Every finding on record at Hannah B G Shaw Home

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) to prevent cross contamination. Findings include:Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to:3-302 Preventing food and ingredient contamination; (A) FOOD shall be protected from cross contamination by: (3) Cleaning equipment and utensils as specified under 4-602.11(A) and sanitizing as specified under S 4-703.11; 4-602.11 Equipment Food-Contact Surfaces and Utensils; (A) Equipment food-contact surfaces and utensils shall be cleaned: (3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD; (5) At any time during the operation when contamination may have occurred. Review of facility's policy titled Food Preparation and Service, Revised November 2022, indicated but was not limited to:-Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices;-Cross contamination can occur when harmful substances, such as, chemical or disease-causing microorganisms are transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned; -Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness;-Appropriate measures are used to prevent cross contamination. These include cleaning and sanitizing work surfaces and food-contact equipment between uses, following food code guidelines;-Food thermometers used to check food temperatures are clean, sanitized, and calibrated. On 9/10/25 at 12:34 P.M., the surveyor observed Dietary Staff #1 deliver lunch to the [NAME] unit, which consisted of food (in covered holding containers) that would be plated on the unit. Dietary Staff #1 began taking food temperatures with two thermometers from the kitchenette drawer. He inserted each thermometer into a food item. He then took the thermometers out and immediately used them to temp the rest of the food. The thermometers were not cleaned or sanitized between food items. Dietary Staff #1 said this was his process for taking temperatures and he was unaware if any residents on the unit had food allergies. He said he should have cleaned and sanitized the thermometers between use to prevent cross contamination. On 9/11/25 at 11:41 A.M., the surveyor observed Dietary Staff #2 deliver food to the [NAME] unit. Dietary Staff #2 used two thermometers to temp the food. She rinsed the thermometer probes under running sink water between each food item and did not wipe or sanitize the probes between food items. Dietary Staff #2 wiped and sanitized the thermometer probes after completing temperatures of all the food. On 9/11/25 at 11:48 A.M., the surveyor observed Dietary Staff #2 taking food temperatures on the [NAME] unit. She used two thermometers to temp the food. She rinsed the thermometer probes under running sink water between each food item and did not wipe or sanitize the probes between food items. Dietary Staff #2 wiped and sanitized the thermometer probes after completing temperatures off all the food. During an interview on 9/11/25 at 2:15 P.M., the Food Service Director said staff should have cleaned and sanitized the thermometers between each food item to prevent cross contamination.

Based on records reviewed and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#26) from a total sample of 15 residents. Specifically, the facility failed to ensure respiratory equipment including oxygen tubing and bilevel positive airway pressure (bipap-medical device used to treat breathing disorders) equipment was properly maintained and stored in a clean and sanitary manner to decrease the risk of potential contamination and infection.Findings include:Review of the facility's policy titled Equipment Changing, undated, indicated but was not limited to the following:- All respiratory therapy equipment must be changed in order to prevent nosocomial infections (infections acquired in healthcare settings).-The equipment should be marked with the date that it was changed.-All equipment should be changed on a weekly basis as well as needed (PRN) if it becomes soiled or falls on the ground. This equipment includes but is not limited to: -air entrainment masks (medical device used to deliver a precise, controlled concentration of oxygen to a patient by mixing room air with a high-velocity oxygen stream) -corrugated tubing (flexible, disposable, single-patient-use tube that connects the BiPAP machine to the patient's mask, delivering pressurized air for breathing support) -oxygen tubingResident #26 was admitted to the facility in April 2024 and had diagnoses including chronic obstructive pulmonary disease (a lung disease that causes long-term damage to the airways and lungs leading to breathing difficulties). Review of the Minimum Data Set assessment, dated 12/26/24, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15 and received oxygen therapy.Review of Resident #26's physician's orders indicated but was not limited to the following:-Change oxygen (O2) tubing weekly on Sunday 11-7, every Sunday (11/5/23)-Apply bipap mask every evening, attach with supplemental O2 at 1.5Liters/minute every evening shift; settings are as follows: Avaps-AETidal Volume 350Max Pressure 24Pressure Support minimum 6 maximum 12EPAP minimum 5 and maximum 12; Respiratory rate 15 per minute FI02 1.5 litersO2 to be run in conjunction with bipap at 1.5L/min (4/12/24)Review of Resident #26's August 2025 Medication Administration/Treatment Administration records (MAR/TAR) indicated he/she utilized bipap treatments as ordered by the physician and oxygen tubing was changed on 9/7/25.During an observation with interview on 9/10/25 at 9:53 A.M., the surveyor observed Resident #26 resting in bed. An oxygen concentrator was noted in the Resident's room with oxygen tubing attached to the concentrator and connected to a bipap machine placed on a bedside table. The oxygen tubing was labeled as having been last changed on 8/27/25 at 9:00 P.M. A bipap mask was noted to be connected to the corrugated tubing and resting on top of the bipap machine exposed to the environment, was not dated, and was not covered with a plastic bag. Resident #26 said he/she uses the bipap machine only at night and does not use oxygen regularly.On 9/11/25 at 1:05 P.M., the surveyor observed Resident #26 lying in bed watching television. Oxygen tubing was attached to the concentrator and connected to a bipap machine that was on a bedside table. The oxygen tubing was labeled as having been last changed on 8/27/25 at 9:00 P.M. A bipap mask was noted to be connected to the corrugated tubing and resting on top of the bipap machine exposed to the environment, was not dated, and was not covered with a plastic bag.During an interview on 9/11/25 at 1:27 P.M., Nurse #2 reviewed Resident #26's medical record and said the Resident's oxygen tubing used for the bipap machine is supposed to be changed every week on Sunday and labeled with the date it was changed. She said the tubing was signed off as having been changed on 9/7/25.During an interview with observation on 9/11/25 at 1:33 P.M., Nurse #2 said the tape secured to the O2 tubing was dated 8/27 at 9:00 P.M. and it should have been changed on 9/7/25 and was not. Nurse #2 noted the bipap mask lying on top of the machine uncovered with the corrugated hosing connected. She said nursing is supposed to remove the hose, clean it and hang it to dry every morning and did not do that. She said the mask should be stored in a plastic bag when not in use and was not.During an interview on 9/12/25 at 10:16 A.M., the Director of Nursing (DON) said Resident #26's oxygen tubing should have been changed as ordered, the hose removed from the bipap unit and cleaned, and the mask should have been placed in a plastic bag and not left on top of the bipap unit uncovered.

Based on record review and interview, for one Resident (#2), out of a total sample of 15 residents, the facility failed to develop a plan of care accounting for the Resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. Findings include: Resident #2 was admitted to the facility in June 2023 with diagnoses which included anxiety, depression, Alzheimer's disease, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD).Review of the Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident #2 was unable to complete the Brief Interview for Mental Status (BIMS) and had a diagnosis of PTSD. Further review of the MDS assessment indicated the Resident exhibited physical behavioral symptoms, verbal behavioral symptom, other behavioral symptoms, rejection of care, and wandering.Review of the Social Service admission Assessment, dated 7/5/23, indicated but was not limited to the following:-Resident #2 was in the process of divorcing his/her spouse-Resident #2 had some difficulty adjusting in his/her new environment and presented with mood swings. His/her mood fluctuated and he/she was irritable and easily angered at times and could be combative with care.-Resident #2 appeared comfortable in a quiet environment but could become anxious in loud settings. Review of the Trauma/PTSD Assessment, dated 7/5/23, indicated that Resident #2 was unable to participate in the assessment, but his/her family reported a history of prior assault, which could make the Resident prone to startle easily.Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: [Resident #2] has had behavioral issues at times due to diagnoses of dementia and a history of brain injury and trauma. When [he/she] is restless and anxious, [he/she] can be resistive to care.INTERVENTIONS: -Explain all procedures to the resident before starting and allow the resident time to adjust to changes.-Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.-Minimize physical touch as much as possible during periods of increased anxiety [sic] or agitation. Respect personal space. Review of Resident #2's Kardex (generated from the electronic health record) and Certified Nursing Assistant (CNA) Care Card failed to indicate information about the Resident's potential trauma trigger as reported by his/her family (Resident's history of prior assault, which could make the Resident prone to startle easily).During an interview on 9/11/25 at 12:53 P.M., CNA #1 said she was not aware of any resident on the unit where Resident #2 resides having a diagnosis of PTSD or any specific trauma triggers. CNA #1 reviewed Resident #2's Resident Care Card with the surveyor, which failed to include information about the Resident's potential trauma trigger as reported by his/her family during completion of the Trauma/PTSD Assessment. CNA #1 said the information could be communicated better between other departments and direct care staff who are providing care to residents.During an interview on 9/11/25 at 1:04 P.M., Social Worker #1 said a trauma assessment is completed for every resident as part of their admission assessment. Social Worker #1 said if she is completing an assessment and a resident feels he/she is through it she would not care plan for PTSD or potential trauma triggers. Social Worker #1 said she has not care planned any resident for a history of trauma. Social Worker #1 reviewed Resident #2's care plans and said she did not see anything specific to the Resident's history of trauma and potential triggers. Social Worker #1 said she is the social worker for the unit on which Resident #2 resides but was not the social worker who did Resident #2's initial assessment when he/she was admitted and could not speak to why his/her care plan did not identify the specific trigger indicated by his/her family related to his/her trauma/physical assault.

Based on observation, interview, and record review, the facility failed for one Resident (#2), out of a total sample of 15 residents, to ensure the Resident was free from physical restraints. Specifically, Resident #2's wheelchair was replaced with a Broda positioning wheelchair which no longer allowed the Resident to self-propel about the unit.Findings include:Review of the facility's policy titled Use of Restraints, revised April 2017, indicated, but was not limited to, the following:-Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.-Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.-When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented.-Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including:c. placing a resident in a chair that prevents the resident from rising-Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.-Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.-A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record.-Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination.-Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.Review of the facility's policy titled Fall Management, dated August 2013, indicated, but was not limited to, the following:-Restraints will not be used as a fall prevention intervention.Resident #2 was admitted to the facility in June 2023 with diagnoses including Alzheimer's disease and impulse disorder. Review of the Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident #2 was unable to complete a Brief Interview for Mental Status (BIMS) and indicated the Resident was dependent on staff for completion of activities of daily living and was not ambulatory. Further review of the MDS indicated no physical restraints were used but chair and bed alarms were used daily. Review of Resident #2's Comprehensive Care Plan indicated, but was not limited to, the following:-Focus: [Resident #2] is dependent on staff for meeting emotional, intellectual, physical, emotional and social needs r/t (related to) Cognitive deficits and Physical Limitations. [Resident #2] ambulates with staff assistance and also uses a wheelchair for mobility, pedaling around the neighborhood. He/She will require staff assistance to attend activity programs in his/her wheelchair with foot pedals off the neighborhood. His/her vision and hearing are adequate at this time.-Focus: [Resident #2] has Functional Abilities Performance deficit in Self-Care and limited physical mobility r/t periprosthetic hip fracture around internal prosthetics left hip (routine healing), osteoporosis, Alzheimer's, Dementia, hx (history) TBI (traumatic brain injury), muscle weakness, dysphagia.Interventions:AMBULATION/LOCOMOTION = N/A The resident requires dependent assistance by 1 staff for locomotion using w/c (wheelchair).-Focus: [Resident #2] is at risk for falls r/t Gait/balance problems, Poor communication/comprehension, Psychoactive drug use, Unaware of safety needs, Wandering/pacing, impulsive behavior, Periprosthetic fracture around internal prosthetics left hip (routine healing), Osteoporosis, hx fallsInterventions:*2 assist with care if unable to leave d/t (due to) safety concern as needed*30 minute safety checks*Anti-rollback system for wheelchair*Anti-tip device for wheelchair*Anticipate and meet the resident's needs*Apply padded hip protector belt as needed/as tolerated*Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance.*Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.*Encourage the resident to participate in activities that promote exercise, physical activity for strengthening, and maintain mobility.*Ensure floor mats in place while resident is in bed*Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c.*Follow facility fall protocol*Keep bed in lowest position when resident is lying in it.*Pt (physical therapy) evaluate and treat as ordered or PRN (as needed)*The resident needs a safe environment with the bed in low position at night.*The resident uses bed electronic alarm. Ensure the device is in place as needed.*The resident uses chair electronic alarm. Ensure the device is in place and functioning as needed. Review of the Comprehensive Care Plan failed to indicate a restraint/potential restraint was implemented for Resident #2.Review of Resident #2's Nursing Progress Notes indicated, but was not limited to, the following:-11/19/24: Resident continuously moving, pulling seats off chairs and entering residents' bedrooms. Resident settles for lunch however later quickly wheeling all around unit while whistling. Alarm on for safety.-12/8/24: Resident presenting with increased anxiety and agitation in late morning; pushing and pulling at staff, yelling out, aggressively whistling rapidly self-propelling unit in wheelchair and attempting to self-transfer multiple times.-12/10/24: Resident self-propelling around the unit - entering other resident's rooms, pushing/pulling furniture, slamming into other residents' walkers.-12/10/24: Resident self-propelling about unit in wheelchair and while self-propelling was observed to lean too far forward in the wheelchair by the nurse. The nurse ran to assist resident, but was unable to get to Resident quick enough to prevent fall from occurring. Resident landed face forward on floor, sustaining a laceration near left eye, large hematoma to forehead, and abrasions to left hand knuckles. The Resident was sent to the hospital for evaluation.12/11/25: Resident was seen at the hospital due to a fall and returned to the facility with diagnoses including nasal fracture and orbital laceration. -12/12/24: Resident pacing in wheelchair on the unit with nurse.-12/14/24: Broda chair to be ordered by hospice. Physician recommends resident not in wheelchair for self-propelling due to safety concerns. Daughter/health care proxy in agreement.-3/7/25: Resident was agitated and complained of pain. He/she was restless and trying to get out of his/her chair. Ativan (an antianxiety medication) and Morphine (an opioid pain reliever) were given, both with positive effect and no further complaints of pain.-3/17/25: Resident displaying increased signs and symptoms of anxiety/restless and trying to get out of his/her chair. 1:1, verbal redirection with minimal effect.-3/18/25: Resident was showing signs/symptoms of anxiety, restlessness, and was trying to climb out of his/her chair.-3/25/25: As needed Trazodone (an antidepressant medication) and Ativan due to increased agitation, whistling, and trying to leave his/her chair.-3/31/25: Resident was showing signs of agitation and restlessness. Whistling in his/her chair and unable to sit still.-4/1/25: Resident was showing signs of agitation and restlessness. Whistling in his/her chair and unable to sit still.-4/10/25: Resident was showing signs and symptoms of increased restlessness and agitation. Whistling and trying to get out of chair.-4/23/25: Resident was anxious and agitated. Face flushed, whistling and unable to sit still.-4/24/25: Resident was anxious and agitated. Face flushed, whistling and unable to sit still.-4/25/25: Resident showing his/her typical signs of restlessness and agitation. Unable to sit still in chair, face flushed, increasingly loud whistling.-4/29/25: Resident was agitated, whistling, face flushed, trying to get out of wheelchair.-5/5/25: Resident was agitated and restless. Whistling, face flushed, unable to sit still. -5/6/25: Resident was agitated and restless. Whistling, face flushed, unable to sit still.-5/20/25: Resident was whistling, face flushed, trying to get out of his/her chair, and showing signs of being uncomfortable.-5/28/25: Resident was whistling, face flushed, trying to get out of her chair-6/19/25: Resident's face was flushed, he/she was making whistling noises, unable to sit still in chair.-6/25/25: Resident was trying to climb out of chair-8/13/25: Resident was restless and agitated, flushed face, whistling, trying to get out of his/her chair.-8/14/25: Resident was agitated and restless, trying to get out of his/her chair, whistling, face flushed, one to one and redirection had no effect.-8/21/25: Resident became agitated, facial flushing, increasingly loud whistling, attempting to get out of chair.-8/27/25: Resident became agitated, facial flushing, increasingly loud whistling, attempting to get out of chair.-8/28/25: Resident became agitated, facial flushing, increasingly loud whistling, attempting to get out of chair.Review of Resident #2's Physician Progress Notes, indicated, but was not limited to, the following: -11/29/24: Patient had a fall. Accidental, no injuries noted. Fall due to patient's poor safety awareness and impulsivity. Patient is very high risk for another fall. -12/12/24: Patient was propelling and fell forward onto his/her face. Sent to hospital. Laceration around eye repaired. Has nasal fractures. Had long discussion with health care proxy (daughter) about patient cannot safely self-propel in wheelchair and we can't allow him/her to be in the wheelchair any longer. There is not enough staff to maintain his/her safety as he/she requires a 1-to-1; He/She is also a danger to other residents as he/she has no awareness of his/her environment. Daughter is in agreement. Daughter to request that patient can be in his/her wheelchair when daughter is in facility and will act as his/her 1-to-1. -12/31/25: Adjusting to loss of wheelchair, taken away due to very significant safety concerns. Status post fall and nasal fracture. Alzheimer's dementia with behaviors. -1/7/25: Continues with intermittent agitation. More falls. Status post fall out of wheelchair and nasal bone fracture. Since taking wheelchair away, less agitated and is adjusting.-3/4/25: Continues with intermittent agitation. More falls. Status post fall out of wheelchair and nasal bone fracture. Since taking wheelchair away, less agitated and is adjusting.-5/1/25: Continues with intermittent agitation. No further falls. Status post fall out of wheelchair and nasal bone fracture. Since taking wheelchair away, less agitated and is adjusting.-7/1/25: Continues with intermittent agitation. No further falls. Status post fall out of wheelchair and nasal bone fracture. Since taking wheelchair away, less agitated and is adjusting.-8/28/25: Wheelchair was taken away due to high risk of injury, status post fall and nasal fractures. -9/2/25: Since taking wheelchair away, less agitated and is adjusting.Review of Resident #2's Interdisciplinary Referral and Rehab Screen, dated 12/12/24, indicated the Resident was status post fall with head strike and hospitalization. Further review indicated hospice was to get the Resident a Broda chair and no decline in mobility was reported.Review of Resident #2's medical record failed to indicate a pre-restraining assessment was conducted or a regular review was done to determine if the Resident was/is a candidate for restraint reduction, less restrictive methods of restraints, or total restraint elimination.On 9/10/25 at 9:05 A.M., the surveyor observed Resident #2 in the unit living room sitting in a Broda chair, slightly reclined with lateral supports in place, feet elevated on footrest, and chair alarm in place.On 9/11/25 at 9:17 A.M., the surveyor observed Resident #2 in the unit living room sitting in a Broda chair, slightly reclined with lateral supports in place, feet elevated on footrest, and chair alarm in place. On 9/12/25 at 10:55 A.M., the surveyor observed Resident #2 in the living room on unit in a Broda chair with feet on footrest, slightly reclined with lateral supports in place and a pillow under his/her head. During an interview on 9/11/25 at 10:00 A.M., CNA #1 said prior to Resident #2's December 2024 fall with nasal fracture, discussion had been had among staff about re-evaluating the Resident's medication regimen and wheelchair because staff felt the Resident may be uncomfortable and was not able to effectively self-propel the way that he/she used to.During an interview on 9/11/25 at 10:00 A.M., Nurse #6 said after Resident #2's fall in December 2024 with nasal fracture, the Resident returned from the hospital in a declined state and was not able to sit comfortable in a standard wheelchair. Nurse #6 said once the Resident started sitting in the Broda chair, he/she appeared more comfortable, and staff saw a reduction in the Resident's behavioral symptoms. During a subsequent interview on 9/12/25 at 11:11 A.M., Nurse #6 said the Resident had a really bad fall resulting in fractures when he/she fell out of his/her wheelchair while self-propelling. She said the Resident was on hospice and shortly after he/she returned from the hospital, hospice decided to put him/her in a Broda chair, probably for safety and comfort. Nurse #6 said the Resident does scoot at times in the chair when he/she is restless but he/she is not capable of getting out of the chair. Nurse #6 said when the Resident is agitated or restless, they have interventions, such as as-needed medication, they can use that work for him/her. During an interview on 9/12/25 at 11:47 A.M., Resident Representative #1 said prior to a really bad fall the Resident had in December 2024, the Resident was self propelling in his/her wheelchair about the unit with supervision. Resident Representative #1 said once Resident #2 returned from the hospital, the Resident's physician called her and said the facility would have to take the wheelchair away for safety reasons and the facility did not have the staff to safely allow him/her to be supervised in the wheelchair while self-propelling. Resident Representative #1 said she initially pushed back because she thought of it as if they were restraining Resident #2 and preventing him/her from being able to move and burn off energy, but they continually reminded her that Resident #2 was on hospice and the goal was for safety and comfort, which they could better ensure if the wheelchair was removed. Resident Representative #1 said she was able to compromise with the facility and when she comes to visit, Resident #2 could use the wheelchair and self-propel as long as Resident Representative #1 was there to supervise. Resident Representative #1 said the first few times she came to visit, Resident #2 would sit in the wheelchair and self-propel around for about an hour, but there was a time gap when she couldn't come to visit, and the Resident has now declined so much that he/she likely wouldn't be able to do that anymore anyway. Resident Representative #1 said there was no offer of any other type of chair or device, like a pedal chair that was low where the Resident's feet could still touch the ground, or offer for the Resident to be supervised in the wheelchair for a period of time each day to self-propel and that they just put him/her from the wheelchair directly to the Broda chair once it arrived from hospice. Resident Representative #1 said no alternative options were provided and she did ask about it being a restraint but wanted her parent to be safe, so she compromised.On 9/12/25 at 12:01 P.M., MDS Nurse #1 said she was familiar with Resident #2. MDS Nurse #1 said the facility is restraint-free and there is no documentation or special areas she would look to find information for a resident being restrained because they don't have any. MDS Nurse #1 was asked if Resident #2 could self-propel in his/her wheelchair and she said yes, at one time the Resident could walk and self-propelled in his/her wheelchair but has since moved to a Broda chair. MDS Nurse #1 said she was unaware of the 12/12/24 Physician Progress Note indicating the wheelchair was being removed for safety. MDS Nurse #1 said if the wheelchair was removed with the intention of not allowing the Resident to self-propel any longer, the Broda chair would be considered a restraint since it would prevent the resident from self-propelling like he/she wanted to. On 9/12/25 at 12:37 P.M., the Director of Nursing (DON) said after the Resident's large fall, the physician and herself had a conversation about the Resident's safety and that of other residents on the unit. The DON said she spoke with Resident Representative #1 about it as well. The DON said the intent was to keep the Resident safe and to keep other residents safe as Resident #2 would self-propel and grab at other people. The DON said eliminating the Resident's ability to move in a way he/she would want to would be considered a restraint and that the facility staff cannot remove a resident's ability to do something without assessing or having conversations about it being a potential restraint. The DON said these discussions were had verbally but she did not know if that information made it into the Resident's record. The DON said no restraint assessment was completed, and the Resident's Care Plans were not reflective of the Resident's current status or use of Broda chair. The DON said she spoke with Resident Representative #1 and did not offer other options or other types of chairs. The DON said Resident Representative #1 did agree to the use of the Broda chair and did come in and assist the Resident in the wheelchair at times to self-propel. During a subsequent interview on 9/12/25 at 2:49 P.M., the DON said she couldn't find any evidence the device was considered or evaluated as a restraint or that the risk vs. benefits of the Broda chair's use were provided. She said she did see the Nursing Progress Notes in which the staff indicate at times through the month of August 2025, the Resident would be restless and attempting to get out of the chair. She said the staff told her the Resident does get in the standard wheelchair occasionally, but there is no documentation to support that. During an interview on 9/15/25 at 9:05 A.M., Physician #2, Resident #2's attending physician, said he had a lengthy discussion with Resident Representative #1 about the Resident's lack of safety awareness. Physician #2 said Resident #2 had one bad fall with multiple facial fractures, but there were numerous other times when the Resident was self-propelling and staff were able to intervene before any accident or injury occurred. Physician #2 said once Resident #2 sustained his/her injuries in December 2024, he called Resident Representative #1 and met with her on the unit to discuss that Resident #2 was very unsafe and there was not enough staff in place to provide a continuous one to one supervision to the Resident. Physician #2 said he made multiple suggestions, such as transfer to another facility where staff would be able to provide one to one supervision, like a psychiatric facility; leaving Resident #2 in the standard wheelchair and waiting for another accident to happen; or to obtain a Broda chair from hospice to keep the Resident from self-propelling. Physician #2 said Resident Representative #1 did not want to transfer the Resident and did not want the Resident or other residents to be injured, so she agreed to use of the Broda chair. Physician #2 said Resident Representative #1 asked if she would be able to supervise the Resident while self-propelling in the standard wheelchair when she was in to visit and he told her she would have to discuss that with the DON. Physician #2 said both he and Resident Representative #1 felt sad about taking away the Resident's ability to self-propel, but he had little doubt that another accident would happen, possibly involving another resident, if they did not. Physician #2 said he hated taking away the Resident's ability to be mobile, but it became too risky. Physician #2 said it was hard for him to say if the facility staff should have completed a restraint assessment as he felt that he did that and reviewed the risks and benefits with Resident Representative #1.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and other opportunistic waterborne pathogens. Findings include: Review of the facility's policy titled Legionella Water Management Program, dated as revised September 2022, indicated but was not limited to: -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease -The water management program includes the following elements: a. an interdisciplinary water management team b. a detailed description and diagram of the water system in the facility c. the identification of areas in the water system that could encourage the growth and spread of Legionella of other waterborne bacteria d. the identification of situations that can lead to Legionella growth e. specific measures used to control the introduction and/or spread of Legionella f. the control limits or parameters that are acceptable and that are monitored g. a diagram of whether control measures are applied h. a system to monitor control limits and the effectiveness of control measures i. a plan for when control limits are not met and/or control measures are not effective and j. documentation of the program During the recertification survey, the facility was unable to provide the surveyor with evidence of a water management program. During an interview on 9/11/24 at 10:28 A.M., the Administrator said there was no actual assessment of the building or evidence of a water management program. During an interview on 9/11/24 at 10:38 A.M., the Director or Maintenance (Property Manager) and Maintenance Staff #1 said the facility did not have a water management program. Maintenance Staff #1 said there was no risk assessment, water diagram, or testing protocols.

Based on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed for three Residents (#57, #270, and #6), of 17 sampled residents, to ensure safe storage of medications and biologicals according to current standards of practice. Findings include: Review of the facility's policy titled Self-Administration of Medications, last revised February 2021, indicated but not limited to: -Self-administrated medications are stored in a safe and secure place not accessible by other residents. A. On 9/9/24 at 8:54 A.M., 10:57 A.M., and 1:36 P.M., the surveyor observed an inhaler containing Albuterol Inhalation Aerosol Solution (a bronchodilator used to relax airway muscles) on Resident #57's bedside table. Review of Resident #57's September 2024 Physician's Orders indicated but was not limited to the following: - May self-administer (dated 6/9/24) During an interview on 9/11/24 at 4:00 P.M., the Director of Nursing (DON) said Resident #57's inhaler should not have been on his/her overbed table. The DON said the medication should have been in a secure place. B. On the following dates/times of survey, the surveyor observed a bottle of Calcium Carbonate (used to treat heart burn/upset stomach) and a bottle of eye drops on Resident #270's windowsill: - 9/9/24 at 8:34 A.M., - 9/9/24 at 9:59 A.M., - 9/9/24 at 10:56 A.M., - 9/9/24 at 1:36 P.M., - 9/9/24 at 4:31 P.M., - 9/10/24 at 8:52 A.M., and - 9/10/24 at 2:28 P.M. Review of Resident #270's September 2024 Physician's Orders indicated but was not limited to the following: - May self-administer (dated 8/30/24) During an interview on 9/9/24 at 1:36 P.M., Resident #270 said he/she used the Calcium Carbonate for an upset stomach and eye drops to treat his/her dry eyes. During an interview on 9/11/24 at 1:11 P.M., Nurse #9 said Resident #270 should not have had their medication on the windowsill. Nurse #9 said Resident #270 should have had their medications secured in his/her nightstand. During an interview on 9/11/24 at 4:00 P.M., the DON said Resident #270's medications should have been in a secured place and not on his/her windowsill. 46562 C. On the following dates of survey, the surveyor observed an inhaler containing Ventolin Inhalation Aerosol Solution (a bronchodilator used to relax airway muscles) on Resident #6's bedside table: -9/9/24 at 8:45 A.M., -9/9/24 at 2:38 P.M., -9/10/24 at 1:32 P.M.; and -9/11/24 at 10:03 A.M. During an interview on 9/11/24 at 10:04 A.M., Resident #6 said he/she keeps the inhaler on the bedside table in case it is needed urgently and did not keep it locked up when not in use. During an interview on 9/11/24 at 2:24 P.M., Nurse #7 said she saw the inhaler on Resident #6's bedside table today and that the inhaler should be locked up when it is not in use. During an interview on 9/11/24 at 4:00 P.M., the DON said Resident #6 was able to self-administer his/her inhaler. The DON said his/her inhaler should be locked in the bedside table when not being administered.

Based on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (Memory Care), out of six units in the facility. Specifically, the facility failed to ensure staff implemented facility sponsored group activities for all residents on the Memory Care unit designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Findings include: Review of the facility's policies titled Activity Programs, last revised June 2018, Therapeutic Programs and Activities for the Dementia Special Care Unit (DSCU), undated, and Individual Activities and Room Visit Program, last revised June 2018, indicated, but was not limited to: -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. -Meaningful Activities: Design activities that engage residents mentally, physically, and emotionally, such as arts and crafts, music sessions, gardening, and storytelling. -Cognitive stimulation: Implement activities like memory games, puzzles, and group discussions to promote cognitive engagement. -Physical activities: Daily exercises, walks, and dance sessions to improve mobility, strength, and overall well-being. -Music and Art Therapy: Offer music sessions that can be calming or invigorating, and art activities that allow residents to express themselves. -Reminiscence Therapy: Use objects, photographs, or music from the past to help stimulate memories and improve mood. -Activities for residents with behavioral or emotional problems who cannot participate in group activities include: a. uncomplicated activities that can be adapted to the level of the individual's attention span and function; b. activities requiring short periods of concentration to reduce frustration; and c. activities tailored to address specific underlying causes of the individual's behavior or attention limitations (e.g. familiar occupation-related activities, exercise and movement activities, engaging the resident in conversation, and using one-to-one activities such as looking at familiar pictures and photo albums). Review of the September 2024 activity calendar for the Memory Care Unit indicated multiple activities listed every day of the month. Each day, some of the activities were typed in regular font and some were typed in bold font. Activities listed for days of observations made during the survey period included: 9/10/24: -9:30 A.M. Morning Greetings (regular font) -10:00 A.M. Good News Report (bold font) -10:30 A.M. Hymn Sing-Along with Chaplain [NAME] & Sterling (bold font) -2:00 P.M. Sunflower Paint Along (bold font) -3:00 P.M. Word Games (bold font) -3:30 P.M. Come Dance With Us (bold font) -3:30 P.M. Hydration Station (regular font) -4:00 P.M. Balloon Games (regular font) -6:00 P.M. Sensory Folding & Sorting (regular font) 9/11/24: -9:30 A.M. Morning Greetings (regular font) -10:00 A.M. Communion with [NAME] Reading, Song & Prayer (bold font) -10:45 A.M. Instrumental Jam Sesh (bold font) -2:00 P.M. Celebrating Bee Keeping (bold font) -3:00 P.M. Lemonade Honey Punch Social (bold font) -3:30 P.M. Hydration Station (regular font) -4:00 P.M. Balloon Games (regular font) -6:00 P.M. Rosary (regular font) During an interview on 9/10/24 at 10:55 A.M., Certified Nursing Assistant (CNA) #1 said there is an activity assistant assigned to the unit every Monday, and all other days of the week, there are no activities for the residents on the unit during the daytime. She said they do activities on the Memory Care unit from 3:00 P.M. to 6:00 P.M. or 7:00 P.M. She said the activities listed on the calendar that are in bold lettering are activities held off the unit upstairs. She said staff come downstairs to take two or three residents to the activity, and the rest are left behind because the activity is not at an appropriate cognitive level for the other residents. She said when there is church service or hymn sing-along, they try to take as many people as they can to it. Otherwise, they stay on the unit with no activities except for sitting in front of the television. -On 9/10/24, the following observations were made of the activity program on the Memory Care Unit: From 8:53 A.M. to 11:50 A.M.: As of 11:50 A.M., no activities had taken place. There were seven residents in the day room. The television was on and playing music. The activity calendar indicated that by this point in the morning, Morning Greetings, Good News Report, Hymn Sing-Along with Chaplain [NAME] and Sterling would have already occurred. All seven residents were sitting in the day room without any meaningful activity taking place. From 1:43 P.M. to 3:30 P.M., six residents were observed sitting in the day room. No activities were taking place on the unit and all six residents were sitting in the day room without any meaningful activity taking place. According to the activity calendar, Sunflower Paint Along and Word Games would have already occurred. -On 9/11/24, the following observations were made of the activity program on the DSCU: From 8:45 A.M. to 11:15 A.M.: At 9:26 A.M., the Therapeutic Activity Director (TAD) started a game of Finish the Lyrics. The game finished at 9:40 A.M. The TAD asked a few residents if they wanted to go to church off the unit. At 10:00 A.M., six residents were seated in chairs on the unit: three residents were in the living room, one was seated at the counter in the kitchen area, one resident was in a common area scooting him/herself in a wheelchair, one resident was seated at a table in the dining area coloring. Five of the six residents on the unit were seated without any meaningful activity taking place. At 1:03 P.M., the surveyor observed six residents seated in chairs in different areas: two residents were in the living room, one seated at the kitchen counter, one resident in a wheelchair scooting him/herself, one resident was asleep in a Broda chair (positioning chair) and one resident was coloring at a table in the dining room. Five of the six residents on the unit were seated without any meaningful activity taking place. During an interview on 9/11/24 at 10:33 A.M., the surveyor and TAD reviewed the activity calendar for the DSCU and other units and she confirmed that the bolded items on the calendar are held upstairs in the main community room and the non-bolded items are held in the Memory Care Unit. She said not all residents go to the activities off the unit, and there are usually two residents who go upstairs that are more cognitively intact and can engage in the activity. She said there are some programs, like church or music, in which more residents will go. She said if eight or more residents go off the unit for activities, an activity staff will accompany them, and there will be no activity staff on the unit leaving only one CNA and one Nurse on the Memory Care Unit. She said she works as the TAD for 20 hours a week, works as a driver for the facility (taking residents to appointments) for 20 hours a week, and picks up hours as a CNA. She said the 20 hours she works as the TAD is mostly spent on doing paperwork. She said there is not enough help on the unit and the residents' needs are not being met. The surveyor asked what activities are implemented for the residents left behind on the unit when other residents attend activities off the unit, and she said there are only scheduled activities on the unit from 3:00 P.M. to about 6:30 P.M. or 7:00 P.M. During an interview on 9/12/24 at 9:55 A.M., Family Member #1 said it's great that some residents go off of the unit to do activities upstairs with the other residents, but they need more specialized activities on the unit for those that don't go upstairs. During an interview on 9/12/24 at 11:09 A.M., Nurse #10 said on Mondays, there is an activity assistant on the unit all day, but all other days of the week, there is no one to do activities during the day and two or three residents go upstairs to the activities held in the community room with residents from the other units. She said scheduled activities on the Memory Care unit begin at 3:00 P.M. every day. Nurse #10 said the afternoons are the most challenging because residents begin to sundown (a state of confusion that occurs in the late afternoon and lasts into the night. Sundowning can cause various behaviors, such as confusion, anxiety, aggression or ignoring directions) and they need more activities and supervision.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was properly stored, labeled, and dated in the main kitchen; and 2. Ensure food was properly stored, labeled, and dated in five of five kitchenettes. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: - 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A)Except when PACKAGING FOOD using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B)Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. - 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). Review of the facility's policy titled Refrigerators and Freezers, dated as last revised November 2022, indicated but was not limited to the following: -All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. -Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage policy. -Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes on packaging. Review of the facility's policy titled Food Receiving and Storage, dated as last revised November 2022, indicated but was not limited to the following: -Foods shall be received and stored in a manner that complies with safe food handling practices. -Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. -Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in - first out system. -All food items to be kept at or below 41 degrees Fahrenheit (F) are placed in the refrigerator located at the nurses' station and labeled with a use by date. -All foods belonging to residents are labeled with the resident's name, the item and the use by date. -Other opened containers are dated when opened and discarded after 24 hours. -Soaps, detergents, cleaning compounds, or similar substances will be stored in separate storage areas from food storage and labeled clearly. Review of the facility's policy titled Resident Food Storage and Heating Policy, undated, indicated but was not limited to the following: -It is the policy of the facility to allow Residents and family to bring food from the outside environments to the facility. It is required of staff to store these items in the neighborhood kitchen or unit refrigerators, making sure the items are clearly labeled and dated with the resident's name, date and room number with labels supplied by the dietary department. If the refrigerated item is 5 days older and the frozen item is 30 days older than the dated item, it is to be discarded immediately to prevent the spread of foodborne illness. 1. On 9/9/24 at 8:01 A.M., the surveyor observed the following in the main kitchen: -one bag of croutons, opened, not dated; -a partial log of bologna in the walk-in refrigerator, not dated; -one bag of frozen ravioli, out of the box, not dated; -one bag of frozen cheese-stuffed shells, out of the box, not dated; -one pitcher in the reach-in refrigerator labeled iced coffee, dated 8/5; -one opened container of Lactaid milk with manufacturer directions stating once opened use within 14 days, with no opened or use by date. On 9/11/24 at 8:50 A.M., the surveyor observed in the main kitchen reach in refrigerator, the following four opened containers of thickened liquids with manufacturer directions stating after opening, may be kept up to seven days under refrigeration: -apple juice dated 9/1; -water dated 9/1; -orange juice dated 9/2; -cranberry juice dated 9/3. On 9/11/24 at 8:50 A.M., the surveyor observed the following in the main kitchen: -one plastic bag of waffles in reach in freezer, opened, not dated; -one plastic bag of pancakes in reach in freezer, opened, not dated; -two packages of croutons, out of box, opened, not dated; -three bags crushed crackers, out of box, no label, not dated; -one jar of sweet pickles (manufacturer best by date of 3/28/23) not dated; -two jars of fig spread (manufacturer best by date of 8/27/22), not dated; -one jar of caperberries (no manufacturer date), not dated; -one four-pound jar of orange marmalade, unopened with contents appearing brown in color (no manufacturer date), not dated; -one vacuum packed bag of sundried tomatoes, not dated; -one box of corn muffin mix (manufacturer date of 1/5/22), dated 2/26; -two boxes of corn muffin mix, not dated; -three graham cracker pie crusts, out of box, no label or date; -one package each of hot chocolate mix and smoothie mix, no manufacturer date, not dated; -two containers of alfredo sauce mix (manufacturer best by date of 3/21/23), not dated; -one box containing a bulk bag of Dutch cocoa, opened with the bag partially open at the top (manufacturer best if used by date of 9/27/21), not dated; -one gallon container of French dressing, dated 1/14/20; -one container of allergen free breadcrumbs (manufacturer best by date of 9/6/23), opened, not dated; -one opened container of Lactaid milk with manufacturer directions stating once opened use within 14 days, with no opened or use by date. During an interview on 9/11/24 at 10:10 A.M., Dietary Staff #1 said she was covering for the Food Service Director. Dietary Staff #1 said all food and beverage, including items taken out of the original box, should be labeled with the date received, a use by date, and the date the product is opened. Dietary Staff #1 said she was unable to locate documentation for length of time of unopened and opened food and beverages are to be stored. During an interview on 9/11/24 at 10:15 A.M., the Dietitian said she expects all food and beverage, which also includes any items removed from the original packaging or box, should be labeled with the date received, a use by date, and the date the product is opened. The Dietitian said she expects food and beverage items to be rotated on a first-in, first-out basis. The Dietitian said she expects dates of stored food and beverage to be monitored by dietary staff and disposed of according to best practice and policy. The Dietitian said she was unable to locate documentation for length of time food and beverages are to be stored. 2. On 9/9/24 at 8:50 A.M., the surveyor observed the following in the [NAME] unit kitchen: -one package of linguica sausage, opened, no resident name or date; -one container of thickened orange juice, manufacturer directions stated after opening, may be kept up to seven days under refrigeration, dated 8/17; -one container of thickened cranberry juice, manufacturer directions stated after opening, may be kept up to seven days under refrigeration, dated 8/31. On 9/10/24 at 9:00 A.M., the surveyor observed the following in the [NAME] unit kitchen: -one container of thickened lemon water with manufacturer directions stating after opening, may be kept up to seven days under refrigeration, dated 6/29; -one container of honey thick cranberry juice with manufacturer directions stating discard if not used within ten days of opening; -two opened containers of Lactaid milk, not dated; -nine Lactaid ice cream cups with no manufacturer date, not dated; -one box of pistachio pudding with manufacturer best by date of 4/2/05, not dated. On 9/11/24 at 10:20 A.M., the surveyor with Dietary Staff #1 observed in the memory care unit kitchen, two containers of thickened liquids, opened, not dated. Dietary Staff #1 said both containers should be labeled with the date they were opened. On 9/11/24 at 11:15 A.M., the surveyor with Dietary Staff #1 observed in the [NAME] unit kitchen one container of thickened liquid, opened, not dated. Dietary Staff #1 said the container should be labeled with the date they were opened. On 9/11/24 at 11:29 A.M., the surveyor with Dietary Staff #1 observed the following in the [NAME] unit kitchen: -one carton of liquid eggs, opened, not dated; -one container of Lactaid milk, opened, not dated; -two containers of thickened liquids, opened, not dated. Dietary Staff #1 said the items should be labeled with the date they were opened. On 9/11/24 at 11:40 A.M., the surveyor with Dietary Staff #1 observed the following in the [NAME] unit kitchen: -one carton of liquid eggs, opened, not dated; -two containers of thickened liquids, opened, not dated. Dietary Staff #1 said the items should be labeled with the date they were opened. On 9/11/24 at 11:50 A.M., the surveyor with Dietary Staff #1 observed in the Short-Term unit kitchen three containers of thickened liquids, opened, not dated. Dietary Staff #1 said the containers should be labeled with the date they were opened. During an interview on 9/11/24 at 12:53 P.M., the Dietitian said she expected all foods in the unit kitchens belonging to residents to be labeled with the resident's name and use by date. The Dietitian said she expected facility-provided food items in unit kitchens to be labeled and dated with opened dates and/or use by dates depending on the item.

Based on observations, record review, and interviews, the facility failed to ensure sufficient staffing levels were maintained to safely and adequately meet each resident's needs on all shifts every day on one (Memory Care) of three units in the facility. Findings include: Review of the Facility Assessment, dated reviewed 7/16/24, indicated the Facility was licensed for 67 beds and there were 12 beds on the Memory Care unit. -The average daily census of the Memory Care unit is 12. Further review indicated that the number of Certified Nurse's Aides (CNA) required to care for residents in the facility is: -2:10 (two staff to care for 10 residents) ratio Days (total licensed or certified) -2:10 ratio Evenings (total licensed or certified) -1.5:10 ratio Nights (total licensed or certified) -2:15 ratio Nights (short term rehab) (total licensed or certified) Review of the CNA daily assignment sheets and daily staffing schedules indicated that on 9/9/24, 9/10/24, 9/11/24, and 9/12/24 one CNA was assigned to the Memory Care unit on the 7:00 A.M.-3:00 P.M., 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts, caring for 12 residents, and not two CNAs as indicated in the facility assessment. Further review of the schedule indicated one additional CNA was assigned to the Memory Care unit from 7:00 A.M. to 8:00 A.M. only, and one float (employees who are not assigned to a single location and instead work in multiple departments or locations) CNA was available to assist on all six units in the facility on each shift. On 9/10/24 at 8:53 A.M. on the Memory Care Unit, the surveyor observed seven residents seated in the living room. Nurse #1 was at the medication cart in the hallway near the living room preparing medications and CNA #1 was providing resident care in a resident's room. Resident #26 was seated in a wheelchair near the window. The resident was scooting/propelling him/herself forward with his/her feet, leaning so far forward that he/she nearly fell out of the wheelchair with each push of his/her feet. Resident #56 was noted to be reclined in a chair with the footrest up. Nurse #1 had reclined the chair at 9:00 A.M., due to the resident being agitated and restless attempting to get out of the chair. While being reclined, the resident moved him/herself to the edge of the chair, pushed the footrest down with the weight of his/her body and got to a standing position thereby activating the chair alarm. Nurse #1 rushed to the aid of this resident and assisted him/her to a seated position in the recliner. At 9:06 A.M., Nurse #1 called to request additional staff to help monitor/sit with the resident because of his/her continual attempts to stand. At 9:09 A.M., Activity Assistant #1 arrived on the unit and sat next to the resident. During this time, Activity Assistant #1 had to repeatedly remind Resident #26, who was propelling him/herself in the wheelchair not to lean forward or he/she was going to fall out of the wheelchair and hit his/her head. Activity Assistant #1 kept shifting her focus from Resident #26 to Resident #56, to ensure neither residents would fall. At 9:30 A.M., Nurse #1 called for more assistance on the unit. She informed the person on the phone that another resident (now two residents) needed one-to-one because of safety concerns and that she only had one staff (Activity Assistant #1) at this time. At 9:34 A.M., the telephone rang at the nursing desk and Activity Assistant #1 proceeded to answer the phone. At this time, Resident #56 stood up from his/her recliner causing the chair alarm to sound. Activity Assistant #1 quickly put down the phone and rushed to assist Resident #56 back to a seated position in the recliner. At 9:47 A.M., another resident, Resident #48, stood up from a chair and began to ambulate unassisted down the hallway. CNA #1 quickly proceeded down the hallway to catch up with the Resident and assist him/her. At 9:50 A.M., another staff member entered the unit to provide assistance. During surveyor observation of the Memory Care unit from 8:53 A.M. until 9:50 A.M. (nearly one hour), multiple residents exhibited impulsive, unsafe behaviors and insufficient staff to monitor them. During an interview on 9/10/24 at 10:55 A.M., CNA #1 said there has always been only one nurse and one CNA scheduled on the unit every shift, every day. She said there are no bed-bound residents on the Memory Care unit, and everyone can get up and out of their rooms at any time. She said what happened yesterday (the surveyor's observation noted above) happens all the time. However, when surveyors are not in the facility, additional staff are not sent to the unit to assist. She said five out of 12 residents on the unit require a two person assist with all care, and if both she and the nurse is busy with care for a resident, there is no one to help. She said 10 of 12 residents on the unit have bed and chair alarms and many times during the day, every day, the alarms are sounding and she and the nurse just can't get to them. The surveyor asked if there are any other staff that are able to come and help and she said there is a float CNA upstairs that can come, but the float is not allowed to go to the Memory Care unit from when they finish assisting with meals on the unit around 12:00 P.M. to 3:00 P.M. She said if the float is not available, they don't get anyone. She said there are a lot of falls on the unit, and they need more staff to assist to provide supervision to prevent falls from happening. CNA #1 said there are three residents that need to have 1:1 supervision because they are a fall risk and keep trying to get up out of their chairs, but they don't have enough staff to do it. She said she has told the hire ups about her concerns about lack of scheduled staffing and resident safety, but they haven't done anything. During an interview on 9/10/24 at 11:50 P.M. and 9/12/24 at 9:55 A.M., Family Member #1 said his loved one has had four falls since residing on the unit. He said one nurse and one CNA are not enough staff to care for the residents considering the special needs of Memory impaired residents. He said the other units each have 10 residents and they staff them the same: one nurse and one CNA. He said he has spoken to the Administrator and the property management company several times about his concerns and he has had no response and nothing changes. During an interview on 9/11/24 at 10:07 A.M., Nurse #1 said she consistently works on the Memory Care unit. She said she does not feel staffing on the unit is adequate to meet the needs of the residents, and she does not feel it is safe. She said the unit has many falls and if there were another scheduled CNA on the unit, she believes the falls could be avoided. She said 10 of 12 residents on the unit have alarms because they are fall risks and often times there are multiple alarms going off at the same time and she has to prioritize who falls. She said there has always been only one nurse and one CNA scheduled on the unit and if the CNA is providing care to one resident and she is providing care to another resident, there is no way we can get to a resident whose alarm is sounding. She said she has brought her concerns to Administration several times and the schedule has not changed. During an interview on 9/11/24 at 10:33 A.M., the Therapeutic Activity Director said she gave her resignation as TAD two weeks ago. She said she couldn't continue on with the role because there is not enough help on the unit and the residents' needs are not being met. The TAD said the residents are unsafe with only two staff on the unit to meet the physical care needs and supervision needs. She said she works as the TAD for 20 hours a week, works as a driver (taking residents to appointments) for 20 hours a week, and also works as a CNA here sporadically on the night shift. She said the 20 hours she works as the TAD is mostly spent on doing paperwork and she is not on the unit. During an interview on 9/12/24 at 7:15 A.M., the Administrator confirmed that there is one nurse and one CNA assigned every shift to each of five units, and the short-term unit has one nurse and two CNAs every shift. She said there is one float CNA available to assist on any of the units each shift. She said there is a homemaker (housekeeper) on the unit as well. However, she said the housekeeper is not a CNA and cannot provide any hands-on assistance to the residents. The surveyor asked the Administrator if the residents' care needs on the Memory Care unit were identical to the care needs on the other five units and she said yes. Review of Point of Care documentation and the most recent Minimum Data Set (MDS) Assessment section GG (Activities of Daily Living), dated September 2024, and the Behavior Summary Report for the week ending 9/12/24 (total census of 62) indicated the following: 1. [NAME] unit: Census- 9 -8 were incontinent of bowel and bladder -2 had identified and exhibited behaviors at times -7 were totally dependent for Activities of Daily Living (ADL) care needs) -2 required minimum to moderate assistance with care -9 incidents of behaviors and/or wandering 2. [NAME]: Census- 10 -7 were incontinent of bowel and bladder -3 had identified and exhibited behaviors at times -3 were totally dependent for ADL care needs -7 required minimum to moderate assistance with care -83 incidents of behaviors and/or wandering 3. [NAME]: Census- 10 -7 were incontinent of bowel and bladder -1 had identified and exhibited behaviors at times -4 were totally dependent for ADL care needs -6 required minimum to moderate assistance with care -26 incidents of behaviors and/or wandering 4. [NAME]: Census- 10 -6 were incontinent of bowel and bladder -1 had identified and exhibited behaviors at times -5 were totally dependent for ADL care needs -5 required minimum to moderate assistance with care -16 incidents of behaviors and/or wandering 5. Short Term Rehab: Census- 11 -2 were incontinent of bowel and bladder -0 had identified and exhibited behaviors at times -0 were totally dependent for ADL care needs -11 required minimum to moderate assistance with care -no data was provided by the facility 6. Memory Care: Census-12 -10 were incontinent of bowel and bladder -11 had identified and exhibited behaviors at times -9 were totally dependent for ADL care needs -3 required minimum to moderate assistance with care -164 incidents of behaviors and/or wandering Further review of the Point of Care documentation and the most recent Minimum Data Set (MDS) Assessment section GG (Activities of Daily Living) and Behavior Summary Report for the week ending 9/12/24 indicated the Memory Care unit had more physical and behavioral care needs than the other five units in the facility, yet the staffing level was the same (except for the short-term unit). On 9/12/24 at 11:09 A.M., Nurse #10 and CNA #4 were interviewed. Nurse #10 said she works on the unit on weekends as well as some days during the week. She said there is only one nurse and one CNA scheduled on the unit. She said a float CNA is assigned to the Memory Care unit from 7:00 A.M. to 8:00 A.M. every morning to assist with feeding, and then goes upstairs to the other units. Nurse #10 and CNA #4 said the float CNA is not allowed to come back to the Memory Care unit after 3:00 P.M. They said the afternoons are the most challenging as residents sundown (a state of confusion that occurs in the late afternoon and lasts into the night. Sundowning can cause various behaviors, such as confusion, anxiety, aggression or ignoring directions) and they need more supervision. Nurse #10 gave an example of assisting a resident in their room and CNA #4 assisting another resident in their room and they hear alarms going off and they can't get to them. They said they do their best and run around like chickens with their heads cut off, but they can't watch everyone at the same time. Nurse #10 said they need another aide on the floor to be able to help and keep the residents safe. Nurse #10 said she has spoken to the Administrator several times about getting more scheduled help on the unit, but nothing has changed. During an interview on 9/12/24 at 11:23 A.M., Family Member #2 approached the surveyor and said the Memory Care unit needs more help. She said her loved one has had a few falls and has a bed and chair alarm. She said there are only two staff on the unit and there are not enough staff to respond to the alarms going off. Family Member #2 said she has brought her concerns about low staffing up to the Administrator about a month ago, and there was no response. She said low staff and resident safety continues to be her greatest concern for the unit.

Based on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Memory Care Unit) of six units in the facility. Specifically, the facility failed to ensure a three-tiered cart with hazardous items stored on it was not easily accessible to wandering residents on a Dementia Special Care Unit. Findings include: On 9/9/24 from 9:20 A.M. to 10:27 A.M. on the Dementia Special Care Unit, the surveyor observed two residents ambulate independently on the short hallway on the unit. On 9/9/24 at 10:27 A.M., on a short hallway on the unit, the surveyor observed a wheeled three-tiered cart with supplies on it. The top tier had stacks of folded towels on it covered with a folded bed sheet. The middle tier had incontinence briefs and slipper socks, and the bottom tier had a clear plastic bin that contained the following items: -8 (4 ounce) bottles of Medline Remedy Essentials Moisture Body Lotion -4 (1.5 ounce) bottles of FreshScent Roll-on Antiperspirant Deodorant -2 (4 ounce) bottles of FreshMoment Mouthwash -1 (8 ounce) bottle of Medline Remedy Phytoplex Moisturizer Nourishing Skin Cream -2 (4 ounce) tubes Medline Remedy Clinical Moisturizer Skin Cream -1 (8 ounce) tube Medline Remedy Clinical Moisturizer Skin Cream -5 (7 ounce) tubes Medline Remedy Prevent Ointment -1 (8 ounce) bottle Remedy Cleanse Spray Cleaner for cleansing & conditioning hair and skin -1 (8 ounce) can Earth Saver Spray -1 Styrofoam cup with 5 disposable razors in it During an interview on 9/9/24 at 10:33 A.M., Nurse #1 and the surveyor reviewed the items in the clear plastic bin on the bottom shelf of the cart. The nurse said all of the items are hazardous and should be kept in a locked closet and not accessible to residents on the unit.

Based on records reviewed and interviews, for one Resident (#20), out of 17 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated. Specifically, the facility failed to ensure Resident #20 was seen by a physician within the first 90 days of admission. Findings include: Review of the facility's policy titled Physician Visits, last revised April 2013, indicated but was not limited to: - The Attending Physician will visit residents in a timely fashion, consistent with the applicable state and federal requirements, and dependent on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. - The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. - After the first ninety (90) days, if the attending physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits may be established, but not to exceed every sixty (60) days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. Resident #20 was admitted to the facility in June 2024 with diagnoses including dysphagia (difficulty swallowing), anemia, chronic renal insufficiency, thyroid disorder, Parkinson's disease (disorder of the central nervous system that affects movement), and major depressive disorder. Review of Resident #20's medical record indicated the Resident had not been seen by the attending Physician since being admitted to the facility. The medical record indicated the initial comprehensive assessment and all subsequent visits were conducted by a Nurse Practitioner. During an interview on 9/12/24 at 12:45 P.M., the Director of Nursing (DON) said Nurse Practitioner #1 performed Resident #20's initial assessment and Nurse Practitioner #1 was actively involved in the Resident's ongoing care. During a telephonic interview on 9/12/24 at 1:53 P.M., the Medical Director said he expected newly admitted residents to be assessed by a Physician within the first 30 days of admission. The Medical Director said if an attending Physician is not available, the facility should contact him (the Medical Director) or another Physician associated with the facility to cover for the attending Physician. The Medical Director said Resident #20 was not his resident and he was not asked to be a provider for the Resident.

Based on observations, interview, record review, and policy review, the facility failed to implement interventions timely after significant weight loss was identified for one Resident (#20), out of a total sample of 17 residents. Specifically, the facility failed to: -assess and evaluate the Resident's nutritional status, and -consider interventions to curb further weight loss, resulting in additional weight loss over a period of two weeks. Findings include: Review of the facility's policy titled Weighing and Measuring the Resident, dated as last revised March 2011, indicated but was not limited to the following: -Report significant weight loss to the nurse supervisor. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss = [usual weight - actual weight] / [usual weight] x 100): a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated as last revised September 2017, indicated but was not limited to the following: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. -The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss. -The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity of consequences of weight loss and/or impaired nutrition. -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. -The physician will help identify medical conditions and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. -The physician (or staff, based on a discussion with the physician) will document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations such as where multiple causes coexist. -The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Review of the facility's policy titled Nutrition Assessment, dated as last revised October 2017, indicated but was not limited to the following: -The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. -The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition: a. cognitive or functional decline; b. chewing or swallowing abnormalities; c. pain; d. medication changes; e. environmental factors; f. increased need for calories and/or protein; g. poor digestion or absorption; h. fluid and nutrient loss; i. inadequate availability of food or fluids. -Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risk for nutritional complications. -Individualized care plans shall address, to the extent possible: a. the identified causes of impaired nutrition; b. the resident's personal preferences; c. goals and benchmarks for improvement; and d. time frames and parameters for monitoring and reassessment. Resident #20 was admitted to the facility in June 2024 with diagnoses including dysphagia (difficulty swallowing), feeding difficulties, chronic renal insufficiency, history of breast cancer, gastroesophageal reflux disorder, diverticulitis, thyroid disorder, Parkinson's disease (disorder of the central nervous system that affects movement), muscle weakness, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 6/15/24, indicated Resident #20 had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS), needed substantial/maximal assistance with meals, was taking an antidepressant, and had weight loss. Review of the Physician's Orders indicated the following: -House diet, pureed texture, honey consistency, pureed/honey thick, active 6/9/24. -Magic cup (an oral nutrition supplement), one time a day, active 6/13/24. -Mighty shake (an oral nutrition supplement), two times a day, honey thick, give 120 milliliters (mL), active 8/14/24. -Add banana at breakfast in the morning for supplement, active 8/22/24. -Mirtazapine (antidepressant, also used to increase appetite) 7.5 milligrams (mg) by mouth in the evening for depression, active 6/9/24. Review of the Weight Summary indicated the following: -9/4/24 weight 116.4 pounds (lbs.) -8/28/24 weight 117.6 lbs. -8/21/24 weight 117 lbs. -8/15/24 weight 115.4 lbs. -8/14/24 weight 113 lbs. -8/13/24 weight 112 lbs. (9.8% weight loss compared to 124 lbs. on 7/17/24) -7/31/24 weight 116.8 lbs. (5.8% weight loss compared to 124 lbs. on 7/17/24) -7/25/24 weight 117.6 lbs. (5.2% weight loss compared to 124 lbs. on 7/17/24) -7/24/24 weight 112.2 lbs. (9.5% weight loss compared to 124 lbs. on 7/17/24) -7/17/24 weight 124 lbs. -7/3/24 weight 123.2 lbs. -6/26/24 weight 120.2 lbs. -6/19/24 weight 122.2 lbs. -6/12/24 weight 122.8 lbs. -6/11/24 weight 122.7 lbs. -6/9/24 weight 122.4 lbs. During an interview on 9/12/24 at 11:53 A.M., the Dietitian said Resident #20's daughter had said the Resident had significant weight loss in the three to six months prior to being admitted into the facility on [DATE]. The Dietitian said the Resident's daughter reported Resident #20's weight had been increasing in recent weeks prior to admission. Review of the Comprehensive Nutrition Assessment, dated 6/12/24, stated but was not limited to the following: -Resident has had significant weight loss over past 3-6 months but daughter states weight is coming up from less than 120 lbs. Seen at noon meal today being fed- Resident can feed self before fatigue settles in. Uses adaptive equipment of nosey cup, lip plate, and angled spoon. Daughter states Resident was drinking Ensure (an oral nutrition supplement) at Assisted Living Facility but will add Magic Cup at noon for 290 calories and 9 grams of protein. Weight goal 123 plus or minus 5 lbs. Awaiting admit labs. Will proceed to plan of care as evidenced by: 12% weight loss in 6 months, intake is less than needs at times. Review of the Nutrition/Dietary Note, dated 8/13/24, stated but was not limited to the following: -Nutrition follow-up: Medical leave of absence (MLOA) 8/8 returned the same day for episode of unresponsiveness. All workup negative. Resident returns on puree diet, honey liquid with Magic cup daily. Appetite has declined and awaiting new weight- weight prior to MLOA 117 which is down from 120 last month. Will add 4 ounce Mighty shake 220 calories each at 10 A.M. and bedtime snack to further augment intake. Seen eating fair at noon being fed by family. Will follow up on readmit weight. Further review of Resident #20's medical record failed to indicate a comprehensive nutritional assessment by the Dietitian, a nurse practitioner, or a physician from 7/11/24 through 8/13/24. During an interview on 9/12/24 at 11:53 A.M., the Dietitian said she was unsure of what caused the Resident's weight loss in July. The Dietitian also said she completed a nutrition assessment for Resident #20 on 6/12/24, 8/13/24, and 9/11/24. Review of the Resident's record indicated there was no documentation of a nutrition encounter or intervention between 7/17/24 and 8/15/24. The Dietitian said there should not have been a three-week delay between documented and confirmed significant weight loss and a nutrition assessment and intervention. During an interview on 9/12/24 at 12:45 P.M., the Director of Nurses (DON) reviewed the facility's Risk book. The DON said Resident #20 was discussed on the following dates: -7/25/24: an increase in Sinemet (a medication to treat Parkinson's disease) and weight increase from 112-117 lbs. -8/13/24 and 8/15/24: Mighty Shakes twice a day, banana at breakfast. -8/23/24: up three pounds. During an interview on 9/12/24 at 12:45 P.M., the DON said her expectation is for weight monitoring to be a concerted effort by nursing, dietitians, and physicians with past weights being reviewed by these disciplines to identify weight changes or trends. The DON said she expects nursing to contact the Dietitian and Physician of any significant weight changes or trends. The DON said she expects residents with significant weight loss to be assessed in a timely manner and interventions, if any, put in place. The DON said Resident #20's weight loss should have been identified and acted upon by the interdisciplinary team around the time the weight loss occurred.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#43), out of a total sample of 17 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address the Resident's behavior of eating non-food items. Findings include: Review of the facility's policies titled Care Plans, Comprehensive Person-Centered and Care Planning-Interdisciplinary Team, last revised March 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The IDT includes, but is not limited to the resident's attending physician. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive, person-centered care plan: -included measurable objectives and timeframes; -describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -includes the resident's stated goals upon admission and desired outcomes; -builds on the resident's strengths; -reflects currently recognized standards of practice for problem areas and conditions -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #43 was admitted to the facility in May 2022 with diagnoses including Alzheimer's disease, anxiety, and major depression. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 5/15/24, indicated Resident #43 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 0 out of 15, and exhibited behavioral symptoms not directed toward others four to six days, but less than daily. Review of the medical record indicated documentation of Resident #43 putting non-food items in his/her mouth on several occasions as follows: -Nursing Note, dated 9/12/24: Resident chews on objects and staff are careful not to give anything harmful. Does have rubber necklace to give to Resident and tolerates well. -Nursing Note, dated 9/26/23: Resident noted frequently chewing on objects and soft mouth device is provided. -Nursing Note, dated 1/6/24: Activities staff witnessed Resident placing cotton ball into mouth then spitting it out. Activities staff educated not to leave any items in front of Resident and that Resident requires continuous supervision and reminders to not place items into mouth. -Social Service Note, dated 3/12/24: Care plan meeting was held on 3/5/24. Resident is noted with episodes of attempting to put non-food items in his/her mouth and staff continue to monitor. -Nursing Note, dated 4/14/24: Laceration noted to right lateral aspect of bruised area. Treatment: cleanse area with normal saline, bacitracin applied leave open to air (LOTA) due to Resident having [NAME] (a pattern of eating non-food materials). MD aware. -Nursing Note, dated 7/31/24: Resident noted to be chewing on something that sounded hard. This nurse assessed and Resident not opening mouth when asked. CNA and this nurse were able to remove Resident's small clear hair clip from his/her mouth. The other hair clip was removed from his/her hair. Will pass on to staff to no longer put hair clips in Resident's hair. -Social Service Note, dated 8/27/24: Requires close supervision due to history of ingesting non-edible items. Review of Psychiatric Nurse Practitioner Progress Notes indicated but was not limited to: -11/30/23: Health Concerns and Risks: National Institute of Health (NIH) guidelines suggest that Trazodone and Luvox together can decrease [NAME] symptoms in frontotemporal dementia without increasing sedation. -2/23/24: Instructions/Recommendations/Plan: If [NAME] is noted, recent research indicates that other medications such as Trazodone and Luvox can be helpful. With return of Pica, primary care physician to rule out medical causes of [NAME] such as iron deficiency anemia. -3/14/24: Health Concerns and Risks: NIH guidelines suggest that Trazodone and Luvox together can decrease [NAME] symptoms in frontotemporal dementia without increasing sedation. Review of Interdisciplinary Care Plan Meeting documentation indicated care plan meetings were held on 12/5/23, 3/5/24, 5/28/24 and 8/27/24. The meetings held on 12/5/23, 3/5/24 and 8/27/24 failed to identify the Resident's behavior of eating non-food items. However, the 5/28/24 care plan meeting indicated Resident #43 requires monitoring due to Pica. The section of the document labeled, Changes to Plan of Care (POC) indicated: medically stable. No recent medication changes. Periods of increased anxiety/agitation, but easily redirected. Escorted to activities. The documentation failed to indicate a change to the care plan was made to address the concern identified as Pica. Review of Resident #43's comprehensive care plans failed to indicate a person-centered comprehensive care plan that included measurable objectives and timeframes was developed and implemented for the Resident's behavior of eating non-food items. Review of the Certified Nursing Assistant (CNA) care card for Resident #43 failed to indicate he/she had a behavior of eating non-food items or required monitoring. During an interview on 9/10/24 at 10:23 A.M., Nurse #2 said Resident #43 has had the behavior of eating non-food items ever since he/she was admitted to the facility. She said the Resident will eat anything that is near him/her and needs items kept away from him/her. The surveyor and Nurse #2 reviewed Resident #43's comprehensive care plans and she said there was no care plan developed for this behavior and there should be one. She said the nurses and CNAs that regularly work on the unit should know about this behavior, but a CNA that may help out on the unit or agency staff would not be aware of this behavior because it is not documented on a care plan or Kardex. During an interview on 9/10/24 at 11:50 A.M., CNA #1 said she has known Resident #43 since he/she was admitted to the facility and that is how she knows the Resident eats non-food items. She said the Resident will bite and try to eat anything that is within his/her reach. The CNA said the other day she had to get a paper napkin out of the Resident's mouth and he/she really needs to be watched closely. She said she does not know if an agency CNA or staff not familiar with the Resident would know about this behavior. On 9/11/24 at 8:45 A.M., the surveyor observed Resident #43 seated in a chair in the unit living room asleep. The Resident's hair was styled with two small braids secured on either side of his/her head with two small brown plastic hair clips and one large yellow clip secured the remainder of the hair on the back of his/her head. During an interview on 9/12/2024 at 1:50 P.M., Physician #1 said he was not aware Resident #43 ate non-food items. He said if he were aware, his expectation would be for staff to pay close attention and make sure there were no non-food items near the Resident that he/she would put in his/her mouth and eat.

Based on interviews and review of grievance documentation, the facility failed to formulate written grievances, follow up, and provide resolution for two Resident's Representatives who voiced grievances. Specifically, 1. Resident #48's Representative voiced concerns to the Administrator regarding resident safety due to low staffing on the Memory Care Unit and the frequent non-functioning of a doorbell outside the unit that alerts staff to unlock the door when someone wishes to gain access to the unit to see their loved one; and 2. Resident #45's Representative voiced concerns to the Administrator regarding resident safety due to low staffing on the Memory Care Unit. Findings include: Review of the facility's policies titled Grievances/Complaints, Filing and Grievances/Complaints, Recording and Investigating, last revised April 2017, indicated but was not limited to: -Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances may also be voiced or filed regarding care that has not been furnished. -All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s) -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer who is the Executive Director -The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received b. The name and room number of the resident filing the grievance/complaint c. The name and relationship of the person filing the grievance/complaint on behalf of the resident d. The date the alleged incident took place e. The name of the person(s) investigating the incident f. The date the resident, or interested party, was informed of the findings g. The disposition of the grievance (i.e. resolved, dispute, etc.) -Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint 1. During interviews on 9/10/24 at 11:50 A.M. and 9/12/24 at 9:55 A.M., Resident #48's Representative (Resident Representative #1) said his loved one has resided in the facility for almost two years and he visits him/her every day. The Representative said Resident #48 has had four falls while residing on the Memory Care Unit and said there is not enough staff on the unit. He said one nurse and one certified nursing assistant (CNA) are not enough considering the special needs of memory impaired residents here on the unit. He said the doorbell to use at the entrance of the secure unit is battery powered and the batteries die frequently. He said there have been several times when he/she has pressed the button and it didn't work and was waiting outside the door for a long time to get onto the unit to see his/her loved one. He said on a few occasions he was waiting so long, he had to call upstairs to the reception desk to have them call the unit to let them know he was at the door waiting to be let on the unit to see his loved one. Resident Representative #1 said he has spoken to the Administrator as well as the property management company several times about his concerns with staffing and the malfunctioning doorbell and nothing changes. He said the last time he/she spoke to the Administrator about his/her concerns was about a month ago, and he mentions it every time he runs into the Administrator in the facility. 2. During an interview on 9/12/24 at 11:23 A.M., Resident #45's Representative (Resident Representative #2) said her loved one has resided at the facility for a year and a half. She said Resident #45 has had a few falls and now has a bed and chair alarm. She said there are only two staff on the floor and that is not enough to meet the resident's needs. The Representative said several other residents on the unit have alarms too and they go off all the time. She said staff can't be everywhere at the same time to get to the residents. She said she has brought her concerns about low staffing to the Administrator several times and most recently about a month ago, and there has been no response to any of her concerns. She said low staff and safety of the residents on the unit is her greatest concern. Using the reasonable person perspective, a resident would want timely access to their loved ones visiting, enough staff to keep them safe and provide the supervision and care they need and be able to file a grievance with the expectation that the facility would make efforts to resolve the concern. Review of the facility's Grievance Book failed to indicate any documentation of Resident #48's and Resident #45's Representative's grievances related to concerns with low staffing and resident safety on the Memory Care unit and the frequent non-functioning of the unit's doorbell outside the unit that limits access to their loved one. During an interview on 9/12/24 at 7:15 A.M. and 3:45 P.M., the Administrator said she was the Grievance Official and grievances, concerns and comments are documented on a Problem Form which are available in several locations in the facility. The surveyor asked the Administrator if she tracks comments, concerns or complaints brought forward by resident representatives/families verbally and she said it should be written on a Problem Form, but she does not document anything brought forward verbally from Resident Representatives. She said she speaks to them and takes care of it. The surveyor shared Resident #48 and #45's Representative's report that concerns with staffing, safety and non-functioning doorbell were brought to her attention several times with no follow-up and resolution. She was unable to explain why the Family Members' concerns were not addressed and there was no follow-up.

Based on observations, interviews, and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility (1) Failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) for two quarantined Residents (#1 and #3); and (2) Failed to ensure residents maintained quarantine status, thereby increasing the potential for transmission of COVID-19 within the facility. Findings include: A review of the facility's policy titled Infection Control Policies and Procedures, dated 5/17/21, indicated in addition to standard precautions, contact and droplet precautions would be implemented for patients suspected or confirmed to have COVID-19 based on Centers for Disease and Control (CDC) guidance and follow local public health and state regulations when applicable. The policy indicated to cancel group outings, group activities, and communal dining for affected units. Review of the facility's quarantine droplet/contact precaution guidance indicated staff was to wear eye protection, N95 mask, gown, and gloves prior to entering the room of a resident on these precautions. The guidance sheet further indicated residents should remain in their room except for medical necessity or scheduled visitation. 1. During an interview on 9/8/21 at 8:25 A.M., the Infection Control Preventionist said Resident #1 was on quarantine related to being newly admitted to the facility and being unvaccinated from COVID-19. On 9/8/21 at 10:15 A.M., the surveyor observed the room of Resident #1 to have a quarantine contact/droplet precaution sign. The surveyor observed Certified Nursing Assistant (CNA) #1 approach the room of Resident #1, wearing eye goggles and a surgical mask. The surveyor observed CNA #1 don (put on) an isolation gown and a pair of gloves and enter the room of Resident #1. The surveyor did not observe CNA #1 change the surgical mask to an N95 mask. The surveyor observed the PPE bin to not have any N95 masks or surgical masks. On 9/8/21 at 9:15 A.M., the surveyor observed CNA #2 to be in the room of quarantined Resident #3 with a meal tray in her hand. CNA #2 was facing the Resident and was observed to say words to the effect of, I'm supposed to be wearing a gown. The surveyor observed CNA #2 exit the Resident's room with the meal tray and go to the unit dining area. 2. During the entrance conference on 9/8/21 at 8:25 A.M., the Infection Control Preventionist said all of the residents on the [NAME] unit were on quarantine status related to positive staff members. On 9/8/21 at 12:00 P.M., the surveyor observed a quarantine droplet/contact precaution sign on the door of Resident #5. The surveyor observed CNA #4 to be in the room of Resident #5 and place a blanket on the Resident. The CNA was not observed to be wearing a gown or gloves. CNA #3 and CNA #4 were observed to then wheel Resident #5 to the unit dining area, neither CNA was observed to be wearing a gown or gloves. On 9/8/21 at 12:03 P.M., the surveyor observed a quarantine droplet/contact precaution sign on the door of Resident #6. The surveyor observed Nurse #1 enter the room of Resident #6 without donning a gown or gloves. Nurse #1 was then observed to bring the Resident to the unit dining area. At this time, the surveyor observed six residents (who were all on quarantine contact/droplet precautions) to be seated in the unit dining area. Two residents were sitting at one table together, while three residents were sitting at another table. The residents were not observed to be socially distanced or observed to be maintaining quarantine status. On 9/8/21 at 12:10 P.M., the surveyor observed CNA #4 sitting at a dining table, directly next to Resident #5 and begin to feed the Resident. CNA #4 was not wearing a gown. On 9/8/21 at 12:12 P.M., the surveyor observed Activity Assistant #1 enter the unit community bathroom, off of the dining area, when a resident was calling out. The surveyor did not observe Activity Assistant #1 get a gown or gloves to go in to the bathroom with the resident. During an interview on 9/8/21 at 12:16 P.M., Activity Assistant #1 said she was in the bathroom with Resident #7, who was on quarantine. She said she did not physically assist the Resident, therefore did not think she needed to wear a gown or gloves while in the bathroom with this Resident. During an interview on 9/8/21 at 12:14 P.M., the Infection Control Preventionist said she did not know the unit was having residents who were on quarantine participate in dining on the unit. She said the three residents who were sitting at the table together were too close together, as well as the two other residents who were at the same table. She said the staff who were feeding the residents should be wearing a gown and gloves.

Based on observation and interview, the facility staff failed to ensure staff implemented infection prevention and control practices during a recent outbreak of COVID-19 (2 residents and 1 staff tested positive). Specifically, the staff failed to utilize the appropriate Personal Protective Equipment (PPE) including gowns, face masks, eye protection and gloves when providing care for residents to prevent the potential spread of infection until no new cases had been identified for at least 14 days. In addition, the facility staff failed to ensure standard infection prevention practices were followed during a wound treatment for one Resident (#11) in a total sample of 15 residents. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 spread in Nursing Homes, updated March 29, 2021, indicated: - When a single new positive case of Covid is detected in any healthcare personnel (HCP) or resident, that the facility implement facility wide testing and continue to follow recommended prevention practices for use of personnel protective equipment (PPE) including gowns, face masks, eye protection and gloves when providing care for residents to prevent the spread of infection until until no new cases have been identified for at least 14 days A review of the Quarantine Precaution sign posted in the facility indicated everyone must clean hands when entering and exiting, wear a gown, mask, eye protection and gloves. Put on eye protection ( i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. Protective eye wear ( e.g., safety glasses, trauma glasses) with gaps between the glasses and the face likely do not protect eyes from all splashes and sprays. - On 5/14/21 at 9:30 A.M., during observations on one ([NAME]) of five resident units, the surveyor observed staff transporting residents to and from their rooms. Residents resided in single rooms and as staff entered the resident room, the door was often closed for privacy. There were no precaution gowns near the entrance to the resident rooms or hanging near the doorway on this unit as observed on other resident units. The surveyor observed Certified Nurse Aide (CNA) # 7 transport a resident to his/her room after breakfast for care (direct contact) and while touching the resident, CNA #7 was not wearing a gown. During an interview on 5/14/21 at 12:35 P.M., Nurse # 3 was asked to explain what the facility practice was for direct resident care and personnel protective equipment. Nurse #3 said that they were not using/wearing gowns or gloves (in addition to face mask and eye protection) when providing direct high contact resident care. Nurse #3 said there were gowns kept in the drawer if needed and pointed toward a plastic storage unit in the corridor. She said staff did use them, but thought it had been 10 days to 14 days and the unit was clean, and had no (positive) cases. Nurse #3 said residents wear a mask when leaving the unit and staff wore goggles (eye protection) and facemask. Nurse #3 confirmed that on 5/14/21 the [NAME] unit staff did not use gowns for any high contact direct resident care. - On 5/18/21 at 8:50 A.M., the surveyor observed two residents seated in the hair salon outside the [NAME] Unit. Neither resident was observed to have their face masks donned properly, as the masks were not covering their noses. The Hairdresser was observed without goggles on as she was blow drying one of the resident's hair. The surveyor entered the hair salon and spoke briefly to the residents and the Hairdresser. At no time during the conversation did the Hairdresser don (put on) eye protection or ask the residents to fix their masks correctly to cover their noses. On 5/18/21 at 8:50 A.M., during observations on the [NAME] Unit, the surveyor observed the following: - Nurse # 2 had eye protection donned, however the eye protection was donned over her eye glasses and failed to provide proper eye protection as there were gaps between the glasses and her face. - Activities Assistant #1 had eye protection donned, however the eye protection was donned over his eye glasses and failed to provide proper eye protection as there were gaps between the glasses and his face. - CNA # 5 had eye protection donned, however the eye protection was sitting on the bridge of her nose and failed to provide proper eye protection as there were gaps between the glasses and her face. - Hospice Nurse #1 had eye protection donned, however the eye protection was sitting on the bridge of her nose and failed to provide proper eye protection as there were gaps between the glasses and her face. - On 5/18/21 at 1:15 P.M., during observations on the [NAME] Unit, the surveyor observed the following: - Nurse # 3 was seated at the nurses' station without her mask donned appropriately as the mask was pulled down on her chin. When Nurse # 3 observed the surveyor enter the area, she immediately pulled the mask up and covered her mouth and nose. - On 5/18/21 at 1:25 P.M., the surveyor observed the Hairdresser manipulating a resident's hair in the hair salon without the required eye protection in place. During an interview on 5/18/21 at 4:31 P.M., the Infection Preventionist Nurse (IPN) said that the Hairdresser was required to follow all guidelines for PPE use in a healthcare facility and the guidelines were not being followed by the Hairdresser. - On 5/18/21 at 3:30 P.M., during observations on the [NAME] Unit, the surveyor observed CNA #2 wearing only a facemask and personal eyeglasses (no goggles/shield). While CNA #2 was engaged in conversation with the residents seated in the common area, she was observed holding a resident's hand and then kissed the top of the resident's hand when the resident would not let go of CNA #2's hand. During an interview on 5/18/21 at 4:45 P.M., CNA #2 was asked what personnel protective equipment was required when on the resident unit and at that time, CNA #2 realized she was not wearing any eye protection. CNA #2 said she had goggles in her bag but got busy putting linen away and forgot to put them on. During an interview on 5/19/21 at 1:47 P.M., the Staff Development Coordinator (SDC) was made aware of the observations and concerns regarding how staff donned the eye protection and wore the eye protection on the bridge of their noses. Review of information provided to the surveyor indicated an in-service on the proper eye protection was completed with all staff in 1/2021. The SDC said staff should be donning the proper eye protection and wearing the eye protection properly and not on the bridge of their noses. During interview on 5/19/21 at 4:30 P.M., the Administrator and Director of Nurses were made aware of the breeches in infection control, specifically in regards to Nurse #3 not having her mask donned in the resident care area. 2. For Resident #11, the facility failed to follow their policy for Dry, Clean Dressing change as well as adhere to standards of practice for infection prevention including the use of Personal Protective Equipment (PPE) during the observation of a treatment for a wound of resident's right lower extremity (RLE). On 5/18/21 at 1:44 P.M., the surveyor observed Nurse #2 use contaminated gloves while applying the clean dressing on Resident #11's RLE. Further, Nurse #2 was observed to wear her contaminated gloves while searching through the drawers of the clean treatment cart for tape. Nurse # 2 removed her gloves at the doorway of the room once completing the dressing change and did not perform hand hygiene until she walked down the hall to a kitchen area to wash her hands bypassing the sink in the resident room and the alcohol based hand sanitizer dispenser outside of the resident's room. During an interview on 05/18/21 at 2:01 P.M., Nurse #2 said she should have changed her gloves and performed hand hygiene after removing the dirty dressing from the resident's RLE, prior to applying the new clean dressing but she was nervous. During an interview on 5/18/21 at 3:55 P.M., the DON was made aware of the surveyor's observations of the wound treatment which included missed hand hygiene opportunities and failure to change gloves throughout the treatment. The DON said Nurse #2 did not maintain good infection control practice or meet the expectations for the dressing change policy.

Based on interview, record review and observation, the facility failed to ensure that pain was appropriately assessed and treated during a wound treatment dressing change to the right lower extremity (RLE) for one Resident (#11) in a total sample of 15 residents. Findings include: Review of the Facility policy titled: Administering Pain Medications, dated 3/2020, indicated the following: Pain management program is based on a commitment to appropriately assess and treat pain based on professional standards of practice. The policy defined pain management as the process of alleviating the resident's pain based on his/her clinical condition and established treatment goals. Resident # 11 was admitted to the facility in April 2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record indicated Resident #11 had a wound to the RLE with a recent biopsy (removal of a piece of tissue for further examination) on 5/14/21. The Resident was being followed by the facility wound specialist and had orders for daily dressing change to be performed by Licensed Nurses. On 5/18/21 at 1:44 P.M., during an observation of wound care, Nurse #2 was cleansing the RLE wound when Resident #11 yelled out: that hurts. Nurse # 2 continued the dressing change when Resident #11 yelled : I'm in pain, in pain, a lot of pain. Nurse # 2 attempted to obtain a verbal pain rating from Resident #11 and distract him/her with conversation without success. Nurse # 2 proceeded with the dressing change and told Resident #11 she was almost done. The surveyor observed Resident #11 grimacing and clenching his/her teeth for the remainder of the dressing change procedure. When Nurse #2 completed the dressing change, she again attempted to obtain a verbal pain rating from the resident. Resident #11 said just get out. Nurse #2 told the Resident she would check to see if she could give the resident Tylenol to help with pain. During an interview on 5/18/21 at 2:01 P.M., immediately following the dressing change to Resident #11's RLE wound, Nurse # 2 said she would normally stop the treatment if a resident was in pain, but she did not want to leave this area open without a dressing in place. Review of Resident #11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) Review of the medical record indicated in the note section of the administered dose of Acetaminophen at 2:32 P.M., the reason indicated was: yelled I'm in pain. A follow up note was written at 16:03 (4:03 P.M.) which indicated the resident's follow up pain level was zero and he/she was resting in bed with their eyes closed. During an interview on 5/18/21 at 3:55 P.M., the Director of Nurses (DON) was made aware of the surveyor's observations during the dressing change for Resident #11. The DON said the nurse did not meet expectations to manage the residents pain and the expectation was that Resident #11's pain would be addressed prior to the nurse completing the dressing change. She said the nurse did not follow the policy for managing the Resident #11's pain.

Based on staff interview and record review, the facility staff failed to ensure staff provided care and services according to accepted standards of clinical practice for one Resident (#260) in a total sample of 15 residents. Findings Include: 1. For Resident #260, the facility staff failed to update the physician once the resident had completed a 14 day cycle of [MEDICATION(S)] (steroid) as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #260 was admitted to the facility in March 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #260's medical record indicated on 4/14/21, a physician's interim/telephone order had been obtained for the following: *Start [MEDICATION(S)] 10 milligrams (mg) by mouth every morning; *Start [MEDICATION(S)] 2.5 mg by mouth every evening with dinner until 4/25; *Then review [MEDICATION(S)] orders with M.D., only On 4/25/21, the physician's interim/telephone order indicated: *Continue [MEDICATION(S)] 2.5 mg by mouth every evening for two weeks; *Continue [MEDICATION(S)] 10 mg by mouth every evening for two weeks; *Re-evaluate with the M.D. in two weeks The date for the re-evaluation by physician was 5/9/21. Further review of the medical record and review of the May 2021 Medication Record Administration (MAR) indicated the [MEDICATION(S)] had not continued after 5/9/21 and there were no further physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in Resident #260's medical record to indicate the physician had been contacted as ordered. During an interview on 5/18/21 at 3:28 P.M., the Director of Nursing said the physician had not been called on 5/9/21 with regard to the status of the [MEDICATION(S)]. The physician resumed the doses of [MEDICATION(S)] on 5/18/21 and the Director of Nursing said that it was missed and the physician had never been called on 5/9/21.

Based on observations, staff interviews, and review of the facility's infection control policies, the facility failed to ensure staff implemented proper infection prevention and control measures to prevent the potential transmission of communicable diseases including COVID-19. Specifically, the facility failed to ensure that all staff and outside Health Care Providers (laboratory services) implemented proper use of personal protective equipment in preventing the spread of the COVID-19 infection. Findings include: Review of the facility's policy titled Emergency Plan for Residents with Suspected COVID-19, dated 3/24/20, indicated the facility abides by the most recent guidance set by local and national standards that includes the Department of Public Health (DPH), Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) to combat the spread and transmission of [MEDICAL CONDITION] COVID-19. 1. On 1/6/21 at 9:10 A.M., the surveyor entered the facility through the visitor entry. The surveyor was provided access by a staff member, who identified themselves as the Receptionist The surveyor observed that the Receptionist was not wearing any face shield or eye goggles at the time of entry. The Receptionist began the screening process of the surveyor. The surveyor observed the Receptionist put on her eye protection halfway through the process. During interview on 1/6/21 at 9:30 A.M., the Director of Nurses (DON) and the Administrator said the facility's infection control prevention and practices are to abide by the current standards and transmission-based precautions identified under the DPH, CMS and CDC guidance. Their practice for prevention included all staff to wear face shields and/or eye goggles and a facemask at all times and to wear full Personal Protective Equipment (mask, eye protection, gown and gloves) when providing care. 2. The surveyor observed a laboratory technician (Tech) on 1/6/21 at 2:00 P.M. on Unit G., enter the room of a resident identified as COVID Negative (refers to a resident who has never tested positive for COVID-19). The facility's policy indicated they followed guidance for standard precautions and transmission based precautions. The surveyor observed the Tech outside the resident's room. She had a phlebotomy cart and was observed removing Personal Protective Equipment and other equipment from the cart. The Tech was wearing a facemask and face shield. The surveyor observed the Tech, after removing equipment from the cart to draw labs, documenting on her papers and removing labels from the paperwork, she then donned a pair of gloves. She was not observed performing hand hygiene or donning her gown prior to putting on the gloves. The Tech then put on a gown and entered the resident's room. She was observed exiting the room a few minutes later and had not removed her gown or gloves, which were considered contaminated. CDC guidance, How To Put On (DON) PPE Gear, updated 6/9/20, indicated the protocol is to perform hand hygiene, don gown (fully covering torso from neck to knees, arms to end of wrists, tie/fasten in back, neck and waist), facemask, and gloves (extend to cover wrist of gown). CDC guidance, How To Take Off (Doff) PPE Gear, updated 6/9/20, indicated to remove gown and gloves, exit the room and perform hand hygiene. The Tech was observed loosening her gown in the hallway, from her shoulders down to her waist. The gown remained hanging off her waist and she continued to wear the contaminated gloves. The surveyor observed the Tech open her phlebotomy cart and placing items in and moved items around inside the cart, still wearing the contaminated gloves. The Tech was documenting on her papers with the Personal Protective Equipment on and when done, she placed the papers in her cart and doffed her gown and gloves. The Tech re-entered the resident's room to deposit the soiled Personal Protective Equipment she had been wearing while providing care and placed them into the resident's trash container. The Tech exited the room and opened up her phlebotomy cart and moved items around the cart, removed some papers, and then walked across the hallway to the kitchen to perform hand hygiene. 3. On 1/6/21 at 2:20 P.M., the surveyor observed the Tech at a second resident's room on Unit G. The resident was identified as COVID-19 negative. The resident's room was identified as requiring all staff wear full Personal Protective Equipment for care. The surveyor observed the Tech open and close her phlebotomy cart and was removing equipment, paperwork and documenting. The surveyor observed the Tech donning a pair of gloves, but not performing hand hygiene or donning a gown as required. The Tech was observed opening the cart several times, thus contaminating her gloves. The Tech was observed removing labels from the papers and sticking the labels on the back of her gloves. Prior to entering the resident's room, the technician made multiple adjustments to her Personal Protective Equipment, including her facemask and face shield, and was in and out of cart before she donned her gown and did not perform hand hygiene, thus further contaminating her gloves and her gown. The surveyor observed the Tech exit the resident's room wearing all of the Personal Protective Equipment. She had not removed and disposed of the soiled Personal Protective Equipment prior to exiting the room as is the standard infection protocol to prevent the spread / transmission of COVID-19. The Tech was observed in her Personal Protective Equipment in the hallway and was opening and depositing items into the cart. She completed documentation and then removed her soiled Personal Protective Equipment and re-entered the resident's room to deposit the soiled items into the resident's trash container. 4. On 1/6/21 at 3:00 P.M., the surveyor observed the Tech enter and exit the room of a resident who was identified as COVID-19 positive. The surveyor observed the Tech wearing a facemask, face shield, and a pair of gloves. The Tech was opening her phlebotomy cart and was observed removing equipment and paperwork from the cart, thus contaminating her gloves. The surveyor observed the Tech don a gown with the contaminated gloves on and then entered the resident's room. The surveyor observed the Tech exit the room wearing the soiled Personal Protective Equipment that she had worn when she entered the room. She was observed depositing items into the phlebotomy cart and documenting on papers. The Tech removed the Personal Protective Equipment and re-entered the resident's room to put the soiled items into the trash. During interview on 1/6/21 at 3:15 P.M. the Tech said she had not removed the Personal Protective Equipment before leaving any rooms. She said she could not bring her phlebotomy cart into rooms and that she left the room in the Personal Protective Equipment so that she could deposit the sharps into the sharps container on her phlebotomy cart. The Tech said she followed her company's guidance for infection control practice and said she had not received training, education or guidance from the facility. 5. On 1/6/21 at 3:15 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 in the hallway of the COVID-19 unit. The CNA was with three other staff members in the hallway and was not wearing eye goggles or an eye shield. During interview CNA #1 said her eye protection was in her pocketbook. During interview on 1/6/21 at 5:00 P.M. the DON said staff are to wear eye protection at all times. During discussion of the laboratory technician's use of Personal Protective Equipment, the DON and the Administrator said that the facility provides the Personal Protective Equipment to the Health Care Providers. The Director said she does not provide education per se, but that the facility follows the standards set by the CDC and CMS. She said that she will follow up with the laboratory company.

Based on record review and staff interviews, the facility failed, during the Covid-19 pandemic, to ensure that staff followed the CMS (Centers for Medicare & Medicaid Services) published interim final rule, dated August 26, 2020, for Long-Term Care (LTC) Facility Testing Requirements for Staff and Residents. For two of four sampled Residents #2, and #3, there was no documentation in the medical record to reflect when the Covid-19 tests were offered, when the tests were administered and the results of the Covid-19 tests. Findings include: During the Covid-19 Focused survey completed on October 29, 2020, the facility identified having six residents identified as PUI (Person Under Investigation)/Quarantine. The facility also identified two healthcare personnel as Covid-19 positive and not working in the facility. The facility did not provide any documentation of when residents had the tests done and the results of the Covid-19 testing were not documented in the residents' medical records as required. The facility staff did not follow the August 26, 2020 CMS (Centers for Medicare & Medicaid Services) published interim final rule for Long-Term Care (LTC) Facility Testing Requirements for Staff and Residents. The memorandum indicated to document in the residents record of the test being offered and the test results be in the medical record of each test. During an interview on 10/29/20 at 8:30 A.M., the Director of Nurses was asked about procedures/policy to address resident and staff who refuse testing or are unable to be tested . The Director said, We know we have to have one but don't have one. The Director said two staff tested positive for Covid-19 and the facility staff had started testing of all staff and residents. The last positive staff person was identified 10/21/20 and the Director said we started swabbing for Covid-19 right after. A review of the following residents' medical record had no laboratory results in the electronic or paper medical records, and no documentation of offering and/or providing the residents the Covid-19 test results. Resident #2 was admitted [DATE] for rehabilitative services following a hospitalization for a laminectomy. A review of the Resident's medical record indicated there was no documentation in the medical record of offering the test and results from the test were not in his/her medical record. The Director of Nurses said all the residents had been tested after 10/17/20. Resident #3 was a long term care resident readmitted to facility, September 2020, following a hospitalization . A review of the Resident's medical record indicated that there was no documentation in the medical record of offering the test and results from the test were not in his/her medical record. The Director of Nurses said all the residents had been tested after 10/17/20. During interview on 10/29/30 at 11:30 A.M., the Director of Nurses said she wasn't aware of the CMS memorandum dated 8/26/20, and the survey team reviewed the memorandum with her. She later returned and said I do have it and said she was just sent the data from an outside vendor.