 degrees Fahrenheit, rooms #31 and #33 were 83 degrees Fahrenheit, and the lobby was 84 degrees Fahrenheit.On 8/19/26, the air temperature in rooms #1, #2, #17, #33 were 83 degrees Fahrenheit, rooms #18 and #19 were 82 degrees Fahrenheit, and the lobby was 84 degrees Fahrenheit.On 8/20/26, the air temperature in room [ROOM NUMBER] was 82 degrees Fahrenheit, rooms #2 and #3 were 83 degrees Fahrenheit, room [ROOM NUMBER] was 84 degrees Fahrenheit, and the lobby was 85 degrees Fahrenheit.On 8/23/26, the air temperature in the lobby was 82 degrees Fahrenheit.Review further of temperatures revealed that there was no documentation for air temperatures for 8/1, 8/2, 8/3, 8/4, 8/8, 8/9, 8/15, 8/16, and 8/23/2026. Resident #1's and Resident #3's rooms were not monitored. Random temperatures were recorded between 7/1/2026 to 7/6/26, 7/10/26, 7/13/26, 7/15/26-7/17/26, and 7/31/26. During those 7 days, 42 of the 150 temperatures taken were about 81 degrees Fahrenheit. Interview on 8/26/26 at approximately 2:00 p.m. with Staff B (Administrator) confirmed the above findings.

Based on observation, interview, and record review, the facility failed to ensure appropriate sanitization of dishware in 1 of 1 kitchen observed.Findings include:Review on 8/27/26 of manufacturer instructions for Cleanslate Knoxville Disinfectant + Sanitizer _Virucide revealed .As a no-rinse sanitizer it requires no potable rinse when used at 1/4 oz (ounce) per gallon of water to sanitize dishes, cooking equipment, glassware and other food contact surfaces. Broad-spectrum hospital disinfectant + food-contact sanitizer kills listed bacteria and viruses (including SARS-CoV-2) in 1 minute) on hard non-porous surfaces; sanitizes 3-compartment sinks and food contact surfaces at 200-400 ppm (parts per million), when used as directed Interview on 8/26/26 at approximately 11:45 a.m. in the kitchen with Staff C (Director of Food Service) revealed that three-compartment sink was being used to wash pots, pans, serving utensils, drink containers, and/or anything they used to cook with, while the dishwasher was out of service for the last two weeks. Interview further revealed that they test the chemical sanitizer solution in the three-compartment sink with a Quaternary Ammonium Compound Quick Response test strip.Observation on 8/26/26 at approximately 11:45 a.m. of the Three-Compartment Sink area revealed there no documentation that the chemical sanitizer solution was tested prior to use over the last 2 weeks when the three-compartment sink was being used to wash dirty cooking equipment.Interview on 8/26/26 at approximately 12:00 p.m. with Staff C confirmed that they were not documenting the results of the Quaternary Ammonium Compound Quick Response test strip to ensure that proper sanitizing was being achieved during use of the three-compartment sink while washing cooking equipment.

Based on interview and record review the facility failed to document post fall assessments for 2 of 3 residents reviewed for falls. (Resident identifiers are #1 and #2.)Findings include:Review on 2/6/26 of Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 2/6/26 revealed, When a Fall Occurs . Step one: assessment. When a patient falls, don't assume that no injury has occurred-this can be a devasting mistake. Before moving the patient . conduct a comprehensive assessment . Step three: monitoring and reassessment. After the patient returns to bed, perform frequent neurologic and vital sign checks . Step four: documentation. Follow your facility's policies and procedures for documentation a fall . documentation for a fall should include: all observations. patient statements. assessments, notifications. interventions. evaluations . Resident #1 Interview on 2/5/26 at 10:25 a.m. with Staff C (Registered Nurse) revealed that on 1/21/26 they had assessed Resident #1 after a fall on 1/21/26. Staff C revealed that Resident #1 was on the floor leaning against the wall complaining that their head hurt. Staff C revealed they assessed Resident #1 to have an egg (a lump) on the back of their head and pointed to their groin area and complained it was painful and sensitive. Staff C revealed that they transferred Resident #1 to a chair with a Licensed Nursing Assistant and then transferred Resident #1 to bed (with Staff B). Staff C revealed that once in bed, Resident #1 had increased pain in the right leg. Staff C revealed that they themself had assessed Resident #1 after the fall but did not document any findings in Resident #1's medical record. Review on 2/5/26 of Resident #1's progress notes revealed the following:On 1/21/26 at 1:50 p.m. [Resident #1] was found on floor in [pronoun omitted] room by staff nurse. [Resident #1 was c/o (complaining of) severe pain on [pronoun omitted] right parietal scalp and in [pronoun omitted] right leg/hip/pelvis area. [Pronoun omitted] was unable to extend [pronoun omitted] leg out straight due to the pain. Provider notified and ordered. sent to the ER for evaluation. This was signed by Staff B (Assistant Director of Nursing). On 1/22/26 at 4:04 p.m. IDT (Interdisciplinary Team) NOTE: [Resident #1] was found on the floor by staff nurse and stated that [pronoun omitted] hit her right side of her head and a small abrasions was noted, a full body assessment was done and no other injuries noted but [name omitted] would not extended [sic] her leg straight out and due to [pronoun omitted] impaired cognition [pronoun omitted] could not articulate if [pronoun omitted] was having pain. [Resident #1] was assisted back to chair and that time [pronoun omitted] c/o pain in [pronoun omitted] right leg. [Resident #1] was lifted to bed without weight bearing on [pronoun omitted] right lower extremity. We were unable to assess her RLE (right lower extremity) for shortening or rotation because [pronoun omitted] pain would not allow. Provider ordered xrays [sic] and they were not able to be completed due to [pronoun omitted] pain. INTERVENTION: Per provider [pronoun omitted] was sent to the ER for evaluation. This was signed by Staff B. Review on 2/5/26 of Resident #1's medical record revealed there were no vital signs or neurological checks were documented, and no documentation by Staff C of the assessment that was performed while Resident #1 was on the floor. Interview on 2/5/26 at 2:00 p.m. with Staff A (Director of Nursing) confirmed documentation regarding Resident #1's fall in the chart. Staff A confirmed that there was no documented vital signs or neurological checks in Resident #1's medical record after the fall despite remaining at the facility for approximately 2 hours before being transported to the hospital. Staff A revealed that Resident #1 should not have been moved if they were complaining of pain. Resident #2 Review on 2/5/26 of Resident #2's medical record revealed a progress note, dated 1/19/26, that revealed: pt [patient] found on floor next to bed when asked why [pronoun omitted] didn't wait for help [pronoun omitted] stated because I don't want to wait pt no skin issues moved from floor to w/c [wheelchair]. Further review of Resident #2's medical record revealed an IDT (Interdisciplinary Team) note dated 1/20/26 that revealed: [Name omitted] had a fall on 1/19 at 1440 in [pronoun omitted] room while trying to transfer [pronoun omitted] from bed to chair. No injuries were noted on full body assessment by unit manager. [Name omitted] was assessed back to bed . No other progress notes or documentation of residents assessment after the fall found. Interview on 2/5/26 with Staff B (Assistant Director of Nursing) at approximately 1:10 p.m. revealed that any documentation of the full body assessment referred to in the above IDT note. Review on 2/5/26 of the facility's policy tilted Assessing Falls and Their Causes with a revision date of March 2018 revealed, . After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Documentation: When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aide, or treatment administered. Review on 2/5/26 of the facility's policy titled Accident and Incidents – Investigation and Reporting revised July 2017 revealed, . The following data, as applicable, shall be included on the Report of Incident/Accident form. i. The condition of the injured person, including his/her vital signs. k. Any corrective action taken.

Based on interview, observation and record review it was determined that the facility failed to follow currently accepted professional principles for labeling and storing medications in 1 of 1 medications cart and in 1 of 1 medication room observed. (Resident identifiers are #1, #21, and #34 .)Findings include: Observation on 12/9/25 at approximately 8:20 a.m. of the facility's medication room revealed one open bottle of Tuberculin Purified Protein Derivative (Mantoux) with an open date of 10/22/25 and to discard after 30 days. Interview on 12/9/25 at approximately 8:25 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Review on 12/9/25 of the manufacturer's instructions for Tuberculin Purified Protein Derivative, dated October 2021, revealed .A vial of Tubersol which has been entered and in use for 30 days should be discarded . Observation on 12/9/25 at approximately 8:45 a.m. of the East Medication Cart revealed one open bottle of Brimodine eye drops with no open date or open expiration date for Resident #21, one Symbicort Inhaler with no open date or open expiration date for Resident #1, one open Breyna inhaler with no open date or open expiration date for Resident #34, and one Symbicort Inhaler with no open date or open expiration date for Resident #34. Interview on 12/9/25 at approximately 9:00 a.m. with Staff B (Registered Nurse) confirmed the above findings. Review on 12/9/25 of the Consumer Medicine Information for Brimodine, Dated May 2017, revealed . Storage . Discard the eye drops 4 weeks after opening . Review on 12/9/25 of the patient instructions for Breyna inhaler, revision date 9/2020, revealed . Throw away Breyna when the counter shows zero ('0) or 3 months after you take your Breyna inhaler out of its foil pouch, whichever comes first . Review on 12/9/25 of the manufacturer's instructions for Symbicort, revised December 2017, revealed . throw away Symbicort when the counter reaches zero (0) or 3 months after you take Symbicort out of its foil pouch, whichever comes first . Review on 12/9/25 of the facility policy titled Administering Medications, revised April 2019, revealed 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the open date is recorded on the container.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that multi dose medications were labeled appropriately in 1 out of 1 medication carts observed. Findings include: Observation on 10/14/24 at approximately 8:20 a.m. of the East Medication Cart with Staff A (Licensed Practical Nurse) revealed the following: Resident #6's open Humalog pen with no open or discard dates; Resident #11's open Lispro insulin pen with a hand written open date of 9/20/24 and an incorrect hand written discard date of 9/1/24; Resident #19's open Lispro insulin vial with no open date or discard date; Resident #19's open Lantus insulin pen with no open date or discard date; Resident #24's two open Humalog insulin pens with no open or discard dates; Resident #30's open Lyumjev insulin pen with no open or discard date; Resident #30's open Tresbia insulin pen with no open or discard date; Resident #32's open Basaglar insulin pen with no open or discard date; Resident #32's open Novolog insulin pen with a hand written open date of 9/11/24 and a hand written discard date of 10/2/24; Resident #33's open Lantus pen with no open or discard dates; Resident #36's open bottle of Ciprofloxine 0.3% Dexamethasone 0.1% ear drops with no open or discard date; Resident #47's open Lispro insulin pen with no open or discard dates; Resident #47's open Admelog insulin pen with a hand written open date of 9/18/24 and a hand written discard date of 10/2/24; Resident #47's open Apidra insulin pen with a hand written open date of 9/10/24, a hand written discard date of 10/8 and a pharmacy sticker that read discard 28 days after opening; An open bottle of Systane gel eye drops with no resident name or identifiers; An open bottle of Prednisolone 1% (percent) eye drops with no resident name or identifiers and a hand written open date of 6/5/24; An open Basaglar insulin pen with no resident name or identifiers, and no open or discard date. Review on 10/16/24 of the following manufacturer's instructions revealed: Lispro insulin vial and pen - discard 28 days after opening; Lantus insulin pen - discard 28 days after opening; Humalog insulin pen - discard 28 days after opening; Lyumjev insulin pen - discard 28 days after opening; Tresbia insulin pen - discard 56 days after opening; Basaglar insulin pen- discard 28 days after opening; Admelog insulin pen -discard 28 days after opening; Interview on 10/14/24 with Staff A confirmed the above findings. Review on 10/16/24 of facility policy titled, Labeling of Medication Containers, revised on April 2019, revealed: . Labeling for individual resident medications include all necessary information, such as: a. The resident's name .Appropriate accessory and cautionary statements .expiration date when applicable .Directions for use .

Based on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications were appropriate for 1 of 1 resident reviewed for choices in a final sample of 15 residents (Resident Identifier #31). Findings include: Observation on 10/14/24 at approximately 9:15 a.m. of Resident #31's room revealed an albuterol inhaler on Resident #31's bedside table. Interview on 10/14/24 at approximately 9:15 a.m. with Resident #31 revealed that they use the albuterol inhaler as needed. Review on 10/14/24 of Resident #31's medical record revealed that there was no physican's order for an albuterol inhaler and no self administration assessment had been completed with Resident #31. Interview on 10/14/24 at approximately 12:00 p.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Review on 10/16/24 of facility policy titled, Self-Administration of Medications, revised on February 2021, revealed: . 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident .

Based on record review and interview, it was determined that the facility failed to notify residents of the bed hold policy before a transfer for 2 of 2 resident's reviewed for hospitalization s in a final survey sample of 15 residents (Resident Identifiers are #8, #47 and #51). Findings include: Resident #8 Review on 10/15/24 of Resident #8's medical record revealed they had been discharged to the hospital on 4/15/24. Further review of Resident #8's medical record revealed no evidence that the bed hold policy was provided to Resident #8 upon transfer to the hospital. Resident #47 Review on 10/15/24 of Resident #47's medical record revealed that they had been discharged to the hospital on 8/20/24 and on 9/21/24. Further review of Resident #47's medical record revealed no evidence that the bed hold policy was provided to Resident #47 upon either transfer to the hospital. 28881 Resident #51 Review on 10/15/24 of Resident #51's medical record revealed that they had been discharged to the hospital on 7/29/24. Further review of Resident #51's medical record revealed no evidence that the bed hold policy was provided to Resident #51 upon transfer to the hospital. Interview on 10/15/24 at 12:00 p.m. with Staff B (Business Office Manager) confirmed that there was no bed hold policy provided to Resident #8, #47 or #51 at the time of transfer. Staff B stated the facility notifies the resident about the bed hold policy at admission as part of the admission packet. Review on 10/15/24 of the facility's policy titled, Bed-Holds and Returns, revised March 2022, revealed: .Residents are provided with written information about these policies at the time of transfer (or, if the transfer was an emergency, within 24 hours) .

Based on observation, interview and record review, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for Enhanced Barrier Precautions (EBP) for 2 of 2 residents reviewed for infection control in a sample of 15 residents (Resident Identifiers are #4 and #10). Findings include: Resident #4 Observation on 10/14/24 at approximately 11:50 a.m. revealed no EBP sign or Personal Protective Equipment (PPE) outside Resident #4's room. Review on 10/14/24 of Resident #4's medical record revealed a care plan for .Hx [History] of MDRO [MultiDrug Resistant Organism] related to ESBL [Extended Spectrum Beta-Lactamase] in urine (colonized) with a history of frequent UTI's [Urinary Tract Infections] . initiated on 8/17/23 and revised on 7/24/24. Further review of the care plan revealed an intervention initiated on 7/17/24 stating .Maintain enhanced barrier precautions related to history of colonized ESBL . Interview on 10/15/24 at approximately 11:30 a.m. with Staff D (Unit Manger) revealed that Resident #4 was not on EBP. Staff D confirmed that Resident #4 was colonized with ESBL in their urine. 28881 Resident #10 Review on 10/14/24 of Resident #10's medical record revealed an open wound on the right heel that the resident had upon admission. Interview on 10/14/24 at approximately 9:30 a.m. with Staff F (Director of Nursing) confirmed Resident #10 had a pressure ulcer to the right heel and was not on any precautions. Observation on 10/15/24 at approximately 11:30 a.m. revealed no EBP sign or PPE inside or outside Resident #10's room. Interview on 10/15/24 at approximately 11:45 a.m. with Resident #10 revealed that when staff provide treatment to the pressure ulcer, they wear gloves but do not wear protective gowns. Interview on 10/16/24 at approximately 10:00 a.m. with Staff E (Infection Preventionist) confirmed the above findings and that Resident #4 and #10 should have had EBP in place. Review on 10/16/24 of the facility policy titled, Enhanced Barrier Precautions, revised on August 2023, revealed: . EBP's are indicated (when contact precautions do not other wise apply) for residents infected or colonized with the following: .g. ESBL-producing Enterobacterales .10. signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms . Review on 10/16/24 of Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) on the CDC website, found at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html and updated on 7/12/22, revealed: .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering,Transferring,Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheotomy/ventilator, Wound care: any skin opening requiring a dressing.

Based on observation and interview, it was determined that the facility failed to ensure that dietary staff use facial hair restraints when cooking and serving food from the steam table and failed to maintain a clean environment for 1 of 1 kitchens observed for meal service and failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchenettes observed. Findings include: Review on 6/4/24 of the U.S. Food and Drug Administration Food Code dated 2017 retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 2 Management and Personnel .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens .Chapter 3 Food .3-305.11 Food Storage .Food shall be protected from contamination by storing the Food: .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods .Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods .Chapter 4 Equipment, Utensils, and Linens .Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-serve and single-use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination and (3) At least 15 cm (6 inches) above the floor. (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted .Chapter 6 Facilities .6-501.12 Cleaning, Frequency and Restrictions. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared .6-501.13 Cleaning Floors, Dustless Methods. Dustless floor cleaning methods must be used so that food; equipment, utensils, and linens; and single-service and single-use articles are not contaminated . Kitchen: Observation on 6/4/24 at 7:00 a.m. of the kitchen floor revealed that there were food particles and food debris built up under the counters and steam table. The floor was sticky and had dried liquid stains in front of the stove and around the steam table. Interview on 6/4/24 at 7:01 a.m. with Staff E (Cook) confirmed the above finding. Interview also revealed that the floors would get swept after each meal and mopped at night after dinner services by the night staff. Staff E stated that many mornings when he/she arrived, the floors still had crumbs and dried food debris from the day before. Observation on 6/4/24 between 7:05 a.m. to 7:55 a.m. of Staff E in the kitchen revealed that Staff E was cooking cream of wheat, eggs and making toast. Staff E had a beard that was over an inch long that was not covered with a beard restraint. Interview on 6/4/24 a.m. with Staff E confirmed the above findings. Staff E revealed that he/she never wore a covering over his/her beard and that the facility doesn't have any to use. Observation on 6/4/24 between 7:55 a.m. to 8:25 a.m. of Staff E in the kitchen revealed that Staff E was serving food from the steam table onto plates and wasn't wearing a beard restraint. Observation on 6/4/24 at 9:45 a.m. of the kitchen revealed that the food mixer was not covered while not in use. Interview on 6/4/24 at 9:46 a.m. with Staff F (Dietary Aide) confirmed that the food mixer was not covered. Staff F was unaware of that last time it was used. Interview on 6/4/24 at 1:00 p.m. with Staff D (Dietary Director) confirmed that the facility did not use any coverings for facial hair. Review on 6/4/24 of the night cook cleaning schedule for May 27-June 2, 2024 revealed no documentation that the kitchen floor was mopped each night. Interview on 6/4/24 at 1:05 p.m. with Staff D confirmed the above findings. Review on 6/4/23 of the facility's policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised October 2017, revealed .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . Review on 6/4/23 of the facility's policy titled, Dining Services Cleaning Procedures, revealed .Floors .Clean Daily . Kitchenette: Observation on 6/4/24 at 10:30 a.m. of the kitchenette refrigerator revealed ten Vanilla Mighty Shakes with no thawed date or use by date. Interview on 6/4/24 at 10:35 a.m. with Staff F confirmed the above findings. Staff F was unaware of when the shakes were thawed. Review on 4/23/24 of the manufacturer's instructions for Vanilla Mighty Shakes under storage and handling revealed .Store frozen. Use thawed product within 14 days. Keep refrigerated .

Based on observation, record review and interview, it was determined that the facility failed to implement residents care plan regarding supervision with meals for 2 of 2 residents reviewed for supervision with meals (Resident Identifiers are #1 and #2). Findings include: Interview on 6/4/24 at approximately 8:00 a.m. with Resident #1 revealed that he/she eats alone in his/her room and staff set him/her up. Observation on 6/4/24 at approximately 8:45 a.m. of Resident #1 revealed that he/she was eating breakfast alone in bed. Interview on 6/4/24 at approximately 8:45 a.m. with Staff C (Licensed Nursing Assistant (LNA)) revealed that Resident #1 always eats alone in his/her room after meal set up. Review on 6/4/24 of Resident #1's care plan revealed: FOCUS: ADL [Activities of Daily Living]: [pronoun omitted] has an ADL self care performance deficit related to declined mobility, deconditioning, weakness. Eating: Staff supervision after set-up. Encourage [pronoun omitted] to get out of bed for meals as tolerated; Revision Date 4/26/24. Review on 6/4/24 of Resident #1's LNA documentation under tasks for Eating over the last 30 days revealed the following meals without supervision: Independent at meals -7 times; Setup or clean up assistance- 35 times. Resident #2 Observation on 6/4/24 at approximately 8:45 a.m. revealed Resident #2 was eating breakfast alone in his/her room. Review on 6/4/24 of Resident #2's care plan revealed: FOCUS: ADL: [pronoun omitted] has an ADL self-care performance deficit related to declined mobility, poor vision, declined cognition .Interventions .Eating: Staff supervision after set-up . Revision Date 1/2/24. Review on 6/4/24 of Resident #2's medical record, under tasks Eating, the last 30 days revealed the following meals without supervision: Independent at meals- 5 times; Setup or clean up assistance- 24 times. Interview on 6/4/24 at approximately 11:00 a.m. with Staff A (Director of Nursing) revealed that his/her expectation of supervision at meals would be staff having a visual on the residents.

Based on observation, record review and interview, it was determined that the facility failed to ensure that a resident received adequate supervision to prevent chocking accidents during meals for 1 out of 2 residents reviewed for supervision with meals (Resident Identifier #1). Findings include: Interview on 6/4/24 at approximately 8:00 a.m. with Resident #1 revealed that he/she eats alone in his/her room and staff set him/her up. Observation on 6/4/24 at approximately 8:45 a.m. of Resident #1 revealed that he/she was eating breakfast alone in bed. Interview on 6/4/24 at approximately 8:45 a.m. with Staff C (Licensed Nursing Assistant (LNA)) revealed that Resident #1 always eats alone in his/her room after meal set up. Review on 6/4/24 of Resident #1's care plan revealed: FOCUS: ADL [Activities of Daily Living]: [pronoun omitted] has an ADL self care performance deficit related to declined mobility, deconditioning, weakness. Eating: Staff supervision after set-up. Encourage [pronoun omitted] to get out of bed for meals as tolerated, Revision Date 4/26/24. Review on 6/4/24 of Resident #1's medical record, nursing notes revealed the following nursing note: dated, 5/2/24: approx. [approximately] 1740 [5:40 p.m.] resident began to choke on [pronoun omitted] dinner. Staff member called this nurse for assistance and immediately sat resident up with bed controls. Upon arrival this nurse observed resident attempting to cough without sound. With the assistance of other staff this nurse pulled resident into a full 90 degree sitting position, patted him on the back two times and encouraged him to attempt to say something back to me. Resident was able to speak and then immediately able to expel the piece of food that [pronoun omitted] had been choking on . Further review of Resident #1's medical record revealed a diagnosis of Dysphagia. Review on 6/4/24 of Resident #1's LNA documentation under tasks for Eating over the last 30 days revealed the following meals without supervision: Independent at meals -7 times; Setup or clean up assistance- 35 times.

Based on observation, interview and record review, it was determined that the facility failed to provide food that is palatable and served at an appetizing temperature (Resident Identifiers are #9 and #10). Findings include: Review on 6/4/24 of the U.S. Food and Drug Administration Food Code dated 2017 retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Chapter 3 .Temperature and Time Control 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC [Celsius] (135oF) [Fahrenheit] or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above . Review on 6/4/24 of the Food Council Meeting Minutes, dated March 28, 2024, revealed the following: The temperature of the food was brought up by all residents. They explained it is cold by the time they receive it. Review on 6/4/24 of the Resident Council Meeting Minutes, dated April 24, 2024, revealed the following: Grievances from the last food council meeting have not been addressed. The food still arrives cold. Interview on 6/4/24 at 7:15 a.m. with Staff E (Cook) revealed that the residents have complained of cold food at breakfast when served in their rooms. Interview further revealed that the dining room was not open for breakfast service. Interview on 6/4/24 at 7:40 a.m. with Staff E revealed that the facility did not have a plate warmer or a heated food cart for trays that were brought to resident rooms. Observations on 6/4/24 at 8:05 a.m. of food service being performed, identified that the holding temperature on the steam table of the scrambled eggs prior to being served was 160 degrees Fahrenheit. The holding temperature of the toast on the steam table prior to being served was 172 degrees Fahrenheit. The holding temperature of the cream of wheat on the stove prior to being served was 140 degrees Fahrenheit. A test tray was prepared and left the kitchen at 8:40 a.m. for the [NAME] unit. The last tray was served to a resident at 8:55 a.m. and the test tray was pulled from the tray cart. At that time the scrambled eggs had a temperature of 76 degrees Fahrenheit, the toast had a temperature of 81 degrees Fahrenheit, and the cream of wheat was 85 degrees Fahrenheit. The toast, scrambled eggs and the cream of wheat were tested for temperature. The toast and cream of wheat were cool when tasted. The eggs were found to be at an unappetizing low temperature. Interview on 6/4/24 at 8:40 a.m. with Staff F (Dietary Aide) confirmed the holding temperature of the food items on the test tray when the test tray left the kitchen. Interview on 6/4/24 at 8:55 a.m with Staff I (Licensed Nursing Assistant) confirmed the holding temperature of the food items on the test tray when the test tray was pulled from the tray cart. 49819 Observation on 6/4/24 between 8:00 a.m. to 8:45 a.m. revealed that at 8:00 a.m., two standard open three-tiered rolling carts with hard plastic bowls of cream of wheat covered with a plastic lid. Further observation revealed that at 8:45 a.m. the staff started serving the bowls of cream of wheat to the [NAME] wing residents. Observation also revealed that the metal enclosed meal cart was left open while serving the East wing residents. Interview on 6/4/24 at approximately 9:00 a.m. with Resident #9 revealed that all his/her meals are cold all the time. Interview on 6/4/24 at approximately 9:00 a.m. with Resident #10 revealed that his/her scrambled eggs were cold.

Based on observation, interview, and record review, it was determined that the facility failed to provide a resident with the necessary assistive devices for eating for 1 of 1 resident observed for assistive devices (Resident Identifier #1). Findings include: Resident #1 Observation on 6/4/24 at approximately 8:45 a.m. of Resident #1 revealed that he/she was eating breakfast alone in bed. Further observation of Resident #1's meal tray revealed his/her meal ticket stated that Resident #1 should have a nosey cup and built up silverware on his/her tray. Resident #1's breakfast tray did not have a nosey cup or built up silverware. Interview on 6/4/24 at approximately 9:45 a.m. with Staff D (Dietary Manager) revealed that Resident #1 should have had a nosey cup and built up silverware on his/her breakfast tray. Review on 6/4/24 of the facility policy titled, Assistance with Meals, revision date of March 2022 revealed: . Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards and/or specialized cups .

Based on observation, interview, and policy review it was determined that the facility failed to ensure that medications were labeled and stored in accordance with manufacturers instructions and expiration date when applicable for 2 of 2 medication carts observed (Resident identifiers are #29 and #40). Findings include: Observation on 10/10/23 at approximately 8:30 a.m. of the East Medication Cart revealed the following: Resident #29 Insulin Lyumjev Lispro-aabc 200 units/milliliter (ml) opened, without an open/expiration date; Resident # 40 Insulin Aspart 100 unit/ml vial opened, without an open/expiration date. Interview on 10/10/23 with Staff A (Registered Nurse (RN)) confirmed the above findings. Review on 10/10/23 of the Manufacturer's Instructions for use of the LYUMJEV KwikPen In-use Pen . Throw away the LYUMJEV KwikPen you are using after 28 days, even if it still has insulin left in it . Review on 10/10/23 of the Manufacturer's Instructions for use of the Insulin Aspart 100 units/ml FlexTouch Pen: .Pen in Use: .The FLASP FlexTouch pen you are using is to be thrown away after 28 days, even if it still has insulin left in it and the expiration date has not passed. Observation on 10/10/23 at approximately 8:45 a.m. of the [NAME] Medication Cart revealed 10 unidentifiable loose pills in the bottom of the top drawer of the medication cart. Interview on 10/10/23 at 8:50 a.m. with Staff B (RN) confirmed the above findings. Review on 10/12/23 of the facility policy titled Storage of Medications 2. Drugs and biological's are stored in the packaging, containers, or other dispensing systems in which they are received

Based on observation, interview, and record review, it was determined that the facility failed to follow return to work guidelines for health care personnel who were positive for COVID-19 illness from working in the facility (Staff identifiers are C, I, J, and K); and failed to ensure that staff were aware of which residents were COVID-19 positive and what type of personal protective equipment (PPE) was required while caring for COVID-19 positive residents. (Staff identifiers are E, F, and G.) The facility also failed to have policies and procedures consistent with national standards and conduct annual reviews of them. These failures increased the likelihood of exposure to pathogens for the facility's census of 47 residents, staff, and visitors, including one resident (Resident #6) who tested positive after being cared for by a COVID-19 positive staff member (Staff C). Findings include: Interview on 3/23/23 at 8:30 a.m. with Staff A (Administrator) revealed that the facility currently had a census of 47 residents. Staff A stated that the current COVID-19 outbreak started on 3/7/23 and that there had been 37 residents and 13 staff positive for COVID-19. Staff A confirmed that COVID-19 positive residents were on both units and that they were not moving residents or cohorting residents. Return to work Interview on 3/23/23 at 2:35 p.m. with Staff A (Administrator) and Staff B (Corporate Clinical Nurse) revealed that the facility follows the Centers for Disease Control and Prevention (CDC) guidelines and recommendations for returning to work after a staff member tests positive for COVID-19. Staff A stated the facility was in COVID-19 outbreak status with both positive residents and staff. Staff B stated that staff were returning to work after 5 days with a negative COVID-19 test as the facility was in crisis mode. Staff B stated Staff O (Minimum Data Set Coordinator) had communicated with New Hampshire (NH) Department of Health and Human Services (DHHS) Bureau of Infectious Disease Control (BIDC) COVID-19 Operations on 3/20/23. Review on 3/23/24 of an email communication, provided by Staff O (Minimum Data Set Coordinator) sent on 3/20/23 at 12:05 p.m. from New NH DHHS BIDC COVID-19 Operations revealed, . Before implementing crisis mode, I strongly recommend adjusting schedule, consider hire temporary healthcare staff through NH health care association . Cancel all non-essential procedures and visits. Shift HCP [Health Care Personnel] who work in these areas to support other . activities in the facility. Facilities will need to ensure these HCP have received appropriate orientation . Identify additional HCP to work in the facility . As appropriate, request that HCP postpone elective time off from work . HCP may return back: At least 5 days have passed since symptoms first appeared (day 0), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. Healthcare facility may choose to confirm resolution of infection with a negative nucleic acid amplification or a series of 2 negative antigen tests taken 48 hours apart . No additional documentation was provided by the facility during the survey to indicate that additional steps had been taken to manage staffing shortages related to COVID-19. Interview on 3/23/23 at 1:30 p.m. with Staff O confirmed the above email was received on 3/20/23. Review on 3/23/23 of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposed to SARS-CoV-2, updated September 23, 2022 and provided by the facility on 3/23/23, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection. The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. After returning to work, HCP should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen. If symptoms recur (e.g. [for example], rebound) these HCP should be restricted from work and follow recommended practices to prevent transmission to others (e.g., use of well-fitting source control) until they again meet the healthcare criteria below to return to work unless an alternative diagnosis is identified. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT [Nucleic Acid Amplification Test] (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Review on 3/24/23 of the CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated September 23, 2022 and provided by the facility on 3/24/23 revealed, . Key Points . CDC's mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency strategies followed by crisis strategies are provide to augment conventional strategies and are meant to be considered and implemented sequentially (i.e.[that is], implementing conventional strategies followed by contingency strategies followed by crisis strategies. Introduction . CDC's mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency, followed by crisis capacity strategies, augment conventional strategies and are meant to be considered and implemented sequentially (i.e., implementing contingency strategies before crisis strategies) . Allowing HCP with SARS-CoV-2 infection to return to work before meeting the conventional criteria could result in healthcare-associated SARS-CoV-2 transmission. Healthcare facilities (in collaboration with risk management) should inform patients and HCP when the facility is utilizing these strategies, specify the changes in practice that should be expected, and describe the actions that will be taken to protect patients and HCP from exposure to SARS-CoV-2 if HCP with suspected or confirmed SARS-CoV-2 infection are requested to work to fulfill staffing needs. As part of conventional strategies, it is recommended that healthcare facilities: Ensure any COVID-19 vaccine requirements for HCP are followed, and where none are applicable, encourage HCP to remain up to date with all recommended COVID-19 vaccine doses. Understand their normal staffing needs and the minimum number of staff needed to provide a safe work environment and safe patient care under normal circumstances. Understand the local epidemiology of COVID-19-related indicators (e.g., community transmission levels). Communicate with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP (e.g., hiring additional HCP, recruiting retired HCP, using students or volunteers), when needed . When staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use contingency capacity strategies to plan and prepare for mitigating this problem. These include: Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities. Cancel all non-essential procedures and visits. Shift HCP who work in these areas to support other patient care activities in the facility. Facilities will need to ensure these HCP have received appropriate orientation and training to work in these areas that are new to them. Attempt to address social factors that might prevent HCP from reporting to work, such as need for transportation or housing that allows for physical distancing, particularly if HCP live with individuals with underlying medical conditions or older adults. Consider that these social factors disproportionately affect persons from some racial and ethnic groups, who are also disproportionally affected by COVID-19 (e.g., African Americans, Hispanics and Latinos, and American Indians and Alaska Natives). Identify additional HCP to work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of HCP. As appropriate, request that HCP postpone elective time off from work. However, there should be consideration for the mental health benefits of time off and that care-taking responsibilities may differ substantially among staff. Developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection. Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows: HCP with mild to moderate illness who are not moderately to severely immunocompromised: At least 5 days have passed since symptoms first appeared (day 0), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. Healthcare facilities may choose to confirm resolution of infection with a negative nucleic acid amplification test (NAAT) or a series of 2 negative antigen tests taken 48 hours apart*. HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: At least 5 days have passed since the date of their first positive viral test (day 0) . Interview on 3/24/23 at 9:00 a.m. with Staff A revealed that the facility did not have a policy and procedure for returning to work after a staff member tests positive for COVID-19 and followed the above CDC recommendations. Interview on 3/24/23 at 1:00 p.m. with Staff A and Staff B confirmed that there was a resident admitted on [DATE] and that admissions had not been put on hold despite the COVID-19 outbreak and concerns with staffing. Staff C Review on 3/23/23 of the facility's COVID-19 line list revealed that Staff C (Registered Nurse) tested positive on 3/18/23 for COVID-19 and had symptoms. Interview on 3/23/23 at 3:05 p.m. with Staff B and Staff A confirmed that Staff C worked on 3/18/23 and 3/20/23 due to staffing shortages. Both confirmed that they were aware that Staff C had tested positive for COVID-19 on 3/18/23. Review on 3/24/23 of the facility's Testing Log revealed that Staff C tested positive for COVID-19 at 8:15 (did not indicate a.m. or p.m.). Further review of the Testing Logs revealed that Staff C again tested positive for COVID-19 on 3/20/23 at 8:20 a.m. Review on 3/24/23 of Staff C's timecard report revealed that Staff C punched in on 3/18/23 at 8:40 a.m. and punched out at 11:29 p.m. Further review revealed that Staff C punched in on 3/20/23 at 8:11 a.m. and punched out at 2:22 p.m. Interview on 3/24/23 at 12:38 p.m. with Staff A confirmed that Staff C tested positive on 3/18/23 at 8:15 a.m. Staff A stated that Staff C left the facility at around 9:00 a.m. and then returned to work around 5:00 p.m., working as a nurse on the West Unit, at which time he/she performed medication administration. Staff A stated that Staff C worked as an LNA (Licensed Nursing Assistant) on 3/20/23 passing breakfast trays to COVID-19 positive residents. Review on 3/24/23 of the facility's Census from 3/18/23 against the facility's COVID-19 line list revealed that there were 7 residents on West Wing that had not tested positive for COVID-19. Review on 3/27/23 of the following 7 resident Medication Administration Records (MARs) for 3/18/23 revealed that Staff C administered medications on 3/18/23 to all 7 COVID-19 negative residents (Resident #'s 5, 6, 7, 8, 9, 10 and 11). Review on 3/27/23 of the facility's updated COVID-19 line listing, provided 3/27/27, revealed that Resident #6 tested positive for COVID-19 on 3/21/23. Staff I Review on 3/23/23 of the facility's COVID-19 line list revealed that Staff I (LNA) tested positive on 3/15/23 and was asymptomatic. Review on 3/24/23 of the facility's testing log revealed that Staff I tested negative 3/20/23. Review on 3/24/23 of the facility's screening revealed that Staff I recorded they had no symptoms of COVID-19 on 3/13/23 and on 3/20/23 on the facility's screening log. Review on 3/24/23 of Staff I's timecard report revealed that Staff I punched into work on 3/13/23 and worked 3:01 p.m. until 11:05 p.m. Further review revealed that Staff I returned to work on 3/20/23 (day 5 after testing positive) at 3:00 p.m. and worked until 11:10 p.m. Staff J Review on 3/23/23 of the facility's COVID-19 line list revealed that Staff J (LNA) tested positive on 3/15/23 with symptom onset date of 3/13/23. Review on 3/24/23 of the facility's COVID-19 screening log revealed that Staff J recorded they had no symptoms on 3/13/23 on the facility's screening log. Review on 3/24/23 of the facility's testing log for COVID-19 revealed that Staff J tested for COVID-19 on the following days: 3/13/23 at 2:00 p.m. and tested negative. 3/15/23 at 2:45 p.m. with no result documented (left blank). 3/20/23 at 2:45 p.m. tested negative. There was no additional negative test noted on the testing logs. Review on 3/24/23 of Staff J's timecard report revealed that Staff J punched into work on the following days: 3/13/23 at 2:53 p.m. and worked until 11:02 p.m. 3/20/23 (day 5 after testing positive) at 2:56 p.m. and worked until 11:25 p.m. Staff K Review on 3/23/23 of the facility's COVID-19 line list revealed that Staff K (Administration Staff) tested positive on 3/16/23 with symptom onset date of 3/16/23. Interview on 3/23/23 at 3:03 p.m. with Staff K revealed that Staff K tested negative on 3/13/23 and had a scratchy throat. Staff K stated he/she did not feel well on 3/14/23 and 3/15/23 and did not work. On 3/16/23 Staff K returned to work and tested positive at 7:45 a.m. Review on 3/24/23 of the facility Testing Log revealed that Staff K tested positive for COVID-19 on 3/16/23 at 7:40 a.m. Further review revealed that Staff K tested negative on 3/21/23. There was no additional negative antigen or polymerase chain reaction (PCR) test noted prior to returning to work. Review on 3/24/23 of Staff K's timecard report revealed that Staff K punched into work on 3/21/23 (day 5 after testing positive) at 10:00 a.m. and worked until 6:00 p.m. Staff wearing PPE Interview on 3/23/23 at 2:35 p.m. with Staff A and Staff B confirmed it was the facility's policy that N95 mask and protective eyewear were required for all staff when in the building. Observation 3/23/23 at 8:30 a.m. of Staff N (Housekeeper) in the common area near the entrance and nursing station mopping the floor with a surgical mask on and no protective eyewear. Interview on 3/24/23 at 8:45 a.m. with Staff N confirmed that he/she wore a surgical mask in the common areas and only wore an N95 mask in resident rooms. Observation on 3/23/23 at 9:00 of Staff F (LNA) wearing a blue surgical mask entering a resident room that had a yellow quarantine droplet contact precautions sign which read staff and providers must wear an N95 mask. Interview on 3/23/23 at 9:10 a.m. with Staff F stated that the resident in the above room had COVID-19. Staff F stated that he/she had a medical waiver that he/she could not wear an N95 mask and confirmed that he/she was allowed to care for COVID-19 positive residents wearing a surgical mask and a face shield. Staff F stated that he/she does not have a routine to change his/her mask, including going from COVID-19 positive residents to COVID-19 negative residents. Both staff confirmed that the facility had enough PPE supplies in the building. Observation on 3/23/23 at 9:03 a.m. of Staff G (Licensed Practical Nurse (LPN)) in a resident room that had a yellow quarantine droplet contact precautions sign which read staff and providers must wear an N95 mask. Staff G had on a blue surgical mask. Staff G was observed doffing his/her gown and gloves, bunched them up, and left the COVID-19 positive room with the dirty PPE in his/her hand. Staff G walked down the hallway towards the lobby/main entrance, with the dirty PPE in his/her hand, turned around and walked pass both staff and residents. Staff G then walked back into the resident's room and discarded the dirty PPE into the trash. Interview on 3/23/23 at 9:03 a.m. with Staff G confirmed that he/she was not wearing an N95 mask. Staff G stated today was his/her first day at the facility, had not been told that he/she needed to wear an N95 mask. Staff G confirmed that the resident in the above room was COVID-19 positive. Staff G stated he/she did know where to throw out the dirty PPE. Observation on 3/23/23 at 9:25 a.m. with Staff M (Maintenance Director) revealed that Staff M was wearing an N95 mask; however, it was positioned off-center with it being loosely fitted with gaps around his/her nose. Interview on 3/23/23 at 9:25 a.m. with Staff M could not recall if he/she had been fit-tested for an N95 mask. Observation on 3/23/23 at 12:20 p.m. of Staff E (LNA) and Staff F in a room that had a yellow quarantine droplet contact precautions sign that read a gown, N95 respirator, eye protection and gloves must be worn. PPE was set up outside the door. Staff E was assisting Resident#2 by the B (window) bed and had gloves and an N95 mask on. Staff F was assisting Resident #1, in the A (door) bed, and had gloves and a blue surgical mask on. Neither staff had eye protection or gowns on. Both staff were observed touching the residents, assisting with positioning in their chairs and touching items in the room such as the over-bed tray tables. Neither staff were observed changing their masks when leaving the room. Interview on 3/23/23 at 12:22 p.m. with Staff E and Staff F revealed that they had been told that the entire unit was no longer on COVID-19 isolation and that this room in particular was no longer on isolation. Staff E stated they had been using PPE in rooms that they did not have to and then stated it was confusing who was or was not on isolation. Staff F stated that he/she could not speak with me due to being upset. Review on 3/23/23 of Resident #1 March 2023 Medication Administration Record revealed the following physician's order with a start date of 3/14/23 Contact/Droplet: COVID [19 positive] Gloves, gown, appropriate masking. Don before room entry, doff before room exit; change before caring for another resident. Face shield may also be needed if performing activity with risk of splash or spray, every shift for covid+ [sic] for 10 days. Review on 3/23/23 of Resident #2's medical record revealed that Resident #2 was not COVID-19 positive. Review on 3/23/23 of the facility's line list confirmed that Resident #1 was COVID-19 positive. Resident #2 was not on the line list. Review on 3/23/23 of the facility's policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised April 2020 revealed, .This facility follows recommended standard and transmission based precautions . 1. This policy is based on current recommendations for standard precautions and transmission-based precautions . 2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including . c. Appropriate use of PPE; d. Transmission-based precautions, where indicated . 12. For a resident with known or suspected COVID-19: a. Staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available (a facemask is an acceptable alternative if a respirator is not available) . 13. If there are COVID-19 cases in the facility: a. Staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability) . Review on 3/23/23 of the facility's policy titled Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, revised September 2021 revealed, . Residents with signs and/or symptoms of COVID-19 are identified and isolated to help control the spread of infection to other residents, staff and visitors . 1. The infection preventionist is responsible for establishing and overseeing screening and monitoring efforts . Establishing a COVID-19 Care Unit 1. A COVID-19 care unit (which may be a dedicated floor, unit, wing or cluster or rooms at the end of a hallway) has been established to cohort and manage the care of residents with confirmed [COVID-19] infection. 2. The location of the COVID-19 care unit is physically separated from the other rooms or units housing residents without confirmed [COVID-19] infection. 3. Staff is assigned to work only on the COVID-19 care unit when it is in use . Ancillary staff is restricted from the unit . Review on 3/23/23 of the facility's policy Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, dated September 2021 revealed, .3. When caring for a resident with suspected or confirmed [COVID-19] infection, the following infection prevention and control practices are followed: a. Personnel who enter the room of resident with suspected or confirmed [COVID-19] infection adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection . Disposable respirators are removed and discarded after exiting the resident's room or care area and closing the door unless implementing extended use or reuse . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area, if not already wearing as part of extended use strategies to optimize PPE supply . A clean isolation gown is donned upon entry into the resident room or area . The gown is removed and discarded in a dedicated container for waste or linen before leaving the resident room or care area . All personnel receive training on and demonstrate an understanding of . when to use PPE . what PPE is necessary . how to properly don, use, and doff PPE in a manner to prevent self-contamination . how to properly dispose of . PPE . Review on 3/24/23 of the additional facility policy revealed the following; Coronavirus Disease (COVID-19) Surge Capacity Staffing was last revised in April 2020; Coronavirus Disease (COVID-19) - Testing Staff was last revised September in 2021; Coronavirus Disease (COVID-19) - Testing Residents was last revised September in 2021; Personal Protective Equipment - Contingency and Crisis Use of Isolation Gowns (COVID-19 Outbreaks) was last revised in September 2021; Coronavirus Disease (COVID-19) - Facemask as Source Control was last updated September 2021. Interview on 3/23/23 at 11:15 p.m. with Staff B confirmed that the above policies dated April 2020 and September 2021 were the most recent and current policies. The facility was asked for documentation of when the facility's policies were last reviewed, but no additional documentation was provided. 45991

Based on interview and record review, the facility failed to administer effectively during a COVID-19 outbreak consistent with national standards with a census of 47 residents. Findings include: Observation, interview and record review revealed administration failed to ensure that the facility had updated and implemented policies and procedures for infection control that were consistent with national standards including return to work guidelines for healthcare personnel who were positive for COVID-19 illness and proper personal protective (PPE) equipment for staff while caring for COVID-19 positive residents. Refer to F880 Infection Prevention and Control. Interview and record review revealed the facility failed to implement the facility's influenza and pneumococcal policies and procedures ensuring that residents were offered the influenza and pneumococcal immunizations and residents received education regarding the benefits and potential side effects of the immunization. Refer to F883 Influenza And Pneumococcal Immunizations. Interview and record review revealed that the facility failed to test staff who were working with symptoms of COVID-19. Refer to F886 Testing-Residents and Staff. Interview and record review revealed that the facility failed to implement the facility's COVID-19 vaccination policies and procedures ensuring residents were offered, and if requested, received the COVID-19 immunization and residents received education regarding the benefits and potential side effects of the immunization. Reference F887 COVID-19 Immunization. 45991

Based on interview, record review, and policy review, it was determined that the facility failed to offer COVID-19 vaccination for 2 out of 5 residents reviewed for COVID-19 Immunization (Resident identifiers are #3 and #12). Findings include: Resident #12 Review on 3/23/23 of Resident #12's medical record revealed Resident #12 admitted to the facility on [DATE]. Further review of Resident #12's medical record revealed a physician's order for pneumococcal and influenza vaccination dated 3/3/23. There was no current order for COVID-19 vaccination. Review on 3/23/23 of Resident #12's medical record revealed a consent for COVID-19 vaccination signed by Resident #12's resident representative dated 3/3/23. Review on 3/23/23 of Resident #12's immunization record revealed no documentation of administration of the COVID-19 vaccination. Interview on 3/23/23 at 2:00 p.m. with Staff K (Medical Records / Administrative Staff) confirmed that Resident #12's resident representative signed the consent for COVID-19 vaccination and that there was no COVID-19 vaccination documentation in Resident #12's medical record. Interview on 3/24/23 at approximately 11:15 a.m. with Staff B confirmed that there was no record of COVID-19 immunization in Resident #12 medical record and that the facility was waiting for Resident #12's vaccination history. 43002 Resident #3 Review on 3/23/23 of Resident #3's Admission Minimum Data Set (MDS) with an assessment reference date of 12/20/22 revealed under Section A1600 Entry Date was coded 12/14/22. Further review revealed under Section C0500 Brief Interview of Mental Status was coded as 15 meaning cognitively intact. Review on 3/23/23 of the facility's COVID-19 line list revealed that Resident #3 tested positive for COVID-19 on 3/10/23. Review on 3/23/23 of Resident #3's electronic medical record revealed that under the immunization tab that there was no COVID-19 vaccination history documented. Review on 3/23/23 of Resident #3's paper medical record revealed that there was no consent for COVID-19 completed and no history was documented that Resident #3 had received the vaccine prior to admission. Further review of Resident #3's paper medical record revealed that Resident #3 had a partially completed a consent to receive vaccinations, including the COVID-19 vaccination, on 12/12/22 (which was prior to admission to the facility); however, there was no follow up to this request documented in the medical record. Observation on 3/23/23 at 1:00 p.m. of Resident #3 revealed the resident in bed with oxygen on. Resident #3's room had an isolation sign on the door and personal protective equipment outside. Interview on 3/23/23 at 1:00 p.m. with Resident #3 revealed that he/she admitted to the facility in 12/14/22 and that he/she had wanted to receive the COVID-19 vaccinations, but was told that he/she had missed the clinic for the COVID-19 vaccination. Resident #3 confirmed that he/she had not been offered the COVID-19 vaccine since admission and that he/she had not been updated as to when he/she would receive it. Resident #3 confirmed that he/she currently had COVID-19 and was on isolation and receiving oxygen. Interview on 3/24/23 at 12:30 p.m. with Staff O (MDS Coordinator) confirmed that Resident #3 did not have the COVID-19 vaccination. Staff O confirmed that above 12/12/22 consent was from prior to Resident #3 admitting the facility and did not know if any follow up had been done. Staff O confirmed that the facility's consent form was not in Resident #3's medical record. Interview on 3/24/23 at 12:35 p.m. via the telephone with Staff D (Infection Preventionist) revealed that Staff D had called to get the COVID-19 vaccination from the pharmacy. When asked if he/she had documented this, Staff D stated he/she did not. Staff D stated that there was no COVID-19 vaccinations in the facility to administer. Staff D confirmed that he/she knew that Resident #3 had wanted the COVID-19 vaccination, but did not document this anywhere. Staff D stated that in her head she had 3 residents that needed the COVID-19 vaccination. Interview on 3/27/23 at 3:10 p.m. with Staff D revealed that he/she had ordered the COVID-19 vaccinations from the pharmacy on 3/25/23. Staff D stated he/she had not ordered COVID-19 vaccinations prior to 3/25/23. Staff D confirmed that Resident #3 had not received the COVID-19 vaccination. Review on 3/24/23 of the facility's policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, revised December 2021, revealed .Policy Statement Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. Policy Interpretation and Implementation .4. The COVID-19 vaccine may be offered and provided directly by the LTC [long term care] facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity 9. Residents must sign a consent to vaccinate form prior to receiving the vaccine. The form is provided to the resident in a language and format understood by the resident or representative 15. A vaccine administration record is provided to the resident and a copy is filed in the resident record Documentation and Reporting .2. If the resident did not receive the COVID-19 vaccine due to a medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record.

Based on interview, and record review, it was determined that the facility failed to ensure that a resident received the influenza and pneumococcal vaccines after consenting to receive for 1 out of 5 residents reviewed for immunizations (Resident identifier is #12). Findings include: Review on 3/23/23 of Resident #12's influenza and pneumococcal consent forms revealed that Resident #12's resident representative gave the facility permission to administer the influenza and pneumococcal vaccine with a sign date of 3/3/23. Review on 3/23/23 of Resident #12's immunization record revealed that Resident #12 did not receive the influenza and pneumococcal vaccination after consent was signed on 3/3/23. Interview on 3/23/23 at 2:00 p.m. with Staff K (Medical Records / Administrative Staff) confirmed that Resident #12's resident representative signed the consent agreeing to the above vaccinations and that there was no documentation of the resident receiving the vaccinations in his/her Medical Record. Review on 3/24/23 of the facility's policy titled, Influenza Vaccine, revised March 2022 revealed .All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza Policy Interpretation and Implementation 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized 4. Prior to vaccination, the resident (or residents legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials). Provision of such education shall be documented in the resident/employee medical record. 5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record. Review on 3/14/23 of the facility's policy titled, Pneumococcal Vaccine, revised March 2022 revealed Policy Statement All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status are conducted within (5) working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) Provision of such education is documented in the resident's medical record. 4. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol 6. For each resident who receives the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record.

Based on interview and record review, it was determined that the facility failed to test staff with symptoms consistent of COVID-19 for 2 of 4 staff reviewed who presented to work with signs and symptoms of COVID-19 (Staff identifier are P and Q). Findings include: Review on 3/27/23 of the Centers for Disease Control and Prevention (CDC) Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [severe acute respiratory syndrome-related coronavirus] Infection or Exposure to SARS-CoV-2 updated 9/23/22, revealed, .Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection. HCP [Health Care Personnel] with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays . Review on 3/27/23 of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/27/22 revealed, .This guidance applies to all U.S. [United States] settings where healthcare is delivered, including nursing homes and home health . Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible . Staff P Review on 3/24/23 of the facility's COVID-19 Screening Log for Visitation and Staff on 3/16/23 revealed that Staff P (Registered Nurse) screened in and recorded yes to having COVID-19 symptoms in the last 48 hours and being exposed to COVID-19 in the last 14 days. Review on 3/24/23 of the facility's COVID-19 testing log revealed no COVID-19 testing was documented as being completed for Staff P on 3/16/23. Review on 3/27/23 of the facility's staffing for 3/16/23 revealed that Staff P worked on [NAME] Wing on 3/16/23. Staff Q Review on 3/24/23 of the facility's COVID-19 Screening Log for Visitation and Staff on 3/19/23 revealed that Staff Q (Licensed Practical Nurse) screened in and recorded yes to having COVID-19 symptoms in the last 48 hours and being exposed to COVID-19 in the last 14 days. Review on 3/24/23 of the facility's COVID-19 testing log revealed no COVID-19 testing was documented as being completed for Staff Q on 3/19/23. Review on 3/27/23 of the facility's staffing for 3/19/23 revealed that Staff Q worked 11:00 p.m. to 7:00 a.m. Review on 3/27/23 of the facility's COVID-19 line listing revealed that Staff Q tested positive for COVID-19 on 3/22/23. Review on 3/27/23 of the facility's policy and procedure titled Coronavirus Disease (COVID-19) - Testing Staff, revised September 2021, revealed, .Staff in the facility, including all paid and unpaid individuals with potential for direct or indirect exposure to residents or infectious material, are tested for the [COVID-19] virus to detect the presence of current infections (viral testing) and to help prevent the transmission of COVID-19 in the facility . Symptomatic staff (those with signs or symptoms associated with COVID-19) are tested immediately, regardless of severity of symptoms . Interview on 3/24/23 at approximately 3:00 p.m. with Staff B (Corporate Clinical Nurse) confirmed that Staff P and Staff Q screened in with symptoms and exposure with no testing documented. 45991

Based on observation, interview, and record review, it was determined that the facility failed to store thickened juices and healthshakes according to manufacturer's instructions for 1 of 1 main kitchen observed and 1 of 1 kitchenette observed. The facility also failed to record testing of dishwasher chemical solution concentration for 2 of 2 months of low-temperature dishwasher (chemical sanitation) logs reviewed. Findings include: Main Kitchen Observation on 10/3/22 at approximately 7:45 a.m. at the kitchen revealed that in 1 of the refrigerators, there was 1 opened nectar thickened cranberry juice and 1 opened honey thickened cranberry juice with no open date or use by date. Review on 10/3/22 of the nectar and honey thickened cranberry juice bottle revealed a manufacturer's instruction to discard, if not used within 10 days of opening. Review on 10/3/22 of the September 2022 and October 2022 low-temperature dishwasher (chemical sanitation) logs revealed no recorded testing of chemical concentration on 9/16/22, 9/17/22, 9/18/22, 9/29/22, 9/30/22, 10/1/22, and 10/2/22. Interview on 10/3/22 with Staff C (Dietary Aide) confirmed the above findings. Kitchenette Observation on 10/3/22 at approximately 11:00 a.m. with Staff D (Food Service Director) at the kitchenette refrigerator revealed that there were 4 healthshakes with no thaw date and 5 opened thickened juices with no open date or use by date. Review on 10/3/22 of the healthshake manufacturer's instruction revealed that healthshakes are good within 14 days after thawing. Review on 10/3/22 of the thickened juices manufacturer's instruction revealed to discard if not used within 10 days of opening. Interview on 10/3/22 at approximately 11:00 a.m. with Staff D confirmed the above findings in the kitchenette refrigerator. Staff D stated that he/she was not aware of the facility's policy on proper storage and labeling of healthshakes or thickened juices. Staff D also stated that the dietary staff stocks the kitchenette and that nursing staff would be responsible for labeling and dating opened thickened juices. Review on 10/4/22 of facility's policy on Food Storage and Retention Guide with no date revealed that special items such as shakes, supplements, and thickened beverages were retained or stored following manufacturer's guidelines. Review on 10/4/22 of the facility's policy on labeling food with revised date of 9/2017 revealed that all food items will be appropriately labeled and dated either through manufacturer's packaging or staff notation. Review on 10/4/22 of the facility's policy on monitoring dish machine temperature and sanitizer with no date revealed .the dishwasher or designee checks the temperature and, if applicable, sanitizer concentration before washing dishes from each meal (breakfast, lunch, dinner). Results are recorded on the log .

Based on observation, interview and review of facility policy and procedures and CDC (Centers for Disease Control) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings, it was determined that the facility failed to follow standard and transmission-based precautions to be followed to prevent the possible spread of infection on one of two units observed. Findings include: Observation on 5/13/20 at approximately 10:45 a.m. on the designated COVID-19 unit revealed Staff A (Licensed Practical Nurse) sitting on floor applying bandages to Resident #1's legs within approximately 1 foot from Resident #1. Resident #1 was not wearing a face mask. Staff A was observed not to have on adequate PPE (personal protective equipment) for a resident on droplet precautions. Staff A was not wearing a gown, gloves, or face shield. Interview on 5/13/20 at approximately 10:45 a.m. with Staff B (Director of Nurses) revealed that staff should be wearing all PPE for droplet precautions when performing direct care on residents with COVID-19. Staff B stated that the facility had an ample supply of PPE. Staff B revealed that Resident #1 had tested positive for COVID-19 and was on droplet precautions. Observation on 5/13/20 at approximately 11:00 a.m. on the designated COVID-19 unit revealed Staff A sitting on the floor touching Resident #1's feet. The top of Staff A's mask was below Staff A's nose. Staff A's nostrils were visible. Staff A was observed for approximately 2 minutes and did not correct their mask to cover their nose. Resident #1 was not wearing a face mask. Review on 5/14/20 of the facility policy and procedure titled, Personal Protective Equipment during the COVID-19 Pandemic, undated, revealed the following: Procedure . All personnel who are in close contact with residents of nursing homes shall use appropriate personal protective equipment, such as masks, face shields, gloves and gowns based on the procedures being performed and the availability of specific forms of PPE. Review on 5/14/20 of the facility policy and procedure titled, Observation Unit during the COVID-19 Pandemic, undated, revealed to following: Procedure , The residents will be placed on Droplet precautions, following the CDC guidance for using personal protective equipment, as well as the CDC's Strategies to Optimize the Supply of PPE and Equipment. Review on 5/14/20 of the CDC (Centers for Disease Control) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings, dated 4/13/20, revealed the following: .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Respirator or Facemask, Eye Protection, Gloves, Gowns Review on 5/14/20 of the COVID-19 designated unit's staffing schedule from 5/ 6/20 to 5/12/20 revealed that Staff A was the nurse assigned to the COVID-19 designated unit on the 7:00 a.m. to 3:00 p.m. shift caring for 26 residents on 5 of the 7 days reviewed (5/6/20, 5/7/20, 5/8/20, 5/11/20, and 5/12/20).

Based on interview and record review, it was determined that the facility failed to ensure that each resident recieves adequate supervision/assistance/assistive devices to prevent accidents from happening for 1 of a survey sample of 15 residents resulting in a fracture. (Resident identifier #3). Findings include: Resident #3: A complaint was received regarding a fall with a fracture that occurred on 3/1/15 while Staff B (LNA) was providing a bed bath and personal care for Resident #3. Record review and interviews revealed the following: Written statement from Staff B (LNA) stated the following: "As I was cleaning up (Resident #3), (the resident's) sheets were soiled and I pulled her close to me with the soaker pad underneath her and I had her roll to her left and hold onto the bar as I proceeded to take the sheet off, (Resident #3) moved her feet and she slipped off the bed, I jumped on the bed to grab her and bring her to the floor." Interview with Staff B (LNA) and with Staff A (DON) on 4/15/15 at approximately 1:15 pm revealed that Resident #3 had right sided hemiparesis from a CVA (stroke/cerebrovascular accident), she is overweight, deconditioned due to being bed ridden, and has severe degenerative bone disease and osteoporosis. Staff B stated when questioned, that Resident #3's leg slid over the side of the bed as Staff B was positioning her toward the opposite side of the bed from where Staff B was standing. Resident #3 then began to slide off the bed. This is when Staff B jumped on the bed and held the resident under her arms to lower her to the floor. Staff B stated that Resident #3's leg was rotated inward as she was sliding to the floor. Care plan concerning ADL care and assistance states: FOCUS: "(Resident #3) has an ADL Self Care Performance Deficit r/t (related to) CVA with right hemiparesis. Right Femur fracture 3/3/15...Target date: 7/5/15... Interventions... Three staff to assist with all care (except eating). Date Initiated 3/6/15 Bed Mobility: She usually requires extensive assist to reposition and turn in bed...Date Initiated 5/3/11... self care deficit expected cours,: declines in function. Date Initiated 5/3/11... Bathing: Provide (Resident) with a sponge bath when full bath or shower cannot be tolerated...Date Initiated 5/3/11... She usually needs total assist for bathing. Date Initiated 5/3/11..." MDS dated [DATE] section G110 codes for the following: Section A. Bed Mobility-3 for self performance; 3 for Support needed. (3 indicates Extensive assistance, two or more person physical assist). Section B. Transfer-3 for self performance; 3 for Support needed. (3 indicates Extensive assistance, two or more person physical assist). Section J. Personal hygiene-3 for self performance; 3 for Support needed. (3 indicates extensive assistance, two or more person physical assist). Section G400 indicates that Resident #3 has impairment on the right side, involving both upper and lower extremities. Section J on MDS assessment dated [DATE] under J1800 concerning falls with or with out injury has been left blank. Record review and interview confirm that Resident #3 had a fall with a spiral fracture of the femur (thigh bone) which was confirmed by XRay on 3/3/15 at hospital. Mosby's Textbook for Nursing Assistants 6th Edition states on page 17: Box 2-1: Rules for Nursing Assistants: *you are an assistant to the nurse. *A nurse assigns and supervises your work. *You report observations about the person's physical or mental status to the nurse. Report changes at once. *The nurse decides what should be done for a person. You do not make these decisions. *Review directions with the nurse before going to the person....... ....*Perform only those functions and tasks that your state and jo b description allow. Pg 325 then states in Delegation Guides for Bathing: To assist with bathing, you need this information from the nurse and the care plan: ....How much help the person needs.....The person's activity or functional limits... The Facility LNA Kardex/Plan of Care states: ADL: Bed mobility: Extensive assistance; Two person physical assist. *This was crossed out and "1-2 assist" was added in pencil. This change was not dated or signed. It is not within the LNA scope of practice to assess whether a resident would need 1 or 2 care givers to assist with care, as mentioned above in Mosby's Textbook for Nursing Assistants.