Every finding on record at The Springs Healthcare and Rehabilitation

Based on record review and interview, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #1). The facility failed to ensure the side rails were up and locked in place on shower bed and CNA D did not shower Resident #1 with the assistance of a second staff, per the care plan, on 5/21/26. Resident #1 fell from the shower bed and hit her head which caused an injury requiring 4 staples. This deficiency could expose residents to harm and injury, due to not being adequately assisted. Finds include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis included impulse disorder, anxiety disorder, repeated falls, personal history of traumatic brain injury. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected resident #1's BIMS score reflected 2 which indicated a moderately impaired cognition. The section GG for functional abilities for personal hygiene, and shower/bathe self was coded with a 01 which meant resident #1 was dependent - helper does all the effort.; resident did none of the effort to complete the activity; or the assistance or 2 or more helpers is required for the resident to complete the activity. Record review of Resident #1's comprehensive care plan dated 03/15/2019 that reflected the resident had an ADL self-care performance deficit related to weakness and debility with an intervention for bathing: I am dependent on 2 staff participation with bathing. Record review of an incident report dated 05/21/2026 revealed Resident # 1 fell from the shower bed in the shower room. Resident #1 was just placed on the shower bed and CNA D stated she adjusted the location of the lift so that she could have better access to the side of the shower bed. Before CNA D could step fully to the side of the shower bed, Resident #1 fell from the bed and hit her head on the leg of the lift. EMS transported Resident #1 to the hospital for further evaluation. Record review of Resident #1's progress notes dated 05/21/2026 at 5:49 PM reflected, 'CNA was getting resident ready for a shower when resident fell of the shower bed to the floor. CNA called out for help. Nurses rushed to help, 911 called. EMS took resident immediately to hospital. Staff stayed with resident and initiated First aide till Emergency help arrived. Resident made a statement, 'I am not in pain'. Resident followed instructions by answering all questions asked, doing ROM, scratching herself, talking, staff noted blood to the back of her head, pressure applied to back of head. Vitals read: T-97.8,137/85, 86,20,02sat 94%. ADON, DON, RP notified. RP to meet her mother at hospital.' During an interview on 06/06/2026 at 10:47 AM with CNA A, she stated when staff was not sure of how to care for a resident they could look it up in the Kardex (resident care guide), care plan or ask a nurse. CNA A stated when using the shower bed, to make sure to lock the wheels, raise the side rails and make sure they were locked in place with the pins. CNA A stated that if only 1 staff member was giving a shower to a resident who was a 2-person assistance the resident could fall and get hurt. During an interview on 06/06/2026 at 11:23 AM with CNA B, stated when using a shower bed, 2 staff members should always be used, make sure it is locked, put the rails up and locked with the pins so they do not slip and slide. When CNA B was asked how she knew how to care for a resident, she stated, by looking at the care plan in the charting system. When CNA B was asked what a potential negative outcome could be if a resident who was a 2-person shower assist was given a shower by 1 person she stated anything could happen including a fall. During an interview on 06/06/2026 at 11:37 AM with CNA C, she stated when using the shower bed, staff should ensure the wheels were locked, rails were up and locked. She stated a potential negative outcome of giving a shower to a resident who was a 2 person assist alone could be a fall resulting in injury. Interview on 06/06/2026 at 2:40 PM the DON stated CNA E came to her and said they needed her help in the 500-hall shower room. The DON said she ran to the shower room and saw Resident # 1 on the floor, getting assistance from CNA D, the ADON was already applying pressure to the back of her head. They switched places and she (DON) began telling everyone what to do, directing the CNA to go sit in her office and write a statement about what happened. The [NAME] said CNA D told her she had just transferred Resident # 1 to the shower bed that she was trying to move the mechanical lift to have a little more space to work in, CNA D had just barely turned her back and Resident # 1 quickly fell out of the shower bed, resulting in an injury to the back of the head requiring 4 staples. The DON stated CNA D stated the rails on the shower bed were not put up and locked in place. The DON stated her expectation for her staff was to follow the policy of the shower bed which was always 2 people and follow the resident's care plan interventions. The DON stated a possible negative outcome for the residents if policies and procedures were not followed could be injury. Interview on 06/06/2026 at 3:02 PM the ADM stated she learned of the incident with Resident # 1 when the EMS was called, the DON let her know what had happened then CNA D did a return demonstration, where she admitted she did not put up the side rails up on the shower bed. The ADM stated her expectation for her staff was to follow policies and procedures for items like the shower bed and mechanical lift which was 2 people use. She stated a possible negative outcome if policies and procedures were not followed could be potential injury for the resident. Interview on 06/06/2026 at 4:17 PM CNA D stated after transferring Resident # 1 to the shower bed she did not recall the side rails being put up and locked. CNA D stated she was giving Resident # 1 a shower in the shower bed by herself. CNA D said she turned for a second to pick up her washcloth with soap and Resident # 1 jumped out of the shower bed and fell on the ground hitting the back of her head on the leg of the mechanical lift. Interview on 06/06/2026 at 4:39 PM CNA E stated she helped CNA D transfer Resident # 1 to the shower bed safely and then left to go and assist her residents and do some documentation at the nurses' station. CNA E said CNA D went to the nurses' station looking for the nurse because she needed help, but the nurse was on break. CNA E stated I got up to see what was wrong and that is when she saw Resident # 1 on the floor. Record review of Bath, Shower/Tub policy dated February 2018 revealed under equipment and supplies the following equipment and supplies will be necessary when performing this procedure 1. Portable bath chair, some residents based upon medical needs & limitations may require a shower bed. This requires 2 staff to remain with the resident the entire time during the bathing process and both rails raised.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 8 residents (Resident #84, Resident #108, and Resident #99) reviewed for ADL care. The facility failed to ensure Resident #84's incontinent brief was changed timely on 04/21/2026. The facility failed to ensure Resident #108 received scheduled showers/bed baths and linens changed after each shower. The facility failed to ensure that Resident #99 had his hair and beard groomed, fingernails trimmed and cleaned. This failure could place residents at an increased risk of not receiving services or care, diminishing quality of life, and decreased self-esteem. Findings included: 1.Record review of Resident #84's face sheet, dated 04/21/2026, reflected an [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included pneumonitis (inflammation of the lung), acute respiratory failure with hypoxia (a critical condition where the lungs fail to transfer enough oxygen into the bloodstream, resulting in low arterial blood oxygen levels), dysphasia (a language disorder caused by brain damage-commonly from stroke, tumor, or injury-that results in partial loss of the ability to produce or comprehend language), and hemiplegia (a severe or total paralysis affecting one side of the body caused by brain or spinal cord injuries) following cerebral infarction (a medical emergency caused by a blockage in a brain artery, cutting off blood flow and causing tissue death) effecting right dominant side. Record review of Resident #84's admission MDS Assessment, dated 02/01/2026, reflected Resident #84's triggered care areas: Urinary incontinence and pressure ulcer. Record review of Resident #84's Comprehensive Care Plan, dated 01/30/2026, reflected focus: ADL self-care performance deficit related to activity intolerance, fatigue, hemiplegia, and impaired balance with interventions: Toilet use: The resident requires 2 staff assist for toileting and focus: Skin impairment related to fragile skin, incontinence with interventions: Reposition resident on CNA rounds. Cleanse resident after incontinent episodes as needed. Record review of Resident #84's Nursing progress notes, dated 04/03/2026, reflected Resident is one person assist with ADL's and brief changes. Resident is incontinent of bowel and bladder. Observation and interview on 04/21/2026 at 10:00 a.m. revealed Resident #84 was sitting at the edge of his bed with Resident #84's family member (FM) changing his incontinent brief, clothing and bedding due to being wet with urine. Resident #84's FM stated that this is not first time she had to change him due to being wet with urine and his clothes smelled of urine. Resident #84's FM demonstrated video recordings on her phone with prolonged waiting time (45mins or longer) for nursing staff to come and assist Resident #84 with incontinent care during the night shifts. Resident #84's FM stated that it was not her job to change Resident #84 and provide care for him at the facility, but she did it because nursing staff at the facility did not do their job. She stated that it made her upset to see Resident #84 wet and she reported it to CNAs and charge nurses, but nothing changed. Observation of Resident #84's skin in his perineum area (around genitals and anus area) on 04/21/2026 at 1:28 p.m. did not reveal any skin issues like skin breakdown or redness. During an interview on 04/21/2026 at 10:10 a.m. Resident #84 had difficulties to communicate clearly regarding how long he had to wait to be changed just nodding and said yes to long time waiting to be changed. 2.Record review of Resident #108's face sheet, dated 04/21/2026, reflected an [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included inclusion body myositis (a progressive, inflammatory muscle disease, typically affecting adults over age [AGE]), dementia (a progressive syndrome, characterized by cognitive decline, including memory loss, confusion, and behavioral changes, permanent atrial fibrillation (normal heart rhythm cannot be restored or maintained), and need for assistance with personal care. Record review of Resident #108's MDS Assessment, dated 04/02/2026, reflected Resident #108's BIMS score of 12 - moderate cognitive impairment and required substantial/maximal assistance when helper does more than half the effort for toileting hygiene and shower/bath. Record review of Resident #108's Comprehensive Care Plan, dated 02/20/2026, reflected focus: ADL self-care performance deficit related to activity intolerance, fatigue, and impaired balance with interventions: Bathing: The resident requires 1 staff assist with bathing/showers. Toileting use: The resident requires 1 staff assist for toileting. During interview on 04/20/2026 at 11:05 a.m., Resident #108 stated he wanted to have showers and not bed baths, but CNAs were too busy to take him to take a shower as he required two people and a mechanical lift to assist him with transfers to the wheelchair. Resident #108 stated that he asked CNAs to be showered multiple times and waited for a while before getting bed baths instead. Resident #108 stated that sometimes CNAs were too busy and were not available to provide him with showers or bed baths at all. He stated that nursing staff did not change bed linens after giving him a bed bath for a couple of weeks. Resident #108 stated that he talked to Social Worker and other staff at the facility regarding not getting showers and his bed linens not being changed after each bathing. Record review of Resident #108's shower sheets revealed only four shower sheets with documented bed baths provided on 04/20/2026, 4/17/2026, 04/15/2026, and 04/13/2026 in last 30 days (03/20/2026 - 04/20/2026). During an interview on 04/21/2026 at 10:20 am, CNA A stated she worked on 500 hall with Resident #84 and Resident #108. She stated that she worked night shifts: 10 p.m. - 6 a.m. She stated that she was able to round on all residents that required incontinent care, but sometimes residents refused and she did not insist on changing them. She stated that she knew that Resident #84 was incontinent of bowel and bladder. CNA A stated that she did not provide incontinent care in the morning before leaving on 04/20/2026 to 04/21/2026 shift due to Resident #84's refusal. She did not tell anybody about him refusing. She stated that she was taking care of 30 residents on 500 hall and felt like she was able to provide good care for those residents. CNA A stated that not rounding on residents every two hours and not assisting them with incontinent care or showers could lead to neglect and skin problems. During an interview on 04/21/2026 at 1:21 p.m., CNA B stated that she worked day shift (6 a.m. to 2 p.m.) on 400 and 500 halls. She stated that she rounded on residents every two hours and was not sure why Resident #84 was soaking wet and not being changed from the beginning of her shift from 6 a.m. until 10 a.m. She stated that she worked with Resident #108 and provided them with bed bath 3 times a week, but sometimes they refused the care. She stated that it was CNAs responsibility to provide showers, assist with incontinent care and change bed linens after each bathing. CAN B did not recall Resident #108 asking for showers instead of bed baths. CNA B stated that if not doing it timely, it could lead to infection and skin breakdown. She stated that she could provide good care for these residents in a timely manner. During an interview on 04/21/2026 at 10:20 a.m., LVN F stated that she worked as a charge nurse during night shift on hall 500. She stated that CNAs and charge nurses were responsible for rounding on residents and assisting them with incontinent care as needed. She stated that she saw CNAs going to residents' rooms but could not tell if CNA A assisted Resident #84 with incontinent care before she left her shift. She stated it was really challenging and stretching thin for CNAs to provide good care with so many residents at night with only one CNA assigned to 500 hall (30 residents). During an interview on 04/10/2026 at 10:40 am, LVN D, charge nurse on day shift (6 a.m. -2 p.m.) on 500 hall, stated CNAs were responsible for residents' incontinent care and showers but charge nurses assisted them as needed. He stated if a CNA observed any problems with a resident's skin during peri care or showers, they were to report it to charge nurse using shower sheets for documentation. He stated he had been in-serviced on incontinent care and showers; however, he did not recall the date. During an interview on 04/21/2026 at 3:58 p.m., DON stated that CNAs were responsible for rounding on each resident every two hours or more often as needed and provide incontinent care if required as soon as possible. She stated that leaving residents who were incontinent without providing incontinent care would lead to skin breakdown and UTIs. She stated that showers or bed baths should be provided to residents on their scheduled days (three times a week) and documented in Point of Care by CNAs and on paper shower sheets and submitted to charge nurses for review if any skin abnormalities were noticed. She stated that electronic Point of Care had an issue with correct documentation of bathing provided to residents and they submitted a ticket to fix it. All refusals had to be documented and reported to charge nurses. She stated that all paper shower reports were collected and reviewed by wound care nurse periodically for assessing wound care needs. She stated that bed linens should be changed after each shower or bed bath by CNAs. She stated that she was not aware about Resident #108 requested showers and not bed baths. She stated that not administering regular showers could cause potential infection. During an interview on 04/21/2026 at 4:15 p.m., ADM stated that nursing staff (CNAs and charge nurses) should round on residents every two hours or sooner. She stated that not providing incontinent care to residents on regular basis could lead to infection, skin breakdown, and other health issues. She stated that nursing management was responsible for monitoring proper care provided including showers and incontinent care. ADM stated that in-cervices on rounding and ADL care is provided to nursing staff annually and periodically throughout the year. 3.Record review of Resident #99's face sheet, dated 04/20/26, reflected Resident #99 was initially admitted on [DATE] and readmitted on [DATE]. He was an [AGE] year-old male diagnosed with dementia, acute respiratory failure, acute kidney failure, muscle weakness, unsteadiness on feet, history of falling, malignant neoplasm of prostate (prostate cancer) and UTI. Record review of Resident #99's quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating her cognition was moderately impaired. Functional Status indicated he required moderate one-person physical assistance to complete personal hygiene. Record review of Resident #99's care plan, dated 03/26/26, reflected that he had an ADL self-care performance deficit r/t activity intolerance, fatigue and impaired balance. The relevant intervention was one staff assistance with personal hygiene and oral care. Observation and interview conducted on 04/19/26 at 10:10 a.m. revealed that Resident #99 was lying in bed, appearing thin and weak. He had a disheveled appearance, with long, untidy hair and facial hair approximately two centimeters long that was unshaved. An examination of his fingers showed overgrown fingernails that were jagged, with a brown substance underneath. The resident stated he preferred to have his hair, beard, and nails trimmed and mentioned that he had his own special shaving set, requesting staff to use it, as his skin was very sensitive. During an interview on 04/19/26 at 10:15 a.m., the FM of Resident #99 stated she was unsure if Resident #99 had requested hygiene care. She explained that Resident #99 was particular about using his own supply of razors and trimmers because he was afraid that the facility's equipment might hurt his sensitive skin. She also mentioned she did not understand why the care was not provided in a timely manner, as she generally observed that the staff at the facility were attentive to residents' personal grooming and overall care. During an interview on 04/20/26 at 11:30 a.m., the DON stated that CNAs were responsible for grooming, trimming, and cleaning residents. She explained that Resident #99 was particular about how these tasks were performed and that he often refused shaving and haircuts due to his sensitive skin. The DON said that maintaining a good appearance and presentation was important to preserve the residents' dignity. She also noted that staff should be aware that residents sometimes need a gentle prompt for grooming and hygiene. The DON highlighted that untrimmed nails could harbor microorganisms, posing a risk of infection, and that jagged nails negatively impact on the resident's overall appearance. Record review of the facility policy Activities of daily living (ADL), supporting, revised in March 2018, reflected: .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:hygiene (bathing, dressing, grooming, and oral care) .c. elimination (toileting). Record review of facility policy Bath, shower/Tub, revised in February 2018, reflected Documentation: the date and time the shower/tub was performed. All assessment data (any reddens areas, sores,. on the resident's skin) obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If residents refused the shower/tub bath, the reason(s). Reporting: 1. Notify the superior if the resident refuses the shower/[NAME] bath.

Findings included:Observation on 04/19/2026 at 9:15 AM in the kitchen of the walk-in cooler revealed: - Boiled eggs with no open date and a use-by date of 4-12-2026. - Tortillas with an open date of 4-10-2026 and a use-by date of 4-17-2026. - Tortillas with no open date and a use-by date of 4-12-2026. - Turkey lunch meat with no open date and a use-by date of 4-17-2026. - Ham lunch meat with no open date and a use-by date of 4-18-2026. - Turkey lunch meat with an open date of 4-11-2026 and no use-by date. - Jelly with an open date of 4-11-2026 and no use-by date.Observation on 04/19/2026 at 9:23 AM of the walk-in freezer revealed: Garlic Bread with no open date and a use-by date of 4-18-2026. Garlic Bread with no open date and no use-by date. Observation on 04/19/2026 at 9:30 AM of the Kitchen. - Cheerios with no open date and a use-by date of 4-11-2026. - Fruit Loops with an open date of 4-6 and no use-by date. - Pasta with an open date of 4-3 and no use-by date. Observation on 04/19/2026 at 9:36 AM of the Dishwasher chemicals test revealed: DA J tested the chemicals in the dishwasher, and the reading was over 200 parts per million which indicates that the sanitizer is too strong. DA J did not have a hair net covering his whole beard. An interview on 04-19-2026 at 9:30 AM with DA J revealed when testing the water in the dishwasher and the reading on the strip is too dark, there are too many chemicals in the water. DA J stated that he tested the water this morning, and it was not that dark. DA J stated that he does not keep track of the test for the chemicals that was done daily on the dishwasher. An interview on 04-19-2026 at 9:30 AM with DM revealed that the hose on the dishwasher broke and she had to cut the hose and piece the hose back together until it could be repaired. The DM stated that she was not aware that there were too many chemicals in the water. An observation on 04/20/2026 at 9:11 AM of CK doing the purees revealed CK pureed the chicken and rinsed the blender and put the blender back to be used and there was still pureed chicken in the blender. While surveyor was taking a picture of the blender, CK grabbed it and cleaned the blender again. An observation on 04/21/2026 at 11:20 AM CK and DA I were not wearing hair restraint coverings over all of their facial hair. An interview on 04/21/2026 12:38 PM DA J revealed the cooks were the ones responsible for labeling and dating food in the walk-in cooler. DA J stated that all his beard was not covered because the hair net bothers his ears. DA J stated that he has not been trained on the dishwasher chemicals and how to adjust the chemicals. DA J stated that he does not know what could happen to the residents if there are too many chemicals in the dishwasher. DA J stated that all hair should be covered when in the kitchen. DA J stated that hair could get in the food and get residents' sick. DA J stated that if food items are not labeled correctly then residents could eat food that was expired and they could get sick. An interview on 04/21/2026 12:43 PM DH I Started a week ago, DH I. DA I stated that he has only been working at the facility for a week. DA I stated that he is not the one who labels and dates the food in the walk-in cooler. DA I stated that he only labels and dates the beverages. DA I stated that he has not been trained on the dishwashers and the chemicals. DA I stated that he checks the chemicals with the test strip and records it in the log. DA I stated that he has not thought about what could happen if too many chemicals are used in the dishwasher. DA I stated that all hair should be covered. DA I stated that his beard was not fully covered because the beard cover pulls his ears down. DA I stated that residents could get sick if hair were to fall into their food. An interview on 04/21/2026 12:46 PM CK H. CK stated that the cooks and the DM are responsible for labeling, dating, and removing expired food from the walk-in cooler. CK stated that dietary aides are responsible for labeling and dating juices. CK H stated that some items in the cooler were labeled by an ex-employee who was terminated on 4-18-2026. CK H stated that if residents ate out-of-date food, they could get sick. CK H stated that hairnets should always be worn and should cover all hair. CK H stated that he had come from outside the kitchen and forgot to cover his facial hair. CK H stated that hair could fall into the food, and residents could get sick from eating it. CK H stated that when he is making puree, the blender should be cleaned and sanitized before using it for the next food item. CK stated that if this is not done, this will just mix food and cause cross-contamination. CK H stated that he ran the blender through the dishwasher, but it was not cleaned. CK H stated that he should have checked it more closely. An interview on 04/21/2026 12:54 PM DM. DM stated that she checks dates in the cooler daily. DM stated that it is everyone's responsibility to label and date food in the kitchen. DM stated that the date on the label, on the use-by line, is the date it was put in the cooler, not the use-by date. DM stated that she can see how confusing that is. DM stated that if residents ate out-of-date food, they could get sick. DM stated that the chemicals in the dishwasher should be checked 3 times a day and documented. DM stated that if the chemicals are incorrect, residents could get sick. DM stated that all staff should wear a hairnet to cover all exposed hair. DM stated that hair could fall into the food, and the residents could get sick. DM stated that when preparing purees, the puree blender should either be rinsed, washed, and sanitized in the sink or run through the dishwasher between each puree. DM stated that when these are not done, there is a risk of cross-contamination. An interview with 04/21/2026 2:03 PM ADM revealed all staff should be always wearing hair nets. The ADM stated that the dishwasher should be tested several times a day to make sure the chemicals are correct. The ADM stated that when doing purees the blender should be washed, rinsed, and sanitized. The ADM stated that not following these procedures could get residents sick. Record review of the facility's Food Preparation and Handling Policy revised on 6/15/2025, reflected: Use clean, sanitized surfaces, equipment and utensils.Record review of the facility's Food Storage Policy revised on 6/15/2025, reflected: Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. Use all leftovers within 72 hours. Discard items that are over 72 hours old.Record review of the facility's Manual Cleaning and Sanitizing of Utensils and Portable Equipment Policy revised on 6/15/2025 reflected: Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. Test and record the parts per million concentration of the solution. A sample Test Strip Log for Three-Compartment Sink follows this policy.

Based on observations, interviews and record review, the facility failed to establish a system of accurate reconciliation, determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 4 medication carts (LVN C's 400-Hall Medication Cart) in the facility affecting 1 resident (Resident #87) and failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 4 medication carts (LVN C's 400-Hall Medication Cart) affecting 2 residents (Resident #76 and Resident #12) reviewed for pharmacy services. The facility failed to ensure LVN C accurately reconciled Resident 87's narcotic medication log when she administered but did not sign for Resident 87's Lacosamide Sol 10mg/ml 15ml on 04/21/2025 at 8:00am.The facility failed to ensure the removal of expired medications: Nystatin topical power for Resident #76 and Glucagon Kit 1 mg for Resident #12 from the 400-hall medication cart. These failures could place residents at risk of medication error, drug diversion, and receiving expired medications which could result in delayed healing. Findings included: 1.Record review of Resident #87's face sheet, dated 04/20/2026, reflected a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia (complete paralysis) and hemiparesis (weakness) following cerebral infarction (a medical emergency caused by a blockage in a brain artery, cutting off blood flow and causing tissue death) affecting left non-dominant side, convulsions (rapid, uncontrollable, rhythmic muscle contractions and relaxations, often characterized by shaking), and major depression (a serious mood disorder characterized by persistent sadness, loss of interest, and hindering daily life). Record Review of Resident #87's comprehensive care plan, dated 02/04/2025, reflected a focus: Resident #87 was on anticonvulsant medication related to altered CNS due to chronic disease process with interventions that included: Administer medications per MD orders. Record review of Resident #87's annual MDS assessment, dated 03/31/2026, reflected a BIMS score of 5 indicating a severe cognitive impairment and taking high-risk drug class medication as anticonvulsant (drugs designed to treat epilepsy and seizures by stabilizing abnormal electrical activity in the brain). Record review of Resident #87's order summary report, dated 04/20/2026, reflected Resident #87's order for Lacosamide Oral Solution 10 mg/ml. Give 15 ml by mouth two times a day related to unspecified convulsions with an order start date of 12/20/2024. Record review of Resident #87's medication administration record for 04/2026 indicated Resident #87 received Lacosamide Oral Solution 10mg/ML 15ml by mouth two times a day related to unspecified convulsions including 04/21/2026 at 7:00 a.m. when medication was not documented in controlled medication administration record. During the 400-hall medication cart's reconciliation and interview on 04/20/2026 at 09:46 a.m., LVN C stated she administered the scheduled Lacosamide Sol 15 ml (controlled anticonvulsant medication) to Resident #87 around 8:00 a.m. this morning, documented in electronic medication administration record but failed to document the administration of Lacosamide Sol 15 ml to Resident #87 in the controlled medication log. LVN C stated she was responsible for documenting on the resident's narcotic log when a narcotic medication was administered but she forgot to sign for Resident #87's controlled medications since she was very busy all morning. LVN C stated that not documenting the administration of controlled medications could cause a discrepancy or a medication error, since the next nurse could not know the resident already received the narcotic medication. 2. Record review of Resident #76's face sheet, dated 04/21/2026, reflected a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: paroxysmal atrial fibrillation (a type of irregular heart rhythm that starts suddenly and stops on its own, usually lasting from minutes to a few days), type 2 diabetes mellites (a chronic condition characterized by high blood sugar due to insulin resistance), and erythema intertrigo (a common inflammatory rash that occurs in skin folds, characterized by bright red, burning, or itching skin caused by heat, moisture, and friction). Record Review of Resident #76's comprehensive care plan, dated 01/10/2019, reflected a focus: Altered skin integrity related to fragile skin, eczema (a chronic inflammatory skin condition causing dry, itchy, and discolored patches) and tinea cruris (itchy fungal infection of the groin, inner thighs, and buttocks) with interventions that included: Follow treatment per MD orders. Record review of Resident #76's annual MDS assessment, dated 02/12/2026, reflected a BIMS score of 15 indicating intact cognition and indicated skin treatments: applications of ointments/medications other than to feet. Record review of Resident #76's order summary report, dated 04/21/2026, reflected Resident #76's order for Nystatin Powder 100000 unit/gm. Apply to per directions topically two times a day every Tuesday, Thursday, Saturday and Sunday for intertrigo, skin health with an order start date of 03/12/2026. Record review of Resident #12's face sheet, dated 04/21/2026, reflected a [AGE] year-old female initially on 04/17/2018 with diagnoses that included: Type 1 Diabetes Mellitus (a chronic autoimmune condition where the pancreas produces little to no insulin, requiring lifelong insulin therapy to manage high blood sugar, vascular dementia progressive form of dementia caused by reduced blood flow to the brain, damaging brain tissue), and chronic kidney disease. Record Review of Resident #12's comprehensive care plan, dated 11/21/2024, reflected a focus: Diabetes Mellitus with potential for abnormal blood sugar levels, poor wound healing and pain with interventions that included: Monitor/document/report as needed any signs and symptoms of hypoglycemia (low blood sugar). Record review of Resident #12's quarterly MDS assessment, dated 03/19/2026, reflected a BIMS score of 9 indicating a moderate cognitive impairment and active diagnosis of diabetes mellitus. Record review of Resident #12's order summary report, dated 04/21/2026, reflected Resident #12's order for Glucagon Emergency Kit 1mg. Inject 1 syringe intramuscularly every 24 hours as needed for hypoglycemia. Give if unconscious or unable to swallow and notify nurse practitioner with an order start date of 05/05/2025. During observation of 400-hall Med cart on 04/21/2026 at 8:15 a.m., revealed expired medication Nystatin topical power (prescription antifungal medication used to treat skin infections caused by Candida yeast) for Resident #76, with expiration date: 02/28/2026 and expired Glucagon Kit 1 mg (a life-saving, fast-acting medication used to treat severe hypoglycemia (critically low blood sugar) by triggering the liver to release stored glucose) for Resident #12 with expiration date: 03/01/2026. During an interview on 04/20/2026 at 09:46 a.m., LVN C stated she was responsible for monitoring expiration dates of medications and removing them from the medication cart. She stated that if expired medications were administered to residents, they would not provide the intended therapeutic benefits and not treating health problems as they could potentially harm residents. During an interview on 04/21/2026 at 3:58 p.m., DON stated the narcotic medication administration should be documented immediately after administration in the electronic medication administration record and controlled medication log. She stated that nurses and medication aides were responsible for the documentation of their medication administration. The DON stated that delay in documenting narcotic medication administration could lead to discrepancy in count and potential residents' overdosing. She stated that in-services on medication storage and medication administration including controlled medications were provided to all nursing staff on an annual basis and periodically throughout the year. She stated that nursing managers were responsible for monitoring the proper medication documentation and expired medication removal from medication carts on a weekly basis. She stated that the pharmacist does the training on medication storage every month and whoever works on medication cart was responsible for making sure that expired medications were removed as administering expired medication would not provide the needed therapeutic benefits to residents. During an interview on 04/21/2026 at 4:15 p.m., ADM stated that charge nurses and medication aides were responsible for documenting controlled medications administration immediately after administration of medications to residents. She stated that if not documented medication administration, it could lead to medication error. She stated if expired medications were not removed from the medication carts could lead to administration of those medications to residents and potentially hinder their health due to reduced potency of those medications. She stated that ADONs and DON were responsible for overseeing the proper medication documentation and medication storage followed by nursing staff at the facility. Record review of facility's Medication Administration policy, revised 11/2020, indicated that If medication is a controlled substance, sign narcotic book. Record review of facility's Storage of Medications policy, revised 11/2020, indicated that 4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record Review of undated Monitoring tool for issue: med carts with frequency: weekly revealed initials of ADON B on the weekly basis from 01/2026 - 04/2026 with last check on 04/07/2026.

Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 6 residents (Resident #107) reviewed for infection control, as indicated by:The facility failed to ensure CNA H changed dirty gloves when handling clean items while providing peri care to Resident #107. Thise failure could place the residents at risk of transmission of diseases and infection. The findings included:Record review of Resident #107's face sheet, dated 04/20/26, reflected Resident #107 was admitted on [DATE]. She was an [AGE] year-old female diagnosed with fracture of lower end of right femur (thigh bone), dementia, muscle weakness, unsteadiness on feet, cognitive communication deficit and need for assistance with personal care.Record review of Resident #107's quarterly MDS dated [DATE] reflected a BIMS score of 07 indicating her cognition was moderately impaired. Further review revealed she needed complete support with toilet hygiene.Record review of Resident #107's care plan dated 03/26/26 reflected that she had an ADL self-care performance deficit r/t activity intolerance, dementia, fatigue, impaired balance, limited ROM and musculoskeletal impairment. The relevant intervention was assistance by one staff member with personal hygiene and oral care.During an observation on April 20, 2026, at 9:30 a.m., CNA H provided peri-care to Resident #107. CNA H donned a new pair of gloves after washing her hands. CNA A removed the old brief and cleaned Resident #107's front and back with wet wipes. She then, without changing the soiled gloves, continued cleaning using wipes directly dispensed from the packet. After completing the task, CNA H operated the bed remote control and pulled up the blanket using the same gloves. In doing so, she contaminated the new brief, the wet wipe packet, the remote control, the bed sheet, and the blanket by touching or handling them with soiled gloves. Finally, before exiting the room, she stored the contaminated wet wipe packet with remaining wipes in the drawer for future use.During an interview on April 20, 2026, at 9:45 a.m., CNA H stated she had started her career at the facility two days prior and was still under orientation. She mentioned she had over a year of experience as a CNA and had been employed at another nursing facility. She explained that incontinent care was part of her previous job and that she had been doing it since the beginning of her career. CNA H requested the state investigator to walk through the peri-care she performed so she could identify her mistakes. She acknowledged that she should have sanitized her hands and changed her gloves at appropriate times and that she should not have handled the wet wipe packet with dirty gloves. She added that she should have handled other clean items only after removing the soiled gloves and sanitizing her hands. She expressed concern that her improper nursing practices could facilitate the spread of various diseases. CNA H stated she wanted to focus on her orientation to learn proper infection control practicesDuring an interview on April 20, 2026, at 1:30 p.m., the DON stated that CNA H should not have handled the wet wipe packet, blanket, or other clean items with soiled gloves. She stated that CNA H was supposed to dispose of the contaminated wet wipe packet instead of saving it for future use. The DON mentioned that she had already conducted a one-on-one in-service with CNA H and planned to extend her orientation to include additional training in peri-care and infection control. The DON emphasized that CNA H's improper practices increased the risk of disease transmission through contaminationRecord review of the facility policy Infection prevention and control Program revised in 08/2016 reflected: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. a. Important facets of infection prevention include:.(3) educating staff and ensuring that they adhere to proper techniques and procedures.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (nursing treatment cart) reviewed for medication storage. The facility failed to ensure that the nursing treatment cart was locked and medications/treatment supplies were secured and not accessible to other staff, residents or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications. Findings include: Observation on 04/19/2026 at 9:24 a.m. revealed the treatment cart located next to the nursing station and 500 hall was unlocked with medications and treatment supplies that were not secured. The locking mechanism was protruding outward on the treatment cart. The State Surveyor opened the drawers and captured photos. There were no nursing staff in the area of the unlocked treatment cart. Multiple visitors and residents were observed walking near the cart and could have direct access to the treatment cart. During an interview on 04/19/2026 at 9:38 a.m., LVN G stated there was no treatment nurse available in the building on Sunday and charge nurses were responsible for providing wound care and using a treatment cart. She stated that she did not know who worked on the treatment cart last and did not lock it. She stated residents and visitors could have access to the medications in the treatment cart. LVN G stated if residents or visitors had ingested another residents' medications there was a possibility the resident may overdose, have an allergic reaction, and may require further care at the hospital. She stated she was in-serviced on locking medication carts when she was not obtaining medications from the cart. LVN G stated she did not recall the date of the in-service of locking medication carts. Interview on 04/21/2026 at 3:58 p.m., DON stated the medication and treatment carts were expected to be locked unless the nurse or medication aides were standing at the carts. She stated if the medication or treatment carts were in the hallway and the nurse was not standing at the medication cart it was expected to be locked, no exceptions. She stated residents or visitors could take medications out of unlocked medication or treatment carts and if they ingested the medications there was potential for harm. She stated the staff were in-serviced on locking medication carts on a weekly basis. Interview on 04/21/2026 at 4:15 p.m., ADM stated that charge nurses or med aides were responsible for locking medication or treatment carts when not in attendance. She stated that nursing managers, ADONs and DON, were responsible for overseeing the nursing staff following the secured medication storage protocol. She stated that if medication carts were not locked, visitors and residents could get access to medications and treatment supplies in the medication carts and potentially could get hurt. Record review of the facility's policy on Medication Storage in the Facility, reviewed 2020, reflected The community stores all drugs and biologicals in a safe, secure, and orderly manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left unattended.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #107) and the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 1 out of 32 residents on 500 Hall (Resident #2) reviewed for privacy. The facility failed to ensure CNA H provided privacy by drawing the privacy curtain during incontinent care for Resident #107. The personal health information of one resident (Resident #2) was left unlocked and displayed on the computer screen on the medication cart of LVN D who administered medications to residents at 500 Hall. This failure could place residents at risk of lack of privacy, not having residents' rights acknowledged, and residents' personal clinical information being exposed to unauthorized individuals. The findings include: 1.Record review of Resident #107's face sheet, dated 04/20/26, reflected Resident #107 was admitted on [DATE]. She was an [AGE] year-old female diagnosed with fracture of lower end of right femur (thigh bone), dementia, muscle weakness, unsteadiness on feet, cognitive communication deficit and need for assistance with personal care. Record review of Resident #107's quarterly MDS dated [DATE] reflected a BIMS score of 07 indicating her cognition was severely impaired. Further review revealed she needed complete support with toilet hygiene. Record review of Resident #107's care plan dated 03/26/26 reflected that she had an ADL self-care performance deficit r/t activity intolerance, dementia, fatigue, impaired balance, limited ROM and musculoskeletal impairment. The relevant intervention was assistance by one staff member with personal hygiene and oral care. During an observation and interview on 04/20/26 at 9:30 am CNA H had provided incontinent care to Resident #107 in her room. CNA H did not draw the privacy curtain fully during the incontinent care. The incontinent care would have been fully visible to anyone who entered the room if anyone opened the door during the incontinent care. Incidentally, when the incontinent care was progressing, the ADON entered the room to pass on information. During an interview on 04/20/26 at 9:40am Resident #107 stated she believed CNA H had done a good job and she was happy with it. She stated she had neither noticed if the privacy curtain was fully closed nor any visitors had a chance to view the incontinent care. During an interview on 04/20/26 at 9:45am CNA H stated she started her career at the facility two days ago and under orientation. She stated she had more than a year experience as a CNA and was working in another nursing facility as a CNA. She stated incontinent care was part of that job and had been doing it since the beginning of her career as a CNA. She stated it was a mistake that the privacy curtain was not closed. CNA H said she was thinking that it was OK to keep the curtain the way it was as the peri care was not visible to Resident #107's roommate as the curtain had separated Resident #107 from her roommate. She stated she believed the incontinent care was seen by the ADON who entered the room while she was doing the care and it would have been visible to anyone who was entering the room. CNA H said by not closing the privacy curtain she compromised Resident #107's right to maintain her privacy during personal care. During an interview conducted on April 20, 2026, at 10:15 a.m., the ADON stated that she observed the peri-care of Resident #107 upon entering the resident's room. She expressed her concern that the procedure was visible to her at that time and wondered why CNA H had not fully closed the privacy curtain. The ADON noted that CNA H had joined the nursing team only a few days prior and was still in the process of completing her orientation. The ADON stated that, as an experienced CNA, she should have exercised greater caution in maintaining the resident's privacy during peri-care. The ADON concluded that by not fully closing the privacy curtain, CNA H risked compromising Resident #107's dignity and privacy, which are inherently protected during personal care procedures involving the exposure of the resident's naked body. During an interview conducted on April 20, 2026, at 1:30 p.m., the DON stated that it was mandatory to respect and uphold residents' privacy and dignity during all nursing care, including incontinent care, by closing doors, windows, and drawing privacy curtains. She said that the privacy curtain of Resident #107 should have been fully closed by the nursing staff prior to beginning the incontinent care. The DON explained that staff training was an ongoing process, and resident rights are a fundamental component of that training. She noted that CNA H had only started working at the facility two days prior and that the facility had ensured she had satisfactorily completed all required nursing skills. Additionally, the DON stated that, according to facility policy, all nursing staff are required to undergo an annual evaluation to assess their nursing skills, knowledge, and competency in respecting residents' rights. Record review of undated facility policy Resident Rights reflected: . Residents will be examined and treated in a manner that maintains the privacy of their bodies. A resident will be granted privacy when going to the bathroom and in other activities of personal hygiene. In situations where a resident requires assistance, authorized staff members are required to respect the individual's need for privacy. Staff members will ensure that privacy curtains are pulled, doors are closed, or the residents are otherwise removed from public view or covered or draped to prevent unnecessary exposure of body parts during the provision of personal care and services. Window coverings should be closed. 2.Record review of Resident #2's face sheet, dated 04/21/2026, revealed a 42-years-old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia effecting left nondominant side (a severe or total paralysis on one side of the body caused by brain or spinal cord damage), hydrocephalus (a condition characterized by an abnormal accumulation of cerebrospinal fluid within the ventricles of the brain, increasing pressure on brain tissue), and major depression (a serious, treatable mood disorder characterized by persistent sadness, loss of interest in activities, and low energy). Observation on 04/21/2026 at 8:32 a.m. revealed the computer screen on LVN D's 500 Hall medication cart was open and unlocked, with Resident #2's personal clinical information, MAR, displayed and visible to unauthorized individuals, including visitors or other residents. No visitors and residents were observed near the cart when LVN D left the computer on medication cart unattended. During an interview on 04/21/2026 at 8:36 a.m., LVN D stated that he had an in-service on HIPAA at hire which included instructions not discussing residents' private clinical information with unauthorized individuals and to lock the computer screen when stepping away from the medication cart. He stated that everybody who works with charting computers was responsible for closing it and locking it when not in attendance. He acknowledged that leaving the screen unlocked with clinical information displayed on it could be harmful for residents as anybody could see it. During an interview on 04/21/2026 at 3:58 p.m., DON stated that the facility's policy was to minimize the charting computers' screens when stepping away. She stated that if the screen was not minimized, someone could have unauthorized access to private clinical information displayed on the screen. She stated that HIPAA in-service was provided to all employees at hire and annually through computer modules which include instructions on locking the computer screens. She stated that the person who worked with residents' private clinical information should lock the screen before walking away. She stated that the potential negative effect to residents could be unauthorized disclosure of residents' private information to public. During an interview on 04/21/2026 at 4:15 p.m., ADM stated that all staff had annual training which covered the importance of maintaining the residents' private information. She stated that whoever uses the computer is responsible for shutting it down to ensure the residents' information is not visible. She stated that the potential risk for not shutting down charting computers was the breach of residents' privacy and their emotional distress. Record review of MOCK (an imitation, simulation, or replica of something real) take away's/observation in-services, dated 11/11/2025, revealed: HIPAA: lock your screen when walking away from your computer. Place paper face down at nurses' station when not attended was completed by LVN D. Record review of undated facility's HIPAA - Resident Rights - Abuse: Do's & Don'ts basics policy revealed: Log off computer when leaving for longer periods of time.

Based on interviews and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 8 residents (Resident #23) reviewed for accuracy of assessments. The facility failed to accurately code Resident #23's use of an antiplatelet medication on her most recent comprehensive MDS assessment dated [DATE]. This failure could have placed the resident at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included:Record review of Resident #23's comprehensive MDS assessment dated [DATE], indicated Resident #23 was a [AGE] year-old female, who was admitted to the facility on [DATE]. Her diagnoses included stroke (when a blood vessel in the brain leaks or bursts, causing bleeding in the brain), Coronary Artery Disease (when coronary become narrowed or blocked due to plaque buildup, which reduces blood flow to the heart), Hypertension (high blood pressure), Diabetes Mellitus (when the body cannot properly use blood sugar, leading to high blood sugar levels), and Hyperlipidemia (a condition which causes high levels of fat or lipids in the blood). Resident #23's BIMS Summary Score was 7, indicating severe cognitive impairment.Record review of Resident #23's comprehensive MDS assessment dated [DATE], reflected other additional active diagnoses for Resident #23, including LONG TERM (CURRENT) USE OF ANTICOAGULANTS.Record review of Resident #23's comprehensive MDS assessment dated [DATE], Section N0415 High-Risk Drug Classes: Use and Indication, reflected the resident was taking an anticoagulant medication (medications that prevent or treat blood clots helping reduce the risk of stroke, heart attack, and blood clots that block and stop blood flow to an artery in the lung) and that there was an indication noted for the use of this drug class. The same comprehensive MDS assessment also reflected Resident #23 was not taking any antiplatelet medication and no indication was noted for the use of this drug class. Record review of Resident #23's care plan dated June 2, 2025, reflected no problems, goals or interventions related to the use of anticoagulant medication(s). The care plan did reflect Resident #23 was on antiplatelet therapy related to CAD and s/p CVA, initiated on June 2, 2025, with the goal being that the resident would have no complications related to antiplatelet therapy through the review date, and interventions including administering antiplatelet medication/s as ordered by the physician, monitoring for abnormal bleeding and excess bruising, and monitoring for adverse reactions of antiplatelet therapy, with those interventions initiated on June 2, 2025. Record review of Resident #23's order summary report dated April 20, 2026, reflected no orders for anticoagulant medication(s). The same order summary report reflected an order for Aspirin EC (special coating that delays absorption until the tablet reaches the small intestine) Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day related to CEREBRAL INFARCTION, UNSPECIFIED, ordered on June 3, 2025 and started on June 4, 2025. In an attempted interview on April 20, 2026, at approximately 10:20AM, it was determined Resident #23 was unable to consistently track questions being asked or topics being discussed and forgot information such as how to spell her first name and what her last name was. Therefore, a reliable resident interview could not be obtained in relation to the resident's status or care provided. In an interview on April 21, 2026, the ADM stated the facility did not have a MDS nurse onsite currently. ADM stated that MDS A vacated her position a couple of weeks prior and was not available for interview. ADM stated they had not hired a replacement. ADM referred this surveyor to their Corp. MDS specialist, MDS B, who officed off-site. In a telephone interview on April 21, 2026, at 1:58 PM, MDS B stated that she was a RN who had 15-20 years of experience with the MDS assessment process. MDS B stated that she had been employed with the company that manages and operates the facility for 4 years. MDS B stated that she is in a supervisory position which oversees and trains MDS nurses and specialists, including completing MDS assessments. MDS B confirmed MDS A was the person responsible for conducting the portions of the comprehensive MDS assessment for Resident #23 dated March 20, 2026, including Section I, Active Diagnoses, and Section N, Medications. During the interview, MDS B reviewed Resident #23's MDS assessment dated [DATE], care plan, diagnoses, and orders. MDS B acknowledged MDS A incorrectly completed the resident's MDS assessment, resulting in inaccuracies. MDS B stated MDS A likely miscoded Aspirin as an anticoagulant drug rather than an antiplatelet drug. MDS B acknowledged Resident #23 had no order for an anticoagulant medication and did not have a diagnosis of long term (current) use of anticoagulants. MDS B stated that MDS A should have known the difference between antiplatelet and anticoagulant drugs from her training as a nurse and specialized training provided by the facility. MDS B stated that she spot checks assessments for accuracy and utilizes scrubbers (software tools used to identify errors, inconsistencies, or missing information) to ensure assessments are accurate and complete. Although, MDS B stated that these scrubbers would not have identified this error. MDS B stated there would be no negative impact on the resident because these errors would not alter resident care. MDS B stated that a MDS nurse or specialist should always review their entries for accuracy. If the errors had been caught during her spot checks, MDS B stated that she would have provided additional training for MDS A and reeducation. MDS B stated that she would initiate the correction process for Resident #23's MDS assessment right away. In an interview on April 21, 2026, at 4PM, ADM stated that her expectations regarding the completion of MDS assessments would be that the MDS nurse would comb the resident's chart for the correct data entry information and speak to relevant staff for the clinical information necessary to accurately complete the assessment. ADM stated that she and the DON conduct MDS assessment audits for information and data entry accuracy. ADM stated that a negative impact resulting from inaccurate assessments would be inaccurate clinical data for the resident and the submission of inaccurate financial data. In an interview on April 21, 2026, at 4:05PM, DON stated she has been employed with the facility for several years. She confirmed the facility does not currently have an onsite MDS nurse but their most recent staff member in that position was MDS A. DON stated that she was familiar with the MDS assessment process and also conducted accuracy checks related to nursing care and information. DON stated that she had been informed of the inaccuracies of Resident #23's MDS assessment dated [DATE], after it was brought to MDS B's attention today. DON stated that MDS accuracy matters because it's meant to be a reflection of the resident's status, the care provided to the resident, and the acuity of care to be provided to the resident. DON stated that inaccurate assessment information could negatively impact the facility's quality measures and rating. DON stated that if a mistake is found, appropriate staff are expected to correct or resolve those errors immediately. DON stated that it is important that assessments are accurate as this is the basis for provision of care. Record Review of the Long-Term Care Facility MDS 3.0 RAI User's Manual effective October 1, 2025, reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status .

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accident, hazards, and supervision. The facility failed to ensure there was adequate supervision to prevent Resident #1 from leaving the facility 01/10/26 without staff knowledge. This failure could place residents at risk of avoidable accidents.Findings included: Record review of Resident #1's face sheet, dated 01/13/26, reflected a [AGE] year-old male, admitted [DATE], with diagnoses that included vascular dementia (decline in cognitive function affecting memory, thinking, and behavior) unspecified severity, generalized anxiety (mental health condition characterized by excessive fear, worry or apprehension), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment, dated 11/26/26, reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG for functional abilities and mobility reflected Resident #1's performance was coded as supervision or touch assistance for short (10 feet) and longer (150 feet) walking. Resident #1's mobility also reflected no required use of wheelchair, walker, motorized scooter or other assistive device, only independent ambulation. Record review of facility incidents and accidents reported a documented incident, dated 01/10/26, for an elopement of Resident #1. Record review of Resident #1's progress notes reflected a completed SBAR summary, dated 01/10/26, related to the elopement incident and reflected, primary care provider responded with the following feedback: recommendations- resident placed on one-on-one observation, wander guard was placed on resident. Record review of Resident #1's nursing progress note, dated 01/10/26, reflected a nursing noted for reeducation provided to Resident #1 and reflected, Resident was asked the following questions: 1. What do you do before crossing the street, he responded by saying that you look both ways. 2. Do you step in the street if a car is coming, he responded by saying no. 3. Is it safe to walk on the street or on the sidewalk, he responded by saying sidewalk. Resident was educated by the nurse on the importance of signing himself out when leaving the facility and notifying staff. He was shown the out-on-pass binder and the process of signing out, he verbalized back understanding. Record review of Resident #1's progress notes, dated 01/12/26, reflected a provider note by NP A which stated, Seen today for medical management in long term care. The patient denies any acute complaints. Over the weekend he eloped from the facility attempting to walk to a nearby hospital where his wife is currently hospitalized . He has baseline anxiety and was administered PRN Ativan for increased anxiety after the incident. A wander guard was placed on his right ankle. His (family member) subsequently picked him up and took him to the hospital to visit his wife without incident. No injuries were sustained during elopement. No other issues reported by staff. During an interview on 01/13/26 at 10:47 a.m., Resident #1's FM stated they became aware of an incident that occurred on 01/10/26 when she was called by Resident #1 after he left the facility and called from a bank down the road. Resident #1's FM stated Resident #1 stated that he was trying to get to the hospital to visit his wife. Resident #1's FM stated Resident #1's wife was also a resident at the same facility but was recently hospitalized and he missed her and wanted to see her which prompted him leaving to attempt to make it to the hospital. Resident #1's FM stated that Resident #1 became tired and stopped at the bank to call so he could get picked up. Resident #1's FM stated she was unable to at the time and contacted the facility and learned they were unaware Resident #1 left the facility. Resident #1's FM stated that although Resident #1 was independent, she was concerned he was able to leave without the facilities knowledge since he was under their supervision. Resident #1's FM stated Resident #1 was picked up soon after by the facility and had no injuries or negative outcomes from the event. During an interview on 01/13/26 at 11:36 a.m., Resident #1 stated he recalled leaving the facility on the weekend and stated he did not alert any staff. He stated he left because his wife, another resident, was recently hospitalized and he wanted to see her. He stated he made it a bit down the road when he became tired and went into a bank to call his family member to pick him up. He stated the family member then called the facility and they picked him up. He stated he didn't know why he didn't alert anyone or sign out before leaving. He stated he had never done something like this before but that he just missed his wife and wanted to see her. Resident #1 stated he did not believe he was in any harm as he was independently ambulatory and knew how to call for help if he needed it. He stated he was gone from the facility less than 30 minutes. Resident #1 stated when he returned to the facility they placed someone to supervise him 1:1 and he was also reeducated on the sign out policy and notifying staff if he wanted to go out. He stated his wife returned from the hospital so he no longer had a reason to want to leave again and would be sure to sign out and notify staff if he wanted to go somewhere in the future. During an interview on 01/13/26 at 02:07 p.m., the DON stated the incident on 01/10/26 with Resident #1 leaving the facility unsupervised she would not call it an elopement. She stated Resident #1 had a plan, and intent and knew what he was doing and had a purpose. She stated Resident #1 was very independent, he knew the code to get out of the facility as he would go outside at times to walk around with staff. She stated Resident #1 did not require assistance ambulating nor an assistive device such as walker/wheelchair. The DON stated Resident #1's muscle memory was very intact, and he knew to call help if he needed it. The DON stated she did not believe Resident #1 was in danger or risk and had safety awareness. She stated he had not displayed elopement behavior in the past, did not previously wear a wander guard and that he left because he missed his wife and wanted to see her at the hospital. The DON stated he was only gone approximately 15 minutes before they realized he was out, and they picked him up from the bank. She stated upon his return to the facility, Resident #1 was assessed and there were no injuries, he was reeducated on the proper way to sign out and to notify staff, and he was provided with a wander guard and placed on 1:1 as additional precaution until his wife returned. The DON stated the wander guard was discontinued today 01/13/26 per the provider as he was not considered a true elopement risk and his wife was back which has made him happy and calmed his anxiety. During an interview on 01/13/26 at 03:03 p.m., CNA B stated Resident #1 is independent and did everything on his own and was supervised as needed. She stated that all residents were under the care of the facility and should be supervised and staff should know where they were. She stated Resident #1 was independently ambulatory and was never exit seeking behavior before but that during this incident she stated Resident #1 was trying to see his wife at the hospital. CNA B stated she was at the facility on 01/10/26 when the incident occurred and it happened near meal services time. She stated they passed out meal trays and Resident #1 was not in his room, which was not unusual because he would get up and go get coffee from the dining room frequently. She stated a few minutes later she was alerted that Resident #1 had left the facility and was being brought back. CNA B stated Resident #1 did not have any injuries and after the incident he was reeducated on signing out. CNA B stated immediately after she was assigned specifically to provide 1:1 with Resident #1 for extra supervision. She stated she was also provided training by the facility on elopement prevention and redirection. During an interview on 01/13/26 at 03:34 p.m., NP A stated Resident #1 had not exhibited exit seeking behavior in the past and was not a concern for elopement. She stated she spoke to Resident #1 and he told her he left to try to see his wife at the hospital because he missed her. NP A stated Resident #1 was independently ambulatory, alert to person/ place/ and situations and able to comprehend where he was. She stated Resident #1 did not have negative behaviors and only some anxiety. She stated Resident #1 was all about his wife and wanted to be wherever she was. NP A stated Resident #1 had not had a wander guard prior because it was not necessary and was only used after the incident as a precaution until his wife returned. She stated it was discontinued today 01/13/26 since Resident #1 was not a true elopement risk. NP A stated after the incident on 01/10/26 Resident #1 was also under close supervision (1:1) and provided Ativan for his anxiety over not having his wife. She stated Resident #1 was very redirectable and provided education upon his return. She stated there were no injuries or negative outcomes for Resident #1 from the incident. During an interview on 01/13/26 at 05:15 p.m., the SW stated she would define elopement as a resident that unsafely left the facility without supervision. She stated she was very familiar with Resident #1 and he was alert and oriented x3 and a very good advocate for himself. She stated she spoke to Resident #1 upon his return and he told her he was only trying to visit his wife at the hospital. SW stated Resident #1 was able to call for assistance and called his family member from a bank down the road. She stated after Resident #1 called his family member, they in turn called the facility who went to retrieve him. SW stated she continued to offer emotional support after the event and Resident #1 was reeducated on the procedure of checking in and out as well as staff on elopement precautions. During an interview on 01/13/26 at 05:34 p.m., the ADM stated she would define elopement as someone who was unaware of their safety and going outside aimlessly without intent to include those with confusion. She stated this was not a description that fit Resident #1 as he was alert and oriented, independent, and had safety awareness. The ADM stated Resident #1 told her he was trying to see his wife at the hospital which was why he left. She stated he is not mentally incompetent, he knows what he is doing and what is going on. The ADM stated, based on their investigation, Resident #1 was only gone from the facility for 15-30 minutes. She stated Resident #1 knew the code to exit the facility because he frequently went on walks around the building. She stated Resident #1 did not have injuries upon his return and he was reeducated on the expectation of signing out and ensuring staff were aware before he left. She stated this was also not reported as an elopement because Resident #1 was able to go on walks unsupervised. During an interview and record review on 01/13/26 at 05:36 p.m., a policy was requested from the ADM, she stated while there was no official policy she provided an email from the senior vice president of clinical operations dated 05/11/23 at 08:49 a.m. that detailed the expectations and record review of the email reflected the following: It's summertime and the ending of PHE and our residents want to go out and family/close friends want to take them out of the building for visits, appointments, etc Please put the attached log in place starting today as we have Mother's Day this weekend. We need to know when our residents are leaving, who they are leaving with, as safety is our concern and not every resident should be leaving especially by themselves if there is any question as to their safety. We are also at times experiencing weather events and if there is a significant weather event, we need to know what residents are in the building at the time of the event and who is out on pass and again their safety during these weather events. Please in-service all staff on all shifts and days of week as well as department heads as to the expectation of completing and maintaining the log. Everyone is responsible in ensuring before the resident goes out the door that the log was completed. Please send a (facility communication system) message also out to the residents and families to let them know. See the below message. (facility communication system) Message:Subject: Resident Sign Out and Sign Back In Log, Its summertime and more of you want to visit your love one and also want to possibly take them out to spend time with them outside of our facility. Whether for a short time such as for lunch or a family party, reunion, Mother's Day, or take them to an appointment, etc. We need your help in signing out the resident on our Resident Sign Out and Sign Back In Log. The log is located at the Nurse's station as a nurse needs to initial it and make sure no medication needs to be administered or provided to your love one before they leave the building. If you have questions, please ask to speak to the Administrator. Thank You Please let myself and (other staff named) know once the log has been put in place and the (facility communication system) message has been sent out. Safety is our concern for our residents when they are in your community and knowing when they are not in the building. Record review of the blank undated Resident sign out and sign back in log reflected the following information required when leaving- Date, time leaving, AM/PM, resident name, resident signature, print name of person leaving with, staff initials, date/time returned, and staff initials.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for one resident ( Resident #1) of three residents reviewed for privacy and confidentiality.The facility failed to ensure the staff provided privacy to Resident #1 by closing the door during bed bath.This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.The findings include:Record review of Resident #1's face sheet dated 12/08/25 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male with a diagnosis of need for assistance with personal care. Record review of Resident #1' MDS dated [DATE] revealed Resident #1's BIMS was 04 indicating his cognition was severely impaired. It indicated he needed assistance throughout the bathing activity. Record review of Resident#1's care plan dated 11/24/25 revealed Resident #1 had ADL self-care performance deficit r/t weakness and cognitive impairment and required assistance for bathing/showering, at least by one staff as necessary.During an observation on 12/08/25 at 12:10pm it was revealed Resident #1 shared his room with another resident. Resident#1 was lying in his bed awake and alert while CNA A and CNA B providing bed bath in his room. It was observed that the privacy curtain of Resident #1 was drawn, however the door to the room was wide open. Resident #1's fully naked body was visible to the investigator and anyone who approaches Resident #1's bed. During an interview on 12/08/25 at 12:15pm, CNA A stated she and CNA B were from the hospice and at the facility to provide bed bath to Resident#1. CNA A stated, before commencing the bed bath she ensured Resident #1's privacy by closing the door to the room and drawing the privacy curtain. CNA A stated, while they were providing the bed bath CNA C entered the room to give the resident his lunch tray and HK D entered to clean the room. During an interview on 12/08/25 at 12:20pm CNA B stated she was from the hospice and accompanied CNA A from the previous week. She stated she remembered she and CNA A ensured the door and privacy curtain were closed after entering the room. She stated, most likely the facility staff who entered the room might have forgotten to close the door after leaving the room. During an interview on 12/08/25 at 12:30pm HK D stated he entered Resident #1's room about 15 minutes before and at that time the door was already opened. He stated he believed the hospice nurses might have forgotten to close the door before giving Resident #1 the bed bath. HK D stated he never thought of closing the door while the bed bath was being provided and kept the door as it was before, before leaving the room. HK D stated closing the door was important to make sure Resident #1's dignity. He stated he did not remember if he received any in service on privacy. During an interview on 12/08/25 at 1:15pm CNA C stated she entered Resident #1's room to supply lunch. She stated she did not remember if the door was already opened when she entered. CNA C stated when she entered the room CNA A and CNA B were providing bed bath to Resident #1. She stated she did not remember if she closed the door after delivering the lunch to Resident #1 and his roommate. CNA C stated closing the door and drawing the curtain was important while providing personal care to maintain privacy. During an interview on 12/08/25 at 1:30pm LVN E stated she was the charge nurse for Resident #1's hall. She stated she had observed CNA A and CNA B closing the door after they entered the room for giving bed bath to Resident #1. She stated, after that she had not noticed any other staff members entering the room as she was busy with administering medications. During an interview on 12/08/25 at 3:00 p.m., the DON stated that resident's privacy must be maintained during nursing care by closing doors, windows, and privacy curtains. She stated that other staff should not enter the room until care is completed unless urgent, and that any staff entering the room should ensure the door was closed upon entry and exit. The DON stated the facility ensured all the newly hired employees completed skill checks. She added that every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in privacy/confidentiality. During the review of the undated facility's policy titled Statement of Resident Rights, reflected: . An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual.An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. Also, provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 6 of 11 residents (Resident #52, Resident #63, Resident #10, Resident #8, Resident #97, and Resident #46) reviewed for infection control. The facility failed to ensure [NAME] E was practicing proper hand hygiene while preparing foods and CNA C while lunch passing trays. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, developing foodborne illnesses, and decreased quality of life. Findings included: Record review of Resident #52's face sheet reflected an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), rheumatoid arthritis (A chronic inflammatory disease that affects the joints, resulting in painful joints, swelling and stiffness in the joints), Parkinson's disease (a nervous system disorder due to reduced levels of dopamine), chronic kidney disease, and major depressive disorder. Record review of Resident #52's Quarterly MDS Assessment, dated 10/30/24, reflected the resident had a BIMS Score of 12, which indicated the resident had a moderate cognitive impairment. Resident #52 required verbal cues and/or touching assistance to eat her meal. Record review of Resident #52's undated Care Plan reflected a focus area of ADL self-care performance. Interventions included staff provided supervision with meal set-up. Record review of Resident #63's face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of diabetes mellitus type 2, polyneuropathy (condition in which a person's peripheral nerves are damaged, affecting the nerves in your skin, muscles, and organs), polyarthritis (medical definition of arthritis that affects five or more of your joints), pain, hypertension, and major depressive disorder. Record review of Resident #63's Quarterly MDS Assessment, dated 12/19/24, reflected the resident had a BIMS Score of 15, which indicated the resident had no cognitive impairment. Record review of Resident #26's Care Plan reflected a focus area for ADL self-care. Interventions included Resident #26 was able to feed self, required delivery and set-up of tray and assist with meal as needed. Record review of Resident #10's face sheet reflected an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease, dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic obstructive pulmonary disease (chronic lung disease), dysphagia (difficulty swallowing), pulmonary embolism (history of a blood clot in lung), and hypertension. Record review of Resident #10's Quarterly MDS Assessment, dated 11/17/2024, reflected the resident had a BIMS Score of 3, which indicated the resident had severe cognitive impairment. Record review of Resident #10's Care Plan reflected she needed the assistance of one staff to eat. Record review of Resident #8's face sheet reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses of anoxic brain damage (when the brain is deprived of oxygen for an extended period of time, leading to cell death and brain damage), age-related physical debility (gradual decline in physical function and strength that occurs with aging), diabetes mellitus type 2, dysphagia, chronic pain, hemiplegia, and hemiparesis ( following cerebral infarction (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dementia (a group of thinking and social symptoms that interfere with daily functioning), and traumatic brain injury. Record review of Resident #8's Quarterly MDS Assessment, dated 01/01/25, reflected the resident had a BIMS Score of 6, which indicated the resident had a severe cognitive impairment. The MDS further reflected Resident #8 was dependent with eating and required staff to assist him with meals. Record review of Resident #8's Care Plan reflected he was dependent on staff for meeting his physical needs related to immobility and physical limitations. Observations of [NAME] E preparing food on 02/04/2025 at 9:11 AM, revealed that [NAME] E threw trash away without washing or sanitizing their hands before going back to preparing food. [NAME] E was witnessed on one occasion using the trashcan foot press to open the trashcan lid to dispose of trash but used their right hand without wearing gloves to close the lid and put on a new pair of gloves without hand washing in between. In another observation, [NAME] E touched the trashcan lid again and returned to the prepping station to grab a tray of baked cornbread with their bare hands without handwashing in between. [NAME] E went on to touch the food warming station and food prep counter before putting on gloves without hand washing and sanitization. It was observed throughout the kitchen area posted signs for proper hand hygiene. An observation on 02/04/25 at 12:00 PM revealed CNA C exited a resident's room and picked up a lunch tray for Resident #52 and brought it into her room. CNA C did not conduct hand hygiene between the residents. CNA C then went to the nurse's station for a cup of ice and brought it to Resident #52. CNA C was then observed bringing a lunch tray to Resident #63, who was Resident #52's roommate. CNA C did not conduct hand hygiene between residents. CNA C brought a lunch tray to Resident #8 and then to Resident #97, who was Resident #8's roommate. CNA C did not conduct hand hygiene between the residents. CNA C then brought a tray to Resident #10, and with no hand hygiene conducted she brought a lunch tray to Resident #46. CNA C was then observed conducting hand hygiene from a hand sanitizer unit located on the wall. An interview on 02/04/25 at 12:18 PM revealed CNA C had forgotten to conduct hand hygiene when passing lunch trays. CNA C stated the importance of conducting good hand hygiene during resident care was to prevent the spread of infection, and the impact on the resident could be an infection. In an interview with [NAME] F on 02/05/2025 at 10:00 AM, it was found that [NAME] E quit and no longer works at the facility. [NAME] F and Dietician stated that [NAME] E quit without notice that morning. Due to [NAME] E quitting and no longer working at the facility as of 02/05/2025, additional observations of [NAME] E and full interview with [NAME] E was not able to be conducted to discuss sanitary food preparation and hand hygiene. In an interview with Dietician on 02/06/2025 at 11:05AM, Dietician stated the following: the expectations when it comes to hand hygiene is for all kitchen staff to maintain cleaning and washing hands in between changing gloves, handling objects, and during prepping food. Dietician stated the reasoning to follow hand hygiene is to not cross-contaminate foods such as, meats, vegetables, fruits, and or other potential kitchen surfaces. Dietician H stated the expectation is for everyone that enters the kitchen area to follow those guidelines the facility has in place. In an interview with [NAME] G on 02/05/2025 at 11:10 AM, [NAME] G stated the following: the expectations for maintaining hand hygiene are making sure fingernails are clean. [NAME] G stated staff are to make sure to wash hands in between any transferring of food, changing gloves, and making sure there is no chance of cross-contamination. [NAME] G stated everyone who enters the kitchen is to wash hands for 30 seconds and to help with keeping track of 30 seconds, they can sing the Happy Birthday song or say the ABC's. [NAME] G stated no one should be touching the trashcan lid and touching food after can cause issues. [NAME] G stated if that was witnessed, then it would be brought up to that person to not do that again and explain the reasoning as it could harm a resident, and make sure they wash their hands. [NAME] G stated if staff are not following hand hygiene, it can lead to a resident getting sick or lead to serious harm if they have a lower immune system and it could potentially be fatal. [NAME] G stated it's expected that hand washing is to be followed. In an interview with Administrator on 02/05/2025 at 11:16 AM, Administrator stated the following: the expectations for washing and cleaning hands in the kitchen area are to be followed. Administrator stated it's expected that before touching anything in the kitchen, staff are to wash their hands. Administrator stated staff are expected to maintain hand washing in between touching objects or handling foods including during glove changing. Administrator stated if not followed, it could cause harm to a resident wearing or without wearing gloves if hand washing in between isn't followed. Administrator stated kitchen staff should not be touching the trashcan and then grabbing any surfaces or food, they are expected to wash their hands. Administrator stated staff not following hand hygiene can get a resident sick or cause potential harm to residents with a lower immune system. Administrator stated they teach staff by conducting repeat demonstrations methods in which they show the staff member how to appropriately handle food and follow through with hand hygiene, then have the individual demonstrate proper food handling and cleanliness. Administrator stated Infection Preventive does 10 random monthly observations to monitor hand hygiene and proper handling of food. Administrator stated Dietician and Infection Preventive go in monthly to teach kitchen staff about safety, hygiene, and food handling to prevent cross-contamination and foodborne illness. Administrator stated that all staff go through in-service trainings and have been trained. An interview on 02/06/25 at 01:43 PM with the DON revealed it was the charge nurse, ADON, IP, and ultimately the DON responsibility for ensuring staff members were conducting hand hygiene between each resident when passing meal trays on the halls. The DON stated her expectation was for all staff to be conducting hand hygiene between each resident when passing trays in hallways. The DON stated she would conduct hand hygiene before getting started, and then conduct hand hygiene between each resident when passing meal trays on hallways. Record review of the Kitchen Hand Hygiene Policy dated 2018 stated the following: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing Stations a. Make sure hand washing stations are in food preparation areas to encourage employees to wash their hands frequently. b. Make sure there are hand-washing stations in all areas that employees hands may become contaminated, including food preparation areas, service areas, dishwashing areas and restrooms. c. Make sure all hand-washing stations are equipped with the following: i. Hot and cold running water. ii. Hand-cleaning liquid, powder or bar soap. iii. Individual, disposable towels, a continuous towel system that supplies the user with a clean towel or a heated-air hand-drying device. iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. d. Sinks used for food preparation or washing utensils, or a service sink or curbed cleaning facility used to dispose of mop water or similar wastes cannot be used as a hand-washing station. 2. Hands should be washed after the following occurrences: a. a. Using the Restroom b. Handling raw food (before and after) c. Touching the hair, face, or body Sneezing or coughing d. Smoking f. Eating or drinking g. Handling chemicals h. Taking out garbage i. Clearing tables j. Touching clothing or aprons k. Touching un-sanitized equipment, work surfaces, or wash cloths l. Assisting residents 3. Hand-washing steps a. Wet hands and exposed arms with hot water at least 100 F. b. Apply soap. c. Scrub hands, exposed arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction. d. Rinse hands and exposed arms thoroughly under hot running water. e. Dry hands and arms with a paper towel. f. Turn off the faucet with the paper towel to avoid contaminating hands and discard towel. Review of 2022 Food Code 2-301.14 states: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #9, Resident #367, and Resident #371) residents reviewed for resident rights. The facility failed to ensure CNA A and CNA B knocked on Resident #9, Resident #367, and Resident #371's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #9's Face Sheet dated 02/06/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9's diagnoses included hypertension (high blood pressure), hyperlipidemia (high cholesterol), hyperthyroidism (excessive production of thyroid hormones), muscle weakness, unsteadiness on feet, cognitive communication deficit (problems with communication), epilepsy (seizure disorder), insomnia (sleep difficulty), post-traumatic stress disorder and constipation. Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed that Resident #9's BIMS score was 15 which means resident had intact cognition. Review of Resident #367's Face Sheet dated 02/06/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #367's diagnoses included muscle spasm, reduced mobility, history of falling, elevated white blood cells, hypertension (high blood pressure), gout (inflammatory arthritis with recurring attacks of pain in a red, tender, hot and swollen joint ), syncope and collapse (fainting), heart disease, unsteadiness on feet, fluid overload, dysphagia (difficulty swallowing), hypomagnesemia (low magnesium in the blood), cognitive communication deficit (problems with communication), type 2 diabetes mellitus without complications (high blood sugar), and retention of urine. Record review of Resident #367's Quarterly MDS assessment dated [DATE] revealed that Resident #367's BIMS score was 06 which means resident had severe cognitive impairment. Review of Resident #371's Face Sheet dated 02/06/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #371's diagnoses included hypertension (high blood pressure), hyperlipidemia (high cholesterol), hyperthyroidism (excessive production of thyroid hormones), chronic obstructive pulmonary disease (chronic progressive lung disease), muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit (problems with communication), reduced mobility, need for assistance with personal care, history of falls, nausea and constipation. Record review of Resident #371's Quarterly MDS assessment dated [DATE] revealed that Resident #371's BIMS score was 13 which means resident had intact cognition. Observation done on 300 hall on 02/04/2025 at 11:59am revealed CNA A did not knock on Resident #367 and Resident #371's door before entering the residents' room. Observation done on 600 hall on 02/04/2025 at 12:14 pm revealed CNA B did not knock on Resident #9's door before entering the resident's room. During an interview with Resident #367 on 02/06/2025 at 8:07am he said that staff do not knock all the time on Resident #367's door. He stated that he would prefer that the staff knock all the time. He also said that he does not get upset when staff do not knock. During an interview with Resident #371 on 02/06/2025 at 9:12am she said staff do not always knock on the Resident #371's door. She said that she would prefer for them to knock all the time especially at night. She also said that sometimes when staff leave to go get something, when they come back, they do not knock. During an interview with Resident #9 on 02/06/2025 at 8:31am she said that staff do not knock all the time. She said the staff do not knock at least two or three times a day. She said that staff will not knock if they forgot something. She said she does not get upset when staff do not knock. She said that she would like for the staff to knock but it did not bother her if the staff did not knock. During an interview with CNA B on 02/06/2025 at 10:26am she said she had been trained on resident rights. She said that staff were supposed to knock on the residents' doors any time staff wanted to enter the resident's room. She said that residents may feel that staff are rude for not knocking. She also said that the facility was their home, and she would not want anyone just walking into her house. She said the nurse was responsible for monitoring to ensure staff knocked on residents' doors. She said knocking was monitored by observations. She also said she did not know why she did not knock on Resident #9's door. She said she knows she was supposed to knock. During an interview with the DON on 02/06/2025 at 10:51am she said that she had been trained on resident rights. She said staff were to knock on the residents' doors before entering. She said that if staff had their hands full, they should be saying knock, knock before entering. She said that residents might not like someone just walking in. She also said that the residents need to know someone is entering their room. She said she was not sure why staff were not knocking before entering residents' rooms. She said that it was not usual practice. She said all management were supposed to monitor to ensure staff were knocking on residents' doors. She said it was monitored by frequent rounding. During an interview with CNA A on 02/06/2025 at 2:16pm she said that she had been trained on resident rights. She said that staff were to knock on the residents' doors every time they wanted to enter the resident's room. She also said that staff were to introduce themselves and inform the resident what was going to be done. She said that staff would not want anyone to just walk into their home and the resident might see it as rude. She said that she did not know why she did not knock on Resident #367 and Resident #371's door, but she knows she should have. She said the nurse was responsible for ensuring that staff were knocking. She said it was monitored by observations and that the nurses are always on the halls. During an interview with the ADM on 02/06/2025 at 1:34pm she said that she had been trained on resident rights. She said that staff were supposed to knock, announce themselves and wait for the resident to invite them in. She also said that the staff should also let the resident know why they are there. She said if staff do not knock that is a violation of the resident's privacy. She said staff may not have knocked because they were in a hurry, but she can only guess. She said that the facility had a monitoring tool in place. She said that management or charge nurses were responsible for monitoring. She said knocking was monitored through the monitoring tool and that she watches for patterns of not knocking. Record review of Quality-of-Life Policy (not dated) revealed that Staff members are trained and reminded to respect each resident's private space and property. Staff members knock on room doors and request permission to enter.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmaceutical services. The facility failed to administer Resident #1's Amlodipine and Metoprolol (blood pressure medications) for eight days after being admitted to the facility on [DATE]. This failure could affect residents by putting them at risk of exacerbation and/or deterioration of their health conditions. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular/rapid heart rhythm), history of stroke and heart attack, and hypertension (high blood pressure). Review of Resident #1's admission MDS assessment, dated 11/13/24, reflected a BIMS was not completed. Section I (Active Diagnoses) reflected she had hypertension. Review of Resident #1's admission care plan, dated 11/11/24, reflected she had altered cardiovascular status r/t acute stroke, hyperlipidemia (high cholesterol), hypertension, and A-fib with an intervention of administering medications per MD orders. Review of Resident #1's hospital discharge paperwork, dated 11/11/24, reflected orders for the following medications: Amlodipine Besylate Oral Tablet - 2.5 MG - once a day; Metoprolol Succinate ER Oral Tablet - take 25 MG once a day. Review of Resident #1's physician order, with a start date of 11/12/24 and a D/C date of 11/12/24 reflected Amlodipine Besylate Oral Tablet - 2.5 MG - give one tablet by mouth one time a day for HTN and Metoprolol Succinate ER- 25 MG Tablet - Give 1 tablet by mouth at bedtime related to HTN. . Review of Resident #1's November 2024 MAR, reflected she was administered Amlodipine and Metoprolol on 11/12/24. Review of Resident #1's blood pressure readings in her EMR, dated 11/21/24, reflected the following: 11/21/24 7:56 AM - 200/90 mmHg 11/21/24 8:00 AM - 200/90 mmHg 11/21/24 8:01 AM - 200/90 mmHg Review of Resident #1's physician order, with a start date of 11/21/24, reflected Metoprolol Succinate ER- 25 MG Tablet - Give 1 tablet by mouth one time a day related to HTN. Review of Resident #1's November 2024 MAR reflected Amlodipine and Metoprolol were administered on 11/12/24 and no blood pressure medications were administered again until 11/21/24 when she was administered Metoprolol. During a telephone interview on 12/11/24 at 12:54 PM, LVN A stated Resident #1 was admitted from the hospital with blood pressure medication. He stated he gave the orders to the NP who okayed them, and he put them in the system. He stated he never discontinued the orders . During an interview on 12/11/24 at 1:46 PM, the DON stated there was a miscommunication between the nurse and NP regarding Resident #1's medications upon admission. She stated the NP wanted to discontinue one of the blood pressure medications and verbally told the nurse. She stated somehow both of the blood pressure medications got discontinued. She stated after this incident she conducted in-services on following hospital discharge orders and putting in orders after NP verification. She stated they no longer allow just a verbal order if the NP is in the facility. She stated a negative outcome of not being administered prescribed blood pressure medication could be a lot of things including cardiac issues . Review of a grievance form, dated 11/20/24 and voiced by Resident #1's RP, reflected the following: Concern/Details: Complaint of high BP and no one did anything about it . Meds were changed and discontinued that weren't to be changed . Action Taken: NP Restarted BP meds in question. Review of the facility's Medication and Treatment Orders Policy, revised July 2016, reflected the following: Orders for medications and treatments will be consistent with principles of safe and effective order writing. . 7. Verbal orders must be signed (written or e-signed) by the prescriber.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents (Residents #1, and #2) reviewed for infection control, as indicated by: The facility failed to ensure MA A cleaned and disinfected the wrist blood pressure monitor while using it on Residents in Hall 6 of the facility; on Resident #1 and Resident # 2. This failure could place the residents at risk of transmission of disease and infection. Findings included: Review of Resident #1's face sheet dated 08/01/24 reflected, Resident #1 was admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with Type 2 Diabetes, Legal Blindness, Muscle weakness, Reduced Mobility, Hypertension, and Retention of Urine. Record review of Resident #1's MDS assessment dated [DATE], reflected her BIMS score was 03, indicating her cognition was severely impaired. Record review of Resident #1's care plan dated 07/05/24 revealed she had hypertension with the potential for abnormal blood pressures and the relevant intervention was monitoring the hypertension. Review of Resident # 1's MAR for August 2024, reflected: Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 10 mg by mouth one time a day related to Essential (primary) Hypertension. Notify NP of SBP >165. Review of Resident #2's face sheet, dated 08/01/24, reflected Resident #2 was admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with Pain, COPD, Muscle Weakness, Dysphagia (Difficulty to swallow), Need for Assistance with Personal Care, and Cognitive Communication Deficit. Record review of Resident #2's quarterly MDS dated [DATE], reflected her BIMS was 03, indicating her cognition was severely impaired. Record review of Resident #2's care plan dated 06/20/24 revealed, she was potential for fluid volume deficit related to diuretic use and the relevant intervention was monitoring /documenting/reporting PRN any sign and symptoms of dehydration. Review of Resident #2's MAR for August 2024 reflected: Furosemide Oral Tablet 20 MG (Furosemide): Give 1 tablet by mouth one time a day for pleural effusions hold for SBP less than or equal to 110. An observation on 08/01/24 at 11:10 a.m., revealed MA A failed to sanitize the wrist blood pressure monitor before and after using it on Resident #1 and Resident #2. There were 37 residents residing on Hall 6. MA A was administering medications on Hall 6, and at that time, out of 37 residents, 3 residents were left for receiving medication. MA A took the blood pressure of Resident #1 with the wrist blood pressure monitor and without sanitizing the monitor; she kept it on the top of the medication cart. After administering the medications to Resident #1, she moved on to Resident #2 and used the same blood pressure monitor on her without sanitizing it. When the investigator asked for sanitizing wipes, MA A searched all the drawers of the med cart approximately for about 30 seconds and stated most likely it was taken away by her colleague. She then searched the drawers once again thoroughly and found one packet of sanitizing wipe in one of the deep corners of a drawer. During an interview on 08/01/24 at 1:30 p.m., the DON stated she was already informed by MA A that she forgot to sanitize the blood pressure cuff in between the residents. The DON added, however, she was not aware that this noncompliance occurred with all the residents in Hall 6. The DON stated the facility policy provided very clear guidelines about the importance of sanitizing medical equipment. She stated the expectation was, the nursing staff followed the facility policy/procedure for handwashing and sanitization of medical equipment that included sanitizing the blood pressure monitor, every time after the use on residents. She added, this was essential to stop spreading transmittable diseases. Review of the in-service records from 04/01/24 to 07/16/24 revealed there were no in-services conducted on disinfection of medical equipment. Review of facility's policy titled Cleaning and disinfection of Resident care Items and equipment revised in October 2018 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard . 1. The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care d. Reusable items: They are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food storage and sanitation. The facility failed to ensure all foods were properly covered, labeled, dated and discarded. The facility failed to ensure chemicals were not stored near food items. The facility failed to ensure the trash can was covered when not in use. The facility failed to ensure CK N washed her hands in between tasks. The facility failed to ensure sanitized the food processor after washing it. These failures placed residents at risk for foodborne illness. Findings included: An observation of the kitchen's walk-in refrigerator on 1/03/2024 at 8:17 a.m. revealed a steam pan of leftover enchiladas dated 12/29/2023. The steam pan was halfway covered with plastic wrap, leaving half of the pan exposed to air. An observation of the kitchen's walk-in refrigerator on 1/03/2024 at 8:18 a.m. revealed a steam pan of unidentifiable substance unlabeled and undated. There was also a 12-quart container of an unidentifiable liquid unlabeled and undated. During an interview on 1/03/2024 at 8:24 a.m., DA O stated the unidentifiable substances were pasta salad and soup from the night prior and they forgot to put a date on it. When asked if the enchiladas should be covered, DA O stated, it's trash and stated leftovers were only kept for three days. An observation of the kitchen's prep area on 1/03/2024 at 8:30 a.m. revealed CK N was preparing a food item at the prep table approximately four feet away from an uncovered trash can which was not in use. An observation of the kitchen on 1/03/2024 at 10:31 a.m. revealed CK N was pureeing green beans. Observed CK N take the food processor to a two-compartment prep sink, wash it, and return it to the prep counter. The two compartment sink did not contain sanitizer. CK N removed her gloves and put on new gloves without washing her hands. CK N proceeded to puree fried chicken. An observation on 1/03/2024 at 10:45 a.m. revealed CK N took off her gloves after she finished pureeing fried chicken, put on new gloves, and rinsed off and scrubbed the food processor using a sudsy liquid from a small red bucket. CK N then removed her gloves and put on new gloves without washing her hands. CK N proceeded to puree scalloped potatoes. During an interview on 1/03/2024 at 10:48 a.m., CK N stated the small red bucket contained dish soap. Observations of the kitchen's dry room storage on 1/03/2024 at 10:59 a.m. revealed one gallon container of Italian dressing and three-gallon containers of pickles with no received date. There were also two boxes filled with 6 bottles each of bleach stored in proximity to food items. An observation of the kitchen's prep area on 1/03/2024 at 11:08 a.m. revealed CK M was preparing cookies approximately 5 feet away from an uncovered trash can which was not in active use. An observation of the puree process on 1/04/2024 at 10:28 a.m. revealed CK N pureed green peas, took the food processor to the three compartment sink in the dish room, and washed, rinsed and sanitized it using a sprayer to squirt sanitizer on the processor. The third compartment did not contain sanitizer. An observation on 1/04/2024 at 10:36 a.m. revealed that after washing the food processor, CK N removed her gloves, put on new gloves, and began pureeing rice. CK N did not wash her hands. An observation on 1/04/2024 at 10:43 a.m. revealed the three compartment sink was then filled with sanitizer solution. CK N washed, rinsed and submerged the food processor in sanitizer. CK N then removed her gloves and put on new gloves but did not wash her hands. CK N proceeded to puree meat. An observation of the kitchen's prep area on 1/04/2024 at 10:53 a.m. revealed CK M was preparing a dessert item approximately four feet from an uncovered trash can which was not actively being used. During an interview on 1/04/2024 at 10:53 a.m., CK N stated she usually used the three compartment sink to wash the food processor but she did not do that the day prior (1/03/2024) because they were working on it. CK N explained that someone else had been using the sink at that time. CK N stated yes that items needed to be submerged in sanitizer solution for them to be sanitized. CK N stated she usually washed her hands after handling dirty dishes, but she had not done that because she wanted to speed it up. During an interview on 1/05/2024 at 8:59 a.m., the DM stated he would need to refer to the facility's written policy to cite what it said in regard to food storage. The DM stated foods should be covered in airtight bags with a label and date. The DM stated yes items also needed a received date. The DM stated they did not have lids for the trash cans, they had been trying to get some, but they were not available through their supplier. The DM stated they tried to keep the trash far away from the prep area. The DM stated chemicals were stored off the ground in the dish room or in a utility closet. The DM stated he was aware of there being bleach in the dry storage room and said, I think we just put it there. The DM stated it was off the ground and not over or under anything, but said he guessed he could find room somewhere else. The DM stated the process for sanitizing dishes was to wash, rinse, sanitize and air dry and said hands needed to be washed in between handling dirty dishes and preparing a food item. The DM stated he monitored the kitchen for food storage and sanitation through daily walk throughs and checklists. The DM stated all dietary staff had been trained in those areas. The DM stated he did not know whether he had done an in-service on food storage in a while but said everyone knew to label and date. The DM stated he had recently completed an in-service on handwashing and said he did hands-on training with staff as well. The DM stated the RD monitored via monthly kitchen audits. The DM said he had worked in the facility for a year and a half and said the facility was a rough one when he first started. The DM stated if food storage and sanitation practices were not followed, it could result in sickness and in this population it's extremely important. During an interview on 1/05/2024 at 1:45 p.m., the RD stated he would have to look up the exact wording of the facility's food storage policy. The RD stated he was unaware of why the kitchen did not have lids to the trash can, stated his company's policy was to discard leftovers after 72 hours, and said he would need to get back to the surveyor on when dietary staff needed to wash their hands. The RD stated if food was not stored properly and sanitation practices were not followed, it could lead to foodborne illness. During an interview on 1/05/2024 at 4:27 p.m., the ADM stated leftovers needed to be labeled, dated and stored for no more than 72 hours. The ADM stated food should not be open to air when stored on the shelf. The ADM stated items needed to be dated when they were received, and she would not expect chemicals to be stored in the same room as food. The ADM stated no the sanitizing process should not be skipped and said hands needed to be washed after washing equipment. The ADM stated the DM, the RD and herself monitored the kitchen for food storage and sanitation through rounding. The ADM stated the trashcan should be covered when not in use. The ADM stated if foods were not stored properly or sanitation practices were not followed, it could lead to contamination of the food which could make residents ill. A record review of the FDA's 2017 Food Code reflected the following: 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms (B) After using the toilet room (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B) (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. A record review of the facility's in-service dated 10/07/2023 reflected dietary staff were in-serviced on the sanitization procedure. A record review of the facility's policy titled Garbage Receptacles dated June 1 2019 reflected the following: Policy: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Indoor receptacles: Waste handling units for refuse and for use with materials containing food residue shall be durable, cleanable, insect and rodent resistant, leak proof, and nonabsorbent. Trash cans will be kept with lid in place when not in use. A record review of the facility's policy titled Manual Cleaning and Sanitizing of Utensils and Portable Equipment dated October 1 2018 reflected the following: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75 F or ii. A minimum of 12.5 parts per million of available iodine in a solution with a pH not higher than five and a temperature not less than 75 F or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75 F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. A record review of the facility's policy titled Food Storage dated June 1 2019 reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedures: 1. Dry storage rooms i. Do not use or store cleaning materials or other chemicals where they might contaminate foods. Label and store them in their original containers when possible. Store in a locked area away from any food products. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (Transition Care Unit Storage room) and 4 of 5 medication carts (600 Hall MA cart, 600 Hall Nurse cart, 300 Hall Nurse cart, 400/500 Hall MA cart) reviewed. The facility failed to ensure expired medications were removed, food products were not in the carts and failed to ensure the carts were clean of potential contaminants. These failures could place residents who receive medications at risk for receiving outdated or contaminated medications which could result in residents not receiving the intended therapeutic effects of their medications. Findings included: Observation on 1/04/20243 at 7:40 AM in the medication storage room on the Transitional Care Unit revealed 1 bottle of Slow-Mag plus Ca with expiration date 10/2023 and 3 bottles of Slow-Mag plus Ca with expiration date 11/2023, MVI with expiration date 12/2023, Ca plus D 5 mcg with expiration date 05/2022, Thiamin B-1 100 mg with expiration date 12/2023, Ocular Vitamins expired 10/2023, 2 bottles Mucus relief Dextromethorphan with expiration dates 03/2023 and 09/2022. In an interview on 01/04/2024 at 7:49 AM ADON stated expired medications could possibly do harm to a patient if given and would not be as effective. Observation on 01/04/2024 at 8:10 AM of the 600 Hall MA cart revealed 1 bottle of Vit B-12, 1,000 mg expired 01/2023, Slow-Mag with Ca expired 11/2023, Vision eye drops expired 12/2023 and Sodium Chloride 1 gm expired 11/2023. In an interview on 01/04/2024 at 8:16 AM the CS/MR stated she had worked in the facility full-time for one year but was still learning her role as the person responsible for checking expired dates on medications. She stated she had not been able to check the carts due to training for medical records and being off for vacation. She stated she tried to check the medication carts once a week on Mondays. Observation on 01/04/2024 at 8:25 AM of the 600 Hall Nurse cart revealed 2 packages of petroleum-based dressings open and with sticky residue on them in the cart with other medications. There were 4 NS 100 ml with expiration dates 11/30/2022, an Albuterol Sulfate inhaler expired on 07/25/2023 and an Albuterol Sulfate Inhaler expired on 10/23/2023. A bottle of Chlorhexidine Gluconate solution (antimicrobial and antiseptic) had an expiration date of 09/2021. In an interview on 01/04/2024 at 8:48 AM RN C stated every nurse is responsible for ensuring medications are not expired. She stated the petroleum-based dressing should have been bagged and dated but would be thrown away. She stated she was supposed to check the cart every day, but she had not checked medications for expired dates on 01/04/2023. She stated she checked the dates on the medications she was administering but no one person was responsible for ensuring expired medications were not on the carts. She further stated the risk to the resident could be adverse side effects and potential harm. Observation on 01/04/2024 at 9:25 AM of the 300 Hall nurse cart revealed tea bags and artificial sweetener in the top drawer of the cart. A loose white powder was observed in the bottom of a box that contained several topical medications. In an interview on 01/04 2024 at 9:30 AM LVN F stated tea bags should not be in the cart. She stated she did not know what the white powder was in the box with the topical medications but speculated it might have been an antifungal power. She further stated the loose powder could potentially contaminate the other medications in the box. Observation on 01/04/2024 at 9:39 AM of the 400/500 Hall MA cart revealed a vitamin herbal complex with an expiration date of 11/2023. In an interview on 01/04/2024 at 9:45 AM MA K stated she had worked at the facility for three years. She stated a resident should not take expired medications as they could have an adverse reaction and the potency would not be as good. In an interview on 01/05/2024 at 11:18 AM the DON stated nurses should be checking the medication expiration dates prior to administering. She stated the CS/MR was responsible for checking the medication storage rooms and they should have been checked prior to her leaving on vacation. She stated she was surprised the Pharmacist did not catch the expired medications. She stated the nurses and medication aides are responsible for keeping the carts clean and that food items are not acceptable in the medication carts. She stated if medications are past their expiration dates it could affect their potency. She stated her expectation was for the medication carts and medication storage rooms to be audited at least weekly for expired medications. In an interview on 01/05/2024 at 1:40 PM the RPh stated she would recommend audits of the medication storage rooms and medication carts either at the beginning or end of the month. She stated the potential risk for residents receiving expired medications would be they would not receive the full potency of the medication. In an interview on 01/05/2024 at 1:43 PM the DRC stated her expectation was for the facility to remove expired medications from the medication carts and storage rooms. She stated food items should not be on the medication carts. She stated the opened petroleum gauze should have been bagged and the resident's name written on it, otherwise it should have been discarded. She stated the carts should be kept clean to prevent contamination of medications. In an interview on 01/05/2024 at 4:50 PM the ADM stated there should not be any expired medications on the carts or in the medication storage rooms. She stated the potential negative outcome to a resident if they received an expired medication was the effectiveness would be changed and it would not treat their medical issue appropriately. She further stated the carts should be kept clean to prevent contamination of medications and to prevent any harm to the nurse handing the medications. She stated any opened wound care products should have been discarded and food items should not be kept in the carts. Record review of the facility Policy and Procedure for Pharmacy Services revised on 12/01/2021 reflected Receipt of medication: Upon delivery by the pharmacy, the facility nurse or designee will assume responsibility for the receipt, proper storage, and distribution of medications. The consultant pharmacist will ensure the proper labeling and storage of all pharmaceutical products, to include medications and biologicals are stored safely, securely, and properly based on manufacturers recommendations and/or currently accepted professional standards.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident for 3 of 8 (Resident #2, Resident #32, and Resident #103) residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #32's and Resident #103's care plans addressed their activity preferences. 2. The facility failed to ensure Resident #2's care plan reflected her current wounds. These failures placed residents at risk of not having interventions in place to address wounds and activities. Findings included: 1. Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder(a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. During an interview on 01/04/24 at 09:25 AM, CNA Q stated Resident #32 only ever sat in his chair watching television. CNA Q stated hhe ad never seen Resident #32 be offered or participate in any activities. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Observation on 01/05/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32 and #103, so the section turned green in the EMR, and it made him think they had been completed. The MDSN A stated he was only responsible for the nursing portion of the care plans, and the other department heads were supposed to complete their own care plan items. He stated he might remind the other department heads to complete their portions of the care plan, but he had no actual authority over them, and it was up to the administrator to enforce. 2. A record review of Resident #2's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (autoimmune disease), paraplegia (impairment in motor or sensory function), and pressure ulcer of unspecified site, unstageable (the wound is covered with a dark tissue known as eschar and the depth and staging cannot be determined). A record review of Resident #2's Medicare 5-day MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Section M (Skin Conditions) reflected she had one or more unhealed pressure ulcers/injuries. A record review of Resident #2's surgical note authored by the Wound Care Physician dated 10/31/2023 reflected she had a stage 4 pressure injury to left hip, thoracic spine, and left fibula, and a stage 3 pressure injury to the left lateral lower extremity. A record review of Resident #2's weekly wound progress report dated 11/01/2023 reflected she had four pressure injuries-one on the upper-mid vertebrae, one on the left trochanter (hip), and two on the left lower leg. A record review on 1/03/2024 of Resident #2's care plan reflected it was revised on 1/03/2024 to include a wound to her left ischial area, left leg and left sacral area. Prior to 1/03/2024, Resident #2's care plan had been revised on 10/24/2023 to reflect she had increased risk for further pressure ulcer development and on 12/10/2023 to reflect she had been readmitted with a surgical flap to the lumbar spine.] During an interview and observation on 1/04/2024 at 3:02 p.m., Resident #2 was observed lying in bed. Resident #2 stated she had been there since October 2023, had wounds when she came in, and said she thought they had been getting better. During an interview on 1/05/2024 at 3:01 p.m., MDSN A stated he revised care plans for the long-term side of the facility, and that MDSN B was responsible for revising care plans on the 200 and 300 halls where Resident #2 resided. MDSN A stated MDSN B had been in that role for six years. MDSN A stated if care plans did not reflect a resident's current wounds, there could be a potential negative outcome if the resident were to transfer to another facility. MDSN A stated yes he considered two months to be a delay in revising Resident #2's care plan. MDSN A stated he could not say what happened in Resident #2's case. MDSN A stated MDSN B was on extended leave and not available for interview. During an interview on 1/05/2024 at 4:19 p.m., the DON stated the MDS coordinators were the ones who revised care plans, but other staff could revise them too. The DON stated ideally, they were revised when there was a change or something new. The DON stated at the time Resident #2 was admitted , there was not a dedicated treatment nurse and it should have been reflected on time. The DON stated MDSN B covered that side of the facility, and it would have been up to her to update Resident #2's care plan. The DON stated she had taken on the role of treatment nurse, and she would create lists and wound reports which MDSN B reviewed. The DON stated, I realized it was missed. The DON stated if care plans did not reflect residents' current wounds, a potential negative resident outcome could include inventions not being followed through. The DON stated with Resident #2, her interventions were put in via orders. The DON stated the facility wanted to make sure it was care planned so it popped up on their electronic records system for nurses to see. The DON stated the facility did not have a written care plan policy, but they went by the RAI manual. During an interview on 1/05/2024 at 4:50 p.m., the ADM stated she started working at the facility on 11/20/2023. The ADM stated yes wounds were supposed to be included in residents' care plans and resolved once something was healed. The ADM stated the facility monitored for care plans during their morning clinical meetings. The ADM stated sometimes the treatment nurse would take over the skin part of the care plan, and right then they did not have a permanent treatment nurse. The ADM clarified that this was how it worked at her last facility. The ADM stated the MDS nurses, ADON, DON or charge nurses could revise care plans. The ADM stated there was a possibility of missing a treatment if staff did not have the resident's full plan of care. Review of undated facility policy titled Activities Program reflected the following: Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. The activity care plan contains a listing of activities that the veteran/resident enjoys, or may enjoy, and that has been approved by the veteran/resident and his or her attending physician. Individualized activity plans are integrated into the veteran/resident's total care plan and are reviewed at least quarterly. The plan is reviewed every time there is a change in the veteran's/resident's physical or mental condition. 45830

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 4 residents of 24 residents (Resident #32, Resident #41, Resident #103, and Resident #104) reviewed for activities. 1. Residents #32 and #103 were not engaged in a person-centered activity program and were not receiving activities. 2. The group activity program did not occur as scheduled from 01/04/24 to 01/05/24, and there were no activities scheduled on 01/03/24. 3. Residents #41, and #104 were observed sitting and doing nothing for hours in a common area of the facility. 4. Residents #32, #41, and #103 did not receive activity assessments on their comprehensive assessments. These failures placed residents at risk of boredom, depression, and a diminished quality of life. Findings included: Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder (a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Review of initial activity evaluations for Resident #32 from his admission on 09/28/23 to 01/05/24 reflected one had not been completed. Review of activity logs for Resident #32 from 12/06/23 to 01/05/24 reflected no activities documented. Observation on 01/03/24 from 08:30 AM to 03:20 PM revealed Resident #32 was in his room and not engaged in any activities. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. Observation on 01/05/24 from 08:30 AM to 01:05 PM revealed Resident #32 was in his room and not engaged in any activities. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Review of initial activity evaluations for Resident #103 from her admission on 09/28/23 reflected one had not been completed. Review of activity logs for Resident #103 from 12/06/23 to 01/05/24 reflected no activities documented. Observation on 01/03/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. Review of the undated face sheet for Resident #41 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), aphasia (speech difficulties), history of transient ischemic attack (minor stroke), unsteadiness on feet, reduced mobility, difficulty in walking, protein-calorie malnutrition, weakness, cognitive communication deficit (communication difficulty caused by impaired cognition), fluency disorder (interruption in the flow of speaking), muscle weakness, speech disturbances, bipolar disorder, hearing loss, and lack of coordination. Review of the significant change MDS for Resident #41 dated 10/20/23 reflected a BIMS score of 03, indicating severe cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #41 dated 10/18/23 reflected the following: I can hear okay in some settings but not as well in large groups or large rooms. Has a variety of activity interests and a general willingness to take part in 1:1 activities. I will express daily satisfaction with daily social contacts and leisure activities by next reevaluation date. Encourage low-commitment, short 1:1 duration social activities to gain comfort due to my recent decline. Decrease the background noise. Encourage and praise attendance, engagement and participation within activities. I love to read. I will be offered reading material on a daily bases (sic). I will be offered adapted TV(closed captioning, magnified screen, or earphones). I will make selections and decisions within activities. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of activity logs for Resident #41 from 12/06/23 to 01/05/24 reflected no activities documented. Observations on 01/03/24 at 08:30 AM, 10:00 AM, and 12:55 PM revealed Resident #41 seated in a geriatric chair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observations on 01/04/24 from 10:12 AM to 11:57 AM and again from 01:10 PM to 03:00 PM revealed Resident #41 seated in a geriatric chair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observation on 01/05/24 at 09:36 AM revealed Resident #41 seated in a geriatric chair in the day area between 500 and 600 halls. He was staring toward the wall and made eye contact but did not respond when addressed. Review of the undated face sheet for Resident #104 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia, protein-calorie malnutrition, unsteadiness on feet, lack of coordination, cognitive communication deficit, muscle weakness, malaise, and dysthymic disorder. Review of the admission MDS assessment for Resident #104 dated 10/27/23 reflected a BIMS score of 06, indicating severe cognitive impairment. The activity preferences section of the assessment reflected staff assessed that it was important to Resident #104 to engage in listening to music, keeping up with the news, doing things with groups of people, and participating in his favorite activities. Observations on 01/03/24 at 08:30 AM, 10:00 AM, and 12:55 PM revealed Resident #104 seated in a wheelchair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. He stared into space. Observations on 01/04/24 from 10:12 AM to 11:57 AM and again from 01:10 PM to 03:00 PM revealed Resident #104 seated in a wheelchair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observation and interview on 01/05/24 at 09:36 AM revealed Resident #104 seated in a wheelchair in the day area between 500 and 600 halls. Resident #104 said he was fine and did not know where he was or what was going on. Review of the activity calendar for January 2024 reflected no activities scheduled for 01/03/24. On 01/04/24 was scheduled the following: 10:00 AM Independent Activity of Your Choice 11:00 AM Chicken Foot Game 01:00 PM Uno Card Game 02:00 PM Skip-Bo Card Game 03:00 PM Dominos On 01/05/24 was scheduled the following: 08:30 AM Reflect & Pray 10:00 AM Bingo w/ (volunteer) 11:00 AM 1431 Cafe Outing 02:00 PM Residents Choice Observation on 01/03/24 between 08:30 AM and 02:00 PM revealed no activities going on. At 03:00 PM, a volunteer arrived at the facility to call bingo. Observation on 01/04/24 at 11:10 AM, 01:10 PM, 02:15 PM, and 03:20 PM revealed Chicken Foot, Uno, Skip-Bo, and Dominos were on a table in the activity room. There was no one in the activity room facilitating the games. Observation on 01/05/24 between 08:30 AM and 03:30 PM revealed none of the scheduled activities occurring. During a confidential interview with nine anonymous residents, they all agreed that activities had barely been occurring and anyone who was not part of the core group of residents who participated in group activities was not receiving any activities at all. They all said the AD was back, and they loved her, but she was too busy going to meetings or something else to assist them with the activities they liked to do. They stated there was always an excuse, and they did not really know what the problem was, but they had complained about it, and nothing had changed . During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. The AD stated Resident #104 was offered individualized activities and mostly liked to watch television. She stated she had offered individualized activities but had not documented and did not document activities in any log for any resident. The AD stated Resident #103 had moved from short term to long term at the facility, and the AD had not interacted with her since she had been there. The AD stated she did not know if Resident #103 was receiving any activities. The AD stated she had seen Resident #103 in bingo, but Resident #103 did not participate. The AD stated she did not know what Resident #103 liked. The AD stated that she did not know Resident #32 and had not assessed him or engaged with him in any way. The AD stated she had received grievances from the resident council about the activities program. She stated they have mostly told her they would like her to be more present. The AD stated she was not present, because she was busy in care plan meetings and doing MDS assessments. The AD stated things had fallen through the cracks but would not elaborate on what she meant. The AD stated none of the residents had withdrawn or become more depressed that she was aware of. She stated she had been sick for the previous couple of days and had been catching up that day 01/05/24. She stated nobody was designated to take over activities when she was not there. She stated some people called bingo while she was gone, but the regular activities that were scheduled on the calendar had not occurred in her absence. The AD stated it was important for all residents to receive recreational therapy because without it, they could decline, have poor motivation, not want to eat, lose weight, or become more depressed. The AD stated when she had the role of activity director before, she had an assistant, but she no longer had one. She stated it was very hard to meet the recreational needs of over 100 residents with just one person, especially when she was catching up on assessments and care plans. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32, #41, and #103, so the section turned green in the EMR, and it made him think they had been completed. The MDSN A stated he was only responsible for the nursing portion of the care plans, and the other department heads were supposed to complete their own care plan items. He stated he might remind the other department heads to complete their portions of the care plan, but he had no actual authority over them, and it was up to the administrator to enforce. During an interview on 01/05/24 at 04:33 PM, the ADM stated there were lots of opportunities to improve the activities program. She stated she had not addressed activities formally with the QAPI , but she needed to work with the AD. The ADM stated she did not think the entire facility's activity needs could be met by one person. The ADM stated residents were all entitled to recreation based on their abilities and preferences and potential negative impacts of not receiving activities were boredom, weight loss, and increased behaviors. Review of undated facility policy titled Activities Program reflected the following: The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each veterans/resident. The activities program is an essential component of the community's fulfillment of its obligation to care for its veterans/residents in a manner and environment that maintain or enhance each veteran/resident's quality of life. The activity program is designed to encourage restoration of self-care and maintenance of normal activity and is geared to meet the individual veterans/resident's needs. The activities program consists of individualized and group sessions, and: flexible schedules, choices, and rights of the veteran/resident; is offered at hours convenient to the veterans/residents, including evenings, holidays, and weekends; reflects the cultural and religious interests of the veterans/residents; appeals to both men and women, as well as to all age groups of veterans/residents residing in the community. The activity program consists of individual and small and large group activities that are designed to meet the needs and interests of each veteran/resident and includes, at a minimum: -social activities -Indoor and outdoor activities -Activities away from the community -Religious programs -Creative activities -Intellectual and educational activities -Exercise activities -Individualized activities -In room activities -Community activities -Military holidays and observance Each resident must have an individualized care plan, and the community is obligated to provide activities that meet each resident's individual needs. Once the veteran/resident is admitted , complete an activity service assessment to identify his or her past and present interests. This assessment is used to develop an individual activity plan that will allow the resident to participate in activities of his or her choice and interest. Sometimes physical and mental conditions prevent residents from participating in activities they have enjoyed throughout their lifetimes. These preferences and passions are noted and included in the assessment. When there is limitation on their ability to participate, the community should find alternative means of addressing the interest. Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. The activity care plan contains a listing of activities that the veteran/resident enjoys, or may enjoy, and that has been approved by the veteran/resident and his or her attending physician. Individualized activity plans are integrated into the veteran/resident's total care plan and are reviewed at least quarterly. The plan is reviewed every time there is a change in the veteran's/resident's physical or mental condition. Activities are conducted in accordance with the activity schedule, which should include input from the community's resident council. The Activity Director is responsible for keeping appropriate departmental records in order to maintain, plan, and develop the activity programs. The following records, at a minimum are maintained by activity department personnel: -Activities services -Attendance records -Calendar of events -Activity, progress, notes -Individualized activity plan -Quarterly MDS assessments -Record of reviews and updates -Other recordkeeping reports as necessary and appropriate.

Based on observation interview, and record review, the facility failed to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS for 3 of 9 residents (Resident #32, Resident #41, and Resident #103) reviewed for comprehensive assessments. Interviews for activity preferences for Residents #32, #41, and #103 were not completed in the most recent comprehensive MDS assessments. This failure placed residents at risk of not having their recreational needs met. Findings included: Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder (a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. Review of the undated face sheet for Resident #41 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), aphasia (speech difficulties), history of transient ischemic attack (minor stroke), unsteadiness on feet, reduced mobility, difficulty in walking, protein-calorie malnutrition, weakness, cognitive communication deficit (communication difficulty caused by impaired cognition), fluency disorder (interruption in the flow of speaking), muscle weakness, speech disturbances, bipolar disorder, hearing loss, and lack of coordination. Review of the significant change MDS for Resident #41 dated 10/20/23 reflected a BIMS score of 03, indicating severe cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #41 dated 10/18/23 reflected the following: I can hear okay in some settings but not as well in large groups or large rooms. Has a variety of activity interests and a general willingness to take part in 1:1 activities. I will express daily satisfaction with daily social contacts and leisure activities by next reevaluation date. Encourage low-commitment, short 1:1 duration social activities to gain comfort due to my recent decline. Decrease the background noise. Encourage and praise attendance, engagement and participation within activities. I love to read. I will be offered reading material on a daily bases (sic). I will be offered adapted TV(closed captioning, magnified screen, or earphones). I will make selections and decisions within activities. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Observation on 01/05/24 at 09:36 AM revealed Resident #41 seated in a geriatric chair in the day area between 500 and 600 halls. He was staring toward the wall and made eye contact but did not respond when addressed. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition . The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Observation on 01/05/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32, #41, and #103, so the section turned green in the EMR, and it made him think they had been completed. During an interview on 01/04/24 at 02:18 PM, the ADM stated the facility used the CMS RAI Manual to determine procedure for MDS assessments and did not have a distinct facility policy. Review of undated facility policy titled Activities Program reflected the following: Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was not dated and was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices. Findings include: A record review of Resident #51's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, acute respiratory failure with hypoxia (low oxygenation), chronic obstructive pulmonary disease (lung disease), epilepsy (seizure disorder), metabolic encephalopathy (disturbed brain function), and cognitive communication deficit. A record review of Resident #51's 5-day MDS assessment dated [DATE] reflected a BIMS score of 07, which indicated severely impaired cognition. Resident #51 required moderate to extensive assistance from another person and frequent bowel and bladder incontinence. A record review of the physician orders dated 12/6/23 reflected Resident #51 was prescribed 2 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of Resident #65's face sheet dated 1/05/2024 reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of Fracture right femur (hip bone), metabolic encephalopathy (disturbed brain function), transient cerebral ischemic attack (blood clot in brain), hypertension, atrial fibrillation, and hypertension. A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderately impaired cognition. Resident #65 required extensive assistance from another person and had bowel and bladder incontinence. A record review of the physician orders dated 6/16/23 reflected Resident #65 was prescribed 2-3 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of Resident #97's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (difficulty communicating), metabolic encephalopathy (disturbed brain function), dysphagia (difficulty swallowing), gastrostomy status (artificial external opening into the stomach for nutritional support), gastro-esophageal reflux disease (acid reflux) and adult failure to thrive. A record review of Resident #97's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. A record review of Resident #97's care plan last revised on 10/24/2023 reflected she received tube feedings related to dysphagia and she was to receive 1 carton of [enteral formula] 1.5 via bolus feedings TID. A record review of Resident #314's face sheet, dated 01/05/24, reflected an [AGE] year-old female admitted on [DATE] with diagnoses of osteoarthritis of left hip, atrial fibrillation, chronic pain syndrome, diabetes mellitus type 2, hypertension, cognitive communication deficit, restless leg syndrome, reduced mobility and unsteadiness on feet. A record review of Resident #314's admission MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #314 required extensive assistance via wheelchair and walker, and bowel and bladder incontinence. A record review of Resident #314's care plan initiated on 12/28/23 reflected she was admitted to skilled services/therapy due to weakness/debility w/potential for decreased functional abilities with acute illness and/or injury, and Resident #314 has actual impairment to skin integrity of the left heel which was initiated on 01/03/24. Intervention for left heel blister initiated on 01/04/24 included to cleanse left heel blister with normal saline and pat dry, apply calcium alginate and cover with dry dressing daily. Replace dressing PRN if soiled, loose, or removed. An observation on 1/03/24 at 8:20am revealed Resident #51's oxygen nasal canula was not dated and was laying on the floor. CNA I entered the room and placed the nasal canula in the resident's nose without cleaning it. An observation on 1/03/2024 at 9:05 a.m. revealed Resident #97 was lying in bed sleeping. There was an opened container of enteral formula dated 1/2/24 sitting on Resident #97's dresser. The formula was not timed or initialed. Resident #97 was non-interviewable. An observation on 1/3/24 at 11:30am revealed Resident #65's O2 nasal cannula on the floor. CNA J picked up the canula to place it back on the resident, but the resident refused to wear it at that time. The cannula was then draped on the resident's left shoulder so he could put it in his nose when needed. The canula was not cleaned by the CNA. An observation on 1/03/2024 at 11:59 a.m. revealed the formula dated 1/2/24 was sitting in the same spot located on Resident #97's dresser. An observation on 1/04/2024 at 9:24 a.m. revealed there was a one third full container of enteral formula dated 1/4/24 on Resident #97's dresser. The formula was not timed or initialed. During an interview on 1/04/2024 at 9:28 a.m., LVN P stated Resident #97 ate food by mouth but if she did not eat, she received extra formula. LVN P stated that morning Resident #97 had refused breakfast, so she got extra formula. An observation on 01/04/24 at 01:26 PM of wound care for Resident #314 with LVN E revealed LVN E washed her hands, donned gloves, and disinfected the bedside table. LVN E removed gloves, placed wax paper on the clean surface, and gathered wound care supplies. DON washed hands, donned gloves, and assisted with Resident #314's left lower limb positioning. LVN E removed the old dressing from the left heel and changed gloves. Resident #314's left heel blister was observed a deep purple color and approximately 3.5cm x 3.0cm. LVN E cleansed the left heel blister with normal saline and 4 x 4 gauze. LVN E changed her gloves, and no handwashing or hand hygiene was observed with the glove change. LVN E applied calcium alginate to the left heel wound and covered it with an adhesive dressing that was initialed and dated. LVN E and DON conducted handwashing upon completion of wound care. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal canula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 1/5/24 at 10:43am RN C stated that if a nasal canula was on the floor she would discard it and get a new one. She stated if a new one was not available, she would sanitize before use. She indicated that failing to sanitize would create a source of infection as they did not know what is on the floor. During an interview on 1/05/2024 at 3:37 p.m., the ADON stated she oversaw the short-term wing where Resident #97 resided. The ADON stated as long as formulas were dated, they could be used at room temperature for 24 hours as long as they were capped. The ADON stated nurses administered formula and they had all been trained on how to store it. The ADON stated nurses were supposed to date, time and initial the bottle when it was opened. During an interview on 01/05/24 at 03:47 PM with DON revealed her expectation of hand hygiene while providing wound care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 1/05/2024 at 3:52 p.m., the DON stated opened enteral formulas were dated and timed and said they were good for 24-48 hours. The DON stated opened containers could be used later but if it was not marked with what time it was opened, nurses should discard it. The DON stated Resident #97's enteral formula was on backorder, so they had to order larger containers. The DON stated nurses monitored other nurses to ensure enteral formulas were labeled appropriately. The DON stated formula administered past its recommended storage time could result in a less potent formula or gastrointestinal symptoms such as upset stomach. During an interview on 1/05/24 at 4:30 p.m., the DON stated her expectation of a nasal canula on the floor would be to change it. She stated an alternative if they could not change it, is to disinfect following the time guidelines on the wipes. She indicated the risk of not disinfecting or replacing the nasal cannula could cause a respiratory infection. During an interview on 1/5/24 at 4:45 p.m., the ADM stated her expectation for a nasal cannula on the floor would be to replace it. If it could not be replaced, then sanitize and date it to avoid the risk of infection. During an interview on 01/05/24 at 04:47 PM with ADM revealed her expectation for infection control protocol during wound care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be cross contamination of wound care products. A record review of the facility's policy titled Handwashing dated 10/24/22 reflected, All staff members are required to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. The CDC guidelines regarding handwashing are to be followed by staff members after each resident contact. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility. A record review of the facility's policy titled Enteral Feedings - Safety Precautions dated November 2018 reflected the following: Purpose To ensure the safe administration of enteral nutrition. General Guidelines Preventing contamination 2. Maintain strict adherence to storage conditions and timeframes. a. Store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). b. Maintain inventory controls and discard any formula past the expiration date. 3. Maintain strict adherence to maximum hang times: a. Powdered, reconstituted formula and formula with additives have a maximum infusing (hang) time of 4 hours. b. Sterile formula in a closed system has a maximum hang time of 48 hours. Preventing errors in administration 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. 45830 49065 Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices. Findings include : A record review of Resident #51's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, epilepsy, metabolic encephalopathy (disturbed brain function), and cognitive communication deficit. A record review of Resident #51's 5-day MDS assessment dated [DATE] reflected a BIMS score of 07, which indicated severely impaired cognition. Resident #51 required moderate to extensive assistance from another person and frequent bowel and bladder incontinence. A record review of Resident #65's face sheet dated 1/05/2024 reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of Fracture right femur, metabolic encephalopathy (disturbed brain function), transient cerebral ischemic attack, hypertension, atrial fibrillation, and hypertension. A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderately impaired cognition. Resident #65 required extensive assistance from another person and had bowel and bladder incontinence. A record review of Resident #97's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (difficulty communicating), metabolic encephalopathy (disturbed brain function), dysphagia (difficulty swallowing), gastrostomy status (artificial external opening into the stomach for nutritional support), gastro-esophageal reflux disease (acid reflux) and adult failure to thrive. A record review of Resident #97's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. A record review of Resident #97's care plan last revised on 10/24/2023 reflected she received tube feedings related to dysphagia and she was to receive 1 carton of [enteral formula] 1.5 via bolus (intermittent) feedings TID. A record review of Resident #314's face sheet, dated 01/05/24, reflected an [AGE] year-old female admitted on [DATE] with diagnoses of osteoarthritis of left hip, atrial fibrillation, chronic pain syndrome, diabetes mellitus type 2, hypertension, cognitive communication deficit, restless leg syndrome, reduced mobility and unsteadiness on feet. A record review of Resident #314's admission MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #314 required extensive assistance via wheelchair and walker, and bowel and bladder incontinence. A record review of Resident #314's care plan initiated on 12/28/23 reflected she was admitted to skilled services/therapy due to weakness/debility w/potential for decreased functional abilities with acute illness and/or injury, and Resident #314 has actual impairment to skin integrity of the left heel which was initiated on 01/03/24. Intervention for left heel blister initiated on 01/04/24 included to cleanse left heel blister with normal saline and pat dry, apply calcium alginate and cover with dry dressing daily. Replace dressing PRN if soiled, loose, or removed. An observation on 1/03/24 at 8:20am revealed Resident #51's oxygen nasal canula was not dated and was laying on the floor. CNA I entered the room and placed the nasal canula in the resident's nose without cleaning it. An observation on 1/03/2024 at 9:05 a.m. revealed Resident #97 was lying in bed sleeping. There was an opened container of enteral formula dated 1/2/24 sitting on Resident #97's dresser. The formula was not timed or initialed. Resident #97 was non-interviewable. An observation on 1/3/24 at 11:30am revealed Resident #65's O2 nasal cannula on the floor. CNA J picked up the canula to place it back on the resident, but the resident refused to wear it at that time. The cannula was then draped on the resident's left shoulder so he could put it in his nose when needed. The canula was not cleaned by the CNA. An observation on 1/03/2024 at 11:59 a.m. revealed the formula dated 1/2/24 was sitting in the same spot located on Resident #97's dresser. An observation on 1/04/2024 at 9:24 a.m. revealed there was a one third full container of enteral formula dated 1/4/24 on Resident #97's dresser. The formula was not timed or initialed. During an interview on 1/04/2024 at 9:28 a.m., LVN P stated Resident #97 ate food by mouth but if she did not eat, she received extra formula. LVN P stated that morning Resident #97 had refused breakfast, so she got extra formula. An observation on 01/04/24 at 01:26 PM of wound care for Resident #314 with LVN E revealed LVN E washed her hands, donned gloves, and disinfected the bedside table. LVN E removed gloves, placed wax paper on the clean surface, and gathered wound care supplies. DON washed hands, donned gloves, and assisted with Resident #314's left lower limb positioning. LVN E removed the old dressing from the left heel and changed gloves. Resident #314's left heel blister was observed a deep purple color and approximately 3.5cm x 3.0cm. LVN E cleansed the left heel blister with normal saline and 4 x 4 gauze. LVN E changed her gloves, and no handwashing or hand hygiene was observed with the glove change. LVN E applied calcium alginate to the left heel wound and covered it with an adhesive dressing that was initialed and dated. LVN E and DON conducted handwashing upon completion of wound care. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal canula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 1/5/24 at 10:43am RN C stated that if a nasal canula was on the floor she would discard it and get a new one. She stated if a new one was not available, she would sanitize before use. She indicated that failing to sanitize would create a source of infection as they did not know what is on the floor. During an interview on 1/05/2024 at 3:37 p.m., the ADON stated she oversaw the short-term wing where Resident #97 resided. The ADON stated as long as formulas were dated, they could be used at room temperature for 24 hours as long as they were capped. The ADON stated nurses administered formula and they had all been trained on how to store it. The ADON stated nurses were supposed to date, time and initial the bottle when it was opened. During an interview on 01/05/24 at 03:47 PM with DON revealed her expectation of hand hygiene while providing wound care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 1/05/2024 at 3:52 p.m., the DON stated opened enteral formulas were dated and timed and said they were good for 24-48 hours. The DON stated opened containers could be used later but if it was not marked with what time it was opened, nurses should discard it. The DON stated Resident #97's enteral formula was on backorder, so they had to order larger containers. The DON stated nurses monitored other nurses to ensure enteral formulas were labeled appropriately. The DON stated formula administered past its recommended storage time could result in a less potent formula or GI symptoms such as upset stomach. During an interview on 1/05/24 at 4:30 p.m., the DON stated her expectation of a nasal canula on the floor would be to change it. She stated an alternative if they could not change it, is to disinfect following the time guidelines on the wipes. She indicated the risk of not disinfecting or replacing the nasal cannula could cause a respiratory infection. During an interview on 1/5/24 at 4:45 p.m., the ADM stated her expectation for a nasal cannula on the floor would be to replace it. If it could not be replaced, then sanitize and date it to avoid the risk of infection. During an interview on 01/05/24 at 04:47 PM with ADM revealed her expectation for infection control protocol during wound care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be cross contamination of wound care products. A record review of the physician orders dated 6/16/23 reflected Resident #65 was prescribed 2-3 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of the physician orders dated 12/6/23 reflected Resident #51 was prescribed 2 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of the facility's policy titled Handwashing dated 10/24/22 reflected, All staff members are required to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. The CDC guidelines regarding handwashing are to be followed by staff members after each resident contact. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility. A record review of the facility's policy titled Enteral Feedings - Safety Precautions dated November 2018 reflected the following: Purpose To ensure the safe administration of enteral nutrition. General Guidelines Preventing contamination 2. Maintain strict adherence to storage conditions and timeframes. a. Store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). b. Maintain inventory controls and discard any formula past the expiration date. 3. Maintain strict adherence to maximum hang times: a. Powdered, reconstituted formula and formula with additives have a maximum infusing (hang) time of 4 hours. b. Sterile formula in a closed system has a maximum hang time of 48 hours. Preventing errors in administration 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

Based on interview and record review, the facility failed to ensure the residents had physician orders for the resident's immediate care for one (Resident #1) out of 15 residents reviewed for physician orders. A nurse failed to transcribe NP telephone orders for Resident #1, a new admission with a diagnosis of diabetes, for accu-checks to the residents EMR to receive the necessary care and services upon admission. Resident #1 was sent to the hospital for a change of condition, his BS level was 498. An IJ was identified on 10/11/2023. The IJ Template was provided to the facility on [DATE] at 04:05 p.m. While the IJ was removed on 10/12/2023, the facility remained out of compliance at a scope of isolated and a severity level of potential harm because the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of inadequate monitoring of medical conditions, not receiving the care and services to meet their needs, proper treatment, and services to prevent serious harm or serious impairment. Findings included: Review of Resident #1's face sheet, dated 10/10/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including heart failure, acute kidney failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. Further review of the face sheet reflected; Resident #1 discharged on [DATE] at 19:42 (07:42 p.m.) to hospital. Review of Resident #1's clinical admission, dated 09/29/2023 17:39 (05:39 p.m.), reflected Resident #1 arrived by ambulance, mode was by wheelchair, no family/support in attendance, living situation prior to admission was with spouse/family, vitals: temperature 97.6, blood pressure 98/53, pulse 89, respiration 16.0, O2 sat (Oxygen Saturation) 96.0, and blood glucose level left blank. Review of Resident #1's admission MDS, dated [DATE], reflected a BIM score of 03, indicating a severe cognitive impairment. Further review reflected the resident was not in a vegetive state, adequate hearing, clear speech, was able to express ideas and wants, understands verbal content, adequate vision, and no corrective lenses. Additional review of Resident #1's MDS revealed-an active Diagnosis was diabetes mellitus. Review of Resident #1's care plan, undated, reflected problem date initiated 10/03/2023 that the resident (Resident #1) had diabetes mellitus with the potential for abnormal blood sugar levels, poor wound healing and pain, goal that the resident (Resident #1) will have no complications related to diabetes, and interventions of dietary consult for nutritional regimen and ongoing monitoring, discuss meal times, portion sizes, dietary restrictions, snack allowed in daily nutritional plan, compliance with nutritional regimes, fasting serum blood sugar as ordered by doctor, monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal pain), Kussmaul breathing (labored breathing), acetone breath (smells fruity), stupor (state of near unconsciousness-insensibility), coma, monitor/document/report PRN (as needed) any s/sx (signs or symptoms)of hypoglycemia: sweating, tremor, increased heart rate (tachycardia) Pallor(unusual signs of brightness in complexion) nervousness, confusion, slurred speech, ack of coordination, staggering gait, monitor/document/report PRN compliance with diet and document any problems, offer substitutes for foods not eaten, and refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of Resident #1's orders, dated 10/10/2023, revealed no orders for insulin medications, to monitor for blood sugar levels, or orders for accu-checks. Review of Resident #1's September 2023 administration records, dated 10/10/2023, revealed no documentation of insulin orders, or or accu-checks completed. Review of Resident #1's October 2023 administration records, dated 10/10/2023, revealed no documentation of insulin orders, or accu-checks completed. Review of Resident #1's September 2023 weights and vitals records, undated, revealed no documentation for blood sugar levels, no information listed for a blood sugar summary. Review of Resident #1's October 2023 weights and vitals records, undated, revealed no documentation for blood sugar levels, no information listed for a blood sugar summary. Review of Resident #1's progress notes, dated 10/10/2023 at 16:38 (04:38 p.m.), revealed a note. Effective date:10/02/2023 Type: SBAR (Situation, Background, Assessment, and Recommendation or Request) Situation: The Change of Condition/s reported were Altered Mental Status BP 106/57-10/02/2023 17:13 (05:13 p.m.) position, lying down with right arm Pulse 81 Temp 97.6 Pulse Oximetry O2 (oxygen) 98 percent Blood Glucose was blank. Mental Status Evaluation was altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) PCP feedback, recommendations is STAT CBC BMP MG UA, sent to ER per family request. Review of Resident #1's Stat Lab Results, dated 10/02/2023, CBC w/Auto Diff (Complete Blood Count with Differential) revealed: Collection Date: 10/02/2023 18:05 (06:05 p.m.), Comprehensive Metabolic Panel Glucose: 498 mg/dl Review of Resident #1's Hospital Records, dated 10/11/2023, revealed an admitted [DATE], the Assessment/Plan indicated: AKI (acute kidney injury), hyperglycemia, hyperkalemia, hyponatremia, NSTEMI (non-ST elevated myocardial infarction). Further review of Resident #1's Hospital Records revealed History of Present Illness, [AGE] year-old male with past medical history of CHF, CKD not on dialysis, diabetes, high cholesterol presents from nursing facility. His (Resident #1) family went to visit him today and stated that he was confused and not at his baseline. His (Resident #1) last know well per family was yesterday. No report of trauma. EMS evaluated patient, noted him to have a wild complex rhythm, and concern for possible peak T waves. Under medical direction, they administered 2 g of calcium gluconate and started on albuterol nebulizer. Patient (Resident #1) received 5 mg albuterol prior to arrival. Additional review of Resident #1's Hospital Records revealed, Comprehensive Metabolic Panel on 10/02/2023 at 21:01(09:01 p.m.), glucose level was at 539 mg/dl. During an interview on 10/10/2023 at 11:50 a.m., NP stated she did not see Resident #1, these are notes from her colleague at the facility. NP stated she dive give the accu-check orders over the phone. NP added, per the record review there was nothing out of the ordinary, his routine labs were changed to stat labs, when the results came in the facility notified the on-call provider and Resident #1 was sent to the hospital. During an interview on 10/10/2023 at 02:53 p.m., DON stated Resident #1 was sent to the hospital, Resident #1s family was visiting and notice changes with Resident #1, family notified RN A, the on-call NP was notified, the NP had labs that were scheduled as routine, then changed it to stat labs, labs were completed the day Resident #1 was sent to the hospital, when the results came back, Resident #1 had been sent to the hospital for altered mental status. the stat labs results were taken on 10/02/23 at 18:05 (06:05 p.m.), and his glucose level was 498. DON stated that the on-call NP did give orders, she does not recall if it was written, it may have been from a telephone order, as sometimes NPs will be at the facility, that day the NPs were not. DON stated that the orders for the accu-checks should have been transcribed to Resident #1's EMR, RN A should have created the orders so it can be followed, and accu-checks were not completed. DON stated the facility investigated the incident, and reported the incident to HHSC, RN A was suspended at this moment. During an interview on 10/10/2023 at 04:03 p.m., RN A stated she was the nurse that admitted Resident #1, when he arrived, he was talking, weak, and RN A recalled that the resident (Resident #1) stated he was in pain. RN A stated he was on pain medications, and the hospital discontinued those medication. RN A stated that the resident's (Resident #1) primary diagnosis was CHF (congestive heart failure). RN A stated that she does not remember seeing orders to address Resident #1's diabetes, she recalled Resident #1 had medication orders for Levimir used for decreased appetite. RN A paged the on-call NP, and had a call with NP, there were telephone orders to Resident #1's blood sugars regularly. RN A stated that the order was used to monitor Resident #1's blood sugar levels, to check for anything abnormal, or high levels. RN A stated that she did not place the orders on Resident #1's EHR, stating, I missed to add the accu-check in the MAR and there was no accu-check completed, I should have double checked it, I remember being so busy that night, I am sorry, I did make a mistake and I am sorry, I wish that did not happen. RN A stated she does not recall having a discussion with Resident #1, or with his family about his diabetes. During an interview on 10/11/2023 at 09:00 a.m., Resident #1's family stated, Resident #1 was diabetic for the last [AGE] years and he was taking insulin for the last three years on a PRN (Pro Re Nata-As needed) bases. Family stated his primary care physician at Waco clinic recommended him to take insulin when his (Resident #1) blood sugar level exceed 400 mg/dl. Family further stated the facility have not given him any insulin or measured his blood sugar level, and that staff did not that he (Resident #1) had diabetes. During an interview on 10/11/2023 at 09:48 p.m., Hospital Doctor stated that Resident #1 was admitted due to a concern of pneumonia, his glucose was levels was at 539 mg/dl and that indicates he was not getting his insulin at the nursing facility, this was possibly due to his uncontrolled diabetes. The Hospital Doctor stated Resident #1s renal failure could have led to his hyperglycemia, it was hard to say, there were concerns focused on sepsis most likely from his pneumonia. During an interview on 10/11/2023 at 11:20 a.m., Facility MD stated that she looked at the hospital records, and the resident was admitted for the concerns of his (Resident #1's) significant heart failure, with volume overload, and possibility of pneumonia, the hospital did not note issues of hypoglycemia. MD stated that the nurse (RN A) should have transcribed the accu-checks, although there was no evidence that the lack of accu-checks resulted to Resident #1 being hospitalized , MD stated, there is no evidence of harm., the resident (Resident #1) had many chronic issues, and he (Resident #1) would have eventually gone to the hospital. Record Review of the Facility's Telephone Order Policy, dated January 2020, revealed a policy statement, Verbal telephone orders may be accepted from each resident's attending physician. Policy Interpretation and Implementation 1. Verbal telephone orders may only be received by licensed personnel (e.g. RN, LPN/LVN, licensed therapist, pharmacist, physician N.P., etc). Orders must be reduced to writing (handwritten on order, faxed, electronically, etc.), by the person receiving the order, and recorded in the resident's medical record. The ADM was notified on 10/11/2023 at 04:05 p.m. an IJ situation was identified due to the above failures and the IJ template was provided. The plan of Removal was accepted on 10/12/2023 at 03:36 p.m., and included: The facility staff failed to ensure that a Resident had sufficient physician orders for the resident's immediate care, orders were given for a resident's accu-checks were transcribed to the medical records system. Resident is a 79 y/o female admitted on [DATE] with diagnoses of Heart failure, acute kidney failure, weakness, and diabetes. The Regional Director of Resident Care Service and Education conducted an inservice with facility DON and ADONs on Admission Checklist on October 10, 2023. A re-inservice on Admission Checklist will be conducted on October 12, 2023. The DON & ADON's In-serviced facility nurses & agency nurses on Completion of the New Admission Checklist to include items below. Those staff members who are not present at the time of inservice, will not take a shift/return to work until the New Admission Checklist inservice is completed. For any future staff members, this Admission Checklist inservice will be part of orientation. o Admitting nurse validated new admitting resident name matches to transfer order - Ask Res. their name, if need to call RP to verify/describe resident. o Nurse completing the admission - All admitting orders verified by MD/N.P. on admission whether in person/phone. o All orders are scheduled appropriately - order written in PCC correctly and completely and is showing up in the MAR/TAR in PCC. o All orders have appropriate diagnosis to support the order o All orders transcribed appropriately after review and approve by MD/N.P. o Diabetes section of Admission Checklist to be reviewed and Checked off by admitting Nurse includes: Accu check order & frequency Blood Sugar perimeters for MD/N.P. notification The Regional Director of Resident Care Services and Education will receive scanned copies from the facility DON and/or ADON's, a minimum of a weekly basis, each new Admission Checklist for monitoring, validating compliance, and completion. This is for ongoing monitoring and compliance. Started 10/11/2023 Completed: 10//12/2023 and ongoing. DON Inservice nurses on Second Nurse validation check on Completion of Admission Checklist and validating with hospital D.C. transfer orders and new orders given by MD/NP are entered into PCC. o Inservice to be done in person for staff present, and then inservice to be recorded by Regional Director of Resident Care Services and Education. Recording will be presented to any staffing agency and all staff who are not present at the time of the initial in-person inservice. The recording will be viewed prior to the scheduled shift to be worked. o For all new newly hired staff, as part of onboarding/orientation, the Admission Checklist will be covered by the facility DON/ADON's. The orientation checklist will be reviewed by the facility HR department for completion and signature(s). o This DON and/or Administrator will monitor and validate compliance. o The Regional Director of Resident Care Services and Education will review inservice sheets on a weekly basis. Started 10/11/2023 Completed: 10/12/203 and ongoing New Admission Checklists to be reviewed by DON, Administrator, and/or ADON in the next day Clinical Morning Meeting for 3rd validation monitoring check. [NAME] discrepancies will be immediately corrected and MD/N.P. notified for further orders. Started 10/11//2023 and ongoing Current inhouse residents with Diabetes diagnosis in E.H.R.'s was audited by the facility DON for accu-check orders and if no order for accu-checks, followed up with MD/N.P. on their medical opinion to add accu-check to the residents E.H.R. orders to be performed or MD/N.P. or rationale not to order accu- checks. Started 10/11/2023 To Be Completed: 10/12/2023 DON/ADON's to check/validate NMAR's for accu-checks completed per frequency order. A monitoring log will be initiated by the DON and monitored daily by the facility Administrator. A minimum of a weekly validation review by the Regional Director of Residence Care Services and Education will be conducted. Started: 10/12/2023 And will be ongoing DON/ADON Inserviced - if missing accu-check noted during validation check - Nurse scheduled at time will be called to validate if completed at time due and not documented or if not performed. If no accu-check obtained since missed check, nursing to immediately perform an accu-check and Notify M.D./N.P. for further orders. A monitoring log will be initiated by the DON and monitored daily by the facility Administrator. A minimum of a weekly validation review by the Regional Director of Residence Care Services and Education will be conducted. Started: 10/12/2023 And will be ongoing The Survey Team monitored the Plan of Removal on 10/12/2023: Observations on 10/12/2023 from 03:40 p.m. to 03:57 p.m., revealed staff in-serviced by Regional RN on Admission Checklist, Diabetic Review Accucheck, Admission Orders. During an interview on 10/12/2023 at from 03:58 p.m. to 05:12 p.m., 1st shift LVN A, 3rd shift ADON A, 1st shift LVN B, 2nd shift ADON B, and 2nd shift LVN C, stated they were educated and completed in-service on transcribing orders to residents EMR, the process of receiving admitting orders, using the new admission checklist, to consult with the NP for any discrepancies in a resident's admitting orders, consult with the admitting residents or family on medical history, validating with hospital D.C. transfer orders and new orders given by MD/NP are entered into PCC. All nurses were aware of the risks of not following the updated procedures, if plans are not followed residents, or admitting resident, may not receive optimal care and treatment, and if the updated procedures are not followed it may cause potential harm, injury, or death to residents. Further interviews ADON A, ADON B, LVN A, and LVN B, stated they are part of nursing management and have been educated and in-serviced on Second Nurse validation check on Completion of Admission Checklist and validating with hospital D.C. transfer orders and new orders given by MD/NP are entered into PCC, next day Clinical Morning Meeting for 3rd validation monitoring check, check/validate NMAR's for accu-checks completed per frequency order, Blood Sugar perimeters and scanning and sending all new admission checklist to the regional director of resident care services and education for monitoring, validating compliance, and completion. During an interview on 10/12/2023 at 05:22 p.m., Regional Nurse stated in-services have been conducted on nurse management, floor nurses, PRN Nurses, she further stated that any PRN nurses that have not been called to work at this time and for all new hires for nurses will receive the same in-services and education as it is ongoing. There are required online videos that educates all incoming nurses, all nurses are required to complete the in-services and education before they start working on the floor. Regional Nurse stated that she will be sent the admission checklist weekly, she will monitor and review for accuracy and compliance. During an interview on 10/12/2023 at 6:00 p.m., DON stated she was in-serviced on requirements of the POR, the updated process of completion of admission checklist, and confirmed the 3 steps validation process for nurses, and the requirement of sending weekly updated of the new admission checklist to the Regional Nurse for monitoring. Record Review on 10/12/2023, revealed in-services on topics of Admission Checklist, Second Nurse validation check on Completion of Admission Checklist and validating with hospital D.C. transfer orders and new orders given by MD/NP, and missing accu-check noted during validation check process. Record review on 10/12/2023, revealed audit by the facility Regional Nurse and DON for accu-check orders and if no order for accu-checks, followed up with MD/N.P. on their medical opinion to add accu-check to the residents E.H.R. orders to be performed or MD/N.P. or rationale not to order accu- checks completed. The ADM was notified on 10/12/2023 at 07:13 p.m. that the Immediate Jeopardy was lowered, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 100 of 100 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 ,10 ,11 ,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 41, 43, 44, 45,46, 47, 48, 49,50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100) reviewed for infection control. A. The facility failed to cohort residents according to COVID-19 status. COVID-19 unknown residents (tested negative) resided in the same room as COVID-19 positive residents. Staff were unable to distinguish which residents were COVID-19 negative and which were COVID-19 positive on the COVID 'hot' hall(hall where there are COVID-19 positive residents). There were no clear separations in the rooms. B. The facility staff failed to properly use PPE while on the warm (unknown status) and hot (positive status) halls. Gowns were not being changed in between caring for COVID-19 positive residents and COVID-19 negative residents. Some staff were wearing KN95 masks and surgical masks on the warm and hot halls. Some staff were wearing N95s that were not airtight. The facility also failed to designate specific areas for the staff to don and doff PPE. C. The facility failed to develop a COVID-19 emergency response plan that is specific to the facility. D. The facility failed to implement housekeeping and laundry policies and procedures to reduce the spread of COVID-19. High touch areas were not being cleaned regularly This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/2020. While the IJ was removed on 1/4/2021, the facility remained out of compliance at a level of actual harm at a scope as pattern due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice placed residents at risk of contracting healthcare-acquired infections, illness, and death. Findings Include: A. Record Review on 12/29/2020 of facilities demographic line list reflected on 12/22/2020 the facility had 11 positive residents; on 12/23/2020 the facility hat 10 positive residents; on 12/28/2020 the facility had 80 positive residents. In an interview on 12/28/2020 at 11:00 am with Admin and DON stated they have 58 positive residents out of 100. Further stated they did not move COVID-19 negative residents off the 'hot hall' because they did not have enough room to move the residents, nor staff to perform the moves because of the Christmas holiday. They stated they also took advice from their medical IDT team who told them to not risk putting potentially positive but tested negative residents in rooms with confirmed and tested negative residents. They stated the residents were potentially positive because they were sharing rooms with residents confirmed positive for COVID-19. In an interview on 12/28/2020 at 11:25 a.m. Admin stated she does not have printouts of resident's test results because they come in one at a time and that would mean she would need to open and print 100 documents. She stated she thought that was 'too much to do'. She stated she would have the DON write down on the roster who was negative and who was positive and after she finished the line list she would give it to me to review. Record review on 12/28/2020 at 11:30 a.m. resident roster dated 12/27/2020 with markings from the DON denoting which residents was positive and which residents was negative. Summary of this document revealed 42 positive and 58 negative residents. On the 400 hall it reflected the following: Room Resident COVID-19 Resident COVID-19 # Status Status 401 Resident 17 positive Resident 18 positive 402 Resident 19 negative Resident 20 negative 403 Resident 21 negative 404 Resident 22 positive Resident 23 positive 405 Resident 24 negative Resident 25 negative 406 Resident 26 negative Resident 27 negative 407 Resident 28 negative Resident 29 negative 408 Resident 30 positive Resident 31 positive 409 Resident 32 positive Resident 33 positive 410 Resident 34 positive Resident 35 positive 411 Resident 36 negative Resident 37 positive 412 Resident 38 positive Resident 39 positive Observation on 12/28/2020 at 7:00 p.m. revealed all residents were in their rooms. Further observation revealed residents were not wearing face masks, there were no room dividers for the residents being utilized other than a curtain and most rooms had curtains pulled halfway to the middle of the resident's bed. Observation on 12/28/2020 at 7:15 p.m. revealed Med Aide A enter room [ROOM NUMBER] where there was a negative and positive resident. Med Aide A did not change PPE between residents. Further observation revealed Med Aide A enter room [ROOM NUMBER] immediately after coming from room [ROOM NUMBER]. Med Aide A did not change PPE prior to or after entering and leaving each room. On the 500 hall it reflected the following: Room Resident COVID-19 Resident COVID-19 # Status Status 501 Resident 40 negative Resident 41 positive 502 Resident 42 positive Resident 43 positive 503 Resident 44 negative Resident 45 negative 504 Resident 46 positive Resident 47 positive 505 Resident 48 positive Resident 49 positive 506 Resident 50 negative Resident 51 negative 507 Resident 52 positive Resident 53 positive 508 Resident 54 positive 509 Resident 56 positive Resident 57 negative 510 Resident 58 positive Resident 1 positive 511 Resident 59 positive Resident 60 negative 512 Resident 61 negative Resident 62 positive 514 Resident 63 positive Resident 64 negative 516 Resident 65 positive Resident 66 positive 518 Resident 67 negative Resident 68 negative 520 Resident 69 positive Resident 70 positive Observation on 12/28/2020 at 7:25 p.m. revealed all residents were in their rooms. Further observation revealed residents were not wearing face masks, there were no room dividers for the residents being utilized other than a curtain and most rooms had curtains pulled halfway to the middle of the resident's bed. On the 600 hall it reflected the following: Room Resident COVID-19 Resident COVID-19 # Status Status 601 Resident 71 positive Resident 72 positive 602 Resident 73 positive Resident 74 positive 603 Resident 76 positive 604 Resident 78 negative Resident 77 negative 605 Resident 80 negative Resident 79 negative 606 Resident 81 positive Resident 82 positive 607 Resident 83 positive Resident 84 positive 608 Resident 85 negative Resident 86 negative 609 Resident 87 positive Resident 88 positive 610 Resident 89 positive Resident 90 positive 611 Resident 92 positive 612 Resident 93 positive Resident 94 positive 613 Resident 95 positive 614 Resident 96 positive Resident 97 positive 615 Resident 98 negative Resident 99 negative 616 Resident 100 positive Resident 101 positive 617 Resident 102 negative 618 Resident 103 positive Resident 104 positive Observation on 12/28/2020 at 7:45 p.m. revealed all residents were in their rooms. Further observation revealed residents were not wearing face masks, there were no room dividers for the residents being utilized other than a curtain and most rooms had curtains pulled halfway to the middle of the resident's bed. Record review on 12/29/2020 at 1:00 p.m. resident roster dated 12/28/2020 with markings from the DON denoting which residents were positive and which residents were negative. Summary of this document revealed 78 positive and 22 negative residents. On the 400 hall it reflected the following: Room Resident COVID-19 Resident COVID-19 # Status Status 401 Resident 17 positive Resident 18 positive 402 Resident 19 positive Resident 20 positive 403 Resident 21 positive 404 Resident 22 positive Resident 23 positive 405 Resident 24 negative Resident 25 negative 406 Resident 26 negative Resident 27 negative 407 Resident 28 negative Resident 29 negative 408 Resident 30 positive Resident 31 positive 409 Resident 32 positive Resident 33 positive 410 Resident 34 positive Resident 35 positive 411 Resident 36 positive Resident 37 positive 412 Resident 38 positive Resident 39 positive On the 500 hall it reflected the following: Room Resident COVID-19 Resident COVID-19 # Status Status 501 Resident 40 positive Resident 41 positive 502 Resident 42 positive Resident 43 positive 503 Resident 44 positive Resident 45 positive 504 Resident 46 positive Resident 47 positive 505 Resident 48 positive Resident 49 positive 506 Resident 50 negative Resident 51 negative 507 Resident 52 positive Resident 53 positive 508 Resident 54 positive 509 Resident 56 positive Resident 57 positive 510 Resident 58 positive Resident 1 positive 511 Resident 59 positive Resident 60 positive 512 Resident 61 positive Resident 62 positive 514 Resident 63 positive Resident 64 positive 516 Resident 65 positive Resident 66 positive 518 Resident 67 positive Resident 68 positive 520 Resident 69 positive Resident 70 positive On the 600 hall it reflected the following: Room Resident COVID-19 Resident COVID-19 # Status Status 601 Resident 71 positive Resident 72 positive 602 Resident 73 positive Resident 74 positive 603 Resident 76 positive 604 Resident 78 positive Resident 77 positive 605 Resident 80 positive Resident 79 positive 606 Resident 81 positive Resident 82 positive 607 Resident 83 positive Resident 84 positive 608 Resident 85 positive Resident 86 positive 609 Resident 87 negative Resident 88 positive 610 Resident 89 positive Resident 90 positive 611 Resident 92 positive 612 Resident 93 positive Resident 94 positive 613 Resident 95 positive 614 Resident 96 positive Resident 97 positive 615 Resident 98 positive Resident 99 positive 616 Resident 100 positive Resident 101 positive 617 Resident 102 positive 618 Resident 103 positive Resident 104 positive In an interview on 12/28/2020 at 1:40 pm DON stated 20 more residents tested positive and they are going to start moving residents to their proper cohort that day. In an interview on 12/28/2020 at 7:00 pm RN C stated she did not know there were negative residents and positive residents in the same hall nor in the same rooms. When asked if she changes her PPE between negative and positive residents she stated No, since I didn't know we had negative people on this side. I was told everyone was positive. In an interview on 12/28/2020 at 7:20 p.m. RN D stated she did not know there were positive and negative residents sharing the same room. Stated they would notify the nurses that there were new cases of COVID-19 through a paper that is left for the nurses. She does not know how CNAs or CMAs would be informed. Record Review on 12/28/2020 at 7:20 p.m. of paper referred to by RN D reflected a room roster with resident room numbers, resident name, and COVID-19 status. Observation on 12/28/2020 at 7:00 p.m. CNA B coming in and out of rooms 502, 501, 506, 507 on the 500 hall. Observation on 12/28/2020 at 7:32 p.m. CNA B wearing a loosely fitting KN95 mask and her visor was off while she was in the dining room on the hot hall. The KN95 was visibly soiled. In an interview on 12/28/2020 at 7:32 p.m. CNA B stated she just started that night. Surveyor asked her if she was aware that this was a 'hot unit' and that there were positive COVID-19 residents on this side of the building. Stated she did know that. Asked her if she was informed there were also negative residents on this side and she stated she was not told that. Asked her where she got her mask because the mask was wrong it was a KN95 and was very large on her face. She stated that no one gave her a mask when she got here that it was her mask from home. In an interview on 12/28/2020 at 7:35 p.m. with CMA 2 when asked if he knew which resident in which room was positive and which was negative stated there are no positives and negatives in the same room. When informed that there were at least 10 rooms in this 'hot zone' that shared positive and negative residents he gasped and stated he did not know that was possible and that since he just found out that there were different statuses then he would have to say that he treats all residents as positive residents and does not change PPE in between caring for residents room to room and bed to bed. Further went on to say that he guesses the residents that wear the masks are positive and the residents that don't wear the masks are negative. When it was pointed out that none of the residents were wearing masks he stated that is why he assumed everyone was positive. In an interview on 12/28/2020 at 7:42 p.m. CMA 3 stated he treats all residents on the 'hot side' as if they were positive. Stated he did not know that there were negative and positive residents in the same rooms. When asked how they use a system to denote whether a resident is positive or negative in the room CMA 3 stated he does not think they do that because he just found out that there were negative residents in rooms with positive residents. In an interview on 12/28/2020 at 8:00 p.m. Nurse 6 Stated she gets a sheet that tells her who is negative and who is positive, and she tries to do all the things for the negative residents first and then tend to the positive residents, but it doesn't always happen that way. Stated many nights she has to mingle care between positive and negative. Stated she believes only the nurses receive the sheets stating who is negative and who is positive, and it is up to those nurses to inform the CMAs and CNAs that there are negative residents, but she was not sure of the full procedure. In an interview on 12/29/2020 at 5:40 p.m. Doctor A stated if the facility had more staff and it was not a holiday weekend he would have advised the facility to move the negative residents to the warm hall. In an interview on 12/29/2020 at 6:30 p.m. DON stated if the facility had more staff, it was not the Christmas holiday weekend, and they had the room to move the residents she would have moved the negative residents to the warm hall. When asked why they did not double up the residents that had private rooms DON stated she did not want to call the families and inform them that even though they are paying for a private room, their loved one would now be sharing a room with another resident because of COVID-19. Observed on 12/28/2020 at 2:00 p.m. 8 rooms on the 200 hall with 16 available beds. In an interview on 12/28/2020 at 3:00 p.m. DON stated room [ROOM NUMBER], 201, 202, 203, 204, 205, 206, 207 and 208 on the 200 hall needed to be cleaned which is why they cannot use them to cohort. Observation on 12/30/20 at 6:45 p.m. 8 double occupancy rooms on the 200 hall. Some of the rooms had no beds. Some of the rooms had beds that had no sheets or pillows. Most of the rooms had no nightstands or other furniture. All of the rooms had debris on the floor ranging from leaves and dirt to empty cardboard boxes and used PPE. Observation on 1/2/2021 at 3:30 p.m. 8 double occupancy rooms on the 200 hall. Some of the rooms had no beds. Some of the rooms had beds that had no sheets or pillows. Most of the rooms had no nightstands or other furniture. All of the rooms still had debris on the floor ranging from leaves and dirt to empty cardboard boxes and used PPE. Observation on 1/3/2021 at 1:00 a.m. 8 double occupancy rooms on the 200 hall. Some of the rooms had no beds. Some of the rooms had beds that had no sheets or pillows. Most of the rooms had no nightstands or other furniture. All of the rooms still had debris on the floor ranging from leaves and dirt to empty cardboard boxes and used PPE. Observation on 1/4/2021 at 4:45 p.m. 8 double occupancy rooms on the 200 hall. Some of the rooms had no beds. Some of the rooms had beds that had no sheets or pillows. Most of the rooms had no nightstands or other furniture. All of the rooms still had debris on the floor ranging from leaves and dirt to empty cardboard boxes and used PPE. All of the rooms had their windows open. In an Interview on 1/4/2021 at 5:15 p.m. Admin stated they still have not had time to clean those rooms out. Stated they hired an additional housekeeper and it will be priority to get the rooms cleaned out for cohorting in the near future. B. Observation on 12/28/2020 at 11:55 a.m. Kitchen Aide A came out of the kitchen without a face shield. Interview on 12/28/2020 at 11:56 a.m. with Kitchen Aide A stated he was issued a face shield but did not like wearing it. Stated he will go put it on. Observation on 12/28/2020 at 1:02 p.m. Kitchen Aide A came out of the kitchen and walked to the double doors which were closed. Observed signage on the door stating, 'Hot Hall'. Kitchen Aide A knocked on the doors but after a moment Kitchen Aide A opened the door to the hot hall and entered the hot hall. Approximately a minute later Kitchen Aide A came back through the door to the warm hall carrying empty drink pitchers. Kitchen Aide A then proceeded into the kitchen with the empty pitchers. Kitchen Aide A did not change his PPE between halls. Interview on 12/28/2020 at 1:06 p.m. with DON stated there should be no one coming through those double doors. Stated she has told everyone repeatedly that if you are on the hot side you stay on the hot side. Interview on 12/28/2020 at 1:09 p.m. with Kitchen Aide A stated he went over to the hot side, collected the pitchers, took them into the kitchen, refilled them and took them back to the hot hall. Stated he did not put them in the sink to be cleaned. Stated he knows he is not supposed to go into that hall but there was no one at the nurse's station to give him the pitchers. Stated the pitchers were for resident consumption. Interview on 12/28/2020 at 1:11 p.m. with Kitchen Manager stated he has educated his staff on not entering the hot hall. Stated he will decontaminate the area the pitchers were taken into the kitchen. Observation on 12/28/2020 at 5:35 p.m. unknown staff came out of the 'hot hall' wearing a gown, gloves, visor and mask and entered the courtyard area. Staff then proceeded through the doors into the 'warm area'. Shortly after observed same staff member come out of the 'warm area' and back into the courtyard. Staff then re-entered the 'hot hall' and removed his PPE. In an interview on 12/28/2020 at 5:45 p.m. Admin stated there are only 2 doors into the courtyard. One is located on the hot hall and the other is located on the warm hall. There are no other doors in or out of the unit. Stated staff should not be going through the courtyard from the hot hall to the warm hall. Observation on 12/29/2020 at 12:15 p.m. revealed Housekeeper A wearing an ill-fitting mask with a large gap at the nose, visor and N95 with no gown. Observed him going in and out of resident's rooms cleaning rooms 301, 302, 303, 304, 305, 306, 307, 308 on the 300 hall. In an interview on 12/29/2020 at 12:17 p.m. Housekeeper A stated he did not know that the mask needed to be as airtight as possible. He stated he will pinch the nose from now on. Observation on 12/29/2020 at 1:00 p.m. revealed CNA A coming down hall 300 a 'warm hall' wearing a visor and 2 surgical masks instead of the N95. In an interview on 12/29/2020 at 1:02 p.m. CNA A stated she knows she is supposed to have and N95 mask on but there were none at the screening area at the front door and she did not know where to get one. Observation on 12/29/2020 at 1:08 p.m. revealed RN A handing CNA A an N95 mask. CNA A then removed her visor, 2 surgical masks in the hallway and donned an N95 mask and replaced her visor Observation on 12/29/2020 at 2:20 p.m. revealed RN C the nurse's station on the warm hall with no visor on and no gloves. Observed RN A at the nurse's station with no visor, observed CNA C at the nurse's station with no visor and also observed Resident 3 (negative status) standing at the nurse's station not wearing a mask and standing less than 6 feet away. Nurses station was no more than 5 feet across and a depth of approximately 24 inches. All staff and residents were in a cluster and not socially distanced. In an interview on 12/29/2020 at 2:21 p.m. RN C stated he knows he is supposed to have his visor and gloves on but he just came on shift and did not do it yet. Observation on 12/29/2020 at 4:58 p.m. revealed Housekeeper B in the 200 hall remove her visor and then her mask stating it was 'too hot' to wear them. Housekeeper B was not wearing a gown. In an interview on 12/29/2020 at 5:00 p.m. Housekeeper B stated she was told to keep her mask and visor on at all times but it was too hot and she needed a break. Observation on 12/28/2020 at 10:00 a.m. upon entry to the building there was 1 small area where staff were having to don and doff PPE. The area was approximately 8 ft across and 10 ft long. It was an alternate entry door for deliveries that they added a table and placed PPE on the table for staff to use. There was no barrier denoting where staff were to don and where they were to doff. The area for donning and doffing was the same. In an interview on 12/28/2020 at 10:05 a.m. Administrator stated that was the only place set up for staff on the warm hall to don and doff PPE. Observation on 12/28/2020 at 7:00 p.m. upon entry into the hot side of the building revealed there was only 1 spot set up for staff to don and doff PPE. The space was approximately 8 ft across and 10 ft long. There was no barrier separating the donning and doffing section. Further observation revealed staff who were leaving and doffing dirty PPE as other staff who were coming in trying to don clean PPE in the same small hallway less than 5 ft apart. Record Review on 1/4/2021 of facility policy titled Universal Source Control & PPE, undated, states All facility staff and essential personnel wear appropriate PPE when they are interacting with residents, to the extent to which PPE is available, and in accordance with CDC PPE optimization strategies. In an interview on 12/29/2020 at 5:00 p.m. VPCS stated the only policy they have on PPE was the Universal Source Control & PPE, undated. C. In an interview on 12/29/2020 at 7:00 p.m. Administrator and DON stated they have reached out to their corporate compliance team and they will supply the facilities COVID-19 Emergency Response Plan. Stated they do not think they have a designated plan just for COVID-19. In an interview on 12/29/2020 at 7:21 p.m. Corporate Compliance Director stated she emailed documents to this investigator and if they were not what was considered a COVID-19 Emergency Response Plan then she did not know what was being requested. In an interview on 12/29/2020 at 5:00 p.m. with the VPCS revealed the documents she emailed me could be pieces of a COVID-19 Emergency Response Plan but would not be sufficient for the whole plan. Record review on 12/29/2020 at 7:30 p.m. revealed the Plan that was emailed from the VPCS did not include areas for staff to don and doff PPE that minimize the movement of staff through other areas of the facility, Resident transport protocols, Plans for obtaining and maintaining a two-week supply of PPE, including surgical facemasks, N95 facemasks, gowns, gloves, and goggles or face shields or Resident recovery plans for continuing care after a resident recovers from COVID-19. In an interview on 12/29/2020 at 7:45 p.m. Administrator stated she did not have a COVID-19 Emergency Response Plan. In an interview on 12/29/2020 at 7:50 p.m. DON stated she has the COVID-19 Emergency Response Plan in her head but nothing on paper. She stated she could just 'write it down for me really quick if that's what I needed'. D. In an interview on 12/29/2020 at 11:30 a.m. with Housekeeping Manager revealed he does not have a policy or procedure created for cleaning and disinfecting for COVID-19 related exposure in the building. Further stated he does not have a policy or procedure for handling COVID-19 exposed laundry. Stated he is working on creating the policy and procedure for his team to follow. Stated his staff do not work past 6:00 p.m. on any night. Stated he leaves bottles of cleaners for the CNAs to use on the night and overnight shift but he has no way of knowing if the cleaning is actually being performed. Stated he only mops the floors twice a week. Stated he has a log for cleaning high touch surface areas but he has only instructed his team to clean them 3 times a day. In an interview on 12/28/2020 at 7:05 p.m. CMA A stated she was not sure who was supposed to be cleaning the high touch surface areas at night. In an interview on 12/28/2020 at 7:08 p.m. RN A stated she was not sure who was supposed to be cleaning the high touch surface areas at night. In an interview on 12/28/2020 at 7:15 p.m. Med Aide B stated he leaves the cleaning for the cleaning crew to do the next day. Stated he does not clean at night. In an interview on 12/28/2020 at 7:25 p.m. LVN B stated there is no cleaning performed at night because housekeeping staff leave at 6 p.m. In an interview on 12/28/2020 at 7:45 p.m. RN E stated she was not sure who was supposed to be cleaning the high touch surface areas at night. Stated they always just leave the housekeeping for the housekeeper's in the morning because the CNA's are too busy at night to clean. In an interview on 12/29/2020 at 12:45 p.m. with Housekeeper A stated he is supposed to clean HTSA twice to three times a day. Stated he has a check off sheet that he signs off on when he does the cleaning. Record review on 12/29/2020 at 12:50 p.m. revealed the month of December's check list stated the following dates and times the cleaning was completed: 12/7 8 am 12/8 8 am 12/9 8 am 12/10 8 am 12/12 8 am 12/20 8 am and 12 pm 12/21 8 am and 12 pm 12/22 8 am and 12 pm 12/23 8 am and 12 pm 12/24 8 am Subsequent interview on 12/29/2020 at 1:00 p.m. with Housekeeper A stated he understands that if he didn't log the cleaning on the checklist then it didn't happen, but he thinks he's cleaned more than the sheet reflects. In an interview on 12/29/2020 at 7:00 p.m. with the Housekeeping Manager revealed he has no check off sheets for any cleaning or laundry duties because he is developing them. When asked to view the previous sheets Housekeeping Manager stated he could not provide them because he threw them away Trashed them. Observation on 12/28/2020 at 11:30 a.m. CNA A in the dining room shuffling trays and placing resident trays on the table nearest the door to organize and check the contents before leaving the kitchen area. Observation on 12/28/2020 at 5:53 p.m. Resident 1, who is positive for COVID-19 and residing on the 500 hall, in the dining room on the 'warm' side of the building complaining to kitchen staff about his dinner. Observed resident wearing a surgical mask under his chin. Observed resident touch table nearest the door, chairs, coffee dispenser, counter tops while he was in the dining room waiting to be helped. Observed debris on the tables, counters and floors. Observed Admin convince the resident to return to the hot hall and she would get someone to make him a breakfast dinner. Observation on 12/29/2020 at 10:45 a.m. dining room had not been cleaned. Observed same debris on tables, counters and floors as the previous night. In an interview on 12/29/2020 at 5:00 p.m. Admin stated she did not instruct housekeeping to clean the dining room. The Administrator was notified on 12/30/2020 at 7:50 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on 12/30/2020 at 7:50 p.m. and a final IJ template was emailed on 1/1/2021 at 1:33 p.m. The following Plan of Removal was submitted by the Administrator on 1/01/2021 and accepted on 1/2/2021 at 8:55 a.m. The (Facility) Plan of Removal The Facility currently has an Infection Control Prevention Policy. The Facility Designee will educate all staff associates on the Infection Control Prevention Policy. Education start on December 28th through 29th, 2020 and will continue ongoing. All new associates will be educated, to include review of infection control policy and procedures in orientation and prior to working the floor. Administrator/designee will monitor staff to ensure they are following proper infection control policies weekly for three weeks, then weekly for a month and monthly thereafter. DON will review all test results and will coordinate room changes and cohorting immediately upon a positive result The Facility relocated the remaining 8 negative residents to the warm side of the building on 12/30/20. Each assigned Department Supervisor will obtain a list of current COVID status on a daily basis. The facility will also include communication on the dashboards in PCC. Transmission based precautions (contact and droplet precautions) will be placed upon on the Resident door, to include a sign that will state, Please See Charge Nurse prior to entering. In the event there is no Charge Nurse available, no staff member should enter the room without a Charge Nurse approval. Every Staff Member will be in-serviced on January 1st and will continue ongoing. Administrator/DON/designee will round daily to ensure the signs stay on the doors. Follow up will be daily for one week, then weekly for a month and monthly thereafter. (Physician) came in on 12/29/20 and did in-service training for donning and doffing and handwashing. All staff will be reeducated on proper donning and doffing procedures as well as to how to wear their N-95 mask properly. This reeducation in-service will be conducted by the facility Infection Preventionist on January 1st, 2021, and will continue ongoing. The designated Infection Preventionist will be re-educating all staff on proper donning and doffing of gowns as well as how to wear their N-95 mask properly. This re-education will start on January 1st, 2021, and will continue ongoing. Administrator/designee will monitor weekly for 3 weeks, then weekly for a month and monthly after that. An area for donning and doffing was set up on 12/30/20. All staff was in-serviced on 12/29/20 on locations currently identified donning at the end of 600 hall and doffing at the end of 500 hall. Donning on the entrance hall is designated with a sign and the doffing at another door, is also designated by a sign. The donning and doffing doors have signs indicating whether or not it is an entrance or exit. Administrator/designee will monitor compliance daily for a week, then weekly for a month and monthly after that. The facility will assign cleaning of high touch surface area(s) 3 times a day and as needed thereafter. There will be ancillary staff to use after hours to continue the cleaning. The Facility Housekeeping Supervisor will complete CDC Train Modules on Environmental Cleaning and Disinfection. After completing the CDC Train Modules on Environmental Cleaning and Disinfection, the Housekeeping Supervisor will educate all housekeeping staff and designated ancillary staff. The CDC Train Module of Environmental Cleaning and Disinfection will be completed by the Housekeeping Supervisor on January 1st. Housekeeping staff will be in-serviced on January 1st, 2021, those that are not working today will be in-ser (TRUNCATED)