Every finding on record at Lakewood Manor

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's ice machine, electric mixer, manual can opener, food preparation pans, and a kitchen drawer which housed food preparation equipment clean; failed to cover and date stored foods; and keep the second-floor service kitchen's ice machine clean. This failure had the potential to affect all 84 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated 01/01/23, revealed, Policy: The food service area shall be maintained in a clean and sanitary manner. 2. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair .12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the facility's policy titled, Food Receiving and Storage, dated 01/01/23, revealed, All foods stored in refrigeration or freezer will be covered, labeled, and dated (use by date). 1. Observation during the initial kitchen inspection on 06/20/23 from 12:35 PM to 1:05 PM, with the facility's Administrator present, revealed the following unclean stored and ready for use food preparation equipment: a. The interior of the kitchen's large ice machine had brown and pink colored substance that could be wiped away with a paper towel. b. The kitchen's large electric mixer had dried food substances on the mixer's metal guard, underside of the mixer's head and the mixer's base. c. A kitchen drawer, with food preparation equipment stored inside had food debris and crumbs. d. The kitchen's manual can opener was attached to a food preparation table had accumulated sticky substances on its blade and metal table base attachment. e. Eight of 10 food preparation pans, stacked tightly together and ready for use, had accumulated moisture on their interior surface. Three of these pans had food residues on their interior surface. During an interview on 06/20/23 at 1:05 PM, the Administrator confirmed the kitchen's ice maker, electric mixer, manual can opener, food preparation pans and a drawer housing food preparation equipment were not clean. The Administrator stated food preparation equipment should be kept clean by staff. 2. Observation during the initial kitchen inspection on 06/20/23 from 12:35 PM to 1:05 PM, with the Administrator present, revealed the following concerns with food storage: a. Observation of food stored in the kitchen's walk-in freezer revealed a large bag of hush puppies and a large bag of potato crisps were stored opened. b. Observation of food stored in the kitchen's walk-in refrigerator revealed the following previously opened foods were not dated: a gallon container of mayonnaise, a gallon container of light raspberry dressing, a gallon container of poppy seed dressing and a gallon container of cocktail sauce. During an interview on 06/20/23 at 1:05 PM, the Administrator stated food should be dated when opened and completely closed when stored by staff. 3. Observation of the second-floor service kitchen, with the Dining Service Manager (DSM) present, on 06/22/23 at 12:10 PM revealed the interior of the kitchen's ice machine had black colored substance. The black colored substance could be wiped away with a paper towel. During an interview on 06/22/23 at 12:10 PM, the DSM stated the second-floor kitchen's ice machine should be kept clean by staff.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide services as outlined in the comprehensive care plan that meet professional standards of quality for 1 Resident (#50) in a survey sample of 33 Residents. The findings included: For Resident #50 the facility staff failed to accurately transcribe the Registered Dietician and the Wound Care Physician's orders. On 6/21/23 a review of the clinical record of Resident #50 was conducted. Excerpts from the dietician notes are as follows: 12/20/22 at 1:18 PM - Sig change for new wound. Please refer to [Registered Dietician name redacted] regarding new wound. Prostat was added daily x 4 weeks. Recommend adding zinc and vitamin c for healing as well. Resident # 50 was seen by the wound specialist on 12/21/23 who made the following notes: Recommendations: Off-load wound. Reposition per facility protocol. Group 2 mattress; Gel cushion to chair, incontinence protocol with brief check and house barrier ointment applies q shift and prn. Vitamin C 500 mg twice daily, Zinc sulphate 220 mg PO daily for 14 days. On 12/21/22 the following orders were put in INCORRECTLY. Vitamin C 500 mg tablet (Ascorbic acid) -500 mg by mouth every day for wound healing. stop date 1/21/23 [The order should have been twice daily] Zinc 50 mg by mouth every day for wound healing stop date 1/21/23 [The order should have been 220 mg.] Prostat 30 ml po q day to supplement X 4 weeks. stop date 12/29/23. [The stop date should have been 1/26/23] On 6/22/23 at approximately 11:00 AM an interview was conducted with Employee J who stated that she had seen the wound and made recommendations to the dietician and the wound care specialist. The error was in the transcription of the orders from the dietician and the wound care specialist regarding the Prostat and the Vitamin C and Zinc orders. The orders were later corrected on 3/16/23 and the appropriate vitamins and supplements were given in the correct amounts. According to the website for the National Institutes of Health following the 5 Rights of Medication Administration can aid in avoiding medication errors. The National Institutes of health website - https://www.ncbi.nlm.nih.gov/books/NBK560654/ 'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. 'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed. 'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. 'Right dose' - Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. On 6/23/23 during the end of day meeting, the Administrator was made aware and no further information was provided.

Based on observation, and interview, the facility failed to make the results of their most recent survey conducted by Federal or State surveyors accessible for residents, family members, and legal representatives of residents to review. This failure had the potential to affect all 84 residents who resided in the facility. Findings include: A group interview was conducted on 06/21/23 at 1:30 PM with eleven residents whom the facility identified as reliable historians. During the meeting, eleven of the eleven residents (Resident (R)5, R7, R19, R30, R32, R41, R51, R54, R58, R190, and R191) who participated were unaware where the facility's previous survey results conducted by Federal and State surveyors could be located and reviewed in the facility. An observation on 06/21/23 from 3:15 PM to 3:45 PM of the facility's first, second, and third floors revealed the facility's previous survey results could not be located and there was no posted information which notified residents, family members, and legal representatives of residents where the facility's previous survey results could be located and reviewed without having to ask a staff member. An observation on 06/23/23 from 12:15 PM to 12:35 PM of the facility's first, second, and third floors, with the Administrator, revealed the facility's previous survey results could not be located in the facility. Additionally, no posted information was observed in the facility which notified residents, family members, and legal representatives of residents where the survey results could be located and reviewed without having to ask a staff member. During an interview on 06/23/23 at 12:35 PM, the Administrator confirmed the facility's prior survey results could not be located in the facility at this time and he would ask staff to continue to try to find them. The Administrator stated the facility's prior survey results were previously placed in a notebook and kept on the first floor for review. Since the facility's first floor was currently undergoing construction a staff member may have moved the survey results notebook to a different location. During an interview on 06/23/23 at 12:50 PM, the facility's Assistant Director of Nursing (ADON), stated she found the notebook which contained the facility's prior survey results. The ADON stated the notebook was found on a shelf on the facility's third floor.

Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement their infection control policy and procedures with regards to COVID-19, including maintaining an accurate record of staff's COVID-19 vaccination status, conducting COVID-19 testing, wearing proper PPE (personal protective equipment). In addition, the facility had a COVID-19 outbreak, which resulted in 14 Residents testing positive for COVID-19 and one Resident (Resident #3) being hospitalized , which is harm. This noncompliance affected Residents on all 5 halls/units within the facility. Specifically, the facility staff failed to implement their infection control policies and procedures with regards to COVID-19, as evidenced by: 1. Two observations were made of staff entering rooms of Residents on TBP (transmission based precautions) (Resident #1 and Resident #20) with confirmed COVID-19, without wearing proper PPE. 2. Staff were observed throughout the facility, on all 5 nursing units/halls, providing direct Resident care without wearing any eye protection. Due to being in an area with a high level of community transmissibility eye protection was to be worn during all patient care encounters. 3. Nine Residents (Resident #5, 6, 7, 9, 10, 12, 13, 14 and 16) who were exposed to COVID-19 and were not up to date with COVID immunization were not placed on quarantine as per CDC guidance. 4. The facility staff failed to conduct testing of Residents who were exposed to COVID positive staff on 4 of 5 Resident halls. The facility staff was not conducting complete and accurate contact tracing to identify other Residents who may have been potentially exposed. 5. The facility staff has failed to maintain complete and accurate documentation with regards to employee's vaccination status. (Staff # 9) was noted on the staff vaccination matrix as completed the COVID primary vaccination series and had received a booster dose, however, her immunization record on-file indicated she had only received one of a two dose vaccination series). 6. The facility staff failed to conduct routine COVID-19 testing of employees who had an approved COVID-19 vaccination exemption. 7. The facility staff failed to conduct routine testing of agency staff who were not up-to-date with immunizations. Immediate Jeopardy was identified on 08/26/22 at 9:40 AM, at which time the facility was notified. After verification, Immediate Jeopardy was removed on 08/30/22 at 4:00 PM. The findings included: 1. Two observations were made of staff entering rooms of Residents on TBP (transmission based precautions) (Resident #1 and Resident #20) with confirmed COVID-19, without wearing proper PPE. On 8/24/22 at approximately 12:50 PM, CNA B was observed to exit the room of Resident #1. CNA B was not wearing any eye protection. There was signage on the door to indicate Resident #1 was on TBP and a station was set-up with personal protective equipment (PPE) outside of the room. When asked, CNA B confirmed that she was feeding Resident #1. When asked about eye protection she said she usually does wear it in the rooms of COVID Residents but I had washed it off and was waiting for it to dry. CNA B confirmed that Resident #1 has an active COVID infection. On 8/25/22 at 9:55 AM, CNA H was observed to enter the room of Resident #20, who had signage on the exterior of the room that they were on TBP. CNA H was wearing a KN-95 only, she was observed to enter without putting on an N-95, eye protection, isolation gown or gloves. CNA H stepped back out into the hallway a moment later with gloves in her hand. When asked what PPE she is supposed to wear when entering the room she stated, gloves, gown, and eye protection. When asked why she had entered without wearing those items she stated she had gone in to get gloves. When asked what was wrong with the gloves on the cart outside of the room, she said she didn't see those. There were two boxes of gloves observed and pointed out that were on top of the cart that contained isolation gowns. CNA H then put on an isolation gown, gloves and eye protection and reentered the room. On 8/25/22, during an end of day meeting the facility Administrator and Director of Nursing confirmed they follow CDC guidance with regards to COVID-19. 2. Staff were observed throughout the facility, on all 5 nursing units/halls, providing direct Resident care without wearing any eye protection. Due to being in an area with a high level of community transmissibility eye protection was to be worn during all patient care encounters. On 8/24/22 at approximately 12 Noon, a tour of the facility was conducted by Surveyor B. Nurses, certified nursing assistants, therapy staff, and housekeeping employees were all observed entering Resident rooms wearing no eye protection on all 5 of the Resident care hallways and entering Resident rooms to provide direct care or be within a few feet of the Residents. The following specific observations were noted on the third floor: a. Employee F was in a room providing care to a Resident without eye protection. According to the staff vaccination matrix, Employee F was not up to date with COVID immunizations. b. LPN C entered a room to provide medication wearing no eye protection. LPN C was not up to date with COVID immunizations. c. CNA C was pushing a Resident in the hallway to their room, wearing no eye protection. CNA C was not up to date with COVID immunization per the staff vaccination matrix. d. Employee E was ambulating a Resident in the hallway wearing no eye protection. Employee E was not up to date with COVID immunizations. e. CNA D was distributing meal trays to various Residents, setting up the Resident and food for the meal and had no eye protection on. CNA D was up to date with COVID immunizations. On 8/24/22 at approximately 12:30 PM, the following specific observations were made on the second floor: a. CNA E was distributing meal trays to Residents and was wearing no eye protection. b. CNA F was sitting beside a Resident feeding them with no eye protection on. c. LPN B was administering eye drops to a Resident wearing no eye protection. LPN B was not up to date with COVID immunizations. d. CNA B was feeding a Resident and had no eye protection on. e. CNA K entered a room to put a towel around the Resident in an effort to provide protection to the Resident's clothing while they ate, CNA K had on no eye protection. f. CNA K entered the room of a Resident and sat beside then and started feeding them without wearing eye protection. On 8/24/22 at 4:00 PM, observations were made on all of the Resident care halls and observations were again made on each hall of staff entering rooms to provide care without any eye protection. They included, but were not limited to, CNA G and LPN D. On 8/25/22 at 9:10 AM, observations were made on each of the Resident care units/hallways. LPN E was observed in a Resident room administering medications and did not have any eye protection on. Eye protection was observed on top of her medication cart, which had been left in the hallway while she entered the Resident room. On 8/25/22 at 9:14 AM, Surveyor B knocked on the door of Resident #7 and upon opening the door observed a therapy staff member in the room providing treatment who was not wearing any eye protection. On 8/25/22, during an end of day meeting the facility Administrator and Director of Nursing confirmed they follow CDC guidance with regards to COVID-19. 3. Nine Residents (Resident #5, 6, 7, 9, 10, 12, 13, 14 and 16) who were exposed to COVID-19 and were not up to date with COVID immunization were not placed on quarantine as per CDC guidance. On 8/24/22, the listing of Resident's COVID immunization status listing that the facility staff provided was reviewed. This review revealed that 12 current Residents are not up to date with COVID immunizations. Three of the 12 were currently on transmission based precautions for an active COVID infection. The other 9 Residents, (Resident #5, 6, 7, 9, 10, 12, 13, 14, and 16) rooms were observed and identified no signage or indication that they were on TBP. On 8/25/22 at 9 AM, a facility tour was conducted with special attention being made to Resident #5, 6, 7, 9, 10, 12, 13, 14, and 16's rooms. There was still no indication that the Residents were on TBP. Review of the facility submitted COVID line listing/infection report revealed that each of the nine Residents who were not up-to-date with immunizations had a possible exposure to COVID-19. The facility had not identified this during their contact tracing. Resident #14 was potentially exposed to CNA M on 8/14/22 and 8/15/22. CNA M tested positive for COVID-19 on 8/16/22. Residents #5, 6, and 16 were potentially exposed to COVID by CNA L on 8/17/22. CNA L tested positive for COVID 19 on 8/19/22. On 8/19/22, LPN G cared for Residents #5, 6, and 16. LPN G then tested positive for COVID-19 after her shift on 8/19/22. Resident #7 and #12 were potentially exposed to CNA L on 8/16/22. CNA L tested positive for COVID-19 on 8/19/22. Resident #13 was cared for by CNA B on 8/16/22 and 8/17/22. CNA B tested positive for COVID-19 on 8/18/22. Residents #9 and #10, were cared for by LPN H on 8/17/22. LPN H reported having COVID symptoms on 8/17/22 and then tested positive for COVID-19 on 8/18/22. Residents #7, 9, 10, 12, and 13 were cared for by LPN F on 8/17/22. LPN F had COVID symptoms on 8/17/22, then tested positive for COVID-19 on 8/18/22. On 8/25/22 at 10:21 AM, an interview was conducted with the facility Infection Preventionist. The IP stated that no one had trained her on how to conduct contact tracing but she knew to look back two days for potential exposures due to COVID having an incubation period. When asked to explain this, the IP said, That is when they may be infectious prior to exhibiting symptoms. When asked if she looked at who the staff had provided care to in the two days prior to a confirmed test, she said, No. 4. The facility staff failed to conduct testing of Residents who were exposed to COVID positive staff on 4 of 5 Resident halls. The facility staff was not conducting complete and accurate contact tracing to identify other Residents who may have been potentially exposed. Review of the testing logs for August 2022, revealed Resident testing occurred on 8/17/22, of the Residents on the 2nd floor third hall. There was a census sheet of the Residents residing on the third floor but no indication of any testing being conducted. Review of the COVID line listing revealed numerous staff had tested positive for COVID-19 in August. Review of the assignment sheets revealed the following: Residents on the second floor halls 1, 2 and 3 were exposed on 8/17/22, by LPN F who worked as the only nurse for the second floor and tested positive for COVID 19 on 8/18/22. Residents on the second floor hall 1 had an additional possible exposure on 8/17/22, by LPN H, who worked 8/17/22, and tested positive on 8/18/22. Residents on the second floor, hall 2 had an additional exposure on 8/16/22 by CNA L, who worked 8/16/22, and tested positive for COVID-19 on 8/18/22. Residents on the third floor, hall 1 were exposed 8/14/22 and 8/15/22, by CNA M, who worked both days and then tested positive for COVID-19 on 8/16/22. Residents on the third floor, hall 2 were exposed 8/17/22, by CNA L, who worked their hall and then tested positive for COVID-19 on 8/18/22. Residents on the third floor, hall 2 also had a possible exposure on 8/18/22 and 8/19/22, by LPN G, who tested positive for COVID-19 on 8/19/22. On 8/25/22, during a meeting with the infection preventionist (IP), the IP confirmed that contact tracing is conducted. When asked who trained her on how to conduct contact tracing, the IP said, No one, but I know to go back 2 days because of the incubation period of COVID. When asked to define incubation period, she indicated this is when a person could be infectious and not be symptomatic. When asked to show evidence of her contact tracing for the above noted staff members, CNA L, CNA M, LPN F, LPN G, and LPN H, she said, I look at the assignment sheet. When asked if she went back to the two days prior to the staff testing positive she said she did not. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy read, . 2) Residents determined to have close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. In this situation, testing is recommended immediately and, if negative again 5-7 days after exposure . The CMS (Centers for Medicare and Medicaid Services) issued QSO-20-38-NH with a revision date of 03/10/2022. It read, .Testing of Staff and Residents in Response to an Outbreak: An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents, regardless of vaccination status, should be tested immediately, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. See CDC guidance Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [CONDITION(S)]-CoV-2 . The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, was reviewed. It read, .Manage Residents with Close Contact: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from [CONDITION(S)]-CoV-2 infection in the prior 90 days who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section . 5. The facility staff has failed to maintain complete and accurate documentation with regards to employee's vaccination status. (Staff # 9) was noted on the staff vaccination matrix as completed the COVID primary vaccination series and had received a booster dose, however, her immunization record on-file indicated she had only received one of a two dose vaccination series). On 8/24/22, during the entrance conference with the facility Administrator, Director of Nursing and Infection Preventionist, they identified that Human Resources (HR) tracks the staff vaccination status. On 8/25/22 at 11:34 AM, a meeting was held with the HR Director, Employee H. She was given staff members names of Staff #1 and Staff #7. When verifying their vaccination status Employee H stated that the scheduling coordinator keeps copies of the agency staff's records. During the same interview on 8/25/22 at 11:34 AM, Employee H confirmed that the staff vaccination matrix submitted listed Staff #9 as having completed the primary vaccination series and had received a booster dose. When Employee H pulled the vaccination information for Staff #9 it was a print out of the Virginia Immunization Information System that noted Staff #9 only had 1 dose of the primary series of a Pfizer vaccine. Employee H confirmed the findings and stated the matrix was not accurate. On 8/25/22 at 2 PM, Employee H provided Surveyor B with a copy of Staff #9's vaccine card. Employee H said, She works 11 PM to 7 AM, shift so we called and woke her up and she took a picture and sent it to us. Employee H confirmed that prior to this, they were unaware that she had completed her primary series and the vaccination matrix was inaccurate. On 8/25/22 at 12:18 PM, Surveyor B met with Employee G, the scheduling coordinator. Employee G was asked if she keeps any record of the agency staff's vaccination status. Employee G said, We require everyone be vaccinated and the agency knows they can't send us anyone who isn't vaccinated. On 8/26/22 at 9:10 AM, Surveyor B met with Employee G again. When asked about agency staff's vaccination status, she said she just knows the facility requires that everyone be vaccinated so when the agency sends her information she just puts it in the file. She confirmed she doesn't keep a log or record of their immunization status. Employee G opened her desk drawer and pulled out a file that had copies of various agency staff's COVID vaccine cards. Review of this file revealed 7 who had indication they had only received 1 dose of a 2 dose primary series. When asked about this, Employee G said she would have to call the agencies. On 8/26/22 at 2 PM, Employee H, the Human Resources Director was conducting an audit of the employee vaccination matrix. She had only gotten 1/3 of the review completed and she told Surveyor B that she had identified 14 employees whose vaccination status was recorded wrong/incorrectly. 6. The facility staff failed to conduct routine COVID-19 testing of employees who had an approved COVID-19 vaccination exemption. Review of the staff vaccination matrix submitted revealed that Staff #3 had been granted an exemption from COVID immunization. On 8/25/22, Surveyor B met with the facility Infection Preventionist (IP) to review testing occurrences of the staff sample. The following was noted during this review: Staff #3, was tested on the following dates in the months of June-August: 6/9/22, 6/28/22, 6/29/22, 7/27/22, 7/29/22, 8/11/22, 8/12/22, 8/18/22, and 8/19/22. Review of Staff #3's timecard revealed in June, she had worked 17 shifts, in July she worked 21 shifts. In August, Staff #3 worked 15 shifts. Review of the facility submitted tracking of the community transmissibility rate of COVID revealed they had remained at a high level for all of June, July and August. Review of the facility policy titled Mandated COVID-19 Vaccine Exemption Review Policy & Procedure with a revision date of 6/29/22, was conducted. This policy read on page 3, 11 .Team members who are not fully vaccinated will be required to submit to weekly, routine COVID-19 testing provided by the community .13. While this policy remains in effect, it is expected that federal, state, and local regulations and operations needs may frequently change. This policy will be updated to accommodate changing conditions as required. The policy titled, Mandated COVID-19 Vaccine- Protocol for Granted Exemptions Policy was reviewed. This policy read on page 3, .Note: if the community is testing at an interval more frequent than weekly, team member will adhere to the more frequent testing interval, i.e. outbreak situation or high to moderate county transmission rate. This will be communicated by community leadership if this applies . 7. The facility staff failed to conduct routine testing of agency staff who were not up-to-date with immunizations. On 8/25/22, Surveyor B used the as-worked schedule and staff vaccination matrix to select a staff sample, which was reviewed for COVID immunization and testing. On 8/25/22 at approximately 10 AM, Surveyor B met with the facility's infection preventionist. The IP confirmed she was the person that maintained records of all of the staff testing. She was given the name of Staff #1 and asked to provide the dates of COVID testing. The IP stated, I don't have her, I don't think she works here. The IP was told she was an agency staff person, and the IP stated that they do not conduct COVID-19 testing of agency staff unless they are symptomatic. The IP was then given the name of Staff #7. The IP said, I don't have her. She was told she was another agency staff member and the IP said, If she was not symptomatic, they screen when they come in but if they aren't symptomatic we don't test them. On 8/25/22 at 11:34 AM, Surveyor B met with the Human Resources Director, Employee H. Employee H was given Staff #1's name and Employee H confirmed that Employee H had worked 8/24/22. The HR Director, Employee H confirmed that Staff #7 was agency and worked 6/29/22, 7/9/22, 7/24/22, 7/25/22, and 8/24/22. Employee H, the HR Director looked and confirmed that she didn't maintain record of the COVID immunization status for agency staff, she identified that Employee G kept that information. On 8/25/22, in the afternoon, Surveyor B met with Employee G, the scheduling coordinator. She was given the name of Staff #1 and #7 and was asked to obtain her COVID vaccination information. Employee G later provided vaccination records that confirmed both Staff #1 and #7 had received the primary vaccination series, but were not boosted, which meant they were not up-to-date, and therefore were subject to routine testing. Employee G provided Surveyor B with a listing of agency staff that had worked at the facility. For the months of June and July, 24 agency staff had worked at the facility. On 8/25/22, during the end of day meeting the facility Infection Preventionist again confirmed that agency staff were not tested for COVID-19 routinely and she had no records for any routing testing of the agency staff. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy read, .[company name redacted] will attempt to follow the testing requirements, to the extent possible, based on the parameters set forth by the Department of Health & Human Services, CMS. This applies to resident and team member testing, including providing services under arrangement and volunteers for COVID-19 .Routine Testing of Team Members: 1) Routine testing of team members, who are not up-to-date, is based on the extent of the virus in the community- using the most recent community transmission level for the trigger for team member testing frequency per CMS guidelines III. Who should be tested : Individuals included in the testing include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in training programs or from affiliated academic institutions . The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 7, read, Expanded screening testing of asymptomatic HCP [Healthcare Personnel] should be as follows: .In nursing homes, HCP who are not up to date with all recommended COVID-19 doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a [CONDITION(S)] test twice a week .If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). Review of the CMS (Centers for Medicare & Medicaid Services) Memo Ref: QSO-20-38-NH, revision date 3/10/2022, subheading Documentation of Testing, page 10, item 3 read, For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated (e.g., every week), and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for staff, who are not up-to-date, and the results of each test and page 11, For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner . 8. During the last 4 weeks the facility had 14 Residents test positive for COVID-19 and Resident #3, was hospitalized and remained in the hospital at the time of survey. Review of the facility submitted COVID line listing revealed that from 8/13/22-8/23/22, 14 Residents had tested positive for COVID-19. According to this line listing, Resident #3 tested positive for COVID on 8/16/22. Review of Resident #3's chart revealed the following: A progress note dated 8/16/22 12:52 PM, read, Pt [patient] test with Rapid covid test with positive result and placed on isolation for 10 days. Pt and RR/Daughter [name redacted] aware of results and infection control nurse [name redacted] given [Resident daughter's name redacted] number to answer questions about request for those med's they put them on and we cannot take her home, I cannot take care of her. A nursing note dated 8/17/22 2:17 PM, read, Resident requested to have another COVID test. Test was completed and it was positive. A note dated 8/22/22 at 3:14 PM read, Resident was sent out to the emergency room by ambulance. Residents Sats [oxygen saturation] were 80% on 3 liters of oxygen. RP [name redacted] was called and made aware that her mom was being sent out to the emergency room to be evaluated. At 4:06 PM, a note read, EMT arrived w [with] stretcher at 1526 [3:26 PM] to transport pt to [hospital name redacted] . At 8:14 PM, a note read, Writer spoke with ED nurse and was informed pt is requiring 15 liters of oxygen/NWB with a current o2 sat of 100% and nebulizer txs with a confirmed COVID test results at the ED [sic] . A review of the hospital history and physical, provided by the facility staff, for Resident #3 was conducted. This document read, .She has been doing well until today, when she developed shortness of breath and dyspnea. EMS [emergency medical services] was called, and she was found to be hypoxic which improved with NRB [non-re-breather] In the ED [emergency department] satting 93% on 10 L NRB [10 liters of oxygen via non re-breather mask] .COVID-19 test positive . Immediate Jeopardy (IJ) was identified and called on 8/26/22 at 9:40 AM. Surveyor B met with the facility Administrator, Director of Nursing and Infection Preventionist to notify them of IJ and the above findings. A copy of the IJ Template was emailed to the facility Administrator and Director of Nursing. On 8/27/22, the facility submitted an acceptable removal plan to remove IJ. The Plan outlined steps to immediate action taken by the facility to prevent a serious adverse outcome from occurring or recurring. The removal plan read as follows, Testing for COVID-19: 100% testing of all current residents will be completed by the end of the day today. Test results will be documented in the resident's medical record. TBP will be implemented for any cases of positive results. New admissions will be tested and appropriate TBP will be implemented based on facility policy and CMS guidelines. All team members, including agency staff, will continue to be screened prior to starting their assigned shift and will have completed a rapid COVID test. Testing of all team members including all agency staff will be completed prior to start of shift. All team members who have an approved COVID vaccine exemption will be tested per facility protocol and based on community outbreak status. Testing results of team members, including agency staff, will be maintained in a log by the IP and updated at least daily Monday through Friday. Re-educate the IP and DON related to the facility policy based on CMS and CDC guidelines regarding the testing of staff and residents. Re-education will be done today by the VP of Clinical Services. Tracking of Team Member Vaccination Status, including agency staff and contracted staff Facility tracking log regarding vaccination status of team members, including agency staff, will be reviewed, and updated to reflect all current staff (including agency and contracted staff) vaccination status including data regarding boosters. This will be done by Human Resources in collaboration with IP and appropriate department heads. Human Resources, in coordination with IP, will be re-educated regarding the tracking of COVID vaccination status, including boosters, of all team members and will maintain a current tracking log. This education will be conducted by the VP of Clinical Services. Appropriate PPE utilization - use of face shields/goggles and use of PPE for residents on TBP All team members will be re-educated regarding the use of appropriate PPE at their next scheduled work assignment. This education will be completed by the IP, DON, and Staff Development Coordinator, or other licensed nursing staff. Facility policy regarding use of PPE will be reviewed to ensure protocol is concurrent with CDC guidelines - and all staff re-educated at their next scheduled work assignment. Use of PPE by team members will be based on CDC's recommendation for healthcare workers working in facilities located in counties with substantial or high transmission. When Henrico County's community is in substantial or high transmission, based on the community positivity rating, team members will not only wear masks as required but eye protection during all resident care encounters. Tracing A broad-based/facility wide testing approach will be utilized when a new case of COVID-19 is identified within a team member or resident except for when tracing identifies exposure did not occur within the facility. IP and DON will be educated on this testing approach today by VP of Clinical Services. Residents who are not up to date with COVID vaccinations will be placed on TBP as appropriate. COVID Education The Administrator, DON, ADON, IP and Staff Development Coordinator will receive education related to the CDC and CMS guidelines for COVID. The VP of Clinical Services. Interim Administrator: [name redacted] Date of Compliance: August 30, 2022 The survey team verified the removal plan which included: On 8/30/22 the surveyor D entered the facility and immediately conducted tour, and observations of all areas. All staff were found to be wearing N-95 masks, eye protection, and other transmission based source control personal protective equipment (PPE), as appropriate to their task performance. PPE stations were located outside of each positive Resident room, and all Resident rooms were private single occupant rooms. Interviews were conducted with staff, to include, Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), the Director of Nursing (DON), Human Resources (HR) Director, and Infection Preventionist (IP). Those staff were able to give an ac [TRUNCATED]

Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement infection control practices and failed to utilize proper PPE (personal protective equipment) as per the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare & Medicaid Services) guidance to prevent the spread of COVID-19 within the facility, on all 5 of the 5 Resident care halls and affecting 11 Residents (Resident #1, 5, 6, 7, 9, 10, 12, 13, 14, 16 and 20), in a survey sample of 20 Residents. The findings included: 1. The facility staff failed to don (put on) appropriate personal protective equipment (PPE), prior to entering the room of two Residents (Resident #1 and #20) who was on Transmission Based Precautions (TBP) for a confirmed COVID-19 infection. On 8/24/22 at approximately 12:50 PM, CNA B was observed to exit the room of Resident #1. CNA B was not wearing any eye protection. There was signage on the door to indicate Resident #1 was on TBP and a station was set-up with personal protective equipment (PPE) outside of the room. When asked, CNA B confirmed that she was feeding Resident #1. When asked about eye protection she said she usually does wear it in the rooms of COVID Residents but I had washed it off and was waiting for it to dry. CNA B confirmed that Resident #1 has an active COVID infection. On 8/25/22 at 9:55 AM, CNA H was observed to enter the room of Resident #20, who had signage on the exterior of the room that they were on TBP. CNA H was wearing a KN-95 only, she was observed to enter without putting on an N-95, eye protection, isolation gown or gloves. CNA H stepped back out into the hallway a moment later with gloves in her hand. When asked what PPE she is supposed to wear when entering the room she stated, gloves, gown, and eye protection. When asked why she had entered without wearing those items she stated she had gone in to get gloves. When asked what was wrong with the gloves on the cart outside of the room, she said she didn't see those. There were two boxes of gloves observed and pointed out that were on top of the cart that contained isolation gowns. CNA H then put on an isolation gown, gloves and eye protection and reentered the room. All COVID related facility policies were requested. Review of the policies submitted/provided, did not address the use of PPE (personal protective equipment). Review of the CDC guidance in the document titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes was conducted. This document read, .Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection: HCP [healthcare personnel] caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 398 1/11 During an end of day meeting on 8/24/22, the facility Administrator, DON and Infection Preventionist were made aware of the above findings. They confirmed they expect staff to wear an N-95 mask, isolation gown, eye protection and gloves prior to entering the room of a Resident on TBP. No further information was provided. 2. The facility staff failed to wear eye protection when providing direct Resident care, while the facility was located in an area of high COVID-19 transmission and during a COVID outbreak as per the guidance from CDC (Centers for Disease Control and Prevention) Prior to the survey team's entry to the facility the CDC COVID Data Tracker was reviewed and it noted the facility was located in an area with a high level of community transmission for COVID-19. On 8/24/22 at approximately 11:30 AM, during an entrance conference with the facility Administrator, Director of Nursing (DON), and Infection Preventionist (IP) they identified that they currently were in a COVID outbreak and staff were required to wear a KN-95 mask on the nursing units. They made no mention of eye protection being required. The facility submitted tracking of the community's COVID transmissibility rates which indicated the facility had remained in an area of substantial or high COVID transmission since December 2021. On 8/24/22 at approximately 12 Noon, a tour of the facility was conducted by Surveyor B. Nurses, certified nursing assistants, therapy staff, and housekeeping employees were all observed entering Resident rooms wearing no eye protection on all 5 of the Resident care hallways and entering Resident rooms to provide direct care or be within a few feet of the Residents. The following specific observations were noted on the third floor: a. Employee F was in a room providing care to a Resident wearing no eye protection. According to the staff vaccination matrix, Employee F was not up to date with COVID immunizations. b. LPN C entered a room to provide medication wearing no eye protection. LPN C was not up to date with COVID immunizations. c. CNA C was pushing a Resident in the hallway to their room, wearing no eye protection. CNA C was not up to date with COVID immunization per the staff vaccination matrix. d. Employee E was ambulating a Resident in the hallway wearing no eye protection. Employee E was not up to date with COVID immunizations. e. CNA D was distributing meal trays to various Residents, setting up the Resident and food for the meal and had no eye protection on. CNA D was up to date with COVID immunizations. On 8/24/22 at approximately 12:30 PM, the following specific observations were made on the second floor: a. CNA E was distributing meal trays to Residents and was wearing no eye protection. b. CNA F was sitting beside a Resident feeding them with no eye protection on. c. LPN B was administering eye drops to a Resident wearing no eye protection. LPN B was not up to date with COVID immunizations. d. CNA B was feeding a Resident and had no eye protection on. e. CNA K entered a room to put a towel around the Resident in an effort to provide protection to the Resident's clothing while they ate, CNA K had on no eye protection. f. CNA K entered the room of a Resident and sat beside then and started feeding them without wearing eye protection. On 8/24/22 at 4:00 PM, observations were made on all of the Resident care halls and observations were again made on each hall of staff entering rooms to provide care without any eye protection. They included, but were not limited to, CNA G and LPN D. On 8/25/22 at 9:10 AM, observations were made on each of the Resident care units/hallways. LPN E was observed in a Resident room administering medications and did not have any eye protection on. Eye protection was observed on top of her medication cart, which had been left in the hallway while she entered the Resident room. On 8/25/22 at 9:14 AM, Surveyor B knocked on the door of Resident #7 and upon opening the door observed a therapy staff member in the room providing treatment who was not wearing any eye protection. On 8/25/22 at 9:25 AM, an interview was conducted with LPN E. When asked why PPE is necessary and the purpose, LPN E said, So you won't transmit infection. All COVID related facility policies were requested. Review of the policies submitted/provided, did not address the use of PPE (personal protective equipment). The CDC guidance document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, with a revision date of Feb. 2, 2022, was reviewed. This document read, Implement Universal Use of Personal Protective Equipment for HCP [health care personnel] .Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html On 8/25/22, during an end of day meeting, the facility Administrator, Director of Nursing and IP were given a copy of the above referenced CDC guidance document. On 8/26/22 at approximately 9:15 AM, the facility Administrator, DON and IP confirmed that they follow CDC guidance. The above CDC guidance references were pointed out to the facility staff and they were made aware of Surveyor B's observations. No further information was provided. 3. The facility staff failed to place 9 Residents, (Resident #5, 6, 7, 9, 10, 12, 13, 14, and 16) who were not up-to-date with COVID immunizations and had a COVID exposure, on transmission based precautions during a COVID outbreak. On 8/24/22, the listing of Resident's COVID immunization status listing that the facility staff provided was reviewed. This review revealed that 12 current Residents are not up to date with COVID immunizations. Three of the 12 were currently on transmission based precautions for an active COVID infection. The other 9 Residents, (Resident #5, 6, 7, 9, 10, 12, 13, 14, and 16) rooms were observed and identified no signage or indication that they were on TBP. On 8/25/22 at 9 AM, a facility tour was conducted with special attention being made to Resident #5, 6, 7, 9, 10, 12, 13, 14, and 16's rooms. There was still no indication that the Residents were on TBP. Review of the facility submitted COVID line listing/infection report revealed that each of the nine Residents who were not up-to-date with immunizations had a possible exposure to COVID-19. The facility had not identified this during their contact tracing. Resident #14 was potentially exposed to CNA M on 8/14/22 and 8/15/22. CNA M tested positive for COVID-19 on 8/16/22. Residents #5, #6, and #16 were potentially exposed to COVID by CNA L on 8/17/22. CNA L tested positive for COVID 19 on 8/19/22. On 8/19/22, LPN G cared for Residents #5, 6, and 16. LPN G then tested positive for COVID-19 after her shift on 8/19/22. Resident #7 and #12 were potentially exposed to CNA L on 8/16/22. CNA L tested positive for COVID-19 on 8/19/22. Resident #13 was cared for by CNA B on 8/16/22 and 8/17/22. CNA B tested positive for COVID-19 on 8/18/22. Residents #9 and #10, were cared for by LPN H on 8/17/22. LPN H reported having COVID symptoms on 8/17/22 and then tested positive for COVID-19 on 8/18/22. Residents #7, #9, #10, #12, and #13 were cared for by LPN F on 8/17/22. LPN F had COVID symptoms on 8/17/22, then tested positive for COVID-19 on 8/18/22. On 8/25/22 at 10:21 AM, an interview was conducted with the facility Infection Preventionist. The IP stated that no one had trained her on how to conduct contact tracing but she knew to look back two days for potential exposures due to COVID having an incubation period. When asked to explain this, the IP said, That is when they may be infectious prior to exhibiting symptoms. When asked if she looked at who the staff had provided care to in the two days prior to a confirmed test, she said, No. All COVID related facility policies were requested. Review of the policies submitted/provided, did not address the use of PPE (personal protective equipment). Review of the CDC guidance in the document titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes was conducted. This document read, .Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who . have had close contact with someone with [CONDITION(S)]-CoV-2 infection if they are not up to date with all recommended COVID-19 vaccine doses .Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 398 1/11 CDC also provides additional guidance when the facility is in a COVID outbreak. This guidance is found in the above referenced guidance document and read, .New Infection in Healthcare Personnel or Residents: Respond to a Newly Identified [CONDITION(S)]-CoV-2-infected HCP or Resident. Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak Residents and HCP who are not up to date with all recommended COVID-19 vaccine doses: These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities. Close contacts, if known, should be managed as described in Section: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection On 8/25/22, during an end of day meeting, the facility Administrator, Director of Nursing and IP were given a copy of the above referenced CDC guidance document. On 8/26/22 at approximately 9:15 AM, the facility Administrator, DON and IP confirmed that they follow CDC guidance. The above CDC guidance references were pointed out to the facility staff and they were made aware of Surveyor B's observations. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements affecting 28 staff (24 agency staff and Staff #2, #3, #6, and #8) and all Residents. The findings included: 1. The facility staff failed to conduct routine and outbreak COVID-19 testing of all 24 agency/contract staff who worked in the facility June-August 2022. On 8/25/22, Surveyor B used the as-worked schedule and staff vaccination matrix to select a staff sample, which was reviewed for COVID immunization and testing. On 8/25/22 at approximately 10 AM, Surveyor B met with the facility's infection preventionist. The IP confirmed she was the person that maintained records of all of the staff testing. She was given the name of Staff #1 and asked to provide the dates of COVID testing. The IP stated, I don't have her, I don't think she works here. The IP was told she was an agency staff person, and the IP stated that they do not conduct COVID-19 testing of agency staff unless they are symptomatic. The IP was then given the name of Staff #7. The IP said, I don't have her. She was told she was another agency staff member and the IP said, If she was not symptomatic, they screen when they come in but if they aren't symptomatic we don't test them. On 8/25/22 at 11:34 AM, Surveyor B met with the Human Resources Director, Employee H. Employee H was given Staff #1's name and Employee H confirmed that Employee H had worked 8/24/22. The HR Director, Employee H confirmed that Staff #7 was agency and worked 6/29/22, 7/9/22, 7/24/22, 7/25/22, and 8/24/22. Employee H, the HR Director looked and confirmed that she didn't maintain record of the COVID immunization status for agency staff, she identified that Employee G kept that information. On 8/25/22, in the afternoon, Surveyor B met with Employee G, the scheduling coordinator. She was given the name of Staff #1 and #7 and was asked to obtain her COVID vaccination information. Employee G later provided vaccination records that confirmed both Staff #1 and #7 had received the primary vaccination series, but were not boosted, which meant they were not up-to-date, and therefore were subject to routine testing. Employee G provided Surveyor B with a listing of agency staff that had worked at the facility. For the months of June and July, 24 agency staff had worked at the facility. On 8/25/22, during the end of day meeting the facility Infection Preventionist again confirmed that agency staff were not tested for COVID-19 routinely and she had no records for any routing testing of the agency staff. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy read, .[company name redacted] will attempt to follow the testing requirements, to the extent possible, based on the parameters set forth by the Department of Health & Human Services, CMS. This applies to resident and team member testing, including providing services under arrangement and volunteers for COVID-19 .Routine Testing of Team Members: 1) Routine testing of team members, who are not up-to-date, is based on the extent of the virus in the community- using the most recent community transmission level for the trigger for team member testing frequency per CMS guidelines III. Who should be tested : Individuals included in the testing include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in training programs or from affiliated academic institutions . The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 7, read, Expanded screening testing of asymptomatic HCP [Healthcare Personnel] should be as follows: .In nursing homes, HCP who are not up to date with all recommended COVID-19 doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a [CONDITION(S)] test twice a week .If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). Review of the CMS (Centers for Medicare & Medicaid Services) Memo Ref: QSO-20-38-NH, revision date 3/10/2022, subheading Documentation of Testing, page 10, item 3 read, For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated (e.g., every week), and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for staff, who are not up-to-date, and the results of each test and page 11, For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner . 2. The facility staff failed to conduct routine COVID-19 testing of staff who were not up to date with COVID immunizations for Staff #2, #3, #6, and #8. Review of the staff vaccination matrix submitted revealed that Staff #2, 6 and 8, were noted to not be up to date with COVID immunizations, as they had not received a booster dose. Staff #3 had been granted an exemption from COVID immunization. On 8/25/22, Surveyor B met with the facility Infection Preventionist (IP) to review testing occurrences of the staff sample. The following was noted during this review: Staff #2 was not tested twice weekly based as required since Staff #2 was not up to date with COVID immunizations and the facility was located in an area of high community transmission of COVID-19. Staff #2 was tested [DATE], and was not tested again until 8/12/22. Review of Staff #2's time card revealed they worked Staff #3, who had been granted an exemption from COVID immunization, was reviewed for testing occurrences. Staff #3 was tested on the following dates in the months of June-August: 6/9/22, 6/28/22, 6/29/22, 7/27/22, 7/29/22, 8/11/22, 8/12/22, 8/18/22, and 8/19/22. Review of Staff #3's timecard revealed in June, she had worked 17 shifts, in July she worked 21 shifts. In August, Staff #3 worked 15 shifts. Staff #6 was tested [DATE], and was not tested again until 6/29/22. Review of Staff #6's timecard revealed she worked 13 shifts during this time frame. When the Infection Preventionist was asked about testing during the time frame from 6/9-6/29, she said, That's all I have for her. Staff #8 had no testing for July. When asked, the IP said, I don't know why I don't have any July testing, I don't know why it's missing. Review of the facility submitted tracking of the community transmissibility rate of COVID revealed they had remained at a high level for all of June, July and August. Review of the facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was conducted. This policy read, .1) Routine testing of team members, who are not up-to-date, is based on the extent of the virus in the community- using the most recent community transmission level for the trigger for team member testing frequency per CMS guidelines Table 2: Routine testing intervals by County COVID-19 Level of Community Transmission: High (red), Minimum testing frequency of staff who are not up-to-date: Twice a week. Review of the CMS (Centers for Medicare & Medicaid Services) Memo Ref: QSO-20-38-NH, revision date 3/10/2022, subheading Documentation of Testing, page 10, item 3 read, For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated (e.g., every week), and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for staff, who are not up-to-date, and the results of each test and page 11, For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner . The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 7, read, Expanded screening testing of asymptomatic HCP [Healthcare Personnel] should be as follows: .In nursing homes, HCP who are not up to date with all recommended COVID-19 doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a [CONDITION(S)] test twice a week .If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). 3. The facility staff failed to maintain documentation of COVID-19 testing occurrences and results in the clinical record for all Residents. On 8/25/22, Surveyor B met with the facility Infection Preventionist (IP) to review testing occurrences of the staff sample. The following was noted during this review: Surveyor B let the IP know she was not able to find COVID-19 testing occurrences within the clinical record. The IP said that she keeps a listing of the Residents who were tested in her testing book that only positive results are documented in the clinical charts. Review of the testing logs the IP had available revealed a Resident listing that would indicate the test date with a minus sign beside a Resident's name to indicate they tested negative. There was no indication as to who had performed the testing and no testing information was noted in the clinical charts. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy read, . VII. Documentation of Testing: .C. Resident testing will be documented in the residents' medical record . The CMS (Centers for Medicare and Medicaid Services) issued QSO-20-38-NH with a revision date of 03/10/2022. It read, . (3) For each instance of testing : .(ii) Document in the resident records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test . 4. The facility staff failed to perform outbreak testing of Residents who were potentially exposed to COVID-19 on 4 of 5 halls/units. Review of the testing logs for August 2022, revealed Resident testing occurred on 8/17/22, of the Residents on the 2nd floor third hall. There was a census sheet of the Residents residing on the third floor but no indication of any testing being conducted. Review of the COVID line listing revealed numerous staff had tested positive for COVID-19 in August. Review of the assignment sheets revealed the following: Residents on the second floor halls 1, 2 and 3 were exposed on 8/17/22, by LPN F who worked as the only nurse for the second floor and tested positive for COVID 19 on 8/18/22. Residents on the second floor hall 1 had an additional possible exposure on 8/17/22, by LPN H, who worked 8/17/22, and tested positive on 8/18/22. Residents on the second floor, hall 2 had an additional exposure on 8/16/22 by CNA L, who worked 8/16/22, and tested positive for COVID-19 on 8/18/22. Residents on the third floor, hall 1 were exposed 8/14/22 and 8/15/22, by CNA M, who worked both days and then tested positive for COVID-19 on 8/16/22. Residents on the third floor, hall 2 were exposed 8/17/22, by CNA L, who worked their hall and then tested positive for COVID-19 on 8/18/22. Residents on the third floor, hall 2 also had a possible exposure on 8/18/22 and 8/19/22, by LPN G, who tested positive for COVID-19 on 8/19/22. On 8/25/22, during a meeting with the infection preventionist (IP), the IP confirmed that contact tracing is conducted. When asked who trained her on how to conduct contact tracing, the IP said, No one, but I know to go back 2 days because of the incubation period of COVID. When asked to define incubation period, she indicated this is when a person could be infectious and not be symptomatic. When asked to show evidence of her contact tracing for the above noted staff members, CNA L, CNA M, LPN F, LPN G, and LPN H, she said, I look at the assignment sheet. When asked if she went back to the two days prior to the staff testing positive she said she did not. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy read, . 2) Residents determined to have close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. In this situation, testing is recommended immediately and, if negative again 5-7 days after exposure . The CMS (Centers for Medicare and Medicaid Services) issued QSO-20-38-NH with a revision date of 03/10/2022. It read, .Testing of Staff and Residents in Response to an Outbreak: An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents, regardless of vaccination status, should be tested immediately, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. See CDC guidance Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [CONDITION(S)]-CoV-2 . The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, was reviewed. It read, .Manage Residents with Close Contact: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from [CONDITION(S)]-CoV-2 infection in the prior 90 days who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section . 5. The facility staff failed to obtain a physician order prior to conducting COVID testing for 1 Resident, (Resident #1). Review of the clinical chart of Resident #1 revealed the following note dated 8/18/22 at 9:50 AM, Resident noted very lethargic and increased confusion. Resident tested + for COVID-19, MD [medical doctor], nursing supervisor & RP [responsible party] made aware. On 8/25/22 at 3:54 PM, Surveyor B and the Infection Preventionist (IP) reviewed Resident testing. Resident #1 had COVID testing conducted and there was no evidence of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During the above interview the IP confirmed that a physician order is required prior to obtaining any type of diagnostic test. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy read, .Residents: 1) A physician/practitioner order (standing order is acceptable) will be obtained prior to administration of test . Review of the Centers for Medicare and Medicaid Services (CMS) Memo titled, QSO-20-38-NH DATE: August 26, 2020, REVISED 04/27/2021, was conducted. This memo stated, .Conducting Testing: In accordance with 42 CFR § 483.50(a)(2)(i), the facility must obtain an order from a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with State law, including scope of practice laws to provide or obtain laboratory services for a resident, which includes COVID-19 testing (see F773). This may be accomplished through the use of physician approved policies (e.g., standing orders), or other means as specified by scope of practice laws and facility policy . 6. The facility staff failed to conduct COVID-19 of new admissions, for 2 of 4 Residents (Resident #4 and #5) reviewed for testing. On 8/25/22 at 3:54 PM, Surveyor B and the Infection Preventionist (IP) reviewed Resident testing. The IP confirmed Resident #4 had been admitted to the facility on [DATE]. There was a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the testing revealed that Resident #4 had no testing occurrences from 6/24/22, to the date of review, 8/25/22. Resident #5 was admitted to the facility on [DATE]. She was tested on [DATE], and had no testing following that date. During an interview with the IP, she stated Residents are to be tested upon admission and then again 5 days later. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak with a revision date of 3/14/22, was reviewed. This policy references regulatory references from QSO-20-38 and QSO-20-29. It also read, Communities will follow the CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic for residents .3) b) Communities will follow current CDC guidelines based on the outcome of the COVID-19 tests . The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 3, read, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. On 8/25/22 and again on 8/26/22, during the end of day meetings, the facility Administrator, Director of Nursing and Infection Preventionist were made aware of all of the above noted COVID testing findings. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy, failed to document influenza and pneumococcal immunization status and failed to offer immunizations to 3 Residents (Resident #2, #3, and #6), in a sample of 5 Residents reviewed for immunizations. The findings included: On 8/25/22, clinical record reviews were conducted for the sampled Residents in the presence of the Infection Preventionist (IP). The review revealed the following with regard to immunizations for flu and pneumonia: 1. Resident #2 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) no information with regards to pneumonia vaccination status was found. The Infection Preventionist looked throughout the clinical record and indicated there was no information available. 2. Resident #3 had been admitted to the facility on [DATE]. The IP reviewed the clinical record of Resident #3 and noted no information was present to indicate Resident #3's immunization status with regard to flu or pneumonia. 3. Resident #6 had been admitted to the facility on [DATE]. Review of the clinical record for Resident #6 revealed no information was available regarding Resident #6's vaccination status for flu or pneumonia. Additionally, there was no evidence that Residents #2, #3 and #6, were educated or offered vaccination for pneumonia. The Infection Preventionist stated that it is the responsibility of the admitting nurse to document all of this information and offer immunizations upon admission. During the above interview with the IP accessed the EHR for Residents #2, #3 and #6. She observed and confirmed the immunization tab had no data recorded. She reviewed the remainder of the record and confirmed there was no information for the missing immunizations and that no information was available to indicate they had been educated on or offered the immunizations. On 8/25/22 at 10:37 AM, an interview was conducted with the facility's Infection Preventionist (IP). The IP was asked, Why is it important for the immunization status to be documented? The IP stated, We should know their immunization status, if they don't have the immunizations we should offer it. When asked if the doctor and other providers should know the immunization status of Residents, the IP said, Yes. When asked where the doctor would look for that information, the IP said, In the chart. During the above interview, the IP was asked if the immunization status of a Resident affects the care that is provided to them, she said, Yes. Review of the facility policy titled, Vaccine- Pneumococcal Vaccine was conducted. This policy read, .1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission . The facility policy titled, Influenza Vaccine Policy was reviewed. This policy was noted to read, . 1. All residents are to be offered vaccination, except those with a history of egg allergy, previous severe reaction to vaccination . 3. The Director of Nursing or designee is responsible for coordinating the administration of vaccinations .Procedure: 1. Prior to vaccination, current educations materials will be offered to residents, and explained as necessary by the nursing staff. The responsible parties of cognitively impaired residents will be contacted with this information. 2. The resident or his responsible party will be asked to sign consent before any vaccine is given. The consent or refusal will become a part of the resident's permanent medical record. 3. A physician's order will be obtained prior to the administration of a vaccine. 4. Documentation will be maintained in the resident's medical record indicating the type of vaccination given, the date given, and the name and title of the staff member administering the vaccination. On 8/25/22 and again 8/26/22, the facility interim Administrator, Director of Nursing and Infection Preventionist were made aware of the above findings. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to document COVID immunization status and failed to offer immunizations to 3 Residents (Resident #2, 3, and 6), in a sample of 5 Residents reviewed for immunizations, and the facility staff failed to provide evidence that staff who are eligible for COVID vaccine doses were educated and offered the vaccine for 3 staff (Staff #2, 6, and 8) in a sample of 14 staff. The findings included: 1. The facility staff failed to failed to document COVID immunization status and failed to offer immunizations to 3 Residents (Resident #2, 3, and 6), in a sample of 5 Residents reviewed for immunizations On 8/25/22, clinical record reviews were conducted for the sampled Residents in the presence of the Infection Preventionist (IP). The review revealed the following with regard to immunizations for COVID: 1a. Resident #2 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) no information with regards to COVID immunization status. The Infection Preventionist looked throughout the clinical record and indicated there was no information available. 1b. Resident #3 had been admitted to the facility on [DATE]. Surveyor B and the IP reviewed the clinical record of Resident #3 and noted no information was present to indicate Resident #3's immunization status with regards to COVID. 1c. Resident #6 had been admitted to the facility on [DATE]. Review of the clinical record for Resident #6 revealed no information was available regarding Resident #6's vaccination status for COVID. Additionally, there was no evidence that Residents #2, 3 and 6, were educated or offered vaccination for COVID-19. The Infection Preventionist (IP) stated that it is the responsibility of the admitting nurse to document all of this information and offer immunizations upon admission. When asked how the Resident's vaccination status was known and able to be reported in NHSN (National Healthcare Safety Network), the IP stated she looks it up in VIIS (Virginia Immunization Information System). When asked if she puts this document into the clinical record of the Residents she stated, No. During the above interview with the IP accessed the EHR for Residents #2, 3 and 6. She observed and confirmed the immunization tab had no data recorded. She reviewed the remainder of the record and confirmed there was no information for the missing immunizations and that no information was available to indicate they had been educated on or offered the immunizations. On 8/25/22 at 10:37 AM, an interview was conducted with the facility's Infection Preventionist (IP). The IP was asked, Why is it important for the immunization status to be documented? The IP stated, We should know their immunization status, if they don't have the immunizations we should offer it. When asked if the doctor and other providers should know the immunization status of Residents, the IP said, Yes. When asked where the doctor would look for that information, the IP said, In the chart. During the above interview, the IP was asked if the immunization status of a Resident affects the care that is provided to them, she said, Yes, it is important for isolation purposes, you have to isolate for 10 days if they haven't had their second booster. Review of the facility policy titled, COVID-19 Vaccination- Federal CDC LTCF (Long Term Care Facility) Pharmacy Partnership and Independent Pharmacy Partnership, Revised 3/15/21, was conducted. This policy read, [Company name redacted] is committed to protecting the health and safety of residents and team members and to taking necessary action to ensure the appropriate mitigation of the spread and impact of COVID-19 on residents, team members, and the general public. [Company name redacted] will offer, or arrange for the offering of, the COVID-19 vaccination to residents and team members to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 . On 8/25/22 and again 8/26/22, the facility interim Administrator, Director of Nursing and Infection Preventionist were made aware of the above findings. No further information was provided. 2. The facility staff failed to document that employees who were eligible for COVID vaccine doses were educated on the benefits of vaccination and were offered vaccination(s) for Staff #2, 6, and 8, in a sample of 14 staff. Review of the staff vaccination matrix submitted revealed that Staff #2, 6 and 8, were noted to not be up to date with COVID immunizations, as they had not received a booster dose. On 8/25/22, the facility Infection Preventionist stated that human resources maintains the information with regards to employee vaccination. On 8/25/22, a meeting was conducted with Employee H, the HR Director. The HR Director was given the names of Staff #2, 6, and 8. Surveyor B explained that they were listed on the staff vaccination record as not receiving the booster dose. Employee H had no evidence that these employees had been offered and declined. On 8/26/22 at 9:31 AM, the Infection Preventionist stated she had no evidence to provide that would indicate the staff were offered the COVID immunizations. She said an all staff meeting was held were she discussed vaccinations and that if they wanted it to see her. On 8/26/22, during the end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on Resident and family interviews, staff interviews, and facility documentation review, the facility staff failed to notify Residents and families when new cases of COVID-19 were identified in the facility, affecting all 73 Residents residing in the facility. The findings included: The facility staff had no evidence of any Resident and family notifications of the facility's COVID outbreaks and mitigating strategies being implemented prior to the current outbreak. On 8/24/22 at 11:30 A.M., evidence of Resident and family notifications of COVID cases and the weekly communication for the last 6 months, February-August, 2022, was requested. On 8/24/22 at 3:00 PM, Employee D, the unit clerk, provided Surveyor B with letters dated 8/18/22, 8/19/22, and 8/23/22, which she stated she had emailed to Resident's families. Review of the email list she used for the notifications was reviewed and identified 9 Residents that the facility had no email address on file for. The 9 Residents with no email address on file included, but was not limited to Resident #2, #4, #6, #8 and #15, which were part of the survey sample. When asked if she placed any calls to those families, she stated, No. Employee D was asked if she had made any notifications prior to 8/18/22, she said No. On 8/24/22 and 8/25/22, reviews of the electronic health record (EHR) for Residents #2, 4, 6, 8, and 15, were conducted. There was no evidence in the clinical record of the Resident or families being notified of the facilities COVID outbreak. On 8/24/22 at approximately 1:00 PM, an interview was conducted with the spouse of Resident #19. During this interview, the spouse was asked how she is made aware of COVID cases within the facility. The spouse of Resident #19 stated, I received an email last week. Surveyor B asked if she had received any communication prior to last week and she said, No. On 8/25/22, the facility interim Administrator, Director of Nursing (DON) and Infection Preventionist (IP) were made aware that there was only evidence provided of letters being sent to those whose emails were on file and that no information prior to 8/18/22, had been provided. On 8/25/22 at 5 PM, the DON provided copies of progress notes dated 8/25/22, where she attempted to call Resident families who had no email address on file. On 8/26/22 at 9:55 AM, an interview was conducted with Resident #5 and her daughter who was at the bedside. The Resident displayed some confusion and difficulty recalling events. The daughter reported that she is made aware of COVID verbally by staff when she visits. When asked if this communication occurs routinely, she said, No, usually I just hear them talking about it. When asked if she had received anything in writing, she stated, No. Review of the COVID line listing revealed that the facility had a COVID outbreak affecting Residents in May and again starting August 14. In May, June, July, and Aug., facility staff tested positive for COVID-19. The facility had no evidence of Residents and families being made aware by 5 PM, the following day as required. Review of the facility policy titled, COVID-19 Testing- Routine, Symptomatic and Outbreak, (Revised 3/14/22), was conducted. This policy read, .5. Residents, family members and team members will be notified of the outbreak promptly and advised as to the measures the community is taking to mitigate the spread of infection. 6. Communities will maintain frequent, ongoing communication with team members, residents and families for updates and facility actions . On 8/26/2022, the interim administrator, Director of Nursing, and Infection Preventionist, were made aware of the above findings and that no additional information had been provided. No further information was submitted prior to the end of survey.

Based on record review, interviews, and review of facility policy, the facility failed to address unplanned significant weight loss; and ensured a comprehensive nutritional assessment was completed upon admission to maintain acceptable parameters of nutritional status for two of seven residents reviewed for nutrition (Resident (R) 83 and R13). This failure had the potential to affect other residents to not receive timely nutritional interventions. Findings include: 1. Review of R83's undated Face Sheet, located in the resident's Electronic Medical Record (EMR), indicated R83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R83's hospital Discharge Summary, dated 03/10/21 located in the hard copy of the medical record, indicated R83 had a right pelvic fracture, was to receive conservative treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R83's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/17/21, located in the resident's EMR under the MDS tab, indicated R83 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. Continued review of R83's MDS revealed the resident required supervision with set up for eating, had no oral or dental issues, and no weight loss. Review of R83's Comprehensive Care Plan, located in the resident's EMR under the care plan tab, revealed the resident had a Nutrition Care Plan related to potential for risk for altered nutritional status and/or weight loss related to DM2. The Care Plan initiated on 03/11/21 documented: dietary consult with Registered Dietician (RD) as indicated to assess nutritional plan, monitor weights, report significant changes in weight to physician and RD as indicated, and document refusal or percentage consumed. Review of R83's weight located in the EMR under the Vital Signs/Weight tab revealed on 03/15/21, the resident weighed 141.4 pounds. Review of the Monthly Charting Flow Sheet, dated 03/11/21 to 03/18/21, located in the resident's EMR under the CNA Documentation tab, documented R83 consumed 76% to 100% for five meals, 51% to 75% for eight meals, and 26% to 50% for four meals. Continued review revealed there was no documentation for four meals. Review of R83's Comprehensive Nutritional Care Area Assessment, dated 03/18/21, located in the resident's EMR under the Dietician tab, documented R83 had a score of 4 that did not indicate a nutritional issue. Continued review of the Nutritional Assessment revealed no documented evidence under the dietary risk items that R83 sometimes ate less than 75%. Review of the Registered Dietician's Note, dated 03/18/21, located under the Interdisciplinary note tab of the EMR documented R83 was 61 inches tall, 141.4 pounds, and was overweight. The RD note stated R83 received a heart healthy diet and consumed 76 % of her meals on average since admission. The RD note indicated the nursing staff stated her appetite is fair, and she is able to self-feed successfully. Review of R83's weight located in the EMR under the Vital Signs/Weight tab dated 03/22/21, indicated the resident weighed 131.4 pounds, which was a 7.07 % weight loss. On 04/01/21 at 6:30 PM the Assistant Director of Nurses (ADON) and the Surveyor reviewed R83's meal percentages dated 03/11/21 to 03/18/21. The ADON stated the meal percentage record was the only place where meal percentages were documented. The ADON stated there was no way of knowing how much R83 consumed on the days where no meal percentage was recorded. The ADON stated if there was a plus or minus of five pound in a resident's weight, the nurse directed the staff member to obtain another weight the same day. The ADON stated if the reweigh variance was valid, a referral was made to the RD, who would make recommendations. The ADON stated she could not recall if she asked the Restorative Certified Nurse Assistant (RCNA) to obtain a reweigh on R83. The ADON stated no reweigh was obtained on R83 and no referral to the RD was initiated. Review of the Monthly Charting Flow Sheet, dated 03/19/21 to 03/26/21, located in the resident's EMR under the CNA documentation tab, documented R83 consumed 76% to 100% for nine meals, 51% to 75% for two meals, and 26% to 50% for nine meals. Continued review revealed there was no documentation for four meals. Review of the Monthly charting Flow Sheet dated 03/27/21 to 03/31/21, located in the resident's EMR under the CNA documentation tab, documented R83 consumed 51% to 75% for four meals, 26% to 50% for two meals, and there was no documentation for nine meals. There were no days R83 consumed 76% to 100 % of her meals. On 04/01/21 at 6:30 PM the ADON stated she was not able to determine how much food R83 consumed on the days where no meal percentage was documented. On 03/31/21, the Surveyor asked the ADON to obtain a weight on R83. The weight dated 03/31/21 was 125.6 pounds, which was a 11.17% weight loss in 16 days. On 04/01/21 at 11:45 AM Licensed Practical Nurse (LPN) 91, stated RCNA126 usually obtained the weights on residents; however, sometimes the CNAs obtained the weights. LPN91 stated after obtaining the resident's weight, RCNA126 or the CNA would enter the weight into the computer. LPN91 stated if the resident's weight were a plus or minus of five pounds or more from the last weight, the RCNA or the CNA would obtain another weight and a nurse would verify the weight. LPN91 stated if the variance was verified, she reported the weight loss or weight gain to the ADON, who reported the issue to the RD. On 04/01/21 at 11:54 AM LPN61 stated the RCNA usually obtained weights on residents and reports a variance of plus or minus 5 pounds to her. LPN61 stated the resident is then reweighed and she verifies the weight. LPN61 stated if the weight variance is verified, she reports the weight issue to the ADON. LPN61 stated R83 ate independently, had no coughing or issues with eating and she was not aware of any weight loss issues until 03/31/21. On 04/01/21 at 11:50 AM RCNA126 stated she usually obtained the weights on residents, unless she had a resident assignment. RCNA126 stated after obtaining a resident's weight, she entered the resident's weight into the computer. RCNA126 stated if the resident's weight was a plus or minus of five pounds, she reweighed the resident and have the nurse verify the reweigh. Interview on 04/01/21 at 11:40 AM with CNA44 revealed when she weighed a resident, she entered the resident's weight into the computer. CNA44 stated if there was a difference of a plus or minus of 10 pounds, she reweighed the resident, entered the weight into the computer and then notified the ADON that there was a significant weight change. Interview on 04/01/21 at 12:01 PM with CNA20 revealed the RCNA usually was the one who weighed the residents. CNA20 stated if the RCNA was assigned an assignment, the CNA was responsible for obtaining the weight. CNA20 stated she reports the weight to the nurse and if a reweigh was needed, she reweighed the resident. CNA20 also stated she does not have the nurse verify the weight if a resident was reweighted. Continued interview on 04/01/21 at 6:30 PM, the ADON stated there were computer issues on 03/29/21 and 03/30/21 and the Charting/Flow Sheets were printed out for each resident for the staff to manually document each residents' meal percentages. The ADON and the Surveyor reviewed the meal percentages for both days and although other information regarding R83 was documented, there was no meal percentages documented for the breakfast and lunch meals. The ADON stated the physician and family member were not notified regarding R83's weight loss and additional interventions were not initiated until 03/31/21. The ADON stated R83 had significant weight loss and the facility did not follow their policy. Review of the Monthly Charting Flow Sheet, dated 04/01/21, documented R83 consumed 51% to 75% for breakfast and 0 to 25 % for lunch. On 04/01/21 at 9:58 AM, the Registered Dietitian (RD) stated although she had not observed R83 eating a meal, the staff reported R83 had a good appetite and reported no eating concerns. The RD stated she based meal consumption of a resident on talking with the resident and staff and meal percentage documentation. The RD stated she was not aware of the missing meal percentages on the Monthly Charting Flow sheet. The RD also stated a resident who did not consume at least 75% of meals would be noted on the Comprehensive Nutritional Care Assessment, which could increase a resident's risk for nutritional issues. The RD stated although R83 had a shocking unexplained significant weight loss, she was not below her ideal body weight. The RD stated interventions for R83's weight loss were not initiated until the reweigh was obtained on 03/31/21. Review of the facility's policy titled, Weight Management dated March 2021, documented .a reweigh will be obtained for any weight change of plus or minus five pounds from the previous weight unless other parameters have been ordered by the physician. All reweighs will be obtained immediately. The reweigh process will be visualized by a licensed nurse. The physician and the resident or resident representative will be notified by the resident's nurse of any significant unexpected and or unplanned weight changes . 2. R13. Review of the Minimum Data Set (MDS) with an ARD date of 01/11/21 revealed the resident was holding food in her mouth and coughing or choking while eating; no height and weight was obtained. Review of the Care Plan dated 01/05/21 revealed the resident had a potential risk for altered nutritional status and/or weight loss related to [CONDITION(S)] with a goal to consume 50% of her meals and plans dated 01/05/21 for a dietary consult with RD as indicated to assess nutritional status and monitor weights as indicated; report significant changes in weight to MD, RD as indicated. Review of physician's orders dated 01/10/21 revealed the resident had mechanical soft heart healthy diet, with thin liquids ordered and on 02/15/21 a regular diet with thin liquids. Review of the Comprehensive Nutritional Care Area assessment dated [DATE] revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Weight and height is unknown due to not coming from a hospital, COVID precautions and resident confusion. The form documented the resident was on a Heart Healthy, mechanical soft diet and was eating an average of 49% of her meals and noted swallowing difficulties were noted by the speech language pathologist. R13's Nutritional Assessment was not person-centered and incomplete and omitted information regarding the resident's caloric needs and nutritional requirements based on height weight, lab values and accepted nutritional parameters. In addition, there were no further Nutritional Assessments in the resident Electronic Medical Record (EMR0 or chart located in the nurse's station. Review of the resident's weights revealed on 01/15/21 the resident weighed 123.1 pounds (lbs.), on 01/19/21 the resident weighed 119.00 lbs, on 02/02/21 the resident weighed 119.4 lbs, and on 03/03/21 the resident weighed 115.4 lbs that represented a 6.18% weight loss since admission. During an interview on 04/01/21 at 10:17 AM, the Registered dietician (RD) acknowledged that the Comprehensive Nutritional Assessment requires completion by the resident's admission ARD date and this was not accomplished for this resident. The RD stated the facility did not have an admission height and weight because the resident was a direct admission from the Assisted Living Facility (ALF) on campus. The RD sated that the facility was in full lockdown because of COVID precautions and the resident's weight was obtained as soon as possible; she provided no explanation for not completing the nutritional assessment. Review of the facility policy titled Nutritional Assessment developed 01/07 and revised on 04/01/21 directs that a complete and comprehensive nutritional assessment is conducted for each Health Care resident and that a plan of care is implemented to address any impairment or alterations in that person's nutritional status. The Registered Dietitian conducts this evaluation with assistance and input from dietary personnel.

Based on observation, interview, and record review, the facility failed to ensure foods were stored and served under safe and sanitary conditions. Observations on 03/29/21 of the 200-floor kitchen revealed unlabeled and undated foods in the refrigerator. Additionally, observations during the 200-floor meal service on 03/29/21, revealed drinking glasses and dining plates were not handled in a sanitary manor. This deficient practice had the potential to affect 45 of 45 residents who were served meals from the 200-floor kitchen. Findings include: 1. On 03/29/21 at 9:05 AM, during a kitchen observation in the 200-floor kitchen, the following was noted in the refrigerator: 18 individual salads in 6 oz [ounce] Styrofoam bowls were on a large tray, three blueberry pies, one large stainless-steel bowl with salad, and 24 single serving 2 oz ketchup containers. None of the items listed were labeled with date or time of preparation nor expiration dates. In an interview on 03/29/21 at 9:05 AM, with Dietary Aide (DA) 128, DA 128 revealed the 18 individual salads, three blueberry pies, the large salad in the stainless-steel bowl and the 24 2 oz ketchup containers should have been labeled with the date of preparation and expiration date. DA128 revealed prepared foods were delivered to the 200-floor kitchen from the main kitchen on the first floor. DA128 stated that all foods should be labeled with the date and time they were made and an expiration date. DA128 also stated she did not know why the items in the refrigerator were not labeled. 2. On 03/29/21 from 12:22 PM to 12:50 PM during a dining observation in the 200-floor dining room, the following was observed: DA128 was in the dining room at the food service window preparing plates and drinks for room trays. DA128 was wearing gloves and grasped a glass of cranberry juice over the top of the glass contaminating the rim of the glass. DA128 then handled plates to place on the delivery cart for resident room trays. DA128 grasped a second glass of cranberry juice from the top at the rim of the glass and placed it on the delivery cart for resident room trays. DA128 then grabbed the hem of her shirt and pulled it down in several areas, then went back to grasping glasses by the rim to place them on the room tray cart for a total of 9 glasses of cranberry juice and 2 glasses of apple juice. DA128 then dropped a packet of crackers on the floor, picked them up, and threw them in the trash, then returned to the serving window. DA128 the, served prepared plates of food to residents who were eating in the dining room. She served 3 plates to residents while holding the plates with her right thumb hooked over the rim of the plates, potentially contaminating the food. DA 128 never changed gloves nor washed her hands during this observation. An interview on 03/29/21 at 9:12 AM, the Registered Dietician (RD) indicated staff should never grasp glasses from the top, but rather on the side, to prevent contaminating the rim of the glass. She further indicated plates should never be handled with the thumb hooked over the edge, but rather should be held from the bottom of the plate only. The RD indicated the facility's policy called for handwashing at the start of meal service and any time the person serving the meal had contaminated their hands. The RD stated if a person serving the meal contaminated their gloves, they should change their gloves and wash their hands in between the glove change. An interview on 04//01/21 at 9:53 AM, the Director of Dining Services (DDS), revealed drinking glasses were to be grasped around the side, and never over the rim, and plates should always be served from the bottom and the thumb should never be hooked over the edge of the plate. On 03/29/21 at 2:00 PM, the DDS provided a binder entitled, FOOD SAFETY MANUAL, and indicated this was the what the facility used for kitchen and dining policy. Review of the manual revealed, .Section 3.5 titled LABELING. Ensure all items are properly labeled with the required information. Items to Label. Ensure all food items are labeled. Be especially cautious to label all food items [NAME] are: Not kept in their original containers, including condiments (e.g., salad dressing, ketchup, etc.) . Label information. Each label must contain the following information: Product name (or common name or identifying description), Use-by date, Date the product was prepared or opened, Time prepared and team member initials where applicable .Section 2.3 HANDWASHING .Required .Immediately before starting work, wash hands and exposed portions of arms. Rewash after the following activities .Touching hair, face and body .touching clothing or aprons .Touching anything else that ay contaminate hand (e.g., dirty equipment, work surfaces, phones or cloths .

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the Resident Representative (RR) for one of three residents reviewed (Resident (R)81) was provided the Notice of Medicare Non-Coverage (NOMNC) at least 48-hours prior to the cessation of services. R81 was notified on 03/24/21 that their skilled services would end on 03/25/21. This failure had the potential for residents and/or their representatives not being informed of potential available services and fees for those services, or the advisement of the ability to appeal the Resident's discharge from Medicare Part A benefits. Findings include: Review of the facility policy titled Advance Beneficiary Notice, revised 02/2020, showed: Purpose Specific Procedures / Requirements: 1. General Guidelines There are two types of required notices: NOMNC - Notice of Medicare Non-Coverage is issued when traditional Medicare or Managed Care plans are ending in the SNF. Notice is only issued if there are days remaining under the covered stay. ABN - Advance Beneficiary Notice is issued only with traditional Medicare and is issued if the resident will continue to receive services in the SNF as a long-term resident but is no longer going to be covered under the Medicare benefit. Notice is issued only if there are days remaining under the covered stay. Issuance of notices: NOMNC - must be issued at least 2 calendar days prior to the last covered day of services. Social worker will issue the NOMNC to the resident or resident representative. If the notice is not issued in person, the social worker will notify the resident representative via telephone and document the conversation. The notice will then be delivered to the resident representative via mail or email per their preference. If the resident is not able to receive the NOMNC, and the resident representative cannot be reached via telephone, the NOMNC will be sent to the resident representative via Certified Mail to the address on record. ABN notice will also be issued to the resident when applicable, or the resident representative Review of R81's undated Profile Face Sheet, located in the resident's electronic medical record (EMR) under the face sheet tab, showed a current admitted to the facility of 03/12/21. Review of R81's Physician Order, located in the resident's EMR under the orders tab, revealed the resident had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Orders also showed orders for Physical therapy, Occupational therapy, and Speech therapy to evaluate and treat as needed. Review of R81's NOMNC showed, The effective date coverage of your current skilled services will end: 3/25/21 on page one, and the signature of the Patient or Resident Representative on page two was dated 3.24.2021. In an interview on 03/31/21 at 5:04 PM, the Administrator reviewed the dates of R81's NOMNC and confirmed it was not the 48 hours' notice as required. In an interview on 03/31/21 at 5:27 PM, the Social Worker (MSW) reviewed R81's NOMNC and stated, I wasn't the social worker and can't find any documentation as to the contact, so it appears they received it 24 hours prior.

Based on interviews and record reviews, the facility failed ensure the facility's abuse policy was followed for one of 22 sampled residents (Resident (R) 21). This includes completing a thorough investigation and reporting an injury of unknown origin. This deficient practice had the potential to affect all residents of the facility. Findings include: Review of the facility's policy titled Abuse revised on 11/2020 directs the facility will maintain systems to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, mistreatment .to the administrator or his or her designee .Designated staff will immediately review and investigate all allegation or observations of abuse The results of all investigations are to be communicated to the administrator or his or her designated representative and other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident. During an interview on 04/01/21, the Director of Nursing (DON) acknowledged that the Fall Investigation dated 08/05/20 was the facility's official investigation for the broken wrist, the facility had no other documented interviews or investigations of the occurrence. The DON also stated the incident was not reported to the State Agency. Refer to F610

Based on interviews, policy review, and record reviews the facility failed to report an injury of unknown origin to the State Agency for one of six sampled residents reviewed for accidents (Resident (R) 21). On 08/04/20, R21 sustained a fracture to her left wrist and the injury was determined to be an injury of unknown origin; however, this was never reported to the State Agency. Findings include: Review of the facility's policy titled Abuse revised on 11/2020 directs the facility will maintain systems to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .The results of all investigations are to be communicated to the administrator or his or her designated representative and other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident. During an interview on 04/01/21, the Director of Nursing (DON) acknowledged that the Fall Investigation dated 08/05/20 related to R21's broken wrist, was not reported to the State Agency. Refer to F610

Based on record review, facility policy review and staff interview, the facility failed to ensure a thorough investigation was completed for an injury of unknow origin for one of six residents reviewed for accidents (Resident (R) 21). On 08/04/20, R21 received a fracture to her left wrist; however, the cause of the fracture was not known. Findings include: Review of the facility's policy titled Abuse, revised on 11/2020 directs the facility will . maintain systems to ensure that injuries of unknow source .Designated staff will immediately review and investigate . Review of the Profile Face Sheet located in the resident's hard copy medical record, revealed R21was originally admitted on [DATE] and readmitted on [DATE]. Review of the Diagnosis/Procedure form dated 01/18/21 in the EMR revealed the resident had an intertrochanteric fracture and right pelvic fracture. Review of the Minimum Data Set (MDS) with an ARD date of 06/30/20 revealed the resident had a Brief Interview Mental Status (BIMS) score of six, indicating severe cognitive impairment and that the resident had one or more falls in the month prior to admission. Review of an Incident Investigation Report, in the interdisciplinary notes in the EMR dated 08/05/20 documented Investigation: Nurse from 3-11 [3:00 PM -11:00PM shift] on 8/4/20 stated the resident hit her hand on the walker last evening, no fall was reported to her .L [left] wrist .xray [sic] today after MD evaluated .positive for fracture of the left wrist. Review of a Fall Investigation, dated 08/05/20 provided by the Administrator from the facility's Administrative files, revealed res [resident] stated she had a fall and was put back to bed, this was unwitnessed by staff. One interview was documented from as follows: 8/5/20 Call w/ [Certified Nurse Aide (CNA) 12] Spoke with CNA [12] regarding disposition of [R21] on 8/4/20. CNA stated she gave the resident a shower in the spa room and helped her back to her room .she checked on during shift and resident in bed. CNA never saw resident on floor, nor did resident tell her that she fell . There were no other staff statements and no resident statemetns documented on the 08/05/20 Fall Investigation for R21 During an interview on 04/01/21 at 5:00 PM, the Director of Nursing (DON) acknowledged that the Fall Investigation dated 08/05/20 was the facility's official investigation for the broken wrist, the facility had no other documented interviews or investigations of the occurrence.

Based on observation, record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, the facility failed to ensure that the assessment accurately reflect the resident's status for two of 22 residents (Resident (R) 81 & R78). Review of the residents' comprehensive assessments revealed the residents were not accurately assessed for existing problems. This deficient practice has the potential to affect all residents in the facility. Findings include: 1. Review of CMS's RAI Version 3.0 Manual Section M1040D directs that Open Lesion(s) Other than Ulcers, Rashes, Cuts, Open [CONDITION(S)] that develop as part of a disease or condition and are not coded elsewhere on the MDS [Minimum Data Set], such as wounds, boils, cysts, and vesicles, should be coded in this item. Review of R81's Profile Face Sheet in the electronic Medical Record (EMR) under the face sheet tab, revealed the resident was originally admitted [DATE] with a current admitted [DATE]. Review of R81's Skin Evaluation Form, dated 01/12/21, documented the resident had a head wound that measure 1.6-centimeter (cm) length x 1.2 cm width x 0.1 cm depth noted open area with small drainage. There were no other Skin Evaluation Forms for the scalp wound in the resident's medical records. During an initial observation of R81 on 03/29/21 at 11:11 AM the surveyor noted that the resident had a wound covered with eschar (dead tissue, usually black or brown in color), approximately the size of a half dollar with eschar and a reddened perimeter and no exudate (wound drainage). During the time of the observation, R81 stated that he used to have problem with skin cancer. Review of R81's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/12/21 and R81's quarterly MDS with and ARD of 03/16/21, located in the resident's EMR under the MDS tab, revealed lack of documentation that R81 was assessed to have a surgical wound. Review of R81's admission MDS with an ARD of 03/16/21 revealed the facility assessed the resident to have a Brief Interview for mental Status (BIMS) score of 15 out of 15 which indicated he was cognitively intact. During an interview on 04/01/21 at 9:13 AM, the Minimum Data Set Coordinator (MDS)1, acknowledged that she did not code the scalp wound on the 01/12/21 MDS or the 03/16/21 MDS because she did not think to code the surgical wound on the MDS. 2. Review of CMS's [Centers for Medicare and Medicaid Services] RAI [Resident assessment Instrument] Version 3.0 Manual Section B100 directs Steps for Assessment 1. Ask direct care staff over all shifts if possible, about the resident's usual vision patterns during the 7-day look-back period (e.g., is the resident able to see newsprint, menus, greeting cards?). 2. Then ask the resident about his or her visual abilities. 3. Test the accuracy of your findings. Review of R78's admission Minimum Data Set (MDS) with an ARD of 03/07/21 revealed the resident was assessed to have adequate vision. During an interview on 03/30/21 at 9:40 AM R78 stated he wore glasses; however, he has a visual problem with double vision for a while and has not seen an ophthalmologist within the past year due to the COVID pandemic. In addition, the resident stated staff have not asked him if he has visual problems. During an interview on 04/01/21 at 9:11 AM, MDS1 stated that to evaluate the residents' vison, she has them read from a standardized format that has different fonts that is formulated to determine their vision capabilities according to MDS guidelines. MDS1 could not recall if she specifically asked the resident if he had visual problems.

Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to provide activities of daily living (ADL) care for two of five residents reviewed for ADL, (Resident (R) 70 and R189). Observations revealed both residents had long white hairs on their chins, upper lips, and/or side of their face. This failure has the potential of affecting all dependent residents to not receive assistance with ADLs. Findings include: 1. Review of R70's undated Face Sheet, located in the resident's Electronic Medical Record (EMR), revealed R70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R70's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/11/21, located in the EMR under the MDS tab, indicated R70 had significant cognitive impairment, required extensive staff assistance for hygiene, was dependent on staff for personal care, and had no behaviors. Review of R70's Care Plan, located in the resident's EMR under the care plan tab, revealed related to the resident's need for assistance with ADL's related to weakness and cognitive decline included, personal hygiene will be supported for shaving with one person assist. Observations of R70 on 03/29/21 at 1:54 PM, 03/30/21 at 08:45 AM, 03/31/21 at 2:33 PM, and 04/01/21 at 8:18 AM, revealed the resident had facial hair on her chin and right side of her face. On 03/30/21 at 2:39 PM Certified Nurse Assistant (CNA) 32 stated R70 was dependent on staff for shaving and personal care and was cooperative with personal care. CNA32 stated the staff were to remove R70's facial hair when observed. Observation and interview on 04/01/21 at 8:16 AM with Licensed Practical Nurse (LPN) 91 revealed while R70 was lying in bed, LPN91 confirmed that R70 had facial hair on her chin and the sides of her face. LPN91 stated she was not sure if R70's family wanted the staff to remove R70's facial hair. Interview on 04/01/21 at 12:45 PM with Family Member (F)130 revealed sometimes R70 had facial hair that the staff did not remove timely. F130 stated she wanted R70 to look her best and wanted the facial hair removed. 2. Review of R189's undated Face Sheet, located in the resident's EMR revealed R189 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R189's Nursing Note, dated 03/24/21, located in the EMR under the Interdisciplinary Note tab, documented R189 had independent cognitive skills for decision making, confusion, and anxiety. During rounds on R189's unit on 03/29/21 at 11:24 AM, 03/30/21 at 8:52 AM, and 03/31/21 at 5:30 PM the Surveyor observed facial hair on R189's chin and above her upper lip. On 03/31/21 at 5:30 PM, when asked, R189 stated she would like someone to remove the facial hair on her face the following day. On 04/01/21 at 9:03 AM CNA20 stated R189 was alert, had periods of confusion, and the staff had to ask her if she wanted something completed by them. CNA20 stated R189 would not ask the staff to shave her face. CNA20 stated the staff had to shave R189 when indicated. CNA20 confirmed R189 had facial hair that had not been shaved and stated R20 wanted the facial hair removed. The ADL Policy dated January 200 stated, the CNA will aid the resident with hygiene if required.

Based on observation, record review, staff and resident interview, and review of the facility's policy, the facility failed to ensure that residents received treatment and care in accordance with the comprehensive person-centered care plan and the residents' choices for one of 22 sampled residents (Resident (R) 81). R81 had a surgical wound on his scalp; however, the facility failed to complete weekly wound assessments. This deficient practice had the potential to place the resident at risk for complications related to wound healing. Findings include: Review of the facility's policy tiled Skin Assessment, dated 10/2017 directs If the area of skin impairment is new (no previous documentation can be located) the Charge Nurse will open up a new skin condition form and document results of the assessment, noting location of wound, wound type, etc. for each area . Each identified area of skin impairment must have a separate entry, a separate-skin condition form for each area. If multiple areas are noted in the same location of the body, complete the description box with the number of areas: example: skin tear #1 located 1 [inch] above the elbow on the inner aspect of the LUE [left upper extremity] and skin tear #2 located 3 below the elbow on the inner aspect of the LUE. Each area must have a detailed description for the location of the area. ln general, the wound nurse will care for all skin impairments that require a dressing . The physician will be contacted with assessment results and specific orders for treatment obtained. Review of R81's Review of the Profile Face Sheet in the Electronic Medical Record (EMR) revealed the resident was originally admitted [DATE] with a current admitted [DATE]. Review of R81's Minimum Data Set (MDS) with an assessment reference (ARD) of 03/16/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of Hospitalist Discharge Summary dated 03/12/21, located in the resident's hard copy medical record at the nurse's station revealed that R81 had a mid-scalp wound that started on 11/26/20 due to skin cancer that was present on the hospital admission on 03/10/21. Review of R81's Initial Nursing Assessment, located in the EMR dated 01/11/21, documented the resident had a wound on the scalp and left ear. Review of R81's Skin Evaluation Form located in the resident's EMR dated 01/12/21 documented the resident had a head wound that measure 1.6 centimeter (cm) length x 1.2 cm width x 0.1 cm depth noted open area with small drainage. There were no other Skin Evaluation Forms for the scalp wound in the resident's medical records. Review of R81's Interdisciplinary Notes located in the resident's EMR dated 02/24/21 revealed the Resident returned from dermatology appointment with a new order to cleanse scalp and back of left ear with daily with soap and water, pat dry and apply small amount of vaseline and non-stick dressing daily until 3/10/21. Follow up with Dermatologist in 3 weeks .will continue plan of care. Review of R81's Discharge Instructions, from the hospital located in the medical record in the nurse's station dated 03/10/21, documented the resident required treatment with [MEDICATION(S)] (used to treat certain skin infections) 2% ointment applied daily to the scalp and left ear for wound treatment. Review of R81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Interdisciplinary Notes dated 03/17/21 located in the resident's EMR revealed the Licensed Practical Nurse (LPN) 74 performed a head-to-toe skin assessment that noted the scab to top of scalp, intact and dry. During an initial observation of R81 on 03/29/21 at 11:11 AM, the surveyor noted that the resident had a wound covered with eschar (or dead tissue usually black or brown in color) approximately the size of a half dollar with eschar and a reddened perimeter and no exudate (the material composed of serum, [MEDICATION(S)], and white blood cells that escapes from blood vessels into a superficial lesion or area of inflammation). During the time of the observation, R81 stated that he used to have problem with skin cancer. During an interview on 04/01/21 at 3:07 PM, LPN74, who was the facility's wound nurse, acknowledged that she should have performed weekly wound evaluations the scalp wound on top of the resident's head. During an interview on 04/01/21 at 8:11 AM, the Medical Director, who was also the resident physician acknowledged that the resident had a surgical wound on his scalp from cancer that required routine treatment. The Medical Director stated the wound nurse should have been documenting the wound characteristics, size, appearance, presence/absence of signs of infection, etc., weekly, in accordance with facility policy.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure that one (Resident (R) 81) of four residents reviewed for pressure ulcers, received the physician ordered treatment, received complete incontinent care, qualified staff cleansed the wound, and was provided treatment in a correct manner. Findings include: Review of the facility's polity titled Skin Care-Pressure Ulcer Prevention and Treatment Protocol, revised on 02/2016, directs that A skin assessment will be done upon admission by the charge nurse and weekly thereafter by a licensed nurse. The assessment will establish a baseline and identify residents at risk. Preventative and/or treatment measures will be implemented as needed .If an ulcer is present on admission, or when it first occurs, it will be assessed by the licensed nurse who will complete a Skin Condition Form. A complete assessment will be completed including site, size, depth (where appropriate), drainage, odor, and condition of surrounding skin. Documentation will include notification of the physician and POA [Power of Attorney] .There will be a weekly visual assessment of each pressure ulcer by the Supervisor and/or designee. This visual assessment will include observation of site, stage, location, size, depth, exudates, odor, healing progress, condition of surrounding skin, and wound bed description .Upon initial assessment, the physician will be contacted with assessment results and specific orders for treatment obtained. There will be further physician notification with changes of condition or when treatment is not effective . Review of the facility's policy titled, Skin Care Protocol, revised on 09/2019, directs the following: lncontinent [sic]Care 1.Check for incontinence every 2-3 hours and/or as indicated 2.Cleanse perineal area with skin cleanser and/or soap and water 3.Assess the condition of the skin: a. lf intact: Use a protective ointment as a moisture barrier b. lf irritated or broken due to exposure to feces and urine, (excoriated, denuded): Use a protective cream/ointment or [MEDICATION(S)] based product Denuded Buttocks Use a cleansing agent and skin protectant; i.e.: 4-in-1 cleansing lotion, skin repair cream, [MEDICATION(S)] skin protectant, Nutrashield [Skin Protectant], Remedy [MEDICATION(S)] protectant paste ([MEDICATION(S)] oxide - will need MD order) [MEDICATION(S)] dressing, i.e.: duoderm [an opaque or transparent dressing for wounds] Pressure Ulcer Treatment lf it's dead, remove it lf it's dry, moisten it lf it's wet, manage it lf there's a hole, fill it. The facility's Skin Care Protocol policy did not define which nursing discipline had the responsibility for the various skin care tasks for the skin treatments, including the physician ordered treatments for the various stages of pressure ulcer treatments. Review of R81's undated, Profile Face Sheet, located in the resident's hard copy medical record at the nurse's station, revealed the resident was originally admitted to the facility on [DATE] and was readmitted on date of 03/12/21 after being transferred to the hospital on 03/10/21. Review of R81 Physician's Orders, dated 01/12/21, located in the resident's EMR under the orders tab, revealed orders for [MEDICATION(S)] [medication used to protect skin from wetness, urine, or stools] O.44 %-20.6 topical ointment [MEDICATION(S)]-[MEDICATION(S)] oxide - small amount Topical Three Times a Day For outer and around the sacral wound; Last Dose: 03/09/21. Review of R81's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/16/21 revealed R81 was at risk for pressure ulcers, had unhealed pressure ulcers, specifically two Stage II pressure ulcers that were not present upon admission, and one Stage 3 that was present upon admission. Review of R81's Care Plan, dated 03/12/21, located in the resident's EMR under the care plan tab, identified a problem of Skin Condition with planned interventions for nursing staff to perform a Braden Scale evaluation and to provide protectant skin barrier with each incontinence episode for CNAs and nursing staff. Review of the R81's Hospitalist Discharge Summary, dated 03/12/21, located in the resident's EMR documented the resident had a Stage II sacral decubitus [pressure ulcer] present on admission on 03/10/21 with recommendations to liberally apply Venelex [deodorizes and protectively covers pressure wounds (ulcers) and provides a moist wound environment] ointment every 8 hours to the sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis), bilateral ischial (curved bone forming the base of each half of the pelvis), bilateral heels and any other reddened bony prominence. The discharge summary also documented the wound [Stage II pressure ulcer] on R81's sacrum was present on hospital admission. Review of R81's Physician's Orders, dated 03/12/21 located in the resident's EMR, directed orders to administer Venelex topical ointment three times a day for skin eruption. Physician order dated 03/17/21, revealed cleanse right buttock with NS [normal saline] apply foam dressing; however, the order did not direct how often this was to be completed. Physician order dated 03/23/21, revealed sacral wound NS apply Santyl (uniquely and actively debrides by cleaning necrotic tissue) Ointment cover with foam dressing QD [daily] for wound care. Review of the R81's Skin Evaluation Form located in the resident's EMR dated 03/17/21, revealed the resident had a Stage 3 pressure injury on the sacrum that measured 7.0 centimeter (cm) length (l), 6.0 cm width (w), 0.2 cm depth (d), some eschar (dead tissue), slough (dead mass of tissue) and epithelial (thin tissue forming the outer layer of a body's surface) tissue treated with Santyl and foam dressing; the surrounding skin (no measurements is red). Review of the R81's Skin Evaluation Form located in the resident's EMR dated 03/17/21 revealed the resident had a second pressure ulcer of the right buttock Stage 2 2.0 cm l, 2.0 cm w, 0.1 cm d. with red surrounding skin (no measurements). Review of the R81's Skin Evaluation Form located in the resident's EMR dated 03/23/21 revealed the resident had a third pressure ulcer area on the left buttock Stage 2 pressure injury 1.5 cm l. x 1.0 cm w x 0.1 cm d, pink wound bed epithelial tissue, no change. During a continual observation on 03/30/21 from 1:25 PM to 2:31 PM the following observations occurred. Certified Nurse Aide (CNA) 41 & CNA 25 were at R81's bedside removing his brief to providing fecal incontinence care. The resident was incontinent of a large amount of soft semi-formed light brown stool. When the CNAs removed the incontinence brief; no dressings were in the brief or on the resident's wounds on the coccyx and buttocks which indicated the resident did not receive the physician ordered barrier treatment in place. Removal of the brief also revealed stool was over the entire buttocks, including all the open wounds, which became visible as the CNA's cleansed the resident with incontinent cleansing wipes. In addition to the open wounds the resident's entire intergluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineumand scrotum) was reddened and the skin was denuded (worn away surface). As the CNAs cleansed the resident, he continued to defecate large amounts of soft semi-formed light brown stool. CNA41 placed [MEDICATION(S)] on the coccyx wound; during the observation, CNA41 stated, I always put it [[MEDICATION(S)]] on there. When she was completed and stated she had concluded incontinence care, the surveyor asked to view the resident's groins, and both were covered in liquid brown stool. CNA41, then cleansed the groins after surveyor intervention. LPN74, was in the resident's room setting up the field to perform wound care when CNA41 told the wound nurse she put cream back there. The resident continued to ooze stool and CNA41 now cleansed the coccyx and buttocks with Remedy Phytoplex No Rinse Cleanser (a cleanser that provides cleansing with a higher degree of moisturizing for use on intact, irritated, or denuded skin) and the wound nurse told the CNA41 not to put barrier cream on the coccyx wound which was now slightly bloody and had two distinct whitish yellow discolorations in the center of the wound. On 03/30/21 at 1:48 PM, LPN74 cleansed the wound with one NS gauze that was slightly bloody tinged; no other irrigation or wound cleanser was used. LPN74 then placed Santyl ointment on the resident's coccyx. During the observation, the surveyor asked the LPN74 to depress the skin on the reddened areas on the buttocks and natal cleft around the central coccyx wound area; the natal cleft areas that were deep red were not blanchable. The wound nurse then placed [MEDICATION(S)] ointment around the localized area around the coccyx wound and covered it with a kidney shaped foam dressing. The resident started oozing stool again and the resident was cleansed with foam cleanser, the soiled dressing was removed, and LPN74 repeated the NS cleanse, Santyl and [MEDICATION(S)] application and placed a clean foam dressing over the coccyx wound. For each buttock wound LPN74 cleansed the area with NS, applied [MEDICATION(S)] to the wound and covered with a foam dressing; the right buttock had a visible open wound. During an interview on 03/31/21 10:42 AM CNA41 stated R81 had chronic skin and bowel/diarrhea problems that were sometimes better, sometimes worse. CNA41 stated the facility staff taught her to placed barrier cream on all areas of skin breakdown, including open wounds, then she will inform the nurse. CNA41 stated she was aware the resident had open wounds on his buttocks that required skin treatments; however, if the treatment is off, she will go ahead and put barrier cream on the wound, knowing the nurse will do the treatment. During an interview on 04/01/21 at 7:46 AM, the Medical Director, who was also the resident's physician, stated R81 had chronic diarrhea and was followed by a gastroenterologist (physician that specializes in disorders of the stomach and intestines) and was receiving medical treatment to manage the diarrhea, with altering success. The Medical Director acknowledged that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director stated that cleansing the open wounds that were contaminated with stool with NS provided adequate cleansing, and he did not believe the use of an antimicrobial solution or lavage was necessary unless the wound showed increase signs of infection, evidenced by increased redness around the wound, foul odor, purulent discharge. During an interview on 04/01/21 at 12:53 PM, LPN74 stated R81 had large amounts of stool every day that required staff to cleanse the resident. Currently the staff were using foam dressings to provide a barrier on the open wounds on the buttocks and coccyx to protect them from the frequent stooling the resident has. LPN74 stated that whoever is taking care of the resident should know that the open wounds required the use of the foam dressings and they should tell the nurse if they become soiled and required replacement; the resident should not be in a brief without them, and the CNAs should inspect the resident's groin and scrotum to make sure the stool is thoroughly cleansed form the resident's skin.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of two residents reviewed for urinary catheters (Resident (R) 81). On 03/30/21 during incontinence care, R81's urinary catheter bag was not placed below the resident's bladder for proper urinary drainage. This deficient practice had the potential to affect all residents who had a urinary catheter. Findings include: Review of the facility's policy titled, Special Needs - Suprapubic Catheter, dated 06/2015, directs to .Always keep the bag below the bladder level to ensure good drainage . Review of the facility's policy titled, Urinary Change in Continence Catheters and Prevention of Urinary Tract Infections, dated 07/2014, directed .Securing the catheter to facilitate urine flow and to prevent the catheter from being pulled out . Review of R81's undated Profile Face Sheet, located in the resident's hard copy medical record located at the nurse's station, revealed the resident was originally admitted [DATE] with a current admitted [DATE]. Review of R81's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 03/16/21 revealed the resident had an indwelling catheter. Review of a Urology report dated 05/11/20 located in the medical record in the nurse's station revealed that the resident, who was a resident of the Assisted Living Facility, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R81's Progress Note, located in the electronic medical record (EMR) dated 01/28/21, revealed R81 had a urine [sic] done recently which has come back positive for [MEDICATION(S)]. He has a chronic Foley catheter and remains high risk for UTIs [urinary tract infections] including [MEDICATION(S)] infections. Review of R81's Progress Note located in the EMR dated 02/25/21 revealed R81 recently admitted to the hospital with [CONDITION(S)]. During a continual observation on 03/30/21 from 1:25PM to 2:31 PM the following observations occurred. Certified Nurse Aide (CNA) 41 & CNA25 were at R81's bedside providing fecal incontinence care. The residents foley bag remained on the bed until 1:47 PM when CNA41 emptied the foley bag of 700 cc of urine and hung the bag on the bed frame below the resident. During an interview on 03/31/21 at 10:42 AM CNA41 stated that she left the Foley bag on the bed because she did not want to drop it or leave it on the floor, and she was also having difficulty hooking it on the bed frame. CNA41 also stated she was taught to hook the foley bag on the side of the bed below the resident's body. During an interview on 04/01/21 at 5:00 PM the Director of Nursing (DON) acknowledged that foley [indwelling catheter] bags were to remain in a dependent position and not placed on the bed during incontinent care.