Every finding on record at Fountain Manor Health & Rehabilitation Center

Based on observations, interviews and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for three Residents (Resident #19, Resident # 28, and Resident #98) out of 16 residents receiving oxygen therapy. As evidenced by the Residents' oxygen concentrators were not delivering the oxygen at the prescribed flow rate. There were 134 residents residing in the facility at the time of the survey. The findings included.Resident #19During an observation on 05/18/2026 at 8:04 AM Resident #19 was in bed awake, oxygen (02) running at 1.5 liters Per Minute (LPM) via nasal Canula (NC), no distress noted.Observations on 05/19/2026 at 9:09 AM Resident#19 was observed sitting up in bed and on 05/20/2026 at 7:27 AM Resident # 19 was in bed with eyes closed and 02 via NC running at 2 LPM, no distress noted.On 05/19/2026 at 9:09 AM, Resident #19 was observed sitting upright in bed. On 05/20/2026 at 7:27 AM, the resident was noted to be in bed with eyes closed. During both observations, oxygen was being administered via nasal cannula at 2 LPM, with no signs of distress observed. Review Resident #19's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Acute respiratory failure with hypoxia, and Chronic Obstructive Pulmonary Disease. Review of the Physician's Orders Sheet for May 2026 revealed Resident #19 had orders that included but not limited to: Oxygen at 2 liters per minute (LPM) via Nasal Canula (NC) as needed for shortness of breath. Record review of Resident # 19 's Significant Change Minimum Data Set (MDS) dated [DATE] documented in Section C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) score 15 on a 1-15 scale indicating the resident is cognitively intact. Section GG for Functional Abilities documented the resident is dependent for care. Section J for Health Conditions documented shortness of breath or trouble breathing when lying flat. Section O for Special Treatments and Procedures documented the resident is receiving oxygen therapy.Record review of Resident #19 's Care Plans Reference Date 02/02/26 revealed: The Resident has Pulmonary Condition diagnosis of respiratory failure, pneumonia, Chronic Obstructive Pulmonary Disease, asthma and has Potential for Difficulty Breathing, history of trach removed 2/3/2026, and allergic rhinitis. Interventions include- Oxygen via NC as ordered, observe for any changes or signs/symptoms of Breathing difficulty such as shortness of breath (SOB) Cough (productive and non-productive) fever chills, difficulty speaking, observe and report any changes in respiratory status to physician for further Interventions.Resident #28Observations on 05/18/2026 at 8:56 AM revealed Resident #28 in bed awake, 02 running at 2 LPM via NC, no distress noted. On 05/19/2026 in the AM Resident #28 in bed awake, family member in the room, 02 running at 2 LPM via NC, no distress noted. Review of Resident #28's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Acute respiratory failure with hypoxia. Resident #28 was discharged on 05/19/2026. Review of the Physician's Orders Sheet for May 2026 revealed Resident #28 had orders that included but not limited to: Oxygen at 3 LPM via NC, titrate to 5 L to keep a saturation above 93%.Record review of Resident # 28 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to determine. Section GG for Functional Abilities documented the resident is dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments and Procedures documented the resident is receiving oxygen therapy, Suctioning and Tracheostomy care.Record review of Resident #28 's Care Plans Reference Date 04/30/2026 revealed the resident has Pulmonary Condition diagnosis and has Potential for Difficulty Breathing. Interventions include- Oxygen at 3 LPM via nasal cannula, titrate to 5L to keep a saturation above 93%. Observe and report any changes in respiratory status to physician for further interventions. Observe for any changes or signs/symptoms of breathing difficulty such as SOB cough (productive and Nnon-productive) fever chills, difficulty speaking.Resident # 98Observation on 05/18/2026 at 7:54 AM revealed Resident # 98 in bed awake and on 05/19/2026 at 9:07 AM Resident #98 was in bed with eyes closed; during both observations 02 via NC was running at 2.5 LPM.Observation on 05/20/2026 at 7:40 AM revealed Resident # 98 in bed asleep with 02 via NC running at 2.5 LPM. Review of Resident #98's medical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Review of the Physician's Orders Sheet for May 2026 revealed Resident #98 had orders that included but not limited to: Oxygen at 2 LPM via NC as needed for Shortness of Breath. Record review of Resident # 98 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to determine. Section GG for Functional Abilities documented the resident is dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments and Procedures documented no special treatments received. Record review of Resident #98 's Care Plans Reference Date 05/04/26 revealed: The resident has Potential for Difficulty Breathing, anemia, hypokalemia. Interventions include- Administer respiratory treatment/nebulizer per doctor's order. O2 via NC as Ordered, observe for any changes or signs/symptoms of breathing difficulty such as SOB, Cough (Productive and Non-Productive) fever chills, difficulty speaking. Interview on 05/20/2026 at 9:45 AM Staff A, Registered Nurse stated: For residents on oxygen therapy, during our shift we check the vital signs and verify the physician orders are the same as the oxygen flow rate running on the concentrators. Interview on 05/20/2026 at 9:54 AM Staff B, Licensed Practical Nurse (LPN) stated: During my shift I verify the residents on prescribed oxygen therapy have the correct flow rate set on their concentrators based on their orders. Review of the facility policy and procedure titled Oxygen Administration revision date October 2010 states: 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 order or facility protocol for oxygen administration.

Based on observations, interviews and record review the facility failed to protect the residents right to be free from physical abuse for one (Resident #1) out of three sampled residents as evidenced by a federal report submitted by the facility regarding a verified allegation of physical abuse from a staff member towards Resident #1. There were 130 residents residing in the facility at the time of survey.The findings Included: On 7/22/25 the facility submitted a federal report [] alleging Resident #1 was physically abused by Mental health technician, Staff A. On 7/28/25, The facility verified the allegation and terminated Staff A's employment.On 07/28/2025 Resident #1 was observed seated on the patio in stable condition.On 7/28/25 at 9:55 AM Resident#1 was interviewed (translated by other surveyor on the team) about the allegation and stated, I am pleased with the staff except one person. That staff hit me, I fell to the floor, and he dragged me to my room. Record review of Resident #1's demographic sheet revealed the resident was admitted on [DATE] with diagnosis that include: Dementia, psychosis, Encephalopathy, Depression, Syncope and collapse, Repeated falls, Difficulty in walking, and OsteoarthritisRecord review of a Quarterly Minimum Data Set (MDS) with a reference date of 7/8/25 indicated Resident #1 is moderately impaired cognitively, had no behavior concerns, was independent for activities of daily living and required chair/bed-to-chair transfers.Record review of a care plan initiated on 5/21/25 and reviewed/revised on 7/24/25 revealed Resident #1 exhibited behaviors: spitting at staff and attempting to hit a staff member with her shoe with interventions that included: Maintain safe distance during episodes of aggression.Record review of Resident #1's Physicians Orders Sheet for March 2025 revealed orders included Memantine 5 milligrams (mg) tablet by mouth twice a day for Dementia, Escitalopram oxalate 10 mg tablet by mouth once a day for Depression, Quetiapine 25 mg tablet by mouth at bedtime for Psychosis and to monitor for agitation every shift.Record review of a Progress Note written on 7/22/25 revealed Resident #1 sustained a fall in the patio area, reported pain in the left knee and right forearm, a physical assessment was performed and found on her left knee a bruise of about three centimeters(cm), and on the right arm a bruise of about one cm, the resident reported pain when bending the knee but she was able to walk, on a scale of 1 to 10 she reported that the pain was 4, and she was offered pain medication but she refused. Vitals signs were within normal limits, and the patient denied vomiting, or shortness of breath. No other positive findings were noted on the physical exam. Nurse Practitioner was called and new stat x rays order to perform right wrist, arm, and left knee received and carried out. The family was notified.Record review of the facility's Policy titled Identifying Types of Abuse Policy Statement: As part of the abuse prevention strategy, volunteers, employees and contractors hired by the facility are expected to be able to identify the different types of abuse that may occur against residentsDuring an interview on 7/28/25 at 10:18 AM, the Unit Manager, Registered Nurse (RN) stated: On 7/22/25, at approximately 4:00 PM while doing my rounds, a resident told me that [Resident #1] was physically abused by [Staff A, Mental Health Technician]. The resident described [Resident #1] was on the patio, placed a bag from a chair onto the floor and sat on the chair. At that time [Staff A, Mental Health Technician] pulled [Resident #1] out of the chair and [Resident #1] took an ash tray and threw it at [Staff A, Mental Health Technician]. Then [Staff A, Mental Health Technician] tried to block the ash tray by holding up the bag and pushed [Resident#1] with the bag and [Resident #1] fell on the floor. At that time [Staff A, Mental Health Technician] dragged [Resident#1] to the room. After hearing the details, I immediately reported it to The Administrator, and the cameras footage was viewed. I then I completed a full assessment on [Resident#1] on the patio and found a scrap on the Resident's right wrist and knee. There was no pain reported but the [Resident#1] was upset and was yelling. I comforted the resident at that time.On 7/28/25 at 1:57 PM The Social Services Director/ Abuse Coordinator revealed: On 7/22/25 it was reported to me by the Administrator that a nurse reported that a resident reported to her that [Staff A, Mental health technician] was aggressive towards another resident. The administrator looked at the cameras and verified that an incident occurred and instructed me to begin the federal report. I notified the police and Department of Children and Family (DCF). The police came and DCF came and investigated. We are completing the investigation today.During an interview regarding the allegations on 7/28/25 at 2:39 PM, Staff B, DCF investigator stated The investigation is ongoing. I spoke with [Staff A, Mental Health Technician] and discovered [Resident #1] was aggressive for the past five days and was attempting to break in the to get cigarettes and attacked [Staff A, Mental Health Technician]. I viewed video surveillance, and it showed [Staff A, Mental Health Technician] sitting on the patio and [Resident #1] threw backpack on the floor and [Staff A, Mental Health Technician] picked up the backpack then grabbed [Resident#1] and somehow the resident fell.Interview on 7/28/25 at 3:16 PM, with the Director of Nursing (DON) about the allegations; he stated: The unit manager reported to me on 7/22/25 around 4:00 PM that an abuse allegation was from another resident between [Staff A, Mental health technician] and Resident#1]. From what I saw on the video, [Resident#1] went towards the smoking locker and grabbed a bag, threw it on the ground, and the [Staff A, Mental health technician] came from the non-smoking area and grabbed the resident's arm and snatched [Resident #1] off the chair where the resident was seated. Then [Resident#1] threw an ash tray towards [Staff A, Mental health technician] and started trying to hit [Staff A, Mental health technician]. [Staff A, Mental health technician] blocked the hits with the bag and [Resident #1] fell onto the floor in a sitting position. At that time, [Staff A, Mental health technician] pulled [Resident #1] from the ground and escorted the resident to the room. [Staff A, Mental health technician], did not report the incident. There were no other staff in the area. [Staff A, Mental health technician], was being rough and there was no need to .and it was completely unacceptable. A head-toe and pain assessment were done, and Medical Doctor and Psychiatrist were notified. The x-rays showed no fracture.The surveyor requested to view the video footage of the incident, but the DON revealed the footage had already been recorded over.Interview on 7/28/25 at 3:36 PM, the Administrator stated: An incident of physical abuse was reported to me by The Unit Manager. I reported it to the Abuse Coordinator. At that time, I viewed the camera footage, and I saw [Resident#1] throw [Staff A, Mental health technician bookbag] and sit on the chair. [Staff A, Mental health technician] grabbed [Resident #1] roughly by the arm and out the chair. [Resident#1] was then seen returning and charging and hitting [Staff A, Mental health technician]. [Staff A, Mental health technician] used the bookbag in defense and the bookbag touched [Resident#1] in the face and the resident fell on the floor, then got up and threw an ash tray at [Staff A, Mental health technician]. [Staff A, Mental health technician] then grabbed [Resident #1] by the arm and inside. I investigated this incident by reviewing the footage and interviewing other residents, family, and staff. We concluded that the allegation was verified, and the employee was terminated on 7/28/25.On 7/29/25 at 9:22 am The Social services Director/ Abuse Coordinator revealed the investigation was concluded and the allegation of physical was abuse verified.

Based on observations, reviews and interviews, the facility's staff failed to notify one (Resident #1) out of three sampled resident's family /representative of a change in condition; as evidenced by Resident #1 had a fall and a progress note written the day of the incident, indicated no next of kin was listed to be notified. The findings included: On 6/16/25 at 1:15 PM Resident#1 was observed seated in the dining area amongst other residents. Resident#1 did not respond when greeted by surveyor. On 6/17/25 at 10:35 AM Resident#1 was observed seated in wheelchair on the patio with staff supervising. Resident #1 stated: Sometimes I have racing thoughts, and I have to calm myself down . Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: abnormalities of gait and mobility, lack of coordination and seizures. Record review of a Quarterly Minimum Data Set (MDS) reference dated 5/14/25 indicated Resident #1 is severely impaired cognitively and had no falls since reentry or the prior assessment. Record review of a Care Plan start date 1/24/23 and last reviewed/revised on 5/15/25 revealed Resident #1 was at high risk for fall and injuries secondary to diagnosis that included: Impaired gait, Seizure disorder, Impaired cognition, fall incident occurred 1/24/23. No injury noted with interventions that included: remind resident not to try to get out of bed by him/herself to use call light and request assistance, maintain walkway free from clutter and encourage resident to use call bell and request assistance as needed . Record review of a progress note dated 1/24/23 at 3:00 AM revealed Resident #1 was found on the floor, the Medical Doctor was notified, and next of kin/responsible party not assigned. Record review of a Fall Event Report dated 1/26/23 for Resident #1 section: Notifications revealed Name of Responsible Party: none assigned. On 6/17/25 at 2:45 PM The admission Coordinator stated: Prior to admission, the demographic sheet is created with the proxy/emergency contact in case there is an incident where the family needs to be notified. On 6/18/25 at 10:34 AM The Director of Nursing stated: The assigned nurse of the resident being transferred is responsible for notifying the first contact at least three times then the next if there are multiple family members listed unless it is specified in the face sheet that a certain family member should not be informed. Further stated, On 1/23/23 [Resident #1] was admitted and on the 24th the resident was found on the floor without an injury, medicated for pain and the medical doctor was notified. The party responsible was listed on the face sheet at the time of the transfer, however there is no progress note indicating that the family was notified about the fall. The nurse who wrote this note has not been employed in the facility for years. Record review of a policy titled Assessing Falls and Their Causes (Revised March 2018) revealed Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure: After a Fall: 5. Notify residents' attending physician and family in an appropriate time frame.

Based on observations, interviews and record review the facility failed to properly store medications in one out of two treatment carts as evidenced by an observation of an unlocked unattended medication/treatment cart. There were 131 residents residing in the facility at the time of the survey. The findings included: On 6/16/25 at 12:59 PM, observation on the 300's hallway revealed an unlocked, unattended medication/treatment cart. The surveyor knocked on the nearest room door and inquired if the assigned nurse was inside the room. On 6/16/25 at 1:09 PM Staff A, wound care nurse exited the room, returned to cart and was notified about the observation and asked about protocol Staff A stated: The cart should always be locked when unattended. Also stated I was helping a resident and left it unlocked by mistake. Interview on 6/18/25 at 10:34 AM, the Director of Nursing revealed: The cart should be locked when unattended. Review of a Policy titled Medication Labeling and Storage 2001 Med Pass, Inc. revealed Policy statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observations, record review and interviews the facility failed to provide catheter care according to professional standards for two (Residents #2 and Resident #3) out of two residents sampled for indwelling urinary catheter care as evidenced by two observations of incorrect indwelling urinary catheter care being provided. The findings included: On 02/10/25 at 11:09 AM, during observation of Resident #2 's indwelling urinary catheter care performed by Staff D, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN), it was noted that Staff C, RN did not perform handwashing before the procedure started. Staff D,CNA drained the catheter bag and cleansed the tip of the catheter bag with [Germicidal Disinfectant Wipes]. Staff D, CNA washed her hands at the bedside with the residents soap [brand body wash] that was personally selected by Staff D, CNA to be used. Staff D, CNA cleaned the outer perineum area first, then the inside labia and lastly the catheter in a top to bottom motion. Review of the medical records for Resident #2 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Urinary Tract Infection (UTI) and Overactive Bladder. Review of Resident #2's Physician's Orders Sheet revealed an order with a start date of 12/30/2022 for indwelling urinary catheter related to (r/t) diagnosis (dx) Obstructive Uropathy and catheter care every shift and as needed (PRN). Review of Resident #2's Annual Minimum Data Set (MDS) dated [DATE] revealed the resident is cognitively impaired, and for Bladder and Bowel urinary continence is not rated because the resident has a catheter and always incontinent for bowel. Review of Resident #2's Care Plans revealed the resident requires an indwelling catheter related to diagnoses of Obstructive Uropathy. Interventions include- Always cover indwelling urinary draining bag. Observe the catheter and change the catheter or bag as indicated or as needed. Be alert for signs of infection including increased temperature, abdominal or flank pain, changes in quantity and quality of urine, hematuria, and disorientation of residents. Resident #3 During observation on 02/10/25 at 12:05 PM, Staff E, CNA and Staff F, RN providing indwelling urinary catheter care for Resident #3; Staff E, CNA and Staff F, RN did not perform hand hygiene before the procedure started. Staff gathered supplies that contained the facility's approved soap, a basin with warm water, wash cloths and towels. Staff E, CNA cleansed the outside of the perineum area first, then pushed back the foreskin and cleaned the tip of the penis in a circular motion, next Staff E, CNA cleaned the catheter in a top to bottom motion without folding or changing washcloths. Staff E, CNA changed gloves, washed hands and dried the resident's perineum area. Review of the medical records for Resident #3 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to UTIs. Review of the Physician's Orders Sheet revealed Resident #3 has an order with a start date of 01/28/2025 for indwelling urinary catheter due to obstructive uropathy for the catheter's draining bag to be changed on the 15th and 28th of each month. Record review of Resident #3's Admission MDS dated [DATE] revealed the resident is cognitively impaired. For bladder, urinary continence is not rated because the resident has a catheter, and bowel is rated as always incontinent for bowel. Review of Resident #3's Care Plans revealed the resident requires an indwelling catheter related to diagnoses of Obstructive Uropathy. Interventions include- Always cover indwelling urinary draining bag. Observe the catheter and change the catheter or bag as indicated or as needed. Be alert for signs of infection including increased temperature, abdominal or flank pain, changes in quantity and quality of urine, hematuria, and disorientation of residents. Interview on 02/10/25 at 02:11 PM with Staff E, CNA stated she been working for the facility for almost 9 years and receive in services on catheter care once a month with supervisor. Staff E, CNA states the steps she take to perform catheter care are getting the supplies, washing your hands, introduce self to resident, getting the water, soap, basin, washcloth and towel. I would clean the resident, empty the water, get new water, rinse and dry. Staff E, CNA stated she washed her hands prior to surveyor observing care. Interview on 02/10/25 at 02:31 PM, Staff C, RN revealed she normally ask to observe indwelling urinary catheter care with CNAs to make sure they are doing the procedure correctly. The steps she would take to perform care would be to gather the supplies, wash her hands, glove and gown up. I would knock on the residents door, get the water, soap and towel. I would clean the resident, remove the water, get new water, rinse and dry. Interview on 02/10/25 at 02:31 PM, Staff F, RN revealed when performing catheter care she washes her hands, apply gown and gloves, gather supplies which consist of warm water, soap, a basin, washcloths and towels. She cleans the perineum area first then the catheter using different washcloths. Staff F, RN explained she normally ask to observe catheter care with CNAs to supervise and educate. Interview on 02/10/25 at 02:20 PM with Staff D, CNA revealed stated she has been working in the facility for almost 3 years and never received in-services on catheter care. The steps she to perform catheter care are: Empty bag, clean bag and put protector on bed, gather the supplies, wash your hands, put on glove and gown, introduce self, get water, soap, towel, remove water, get new water, rinse and dry off resident. Review of the facility policy and procedure regarding catheter care 09/2014, states the staff should wash and dry hands thoroughly. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. For a male resident male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 48906 During an interview on 2/10/25 at 2:40 PM; the Infection Preventionist (ICP) stated, I have been ICP for two years. I in-service staff weekly on infection control protocols and as needed depending on if I see incorrect practices performed. The last in-service for catheter care was November and December of last year. We in-service staff on ways to prevent Urinary Tract Infections (UTI) through proper catheter care and hydration care .Certified Nursing Assistants are to wash their hands before and during incontinence care when going from a dirty to clean surface. Staff should be washing hands with soap and water in the sink in the bathroom, not in a basin. Staff should use the soap provided by the facility when cleaning the perineal area. When emptying the urinary drainage bag, The port is to be cleaned with an alcohol pad, not sanitizing wipes. On 2/10/25 at 1:45 PM, The Director of Nursing (DON) stated, Protocols we have in place to help prevent UTIs are keeping residents, performing routine labs for all residents which include a urine analysis and practice routine peri-care. The CNAs are to clean resident's perineal area every shift with soap and water using the fragrant free soap provided by the facility and report any abnormalities to the nurse. Fragrant soaps can irritate the perineal area and lead to an infection. We also change the indwelling catheter and drainage bags bi-monthly. When a resident is admitted with an indwelling urinary catheter, we verify if there is a pertinent diagnosis. If there is no pertinent diagnosis, we receive an order from the doctor to remove it.

Based on observations, record review and interviews the facility failed to reduce the risk of Urinary Tract Infections for two (Residents #2 and Resident #3) out of two residents sampled for indwelling urinary catheter care, as evidenced by staffs' failure to implement infection prevention and control precautions during perineal care for Resident #2 and Resident #3 with indwelling urinary catheter. The findings included: On 02/10/25 at 11:09 AM, during observation of Resident #2's indwelling urinary catheter care performed by Staff D, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN), it was noted that Staff C, RN did not perform handwashing before the procedure started. Staff D,CNA drained the catheter bag and cleansed the tip of the catheter bag with [Germicidal Disinfectant Wipes]. Staff D, CNA washed her hands at the bedside with the residents soap [brand body wash] that was personally selected by Staff D, CNA to be used. Staff D, CNA cleaned the outer perineum area first, then the inside labia and lastly the catheter in a top to bottom motion. Review of the medical records for Resident #2 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Urinary Tract Infection (UTI) and Overactive Bladder. Review of Resident #2's Physician's Orders Sheet revealed an order with a start date of 12/30/2022 for indwelling urinary catheter related to (r/t) diagnosis (dx) Obstructive Uropathy and catheter care every shift and as needed (PRN). Resident #3 During observation on 02/10/25 at 12:05 PM, Staff E, CNA and Staff F, RN providing indwelling urinary catheter care for Resident #3; Staff E, CNA and Staff F, RN did not perform hand hygiene before the procedure started. Staff gathered supplies that contained the facility's approved soap, a basin with warm water, wash cloths and towels. Staff E, CNA cleansed the outside of the perineum area first, then pushed back the foreskin and cleaned the tip of the penis in a circular motion, next Staff E, CNA cleaned the catheter in a top to bottom motion without folding or changing washcloths. Staff E, CNA changed gloves, washed hands and dried the resident's perineum area. Review of the medical records for Resident #3 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to UTIs. Review of the Physician's Orders Sheet revealed Resident #3 has an order with a start date of 01/28/2025 for indwelling urinary catheter due to obstructive uropathy for the catheter's draining bag to be changed on the 15th and 28th of each month. Review of Resident #3's Care Plans revealed the resident requires an indwelling catheter related to diagnoses of Obstructive Uropathy. Interventions include- Always cover indwelling urinary draining bag. Observe the catheter and change the catheter or bag as indicated or as needed. Be alert for signs of infection including increased temperature, abdominal or flank pain, changes in quantity and quality of urine, hematuria, and disorientation of residents. Interview on 02/10/25 at 02:11 PM with Staff E, CNA stated she been working for the facility for almost 9 years and receive in services on catheter care once a month with supervisor. Staff E, CNA states the steps she take to perform catheter care are getting the supplies, washing your hands, introduce self to resident, getting the water, soap, basin, washcloth and towel. I would clean the resident, empty the water, get new water, rinse and dry. Staff E, CNA stated she washed her hands prior to surveyor observing care. Interview on 02/10/25 at 02:31 PM, Staff C, RN revealed she normally ask to observe indwelling urinary catheter care with CNAs to make sure they are doing the procedure correctly. The steps she would take to perform care would be to gather the supplies, wash her hands, glove and gown up. I would knock on the residents door, get the water, soap and towel. I would clean the resident, remove the water, get new water, rinse and dry. Interview on 02/10/25 at 02:31 PM, Staff F, RN revealed when performing catheter care she washes her hands, apply gown and gloves, gather supplies which consist of warm water, soap, a basin, washcloths and towels. She cleans the perineum area first then the catheter using different washcloths. Staff F, RN explained she normally ask to observe catheter care with CNAs to supervise and educate. Interview on 02/10/25 at 02:20 PM with Staff D, CNA revealed stated she has been working in the facility for almost 3 years and never received in-services on catheter care. The steps she to perform catheter care are: Empty bag, clean bag and put protector on bed, gather the supplies, wash your hands, put on glove and gown, introduce self, get water, soap, towel, remove water, get new water, rinse and dry off resident. Review of the facility's policy and procedure regarding catheter care 09/2014, states the staff should wash and dry hands thoroughly. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. For a male resident male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 48906 During an interview on 2/10/25 at 2:40 PM; the Infection Preventionist (ICP) stated, I have been ICP for two years. I in-service staff weekly on infection control protocols and as needed depending on if I see incorrect practices performed. The last in-service for catheter care was November and December of last year. We in-service staff on ways to prevent Urinary Tract Infections (UTI) through proper catheter care and hydration care .Certified Nursing Assistants are to wash their hands before and during incontinence care when going from a dirty to clean surface. Staff should be washing hands with soap and water in the sink in the bathroom, not in a basin. Staff should use the soap provided by the facility when cleaning the perineal area. When emptying the urinary drainage bag, The port is to be cleaned with an alcohol pad, not sanitizing wipes. On 2/10/25 at 1:45 PM, The Director of Nursing (DON) stated, Protocols we have in place to help prevent UTIs are keeping residents, performing routine labs for all residents which include a urine analysis and practice routine peri-care. The CNAs are to clean resident's perineal area every shift with soap and water using the fragrant free soap provided by the facility and report any abnormalities to the nurse. Fragrant soaps can irritate the perineal area and lead to an infection. We also change the indwelling catheter and drainage bags bi-monthly. When a resident is admitted with an indwelling urinary catheter, we verify if there is a pertinent diagnosis. If there is no pertinent diagnosis, we receive an order from the doctor to remove it.

Based on observation, interview, and record review the facility failed to ensure the safety of a vulnerable Resident (Resident #32) out of 29 sampled residents. As evidenced by disposable shaving razors were observed at the resident's bedside. There were 133 residents residing in the facility at the time of the survey. The findings Included: On 11 /12/24 at 09:05 AM and on 11/12/24 at 01:00 PM shaving razors observed on Resident #32's bedside table. On 11/14/24 at 09:10 AM three (3) shaving razors were observed on the resident's bedside table. Review of Resident #32's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Paranoid schizophrenia and Bipolar disorder. Review of the Physician's Orders Sheet for November 2024 revealed Resident #32 had orders that included daily medications for Schizophrenia and a medication three times a day for Anxiety. Review of Resident # 32's Schedule 5 Day Minimum Data Set (MDS) dated [DATE] indicated in Section C for Cognitive Patterns a Brief Interview for Mental status Score of 15 out of 15 indicating the resident is cognitively intact. Section GG for Functional Status documented Partial moderate assistance for activities of daily living. Record review of Resident # 32's Care Plans Reference date 07/04/2024 revealed: Resident is noted with self-care deficit, resident needs assistance with his activities of daily living (ADL) due to a Diagnosis of Altered Mental Status, Parkinson's Disease, Chronic Diarrhea, Schizophrenia, Bipolar Disease, Insomnia, Anxiety, and Cancer of Skin. Interventions include-Obtain all equipment necessary for ADL care and place items close to resident, assist with dressing, grooming, and hygiene needs daily to keep resident clean and neat During an interview on 11/14/24 at 09:42 AM Certified Nursing assistant (CNAs) (Staff A) revealed; the resident requires supervision for his ADLs, he loves to shave himself and he is supervised when he is shaving, the resident always get razors from somewhere and takes it to his room every time; whenever she sees razors in his room she takes it away and store it properly in the storage area. Staff A went to the resident's room during the interview with the surveyor and removed the 3 razors on Resident #32's bedside table. On 11/14/24 at 09:45 AM Licensed Practical Nurse (LPN) (Staff B) revealed the resident goes down to central supply and ask for his razors himself; the razors are stored in the supply room. We are constantly checking on this resident because he is all over the place and always collecting different items, we check his room often during the shift and are always removing items that are not supposed to be in his room. On 11/14/24 at 11:00 AM Resident #32 refused to be interviewed. Interview on 11/15/24 at 09:34 AM; the Director of Nursing (DON) was informed of the razors observed on Resident #32's bedside table. Review of the facility's policy and procedure titled Hazardous Areas, Devices and Equipment revision date July 2017 states: All Hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate hazards to the extent possible.

Based on observation, interview and record review the facility failed to follow infection control standards for one (Resident #103) out of 29 sampled residents. As evidenced by Resident# 103's nebulizer and oxygen tubing were not protected in a bag/covering on the residents bedside table. The findings Included: During observation on 11/12/24 at 08:43 AM, Resident #103 was asleep in bed and the nebulizer and tubing were not in a protective bag/covering on the bedside table. Review of the medical records for Resident #103 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic respiratory failure with hypoxia. Chronic Obstructive Pulmonary disease. Review of the Physician's Orders Sheet for November 2024 revealed, Resident #103 had orders that included but not limited to: Ipratropium-Albuterol solution via nebulization three times a day for Chronic Obstructive Pulmonary disease. Record review of Resident #103 's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status score 15 out of 15 scale indicating the resident is cognitively intact. Record review of Resident #103 's Care Plans Reference date 10/11/2024 revealed: Resident has pulmonary condition and has potential for difficulty breathing, with history of respiratory failure with hypoxia, COPD, history of pneumonia. Resident will be maintained at their respiratory baseline with a patent airway and unlabored Respiration's through nest review date. Interventions include administer respiratory treatment per MD order, oxygen via nasal cannula as ordered . Interview on 11/14/24 at 09:49 AM, Registered Nurse (Staff C) stated: I saw the nebulizer at the resident's bedside laying on top of the bedside table on Tuesday (11/12/24) in the morning during my rounds and I threw the nebulizer and the tubing away, the respiratory supplies have to be stored in a bag with the date the supplies were last changed. Review of the facility's policy and procedure titled Infection Prevention and Control Program revision date October 2018 indicate: An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on record review and interview, the facility failed to implement policies and procedures for ensuring timely reporting of abuse or mistreatment for three out of three sampled residents (Residents #4, 5, and #8). There were 98 residents residing in the facility at the time of the survey. The findings included: Review of facility's abuse log noting Abuse, neglect, Mis-Management of Funds, Incidents of Unknown Origin log from January 2023 to October 2023 revealed: On February 18, 2023, at 11:15 AM, an incident or altercation happened between Resident #4 and Resident #8. Further review showed that the facility reported the incident to the Agency for Healthcare Administration (AHCA) Immediate Report system on February 20, 2023, at 03:07 PM. Review of the facility's incident report revealed that Staff A, Registered Nurse (RN), was aware of the incident on February 18, 2023, at 10:50 AM and reported it to the Director of Social Worker and the Director of Nursing (DON) on February 20, 2023 at 09:45 AM. During an interview with the Director of Social Worker on 10/30/2023 at 11:37 AM regarding the incident, the Director of Social Worker stated, There were 2 patients involved. They were aggressive toward each other. [Resident #4] tried to kick [Resident #8], but the kick did not land. [Resident #8] threw a cup of water that was in his hand to [Resident #4]. After reviewing the camera, the kick wasn't landed. Further interview at 01:27 PM on 10/30/2023 regarding the incident reporting, the Director of Social Worker stated, The incident on the 18th of February was during a weekend. When I got here on Monday, I reported it. It must be in the afternoon when they reported it to me. The immediate report, I had my laptop with me. I reported it the time they told me that. It shows on the bottom of this report that I reported it 02/18/23 at 11:04 AM. I would not be able to make this up. I don't know; there must be some kind of glitch in the system. Further review of the facility's abuse log revealed that on March 21, 2023 at 07:15 PM, Resident #5's family member reported that Resident #5 was verbally abused by a staff member. Further review showed that the facility did not report the incident to the Agency for Healthcare Administration (AHCA) Immediate Reporting system until March 23, 2023, at 04:26 PM. During an interview with the Director of Social Worker on 10/30/2023 at 11:32 AM regarding the incident, the Director of Social Worker stated, There was something wrong with my passwords. No one could have reported it. The time seen in the report is 4:00 PM the next day. It was an issue. We spent the whole day with AHCA trying to report it. It was unsubstantiated. Further interview at 12:35 PM on 10/30/2023 regarding the incident reporting, the Director of Social Worker stated that the abuse reports were reporting on time. She then stated, What happened is that the resident called her son at about 03:45 PM and had her son to come to the facility. The son reported it at about 07:00 PM, and the time we knew about it, we reported it. For this one in March, it also happened during the weekend. It was reported to me on the 20th. There was a glitch in the system. Both incidents happened the same day during the weekend. I don't know why the system showed 1 month later. On 10/30/2023 at 02:25 PM, during an interview with the Director of Nursing (DON) regarding the February 18, 2023 incident, the DON stated, for Resident #4 and Resident #8, it happened on a weekend, a Saturday. I remember that day [Director of Social Worker] had a problem with her login. We were trying to get in contact with AHCA to see why she couldn't report it. I don't remember if it was our system or theirs. On 10/30/2023 at 02:28 PM, during an interview with the DON regarding the March 21, 2023 incident, the DON stated, For [Resident #5], the incident happened on a weekend. We didn't find out until Monday. [The son] came on Monday and reported it to us. He stated what happened during the weekend. I don't remember exactly the incident, but I remember we found out on Monday when the son came to report it. I know [the son] usually came in the afternoon after lunch because of his .; wait for transportation. I never saw him come in the morning. The day he came, he spoke to the [Director of Social Worker]. Review of the facility's policy and procedures relating to reporting abuse to State agencies and other entities/individuals, revised December 2009, revealed: Policy statement: All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Policy Interpretation and Implementation: 1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident as appropriate: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The Resident's Representative (Sponsor) of Record; c. Adult Protective Services; d. Law enforcement officials (as required); e. The resident's Attending Physician. 2. Verbal/written notices will be submitted to agencies as required by law. An Immediate Report will be submitted as soon as possible, but no later than 24 hours of discovery of the incident. If the events that cause the allegation involve abuse or result in serious bodily injury, they must be reported within two hours after the allegation is made. If such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone. Notice will include, as appropriate .

Based on interview and record review, the facility failed to honor the resident's choice of food for one (Resident #109) out of three residents investigated for food. This deficient practice has the potential to limit the residents' right to make personal dietary choices. The facility had a census of 136 residents at the time of this survey. Findings included: During an interview on 06/26/23 at 10:36 AM, Resident #109 stated, I don't like the food. I used to get boiled eggs, but now they changed it to scrambled eggs. I don't like scrambled eggs; I preferred boiled egg. I never eat scrambled or fried eggs. They can see that I never eat their eggs. During an interview on 06/28/23 at 09:18 AM with Staff B, a CNA (Certified Nursing Assistant), regarding resident's food choices, Staff B stated, as CNAs, they don't really know about the residents' diet. They only go and set up the food for the residents; however, the residents always have options when they give them the food. They can call the kitchen or let them know if they don't like the food, so they can bring something else. Staff B further stated, she knew Resident #109 sometimes requests for other food. She stated, she had seen they sent her boiled eggs and sometimes scrambled eggs, muffin, flat bread, jelly and other choices of food before. Also, they always give Resident #109 a lot of food, so she can choose what she wants. On 06/28/23 at 02:06 PM, during a follow up interview with Resident #109, the resident stated, They gave me scrambled eggs this morning. I didn't eat it. I didn't tell them this morning, but I told them before. They still bring it to me. During an interview with Staff C, Licensed Practical Nurse (LPN), on 06/28/23 at 02:12 PM regarding Resident #109's food choices, Staff C stated, the only food she knew that Resident #109 doesn't like is cereal with dry raisins. Staff C stated, she didn't know about Resident #109's egg preferences. Staff C further stated, if a resident doesn't like a food, the resident would tell a CNA or a nurse, then the CNA or the nurse would call the Dietitian to come and talk to the resident to change the resident's food preference. On 06/28/23 at 02:19 PM, the Dietary Director stated, For food preferences, we make notes in the system. I don't know the food preference for breakfast for Resident #109. My Dietitian spoke to her. On 06/28/23 at 02:27 PM while interviewing the Dietitian inside Resident #109's room regarding food preferences, Resident #109 stated, I spoke to her (Dietitian) about the eggs. That time, I told her that I wanted salt. Since then, I've been getting fried or scrambled eggs. They used to give me boiled eggs before, but after I talked to her, I've only been receiving fried or scrambled eggs. I don't eat them. It's a waste. I never tell them I want scrambled or fried eggs. I only asked to send me some salt with the egg. On 06/28/23 at 02:28 PM, the Dietitian stated, I think it was a miscommunication. Yes, I spoke to her, and she told me about the salt. I thought she told me she did not want the boiled eggs anymore; that's right her preference is fried or scrambled eggs right now. Review of Resident #109's Care Plan dated 02/23/2023 regarding food preferences revealed, Provide nutritional supplements as ordered; offer snacks and/or supplements as ordered; offer alternatives if the main meal is disliked; update food preferences PRN (Pro Re Nata meaning as necessary); provide diet as physician ordered. Review of Resident #109's food preference labeled Cart 5 revealed: Breakfast: General regular, coffee, grits or cold cereal - no raisin, eggs - fried or scrambled, salt. Dislike: Oatmeal mexin casserole Lunch: General regular, coffee Dislike: Oatmeal mexin casserole Dinner: General regular, coffee Dislike: Oatmeal mexin casserole On 06/28/23 at 03:48 PM, the Dietary Director brought a new food preference menu with Resident #109's name written on top. She stated, Resident #109's food preference has been updated. From now, she will receive boiled eggs instead of fried eggs. Here is the change. Review of Resident #109's food preference Cart 5 revealed, fried or scrambled eggs on the menu were replaced by 2 hard-boiled eggs. Review of the facility's resident food preferences policy, titled, Food preference interpretation and statement revealed: Individual food preferences will be assessed upon and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's food and eating preferences in the care plan. 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 11. The facility's quality assessment and performance improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

Based on observation, record review and interview, the facility failed to ensure pharmaceutical procedures were followed during medication administration for 1) One (Resident # 63) out of three (3) residents sampled as evidenced by the Licensed Practical Nurse (Staff C) signing off on the medications as given/completed in the Electronic Medication Administration Record (EMAR) before administering medications to Resident #63 2) The narcotic count being inaccurate during a narcotic count. The Findings Included: 1. During Observation on 05/24/22 at 8:25 AM, the Medication Administration obsevation with (Staff C), Licensed Practical Nurse(LPN). Staff C signed off on all of Resident #63's medication as given and completed in the Electronic Medication Administration Record (EMAR) before the medication was given to Resident #63. Review of the medical records for Resident #63 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: [CONDITION(S)], Muscle Wasting and Atrophy, Acute [CONDITION(S)] with [CONDITION(S)] and Severe [CONDITION(S)] without Septic Shock. Record Review of the Physician's Orders Sheet for May 2022 revealed, Resident #63 had orders that included but were not limited to: [MEDICATION(S)] 10MG (milligram) (1) tablet (tab), Vitamin D 500 MG (2) tabs, [MEDICATION(S)] 20MG (1) tab, [MEDICATION(S)] tablet 120 mg (1) tab-Not given/found during medication reconciliation. Record review of Resident # 63's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status Score (BIMS) 7 on a 0-15 scale, indicating the resident is severely impaired cognitively. Interview on 5/24/22 at 8:40 AM with Staff C, When asked by the surveyor why did she sign off the medications as completed before giving them to the residents, Staff C stated, I know this resident and he always takes his medication, so I signed it off beforehand, I know I am supposed to sign off on the medications after I give it. Interview on 05/24/22 at 10:45 AM, the Director of Nursing (DON) reported, Staff C told me she was nervous during the medication administration observation with the surveyor, and she signed off the medications for the resident before giving it. Review of the facility's policies and procedures titled, Administering Medications revision date 4/2019 states: The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 2. On 05/25/22 at 09:55 AM, a narcotic count was completed with Staff C, on Cart 2, Station 2. While counting the [MEDICATION(S)] 1 mg tablets, the form documented there were 2 remaining [MEDICATION(S)], but there were 3 tablets remaining. Staff C corrected the count to document there were 3 tablets remaining. During the review of the facility's policy and procedure for Controlled Substances dated revised April 2019. The Policy Statement revealed, The facility complies with all laws, regulations and other requirements related to handling, sotrage, disposal and documentation of controlled medications. Policy Interpretation and Implementation: 7. Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift.

Based on observations, interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I or Level II for mental disorder (MD) or intellectual disability (ID) was completed for 6 out of 6 sampled residents (Resident #33, #63, #82, #92, #95, #109). This deficiency had the potential to affect 131 residents residing in the facility at the time of the survey. The findings included: 1. Record review of Face sheet revealed resident #33 was admitted on [DATE] and readmitted on [DATE]. Record review of the Medical Diagnoses revealed the resident's diagnoses included, but are not limited to, Major depressive disorder, recurrent, unspecified; Other psychoactive substance use, unspecified with withdrawal, unspecified; [CONDITION(S)], unspecified. Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Orders dated 08/11/2021 revealed the resident is currently receiving [MEDICATION(S)] tablet 7.5 mg at bedtime. give 2 tablets for depression. Record review of Orders dated 03/24/2021 revealed the resident is currently receiving [MEDICATION(S)] tablet 1 mg at bedtime for [CONDITION(S)]. The residents record did not include a Level I PASARR. 2. On 05/25/22 at 11:15 AM, residents #63 was observed seated on a chair by his room door. He was observed talking with every staff member that passed by. No anxiety or distress was noted. Record review of the Face sheet revealed the resident was admitted to the facility on [DATE]. Record review of the Medical Diagnoses revealed the resident's diagnoses included, but are not limited to, Psychotic disorder with delusions due to known physiological condition; Major depressive disorder, recurrent, moderate; Unspecified dementia without behavioral disturbance. Record review of PASARR Level I dated 03/06/2022 revealed the Section I: PASARR Screen Decision Maker was not completed with the resident's diagnoses. Section IV: PASARR Screen completion revealed the resident has no diagnoses of Mental Illness. Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS Section A-Identification dated 03/27/2022, A1500 revealed, the resident is not considered for a Level II PASARR. A1510 is coded for the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS Section I-Active Diagnoses dated 03/27/2022 revealed, the resident had depression and a psychotic disorder. Record review of the Admission MDS Section N-Medications dated 03/27/2022 revealed the resident had antipsychotic and antidepressant medications six (6) times in a week. Record review of the Admission MDS Section O-Special Treatment, Procedures and Programs dated 03/27/2022 revealed the resident is not receiving psychological therapy. During interview with the Director of Nursing on 05/26/22 at 12:05 PM, he stated for PASARR requirements they follow the policies and procedures and the regulations. He stated the residents admission is based on the Level I PASARR. The Level II PASARR is triggered if the resident had a mental illness or intellectual disability and the questions in Section II are answered yes. The level II PASRR had to be requested. Residents who don't exhibit any behaviors or the Psychiatrist certified they had no issues, then we don't requested a Level II PASARR after the 30 days admission. 3. Record review of Face Sheet revealed resident #82 was admitted to the facility on [DATE] Record review of Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Level I PASARR found resident # 82's medical record. 4. Record review of Face Sheet revealed resident #92 was admitted to the facility on [DATE] and readmitted on [DATE]. Observation of resident # 92 on 05/25/22 at 11:30 AM revealed the resident was laying on her bed, awake. No distress or anxiety was noted. Record review of the residents Medical Diagnoses revealed the resident's diagnoses included, but are not limited to, Unspecified; Cachexia; Dysphagia following cerebral infarction. Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS Section A-Identification dated 04/19/2021, A1510 Level II PASARR revealed the resident had a serious mental illness, intellectual disability, other related conditions. Record review of the Annual MDS Section C-Cognitive Patterns dated 04/20/2022 revealed the resident Brief Interview for Mental Status (BIMS) Summary score was 99, meaning unable to complete the interview. Record review of the Annual MDS Section E-Behavior dated 04/20/2022 revealed the resident had no potential indicators of [CONDITION(S)]. Record review of the Annual MDS Section G-Functional Status dated 04/20/2022 revealed the resident needed extensive assistance with one-person physical assistance for bed mobility, dressing. The resident needed total dependence with two-person physical assistance for transfer, locomotion, eating, toilet use, personal hygiene and bathing. Record review of the Annual MDS Section I-Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual MDS Section N-Medications dated 04/20/2022 revealed the resident was receiving antipsychotics, seven (7) times in a week. Record review of the Annual MDS Section O-Special Treatments, Procedures and Programs dated 04/20/2022 revealed the resident was not receiving psychological therapy. Record review of the Psychiatrist Consultation dated 05/16/2021 revealed the resident was seen for a complete evaluation. The Doctor recommended the resident continues with the treatment. She continues to exhibit symptoms of an emotional disorder, that interfere with day to day functioning and she is unable to alleviate these symptoms on her own and is in need of medication management and requires continued medications. Decrease [MEDICATION(S)] 50 mg(milligrams) by mouth to 25 mg by mouth at bedtime. There was no Level II in the residents medical record. 5. Record review of the PASARR Level I revealed resident #95 had a mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of resident # 95 on 05/25/22 at 11:41 AM revealed, resident #95 was laying on his bed, awake. The resident was looking at the surveyor, but was not talking. No distress or anxiety was noted. Record review of the Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of the Medical Diagnoses revealed the resident's diagnoses included, but are not limited to, [CONDITION(S)], Unspecified; Altered Mental Status, Unspecified; Anxiety disorder; Unspecified [CONDITION(S)] not due to a substance or known physiological condition. Record review of the Level I PASARR dated 04/16/2022 revealed Section IV: PASARR Screen Completion Individual may not be admitted to a Nursing Facility. Required a Level II PASRR. Resident had Serious Mental Illness. Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS Section A-Identification dated 04/24/2022, A1500 revealed the resident is not considered for a Level II PASARR. Record review of the Admission MDS Section C-Cognitive Patterns dated 04/24/2022 revealed the resident BIMS summary Score was 03, meaning severe cognitive impairment. Record review of the Admission MDS Section E-Behavior dated 04/24/2022 revealed the resident had no potential indicators for [CONDITION(S)] and no behavioral symptoms. Record review of the Admission MDS Section I-Active Diagnoses dated 04/24/2022 revealed the resident had a Psychotic Disorder. Record review of the Admission MDS Section N-Medications dated 04/24/2022 revealed the resident was receiving antipsychotic medications, seven (7) times in a week. Record review of the Admission MDS Section O-Special Treatment, Procedures and Programs dated 04/24/2022 revealed the resident had no Psychological Therapy. 6. Record review of the Face Sheet revealed resident #109 was admitted to the facility on [DATE]. Record review of the Medical Diagnoses revealed the resident's diagnoses include, but are not limited to, Major depressive disorder, recurrent, moderate; Generalized anxiety disorder (History of). Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Psychiatrist Consultation dated 04/13/2022 revealed the resident was seen by the MD. The plan was to decrease some medications. Reviewed and Discussed the risk and benefits of medication. Patient voiced understanding. Monitor for changes and side effects. Follow with psychiatrist as needed. Record review of the Annual MDS Section A-Identification dated 05/04/2022, A1500 revealed the resident is not considered for Level II PASARR. A1510 revealed the resident had serious mental illness, intellectual disability and other related conditions. Record review of the Annual MDS Section I-Active Diagnoses dated 05/04/2022 revealed the resident had Depression and [CONDITION(S)]. Record review of the Annual MDS Section N dated 05/04/2022 revealed the resident was receiving an antipsychotic and antianxiety seven (7) times in a week. Record review of the Annual MDS Section O-Special Treatments, Procedures and Programs dated 05/04/2022 revealed the resident is not receiving psychological therapy. Interview with Director of Nursing on 05/26/22 at 12:05 PM, he stated for PASARR requirements they follow the policies and procedures and the regulations. He stated the residents admission is based on a Level I PASARR. The Level II PASARR is triggered if the resident had a mental illness or intellectual disability and the questions in Section II are answered, yes. The level II PASARR had to be requested. Residents who don't exhibit any behaviors or the Psychiatrist certified that had no issues, then we don't request a Level II PASARR after the 30 days admission.

Based on observation, interview and record review, the facility failed to have a care plan to address one out of 28 sampled residents (Resident #76) range of motion. The facility had 37 residents with contractures at the time of the survey. The facility's census was 131 at the time of the survey. The findings included: On 05/26/22 at 11:15 AM, resident #76 was observed in bed asleep, music was playing in the room and a radio on was on the bedsiden table. The residents legs appeared to be contracted bilaterally. The residents legs were bent at the knee and were bent against her buttocks. The residents siderails were padded bilaterally. During the review of the medical record it noted the resident was admitted to the facility on [DATE]. The residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of the Minimum Data Set (MDS) Annual MDS dated [DATE] and Quarterly assessment dated [DATE] it was noted in Section G-Functional Status, the following was coded: Bed Mobility - 4/2(Total Dependence/One person physical assist), Transfer-4/3(Total Dependence/Two person physical Assist), Range of Motion (ROM)-A-No upper extremity impairment, B- lower extremity Impairment on both sides. Section O-Special Treatments, Procedures and Programs documented: O400D-Occupational Therapy (OT)-0, O400C-Physical Therapy (PT)-0, Restorative Nursing Programs - O500- A to J-0. During the review of Resident #76 care plans was noted the residents care plans included: At risk for falls d/t (due to) impaired balance and mobility, poor safety awareness, impaired cognition, Self Care Deficit d/t impaired balance and mobility, poor safety awareness, incontinence B & B (Bowel & Bladder), functions dx (diagnosis) [CONDITION(S)], CAD ([CONDITION(S)]), vitamin deficiency, [CONDITION(S)], DM, peg. (Percutaneous Endoscopic Gastrostomy) Category- ADL (Activity of Daily Living) Function and Rehab Potential. During the review of the care plans it was noted the care plans did not include approaches for ROM for the residents lower extremities. During an interview on 05/26/22 at 03:05 PM with Staff D, Registered Nurse, she reports she only does a care plan if they're on restorative. She reports, the resident straightens her legs, she reports, she would be on maintenance with Certified Nursing Assistants (C N As). Interview on 05/26/22 at 03:20 PM with the Director of Nurses (DON) revealed, no care plan is completed for maintenance of ROM. During the review of the facility's policy on Resident Mobility and Range of Motion dated July 2017, revealed the Policy Statement - 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services and/or prevent a futher decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation: 4. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on observation, record review and interview, the facility failed to ensure standard precautions were implemented for 1out of 2 residents reviewed for pressure ulcers ( Resident #99) during a wound care observation, as evidenced by Registered Nurse (Staff A) not performing hand hygiene and changing gloves when transitioning from contaminated/dirty to clean during wound care. This had the potential to affect 27 residents in the facility receiving wound care treatment at the time of this survey The Findings Included: During observation on 05/25/22 at 10:57 AM, Staff A, Registered Nurse Wound Care Nurse, Staff B, Certified Nursing Assistant assisting with wound care, during the observation Resident #99 was in bed, Staff A identified the resident, exited the room, completed hand hygiene, prepared supplies, brought the overbed table to to the room door, completed hand hygiene, Donned gloves, used a Sani-Cloth to wipe down the overbed table, discarded the gloves, completed hand hygiene, set up multiple trays, set up the red biohazard bag, gloves were on a tray, Alginate was on tray, the dry dressing tape was dated 5/25/22 and initialed, Staff A had tongue depressors with supplies, completed hand hygiene, Donned gloves, opened a new tube of Santyl, dated the tube 5/25/22, a dry 4x4 gauze, the 4x4 gauze was soaked in a wound cleaner. Staff A entered resident #99s' room, washed hands, Donned gloves. Staff B washed hands, Donned gloves, talked with the resident, repositioned the resident for wound care. Staff A removed the old dressing dated 5/24/22, slight light yellow drainage was observed, the wound was deep, pink and dark colored. Staff A washed her hands, Donned gloves, cleaned the wound with the gauze soaked in wound cleaner x2, dried the wound with gauze x 2, applied Santyl, applied Alginate, applied 4x4 gauze, covered with the dry dressing tape dated 5/25/22 and initialed, disposed of supplies in the red biohazard bag, completed hand hygiene, Donned gloves, closed the red biohazard bag. Staff B changed Resident #99's brief. Staff A took the red biohazard bag to the soiled utility room, disposed of the red biohazard bag in red bin, washed hands, exited the soiled utility room, and signed off on the wound care treatment. Review of the medical records for Resident #99 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #99's Discharge Minimum Data Set (MDS) dated [DATE] revealed: Section C-Cognitive Patterns-Brief Interview for Mental Status Score (BIMS)-unable to determine. Section G-Functional Status-Total dependence for Activities of Daily Living. Section H-Bowel and Bladder-Always incontinent of bowel and bladder. Section J-Health Conditions-Resident received scheduled pain medications in the last 5 days. Section K-Nutritional Status-Resident has weight loss and is not on a physician prescribed weight loss regimen. Section M-Skin Conditions-Stage 4 pressure ulcer not present on admission. Record review of Resident #99's Care Plans Dated 05/04/22 revealed: Problem: Resident has pressure ulcer to the sacrum at risk for developing further skin breakdown. Goal: Resident will have affected area show evidence of healthy healing tissue and reduce in size and will minimize the risk of infection by the next review date. Interventions: Low air loss mattress, Monitor for signs and symptoms of infection, wound care nurse to observe and document weekly, pressure relieving device for bed/chair, use aseptic technique during dressing change, proper hand washing before and after dressing change, dietary consult as ordered to asses nutritional needs, encourage 100 percent dietary intake daily, assist resident to turn and reposition frequently, treatment to affected area as ordered, observe for improvement or decline in condition of wound and for possible need to change treatment and Evaluate wound size, characteristic, presence of drainage, color and document weekly. Record review of Resident #99's [V ] Wound Care notes for five weeks revealed: 5/17/22-sacral wound deteriorated, 5/10/22-sacral wound improved, 5/3/22-sacral wound improved, 4/26/22-sacral wound improved, and 4/19/22-sacral wound improved. Interview on 05/25/22 at 11:47 with Staff A, she reported she has been doing wound care for six months in the facility. Staff A stated this resident has been in this facility for years, she has a sacral wound, stage 4 that has reopened, treatment is to clean the sacral wound with wound cleaner, apply Santyl and cover with Alginate and dry dressing. This resident wound is getting better, but it is taking time to heal because she cannot sit for long periods of time because of the pressure on the wounds. We make sure she is being turned often, not less than every 2 hours, I check to make sure the resident is facing a different direction after 2 hours to ensure the Certified Nursing Assistants (CNAs) and direct care staff are turning this resident. [V ] wound care comes to the facility on ce a week, every Tuesday, I do rounds with the [V ] team, the Wound Care Physician (MD) measures all wounds, assess the wounds, and gives recommendations as needed. We access the [V ] notes to see what new orders or treatment the wound care MD orders, there are two wound care nurses and one of us is always working, and we have two other nurses that have experience with wound care that can cover if needed. Staff A explained the steps to the wound care procedure she performed on Resident # 99, it was shared with Staff A the step between cleaning Resident #99's wound and applying the clean dressing, she did not change her gloves and wash her hands. Staff A stated yes, I did not change my gloves after I cleaned the resident's wound, I put the clean dressing on right away, I was so nervous. Review of the facility's policy and procedures titled, Infection Prevention and Control Program revision date 10/2018 states: Policy Interpretation and Implementation Step 11-Prevention of Infection-Step 3-educating staff and ensuring that they adhere to proper techniques and procedures. Step 4-Communicating the importance of standard precautions.

Based on records reviewed and interviews the facility failed to ensure adequate supervision for one resident (Resident #1) reviewed for elopement out of five sampled residents. Resident #1, a vulnerable adult, a smoker that required supervision, used a wheelchair, incontinent of bowel and bladder and required extensive assistance with Activities of Daily Living (ADL) eloped after being dropped off by facility's transportation and staff unsupervised to receive his first [CONDITION(S)] at a local hospital's oncology department 10 miles away from the nursing home. After his first [CONDITION(S)] treatment Resident #1 eloped and his whereabouts remain unknown. Resident #1's health, safety, and life remained at risk. This facility's deficient practice has the potential to have an adverse effect on all newly admitted , vulnerable and or cognitively impaired residents in the facility that go for outside appointments. The Findings Included: Record review of the facility's policies and procedures revealed the policy for Wandering and Elopements. It noted: The facility will identify resident who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 3. If a resident is missing, initiate the elopement /missing resident emergency procedure: C. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the Attending Physician, law enforcement official and as necessary volunteer agencies . (I.e., Emergency Management, Rescue Squads, etc.) Review of Resident #1's clinical record showed that Resident #1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with clinical diagnoses that include but not limited to Neoplasm of uncertain behavior of larynx-supraglottic mass, adult failure to thrive, other abnormalities of gait and mobility, unsteadiness on feet, dysphagia, chronic, obstructive pulmonary disease, hypertension and [CONDITION(S)]. Resident #1 was alert and oriented times 2, able to communicate with periods of confusion, required extensive to limited assistance with ADL and transfer/mobility. Used a wheelchair for mobility for long distance as safety precaution. The most recent Minimum Data Set (MDS) comprehensive assessment for Resident #1 was completed in [DATE] - Admission assessment. Cognitive patterns showed a score of 5 out of 15 on his Brief Interview of Mental Status (BIMS). Indicating that Resident #1 was cognitively impaired. His Speech was not clear, sometimes he was understood and sometimes he was able to understand. Resident #1's Functional Status indicated he required extensive assistance for bed mobility one person. Extensive assistance of two people to transfer from bed to wheelchair . He was also frequently incontinent for urinary and bowel. His active diagnoses coded; Cancer, [CONDITION(S)], Hypertension, Reflux, [CONDITION(S)] ([CONDITION(S)]) malnutrition, asthma, failure to thrive, unsteadiness on feet and [CONDITION(S)]. Review of Resident #1's Elopement assessment dated [DATE] showed he was a low risk for elopement. Review of progress notes dated [DATE] time stamped 08:42 PM revealed, Social worker visited resident in his room for his to welcome him into the facility, introduce self and provided emotional support. Resident is alert and oriented X 2 (times 2) moderate cognitive deficit with periods of confusion, disorientation, and forgetfulness able to make basic needs known, answer yes/no and simple questions with unclear slurred speech sometimes understands sometimes is understood . Resident is currently taking a hypnotic medication. Resident with no indication of traumatic event. Resident is a smoker; he is being explained the facility smoking policy. Resident came to the facility from hospital due to failure to thrive and weight loss. Resident is at the facility for care and therapy purposes. Resident was living at home alone and requires ALF (Assisted Living Facility) placement after completing skilled rehab. Resident stated to have family in [NAME]; however, he has no family close by . Further review of Resident #1 's progress notes documented on [DATE] time stamped 07:12 AM : Resident out of the facility for medical appointment, no distress noted, stable condition. Documentation by written by Staff C, Registered Nurse ( RN) dated [DATE] time stamped 02:30 PM recorded as Late Entry on [DATE] time stamped 01:29 PM I was informed that Resident left from [local hospital's oncology department name]. I called the Doctor's office to get report and spoke to [Staff F-oncology department staff], but she was with the police and transferred me to [Staff E] Customer Services at the hospital's Oncology Department. I asked [Staff E] to send us and email explaining what had happened. Documentation by Staff D, RN /Risk Manager on [DATE] time stamped 02:40 PM -recorded as Late Entry- on [DATE] time stamped 01:29 PM: I was informed that Resident left from [ hospital's oncology department]. I called the Doctor's office to get a report and spoke to [Staff F ] Floor Supervisor, Oncology Department but she was with the police and transferred me to [Staff E] (Customer Service, Patient Finance Services, Oncology Department, I asked [Staff E] to send us and email explaining what had happened. Documentation by Social Services dated [DATE] time stamped 06:30 PM indicated : At 1:45 PM facility was contacted by [Hospital's Oncology Department]. Facility was informed that resident left the hospital after receiving [CONDITION(S)] treatment. This writer interviewed transportation staff and contacted the hospital. This writer was informed that the police was called, and the report was given. Also, this writer was informed that a complete search at the hospital was completed, and the resident could not be located. Resident was accompanied by CNA (Certified Nursing Assistant) provided by this facility until the treatment was started. As per Oncology office, the staff has to come back to pick up the patient around 2:30 PM as the treatment was about 6 hours long. Resident is alert and oriented x 2 (times two) moderate cognitive deficit with periods of confusion and forgetfulness he is able to make simple needs known. Resident has no family members on file. Oncology Department at [local hospital name] stated that when treatment was done, resident was directed to a waiting room to wait . Documentation by the Director of Nursing (DON) on [DATE] time stamped 08:17 PM: After the call from the [Oncology center ] informing our facility that the patient had left without being notified, we followed all the protocols and rules to do an investigation with the goal of finding the resident, we have followed up with each required department and at this time the resident has not been found. We have just called the emergency department to continue monitoring the situation in favor of the resident's stability, we were treated by [Staff G Oncology Department] and they have just informed us that he is not there, we will continue to monitor the situation. Documentation by Nursing Staff H a Licensed Practical Nurse (LPN) on [DATE] time stamped 10:19 PM: Call placed to [Hospital's Oncology Department] to inquire on the resident whereabouts. As per ER (emergency room ) receptionist the resident is not located on their system. Documentation dated [DATE] time stamped 10:28 AM recorded as Late Entry on [DATE] time stamped 11:32 AM: Facility contacted [Hospital's Oncology Department] to check if they have any news about resident and to obtain a police case number to follow up. As per receptionist, police were called and stated that no report was not written as resident is alert and oriented and able to make needs known. A statement of incident was requested. Social worker will continue to monitor. Documentation by Staff D RN /Risk Manager on [DATE] 12:29 PM I called the Oncology and spoke to [oncology Department Staff]. She told me that the police did not do a police report because resident was AAOX3 (awake, alert, oriented times 3) and have the right to leave the hospital. I asked her for the second time to please send me a statement of what happened in writing via email, and she agreed. Interview on [DATE] at 12:28 PM, Staff A, Certified Nursing Assistant (CNA) and transportation coordinator reported she was the person in charge of scheduling outside appointments. She explained that on [DATE] Resident #1 had [CONDITION(S)] treatment. The day before the appointment, [Staff F - Floor Supervisor, Oncology Department] called me to confirm. She gave instructions about the procedure and documents she needed and for the patient to be there between 7:30 AM and 8:00 AM. I asked her about how long the procedure would take. She told me around six hours. I asked her, since it's going to take that long, I would send somebody with the resident. I sent [Staff B] a Certified Nursing Assistant (CNA) and Transportation Escort. I told her (Staff F) that I would let the CNA [Staff B] come back to the facility after dropping off the resident for treatment. The Nurse asked me if the patient was able to stay, meaning if the patient would be able to cooperate after the treatment and wait. Staff A reported that she explained to Staff F that Resident #1 was Alert and Oriented times three. Staff A stated: The expectation was that [Staff F] the Floor Supervisor from the Oncology Department, would call us when the resident was ready to be picked up after treatment . At 1:45 PM [Staff F] called me, told me the resident went to the restroom, when she went back to look for the resident, the resident had eloped. She asked if we knew anything about what happened. [Staff F] was very concerned, looked in their system she saw that the resident went to buy coffee . When asked, Staff A explained; I believe the patient was ok to be left unsupervised because I talked to the resident .He was not confused. As far as responsibility for resident's safety and supervision, I guess . Staff A later agreed; Yes, all of us are responsible. If I had an idea that it was unsafe to leave the resident unsupervised, I would have remained next to him . We were waiting for [Staff F] to call us, we were not there when he finished . During an interview on [DATE] at 2:09 PM, Staff D, a Registered Nurse (RN) and the facility's Risk Manager reported: My job is to serve as Risk Manager and as infection control and prevention specialist since [DATE] . When it comes to elopement, starts with the assessments. Assessments for elopement risk are completed by our restorative nurse, as well as MDS. Social Services is also involved. From a risk management perspective, a resident is at risk for elopement when disoriented, when new admission, when they are in new environment . Staff D, RN acknowledged that disorientation and weakness might also be a side effect of [CONDITION(S)] treatment. Staff D stated : Once we understand that a resident is at risk for elopement, even if he is low risk. We have safety measures in place, and we care plan for them. Interventions we normally have in place, include placing the resident near the nurse's station, wander guard when appropriate, observation/supervision. Risk and needed interventions are communicated to staff through the elopement book, and we do in-service trainings to all staff on elopement, and supervision. On ,d+[DATE] /21 after noon, at approximately 2:00 PM, [Staff A] received a phone call from [Staff F] the Floor Supervisor at the Hospital's Oncology Department saying that the patient left and they wondered if we picked him up. On [DATE] at 2:30 PM, I got a page from the Nursing Home Administrator at the time to go to her office, where I was informed that the patient left/eloped from the hospital. On [DATE] at 2:40 PM, I wrote a note in resident's record to document that I called the doctor's office. I spoke to [Staff F] the Floor Supervisor at the Hospital's Oncology Department, she placed me on hold, she explained to me that she was communicating with the hospital security guard and with the police department. On [DATE] at 2:45 PM maybe, She transferred me to [Staff E] Customer Service, Patient Finance Services in the Oncology Department so that [Staff E] could give me an update. I asked her to email me a summary of what happened. On [DATE] at 12:00 PM I called again spoke with [Staff E] to see if any news and asked that she again send the summary. She explained to me that the police did not write a report because the patient was alert and oriented times three and he had the right to leave the hospital. She also told me that the patient was seen on camera, he went to the cafeteria, and they noticed he exited the facility. We made an immediate report and a five-day report, after the report, we called the police, they completed a report . The ADON later demonstrated that the Police did not write a report. Case # PD 1 dated [DATE] noted; Contact Only - No Report Written. The Risk Manager continued; Then I initiated my investigation. The investigation included: Review of resident history. I interviewed the resident's nurse but did not document the interview. Reviewed the admission record of when the Resident was admitted to the facility. From last admission. I reviewed medications. I interviewed the roommate. The only thing we knew is that [Resident #1] communicated to Social Services Department that he was interested in going to the Bank. The Risk Manager provided no documentation of corrective actions implemented by the facility. When the Risk Manager was asked about the results of her investigation and root cause analysis, the Risk Manager reported My investigation showed that Resident #1 decided to leave, he was homeless prior to being readmitted to the facility. He left; We do not know where he is now. The Risk manager was asked if Resident #1 should have been supervised while offsite for an appointment. The Risk Manager agreed; He did require supervision. We are responsible for the resident's safety. From now on, we will make sure that staff is there with the resident, when the resident is ready to leave. I did not interview any other staff. I did not review [Resident#1's] elopement risk assessment. During the interview, the Risk Manager agreed to review Resident#1's risk assessments, the assessment showed that Resident #1 had low elopement risk at score of 4. The Risk Manager agreed and stated: Interventions should be on care plan. During an interview on [DATE] at 3:13 PM Staff I, CNA revealed, that she provided care to Resident #1 for a less than two months, I know he was alert and oriented X 3 because he helped a lot when he required care. He transferred to the wheelchair without assistance. He stood up and walked in the room by himself . Sometimes he had behavior like assembling everything inside the drawers with used plates, eating utensils and garbage like empty juice box. He also tended to put the dirty clothes back on like he'd get confused he would put them back if I did put or took them away quick enough. I used to give him a shower every other day. He cooperated . He liked to go around the facility, would go to the patio, smoke, and come back to his room. Part of my job was to supervise him .I don't think he was safe to be alone anywhere without supervision. When they go to the patio, or when they go anywhere, we supervise. I remember on the day he left he had an orange shirt. I helped him get ready to go to an appointment. Staff I, CNA added that Resident#1 gave no indication that he intended to leave the facility. On [DATE] at approximately 3:45 PM, Staff B, Certified Nursing Assistant (CNA) and Transportation Escort reported; In our training, we do not really have to supervise the resident. He was alert and oriented .I saw it. Staff B explained this was the first time that Resident #1 went to a [CONDITION(S)] treatment. She later agreed that Resident #1 probably required assistance provided by facility staff including but not limited to assistance in use the bathroom. Interview on [DATE] at 8:18 AM with Rehab Director, revealed, The Rehab Director was familiar with Resident #1 since ,d+[DATE]. But he was previously admitted on [DATE]. She explained; We screen and assess all residents upon admission . if they qualify for therapy we do the screen, then the evaluation. The evaluation determines the plan of care for the resident. He was admitted on [DATE] and he was evaluated by Pt (Physical Therapy ) and OT (occupational Therapy) on [DATE]. The evaluation for PT was completed by [Staff J]. He is out today. The evaluation showed that the resident required maximum assistance for bed mobility and transfers. Walked about 10 feet with maximum assistant. Physical therapy was provided five times a week. The Therapy provided varies, depending on who is available. We have daily notes completed by the therapist that provided the therapy. And we have weekly notes as well. The last time he received therapy was on [DATE] for OT. PT the last time he received it was on [DATE]. During the above-mentioned interview, record review and of Physical Therapists notes showed that Resident #1 functional status remained the same from time of his first evaluation on [DATE] until the last time he received physical Therapy on [DATE], She explained: When we say the resident requires maximum assistance, it is expected that assistance will be provided by facility staff. The accuracy of the record concern related to the resident receiving PT on [DATE], the physical therapist reported the resident might have received therapy prior to leaving the facility between 5:00 AM to 6:30 AM. On [DATE] at 8:54 AM the Speech Therapist, reported she last screened Resident #1 on [DATE] she completed an assessment for the Resident's BIMS, he scored at 9 out of 15, indicating his cognition was moderately impaired. When asked, the Speech Therapist reported she was aware that Resident#1's BIMS showed he had a score of 5 on the MDS. She acknowledged; There was a discrepancy in our score Interview on [DATE] at 9:05 AM with the Social Services Director (SSD) and with the Social Services Assistant (SSA) revealed; Social Services explained they completed Resident#1's MDS and psychosocial assessment within 5 days of his admission. They got information from the Resident only, he had no family or legal representative. The assessment included a plan for discharge. The SSD reported their assessment showed that Resident #1 needed placement, had no support from family. He lived with someone for a while .and that person died . His family lived in [NAME], and he had no contact with them. Resident #1 worked in construction. His cognition was also assessed on that day, (BIMS of 5) the SSA reported Based on hospital record, He refused medication at the hospital. His concerning diagnoses included Smoking and Alcoholism, The Police officer reported to hospital staff that he was homeless (Hospital record pg. 35) The SSD explained; The plan was that we would find an ALF (Assisted Living Facility) when he qualified. Depending on his progress in therapy. As of [DATE] The plan was that he remained in the facility for skill rehab . During the above-mentioned interview, Record review of progress notes revealed documentation dated [DATE] time stamped 08:42 PM indicated : Social worker visited resident in his room to welcome him into the facility, introduce self and provided emotional support. Resident is alert and oriented x 2 moderate cognitive deficit with periods of confusion, disorientation, and forgetfulness able to make basic needs known, answer yes/no and simple questions with unclear slurred speech sometimes understands sometimes is understood. Resident with no signs or symptoms of emotional distress at the time of visit. Resident is currently taking a hypnotic medication. Resident with no indication of traumatic event. Resident is a smoker; he is being explained the facility smoking policy. Resident came to the facility from hospital due to failure to thrive and weight loss. Resident is at the facility for care and therapy purposes. Resident was living at home alone and requires ALF placement after completing skilled rehab. Resident stated to have family in [NAME]; however, he has no family close by. Advanced directives discussed Review of Care Plans showed a plan of care with Category: Cognitive Loss / Dementia, Start Date: [DATE]. It was last Reviewed/Revised: [DATE] it noted; Resident #1 with Moderate cognitive deficit with periods of confusion, disorientation and forgetfulness impair communication sometimes understands sometimes is understood with unclear slurred speech related to diagnoses: Dysphagia, Neoplasm . Larynx Supraglottic mass, Failure to thrive, [CONDITION(S)], GERD, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. Long Term Goal dated [DATE] noted: Resident #1 will be encouraged to follow commands and express basic needs, cues prompting, and redirection will be provided as needed . Approaches included but not limited: Allow Resident time to respond and participate in care. Provide cues prompting and re-direction as needed. Resident #1's Discharge care plan noted as Goal indicated that Resident #1 will be discharged to ALF. Interventions included but not limited: Arrange follow-up with Primary Care Physician in the community as needed. Assist the resident and/or support person in locating and coordinating pos-discharge services. Encourage verbalizations of fears and concerns. Clarify misconceptions. Provide opportunity for resident/support person to return demonstrate treatment regimen/skills prior to discharge. On [DATE] at 10:18 AM during an interview with Staff C, RN, she reported; I am familiar with Resident #1's care. Regarding his mental status. The patient was Alert and Oriented x 3. I was the nurse that last saw him in the facility, he did not mention any desire to leave the facility. He appeared to be satisfied with the care he received, to my knowledge he would continue to receive care here. During an interview on [DATE] at 10:22 AM, interview with Resident #1's Physician, he reported, that Resident #1 was assessed on [DATE] by his nurse practitioner. I was here [Resident #1] was alert and oriented times 3. We discussed his need for [CONDITION(S)] treatment, he understood it would be beneficial . The Physician explained that Resident #1 did not report any concerns with care or treatments provided by facility staff. Resident #1 showed no indication that he intended to leave the facility. The nursing home notified me that the Resident was missing two days ago. The physician agreed that Resident #1 required services, care and treatments provided by the nursing facility. Services required included supervision. Acknowledge that facility did not know his whereabouts, and they notified him two days ago. (on [DATE]) Agreed there was no evidence that Resident #1 was safe or alive. The physician added; My experience with him is that he was homeless before, he was in a shelter before. He seemed like someone that managed himself out there. Phone interview with Staff E-at the local hospital's Customer Service, Patient Finance Services, Oncology Department on [DATE] at 11:10 AM. She reported she could not remember times but on the day that Resident #1 disappeared, the facility CNA (Staff B) dropped off the resident in the waiting room area. Staff F - Floor Supervisor, Oncology Department asked the C N A (Staff B) if the resident was ok to be without supervision and the CNA responded yes The resident finished his first treatment, not sure what time but he was in the waiting room, then said he needed to use the bathroom. When it was time for the second treatment, the resident was nowhere to be found .

Based on records reviewed and interviews the facility failed to thoroughly investigate, notify the physician, file a missing person's report related to the disappearance /elopement of one resident (Resident #1) out of five residents investigated during a complaint investigation. Resident #1 was a vulnerable adult that required supervision in addition to extensive assistance with Activities of Daily Living (ADL). He eloped while left unsupervised for his first [CONDITION(S)] treatment during an offsite appointment at a local hospital's oncology department and as of the day of this survey his whereabouts remained unknown. Resident #1's health, safety, and life remained at risk. This facility's deficient practice has the potential to have an adverse effect on all newly admitted , vulnerable and or cognitively impaired residents in the facility that go for outside appointments. The Findings Included: Review of Resident #1's clinical record showed that Resident #1 was readmitted to the facility on [DATE] with clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was alert and oriented times 2, able to communicate with periods of confusion, required extensive to limited assistance with ADL and transfer/mobility. The most recent Minimum Data Set (MDS) comprehensive assessment for Resident #1 was completed in 09/28/2021 - Admission assessment. Cognitive patterns showed a score of 5 out of 15 on his Brief Interview of Mental Status (BIMS). Indicating that Resident #1 was cognitively impaired. His Speech was not clear, sometimes he was understood and sometimes he was able to understand. Resident #1's Functional Status indicated he required extensive assistance for bed mobility one person. Extensive assistance of two people to transfer from bed to wheelchair . He was also frequently incontinent for urinary and bowel. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes dated 10/03/2021 time stamped 08:42 PM revealed, Social worker visited resident in his room to welcome him into the facility, introduce self and provided emotional support. Resident is alert and oriented X2 (times 2) moderate cognitive deficit with periods of confusion, disorientation, and forgetfulness able to make basic needs known, answer yes/no and simple questions with unclear slurred speech sometimes understands sometimes is understood . Resident is currently taking a hypnotic medication. Resident with no indication of traumatic event. Resident is a smoker; he is being explained the facility smoking policy. Resident came to the facility from hospital due to failure to thrive and weight loss. Resident is at the facility for care and therapy purposes. Resident was living at home alone and requires ALF (Assisted Living Facility ) placement after completing skilled rehab. Resident stated to have family in Cuba; however, he has no family close by . During an interview on 11/23/2021 at 2:09 PM, Staff D, a Registered Nurse (RN) and the facility's Risk Manager reported: My job is to serve as Risk Manager and as infection control and prevention specialist since May 2021 . When it comes to elopement, starts with the assessments. Assessments for elopement risk are completed by our restorative nurse, as well as MDS. Social Services is also involved. From a risk management perspective, a resident is at risk for elopement when disoriented, when new admission, when they are in new environment . Staff D, RN acknowledged that disorientation and weakness might also be a side effect of [CONDITION(S)] treatment. Staff D stated : Once we understand that a resident is at risk for elopement, even if he is low risk. We have safety measures in place, and we care plan for them. Interventions we normally have in place, include placing the resident near the nurse's station, wander guard when appropriate, observation/supervision. Risk and needed interventions are communicated to staff through the elopement book, and we do in-service trainings to all staff on elopement, and supervision. On 11/10 /21 after noon, at approximately 2:00 PM, [Staff A] received a phone call from [Staff F] the Floor Supervisor at the hospital's Oncology Department saying that the patient left and they wondered if we picked him up. On 11/10/2021 at 2:30PM, I got a page from the Nursing Home Administrator at the time to go to her office, where I was informed that the patient left/eloped from the hospital. On 11/10/2021 at 2:40PM, I wrote a note in resident's record to document that I called the doctor's office. I spoke to [Staff F] the Floor Supervisor at the Hospital's Oncology Department, she placed me on hold, she explained to me that she was communicating with the hospital security guard and with the police department. On 11/10/201 at 2:45PM maybe, she transferred me to [Staff E] Customer Service, Patient Finance Services in the Hospital's Oncology Department so that [Staff E] could give me an update. I asked her to email me a summary of what happened. On 11/11/2021 at 12:00 PM I called again spoke with [Staff E] to see if any news and asked that she again send the summary. She explained to me that the police did not write a report because the patient was alert and oriented times three and he had the right to leave the hospital. She also told me that the patient was seen on camera, he went to the cafeteria, and they noticed he exited the facility. We made an immediate report and a five-day report, after the report, we called the police, they completed a report . The ADON later demonstrated that the Police did not write a report. Case # PD 1 dated 11-20-2021 noted; Contact Only - No Report Written. The Risk Manager continued; Then I initiated my investigation. The investigation included: Review of resident history. I interviewed the resident's nurse but did not document the interview. Reviewed the admission record of when the Resident was admitted to the facility. From last admission. I reviewed medications. I interviewed the roommate. The only thing we knew is that [Resident #1] communicated to Social Services Department that he was interested in going to the Bank. The Risk Manager provided no documentation of corrective actions implemented by the facility. When the Risk Manager was asked about the results of her investigation and root cause analysis, the Risk Manager reported My investigation showed that Resident #1 decided to leave, he was homeless prior to being readmitted to the facility. He left; We do not know where he is now. The Risk manager was asked if Resident #1 should have been supervised while offsite for an appointment. The Risk Manager agreed; He did require supervision. We are responsible for the resident's safety. From now on, we will make sure that staff is there with the resident, when the resident is ready to leave. I did not interview any other staff. I did not review [Resident#1's] elopement risk assessment. During the interview, the Risk Manager agreed to review Resident#1's risk assessments, the assessment showed that Resident #1 had low elopement risk at score of 4. The Risk Manager agreed and stated: Interventions should be on care plan. Further review of Care Plans showed a plan of care with Category: Cognitive Loss / Dementia, Start Date: 09/21/2021. It was last Reviewed/Revised: 10/03/2021 it noted; Resident #1 with moderate cognitive deficit with periods of confusion, disorientation and forgetfulness impair communication sometimes understands sometimes is understood with unclear slurred speech related to Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Long Term Goal dated 12/21/2021 noted: Resident #1 will be encouraged to follow commands and express basic needs, cues prompting, and redirection will be provided as needed . Approaches included but not limited: Allow Resident time to respond and participate in care. Provide cues prompting and re-direction as needed. During an interview on 11/24/2021 at 10:22 AM, with Resident #1's Physician, he reported, that Resident #1 was assessed on 11/08/2021 by him and his nurse practitioner. I was here [Resident #1] was alert and oriented times 3. We discussed his need for [CONDITION(S)] treatment, he understood it would be beneficial . The Physician explained that Resident #1 did not report any concerns with care or treatments provided by facility staff. Resident #1 showed no indication that he intended to leave the facility. The nursing home notified him that the Resident was missing two days ago. The physician agreed that Resident #1 required services, care and treatments provided by the nursing facility. Services required included supervision. The physician acknowledge that the facility did not know his whereabouts, and they notified him two days ago (on 11/22/2021) and acknowledged that there was no evidence to indicate if Resident #1 was safe or alive. The physician added; My experience with him is that he was homeless before, he was in a shelter before. He seemed like someone that managed himself out there. Record review of Timeline for Resident #1 showed an analysis of the incident: Resident was alert and oriented times 3 with no prior history of mental illness. The Resident's rights to agree or disagree with treatment were honored. Corrective Actions noted: Staff members educated on resident's rights to agree or disagree with treatment. Record review of the facility's policies and procedures revealed the policy for Wandering and Elopements. It noted: The facility will identify resident who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 3. If a resident is missing, initiate the elopement /missing resident emergency procedure: C. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the Attending Physician, law enforcement official and as necessary volunteer agencies . (I.e., Emergency Management, Rescue Squads, etc.).

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for one resident (Resident #1) out of five sampled residents during a complaint investigation survey, as evidence by the MDS did not accurately reflect Resident #1's conditions. The Findings Included: Review of the most recent Minimum Data Set (MDS) comprehensive assessment for Resident #1 was completed on 09/28/2021. Cognitive patterns showed a score of 5 out of 15 on his Brief Interview of Mental Status (BIMS). Indicating that Resident #1 was cognitively impaired. His Speech was not clear, sometimes he was understood and sometimes he was able to understand. The MDS indicated that Resident #1 was not a smoker. Review of Resident #1's progress notes dated 10/03/2021 time stamped 08:42 PM revealed, Social worker visited resident in his room . to welcome him into the facility, introduce self and provided emotional support. Resident is alert and oriented X 2 ( times 2) moderate cognitive deficit with periods of confusion, disorientation, and forgetfulness able to make basic needs known, answer yes/no and simple questions with unclear slurred speech sometimes understands sometimes is understood . Resident is currently taking a hypnotic medication. Resident with no indication of traumatic event. Resident is a smoker; he is being explained the facility smoking policy. Resident came to the facility from hospital due to failure to thrive and weight loss. Resident is at the facility for care and therapy purposes. Resident was living at home alone and requires ALF (Assisted Living Facility) placement after completing skilled rehab. Resident stated to have family in Cuba; however, he has no family close by . On 11/24/201 at 8:54 AM, the Speech Therapist, reported she last screened Resident #1 on 09/22/2021 and completed an assessment for the Resident's BIMS, he scored a 9 out of 15, indicating his cognition was moderately impaired. When asked, the Speech Therapist reported she was aware that Resident # 1's BIMS showed he had a score of 5 on the MDS. The Speech Therapist stated; There was a discrepancy in our score During clinical record review and interview on 11/23/2021 at approximately 11:30 AM with the MDS coordinators, Staff H, RN and Staff X,RN it was revealed that Resident' #1's risk assessments showed that he signed a smoking informed consent dated 09/21/2021. The MDS coordinators agreed the MDS was not accurately coded.

Based on interviews, and record review, the facility failed to report the immediate report within two hours that lead to a negative outcome for four (Resident #2, #3, #5 and #6) out of four sampled residents. As evidenced by, those residents had a fracture due to falls and the facility reported as Adverse incident report four to fifteen days after the incidents occurred. The facility deficiency has the capacity to affect 136 residents living in the facility at the time of survey. The findings included: Review of the Abuse Investigation and Reporting policy revised in January 2021 revealed, that An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than: a. two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury and Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. On 5/12/2021 at 9:06 AM, during interview with Interim Director of Nursing (DON)/ Infection Control/ Risk Manager and the Assistant Infection Control/ Risk Manager Assistant revealed, that they immediately report an incident in 2 hours when the patient has a fall with fracture, or the patient has a bruise, skin tear with unknown origin or a resident to resident interaction. The following resident incidents were identified: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/15/21 resident #3 got out the bed, the nurse saw her in the restroom sitting on the floor, she was bleeding; the fall was an unwitnessed. When the nurse assessed the resident, she had a small laceration. She was transferred to the hospital. She came back to the facility two hours later. On 4/16/21 resident #3 was in a supervised area on the patio, the resident tried to get up and slipped. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital. The incident was reported to the Agency for Health Care Administration on 4/30/21. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2, was on the patio on 3/11/21. The resident was in his wheelchair and tried to get something from the floor. Resident #2 hit the floor on his left side. An x-ray was ordered on the same day. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident was reported to the Agency for Health Care Administration on 3/15/21. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/17/21, resident #5 tried to go to the bathroom by herself and the nurse found her on the floor with a small cut to her eyebrow, she did not complain of pain or discomfort at the time of the fall. An an x-ray ordered it showed a fractures of the 2nd, 3rd and 4th metatarsal. The doctor gave an order to transfer the resident to the hospital. Resident #5 was a hospice resident. The incident was reported to the Agency for Health Care Administration on 3/2/21. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/4/21, resident #6 was trying to go to the restroom and fell . The fall was unwitnessed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital on the same day. The incident was reported to the Agency for Health Care Administration on 2/17/21. On 5/12/2021 at 9:53 AM, during an interview with the Administrator she stated she started to work in the facility on 11/10/2020 and there was a problem accessing the reporting system.

Based on observations, interviews, and record review, the facility failed to maintain the laundry room's floor in good condition as evidenced by multiple holes in the floors surface in the laundry rooms dirty area, and accumulating water. The findings included: Review of the Policy and Procedures of Maintenance Service, revised December 2020 revealed, Maintenance service shall be provided to all areas of the building, grounds, and equipment. It further showed that the facility should be maintaining the building in good repair and free from hazards. On 5/11/2021 at 4:43 PM, during observation and interview in the laundry accompanied by Director of Environmental Services revealed, the floor in the laundry room dirty area had multiple holes with water accumulated (Photographic evidence). The Maintenance Director accompanied by the Director of Environmental Services revealed that he reported he was working on the project to fix the floor and he was researching the right material to put on the floor. In addition, he stated that he did not have any paperwork right now to demostrate he was going to fix it.

Based on observation, interview and record review, the facility failed to implement infection control and prevention as evidenced by 1) failure to perform hand hygiene before and after touching face mask, 2) failure to correctly wear face mask 3) failure to handle clean linen in a manner that will avoid the risk of cross-contamination in the clean laundry area and 4) failure to follow the facility's procedures for the handling of used food trays removed from isolation rooms. There were 112 residents residing in the facility at the time of the survey. The findings included: Observation on 07/07/2020 at 9:11 a.m. in the clean laundry revealed that the Staff A, Laundry Aide was wearing a face mask with her nose uncovered. Staff A touched the front the mask twice to cover her nose and did not perform hand hygiene and after touching the front of the mask. Further observation of the clean laundry area revealed no Alcohol Based Hand Rub (ABHR) or hand washing station observed in the clean laundry. On 07/07/2020 at 9:17 a.m. Staff A, Laundry Aide, was asked why the face mask was not covering her nose. Staff A, at that time that acknowledged that the face mask was not covering her nose. Staff A then removed the mask by touching the front of the mask, made a knot on the elastic ear loop area of the mask and placed the mask back on her face. Staff A did not perform hand hygiene. Staff A proceeded to continue folding the clean linen. While folding, a bed linen fell on the floor and Staff A, picked up the line from the floor folded it and placed it and placed it with the clean linen. Staff A was asked about the above concerns with handling of the laundry that fell on the floor and hand hygiene. Staff A explained that in case she dropped the clean laundry on the floor, it was supposed to be wash again and, by mistake, she placed the linen that dropped on the floor together with the clean linens. Staff A acknowledged that she did not perform hand hygiene and explained that she should have used hand sanitizer on her hands after she touched her mask. On 07/07/2020 at 9:28 am the Housekeeping Director stated, staff should have the nose covered by the face mask and hand hygiene must be done after they touch the mask. The Housekeeping Director confirmed that they did not have hand sanitizer in the clean laundry area nor area to perform hand hygiene and that he was going to install one wall hand sanitizer inside the clean laundry area . The housekeeping Director stated that in case the staff had dropped the clean linen on the floor, they should put it back to be rewashed. On 07/07/2020 at 12:37 PM during an interview with Staff B, Registered Nurse (RN) , a food tray was observed on a cart containing clean Personal Protective Equipment (PPE) on the hallway. Staff C a Certified Nursing Assistant (CNA) was observed removing a used non-disposable uncovered food tray from the room of a resident on contact and droplet isolation precautions for COVID-19, Staff C placed the used tray on the top of the cart that contained clean PPE. (Photographic evidence). The trays stayed on the cart outside of the isolation room for about 10 minutes. The RN explained noted that the staff should have placed the kitchen tray in a plastic bag inside the isolation room and send them back to the kitchen. On 07/07/2020 at 12:47 PM, Staff C, CNA stated that she should have placed the food trays inside a plastic bag before she left the resident's room and acknowledged she should not have place them on a clean PPE cart. On 07/07/20 at 12:59 PM the concerns were discussed with the Assistant Director of Nursing (ADON). The ADON stated that staff should put the used trays from the isolation rooms inside a plastic bag before they come out of the isolation rooms. The ADON explained that the staff had in-service regarding hand hygiene and an in-services that mask should cover nose and mouth. Interview on 07/07/2020 at 1:17 PM with Infection Preventionist revealed that if the staff was folding the linen and the linen dropped on the floor, the linen should be rewashed. The mask should be covering the nose and the mouth all times. About the food trays, the staff are supposed to place the used trays inside the bag before they leave the isolation room. Record review of the in-service sign-in sheet on 06/30/2020 provided by facility noted following Center for Disease Control and Prevention (CDC) regarding Face masks Do's and Don'ts, dated 06/02/2020, indicating mask should cover nose and mouth. It further showed that staff should not touch or adjust the facemask without cleaning their hands before and after. Record review of the Infection Prevention and Control Program, not dated, revealed properly store, handle, process, and transport linens to minimize contamination. Review of the in-service sign-in sheet dated 04/01/2020 showed indicated. The used food trays that go inside COVID-19 unit (isolation area) must be covered by a plastic bag when being removed.