Every finding on record at Senior Care of Marion

Based on review of the facility policy, record review and interview, the facility failed to ensure Resident (R)1 was free from verbal abuse, for 1 of 1 resident reviewed for verbal abuse. Specifically, Licensed Practical Nurse (LPN)1, used curse words directed at R1 when R1 refused to take her medications. Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation documented, It is the policy of this facility to provide protection for the, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under definitions: the definition of abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging, and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mistreatment means inappropriate treatment or exploitation of a resident.Review of R1's Face Sheet revealed the facility admitted R1 with diagnoses including, but not limited to, anxiety, major depressive disorder, schizophrenia and tremors.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/26, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact.Review of the facility's investigation revealed a documented statement dated 10/08/25 revealed, Certified Nursing Assistant (CNA)1 was in the adjoining restroom to R1's room and overheard the altercation. CNA1's statement revealed that the nurse brought the medication into R1's room on 10/04/25 and R1 was not ready to take the medication and wanted the nurse to leave it in the room. The nurse informed the resident that she could not leave it, so the nurse tried to get it back. So Licensed Practical Nurse (LPN)1 held R1's arm while trying to get the medication cup from her other hand. CNA1 reported bad words being said to R1. CNA1 asked the nurse to leave R1 alone so she could calm down. The altercation was reported to the unit manager at this time.During an attempted interview with LPN1 on 01/28/26 at 2:12 PM, was unsuccessful due to the number being discontinued.During an interview on 01/28/26 at 2:16 PM, CNA1 stated she was in the shared restroom with a roommate and she heard R1 and the nurse arguing back and forth. CNA1 stated the resident was holding the cup of medication in her hand and the nurse was holding her other arm and trying to get the cup of medications from the resident. CNA1 stated, I did not hear the nurse call the resident a b**** but I heard the word c*** a few times.During an interview on 01/28/26 at 4:20 PM, R1 stated she remembered the incident very well. She went on to say that the nurse brought medications in her room in a cup. It was early, so I asked her what medications she was going to give me. The nurse started yelling for me to just take them and I told her I wanted to know what medicines they were. The nurse started to take the medication cup out of my hand. She kept calling me a big fat c*** and kept saying it over and over. I was really scared because she came in the next day. I did not want her taking care of me again. I don't want anyone else to have to be scared and treated like I was treated.During an interview on 01/28/26 at 1:16 PM, the Administrator stated they had to let the nurse go because the nurse said bad words to the resident.During an interview on 01/28/26 at 3:00 PM, the Director of Nursing stated the nurse was fired, because she stated she did call the resident a b****.

Based on review of facility policy, record review and interview, the facility failed to report an allegation of verbal abuse within the 2 hour reporting timeframe for an altercation between Resident (R)1 and Licensed Practical Nurse (LPN)1 for 1 of 3 residents reviewed for abuse. Findings include:Review of the facility policy titled Abuse, Neglect, and Exploitation documents under Section VII. Reporting/Reponse of Abuse, Neglect and Exploitation, When abuse, neglect or exploitation is suspected: 1. Immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified time frames; 2. Assure that reporters are free from retaliation or reprisal; 3. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service.Review of R1's Face Sheet revealed the facility admitted R1 with diagnoses including, but not limited to, anxiety, major depressive disorder, schizophrenia and tremors.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/07/26, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 had intact congnition. Review of the facility's investigation revealed a statement written by Certified Nursing Assistant (CNA)1 dated 10/08/25, in which CNA1 was in the adjoining restroom to R1's room and overheard the altercation. CNA1 stated that the nurse brought the medication into R1's room on 10/04/25 and R1 was not ready to take the medication and wanted the nurse to leave it in the room. The nurse informed the resident that she could not leave it, so the nurse tried to get it back so Licensed Practical Nurse (LPN)1 held R1's arm while trying to get the medication cup from her other hand. CNA1 reported bad words being said to R1. CNA1 asked the nurse to leave R1 alone so she could calm down. The altercation was reported to the Unit Manager at this time.During an interview on 01/28/26 at 1:16 PM, the Administrator stated they had to let the nurse go. The night it happened the charge nurse did not let us know it happened. The nurse should have been walked out of the facility but the nurse supervisor did not.During an interview on 01/28/26 at 3:00 PM, the Director of Nursing stated the nurse was fired, because the nurse stated she did call the resident a b****. The resident reported the incident after she returned from the hospital and not at the time it happened.

Based on review of facility policy, observation and interview, the facility failed to follow Enhanced Barrier Precautions (EBP) while providing care for Resident (R)4 for 1 of 1 resident observed receiving care while on EBP. The facility further failed to follow infection control protocols and procedures during laundry services in 1 of 1 laundry rooms. Findings include: (1) Review of the undated facility policy titled Enhanced Barrier Precautions revealed, Policy Statement Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing b. bathing/showering; c. transfering; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central ine, urinary catheter, feeding tube, tracheostomy/ventilation, etc); and h. wound care (any skin opening requiring a dressing) . 8. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 11. PPE (Personal Protective Equipment) is available outside of the resident rooms. Review of R4's Medical Record revealed the facility admitted R4 with severe sepsis, urinary tract infection, methicillin-resistant staphylococcus aureus infection, a stage 4 pressure ulcer and osteomyelitis. During an observation of medication administration on 09/04/25 at 7:50 AM for R4, Registered Nurse (RN)1 entered the room and did not don (put on) gloves or a gown prior to administering the medication. RN1, additionally, using her bare hands, got a personal pillow belonging to R4 and again with bare hands, lifted his left arm to position it comfortably on the pillow. RN1 then lifted the cover from the resident to check the colostomy bag and then recovered the resident. After conversing with R4 further, RN1 opened his water cup with her bare hands and poured in a soft drink that was on the bedside table. RN1 was not observed washing or sanitizing her hands after caring for R4 and before leaving the room. During an interview on 09/04/25 at 8:02 AM RN1 confirmed that she had not worn gloves to position the resident's arm on a pillow with her bare hands and then lifted the covers with her bare hands and assessed the colostomy, and then using her bare hands she covered him back up and then left the room. RN1 stated that she should have applied gloves and a gown to position the resident and to lift the covers to assess his colostomy bag. During an interview on 09/04/25 at 11:32 AM, the Registered Nurse Infection Preventionist stated that if there was high contact with the resident, the nurse should have worn gloves and a gown. The Registered Nurse Infection Preventionist did not consider touching the resident with her bare hands to position his arm on a pillow as high contact. She then asked for a length of time RN1 physically touched the resident's skin and how much time was spent in the resident's room providing care. (2) Review of the undated facility policy titled Laundry Policy stated, It is the policy of the facility to follow infection control methods related to washing clothes. Review of the undated policy titled Handling Soiled Linen stated, It is the policy of this facility that linens are handled, stored, processed, and transported in a safe and sanitary method to prevent the spread of infection. The policy further directed that all used linen should be treated as potentially contaminated, handled using standard precautions (i.e., gloves), and should not touch the uniform or floor. Linen should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. During observation on 09/02/25 at 11:36 AM, in the laundry room with Laundry Aide 1 and Laundry Aide 2, soiled linen was observed on the floor next to the washing machine. Laundry Aide 1 picked the linen up from the floor and placed it directly into the washer. Two bottles of household bleach and a red disposable Solo cup were also observed on a shelf in the laundry room. During observation on 09/03/25 at 1:15 PM, bleach was observed being automatically dispensed into the washer from the built-in automatic dispenser system. During an interview on 09/02/25 at approximately 11:40 AM, Laundry Aide 1 stated she manually adds bleach to the machine using a red solo cup because the automatic bleach dispenser has not been working for approximately 3 months. Laundry Aide 1 reported that she had verbally informed the Housekeeping Supervisor. Laundry Aide 1 confirmed that linen should not be placed on the floor and stated that she was nervous, and this is why she did it. During an interview on 09/02/25 at 12:36 PM, the Housekeeping Supervisor stated he had been in the role for 6 to 7 months, was still in training, and was unaware of how frequently laundry equipment was maintained. He stated machines are maintained by an outside vendor and that bleach is expected to be dispensed automatically. He was unaware that staff were adding bleach manually. During an interview on 09/02/25 at approximately 12:46 PM, the Maintenance Director stated, That's above my pay grade; I don't have anything to do with laundry. When asked about the maintenance of the automatic bleach dispenser, he reported that there were no logs used and that all maintenance issues were communicated verbally. During a follow-up interview on 09/03/25 at 1:16 PM in the presence of the Maintenance Director, Laundry Aide 1 again confirmed she manually adds bleach to the washer to ensure white clothing appears white. During an interview on 09/04/25 at 3:17 PM, the Housekeeping Supervisor stated that linen should never be sorted from the floor under any circumstance. He reiterated that bleach should be dispensed automatically by the machine and not manually added by staff. During an interview on 09/04/25 at 3:44 PM, the Administrator confirmed that laundry and linen handling must follow facility policy. The Administrator stated linen should never be sorted from the floor, and bleach should only be dispensed per machine design and manufacturer instructions—not manually using a disposable cup. These practices are not in accordance with infection prevention protocols or the facility's policy and present a risk of cross-contamination, ineffective laundering, and the potential spread of infection.

Based on review of facility policy, observation and interview, the facility failed to check the placement of a feeding tube for Resident (R)23 prior to flushing the feeding tube with 60 milliliters of water for 1 of 1 residents observed with a feeding tube. Review of the undated facility policy titled Medication Administration via Enteral Tube revealed, It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . Policy Explanation and Compliance Guidelines: . 8. Enteral tube placement must be verified prior to administering any fluids or medication.Review of the undated facility policy titled Flushing a Feeding Tube revealed It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, and competent in, and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice . Definition: Feeding tube refers to a medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake. There are two basic types, naso-gastric and gastrostomy . Policy Explanation and Compliance Guidelines: . 9. After tube placement has been verified, flush the tube utilizing the 60 milliliters catheter tip syringe with the prescribed amount of water every 4 hours, before and after feeding and medications or as directed by the physician .Review of R23's Medical Record revealed the facility admitted R23 on 05/19/25 with diagnoses including, but not limited to, dysphagia, gastroesophageal reflux disease, and a gastrostomy tube. During an observation on 09/03/25 at 8:28 AM revealed Licensed Practical Nurse (LPN)1 did not check the placement of the feeding tube prior to flushing a feeding tube for R23.During an interview on 09/03/25 at 8:30 AM LPN1 confirmed that she had not first checked placement and that she should have done so prior to flushing the feeding tube with 60 milliliters of water as ordered by the physician for patency.

Based on review of the facility policy, record reviews and interviews, the facility failed to provide sufficient preparation and orientation to a resident to ensure safe and orderly discharge from the facility, for 1 of 3 residents. Specifically, Resident (CR)1 was transported and discharged from the facility on 01/23/24 to the local social security office. On 02/02/24 at 10:02 AM, the Administrator was notified that the failure to provide Resident (CR)1 with a safe discharge constituted Immediate Jeopardy (IJ) at F624. On 02/02/24 art 10:02 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy Template and informed the facility IJ existed as of 01/23/24. The IJ was related to 42 CFR 483.15 - Admission, Transfer, and Discharge. On 02/02/24 at 3:53 PM, the facility provided an acceptable IJ Removal Plan. On 02/02/24, survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F624 at a lower scope and severity of D. Findings include: Review of the undated facility policy titled Discharge/Transfer, states, The patient/resident will be discharged /transferred (home/another entity) by order of his/her attending physician. Facility will include the patient/resident and family in developing a safe discharge plan to address the patient's/resident's individual need. Review of CR1's Face Sheet, revealed CR1 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 diabetes mellitus with diabetic amyotrophy, ventricular tachycardia, abnormalities of gait and mobility, essential (Primary) hypertension, epileptic seizures elated to external causes, anemia, hemiplegia, heart failure and peripheral vascular disease. Review of CR1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating CR1 was cognitively intact. Review of CR1's Physician Orders revealed the following order, Discharge home with: Skilled nursing, Aide, Social Services, PT and OT. Review of CR1's Care Plan dated 01/25/24 revealed, CR1 was to be discharged to the community and the facility was to establish a pre discharge plan with CR1/family/caregivers and evaluate progress and revise plan as needed. During an interview on 02/01/24 at 11:45 AM, the Social Worker (SW) revealed, CR1 was supposed to be discharged home with a friend that he resided with prior to hospitalization . The SW stated she tried to contact the friend and each time she tried to phone him she did not make contact. The SW further stated CR1 was discharged to the parking lot at the local social security office. The SW concluded that, [CR1] had a BIMS of 15 and he was in his right mind, it wasn't a safe discharge but [CR1] was focused on getting his money right with the social security office, so he was taken there. During an interview on 02/01/24 at 1:05 PM, the Director of Nursing (DON) denied being on duty the day CR1 was discharged and further denies being told he was discharged . The DON stated, I was told they were going to stop by the social security office and his friend was going to meet him there. I would have called to confirm if he got picked up by his friend. I was just told he was stopping there first. Social Services should have followed up with the call to confirm he was being picked up by a friend. When transportation came back, I do not think I was here. The DON further stated, I would not discharge a patient to the social security office. I do not know the circumstances of his discharge, but I would have dropped him off at another place. I would discharge him home or to another facility. The DON concluded, There was no mention of him being homeless. He said his girlfriend would take care of him. The DON responded that she has never seen CR1's girlfriend visit him at the facility. During an interview on 02/01/24 at 1:19 PM, Certified Nursing Assistant (CNA)1 denied seeing any family or friends visit CR1 at the facility. CNA1 stated, [CR1] did not have a cell phone and used the facility's phone like it was his own. During an interview on 02/01/24 at 1:35 PM, CNA2, who assisted with the transport of CR1, stated, Me and the driver left the faciity on [DATE] to transport [CR1] to the social security office which was located in [NAME], SC. We had to turn around because [CR1] left his black bag and asked us to take him back to the facility, so we turned around. Once we got [CR1's] black bag, we drove to the social security office. I took [CR1] in and checked him in using the kiosk system. The driver got his bags and brought them in. CNA2 concluded, We asked [CR1] want time his ride would get here and [CR1] said my ride is on the way, so we left. The security guard followed us and asked us if [CR1] had a ride, and we told him Yes and the security guard told us he would look after [CR1] until his ride got there. During an interview on 02/01/24 at 1:40 PM, the Driver (D)1 confirmed driving CR1 to the social security office in [NAME], SC, which was about 30 miles away. D1 stated, We had to sign [CR1] in at the social security office, he told us he had a ride, and his girlfriend would come and pick him up. D1 further stated, We got to the social security office and we took [CR1] and his things in the building and when me and CNA2 tried to leave, we were asked by a security guard if [CR1] had transportation home and we responded yes. The security guard said he would look out for [CR1] until his ride came. During an interview on 02/01/24 at 2:16 PM, the Assistant Administrator stated the expectation for a safe discharge is, If the resident has a BIMS of 11 or higher and is discharged to a home or shelter and the person has all the discharge equipment. If the resident requests to be taken someplace other than what they told us during discharge, we can, since they are in their right mind. During an observation and interview on 02/02/24 at 3:35 PM, CR1 was back in the facility sitting in a wheelchair and appropriately dressed. CR1 revealed, The day I was discharged from here, I was in a hurry to get to the social security office. The staff dropped me off at the social security office because that is where I told them I needed to go. I told the staff that I had a ride home. But that person did not come, so I had to call someone else to pick me up. CR1 further stated, I have been staying at a local motel, it's expensive. I do not plan to stay here long, maybe for 1-2 days because the repairs to my house should be completed. Everything that they do here (the facility), I can do it at home, I do not want to stay here, I need to be able to leave and come and go as I want, I cannot do that here. I do not need physical therapy, I can learn to walk on my own. On 02/02/24 at 3:53 PM, the Facility provided an Allegation of Compliance, which included the following: 1. On 2/2/24 Social Services, Director of Rehab and CNA followed up with CR1 and he expressed the need to be readmitted to Senior Care of [NAME]. DON notified NP and readmission orders obtained. CR1 readmitted to Senior Care of [NAME] on 2/02/24 per NP orders. Facility halted Discharges on 2/2/2024 per the Administrator until upcoming discharge locations have been reviewed by Interdisciplinary team and deemed appropriate and safe discharges. 2. All current Residents' Discharge Plans reviewed on 02/02/24 per RN MDS Coordinator, Social Services and Director of Rehab to ensure resident Discharge Plans address resident's individual needs and includes discharge to an appropriate and safe location. 3. The Administrator revised Transfer and Discharge policy/procedure on 2/02/24 to include appropriate and safe discharge location in the planned discharge area. The Administrator also terminated any additional resident requested location transportation outside of the planned discharge location. On 2/02/24 the interdisciplinary team and transport team were educated by Administrator on revised Transfer and Discharge policy/procedure and safe discharges. Resident Discharge Plan will be developed and reviewed in the Initial Care Plan meeting within 72 hours of admission and reviewed weekly and prn by the Interdisciplinary Team to ensure safe discharge plans to include the resident's individual needs and discharge to an appropriate location. Social Services re-educated 2/2/24 per Administrator to document resident's discharge plan post Initial Care Plan meeting. the Interdisciplinary team will update discharge plans as indicated per resident/resident representative wishes and updates will be documented in resident progress notes. The Administrator or Assistant Administrator will review Discharges on a weekly basis x4 then monthly to ensure resident's individual needs are addressed an a safe discharge location is provided and address any issues identified with Interdisciplinary team. 4. The Administrator or Assistant Administrator will audit resident discharges monthly for appropriate discharge planning to ensure facility addressed residents' individual needs and discharge to a safe and appropriate location. Results of this audit will be presented and reviewed by the Administrator to QAPI team until substantial compliance is met. 5. Compliance Date; February 2, 2024.

Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report an allegation of abuse for Resident (R1) within the 2 hour time frame as required for 1 of 1 resident reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, states, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Section VI. Identification of Abuse, Neglect and Exploitation: A.This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. Section VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The facility admitted R1 with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebrovascular accident, and right shoulder pain. Review of the medical record revealed a Minimum Data Set (MDS) quarterly assessment which R1 was scored a 14 out 15 for the Brief Interview for Mental Status (BIMS), indicating that R1 was cognitively able to make her own healthcare decisions. Review of the allegation of abuse for R1 revealed the allegation was reported to the Activity Director on 09/30/22 at 9:20 AM. The Activity Director then contacted the Director of Nursing (DON) and the allegation was dismissed as a concern. The allegation of abuse for R1 was reported to the state agency at 12:02 PM and not the required 2 hour time frame. During an interview on 03/23/23 at 1:02 PM with the Administrator, she stated that the Activity Director was informed by the resident on 09/30/22 at 9:20 AM that 3 Certified Nursing Assistants (CNAs) were rough with her during care. During a second interview on 03/23/23 at 1:30 PM with the Administrator, she stated that on 09/30/22 at 9:30 AM the DON (not available for interview) went into R1's room and R1 told the DON she was ok. So the DON thought there was no need to report the allegation of rough treatment to the state agency. The allegation was reported at 12:02 PM on 09/30/22 and not within the required 2 hours.

Based on observations, interviews and review of facility policies, the facility failed to store, prepare and serve foods under sanitary conditions in 1 of 1 main kitchen. This failure had the potential to increase the spread of foodborne illness to all residents. Findings Include: Review of the undated facility policy titled Food Storage, under the section Canned Foods, revealed, Dented or bulging cans shall be placed on damaged goods shelf and returned for credit. Review of the facility policy titled Serving Utensils dated 08/2018 revealed, Standard serving utensils will be used for serving appropriate products. Review of the undated facility policy titled Hand Washing and Glove Use, revealed, Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout the department. Section 2 Handwashing Procedure: Hands must be washed prior . working with different food substances i.e. raw chicken to fresh fruit, following contact with any unsanitary surface i.e. touching hair sneezing, opening doors, etc. An observation during the initial tour of the main kitchen on 05/31/22 at 9:26 AM revealed the following: 1. A total of 6 dented cans in the dry storage area: 1 can of tomato soup, 1 can of lima beans, 2 cans of greens beans, 1 can of spaghetti sauce, and 1 can of peaches. 2. A buildup of some foreign substance on the inside of the ice machine. An interview with the Administrator on 05/31/22 at 9:36 AM, verifies the dented cans and foreign substance in the ice machine. The administrator stated all damaged cans should be thrown away. The Administrator then directed the kitchen staff to discard of the dented cans and to review all remaining cans for damage. The Administrator further stated the ice machine is deep cleaned by the maintenance department, but the kitchen staff will clean it as necessary. This surveyor requested a cleaning log of the ice machine, but one could not be provided. During a follow-up visit to the main kitchen on 06/01/22 at 12:52 PM observations were made during temperatures of the tray line and food plating. Cook1 was observed grabbing multiple pieces of fried chicken with a gloved hand and placing the chicken on several plates. Cook1 proceeded to grab multiple serving utensils of different food items with the same gloved hand. It was also observed that Cook1, with the same gloved hand, open the freezer door and remove items from the freezer. Cook1 grabbed a thermometer and measured the temperature of the freezer items, with the same gloved hand. Cook1 did not attempt to change gloves or wash his hands after grabbing the fried chicken. An interview with Cook1 on 06/01/22 at 12:58 PM, verifies the potential for cross contamination and lack of sanitary food handling. Cook1 stated he should not be grabbing the fried chicken with a gloved hand and touching other surfaces. Cook1 further states he should have used tongs to plate the food. There was no follow-up with the CDM as she was unavailable due to a car accident.

Based on observations, interviews, and review of facility policy, the facility failed to ensure kitchen staff maintained appropriate infection control measures for the safe handling of foods in 1 of 1 main kitchen. This failure had the potential to increase the spread of foodborne illness to all residents, due to cross contamination. Findings Include: Review of the facility policy titled Serving Utensils dated 08/2018 revealed, Standard serving utensils will be used for serving appropriate products. Review of the undated facility policy titled, Hand Washing and Glove Use, revealed, Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout the department. Section 2 Handwashing Procedure: Hands must be washed prior . working with different food substances i.e. raw chicken to fresh fruit, following contact with any unsanitary surface i.e. touching hair sneezing, opening doors, etc. During a follow-up observation of the main kitchen on 06/01/22 at 12:52 PM observations were made during temperatures of the tray line and food plating. Cook1 was observed grabbing multiple pieces of fried chicken with a gloved hand and placing the chicken on several plates. Cook1 proceeded to grab multiple serving utensils of different food items with the same gloved hand. It was also observed that Cook1, with the same gloved hand, open the freezer door and remove items from the freezer. Cook1 grabbed a thermometer and measured the temperature of the freezer items, with the same gloved hand. Cook1 did not attempt to change gloves or wash his hands after grabbing the fried chicken. An interview with Cook1 on 06/01/22 at 12:58 PM, verifies the potential for cross contamination and sanitary food handling. Cook1 stated he should not be grabbing the fried chicken with a gloved hand and touching other surfaces. Cook1 further states he should have used tongs to plate the food. There was no follow-up with the CDM as she was unavailable due to a car accident.

Based on record reviews, interviews and review of the facility policy titled, Promoting/Maintaining Resident Dignity, the facility failed to ensure resident's call bells were answered timely for Resident (R)127, for 1 of 2 residents reviewed for call bells not being answered timely. The findings include: Review of the undated facility policy titled, Promoting/Maintaining Resident Dignity, states, Policy, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 4. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. 6. Respond to requests for assistance in a timely manner. 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. The facility admitted R127 on 5/17/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 6/1/2022 at 10:30 AM with a family member, revealed R127 was not receiving the care and assistance he needed from the staff in a timely manner. An interview on 6/1/2002 at 10:35 AM with R127, revealed the staff were not answering the call bells timely, and due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review on 6/1/2022 at 2:43 PM of the grievance log dated 5/20/2022 revealed a grievance filed by the Responsible Party for R127. The nature of the concern states, too slow of call bell response. Further review revealed a form titled, Resident Incident Details Report. The report included each time R127 called for assistance. The following are the details of the report: On 5/17/2022 at 6:48 PM, R127 called for assistance by pushing the call bell. The bell rang for 14 minutes. On 5/18/2022 at 12:10 PM the call bell rang for 8 minutes. On 5/18/2022 at 6:25 PM the call bell rang for 15 minutes. On 5/18/2022 at 6:41 PM the call bell rang for 8 minutes. On 5/18/2022 at 9:51 PM the call bell rang for 6 minutes. On 5/18/2022 at 10:48 PM the call bell rang for 6 minutes. On 5/19/2022 R127 called for assistance 16 different times, the duration of the call bell sounding and not answered was from 20 minutes to 1 minute. On 5/20/2022 R127 called for assistance 38 different times, the duration of the call bell sounding and not answered was from 12 seconds to 1 hour and 12 minutes. There were numerous times each day from 5/21/2022 through 5/31/2022 that R127 called for assistance and the call bell rang for an extended duration of time without being answered. Education was provided for the staff on 5/20/2022. After the education with staff on 5/20/2022 the Administrator documented on the grievance form that the Concern & Grievance Resolved on 5/23/2022, however, on 5/23/2022 through 5/31/2022 the slow response to answer the call bell for Resident #127 continued.

Based on record review, interviews and review of the facility weight policy, the facility failed to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's weight policy (undated) states If the month-to-month weight has more than a 5% (percent) change, then the weight will be retaken within 24 hours and in the presence of a licensed personnel and Weights will be obtained on all other residents on the 5th of each month 1. On 06/02/22 at approximately 09:25 AM, a six month review of the medical record for R24, who had been admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed that all weights taken were in a mechanical lift with no weights recorded for 02/22 and 05/22. The weight 127.4 lbs (pounds) was recorded on 04/26/22 by Licensed Practical Nurse (LPN) 4. This represents a 32% gain in weight over the 95.1 lbs recorded on 03/24/22. In an interview on 06/02/22 at approximately 10:02 AM, the Administrator reviewed the findings and stated, weights were not being recorded according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 06/02/22 at approximately 4:07 PM, the Registered Dietician stated, getting weights on all residents has been a long standing problem, both at admission and monthly. She further stated, she must communicate weekly with staff in an attempt to get weights and that she completed training with staff last summer on how to take weights with mechanical lift, in wheelchair and standing and the importance of consistency with each. The RD confirmed there was a QAPI (Quality Assurance/Performance Improvement) meeting, but nothing has improved. 2. The facility admitted R26 on 2/2/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 6/1/2022 at 8:44 AM for R26 under Vital Signs, revealed the weights for R26: On 2/2/2022 (admission) R26 weighed 222.0 pounds. On 2/3/2022 R26 weighed 222.4 pounds. On 2/23/2022 R26 weighed 184.4 pounds. On 3/17/2022 R26 weighed 186.0 pounds. On 3/22/2022 R26 weighed 184.2 pounds. On 4/26/2022 R26 weighed 184.4 pounds. The weight loss in less than 30 days was 37.6 lbs, which is a 16.94% weight loss since admission. Review on 6/1/2022 at 8:50 AM of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/1/2022 at 9:00 AM with the Administrator, she denied having a protocol for residents with a feeding tube, for guidance to monitor for weight loss. 3. The facility admitted R7 on 4/7/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/1/2022 at 10:48 AM of the medical record for R7 revealed the following weights: On 4/8/2022 (admission weight) R7 weighed 234.8 pounds. On 4/14/2022 R7 weighed 234.0 pounds. On 4/21/2022 R7 weighed 222.4 pounds. On 5/17/2022 R7 weighed 222.0 pounds. The weight loss is a difference of 12.8 pounds or 5.77 percent. Review on 6/1/2022 at 11:00 AM of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 was not weighed on the fifth day of May nor June. Review on 6/1/2022 at 1:40 PM of the facility policy titled, Weight Prevention, states, The Registered Dietician/Designee will review the patient/resident's nutritional status to prevent and control undesirable weight loss.

Based on record reviews, interviews, and review of the facility policy titled, Notification of Changes, the facility failed to notify the attending physician and the personal representative of a significant weight loss for Resident (R)7 and R26, for 2 of 3 residents reviewed for nutrition. The findings include: Review of the undated facility policy titled, Notification of Changes, states, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include: 2. Significant change in the resident's physical , mental psychosocial condition such as deterioration in health, mental or psychosocial status. 3. Circumstances that require a need to alter treatment. Additional considerations: Competent individuals: The facility must still contact the resident's physician and notify resident's representative, if known. Residents incapable of making decisions: The representative would make any decisions that have to be made. The resident would still be told what is happening to him or her. The facility admitted R7 on 4/7/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/1/2022 at 10:48 AM of the medical record for R7 revealed the following weights: On 4/8/2022 (admission weight) R7 weighed 234.8 pounds. On 4/14/2022 R7 weighed 234.0 pounds. On 4/21/2022 R7 weighed 222.4 pounds. On 5/17/2022 R7 weighed 222.0 pounds. The weight loss is a difference of 12.8 pounds or 5.77 percent. The facility admitted R26 on 2/2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 6/1/2022 at 8:44 AM for R26 under Vital Signs, revealed the following weights for R26: On 2/2/2022 (admission) R26 weighed 222.0 pounds. On 2/3/2022 R26 weighed 222.4 pounds. On 2/23/2022 R26 weighed 184.4 pounds. On 3/17/2022 R26 weighed 186.0 pounds. On 3/22/2022 R26 weighed 184.2 pounds. On 4/26/2022 R26 weighed 184.4 pounds. The weight loss in less than 30 days was 37.6 lbs, which is a 16.94% weight loss since admission. Further review on 6/1/2022 at 8:44 AM of the physician orders for R26 revealed an order to give [MEDICATION(S)] 1.5, 6 cans per day with 50 milliliters of water flush before and after each bolus administered. Include 350 milliliters of free water with/in between administration of bolus feeds to total 2080 milliliters of water in 24 hours. The orders also included to weigh the resident each week on Thursday per protocol for tube feeding. R26 was not weighed weekly and the facility was unable to provide the tube feeding protocol for weighing residents receiving tube feedings. Review on 6/1/2022 at 11:00 AM of the nurses notes for R7 dated 4/7/2022 through 6/1/2022 revealed no documentation to ensure the attending physician nor the personal representative was notified of the weight loss for R7. Review on 6/2/2022 at 9:00 AM of the nurses notes for R26 dated 5/24/2022 and 6/2/2022 state the the resident refuses tube feedings and medications at times, and it is mentioned throughout the nurses notes. No documentation could be found in the medical record for R26 to ensure the attending physician or the personal representative were notified of a significant weight loss or of the refusal of care and refusal of tube feeding. An interview on 6/2/2022 at 9:10 AM with Licensed Practical Nurse (LPN) 2, confirmed R26 would at times refuse the tube feedings and medications. LPN2 also stated that she had not called the physician nor the personal representative to inform them of the refusal of medications and tube feedings. She went on to say that she felt sure they knew it. An interview on 6/2/2022 at 9:20 AM with LPN1, confirmed that R26 does refuse tube feeding and medications at times and she too had not called the physician nor the personal representative to let them know that R26 was refusing his medications and tube feeding.

Based on record reviews and interviews, the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised with interventions to prevent weight loss and or decrease further weight loss for Resident #26 and Resident #7 for 2 of 3 residents reviewed for Nutrition. The findings included: The facility admitted R26 on 2/2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/31/2022 at 5:24 PM of the Comprehensive Plan of Care for Resident #26 states under, Need, states, Resident is at risk for weight loss. NPO (nothing by mouth) receives enteral feeding per MD order. [MEDICATION(S)] 1.5 can bolus, 6 times daily with 50ml flush before and after each bolus administered. Include 350 mls of water with/in between administration of bolus feed to total 2080 mls of water in 24 hours. Goals: Resident will not have a significant weight loss through review period. The Interventions include: Keep HOB (head of bed) elevated minimal 30 degrees. Labs/diagnostics as ordered. Monitor tube feeding tolerance, notify MD of abnormal findings. NPO (Nothing by Mouth) RD (Registered Dietician) consult as indicated. Therapy as ordered Tube feeding and supplements as ordered. (No supplements are ordered) Weight per MD order. The Comprehensive Plan of Care was not revised with interventions in place to prevent weight loss or to decrease further weight loss for R26. Review of the medical record on 6/1/2022 at 8:44 AM for R26 under Vital Signs, revealed the weights for R26: On 2/2/2022 (admission) R26 weighed 222.0 pounds. On 2/3/2022 R26 weighed 222.4 pounds. On 2/23/2022 R26 weighed 184.4 pounds. On 3/17/2022 R26 weighed 186.0 pounds. On 3/22/2022 R26 weighed 184.2 pounds. On 4/26/2022 R26 weighed 184.4 pounds. The weight loss in less than 30 days was 37.6 lbs, which is a 16.94% weight loss since admission. The facility admitted R7 on 4/7/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/1/2022 at 8:44 AM of the Comprehensive Plan of Care for R7 dated 5/25/2022 revealed the following: Need: Resident is at risk for weight fluctuations on NAS (No Added Salt) diet. Has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: Resident will not have a significant weight change through review period. Interventions: Diet and supplements as ordered. Labs/diagnostics as ordered. Monitor intake, offer alternates if PO (By Mouth) intake decreased. RD (Registered Dietician) consult as needed/indicated Weigh as ordered. The Comprehensive Plan of Care has not been reviewed and revised with interventions to aid in preventing weight loss or to decrease weight loss for Resident #7. Review on 6/1/2022 at 10:48 AM of the medical record for R7 revealed the following weights: On 4/8/2022 (admission weight) R7 weighed 234.8 pounds. On 4/14/2022 R7 weighed 234.0 pounds. On 4/21/2022 R7 weighed 222.4 pounds. On 5/17/2022 R7 weighed 222.0 pounds. The weight loss is a difference of 12.8 pounds or 5.77 percent. During an interview on 6/1/2022 at 12:30 PM with the Registered Nurse (RN) Assistant Director of Nursing (ADON) verified the findings.

Based on record reviews, interviews, and review of the facility policy titled Weight Prevention, the facility failed to monitor weights and to ensure interventions were put into place to prevent further weight loss or to decrease weight loss for Resident (R)26 and R7 for 2 of 3 residents reviewed for nutrition. The Findings include: Review of the undated facility policy titled, Weight Prevention, states, The Registered Dietician/Designee will review the patient/resident's nutritional status to prevent and control undesirable weight loss. The Policy Explanation and Compliance Guidelines, are as follows: 1. Input monthly weights into the computer. Review the computer-generated weight reports to identify significant eight changes and insidious weight trends. 8. Address significant weight loss or gain in the dietary progress notes and by developing and/or updating the plan of care. 9. Determine why weight loss has occurred. With patient/resident input, develop an appropriate plan to increase intake. 11. Supplements as ordered. The facility admitted R26 on 2/2/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/31/22 at 5:24 PM of the Comprehensive Plan of Care for R26 under, Need, states, Resident is at risk for milliliter (ml) flush before and after each bolus administered. Include 350 ml's of water with/in between administration of bolus feed to total 2080 ml's of water in 24 hours. Goals: Resident will not have a significant weight loss through review period. The Interventions include: Keep HOB (head of bed) elevated minimal 30 degrees. Labs/diagnostics as ordered. Monitor tube feeding tolerance, notify MD of abnormal findings. NPO (Nothing by Mouth) RD (Registered Dietician) consult as indicated. Therapy as ordered Tube feeding and supplements as ordered. (No supplements are ordered) Weight per MD order. The Comprehensive Plan of Care was not revised with interventions in place to prevent weight loss or to decrease further weight loss for R26 nor were supplements added to increase caloric intake. Review of the medical record on 6/1/22 at 8:44 AM for R26 under Vital Signs, revealed the weights for R26: On 2/2/2022 (admission) R26 weighed 222.0 pounds. On 2/3/2022 R26 weighed 222.4 pounds. On 2/23/2022 R26 weighed 184.4 pounds. On 3/17/2022 R26 weighed 186.0 pounds. On 3/22/2022 R26 weighed 184.2 pounds. On 4/26/2022 R26 weighed 184.4 pounds. The weight loss in less than 30 days was 37.6 lbs, which is a 16.94% weight loss since admission. Review on 6/1/22 at 8:50 AM of physician's orders for R26 states, Weigh each week on Thursday per protocol for tube feeding. In an interview on 6/1/22 at 9:00 AM with the Administrator, she denied having a protocol for residents with a feeding tube, for guidance to monitor for weight loss. The facility admitted R7 on 4/7/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/1/22 at 8:44 AM of the Comprehensive Plan of Care for R7 dated 5/25/22 revealed the following: Need: Resident is at risk for weight fluctuations on NAS (No Added Salt) diet. Has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: Resident will not have a significant weight change through review period. Interventions: Diet and supplements as ordered. Labs/diagnostics as ordered. Monitor intake, offer alternates if PO (By Mouth) intake decreased. RD (Registered Dietician) consult as needed/indicated Weigh as ordered. The Comprehensive Plan of Care has not been reviewed and revised with interventions to aid in preventing weight loss or to decrease further weight loss for Resident #7. Review on 6/1/22 at 10:48 AM of the medical record for R7 revealed the following weights: On 4/8/2022 (admission weight) R7 weighed 234.8 pounds. On 4/14/2022 R7 weighed 234.0 pounds. On 4/21/2022 R7 weighed 222.4 pounds. On 5/17/2022 R7 weighed 222.0 pounds. The weight loss is a difference of 12.8 pounds or 5.77 percent. Review on 6/1/22 at 11:00 AM of the physician orders for R7 include an order which reads, Monthly weight on every 5th day of the month. R7 was not weighed on the fifth day of May nor June. In an interview on 6/1/22 at 12:30 PM with the Registered Nurse (RN) and Assistant Director of Nursing (ADON) verified that the facility did not ensure R7 and R26 were correctly monitored for weight loss.

Based on observations, interviews, and review of the facility policy titled, Dryer Vents/Lint Check, the facility failed to remove an excessive amount of lint built up on the wiring above the lint basket and the inside upper three sides of 1 of 1 clothes dryers Findings include: Review of the facility policy titled, Dryer Vents/Lint Check states, Confirm that the lint is removed from the stack and inside the dryer. It is a fire hazard and a code violation if this is not maintained. Laundry staff will check and clean daily. Lint Catch/Screens: 1. Lint catchers should be cleaned after each load. 3. A fine layer of lint can form across the screen and stop the flow of clean air out of the dryer, hampering the speed of drying the items. An observation on 6/2/22 at 8:35 AM revealed an excessive amount of lint over the lint basket on the wiring and on the inside upper 3 sides of 1 clothes dryer. An interview on 6/2/22 at 8:40 AM with the laundry worker and the Housekeeping Supervisor confirmed the findings.

Based on observations, review of medical records, interviews and review of the facility policy titled, Wound Treatment Guidelines, the facility failed to ensure a procedure was followed during wound care to prevent infection and to promote wound healing for Resident (R)7. Specifically, Licensed Practical Nurse (LPN) #1 failed to clean scissors before use, during a dressing change for R7 for 1 of 1 residents reviewed for wound care. The findings included: Review on 6/1/2022 at 10:47 AM of the wound care policy titled, Wound Treatment Guidelines, states, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence based treatments in accordance with current standards of practice and physician orders. The facility admitted R7 on 4/7/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/31/2022 at 5:24 PM of the medical record revealed a physician's order which read: Clean area to left buttock with wound cleanser, apply Calcium Alginate, and cover with border gauze daily. An observation on 6/1/2022 at 9:20 AM of wound care for R7 was performed as follows: The Licensed Practical Nurse (LPN)1 knocked on the door and R7 asked us in. The LPN1 explained the treatment and provided privacy. This surveyor asked permission to observe the LPN1 performing the wound care and R7 agreed. LPN1 washed her hands and applied gloves, took a bleach wipe and wiped off the over bed table. LPN1 then removed her gloves and washed her hands and applied gloves, finished pulling the privacy curtain all the way closed, then lowered the head of the bed and the foot of the bed. LPN1 applied a towel over the top of the over bed table and opened the drawer of the over bed table and removed the wound cleanser. LPN1 then removed her gloves and washed her hands. LPN1 then applied gloves and took the supplies from a plastic bag held by the Registered Nurse (RN) that was assisting with wound care. LPN1 then opened the border gauze, and the calcium alginate and placed them on the over bed table. She took a permanent marker and a pair of scissors from her pocket and placed them on the over bed table, (LPN1 did not clean the scissors before placing them on the table with the other supplies that she had opened.). LPN1 then aided the resident in turning to his right side and unfastened his brief and removed the soiled dressing from the wound bed. The RN then washed her hands and applied gloves, LPN1 then removed her gloves and washed her hands. (The wound bed is clean with a small amount of serous drainage, no odor. The wound bed is beefy red and the surrounding tissue clean and normal color.) LPN1 applied gloves and took a large hand full of 4 x 4's and sprayed them with wound cleanser, then took a drape in her right hand and laid it down by the resident's hip. Then taking several 4 x 4's that she sprayed with wound cleansed and wiped from inside out of the wound x2. LPN1 removed her gloves and washed her hands and applied gloves and then cut a small piece of calcium alginate (with the scissors that she had previously removed from her pocket and had not cleaned) and placed the calcium alginate in the wound bed and covered it with a border gauze and wrote the date, time and her initials on it with the marker removed from her pocket. LPN1 then refastened R7's brief and made him comfortable, then bagged the trash and the soiled linen from the over bed table. The RN removed her gloves, and LPN1 raised the head of the the bed. The RN washed her hands, and LPN1 removed her gloves and washed her hands. LPN1 then carried the trash and the soiled linen to the janitor's closet. She then cleaned her hands with hand sanitizer and charted the treatment. In an interview on 6/1/2022 at 9:50 AM with LPN1, she confirmed that she had not cleaned the scissors that she removed from her pocket before cutting the calcium alginate and placing it in the wound bed of R7. LPN1 stated she usually cleans the scissors after the treatment is complete.

Based on interviews, record reviews, review of facility policy titled, Unnecessary Drugs - Without Adequate Indication for Use, the facility failed to ensure Resident (R)179 was free from an unnecessary medication, [MEDICATION(S)], an antipsychotic medication for 1 of 5 residents reviewed for Unnecessary Medications. Findings Include: Review of the undated facility policy titled, Unnecessary Drugs - Without Adequate Indication for Use revealed, It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being . 2. The attending physician will assume leadership in medication management . taking into consideration the following elements: a. Dose b. Duration of use c. Indications and clinical need for medication. 3. Documentation will be provided in the resident's medical record to show adequate indications for medication's use and the diagnosed condition for which it was prescribed. The facility admitted R179, a [AGE] year old male, on 05/17/2022 with diagnoses including but not limited to: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side (mild to severe loss of strength to one side of the body), type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar), [CONDITION(S)] unspecified (sleep disorder characterized by difficulty in falling asleep and/or remaining asleep), and anxiety disorder unspecified. Review of R179's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/22 revealed R179 had a Brief Interview for Mentals Status (BIMS) score of 3 out of 15, indicating R179 suffers from severe cognitive impairment. It was documented that R179 had been receiving antipsychotic medication for 6 days. Review of R179's Preadmission Screening and Resident Review (PASRR) dated 05/17/2022, indicated R179 did not have a mental illness and did not need further evaluation. Review of R179's orders located in the electronic medical record (EMR) revealed R179 had an order for the antipsychotic medication [MEDICATION(S)] tablet 200 milligrams (mg), give 1 tablet by mouth related to the diagnosis of [CONDITION(S)], with an order date of 05/18/2022. Further review of the EMR revealed R179 does not have a diagnosis to ensure the use of [MEDICATION(S)]. Review of R179's Medication Administration Record (MAR) revealed, R179 was receiving [MEDICATION(S)] Tablet 200 MG ([MEDICATION(S)]) Give 1 tablet by mouth at bedtime for [CONDITION(S)] related to [CONDITION(S)], UNSPECIFIED Start Date 05/18/2022, from 05/18/2022 to current. Review of R179's Hospital Discharge Summary dated 05/17/2022 revealed, continue with these medications: [MEDICATION(S)] ([MEDICATION(S)]) 200 MG associated diagnosis [CONDITION(S)], unspecified. Review of R179's History and Physical dated 05/26/2022 revealed, Chief compliant of visit - Gradual Dose Reduction (GDR) per pharmacy recommendations. Pharmacy recommends a GDR of [MEDICATION(S)] at bedtime, currently on 200 MG, will start 150 mg for 4 days than 100 mg (qpm) once a day in the evening. There was no indication in R179's EMR of the Pharmacy Recommendation for GDR and the physician's actions based on the GDR. Furthermore, there was no indication that the facility had began the Pharmacy Recommendation for GDR. Review of the [MEDICATION(S)] (quetipine [MEDICATION(S)]) (an antipsychotic) Black Box Warning (The United States Food and Drug Administration's most serious warning about drugs or medical devices. A drug or device with a black box warning has side effects that may cause serious injury or death.) which states: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [CONDITION(S)]. ELDERLY PATIENTS WITH DEMENTIA-RELATED [CONDITION(S)] TREATED WITH ANTIPSYCHOTIC DRUGS ARE AT AN INCREASED RISK OF DEATH. [MEDICATION(S)] IS NOT APPROVED FOR THE TREATMENT OF PATIENTS WITH DEMENTIA-RELATED PSYCHOSES. AstraZeneca Pharmaceuticals specified INDICATIONS AND USAGE states: 1.1 [MEDICATION(S)] is indicated for the treatment of [CONDITION(S)] and 1.2 [MEDICATION(S)] is indicated as monotherapy for the acute treatment of manic episodes associated with [CONDITION(S)] I disorder, both as monotherapy and as an adjunct to [MEDICATION(S)] or [MEDICATION(S)]. Review of R179's Care Plan dated 05/23/2022 revealed, a care plan for the diagnosis of [CONDITION(S)] with interventions to include Evaluate other factors potentially causing [CONDITION(S)], for example: environment (excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Further review revealed a care plan for R179's psychosocial well-being problem for antianxiety and antipsychotics, with interventions to include but not limited to: GDR as ordered. In an interview with the Director of Nursing (DON) on 06/02/22 at 11:24 AM, verified R179 was taking [MEDICATION(S)] for the diagnosis of [CONDITION(S)]. The DON stated R179 came from the hospital and was already taking [MEDICATION(S)]. The DON further stated that she just received the pharmacy recommendation for May and has not been able to review them yet. In her professional experience, the DON stated she would speak to the physician and get the resident off [MEDICATION(S)]. This surveyor informed the DON of the History and Physical which included the pharmacist GDR of [MEDICATION(S)], The DON states that the NP sends in the History and Physical, but she does not receive it. The DON confirms that there have been no new orders for the GDR of [MEDICATION(S)]. In an interview with the Nurse Practitioner (NP) on 06/02/22 at 11:30 AM, the NP stated if he did not come to us on the [MEDICATION(S)] then she is not sure why R179 is prescribed that. In her professional experience, the NP stated she would prescribe [MEDICATION(S)] for the diagnosis of [CONDITION(S)].

Based record review, interview and review of the form titled, Treatment Administration Record and Progress Notes, the facility failed to ensure wound care was completed daily for Resident (R)1 and R2 for 2 of 3 residents reviewed for wound care. The findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the form titled, Treatment Administration Record, on 11/18/2021 at 3:45 PM revealed no treatments listed as complete for R1. Review of the form titled, Progress Notes, on 11/18/2021 at 3:55 PM revealed no mention of any wound care from 9/6/2021 through 9/11/2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 9/7/2021 and then the physician ordered to, Gently clean open wounds of left foot daily with normal saline. Pat dry. Place saline soaked gauze directly in wound beds. Cover with dry gauze. Wrap with roll gauze or [MEDICATION(S)]. May use ABD pad secured to bottom of foot to prevent pressure on ball or heel of foot when ambulating. Secure all dressings with netting if available or tape to secure every day shift for wound care. No documentation could be found on the Treatment Administration Record or in the Progress Notes to ensure R1 received wound care to his left foot as ordered. During and interview on 11/20/2021 at 3:15 PM with the facility Administrator regarding the wound care and the documentation for wound care and she stated, the order was entered as other, and not as actual wound care to be completed for R1. No documentation could be found to ensure R1's wound care was completed as ordered on 9/6/2021 through 9/11/2021. The facility admitted R2 on 11/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of a form titled, Treatment Administration Record, and the Progress Notes, revealed multiple days from admission on 11/2/2021 until 11/18/2021 in which wound care was not documented as done. The dates wound care was not documented as done on the Treatment Administration Record and in the Progress Notes, were 11/3/21, 11/4/21, 11/5/21, 11/6/21, 11/11/21, 11/13/21 and 11/16/21 and 11/17/21. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Clean all areas on sacrum with wound cleanser. Apply Mesalt to each area. Cover with foam border daily and PRN (as needed). Clean areas on lower back with wound cleanser. Apply Mesalt and cover with border gauze daily and PRN. Clean area to right inner thigh with wound cleanser and pack with Mesalt strip daily and as needed every day shift. Clean area to lateral lower left leg with wound cleanser or normal saline. Apply calcium alginate and cover with border foam daily and PRN every shift. Clean right heel with wound cleanser. Apply calcium alginate and cover with border daily and as needed every day shift. Clean the areas (cluster of stasis ulcers) on top and lateral aspect of right foot with normal saline or wound cleanser. Apply Xeroform, cover with non-adherent dressing and wrap with sponge gauze daily and as needed, every day shift.

Based on record review and review of the baseline care plan for Resident (R)2, the facility failed to follow the baseline care plan related to wound care for 1 of 3 residents review for wound care. The finding include: The facility admitted R2 on 11/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of a form titled, Treatment Administration Record, revealed multiple days from admission on 11/2/2021 until 11/18/2021 in which wound care was not documented as done. Review of the Baseline Care Plan dated 11/4/2021 included multiple areas in which R2 had pressure ulcers and stasis ucers. The care plan included, Provide treatment as ordered for R2's back, heels, legs and etc. No documentation could be found to ensure the treatment had been provided for R2 and the baseline care plan had been followed.

Based record review, interview and review of the form titled, Treatment Administration Record and Progress Notes, the facility failed to ensure complete and accurate records for Resident (R)1 and R2 related to wound care for 2 of 3 residents reviewed for wound care. The findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the form titled, Treatment Administration Record, on 11/18/2021 at 3:45 PM revealed no treatments listed as complete for R1. Review of the form titled, Progress Notes, on 11/18/2021 at 3:55 PM revealed no mention of any wound care from 9/6/2021 through 9/11/2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 9/7/2021 and then the physician ordered to, Gently clean open wounds of left foot daily with normal saline. Pat dry. Place saline soaked gauze directly in wound beds. Cover with dry gauze. Wrap with roll gauze or [MEDICATION(S)]. May use ABD pad secured to bottom of foot to prevent pressure on ball or heel of foot when ambulating. Secure all dressings with netting if available or tape to secure every day shift for wound care. No documentation could be found on the Treatment Administration Record or in the Progress Notes to ensure R1 received wound care to his left foot as ordered. During and interview on 11/20/2021 at 3:15 PM with the facility Administrator regarding the wound care and the documentation for wound care and she stated, the order was entered as other, and not as actual wound care to be completed for R1. No documentation could be found to ensure R1's wound care was completed as ordered on 9/6/2021 through 9/11/2021. The facility admitted R2 on 11/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of a form titled, Treatment Administration Record, and the Progress Notes, revealed multiple days from admission on 11/2/2021 until 11/18/2021 in which wound care was not documented as done. The dates wound care was not documented as done on the Treatment Administration Record and in the Progress Notes, were 11/3/21, 11/4/21, 11/5/21, 11/6/21, 11/11/21, 11/13/21 and 11/16/21 and 11/17/21. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Clean all areas on sacrum with wound cleanser. Apply Mesalt to each area. Cover with foam border daily and PRN (as needed). Clean areas on lower back with wound cleanser. Apply Mesalt and cover with border gauze daily and PRN. Clean area to right inner thigh with wound cleanser and pack with Mesalt strip daily and as needed every day shift. Clean area to lateral lower left leg with wound cleanser or normal saline. Apply calcium alginate and cover with border foam daily and PRN every shift. Clean right heel with wound cleanser. Apply calcium alginate and cover with border daily and as needed every day shift. Clean the areas (cluster of stasis ulcers) on top and lateral aspect of right foot with normal saline or wound cleanser. Apply Xeroform, cover with non-adherent dressing and wrap with sponge gauze daily and as needed, every day shift.

Based on record reviews and interviews, the facility failed to ensure a baseline care plan was formulated related to wound care for Resident (R)1 for 2 of 3 residents reviewed for wound care. The findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Baseline Care Plan on 10/18/2021 at 11:30 AM for R1 made no mention of any type of wound care even though it did state he had skin issues. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Treatment Administration Record (TAR) on 10/18/2021 at 11:45 AM did not include any charted wound care for R1 from 9/6/2021 until his discharge on 9/11/2021. Review of the Progress Notes from 9/6/2021 through 9/11/2021 did not include any documentation for wound care for R1. During an interview on 10/20/2021 at 11:15 AM with the Resident Representative for R1, she stated, the facility did not change the bandages for R1 from admission on Monday, 9/6/2021 until she insisted they be changed on Wednesday, 9/8/2021. She also stated they were not changed again during his entire stay in the facility. During an interview on 10/20/2021 at 3:15 PM with the facility Administrator, she confirmed that the order for wound care, a wet to dry dressing daily, did not show in the medical record due to the fact it was put into the computer system as, Other.

Based on observations, resident and staff interviews, record review, and review of the facility's documents, the facility failed to employ an Infection Control Preventionist (ICP) who had completed specialized training in infection prevention and control who would be responsible for understanding the risks associated with a potential COVID-19 outbreak. This had the potential to affect the 27 residents in the facility at the time of this survey. On 10/08/20 at 5:10 PM, the Administrator was notified of the immediate jeopardy at F882 (Infection Control Preventionist) related to not having a qualified ICP. The facility presented an acceptable removal plan for the immediate jeopardy at F882 on 10/09/20 at 1:07 PM. The removal plan indicated the current infection control nurse would complete the Centers for Disease Control (CDC) training for certification in infection control prevention by 10/10/20. The removal plan was verified through observations, staff interview, and document review. The ICP completed the CDC training for certification on 10/09/20 at 3:15 PM. The surveyor notified the Administrator the immediate jeopardy was removed on 10/09/20 at 3:34 PM. The deficient practice was lowered to an F (widespread scope and severity with a potential for more than minimum harm) following the removal of the immediate jeopardy. Findings include: Per CDC, .Preparing for COVID-19 in Nursing Homes, dated 06/25/20, indicated . Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens.As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP).Facilities should assign at least one individual with training in IPC to provide on-site management of their COVID-19 prevention and response activities because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of HCP, and auditing adherence to recommended IPC practices. During an interview on 10/08/20 at 9:57 AM, Registered Nurse (RN) #9, who presented as the wound nurse and infection control nurse, stated he/she did not have his/her certification as an ICP. When asked what infection control guidelines were used to decide to house a resident positive for COVID-19 with new admission/readmissions/Persons Under Investigation (PUI), RN#9 stated that the 300 unit had been set up, decisions on the use of Standard Precautions instead of Contact Precautions and Personal Protective Equipment (PPE), and the three day quarantine were in place and no changes to infection control policies have been made since he/she was hired in August During an interview on 10/08/20 at 4:35 PM, Human Resource Manager confirmed RN #9 did not have certification as an ICP. He/she also confirmed neither did the Director of Nursing (DON). The Human Resource Manager stated there was no job description for the ICP. He/she said there was a job description for the DON who would be responsible for the infection control policies. Review of a job description document titled, Director of Nursing, undated revealed, . Protects patients and employees by developing and interpreting infection-control policies and protocols.

Based on observations, resident and staff interviews, record review, and review of the facility's policy and procedure, the facility failed to house and provide dedicated staff for a resident positive with COVID-19 separate from the Persons Under Investigation (PUI), to prohibit access to the designated quarantine area by residents from the general population of the facility, failed to maintain a 14 day quarantine, and failed to ensure staff followed transmission-based precautions requiring the use of full Personal Protective Equipment (PPE) (gloves, gowns, face mask, goggles or face shield) while providing care to PUI. Specifically, a resident positive for COVID-19 was housed and staffed on the same unit as the PUI, residents from the facility's general population traveled through the quarantine unit to reach the therapy room, the facility staff transported PUI, who were to remain quarantined for 14 days, to therapy with residents not in quarantine, and facility staff wore only a face mask and gloves while providing care to the PUI. Failure to appropriately quarantine residents and implement transmission-based precautions with full PPE increased the risk of COVID-19 transmission to the 27 residents residing in the facility. These failures constituted an immediate jeopardy. On 10/08/20 at 5:10 PM, the Administrator was notified of the immediate jeopardy at F880 (Infection Control) related to the facility's failure to have a dedicated COVID unit, to prohibit access by residents not on quarantine to the designated quarantine unit, to maintain a 14 day quarantine for new admissions/readmissions/PUI, and to implement transmission-based precautions including full PPE. The facility presented an acceptable removal plan for the immediate jeopardy at F880 on 10/09/20 at 1:07 PM. The removal plan indicated residents who are newly admitted /readmitted to the facility would be admitted to rooms on the designated quarantine unit. The facility identified five current residents admitted within the 14-day quarantine who would be moved to private rooms on the designated unit. The removal plan included posting signs on the door leading to the unit, which stated restricted access. The plan included all residents on this unit would remain in their rooms until the 14-days of quarantine was completed. All services, including therapy, would be provided in the residents' rooms on the unit. The removal plan included dedicated staff would work this unit and that full PPE would be available. The removal plan included staff training on donning and doffing PPE to include gowns, gloves, face mask, and face shield. Implementation of the removal plan was verified through observations, staff interviews, and record review. Observations verified that residents were moved from the general population to a dedicated unit, signage was posted restricting access, and PPE was available on the unit. Interviews and record reviews were conducted and verified staff were trained on the proper use of PPE and contact precautions. The Administrator was notified that the immediate jeopardy was removed on 10/09/20 at 3:34 PM. The deficient practice was lowered to an E (pattern scope and severity with a potential for more than minimum harm) following the removal of the immediate jeopardy. Findings include: Per Centers for Disease Control (CDC), Responding to Coronavirus (COVID-19) in Nursing Homes, updated 04/30/20, . Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 . Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP (Health Care Personnel) with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit . Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility . Per Centers for Disease Control (CDC), Preparing for COVID-19 in Nursing Homes, dated 06/25/20, indicated, .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown.Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Health Care Professionals) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Review of the facility's policy titled, Novel Coronavirus Prevention and Response, dated 03/05/20, indicated to .Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection . Promote easy and correct use of personal protective equipment (PPE) by . Posting signs on the door or wall outside of the resident room that clearly describe . the type of precautions needed and required PPE. ii. Make PPE, including facemask, eye protection, gowns, and gloves, available . immediately outside of the resident's room . Procedure when COVID-19 is suspected . implement standard, contact, and airborne precautions . Wear gloves, gowns, goggles/face shields, and masks . upon entering room and caring for the resident . During the entrance conference on 10/08/20 at 8:45 AM, the Assistant Director of Nursing (ADON) stated a resident (Resident #2) was previously admitted to their facility positive with COVID-19 and the staff used contact precautions along with a face shield to provide care to this resident. The ADON stated Resident #2 was placed on the 300 unit in a private room. The 300 unit of the facility is the quarantine unit for new admissions/readmissions/PUI. The 300 unit does not have staff dedicated to that unit. The ADON stated Resident #2 has since been readmitted back to the hospital for respiratory distress. A policy for COVID-19 positive residents to include isolation, PPE usage, and dedicated staffing was requested but none was provided. Review of the facility's document titled, COVID -19 Plan of Action, undated revealed, . New Admissions without prior testing are being tested immediately upon admission and then admitted into a room with protocols in place. These protocols include contact precautions . 3-day symptoms watch . During an interview on 10/08/20 at 2:45 PM, the Director of Nursing (DON) pointed out the policy on the three days under quarantine. A request for a professional source was made for the three-day room stay while under quarantine. A subsequent interview was conducted on 10/08/20 at 3:23 PM, the DON stated he/she could not find a professional source for the 3-day in room stay for new admissions/readmissions. During the entrance conference conducted on 10/08/20 at 8:45 AM, the ADON confirmed the newly admitted /readmitted residents were placed on the 300 unit and no personal protective equipment (PPE) was donned except for a face mask. The ADON stated staff were to use standard precautions, that is to wear a face mask and to use good hand hygiene During continued interview 9:05 AM, the ADON stated newly admitted residents were placed on only 3-day room stay for more intense monitoring for symptoms and then were allowed out of their room During an interview on 10/08/20 at 9:22 AM, Director of Nursing (DON) stated all new admissions/readmissions go to the 300 hall and the staff monitor the residents, twice a day, for 14 days for signs and symptoms for COVID-19. She stated the only PPE requirement for staff was to wear a face mask unless the staff knew the resident had positive COVID-19 results. The DON stated the staff would then wear a gown, gloves, and a face shield. She stated that they do not post signs on resident doors for contact isolation or other infections due to dignity issues. 1.Review of the electronic medical record (EMR) Admission Record, revealed Resident #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the EMR Baseline Care Plan, dated 09/29/20, revealed Resident #2 was to be placed on contact isolation due to [DIAGNOSES REDACTED]. The resident was placed at the end of the hall on unit 300 which housed new admissions/readmissions/PUI. Review of the EMR, Progress Notes, dated 10/01/20, Resident #2 was transferred to the emergency room due to a low oxygen saturation rate and had not returned to the facility. During an interview on 10/08/20 at 9:57 AM, Registered Nurse (RN) #9, the Infection Control nurse, stated if a resident was admitted positive for COVID-19, they were placed at the end of the 300 hallway, so they were not close to other residents. RN#9 stated the Resident #2 was placed in quarantine and all staff who entered his/her room had on a N95 mask, gloves, gowns, and a face shield. RN#9 stated staff was not dedicated to care for only Resident #2 but also cared for the other residents on the 300 unit. According to RN#9, staff who left the room of Resident #2 would doff (remove) the PPE, wash their hands, and then move on to care for another resident on the 300 unit. The rest of the residents on the 300 unit were new admissions/readmissions/PUI in quarantine due to their potential exposure prior to admission to the facility. The failure to have a separate COVID unit with staff dedicated to providing care for the residents with a known COVID-19 infection increased the risk of transmission to the other residents on the 300 unit. 2. Review of the EMR, Admission Record, revealed Resident #3, was admitted to the facility on 10/01/20. Review of a document titled, Flowsheet, dated 09/25/20, noted Resident #3 had a presumptive negative COVID-19 test, six days prior to admission to the facility. Review of the EMR Baseline Care Plan, dated 10/01/20, revealed Resident #3, was not placed under PUI precautions as a new admission to the facility despite having an unknown COVID-19 exposure the six days between testing and admission to the facility. 3. Review of the EMR, Admission Record, revealed Resident #6 was admitted to the facility on 10/02/20. Resident #6 was placed in the same room as Resident #3 on the 300 unit, increasing the risk of transmission of COVID-19 between Resident #6 and Resident #3. Review of a document titled, Hospital to Post-Acute Care Facility Transfer, revealed Resident #6 tested negative for COVID-19 on 09/15/20, 17 days prior to admission to the facility. Review of the EMR Baseline Care Plan, dated 10/02/20, revealed Resident #6, was not placed under PUI precautions as a new admission to the facility, despite having an unknown COVID-19 exposure the 17 days between testing and admission to the facility. During an observation of Resident #3 and Resident #6's room on 10/08/20 at 3:40 PM, Certified Nursing Assistant (CNA) #6 stated she only wears a face mask, face shield, and gloves but no gown when she enters the residents' room. 4.Review of the EMR, Admission Record, revealed Resident #9 was admitted to the 300 unit of the facility on 09/23/20. On 10/08/20 at 10:47 AM, Resident #9 was observed to roll herself/himself in a wheelchair down the 300 hallway (quarantine unit) to the therapy area on the 400 unit (non-quarantine unit). 5.Review of the EMR, Admission Record, revealed Resident #5 was admitted to the facility on 06/15/20. The resident resided on the 200 unit, which housed the facility's general population who were not in quarantine. Resident #5 was observed on 10/08/20 at 10:31 AM, to roll herself/himself from the 200-unit (non-quarantine unit) through the 300-unit (quarantine unit) and enter the 400 (non-quarantine) unit. 6.Review of the EMR, Admission Record, revealed Resident #4 was admitted to the facility on 05/01/20. The resident resided on the 200 unit. Resident #4 was observed on 10/08/20 at 2:05 PM until 2:16 PM sitting next to the nursing station on the 300 unit. 7.Review of the EMR, Admission Record, revealed Resident #10 was admitted to the facility on 08/28/20. The resident resided on the 200 unit. Observation on 10/08/20 at 11:12 AM, revealed Resident #10 transported herself/himself, in a wheelchair, and stated she/he was on her/his way to therapy. During an interview on 10/08/20 at 11:12 AM, Licensed Practical Nurse (LPN) #4, stated it was typical for a resident from the 200 unit to push themselves through the 300 unit to get the therapy department which was located next to the 400 unit. Observation on 10/08/20 at 10:25 AM, housekeeper #1 entered the room [ROOM NUMBER]. The only PPE observed on the staff member was a face mask. Observation on 10/08/20 at 10:49 AM, housekeeping #1 entered room [ROOM NUMBER]. The only PPE observed on the staff member was a face mask. Then at 10:53 AM, the same housekeeper entered room [ROOM NUMBER] with a face mask on and no other PPE. Observation on 10/08/20 at 10:59 AM, CNA #7 exited room [ROOM NUMBER]. The only PPE the staff member had on was a face mask. During an interview on 10/08/20 at 2:05 PM, LPN #4 confirmed he/she provided care to newly admitted residents/readmissions residents without a gown or face shield. LPN #3 was interviewed on 10/08/20 at 2:26 PM and stated new admissions were kept in their rooms for three days and then permitted to leave to go to therapy even though they are considered under quarantine. LPN #3 stated that she has provided care to the new admissions/readmissions without wearing a gown or face shield but did wear gloves. CNA #7 was observed entering the room [ROOM NUMBER] with just a face mask on 10/08/20 at 2:31 PM. No other PPE was observed on the staff member other than the face mask. During an interview on 10/08/20 at 3:38 PM, CNA #8 confirmed she has provided care to residents who were on the 14-day quarantine. In addition, she said she has not donned a face shield or a gown, just a face mask and gloves. Observation on 10/08/20 at 3:46 PM revealed RN #9, the Infection Control nurse, knocked on the door to room [ROOM NUMBER] and entered wearing only a face mask. Observation was conducted on 10/08/20 at 11:20 AM of a therapy session. There were five residents present in the open therapy area. The residents were socially separated. All had face masks on. During an interview on 10/08/20 at 11:27 AM, Director of Rehabilitation stated that therapy was provided in the resident room to newly admitted residents for the first three days. After three days, the residents could come down to participate in therapy. The Director of Rehabilitation stated he/she wears a gown, face mask, and gloves for in room therapy. The Director of Rehabilitation stated he/she wears a face mask while providing therapy in the rehab department despite providing care to PUI. Observation on 10/08/20 at 11:27 AM verified that the Director of Rehabilitation was wearing only a face mask despite two quarantined residents, Resident #3 and Resident #6, participating in therapy. On 10/08/20 at 12:18 PM a telephone interview was conducted with the Medical Director who stated he/she never considered a designated unit for the new admissions or that staff should be using Contact Precautions with full PPE for the new admissions/readmissions. The Medical Director stated since the staff were [MEDICATION NAME] good hand hygiene and using a face mask, he/she felt there was limited risk of transmission. During the interview on 10/09/20 at 10:28 AM, maintenance #12 stated she/he participated in the transfer of the five residents from the 300 unit to the newly designated 100 unit for new admissions/readmissions/PUI. During an observation on 10/09/20 at 10:50 AM on the 100 unit, all five PUIs (residents under quarantine) were moved from the 300 unit by staff. The 100 hallway is separate from the general population of the facility. Each of the five residents were moved to a room by themselves. Each room has a cart in the front with appropriate PPE, such as gowns, gloves, and face shields. The Dietary Manager was observed to don a gown, gloves and face shield before entering each room to pass water. She/he was then observed to doff the gown, then gloves before exiting, used ABHS (alcohol-based hand sanitizer) and then began to don a gown and gloves prior to entering the room of the next resident.