Every finding on record at Lakeview Health Center

Based on record review, interviews, and facility policy review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of six sample residents (R1) reviewed for abuse. a Certified Nursing Assistant (CNA) was aware of an incident involving R1 and another CNA that was not reported within the required timeframes. Findings include: Review of the facility's undated policy titled, Resident Protection: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property; Injuries of Unknown Source revealed Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the administrator (or designee), and that Staff must always report any 'abuse' or suspicion of 'Abuse' immediately to their supervisor or the administrator. Failure to report is considered to be resident abuse. The policy required that abuse allegations be reported immediately, but not later than 2 hours after the allegation is made when the events involve abuse or serious bodily injury. Review of R1's face sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and alcohol related dementia. Review of R1's care plan located under the Care Plan tab of the EMR revealed an area of concern, implemented on 08/08/24, that indicated R1 may make threats, may strike out at you, push or grab, requiring staff to use a calm approach to complete care. Review of a facility reported incident (FRI), dated 11/04/25, revealed that on the evening of 11/03/25, Certified Nursing Assistants (CNAs) 1 and CNA2 were assisting R1 with a bath. CNA1 reported that during the bath, R1 was combative and resistive to care and CNA2 stated, [R1] if you don't stop, I am going to give you a cold shot. Per the report, CNA1 added that CNA2 then took the shower head and sprayed the resident on his legs. During an interview on 05/19/26 at 1:58 PM, CNA1 confirmed that on 11/04/25 she notified the Director of Nursing (DON) that she believed CNA2 behaved inappropriately in both speech and actions during resident care. CNA1 stated that on 11/03/25 at approximately 6:30 PM, she was assisting CNA2 with bathing R1 using a tub and motorized shower chair. She reported that during the bath, R1 became agitated, physically aggressive, and may have spit at CNA2. CNA1 stated she heard CNA2 say to R1, [R1] if you don't stop, I am going to give you a cold shot, or if you don't calm down, I will give you a cold shot. CNA1 stated the comment took her by surprise, and she intervened to step in and take control of the situation. She indicated that R1 did not appear injured or in distress and was calmer when care was completed by her alone. CNA1 reported that she had not previously observed CNA2 act abusively toward other residents but described CNA2 as sometimes being short and using a raised tone of voice. CNA1 acknowledged that she was aware of the facility's abuse and reporting policy, and that concerns should be reported immediately to the nurse supervisor. When asked why she did not tell anyone about the incident immediately, CNA1 stated that in her experience at other facilities, reports didn't always make it to administration, and she wanted to report it directly to the DON. She reported that she notified the DON the following day, 11/04/25, rather than at the time of the incident. During an interview on 05/18/26 at 1:15 PM, the DON confirmed CNA2 was hired under a CNA training program being offered at the facility and described CNA2 as soft spoken and friendly with no prior concerns reported and added that the CNA2 has completed the Abuse training as part of her orientation on 10/29/26. In a subsequent interview on 05/20/26 at 2:30 PM, the DON confirmed CNA1 reported the incident to her on 11/04/25. When asked why the incident was not reported immediately, the DON stated CNA1 said the situation made her uncomfortable, but she was unsure whether it should be reported. The incident between R1 and CNA2 was not reported timely to facility management/administration.

Based on record review, interviews, personnel file review, and facility policy review, the facility failed to ensure residents were free from verbal and physical abuse from staff for two of six sampled Residents (R1 and R4). Facility staff used inappropriate and unprofessional language toward residents and handled residents during care in a manner described as rough and not aligned with individualized care approaches for residents with known behavioral symptoms. Findings include: Review of the facility's undated policy titled, Resident Protection: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property; Injuries of Unknown Source, revealed Its purpose is that each resident/client will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion.residents will be protected from abuse, neglect, and harm while they are resident at the facility. No abuse or harm of any type will be tolerated, and resident and staff will be monitored for protection. Violations involving mistreatment, resident abuse, neglect or misappropriation of resident property will not be tolerated by this facility. All efforts will be aided to prevent these acts by employees, volunteers, contractors, and residents and to take significant and effective action should they occur. Example 1 Review of R1's face sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and alcohol related dementia. Review of R1's quarterly Minimum Data Set (MDS) at the time of the incident, found under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/22/25, revealed the resident exhibited physical behavioral symptoms, and was highly dependent on staff for activities of daily living (ADLs), requiring extensive nursing care and supervision. Review of R1's care plan located under the Care Plan tab of the EMR revealed an area of concern, implemented on 08/08/24, that indicated R1 may make threats, may strike out at you, push or grab requiring staff to use a calm approach to complete care. Review of a facility reported incident (FRI), provided by the facility, and dated 11/04/25, revealed that on the evening of 11/03/25, Certified Nursing Assistants (CNAs) 1 and CNA2 were assisting R1 with a bath. CNA1 reported that during the bath, the resident was combative and resistive to care and CNA2 stated, [R1] if you don't stop, I am going to give you a cold shot. Per the report, CNA1 added that CNA2 then took the shower head and sprayed the resident on his legs. During an interview on 05/19/26 at 1:58 PM, CNA1 confirmed she had been employed at the facility since September 2025 and obtained her certification through the facility's training program. CNA1 reported that on 11/04/25 she notified the Director of Nursing (DON) that she believed CNA2 behaved inappropriately in both speech and actions during resident care. CNA1 stated that on 11/03/25 at approximately 6:30 PM, she was assisting CNA2 with bathing R1 using a tub and motorized shower chair. She reported that during the bath, R1 became agitated, physically aggressive, and may have spit at CNA2. CNA1 stated she heard CNA2 say to the resident, [R1] if you don't stop, I am going to give you a cold shot, or if you don't calm down, I will give you a cold shot. CNA1 stated the comment took her by surprise, and she intervened to take control of the situation. She indicated that the resident did not appear injured or in distress and was calmer when care was completed by her alone. CNA1 reported she had not previously observed CNA2 act abusively toward other residents but described CNA2 as sometimes being short and using a raised tone of voice. CNA1 acknowledged awareness of the facility's abuse policy. Review of CNA1's facility provided personnel file confirmed completion of abuse training on 10/28/25 and dementia training on 10/29/25. During an interview on 05/20/26 at 8:19 AM, CNA2 confirmed that the incident occurred on a scheduled shower day and described the R1 as always very combative. She reported that she and another staff member were attempting to transfer the resident into the shower chair, which required time to properly secure and position the resident. She added that once the resident was in position, she turned the water on to warm up. CNA2 stated that during the process, R1 was physically aggressive, grabbing her hair and her arm. She indicated that once the resident was positioned, she initiated the bath and reached behind her to obtain the handheld shower head. She reported that the water had been running for approximately 90 seconds and described the temperature as what she considered normal, although she acknowledged that she did not check the water temperature prior to use. CNA2 stated she held the shower head in her right hand over the resident's left shoulder and intended to begin spraying at the resident's feet and gradually move upward. She indicated that when the water contacted the resident's legs, he released her arm, allowing her to proceed. She reported that the bath was completed, with her assigned partner assisting by positioning the resident's feet in the tub. CNA2 stated that following the shower, the resident was dressed and returned to his room. She reported that at the end of the shift, her coworker commented that she had water boarded the resident. CNA2 acknowledged that it was possible water may have contacted the resident's face when she passed the shower head over his shoulder. CNA2 reported that she was contacted by facility administration the following day and participated in an interview, during which she stated she was not attempting to harm the resident. She indicated that upon returning for her next scheduled shift, she was terminated on 11/05/25. CNA2 further reported that law enforcement was not involved but that DON advised her that her actions could be seen as abuse. She stated she no longer held a CNA certification and received notification that she was placed on a barred list. A review of CNA2's facility provided personnel file revealed she had completed orientation Abuse/Neglect/Exploitation training on 10/28/25, and Hand in Hand dementia training on 10/29/25. During an interview on 05/28/26 at 1:15 PM, the DON confirmed that CNA2 was hired under a CNA training program that was being offered at the facility at the time. She added that there were no concerns prior to this that would indicate a concern. The DON also confirmed that the facility conducted interviews of all residents or their representatives who had received care from CNA2 and received no complaints. The DON also provided documentation of an Abuse and Reporting Reminder course that was assigned facility wide 100% completion by 11/25/25. During an interview on 05/18/26 at 3:19 PM, Nurse Manager (NM) 1, reported that he was notified by the DON that an assessment needed to be completed for R1 as an allegation of abuse had been reported. He reported that he found no skin injury or change in the resident from his baseline emotional state and described R1's baseline as tense and aggressive during care, with hitting and elbowing. Review of the Skin Assessments notes from 11/04/25 through 11/07/25 and located under the Nursing Notes tab of the EMR revealed no concerns. Example 2 Review of the admission MDS under the MDS tab of the EMR with ARD of 02/12/26, revealed a Brief Interview for Mental Status (BIMS) of 00 out of 15 which indicated R4 was severely cognitively impaired. Review of R4's Care Plan located under the Care Plan tab of the EMR, revealed the resident had an alteration in thought process and compromised decision making and indicated that R4 can become verbally agitated and physically aggressive when uncertain. Staff are not to argue or engage in power struggles. Use simple and direct language. Do NOT reorient as this increase agitation. Review of a FRI investigation, provided by the facility and dated 03/07/26, revealed that CNA3 was alleged to have been rough and verbally aggressive during care. The investigation indicated that the Administrator was advised by the night supervisor, Registered Nurse (RN) 2. RN2 advised the Administrator that CNA4 and CNA5 alleged that the staff member cursed at R4 and physically prevented her from getting out of bed. During an interview on 05/20/26 at 10:21 AM, CNA5 confirmed that she was preparing to leave at the end of her shift, with CNA3 scheduled to take over the assignment. CNA5 stated that she and CNA4 had been unable to complete their assignment prior to shift change, which appeared to upset CNA3. CNA5 reported that CNA3 began cursing, stating, I am not dealing with this shit tonight, and then entered R4's room and said to the resident, I am not dealing with your shit tonight. CNA5 reported that R4 was frequently confused and often resisted being put to bed, and that on this occasion, R4 was attempting to get out of bed by placing her feet on the floor. CNA5 stated that CNA3 responded by grabbing the resident by the ankles and throwing her legs back onto the bed multiple times. CNA5 indicated that she believed the force used had the potential to cause injury to R4. CNA5 stated that she and CNA4 suggested getting R4 up using a mechanical lift, and CNA4 went to retrieve the Hoyer lift. While preparing the resident, CNA5 reported that CNA3 roughly rolled the resident onto her side to place the sling underneath her. CNA5 further reported that while the resident was being lifted, CNA3 swatted the resident's hand as the resident reached for the lift straps. CNA5 clarified that the action was between a push and a slap. CNA5 stated that she reported the incident to the manager on duty (RN2), who subsequently removed CNA3 from the floor. (CNA4 and CNA3 were unable to be interviewed) During an interview on 05/20/26 at 9:30 AM, RN2 reported that the allegation was brought to her attention at approximately 10:30 PM on the evening of 03/07/26, which was her first night supervising. RN2 stated she immediately consulted with NM1 and removed CNA3 from the floor. RN2 reported that staff alleged CNA3 was cursing in the presence of R4 and handling the resident in a rough manner, including throwing the resident's legs back onto the bed, rolling the resident roughly, and swatting at the resident's hand during care. RN2 stated she conducted an immediate assessment of R4 and identified no observable signs of injury or indications of pain. She described the resident as having a flat effect and not displaying behaviors indicative of distress. RN2 reported that during the initial interview, CNA3 denied wrongdoing but admitted to using profanity, stating it was not directed at R4. CNA3 also acknowledged repositioning the resident's legs back onto the bed but denied doing so in a rough manner. RN2 stated she had not received any prior complaints regarding CNA3 and noted this was CNA3's first time working with R4. During an interview on 05/19/26 at 9:12 AM, the Social Worker (SW)/Grievance Official reported that the allegation was reported to the DON, who completed an evaluation of the resident with no concerns identified. He confirmed that he assumed responsibility for the investigation, including conducting staff interviews and record reviews. He added that he was not aware of any prior grievances or care-related concerns involving the staff member, and there were no identified concerns related to other residents prior to this incident. During an interview on 05/18/26 at 1:15 PM, the DON reported that CNA3 had no prior complaints or concerns reported by residents or coworkers. When asked about the employee's separation from the facility, the DON stated it was not directly related to care concerns but indicated that CNA3 had a history of frequent callouts and may have been experiencing caregiver burnout. The DON further stated that local law enforcement had been involved but were unable to substantiate a violation, as accounts of the incident were conflicting among staff. Review of CNA3's facility provided personnel file revealed she had completed Abuse/ Neglect/ Exploitation training on 01/01/26, as well as care giver burnout training on 11/21/25.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (R38 and R3) reviewed for proper hand hygiene during cares and for 1 of 5 residents (R38) observed for washing down the lift after use. Certified Nursing Assistant (CNA) did not perform hand hygiene with cares for R38 and R3. CNA did not wash the lift after use with R38. Findings: Facility policy titled, INFECTION CONTROL STANDARD (IC) reviewed 5/13/25, stated in part: …DISINFECTING SURFACES AND NON-DISPOSABLE MULTI-USE RESIDENT EQUIPMENT staff will use green top Clorox Peroxide wipes .BOWEL AND BLADDER CARE GUIDELINES . *Prior to beginning resident bowel, bladder or peri-care, perform hand hygiene *Don Gloves . *Remove gloves and perform hand hygiene . Example 1 R38 was admitted to the facility on [DATE], with a brief interview of mental status (BIMS) score of 00/15, which indicated R38 had severely impaired cognition. R38's minimum data set (MDS), dated [DATE], revealed R38 was dependent on staff for toileting, upper and lower body dressing, personal hygiene, rolling left and right in bed and toilet transfer. On 07/15/25 at 11:51 AM, Surveyor observed CNA G and CNA H perform toileting cares for R38. The staff performed hand hygiene and glove use upon entering R38's room and assisted R38 into the bed with the Hoyer lift. CNA G removed the attends from R38's right side and tucked it under R38. CNA G removed the soiled glove from CNA G's right hand and put on a new glove without performing any hand hygiene. R38 was rolled onto her right side. CNA H removed the soiled attends. CNA H removed the soiled gloves, put clean gloves on and did not perform any hand hygiene between glove changes. The remaining observation of this care was performed without any breaks in infection control practice. When leaving the room CNA H took the garbage in the right hand, pushed the dirty lift down to the soiled holding room and pushed the dirty lift into the alcove where the lifts are kept. CNA H took the garbage into the soiled holding room. Surveyor watched CNA G take the dirty Hoyer lift down the hall and into another resident's room. Surveyor stopped CNA G and asked, How often are these lifts cleaned? CNA G replied, We clean them after every use. Surveyor explained this lift was not cleaned since it was used for R38. CNA G replied, Oh, well then I will clean it quick. On 07/15/2025 at 1:47 PM, Surveyor explained the observation made with R38's peri-care to both CNA G and CNA H. Surveyor asked, I noticed that when you provided peri care and changed [R38's] attends you changed your gloves without any hand hygiene. Is this normal? CNA G replied, No, 90% of the time we perform hand hygiene. I just felt like we could not take the time to do it and sometimes it takes a while for the hand sanitizer to dry so you can put a clean pair of gloves on. On 07/15/2025 at 2:14 AM, Surveyor interviewed Director of Nursing (DON) B with observation of hand hygiene and the interview with CNA G who indicated CNA G performs hand hygiene 90% of the time. DON B replied, That is not acceptable. I cannot believe that she even told you that. On 07/16/2025 at 6:25 AM, Surveyor interviewed DON B about observation of lift not being cleaned between residents. DON B replied, It is expected that the lifts get cleaned after each use. Surveyor asked for a policy for hand hygiene and cleaning lifts. Example 2 On 07/16/25 at 7:20 AM, Surveyor observed Certified Nurse Assistant (CNA) E and CNA C enter R3's room. CNA E entered without sanitizing hands before donning gloves. CNA C donned Personal Protective Equipment (PPE) and started draining R3's catheter. CNA E started peri cares on R3. Surveyor observed CNA E leaning over the bed with CNA E's scrubs touching the side of R3's bed. CNA E took wipes and cleaned the shaft and corona of R3's penis. CNA E told R3 to help roll towards CNA E. Surveyor observed CNA E's scrubs touching R3's contaminated bedding. CNA E cleaned bowel movement off R3's buttocks. CNA E rolled R3 back towards the wall and cleaned R3's buttocks further. CNA E rolled R3 back unto back and began pulling R3's pants up with contaminated gloves. CNA E continued repositioning R3 to the edge of bed. CNA E grabbed R3's back of neck and swung legs over to the side with contaminated gloves. CNA C doffed PPE and sanitized hands. CNA C applied gloves and started to re-position R3 to edge of bed by grabbing upper body behind neck and shoulders. Surveyor did not observe CNA C and CNA E have full PPE on while providing cares to R3. Surveyor observed while CNA C was repositioning R3 to edge of bed further, CNA E was placing sling behind R3 with contaminated gloves and touching handles and sling to the Portable Aquatic Lift (PAL) lift, while connecting R3 to the PAL lift. CNA E doffed contaminated gloves, sanitized hands then applied new gloves as CNA C was finishing connecting CNA C's side of sling to PAL lift. CNA E and CNA C continued assisting R3 with positioning to wheelchair. Surveyor observed CNA E place contaminated sling that was used for R3 and laid on PAL machine. Surveyor observed CNA E exit R3's room pushing R3 in wheelchair and PAL lift down the hallway. Surveyor did not observe CNA E wipe down the PAL lift. On 07/16/25 at 7:33 AM, Surveyor observed CNA E take PAL lift with contaminated sling into R7's room to provide cares and transfer from bed to wheelchair. On 07/16/25 at 9:04 AM, Surveyor interviewed CNA E and CNA C and asked the process for utilizing PPE during cares with R3 who is on Enhanced Barrier Precautions (EBP). CNA E and CNA C reported to Surveyor that CNA E and CNA C should have used PPE when providing direct cares during peri cares and repositioning in bed to get up for the morning. Surveyor asked CNA E if CNA E wiped down the PAL lift before going into R7's room and using the PAL lift on R7. CNA E reported that CNA E did not wipe down the lift and should have especially coming out of an EBP room. On 07/16/25 at 12:48 PM, Surveyor interviewed DON B and asked DON B's expectation for PPE usage in an EBP room. DON B reported expectation would be that all staff wear PPE during cares within R3's room. Surveyor told DON B that CNA E's scrubs were touching the contaminated bedding in R3's room. DON B reported to Surveyor that CNA E and CNA C should have been using full PPE when in an EBP room. Surveyor asked DON B's expectation of hand hygiene during glove changes and expectation in between peri cares. DON B reported that CNA E should have sanitized hands before and after applying gloves. DON B reported to Surveyor that CNA E should have removed contaminated gloves after providing peri care before pulling pants up and repositioning to edge of bed and transferring to wheelchair.

Based on observation, interview and record review, the facility did not ensure residents receive and consume foods in the appropriate therapeutic diet form for 1 of 1 resident sampled for altered diets (R26). On 07/17/25, R26 was served unknown consistency of orange juice, when R26 is to receive only nectar thick liquids with diet. This is evidenced by:R26 was admitted to the facility on [DATE], with diagnoses in part, non-Alzheimer's dementia, Parkinson's disease, and end stage renal failure. Minimum Data Set (MDS) indicates R26 scored 0 on the Brief Interview for Mental Status (BIMS), not able to answer questions.R26's physician orders state in part, R26 is on nectar thick consistency diet due to possible swallowing issues.On 07/15/25 at 12:05 PM, Surveyor observed Certified Nurse Assistant (CNA) F prep thickened liquids for R26. CNA F emptied 2 packets of thickener into a 120cc cup of orange juice and started mixing the liquid. After mixing for about 30 seconds, CNA F asked CNA D if the orange juice was thick enough. CNA D looked at CNA F and then the orange juice and stated, Uh yeah I think so, looks about right I guess. CNA F stated, Yeah, it kind of looks like this premade thickened cranberry juice.On 07/15/25 at 12:06 PM, CNA F served R26 the prepped orange juice.On 07/15/2025 at 12:25 PM, Surveyor interviewed CNA F and asked CNA F how CNA F knows what consistency the thickener should be and what is CNA F's process for mixing thickeners. CNA F reported to Surveyor that CNA F tries to mimic the already processed thickener container of cranberry juice and estimates how thick it is for the orange juice. Surveyor asked CNA F if there was a list or instructions on how to prepare the thickener for R26. CNA F reported to Surveyor that CNA F just mimics other thickeners. CNA F reported to Surveyor that CNA F looked on the coffee thickener packet and mimicked those instructions even though it wasn't the same for orange juice.On 07/15/2025 at 1:01 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B for thickened liquids policy. DON B reported to Surveyor the facility did not have a thickener for liquids policy but would be making one as soon as possible. Surveyor asked DON B what DON B's expectation was for CNAs to mix thickener into orange juice. DON B reported to Surveyor that CNAs should follow the list of residents' diets and consistency of liquids and follow the instructions of the packet of thickener it specifies. DON B reported to Surveyor that DON B will start education now. On 07/15/2025 at 1:25 PM, DON B approached Surveyor and reported to Surveyor that DON B had conversation with CNA F. CNA F had reported to DON B that CNA F was just trying to follow the coffee packet thickener to prep R26's orange juice instead of the nectar thick packet instructions that CNA F used in the orange juice.Surveyor reviewed a thickener packet given from CNA F to Surveyor, which states in part, Hormel Thick and Easy instant food and beverage thickener nectar consistency. Instructions state in part, Directions: Add contents to empty, dry glass. Add 4fl.oz of desired liquid quickly while stirring briskly with fork until dissolved. Allow 5-10 minutes for product to reach desired thickness.

Based on observation, record review and interview, the facility did not ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Medical equipment was not sanitized for 4 of 4 residents (R26, R22, R2, and R28) observed for reusable mechanical lifts. Inappropriate glove use was observed during medication pass with 2 of 4 residents (R45 and R8) observed. There was no sanitization of a common area table after used lancet and glucometer were placed on the table with 1 of 2 residents (R20) observed during blood glucose checks. Findings: Example 1 Facility policy titled, MECHANICAL LIFT SANITIZING AND ROUTINE CLEANING, last reviewed 3/08/23, states in part: .All lift surfaces that make contact with staff hand/gloves or resident must be sanitized with hydrogen peroxide wipes between each resident. R26 was admitted on [DATE] with both short- and long-term memory problem. R26's diagnosis included ulcerative colitis (an inflammatory bowel disease (IBD) that causes inflammation and ulcers (sores) in your digestive tract). R26's Minimum Data Set (MDS) dated [DATE] indicated this resident was always incontinent of both bowel and bladder. On 05/14/24 at 9:50 AM, Surveyor observed Certified Nursing Assistant (CNA) D take mechanical lift (hoyer) out of R26's room and did not wipe down or wash the lift and took it to store it in another room. Surveyor asked CNA D, When do you typically wash the lifts? CNA D replied, We wash them at nighttime. Surveyor clarified, So you don't clean them in between residents, but just at nighttime? CNA D replied, Yes, that is correct, at night. On 05/14/24 at 9:55 AM, Surveyor interviewed Registered Nurse (RN) C. Surveyor asked, What is the process for cleaning hoyer lifts here? RN C replied, Each resident has their own hoyer sling. So, the hoyer gets cleaned once at night. On 05/14/24 at 11:45 AM, Surveyor interviewed Director of Nursing (DON) B about observations and interviews about cleaning lifts. DON B replied, We are already doing education with all staff about this. The staff know that they are to be cleaned when exiting the resident's room after each use. 48793 Example 2 R22 was admitted on [DATE] with a Suprapubic catheter and on Enhanced Barrier Precautions (EBP). R2 was admitted on [DATE] with an indwelling catheter and on EBP. On 05/14/24 at 7:20 AM, Surveyor observed CNA G wheel the Hoyer lift outside of R22's EBP room. Surveyor did not observe CNA G wipe down the Hoyer lift. On 05/14/24 at 8:38 AM, Surveyor observed Certified Nursing Assistant (CNA) H enter R2's EBP room with full PPE on. CNA H performed peri care on R2. CNA H called CNA G into R2's room for assistance. CNA G entered R2's room with the Hoyer lift from the hallway. CNA G parked the Hoyer lift by the bathroom door. CNA H with gloves walked by the Hoyer lift and pushed Hoyer lift backwards with soiled gloved hands touching the handles of the Hoyer lift. CNA H doffed soiled gloves, sanitized, and donned new gloves. CNA H completed catheter care on R2. CNA H re-covered the catheter bag and hooked it to the Hoyer sling while transferring R2 to the wheelchair. CNA H and CNA G kept soiled gloves on, held onto the Hoyer lift and transferred R2 to R2's wheelchair. CNA G doffed PPE, wheeled the Hoyer lift out of R2's room and parked the Hoyer lift in the hallway. Surveyor did not observe CNA G wipe down the Hoyer lift with sanitizing wipes after providing care and transfer in R2's room. On 05/14/24 at 10:11 AM, Surveyor observed CNA H wheel the same Hoyer lift into R28's room. CNA H performed hygiene care, wiping the face with a washcloth and rolling to place the Hoyer sling under R28. CNA H hooked R28's sling to Hoyer lift, and CNA G entered R28's room to assist with the transfer. Surveyor observed CNA H and CNA G transfer R28 into the bath chair. Surveyor did not observe the Hoyer lift sanitized before using the Hoyer lift to transfer R28 from the bed to the bath chair. On 05/14/24 at 10:45 AM, Surveyor observed CNA H wheel R28 back to R28's room, and CNA G entered to assist in R28's room. CNA H and CNA G lifted R28 with the Hoyer lift from the bath chair to R28's bed. CNA H and CNA G rolled and dressed R28 in bed and then lifted R28 from the bed to the wheelchair. On 05/14/24 at 10:55 AM, Surveyor observed CNA G wheel the Hoyer lift out of R28's room and park the Hoyer lift in the hallway. Surveyor did not observe CNA G sanitize the Hoyer lift after the use of transferring R28 to the bath chair, and then back to bed after R28's bath. On 05/14/24 at 11:01 AM, Surveyor interviewed CNA G and asked what the process for sanitizing Hoyer lifts was between residents. CNA G indicated the expectation is to wipe down the lifts between resident use. CNA G stated, I'll admit, I did not wipe down the Hoyer lift after taking the Hoyer lift out of [R22's] room, before or after entering and exiting [R2's room], and before or after entering or exiting [R28's] room. Surveyor asked where wipes would be when CNA G does wipe the Hoyer lift between residents. CNA G indicated there were no wipe containers on the Hoyer lift, and CNA G would stock wipes on the lift going forward. On 05/14/24 at 11:16 AM, Surveyor interviewed DON B and asked what the expectation is for sanitizing lifts between residents' use, especially after using an EBP room. DON B indicated that all lifts are to be wiped down and sanitized with green top white container wipes which are located on lifts in bags. DON B indicated the facility increased the amount of lifts the facility had so that when there were EBP rooms some lifts were able to be stored in the EBP room and stay in the room for each use for that designated resident. Surveyor indicated to DON B that Surveyor did not observe CNA G sanitize the Hoyer lift used in R22, R2, and R28's rooms in between residents' cares and transfers. DON B indicated that CNA G should have sanitized lifts before each use for different residents. 47284 The facility policy, entitled Infection Control Precautions, dated 4/10/24, states: .Standard precautions designed to incorporate the protection against blood borne pathogens achieved by universal precautions and the protection against other pathogens achieved by body substance isolation. Standard precautions are to be used on all residents, regardless of their diagnosis or presumed infectious status, when coming into contact (or at risk of contact) with any of the following: blood, all body fluids, secretions, and excretions except sweat, non-intact skin, and mucous membranes. Standard precautions consist of .consistent and correct glove use .regular cleaning of all environmental surfaces . Example 3 R45 was admitted to the facility on [DATE] and had a diagnosis that included in part seborrheic dermatitis. R45's provider order of Ketoconazole 2% cream topically to flaking skin on face daily am, started 11/21/23. On 5/14/24 at 7:12 AM, Surveyor observed Registered Nurse (RN) C during medication pass. RN C applied gloves to both hands. With gloved hands, RN C closed the computer screen, grabbed the cup of medication, cup of apple juice, and walked to R45's room. RN C knocked on R45's door and grabbed the handle to open the door. RN C gave R45 his cup of medication and cup of apple juice. Still wearing the same pair of gloves, RN C then reached into the pocket of her scrub top to get R45's ketoconazole cream. Still wearing the same gloves, RN C grabbed her glasses from the top of her head and placed them onto her face and then applied the cream to R45's face. The gloves worn the entire time were contaminated by touching all those surfaces and should have been changed, hand hygiene preformed, and a new pair of gloves applied before applying the cream to R45's face. Example 4 R8 was admitted to the facility on [DATE] and had a diagnosis that included in part diabetes. On 5/15/24 at 7:49 AM, Surveyor observed RN C open the door of the storage room with gloves on and glucometer in hand and walked over to R8 with the same gloves still on. R8 was sitting in his broda chair in the middle of the common area. RN C held R8's hand and finger to obtain the blood sample with the lancet (device with a spring-loaded needle used to obtain blood for a finger stick). RN C then grabbed her glasses from top of her head with the gloves still on. RN C then used the lancet to obtain a blood sample from R8's finger and grabbed the glucometer to obtain the blood sample. After the blood sample was obtained, RN C took the glucometer and with the same gloves still on went back to the storage room, grabbed the door handle, and went inside the room to store the glucometer and removed her gloves. RN C did not sanitize the door handle to the storage room after grabbing it with contaminated gloves on. The gloves worn the entire time were contaminated by touching all those surfaces. The door handle should have been sanitized after being touched with contaminated gloves. Example 5 R20 was admitted to the facility on [DATE] and had a diagnosis to include in part diabetes. On 5/14/24 at 7:57 AM, Surveyor observed R20 sitting on a recliner with a side table next to him in the common area. Next to the side table was a couch. RN C used the lancet to stick R20's finger and placed the used lancet, that had been in contact with blood, on top of the side table with no barrier. RN C then took the glucometer with the test strip to obtain R20's blood sample and placed the glucometer with the test strip that contained blood on top of the side table with no barrier. RN C did not sanitize the side table after removing the items. The side table should have been sanitized after removing the lancet and glucometer as they both had the resident's blood on them. Interviews: On 5/15/24 at 8:01 AM, Surveyor interviewed RN C and explained what observations were made during medication pass on 05/14/24 and again on 05/15/24 regarding glove use. Surveyor asked RN C what the expectation of glove use was. RN C said she should have changed her gloves or only use the gloves when needed. Surveyor asked RN C what the expectation was for placing used lancet and glucometer on top of a common area table. RN C said the table should be sanitized after use. On 5/15/24 at 8:50 AM, Surveyor interviewed RN J and advised what observations were observed regarding glove use. Surveyor asked RN J what the expectation was for glove use in this situation. RN J said the gloves should have been applied just prior to adding the cream and not worn throughout the entire medication pass touching all those items or get a new set of gloves after using hand sanitizer once the old pair was removed. Surveyor advised RN J what observation was observed concerning the lancet and glucometer sitting on the common area table after used on R20 with no barrier and not sanitized after completed. Surveyor asked RN J what the expectation was for placing these items on the table. RN J said a barrier should have been used and the area should have been sanitized after removing the items. On 5/15/24 at 9:31 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B to advise of the observations observed with the gloves and glucometer/lancet. DON B said she was already aware of the situation and working on education. DON B said the RN should have changed gloves or used the gloves only to apply the cream. DON B also said the common area table needed to be sanitized after the glucometer and lancet were removed.

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not wearing hair nets or covering over facial hair while preparing and serving food in the Garden Terrace kitchenette. This had the potential to affect all 12 residents in the Garden Terrace unit. Findings include: According to the FDA Food Code 2022 documents at 2-402.11 Hair restraints: Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single use articles. Facility policy and procedure entitled Culinary Services Dress Code, last reviewed/revised 01/2024, stated in part, .Hair restraints are to be worn at all times, covering all hair .If males have beards (anything past 5 o'clock shadow) these must be covered with a beard restraint . On 05/14/24 at 8:16 AM, Surveyor observed Certified Nursing Assistant (CNA) E go behind the counter in Garden Terrace kitchenette while the culinary assistant was serving breakfast. CNA E was wearing a hair net, but no beard restraint to cover his facial hair. CNA E had a beard greater in length than a 5 o'clock shadow. CNA E prepared cold cereal with milk and served it to a resident in the dining room. At 8:20 AM, CNA E walked behind the counter again while the culinary assistant was serving breakfast. CNA E was not wearing a beard restraint to cover facial hair. CNA E took a coffee cup, went to the refrigerator and took some cream out, poured coffee and cream in the cup and placed the cup on a tray behind the counter. CNA E went into a back room carrying a plastic cup, came back out and placed a cup filled with ice water on a tray that the culinary assistant had placed a plate of food on. CNA E carried the tray to a resident room. On 05/14/24 at 11:59 AM, Surveyor observed CNA E enter the Garden Terrace kitchenette while the culinary assistant was serving lunch. CNA E was not wearing a hair net or beard restraint. CNA E picked up a plate of food prepared by the culinary assistant and carried it to a resident in the dining room. At 12:00 PM, CNA E returned to the kitchenette and applied a hair net to cover all hair on their head. CNA E did not put on a beard restraint. CNA E picked up a plate of food and delivered it to a resident in the dining room. On 05/14/24 at 2:05 PM, Surveyor interviewed CNA E about observations of CNA E in the kitchenette during food service for breakfast and lunch without a hair net or beard restraint on. CNA E stated they were supposed to have a hair net on every time they entered the kitchenette during food service. CNA E stated they forgot to put on a hair net a couple of times today. Surveyor asked if CNA E was supposed to be wearing a beard restraint when in the kitchenette during food service. CNA E was not sure if they were supposed to wear a beard restraint. CNA E did not remember what they were taught about covering facial hair in the food service area. On 05/15/24 at 8:27 AM, Surveyor interviewed Dietary Manager (DM) I about the facility policy for staff hair and beard coverings in the unit kitchenettes during meal service. DM I stated the expectation was all staff who go into the food service area on the units would wear hair and beard (if applicable) restraints. DM I stated they have all received education regarding that expectation. DM I stated there are hair and beard nets available in each unit kitchenette.

Based on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. Surveyor observed staff leave the Medication Administration Record (MAR) open with resident information visible when leaving the medication cart unattended during medication administration. This occurred for 4 residents (R) during medication administration. (R45, R48, R7 and R33) Findings include: On 05/14/24 at 7:24 AM, Surveyor observed Registered Nurse (RN) C leave the medication cart to obtain additional medication from backup supply. While RN C was away from the medication cart, Surveyor observed R45's information was visible on the MAR on top of the medication cart. On 05/14/24 at 11:24 AM, Surveyor observed RN F walk away from the medication cart to get ice cream from the refrigerator in the kitchenette. While RN F was in the kitchenette, Surveyor observed the MAR open with R48's information visible for anyone who walked by the cart. On 05/14/24 at 11:31 AM, Surveyor observed RN F prepare medications and carry them to R7 in the dining area. While RN F was away from the medication cart, Surveyor observed the MAR open on top of the medication cart with R7's information visible to anyone who walked by the cart. On 05/14/24 at 11:36 AM, Surveyor observed RN F prepare medications and carry them to R33 in the dining area. While RN F was away from the cart, Surveyor observed the MAR open on top of the medication cart with R33's information visible to anyone who walked by the cart. On 05/14/24 at 12:35 PM, Surveyor interviewed RN F about the observations of the MAR being left open with resident information visible during medication administration. RN F stated they were supposed to close the MAR every time they walked away from the cart so resident information was not visible. RN F stated sometimes they were in a hurry and forgot to close the MAR. On 05/15/24 at 6:54 AM, Surveyor interviewed Director of Nursing (DON) B about the facility policy and procedure for leaving the MAR visible on top of the medication cart when leaving the cart unattended during the medication administration. DON B stated every time the nurse leaves the cart the MAR should be put down so people walking by can not see resident's confidential information. Surveyor informed DON B of observations made during the survey of nurses leaving the MAR open with resident information visible when they left the medication cart unattended. DON B stated they should have closed the MAR when they left the cart. DON B will re-educate all staff who pass medications.

Based on observation, record review and interview, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents. The facility did not use gait belt to transfer resident safely. This occurred for 1 out of 1 resident (R33). R33 was transferred by staff without using a gait belt. This is evidenced by: Resident 33 (R33) was admitted to the facility on [DATE], with diagnoses that include paranoid [CONDITION(S)], unspecified dementia with behavioral disturbance. R33's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 00. R33 is severely cognitively impaired. R33 needs extensive assistance when involved in activities of turning around, moving on and off toilet, surface to surface transfer. For balance during transition in walking R33 is not steady and only able to stabilize with staff assistance. R33's Care Plan was reviewed by Surveyor with no mention of gait belt to be used during transfers. R33's Record Review of nurse's note from 03/02/22, read in part: . balance during walking: Walking (with assistive device, if used): not steady, only able to stabilize with human assistance. Turning around the facing the opposite direction while walking. On 03/29/22 at 9:02 AM, Surveyor observed Certified Nursing Assistant (CNA) C assist R33 out of her wheelchair without a gait belt and held R33's hand. CNA C walked R33 into the bathroom to wash her face and freshen her breath, without using a gait belt to ensure R33's safety. On 03/29/22 at 11:52 AM, Surveyor observed CNA C encourage resident to stand up and walk to the bathroom. Once R33 stood up, CNA C took her hand and walked R33 into the bathroom without using a gait belt. Once done in the bathroom, CNA C walked the resident back to her wheelchair, again without a gait belt. On 03/29/22 at 12:02 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D and asked about the use of gait belt. LPN D indicated each resident has a gait belt in their room and that staff are to use the gait belt for ambulation and transfer assist. On 03/29/22 at 1:14 PM, Surveyor interviewed Director of Nursing (DON) B about gait belt policy when a resident is being transferred or walked. DON B indicted that when staff are transferring or walking a resident, resident should have a gait belt on. Surveyor reviewed facility's policy Received Low Lift Program Policy., Revised date 07/08/21, read in part: Goal: Our Low Lift Program is designed to meet the following goals.; Procedure: This program will limit and remove as much lifting as possible. H. Gait belts will be used to guide and assist with transferring while maintaining proper lifting posture.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control and Prevention (CDC), observation, interview, and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure to: properly disinfect shared medical equipment after each use; adhere to social distancing; perform hand hygiene and utilize gloves properly; and proper handling of linen. Findings include: 1. A. Review of R1's medical record revealed [DIAGNOSES REDACTED]. On 6/23/20 at 11:41am, Registered Nurse1 (RN1) was observed during provision of care to R1. RN1 checked R1's blood pressure, temperature and oxygen saturation level (oxygen level in the blood). After the procedure, RN1 wiped the pulse oximeter (device that measures the amount of oxygen in the blood) using one small alcohol pad for five seconds and using the same alcohol pad, RN1 wiped the(NAME)digital thermometer for six seconds. RN1 then placed the pulse oximeter and the thermometer back in the storage basket and disposed the wipe. RN1 took one Hydrogen Peroxide wipe (disinfecting wipe) and wiped the blood pressure cuff for 10 seconds. Surveyor used the stopwatch app from the computer. RN1 failed to observe the equipment to ensure that it remained wet for the recommended contact time. When asked how long should the wet or contact time be for the blood pressure cuff using the Hydrogen Peroxide disinfecting wipe, RN1 was unsure and looked at the label of the disinfecting wipes. RN1 then stated 30 seconds. RN1 further stated that sometimes she would use the alcohol pad and other times she would use the Hydrogen Peroxide wipes. B. Review of R2's medical record revealed [DIAGNOSES REDACTED]. On 6/23/20 at 2:52pm, RN2 was observed checking R2's oxygen saturation level, temperature and assessed R2's lung sounds using the stethoscope (medical device used to listen to the heart and lung sounds). After the procedure, RN2 wiped the pulse oximeter using one Clorox Hydrogen Peroxide wipe for six seconds, wiped the digital thermometer for five seconds and returned both items in the storage basket. Using the same wipe, RN2 wiped the stethoscope for seven seconds. Surveyor used the stopwatch app from the computer. RN2 failed to observe the equipment to ensure that it remained wet for the recommended contact time. C. Review of R3's medical record revealed [DIAGNOSES REDACTED]. On 6/23/20 at 2:57pm, RN2 was observed checking R3's oxygen saturation level, temperature and assessed R3's lung sounds using the stethoscope. After the procedure, RN wiped the pulse oximeter for 10 seconds using one Clorox Hydrogen Peroxide wipe. Using the same wipe, RN2 wiped the digital thermometer for seven seconds and the stethoscope for 10 seconds. Surveyor used the stopwatch app from the computer. RN2 failed to observe the equipment to ensure that it remained wet for the recommended contact time. When asked how long should the wet time or contact time be, RN2 checked the label and stated, 30 seconds. During interview with the Director of Nursing (DON) on 7/8/20 at 9:20am, when asked about her expectation from staff to ensure that shared medical equipment are exposed to the disinfectant for the required contact time, the DON stated, If we use it on one resident, that we clean it before using it on another resident. They need to clean it with disinfectant before going to another resident. They do not need to scrub it for 30 seconds per manufacturer, they do need to wipe it because it says contact for 30 seconds. Review of facility's policy titled Standard Precautions (IC) dated 3/26/20 revealed under Resident Care Equipment, it revealed, Clean and disinfect non-disposable and multi-use equipment before use on another person. Review of the Clorox Hydrogen Peroxide Portfolio Overview revealed, Kill bacteria [MEDICAL CONDITION] in as fast as 30 seconds with the power of hydrogen peroxide. Under Usage, it revealed, Directions .To clean and disinfect hard, nonporous surfaces: Wipe surface until completely wet. Allow surface to remain wet for contact time listed on label. Let air-dry. For heavily soiled areas, pre-cleaning is required. https://www.cloroxpro.com/products/clorox/hydrogen-peroxide-disinfecting-cleaners/ Review of the Clorox Hydrogen Peroxide Directions for use video revealed, Keep surface visibly wet for the required contact time. You may dry the surface after the contact time has been reached. Recap: Put on PPE. Remove Soil (clean). Wipe surface (disinfect). Wait (contact time). Discard wipe. https://www.cloroxpro.com/products/clorox-healthcare/hydrogen-peroxide-cleaner-disinfectants/?gclid=EAIaIQobChMIvIeC84id6gIVE77ACh0kZANcEAAYASAAEgLAT_D_BwE&gclsrc=aw.ds In a CDC article titled Factors affecting the Efficacy of Disinfection and Sterilization dated [DATE] revealed, The activity of germicides against microorganisms depends on a number of factors, some of which are [MEDICATION NAME] qualities of the organism, others of which are the chemical and external physical environment. Awareness of these factors should lead to better use of disinfection and sterilization processes. Under Duration of Exposure, it revealed, Items must be exposed to the germicide for the appropriate minimum contact time. Multiple investigators have demonstrated the effectiveness of low-level disinfectants against vegetative bacteria (e.g., Listeria, E. coli, Salmonella, VRE,[MEDICAL CONDITION]), yeasts (e.g., Candida), mycobacteria (e.g., M. [MEDICAL CONDITION]), [MEDICAL CONDITION] (e.g., [MEDICATION NAME]) at exposure times of 30-60 seconds. By law, all applicable label instructions on EPA-registered products must be followed. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/efficacy.html 2. Review of R4's record revealed [DIAGNOSES REDACTED]. mellitus (chronic disease characterized by high levels of sugar in the blood). Review of R5's medical record revealed [DIAGNOSES REDACTED]. This makes it hard to breathe and causes wheezing), and unspecified asthma (airways become blocked or narrowed causing breathing difficulty). On 6/23/20 at 12:12pm, while inside the Cedar Lane Unit, R4 was observed sitting in the same table with R5. R4 was sitting across from R5 while they ate lunch. The distance between R4 and R5 was less than six feet. The table was approximately four feet by four feet in size. R4 sniffled several times and R5 coughed three times but R5 covered her mouth while R4 continued to eat his lunch. There were staff present in the dining area, but the staff failed to remind both residents on social distancing and for R5 to perform hand hygiene after coughing. Licensed Practical Nurse1 (LPN1) stated that R4 and R5 preferred to sit in the same table and that both residents refused to move to another table. There was no documentation under progress notes on both residents from May 2020 to present that they have attempted to remind both residents on social distancing. During interview with the Director of Nursing (DON) on 7/8/20 at 9:20am, when asked about her expectation from staff when they see two residents seated in the same table, the DON stated, So we do ask that they (staff) ask residents to move, to check their care plan and see. If we are talking about two residents that can seat together, the risks and benefits have been done with the residents' representative or guardian. Even with the pandemic, residents have the right to choose. Our plan is one resident per table. Review of facility's policy titled Pandemic Plan - COVID-19 (IC) dated 6/19/20 revealed under Resident Dining Plan, 1. All residents must remain an appropriate social distancing space apart (at least 6 ft) at meals. 2. No more than one resident per table. In a CDC article titled Preparing for COVID-19 in Nursing Homes dated June 25, 2020, revealed under Core Practices, Implement Social Distancing Measures. Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Cancel communal dining .Remind residents to practice social distancing, wear a face cloth covering (if tolerated), and perform hand hygiene . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html 3. A. On 6/23/20 at 11:56am, Culinary Service Assistant (E1) was observed lifting the lids of the food storage containers for lunch. E1 was wearing face mask and a face shield. E1 was observed touching her face mask with both hands. E1 failed to perform hand hygiene. E1 proceeded to touch the lids and removed the plastic covers from the steel containers. E1 failed to perform hand hygiene after touching her facemask. When asked what she missed, E1 stated she did not wash her hands. B. On 6/23/20 at 12:09pm, while in the kitchen area of the Northwood unit, Certified Nursing Assistant1 (NA1) was observed pouring juice in cups. NA1 paused and lifted the bottom part of her facemask for a few seconds. NA1 proceeded to pour more juice in cups. NA1 failed to perform hand hygiene after touching her facemask. During interview with the DON on 7/8/20 at 9:20am, when asked about her expectation from staff after touching their facemasks, the DON stated, I expect them to use a hand sanitizer or wash their hands. When asked if she thought this was important especially when setting up for lunch and preparing drinks for the residents, the DON further stated, Yes. I do. Review of facility's policy titled, Infection Control Standards (IC) dated 2/19/20 did not reveal any documentation to perform hand hygiene after contact with gloves or other personal protective equipment. In a CDC article titled Facemask Do's and Don'ts for Healthcare Personnel dated June 2, 2020 revealed, When wearing a face mask, don't do the following, DON'T touch or adjust your facemask without cleaning your hands before and after . https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/fs-facemask-dos-donts.pdf 4. A. On 6/23/20 at 11:32am, NA2 was observed pushing the Volaro hoyer lift (device used to assist healthcare personnel with safe patient transfers and handling) in the hallway. NA2 exited R9's room wearing gloves, held the soiled linen and sling on her left gloved hand while pushing the hoyer lift. NA2 parked the hoyer lift in the storage area. NA2 went to room [ROOM NUMBER] and disposed the soiled underpad and sling. NA2 exited the room with a blanket and proceeded to walk towards the laundry room. Still wearing gloves, NA2 opened the laundry room using a key which she took from her pocket. NA2 opened the door to the washing machine, placed the blanket inside and turned the setting knob on. While in the laundry room, NA2 removed her gloves and immediately lifted her goggles. NA2 failed to perform hand hygiene immediately after glove removal and before touching her goggles. NA2 paused for several seconds, took a few breaths, then walked to the sink to wash her hands. When asked if she could wear gloves in the hallway, NA2 stated, I changed my gloves before leaving the room (R9's room). When asked if she could carry loose soiled linen out of the room, without a bag, NA2 further stated that the R9 had a bowel movement and she cleaned the resident. NA2 further stated, I didn't have a bag to put the linens in. I should. During interview DON on 7/8/20 at 9:20am, when asked about her expectation from staff when carrying soiled linen from a resident's room, The DON stated, They should be bagged. When asked what staff should do after glove removal and before touching knobs or other equipment, the DON stated, They should take their soiled gloves off and wash their hands. Review of facility's policy titled Infection Control Standards (IC) dated 2/19/20 revealed under hand hygiene and glove use, Staff should NOT be wearing gloves in common areas such as hallways and the Dining areas. Under Guidelines for Hand Washing and Hand Antisepsis, it revealed, Decontaminate means using an alcohol-based rub .Decontaminate hands after removing gloves. Under handling soiled linen, it revealed, Obtain clean clear plastic bag prior to changing soiled linen .Place soiled linen immediately into bag for transport to dirty linen room .DO NOT carry soiled linens or soiled incontinence products across common areas. Remove gloves. Perform hand hygiene. Review of facility's policy titled Exposure Control Plan - Bloodborne Pathogens revealed under Personal Protective Equipment (PPE), All employees using PPE will follow these requirements: hand hygiene is performed immediately or as soon as possible after removal of gloves or other PPE. Review of facility's policy titled Soiled Linen Handling dated 8/28/19 revealed under Procedure, 2. Distribute soiled linens and clothing to container utilizing wheeled cart or garbage bag for transport .7. For personal laundry soiled with blood/body fluids .place soiled linen in yellow biohazard bag and transport to the laundry room for immediate washing. In a CDC article titled Personal Protective Equipment: Questions and Answers dated March 14, 2020, revealed, It is important for HCP to perform hand hygiene after removing PPE. Hand hygiene should be performed by using an alcohol-based hand sanitizer that contains 60-95% alcohol or washing hands with soap and water for at least 20 seconds. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html#Gloves In a CDC article titled Appendix D - Linen and laundry management dated March 27, 2020 revealed, Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html In a CDC power point presentation titled Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings revealed under Do's and Don'ts of Glove Use, Limit opportunities for touch contamination - protect yourself, others, and the environment .Don't touch environmental surfaces except as necessary during patient care. Gloves protect you against contact with infectious materials. However, once contaminated, gloves can become a means for spreading infectious materials to yourself, other patients or environmental surfaces. Therefore, the way you use gloves can influence the risk of disease transmission in your healthcare setting .Limit opportunities for touch contamination - protect yourself, others and environmental surfaces. How many times have you seen someone adjust their glasses, rub their nose or touch their face with gloves that have been in contact with a patient? This is one example of touch contamination that can potentially expose oneself to infectious agents. Think about environmental surfaces too and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches, door and cabinet knobs can become contaminated if touched by soiled gloves. Under Key Points about PPE, it revealed, Use carefully - don't spread contamination. Remove and discard carefully, either at the doorway or immediately outside patient room .immediately perform hand hygiene. Under Hand Hygiene, it revealed, Hand hygiene is the cornerstone of preventing infection transmission. You should perform hand hygiene immediately after removing PPE. https://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdf B. On 6/23/20 at 11:39am, NA1 was observed coming out of the laundry room carrying a clean, printed blanket, without a covering. NA1 was holding the blanket to her side, touching her body and was touching her scrub top. NA1 brought the blanket to R8's room. When asked how should staff carry clean linen, NA1 stated, Carrying it away like that while showing surveyor how clean linen should be held away from the body. During interview with the DON on 7/8/20 at 9:20am, when asked about her expectation from staff when carrying clean linen, the DON stated, Away from their scrubs. Review of facility's policy titled Infection Control Standards (IC) dated 2/19/20, did not reveal any documentation on handling clean linens. In a CDC article titled Appendix D - Linen and laundry management dated March 27, 2020, revealed under Best practices for management of clean linen, Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html

Based on observation, interview and record review, the facility did not ensure staff followed proper sanitation and safe food handling practices while serving food, with the potential to effect 12 residents on Garden Terrace, out of a total census of 48 residents. Hand hygiene was not completed at appropriate times or for the appropriate length of time. Bare hand contact with butter, serving food with wet hands, and hair nets not utilized properly. This is evidenced by: Facility Policy entitled Food Handling, revised 5/8/17, states, in part: Food will be handled safely to prevent food borne illness or any other food safety concerns.9. No bare hand contact with ready-to-eat foods- except when washing fruits and vegetables, food employees may not contact exposed, ready-to-eat food with their bare hands. Food employees shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment. Facility Policy entitled Hand Hygiene and Glove Use, revised 12/4/19, states, in part: .Alcohol- based product - when decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry, about 20 seconds. Soap and water. When washing hands with soap and water, wet hands first with water. Apply soap product. Rub hands together vigorously for at least 15 -20 seconds, per CDC (Center for Disease Control and Prevention) guidelines, covering all surfaces of the hands and fingers. Rinse hands with water. Dry thoroughly with a disposable towel. Use towel to turn off the faucet . On 1/29/20 at 11:39 AM, Surveyor observed dining services on the Garden Terrace unit with the following observations: On 1/29/20 at 11:42 AM, Surveyor observed CNA H (Certified Nursing Assistant) go behind the counter, where CSW I was dishing up and plating food, without all of her hair being restrained in a hair net. CNA H had two large chunks of hair on both sides of her face, approximately 2 inches thick, hanging out of her hair net. CNA H is serving plated food from behind the counter to the residents in the dining room. On 1/29/20 at 11:43 AM, Surveyor observed CSW I scooping out butter bare handed with a spoon. CSW I placed his right hand into the butter container, and upon removal, CSW I had butter visible on the back of his right hand. CSW I placed the butter onto a serving of mashed potatoes, then went over to the sink to wash his hands. CSW I performed hand washing/hygiene for less than 15 seconds and CSW I's hands were still visibly wet. CSW I, at this time, wiped his wet hands on his work top and then began plating food again for the residents. On 1/29/20 at 11:44 AM, Surveyor interviewed CNA H regarding her hair net. CNA H indicated that her hair probably wasn't contained in the back. Surveyor had to point out to CNA H that she had hair hanging out of her hair net along both sides of her face. CNA H began to tuck her hair into the hair net at this time, leaving approximately 1 inch sections of hair along both sides of her face. On 1/29/20 at 11:48 AM, Surveyor observed CSW I use a spoon, with his bare hand, to dip into the butter container and serve R42 butter. (Please note this is the same container that CSW I used earlier in which his hand came out with butter on it.) CSW I performed hand hygiene/washing for less than 10 seconds, visible water spots observed on CSW I's work top/shirt. CSW I's hands were visibly still wet and he went back to plating food for the residents on the unit. CSW I went from plating food to touching a door handle under the steam table to getting out a plate cover. CSW I then placed the plate cover onto a plate, then proceeded to open a drawer, where he removed a pen and wrote on top of the plate cover. CSW I, bare handed, took the plate over to the fridge, where he touched the fridge handle and placed the plate into the fridge. After touching the fridge, CSW I did not perform hand hygiene/washing before going back to plating food for the residents without gloves. On 1/29/20 at 11:51 AM, Surveyor observed CSW I reach under and open the cupboard door, under the steam table, once again to get out a lipped plate. CSW I did not wash his hands at this time and began plating food onto the lipped plate at this time. On 1/29/20 at 11:54 AM, Surveyor observed CSW I move out from the serving area, into the dining table area, where he was touching the dining table, to ask R18 what she would like for lunch. CSW I did not wash his hands prior to going back to the serving area, before plating food for R18. On 1/29/20 at 11:57 AM, Surveyor observed RT J (Recreational Therapist) go behind the kitchenette counter, where CSW I was serving food to residents, without a hair net on and go into the fridge. Surveyor interviewed RT J at this time, who indicated she is to wear a hair net when in close proximity of food being prepared, and that she should have a hair net on. On 1/29/20 at 12:05 PM, Surveyor interviewed CSW I regarding the dining observation. CSW I indicated hand washing/hygiene is to be done before serving food, if something is on your hands, after getting cups, plates, silverware, and touching anything not sterile, you should wash your hands first. CSW I indicated hand washing is to be at least 14 seconds. CSW I indicated he does not use gloves to scoop butter, due to always using a spoon. CSW I indicated his hand came out with butter on it and that he should use gloves. CSW I indicated that he did not wash his hands every time he touched a cupboard or handle and that he should have washed his hands. CSW I indicated he did not wash his hands after coming out to residential areas, such as the dining room, and that he should have washed his hands before returning to serve food. On 2/3/20 at 1:24 PM, Surveyor interviewed DM F (Dietary Manager) and SSM G (Support Service Manager) regarding dining observations. DM F indicated that handwashing is to be done prior to serving, any time between serving, if hands are soiled or if they have food on them. DM F indicated staff should not go back to serving food after touching drawers, handles and cabinets, without washing their hands first. DM F indicated the butter should not be served to residents after CSW I's bare hand had touched the butter container. DM F indicated hand washing is to be done for 20 seconds. DM F indicated staff are not to wipe their hands on their work top/shirt and that staff are not to serve food with wet hands. DM F indicated she expects all hair to be contained in hair nets. DM F indicated that CSW I was last in-serviced on hand hygiene in (MONTH) of 2019. DM F indicated CSW I should have washed his hands before continuing to serve food after being in the dining room.

Based on observation, interview and record review, the facility did not ensure residents received food that is palatable and at a safe and appetizing temperature for 1 of 1 resident test trays (R28). R28 was observed sitting for approximately 25 minutes with her breakfast meal uncovered, while waiting for assistance. R28's breakfast tray temperatures were not appetizing or palatable. This is evidenced by: R28 was admitted , on 10/4/10, with [DIAGNOSES REDACTED]. R28's Annual MDS (Minimum Data Set), dated 12/2/19, indicates R28 is severely cognitively impaired and requires extensive assist of one person for eating. (Please note that R28 would not be able to eat her meal on her own.) On 1/30/20 at 7:44 AM, Surveyor observed R28 sitting with the back of her Broda chair to the dining table. On 1/30/20 at 8:00 AM, Surveyor observed R28 sitting in her Broda chair with the back of her chair to table. R28 received her pureed breakfast at this time. R28 received pureed hot cereal, pureed cottage cheese, pureed pancake, gelled Breeze (supplement) and gelled juice. On 1/30/20 at 8:19 AM, Surveyor observed R28 still sitting with her back to the table. R28's food looks untouched and has not been offered assistance with her meal. On 1/30/20 at 8:21 AM, Surveyor observed CNA D (Certified Nursing Assistant) go over to R28 to assist her with her breakfast. CNA D did not offer to heat up R28's breakfast meal at this time. Surveyor asked CNA D if he could obtain R28 a new tray. CNA D called down to the kitchen and R28 received a new tray. On 1/30/20 at 8:25 AM, Surveyor had the following observations of R28's breakfast tray: Hot cereal appeared to have a glazed over appearance and had a temperature of 126.5 degrees F (Fahrenheit), and tasted luke warm. Pureed pancakes had a temperature of 76.0 degrees F and tasted cold. Cottage cheese had a temperature of 58.7 degrees F and did not taste cold. On 1/30/20, at approximately 8:30 AM, Surveyor interviewed CNA D and CSW [NAME] (Culinary Service Worker) regarding R28's meal. CNA D indicated that staff were helping another resident, that's why R28 was not assisted promptly. CNA D stated a reasonable person would expect hot oatmeal and pancakes. CSW [NAME] indicated hot food should be hot and indicated that staff are busy this morning. On 1/30/20 at 8:33 AM, Surveyor interviewed DON B (Director of Nursing) regarding meals. DON B indicated staff are to assist residents with their food, otherwise if not able to assist, meal is to be covered until able to assist them. On 2/03/20 at 1:24 PM, Surveyor interviewed DM F (Dietary Manager) and SSM G (Support Systems Manager) regarding palatability. DM F indicated that temperatures should not fall below 120 degrees for hot food. DM F indicated that pancakes with a temperature of 76 degrees and cottage cheese at 58 degrees is not considered palatable.

Based on observation, interview and record review, the facility did not ensure accurate labeling to facilitate safe administration of medications for 1 of 2 medication carts with the potential to affect 11 residents (R24 and R13). R24's [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) vial foil pack was opened with 5 vials remaining, without an open date. R13's [MEDICATION NAME] vial foil pack was opened with 2 vials remaining, without an open date. One stock bottle of multivitamin tablets in circulation after expiration date. (Per Drugs.com, a [MEDICATION NAME] is a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs.) This is evidenced by: Facility policy entitled Storage, Stability, and Proper Use of Bulk Medications, dated ,[DATE], states, in part: Drug: [MEDICATION NAME]/[MEDICATION NAME] inhalation solution. Storage: keep in foil pouch until ready for use. Expiration: Must be used within 1 weeks (SIC) after removing from foil pouch, vials are single-use only . Example 1 R24's signed Physician Order's state, in part: [DATE] Drug: ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] 0.5 mg (milligrams)/3 ML (milliliters) - 2.5 (3)/3 ML solution. Dose ordered: (3 ml) inhalation twice a day 0800 (8:00 AM) 2000 (8:00 PM) . For: Wheezing . On [DATE] at 9:19 AM, Surveyor conducted medication storage observation of the North [NAME] cart with LPN C (Licensed Practical Nurse). Surveyor and LPN C observed R24's box of [MEDICATION NAME] inhalation solutions to have an opened foil pack, with 5 vials of solution lose, without an open date. LPN C was unable to say when R24's foil pack was opened. LPN C indicated that it's good for 7 days, once the pack is opened. LPN C removed R24's [MEDICATION NAME], at this time, from the medication cart. Example 2 R13's signed Physician Order's state, in part: (Duo Neb) [MEDICATION NAME]-[MEDICATION NAME] 0.5 mg /3 ML - 2.5 (3)mg/3 ML solution inhalation every 4 (four) hours as needed .For [MEDICAL CONDITIONS] with [MEDICATION NAME] . On [DATE] at 9:19 AM, Surveyor conducted medication storage observation of the North [NAME] cart with LPN C. Surveyor and LPN C observed R13's box of [MEDICATION NAME] inhalation solutions to have an opened foil pack, with 2 vials of solution lose, without an open date. LPN C was unable to say when R13's foil pack was opened. LPN C indicated that it's good for 7 days, once pack is opened. LPN C removed R13's [MEDICATION NAME] at this time from the medication cart. On [DATE] at 10:02 AM, Surveyor interviewed DON B (Director of Nursing) regarding medication storage. DON B indicated that [MEDICATION NAME] is only good for 7 days once the foil is open. DON B indicated staff should be dating the foil pack(s) when it's opened, in order to know it's within the 7 days. Example 3 On [DATE] at 9:19 AM, Surveyor conducted medication storage observation of the North [NAME] cart with LPN C. Surveyor and LPN C observed an open stock bottle of multivitamin tablets with a manufacturer date of ,[DATE] ([DATE]) in the top drawer of the medication cart. LPN C indicated the bottle was expired and should not be in the cart. LPN C removed the bottle of multivitamins.

Based on observation and interview, the facility did not ensure that each resident was treated with dignity and respect for 1 of 15 sampled residents (R19). Surveyor noted that R19 had an odor of bowel movement (BM). CNA C (Certified Nursing Assistant) stated, Somebody doesn't smell good, and did not investigate who was incontinent of bowel. Surveyor asked CNA D to check R19 and R19's brief was full of BM. This is evidenced by: The facility's Dignity Standard that is provided to staff during new employee orientation and annually in Resident Rights training states as follows: (Facility) promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R19's Quarterly Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) was completed with R19 scoring a 0, indicating severe cognitive impairment. Section G0110, Activities of Daily Living (ADL's), indicates R19 requires 2 plus staff and extensive assist for toileting and personal hygiene. R19's CNA Care Plan states, in part, for Basic Care Needs - I need my Aides to - I use the bathroom with the help of 1 person. It is difficult to get me to sit on the toilet at times as I do not understand what it is or what you are doing. Provide verbal and physical cues. Offer and assist me to the toilet upon rising, after meals, before bedtime, and PRN (as needed.) Please check to see if I have incontinence at night on rounds and assist in changing and cleansing. I have some incontinence even with assist. I use a brief for dignity and to wick moisture away from my skin. Briefs do not stay up well when I walk. I wear underwear over them to aid in keeping it up. Redirect me if I am voiding or defecating in inappropriate places. I don't have toilet paper in my bathroom as I will eat it. On 11/27/18 at 10:25 AM, Surveyor walked onto the unit and noted R19 in a room which was not R19's room. R19 walked up next to Surveyor, Surveyor noted an odor of BM. R19 was ambulating independently in the dining room. On 11/27/18 at 10:40 AM, CNA C walked into the dining room where R19 and R7 were sitting and stated, Somebody doesn't smell good. CNA C took R7 to R7's room and CNA C and CNA D toileted R7 and provided perineal care. After providing cares, CNA C and CNA D brought R7 to the TV (television) area next to the dining room. On 11/27/18 at 11:07 AM, Surveyor observed CNA C walk through the TV area and again state, Somebody doesn't smell good, and CNA C kept on walking to care for other residents. At this time in TV area there were three residents, R7, who had just been toileted and provided perineal care, R14 and R19. CNA C did not check R14 or R19 in attempt to determine who was soiled and in need of toileting/perineal care. Surveyor observed the residents in the TV area and CNA C did not return to check R14 or R19. On 11/27/18 at 11:15 AM, Surveyor observed R19 stand up from the couch in the TV area, grabbing at the back of his sweatpants. On 11/27/18 at 12:05 PM, Surveyor stated to CNA D that Surveyor smelled an odor of BM and asked if R19 could be checked. CNA D took R19 into bathroom. After arriving to the bathroom, CNA C knocked on the door and stated, (R19's) messy and I definitely smell something. CNA D removed R19's brief which was full of BM. On 11/27/18 at 12:20 PM, Surveyor spoke with CNA C. Surveyor asked CNA C if R19 is on a toileting schedule or if R19 is a check and change. CNA C stated that R19 is a check and change. Surveyor asked CNA C when R19 was last changed. CNA C stated CNA C changed R19 when we got resident up about 7:30 AM and shortly after 9:00 AM, after breakfast. CNA C stated we will sit R19 on the toilet at times, if dry in the morning or at any time, we toilet R19. CNA C stated that a staff member stated that CNA D was taking R19 to R19's room and CNA C stated CNA C came to assist. Surveyor asked CNA C if CNA C went back to check R19 after making the statement, Somebody doesn't smell good, in the TV area. CNA C stated I checked R19. R19 wasn't soiled, but R7 was soiled. CNA C added, My nose checked R19. CNA C stated when R19 has to have a BM, resident gets up, fidgets, and pokes head in everybody's room. Surveyor stated to CNA C, when I first saw R19, R19 was in another resident's room. CNA C stated I thought R7 was the source of the odor and didn't realize it was R19; however, CNA C did not check R19. R19 was sitting in a soiled brief for at least 1 hour and 45 minutes. On 11/28/18 at 2:05 PM, Surveyor spoke with DON B (Director of Nursing) and RN MGR E (Registered Nurse Manager). Surveyor asked RN MGR E if a resident is a check and change when should staff be checking and changing the resident. RN MGR E stated upon rising, after meals, before bed, as needed, and when repositioning. Surveyor asked RN MGR E when should they check the resident if they smell an odor? RN MGR E stated staff should be immediately checking the resident. RN MGR E stated it is the expectation that CNA C would have come back to check R19 after noting the odor of BM.

Based on observation and interview, the facility did not care for each resident in a manner to enhance the quality of life, or promote the individual rights of the resident. This has the potential to affect all thirteen residents on Cedar Lane. R16 had complaints of another resident violating R16's personal space and property, and the facility did not provide interventions to ensure these violations did not continue. R18 was receiving cares when another resident opened R18's door and walked into the room unannounced and uninvited. R17 was unaware another resident had wandered into her room without her permission. R17 was in her room when the same resident wandered into her room without her permission and requested she be made to leave. R6 had complaints of another resident violating R6's personal space and property, the facility did not provide interventions to ensure these violations did not continue. This is evidenced by: 1. On 08/07/17 at 1:15 p.m., Surveyor conducted a resident group interview. When the group was asked about the resident's personal property, R16 responded R9 enters R16's room many times throughout the day and night. R16 further stated, .I ring my bell, (staff) don't come so I scream .R9 won't leave (my room). (R9) woke me up at 3:00 a.m .this has been going on quite a while. R16 stated it takes ten minutes for staff to respond to the call light, and to remove R9 from the room. R16 explained R9 once removed a Welcome sign from R16's room, and the sign was returned with a broken piece. R16 stated R9 will remove items from R16's end tables, R9 will frequently untie the bag which is tied to the back of R16's wheelchair, and R9 will go through R16's other room belongings without permission. R16 further explained she has spoken to the facility Social Worker (SW) about this concern, and there was a discussion with the SW about placing a mesh Stop sign across R16's room doorway. R16 stated she would like to stop R9 from coming into her room, and indicated this is the resident's number one concern. R16 and R9 both reside on the Cedar Lane household. On 08/08/17 at 1:25 p.m., Surveyor saw R16 coming into the Cedar Lane household, yelling out, Who is in my room, my door is open, is she in there? R16 then asked if Surveyor had been in her room. Surveyor responded that she had not been in R16's room at any time. R16 was very anxious about why her door was open. R16 stated she left the door closed when she left. A staff member then told R16 that it was the housekeeper in R16's room. R16 calmed down at that time. On 08/08/17 at 3:05 p.m., Surveyor interviewed R16 in the resident's room. There was an approximate 8 by 10 sign outside the room door, which read, (R16's first name) Room. There was a wig placed on the resident's dresser, along with a small orange toy tiger. R16 stated R9 comes into R16's room almost daily and touches the wig. R16 further explained she has witnessed R9 pick up the small toy tiger, which was made by R16's granddaughter, and R9 places the tiger in R9's mouth and places the tiger back on the dresser. R16 stated R9 has come into the room several times throughout the night and has awoken R16. R16 indicated she closes the room door during the day when the resident is out for meals or activities. R16 stated keeping the room door closed tends to keep everybody out. R16 indicated facility staff have told the resident to keep the room door closed while R16 is in the room; in order to prevent R9 from coming into the room. R16 stated she likes keeping her room door open while in the room, and stated it is not fair the resident would have to keep her room door closed all the time. R16 stated the sign outside the room, with R16's first name, does not keep R9 out of the room. Surveyor reviewed R16's most recent Brief Interview for Mental Status (BIMS) score, dated 06/12/17, which was a 12 out of 15 possible points indicating moderately impaired cognition. R16 was admitted to the facility on [DATE]. At 10:04 a.m., Surveyor interviewed Household Assistant (HA) B. HA B stated R9 wanders into the rooms of other residents a lot, and HA B has seen R9 enter the room of R16 at least one to two times a week. On 08/09/17 at 12:46 p.m., Surveyor interviewed SW L, discussing the interview with R16 and observations of R9. SW L stated he recently met with R16 regarding R9's behavior. SW L stated R16 has been educated and is aware the resident can use the call light when R9 enters R16's room, and staff will assist R9 out of the area. SW L stated the facility does not use the mesh Stop signs across the room doorways, as the SW believes R9 would not be able to read these signs. SW L stated the facility recently placed a sign outside R16's room door with the resident's first name, with the hopes it would deter R9 from entering R16's room. 2. On 08/08/17 at 10:00 a.m., Surveyor was on the Cedar Lane household. At this time, R9 walked up to the closed door of R18's room, opened the door and started to walk in the room. Surveyor was able to see R18's bare legs and feet on a bed, and nursing assistants were inside the resident's room. HA B entered R18's doorway and redirected R9 from the room, and closed the room door. 3. At 3:21 p.m., Surveyor was on the Cedar Lane household and observed R9 walk into R17's room and sit on the bed. R9 left the room at 3:27 p.m. R17 was not in the room during this observation. No staff were present in the area. At 3:27 p.m., R9 walked back into R17's room. R17 was not present. At approximately 3:29 p.m., R9 walked out of R17's room. At 3:41 p.m., R9 was observed to enter R17's room. R17 was in the room at this time and began yelling, She's in my room! Get someone! Get her out of here! No staff were present in the area. At 3:42 p.m., R9 left R17's room and walked down the hallway towards R16, who was seated in a wheelchair in the hall. Nurse Technician (NT) D was located next to R16. When R9 approached, R16 yelled, Get her away from me! NT D directed R9 to sit in a lounge next to the hallway, in which R16 was seated; however, R9 walked back towards R16. As R9 re-approached, R16 yelled, I said get her away from me! NT D walked R9 to the lounge and had the resident sit on a couch. At 3:48 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) A. CNA A stated R9 walks in and out of other residents' rooms day and night, and the resident is sometimes hard to redirect to another area. CNA A stated there are times in which staff have had a difficult time finding R9, since she is in another resident's room. CNA A stated R9 will take other resident's belongings out of their rooms at times. When Surveyor asked what staff has done for interventions, CNA A replied staff attempt to take R9 for a walk, offer something to eat, offer the resident an activity or to clean, or provide a doll which helps the resident. Surveyor did not observe staff provide these interventions during the above observations. 4. R6 was admitted to the facility 07/17/17. R6 lives on the Cedar Lane Household. Currently 13 residents reside in this household. On 08/09/17 at 8:00 a.m., Surveyor interviewed R6 about his room and environment. R6 indicated everything was going well except for the lady who kept coming into his room all the time. R6 went on to say that this lady had come into the room at 4 a.m., and messed with all of his personal photographs that he has on display. R6 stated that sometimes the resident actually takes the items from his room. R6 does not know what can be done about this, but would like to have this resident stay out of his room and not touch his belongings. R6 indicated he likes to spend most of his time in his room, and likes privacy. Surveyors observed R9 during two days of survey wandering in and out of resident rooms, as well as wandering into other living areas of the facility. R9's care plan, Alteration in thought process, related to dementia, manifested by: .wandering .intrusiveness .Interventions: .likes to walk wander around. Can be intrusive into others rooms/space. If it is not causing an issue when rearranging items allow her to do this and return item later . On 08/09/17 at 1:30 p.m., Surveyor interviewed the Director of Nursing (DON) about the above concerns. Surveyor shared R9 was invading the privacy of all the residents that reside on the Cedar Lane Household, and taking their belongings at times. The DON acknowledged that R9 was very busy and was known to go in others' rooms. Surveyor shared residents had expressed a concern with the lack of privacy and ability to protect their personal belongings from R9.

Based on medical record review, interview and observation, the facility did not ensure that residents who are unable to carry out activities of daily living receive the services to maintain good nutrition for 3 of 23 sampled and supplemental residents (R10, R15, R22), or provide services to maintain oral hygiene for 1 of 13 (R7) sampled residents. R10, R15, and R22 have cognitive impairments and need assistance at meal time. The residents did not receive the assistance needed for three meal observations. R7 was observed during morning personal cares. R7 was not offered or assisted with oral care. This is evidenced by: 1. R10 has a [DIAGNOSES REDACTED]. The care plan in part, Eating: Cues/supervison . On 08/08/17 at 12:00 p.m., Surveyor observed R10 served the lunch meal that consists of potatoes, pork, gravy, and asparagus. R10 was not feeding herself. -At 12:10 p.m., R10 started wheeling away from the table. -At 12:20 p.m., R10 sat with food untouched, no cues or assistance was provided to R10. -At 12:25 p.m., R10 wheeled away from the table, without eating any of the food. The food was cleared and discarded. On 08/09/17 at 7:55 a.m., R10 was up in her wheelchair with her head leaning forward, almost into her lap. R10 was seated at the kitchen counter area and served her breakfast at 8:20 a.m. The breakfast was pancakes, sausage and a soft cooked egg. Surveyor continued to observe R10 sleeping at 8:30 a.m., no assist, cues or supervision was given. Surveyor continued to observe R10 until 9:05 a.m., sleeping with her head leaning forward. No assist or cues were given. At 9:10 a.m., Certified Nursing Assistant (CNA) I took all of the untouched food and drinks and discarded it. On 08/09/17 at 12:30 p.m., Surveyor observed R10 seated at the counter with her noon meal in front of her. R10 kept standing up from her wheelchair. CNA K told R10 to sit down. No cues or assistance with the meal were given. At 12:38 p.m., R10 stood up again pushing back on her wheelchair. No cues or supervision were given to assist R10 with eating. At 12:45 p.m., R10 was not eating but standing up and started to climb over the wheelchair. R10 had not eaten any food at this time. 2. R15's care plan in part: Eating/swallowing: Staff to feed R15 as he is not able to feed self, dependent 1 assist . On 08/08/17 at 12:05 p.m., Surveyor observed R15 served his lunch, Surveyor continued to observe as R15's meal sat in front of him with no assistance offered. The observation continued until 12:25 p.m. R15 had not been helped to consume any of his food or fluids. 3. R22's care plan in part: Eating/swallowing: .needs to be 1:1 observation due to delay of swallow and aspiration risk .dependent 1 assist . On 08/08/17 at 11:55 a.m., Surveyor observed R22 being served his noon meal. The two CNAs on the unit were in the kitchen area serving food, as the meal sat in front of R22. The food sat uncovered and untouched until 12:15 p.m. when R22 was assisted with the meal. On 08/09/17 at 8:30 a.m., R22 was served his breakfast, but not offered any assistance to eat. The two CNAs were in the kitchen area serving drinks and other items. -At 8:35 a.m., CNA I assisted a dependent resident to the left of R22, but did not assist R22. -At 8:40 a.m., CNA K spoke to R22 and lifted the broda chair up into a sitting position. CNA K then left the dining area. -At 8:44 a.m., R22 was offered his first bite of food. On 08/09/17 at 12:20 p.m., R22 was served his noon meal. At 12:38 p.m., CNA K assisted R22 with his meal. On 08/09/17, Surveyor interviewed the Director of Nursing (DON) about the above observations. The DON indicated the staff are to serve the residents as they come to each meal and assist them right away. The DON stated there is a call tree staff are to use to ask for assistance at meal time if they are having problems. On 08/10/17, Surveyor interviewed CNA K about the process for serving dependent residents. CNA K said ideally it is to be person centered. The dependent residents should not be served until the staff are available to help them. CNA K acknowledged the staff should have called for more assistance. Surveyor asked why that did not happen. CNA K stated, We were busy and did not think of it. The 04/21/17 facility policy entitled Oral Hygiene reads in part: Good oral health is important to our residents overall well being. The purpose of oral hygiene is to keep the mouth, teeth, gums, and tongue healthy. All residents should receive oral hygiene at least twice daily, in the morning and evening. R7's 06/07/17, Minimum Data Set (MDS) assessment identifies R7 requires extensive assistance of one-two staff with dressing, hygiene, bathing and other activities of daily living. This MDS also identifies R7 is edentulous. R7's Certified Nursing Assistant (CNA) Assignment Card/Care Plan reads in part: ORAL CARE: Extensive assist 1 assist often refuses. Per primary staff if you assure him that you will be quick with swabbing with the toothette he will be more open to allowing oral care. He is edentulous. On 08/08/17 beginning at 7:03 a.m., Surveyor observed CNA E and CNA F provide personal cares for R7. After R7 was in his Broda chair, CNA E left the room. CNA F put R7's tray table by him with his call light. As CNA F was about to leave the room, Surveyor asked if they were done with R7's cares. CNA F said yes. Prior to starting R7's personal cares, Surveyor noted R7 had an approximate 0.5 centimeter (cm) by 0.3 cm area of a dried substance on R7's left upper lip. This substance was present after CNA E had washed R7's face. During the above care observation, R7 was not offered or assisted with oral care. On 08/08/17 at 1:50 p.m., Surveyor interviewed CNA E regarding the observation of R7's cares that morning. Surveyor asked CNA E if they had done oral care prior to Surveyor entering the room for cares. CNA E said no. CNA E asked Surveyor, didn't (CNA F) do it after I (CNA E) left the room. Surveyor said no. CNA E then said we usually do it after the meal and that R7 does not like to have oral care done.

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 9 (R9, R10, R6) sampled residents reviewed for accidents and supervision. R9 has a history of wandering, exit seeking, and being intrusive to other resident's rooms. R9 was observed to wander into a laundry room, unable to get out. The laundry room contained chemicals that were unlocked. R10 has a history of three recent falls from her wheelchair. R10 was observed to nearly fall three times during survey without supervision or assistance of staff. R6 has a history of five falls in three weeks. The most current fall intervention to wear only velcro shoes was not implemented for R6. This is evidenced by: 1. R9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R9 was identified as an elopement risk and has a wanderguard in place. R9's brief interview for mental status score on the 06/12/17 Minimum Data Set identifies severe cognitive impairment. The care plan, Alteration in thought process related to dementia, manifested by: .wandering .intrusiveness .Goal: Will not elope .Maintain safe environment for self and others. Increase level of supervision as needed to maintain safety . R9 was observed on the first two days of survey wandering in and out of several rooms on the Cedar Lane household. On 08/08/17 at 1:20 p.m., R9 was wandering in and out of the Garden Terrace household. Surveyor continued to observe R9 wandering around the Cedar Lane household. -At 1:35 p.m., R9 started to play with the laundry room door handle. -At 1:40 p.m., R9 was able to open the laundry room door and enter the room. Surveyor observed R9 in the laundry room, trying to get back out. The staff on the unit were not aware of R9's location. Surveyor observed R9 play with the door handle trying to get out of the room. -At 1:45 p.m., a male visitor approached Surveyor and asked if anyone knew where his wife was. Surveyor asked for the name of the resident. The male visitor stated R9's name. Surveyor pointed in the direction of the laundry room that was visible from where they were standing. At this time, Licensed Practical Nurse (LPN) J heard the conversation and came to assist R9 out of the laundry room At 1:50 p.m., Surveyor entered the laundry room and noted the cupboards were not locked, and easily accessible to R9. The first top cupboard contained Odo Ban that stated, Store in areas inaccessible to small children, avoid contact with eyes. If on skin, rinse immediately. The second cupboard contained an open bottle of Isopropyl Rubbing Alcohol 70%. The material safety data sheet includes in part: Ingestion: If swallowed obtain immediate medical attention .Eyes: causes serious eye irritation. Irrigate copiously with clean water for at least 15 minutes . On 08/08/17 at 1:35 p.m., Surveyor interviewed the Director of Nursing (DON) about the above observation. The DON indicated all laundry rooms were to be locked. The DON acknowledged that R9 was very busy with her wandering and needed increased supervision to be safe in the facility. 2. R10 was admitted [DATE] with a history of falls prior to admission. R10 had four falls from her wheelchair from 06/16/17 - 08/01/17. The falls care plan in part: Potential for trauma-falls .See ADL (activities of daily living) care plan which includes in part: Locomotion: 1 assist with walker, standby .Transferring: Standby, 1 assist will transfer herself. If witness doing so, standby .Ambulation: 1 assist walker .Equipment: W/C auto-brakes, walker pressure reduction cushion, .wedge pillow at table or on lap when she is sleepy and sitting with head bent into lap or forward in her chair . Observations On 08/08/17 at 11:58 a.m., Surveyor was observing the noon meal. R10 was in the TV living area, and standing from her wheelchair, pushing back on the chair. Staff were not in the area, as R10 started to ambulate away from the wheelchair. Surveyor called out to Licensed Practical Nurse (LPN) J to assist R10 so she did not fall. On 08/08/17 at 1:30 p.m., Surveyor was observing residents and noted R10 by the couch in the living area, leaning forward, using her hands to grab the end table in front of her to try to stand. Surveyor observed as R10 made three attempts to stand. R10 tried again and stood up from the wheelchair, leaning far forward. Staff were not supervising R10. Surveyor went to LPN J to get assistance for R10 so she did not fall. On 08/09/17 at 12:30 p.m., Surveyor observed R10 seated at the kitchen counter for her noon meal. R10 was standing up from the wheelchair several times. -At 12:35 p.m., CNA K told R10 to sit down. -At 12:38 p.m., R10 stood up again, pushing back on the wheelchair with the anti-tip device and auto brakes. R10 was lifting up the front wheels of the wheelchair as she pushed back harder on the wheelchair. -At 12:45 p.m., R10 continued to stand up and push back on the wheelchair, at this time R10 lifted her left leg up and around the left arm rest of the wheelchair to try to walk away from the wheelchair. Staff were not supervising R10. At this time, Surveyor went to CNA I to get assistance for R10 so she did not fall from her wheelchair. On 08/09/17 at 1:30 p.m., Surveyor interviewed the DON about the above observations. The DON acknowledged that R10 will get up and try to walk on her own, staff are expected to supervise and assist R10 at these times to prevent falls. 3. R6 was admitted to the facility on [DATE] with Parkinson's disease and a history of falls prior to admission. R6 has had four falls since admission. The most recent fall occurred on 08/07/17. The root cause was identified as having the shoe laces untied, causing a tripping hazard. The new intervention was to wear velcro secured shoes. The care plan, Potential for trauma-falls, related to weakness, confusion, impaired balance, Parkinson's Interventions: Therapy recommendations (08/02/17) use the 4 WW .encourage and assist to keep room picked up a and free from clutter.encourage non-skid footwear. 07/21/17, Signs placed in resident's room/bathroom reminding him to use call light if assistance is needed. The CNA care plan contains the same information. On 08/08/17 at 9:00 a.m., Surveyor observed R6 at breakfast ambulating with his four wheeled walker, wearing tennis shoes with laces. -At 12:00 p.m., Surveyor observed R6 in the dining area at the table wearing tennis shoes with shoe laces. On 08/09/17 at 7:00 a.m., Surveyor observed R6 in his room wearing tennis shoes with laces. The black velcro tennis shoes were lying by the bed. -At 8:44 a.m., Surveyor observed R6 walking with the four wheeled walker to the dining room, with the long laces hitting the floor as R6 was walking. On 08/09/17 at 1:30 p.m., Surveyor interviewed the DON about the above observation. At 2:30 p.m., the DON provided Surveyor with a memo instructing the staff to have R6 wear only velcro shoes. The most recent intervention was not located on the care plan.

Based on observation and interview, the facility did not ensure accurate administration of insulin for 3 (R19, R20, and R21) of 3 residents observed receiving insulin during medication pass. The insulin syringes had been drawn up and placed into a plastic cup prior to administering. The insulin syringes were not labeled. This is evidenced by: The Association for Professionals in Infection Control (APIC) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care, (YEAR) states in part: Label all syringes containing medication if not immediately administered. Include patient identification information, names and amounts of all ingredients, and the name/or initials of the person who prepared the CSP (Compounded Sterile Products, which include compounded biologics and drugs), date and time the CSP was prepared, and beyond use date and time. On 08/08/17 at approximately 7:45 a.m., Surveyor observed Licensed Practical Nurse (LPN) G administer insulin to R19. LPN G took a plastic cup from the medication cart that had R19's first name on it with an insulin syringe in the cup. The insulin syringe did not have a label on it and contained 18 units of insulin. LPN G stated she did not have the insulin vial on the medication cart. LPN G stated the insulin was drawn up in the morning at approximately 7:00 a.m. in the medication room with LPN J. LPN G told Surveyor that R20 and R21's insulins were also drawn up. LPN G showed Surveyor two additional plastic cups. These cups were labeled with R20's first name and R21's first name. Both cups contained an insulin syringe without a label. The cups were stored in the medication cart. At 7:50 a.m., Surveyor observed LPN G administer insulin to R20. R20's insulin was stored in the plastic cup without a label. At 8:10 a.m., LPN G told Surveyor that she should have kept the vials of insulin in the cups with the syringes. On 08/08/17 at 3:55 p.m., the Director of Nursing (DON) explained to Surveyor the procedure for the facility was to draw up the insulin with two nurses, and place the syringe and the vial in the plastic cup. The DON did not indicate that the syringe should be labeled.

Based on observation and interview, the facility did not establish and maintain an Infection Control Program designed to provide a sanitary environment and to help prevent the transmission of disease and infection for 2 of 12 sampled residents and 1 supplemental resident (R9, R17 and R7). Staff did not assist Resident (R) 9 with washing or sanitizing the resident's hands, after the resident touched a soiled incontinent product, then touched another resident on the unit. This affected one of 13 residents (R17) on Cedar Lane. R7 was observed during incontinence care, where the Certified Nursing Assistant (CNA) did not perform hand hygiene in a manner to prevent the spread of infection. This is evidenced by: 1. On 08/08/17 at 3:27 p.m., R9 walked into R17's room. R17 was not present. R9 walked to a garbage container located adjacent to the bathroom. R9 pulled the garbage bag up from the container with the left hand, reached into the bag with the right hand and rummaged in the bag At 3:28 p.m., R9 pulled out a soiled incontinence pad from the garbage container, turned and walked around R17's bed, holding the soiled pad. The pad was soiled with fecal matter. At this time, Certified Nursing Assistant (CNA) C walked by the room. Surveyor asked CNA C to assist R9. CNA C entered R17's room, gloved and removed the incontinence pad from R9. CNA C then went into R17's bathroom. CNA C did not attempt to wash or sanitize R9's hands after removing the soiled incontinence pad. At approximately 3:29 p.m., R9 walked out of the room and into the hallway. R9 walked approximately eight feet down the hall and approached R17, who was seated in a wheelchair. R9 used both hands to touch R17's left shoulder for approximately three seconds, then R9 used both hands to touch R17's left cheek for approximately three seconds. At 3:31 p.m., R9 walked towards Nurse Technician (NT) D, and touched NT D's left hand. At this time, CNA C approached R9 and had the resident sit on a couch in the lounge. CNA C handed R9 one sheet of a sanitizing wipe and both CNA C and NT D told R9 to wipe her hands with the wipe. NT D left the area. Surveyor observed R9 ball up the sanitizing wipe in the left hand and appeared to not know how to use the wipe. R9 did not correctly use the sanitizing wipe by wiping both hands, palms, fingers, fingertips, and between the fingers. At 3:35 p.m., CNA C left the lounge and NT D removed the sanitizing wipe from R9's hands. Staff did not attempt to wash or correctly sanitize R9's hands after touching a soiled incontinence product. The resident's Brief Interview for Mental Status (BIMS) score, dated 06/12/17, indicates the resident has severely impaired cognition. On 08/09/17 at 2:44 p.m., Surveyor discussed the above observation with the Director of Nursing (DON). The DON stated CNA C should have thrown the incontinence product away and immediately washed or sanitized R9's hands. The facility's Infection Control Standards policy revised 05/16/17, read in part: Decontaminate hands after removing gloves. And Perform peri-care . Remove gloves and perform hand hygiene. 2. R7 has [DIAGNOSES REDACTED]. R7's 06/07/17, Minimum Data Set (MDS) assessment identifies R7 requires extensive assistance of one-two staff with hygiene, bathing and toileting needs. On 08/08/17 beginning at 7:03 a.m., Surveyor observed CNA E and CNA F provide personal cares for R7. R7 was incontinent of feces. CNA E cleansed R7's rectal area and inner buttocks and dried these areas. Without removing her gloves and performing hand hygiene, CNA E handled a tube of barrier cream and squeezed the barrier cream into her soiled right glove and applied the barrier cream to R7's peri rectal area, inner buttocks and outer buttocks. CNA E then removed her soiled gloves, grabbed some paper towels and wiped sweat from her forehead and face and then sanitized her hands. On 08/08/17, beginning at 1:50 p.m., Surveyor spoke with CNA E about infection control concerns during the above observation. CNA E told Surveyor she has always done the barrier cream that way and no one has said anything about it before.