**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, a facility policy titled, Assisting the Impaired Resident with In-Room Meals and a facility document titled, Inservice Dignity and Respect, the facility failed to ensure a CNA (Certified Nursing Assistant) did not stand while feeding RI (Resident Identifier) #46 the lunch meal on 03/10/20. This deficient practice affected RI #46, one of four sampled residents who required assistance with feedings. Findings Include: A review of a facility policy titled, Assisting the Impaired Resident with In-Room Meals, with no date revealed the following: Policy: The purpose of this procedure is to provide a well-balanced meal to the resident who needs assistance with eating . Procedure: . 3 . be seated during the feeding, position a chair where it will be convenient for you and the resident, providing resident dignity . A review of a facility document titled, Inservice Dignity and Respect, with no date, revealed the following: . the facility must promote care for residents in a manner . that maintains or enhances each resident's dignity . Promoting resident . dignity in dining such as avoidance of: . Staff standing over residents while assisting them to eat: . RI #46 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses to include Dysphasia, oral phase. RI #46's Care Plan revealed the following: Problem Onset 10/3/14 . ADL's (activities of daily living) Resident requires assist w/(with) . eating . Approaches .* Provide assistance with meals . On 03/10/20 at 12:20 p.m., the surveyor observed EI (Employee Identifier) #1 standing up while feeding RI #46, while the resident was sitting on the side of the bed. On 03/10/20 at 12:39 p.m., an interview was conducted with EI #1, a CNA. EI #1 was asked did she feed EI #46 his/her lunch meal. EI #1 said yes. EI #1 was asked what position was she feeding RI #46. EI #1 said she was standing. EI #1 was asked what was she taught about feeding residents. EI #1 said to sit down on the side of them (resident), pay attention to them and make sure they are offered everything on the tray. EI #1 was asked what position should she have been in when feeding the resident. EI #1 said she should have been sitting in front of, or on the side of RI #46. EI #1 was asked why was she standing feeding RI #46. EI #1 said there was no chair so she just stood up. EI #1 was asked what was the concern with standing up feeding a resident, would it be a dignity concern. EI #1 said yes it would be a dignity issue. On 03/12/20 at 2:25 p.m., an interview was conducted with EI #2, RN (Registered Nurse), Staff Development Coordinator. EI #2 was asked how were CNAs trained to assist the residents with feeding. EI #2 said they were trained to sit down to feed residents, for safety purposes of the residents. EI #2 was asked what position should the CNA be in when feeding residents. She said sitting down facing the resident. EI #2 was asked should staff be standing feeding a resident. She said no. EI #2 was asked what was the concern with the CNA standing while feeding a resident. EI #2 said it is a dignity concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure Resident Identifier (RI) #6 had an isolation sign outside of the door. This affected RI #6, one of one resident observed on isolation. Findings include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE]. RI # 6 had a diagnosis of Extended spectrum beta lactamase (ESBL) resistance. On 03/10/20 at 3:29 p.m., an observation was made of RI #6's room, an isolation cart containing gloves, mask, and gowns were outside of the room. No observed isolation sign on the door indicating the type of isolation such as contact, airborne, or droplett the resident was on, or what staff/visitors should do before entering the room. On 03/11/20 at 9:09 a.m., an observation was made of RI #6's room, an isolation cart (remained) outside of the room. Still no observed isolation sign on the door indicating the type of isolation the resident was on, or what staff/visitors should do before entering the room. On 03/12/20 at 8:09 a.m., an observation was made of RI #6's room, an isolation cart remained outside of the room. No observed isolation sign on the door indicating the type of isolation the resident was on, or what staff/visitors should do before entering the room. On 03/12/20 at 1:29 p.m., an interview was conducted with Employee Identifier (EI) #3, Unit Manager. EI #3 was asked, who was the unit manager on the hall where RI #6 was. EI #3 replied, she was. EI #3 was asked, what kind of precautions was RI #6 on. EI #3 replied, on contact isolation. EI #3 was asked, why was the resident on these precautions. EI #3 replied, the resident had ESBL positive urine. EI #3 was asked how staff knew what precautions the resident was on. EI #3 replied there was a sign, it was on the care plan, it was in the books. The resident had a door hanger and they changed it out, she thought that they must have taken it off when they took it because it was attached to it. EI #3 was asked, how do visitors know what to do. EI #3 replied, usually the only visitor the resident had was her/his sister and she came once or twice a week and has been told what to do. EI #3 was asked, was there a sign on the door. EI #3 replied, no. EI #3 was asked, where was the sign for the door. EI #3 replied she did not know but it had been there. EI #3 was asked, should there be a sign. EI #3 replied, yes. EI #3 was asked, why was there not a sign for the door. EI #3 replied it obviously came off the door. EI #3 was asked, who was responsible for ensuring there was a sign on the door. EI # 3 replied that would be every personnel in this building. EI #3 was asked what was the potential concern of not having a sign outside of a resident's room that was on transmission-based precautions. EI #3 replied, that someone may come in and get contaminated and expose it to someone else. On 03/12/20 at 1:46 p.m., an interview was conducted with EI #4, Infection Control Nurse. EI #4 was asked, what kind of precautions was RI #6 on. EI #4 replied, on contact isolation. EI #4 was asked, why was the resident on these precautions. EI #4 replied the resident had ESBL in the wound and urine. EI #4 was asked, how did staff know what precautions the resident was on. EI #4 replied it was posted on the door, and every time they put residents on precautions they did in-services. EI #4 was asked, how did visitors know what precautions the resident was on. EI #4 replied when they first put the resident on precautions they contacted them and let them know. EI #4 was asked, where was the sign for the door. EI #4 replied usually they put it on the door and it was under the resident's name. EI #4 was asked, should there be a sign. EI #4 replied yes. EI #4 was asked, why was there not a sign for the door. EI #4 replied, she did not know if it fell off, she really did not know, but there was a sign on the door. EI #4 was asked, who was responsible for ensuring there was a sign on the door. EI #4 replied all staff really, she was the infection control person, so she initiated it. EI #4 was asked, what was the potential concern of not having a sign outside of a resident's room that was on transmission-based precautions. EI #4 replied that someone entering into that room without the proper Personal Protective Equipment (PPE) could cause a visitor or another resident to get what that resident had.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy titled, Medication Administration - General Guidelines, the facility failed to ensure a licensed nurse washed her hands after returning to the medication cart to continue preparing medication for Resident Identifier (RI) #21. Further, the facility failed to ensure a licensed nurse did not place a contaminated blister medication card into the medication cart after it had fallen on the floor. This affected one of four residents and one of three nurses observed during medication pass administration. Findings Include: A review of the facility's policy titled, Medication Administration - General Guidelines, dated 01/12 revealed: . Procedures . 6. Cleanse hands with soap and water before handling medication . RI #21 was admitted to the facility on [DATE] with a diagnosis to include Type 2 Diabetes Mellitus without complications. On 1/16/19 at 8:14 a.m., the surveyor observed Employee Identifier (EI ) #1, Licensed Practical Nurse, leave the medication cart to go to the medication room to retrieve more insulin. EI #21 was observed touching items in the medication room, such as the door handle, the refrigerator, and the emergency medication box. EI #1 did not wash her hands when she returned to the medication cart to continue preparing RI #21's medication. EI #1 then placed a medication blister card that had fallen on the floor into the medication cart. An interview was conducted on 1/16/19 at 4:04 p.m. EI #1 was asked, what should be done after returning to the medication cart and before continuing to prepare medication. EI #1 stated, I should have . washed my hands in the sink at the nursing station. EI #1 was asked, what should be done after the nurse picked up the medication blister pack off the floor and handed it to you. EI #1 stated, I should have used a kleenex to take the blister pack from her. EI #1 was asked, should the blister pack have been placed into the medication cart. EI #1 stated, No, it should have been placed in the drug destruction box. EI #1 was asked, what was the potential for harm. EI #1 stated, Germs, . can cause other residents to get sick. An interview was conducted on 1/16/19 at 4:12 p.m. with EI #2, Registered Nurse/ Quality Assurance, Infection Control. EI #2 was asked, what should be done after a nurse returns to the medication cart to continue preparing medications. EI #2 stated, Wash her hands. EI #2 was asked, if a blister pack of medications falls on the floor, what should the nurse do. EI #2 stated, She must throw the medication away after it hits the floor because it is contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a review of a smoking assessment, the facility failed to ensure a smoking assessment was accurately completed for RI (Resident Identifier) #157. This affected RI #157, one of twenty-one sampled residents. Findings Include: A review of a facility policy titled, NURSING PROCEDURES MANUAL, with an effective date of 03/08, revealed: PURPOSE: The resident has the right to smoke, if desired. However, smoking is generally supervised to protect the resident from fire hazards. PROCESS: 1. Upon admission, quarterly, and a significant change, the resident's smoking desires should be determined, along with their ability to smoke unattended. A review of the medical record revealed RI #157 was re-admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Hemiplegia following Cerebral Infarct, and Nicotine Dependence. A review of the care plan for RI #157 revealed, . Problem/Need . SMOKER Res (Resident) has the potential for injury r/t (related to) smoking due to CVA (Cerebrovascular Accident) w/(with) right-sided wkns (weakness) . Apply smoking apron whenever smoking . A review of a facility document titled, Smoker's Assessment, revealed a section for Cognitive Assessment, Motor Skills Assessment, and Safety Assessment. In the Safety Assessment section, the following abilities were to be assessed: .Wears apron when smoking Put ashes in proper container Lights cigarette on right end Knows when cigarette is finished Puts cigarette in proper container when finished. A review of the Smoking Assessment for RI #157 was dated 1/25/18, and revealed the ability, Wears apron when smoking, had not been checked. An observation was made on 02/01/18 at 2:33 PM of EI (Employee Identifier) #4, a CNA (Certified Nursing Assistant), asking if RI #157 was ready to go out to smoke. EI #4 got a storage bag with cigarettes and a smoking apron and walked down the hallway with RI #157. EI #4 put the smoking apron on RI #157. EI #4 passed a cigarette and lighter to RI #157. RI #157 lit the cigarette with a steady hand. At 2:52 PM, RI #157 extinguished their second cigarette, stood up, and EI #4 detached the smoking apron. An interview was conducted on 02/01/18 at 3:30 PM with EI #5, the Social Services Director. EI #5 was asked who completed the smoking assessment for RI #157. EI #5 answered a trainee and herself. EI #5 was asked what the assessment indicated related to RI #157 needing a smoking apron. EI # 5 answered it was not checked, EI #5 was asked what it meant when the line by need for apron was left blank. EI #5 answered that would say there was no need for an apron. EI #5 was asked what did the care plan indicate related to RI #157's use of a smoking apron and she answered to apply a smoking apron whenever smoking. EI #5 was asked should the plan of care match the assessment and she answered it should. EI #5 was asked which one was correct and she answered the care plan. EI #5 was asked what was the facility policy regarding the assessment and plan of care correlating and she answered they should match. EI #5 was asked what was the concern of the plan of care not matching the assessment. EI #5 answered she would be concerned that it may not match what the resident needs. An interview was conducted with EI #1, the Administrator, on 02/01/18 at 3:39 PM. EI #1 was asked if the care plan and assessment should match and she answered yes. EI #1 was asked what was the facility's policy regarding the assessment and plan of care correlating and she answered they should match. EI #1 was asked what was the concern of the plan of care not matching the assessment. EI #1 answered staff might not meet a resident's needs.

Based on observations, interviews, and a review of the 2013 Food Code, the facility failed to ensure a dietary worker washed her hands after handling soiled dishes and prior to handling clean dishes. This had the potential to affect all fifty-seven residents that were served meals from the kitchen. Findings Include: A review of the 2013 FDA (Food and Drug Administration) Food Code revealed: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and . (E) After handling soiled EQUIPMENT or UTENSILS; . (I) After engaging in other activities that contaminate the hands . An observation was made on 01/31/18 at 9:18 AM of EI (Employee Identifier) #3, a Dietary Aide, washing silverware. EI #3 was observed to send the silverware through the dishwasher flat, then removed the washed silverware and stacked the silverware in holders with the tines up without washing her hands between handling the soiled silverware then the clean silverware. EI #3 then removed a clean rack and changed tines to down and re-washed silverware without her hands being washed. EI #3 washed and wiped multiple surfaces in the dirty dish-washing area with a wash cloth. Without washing her hands, EI #3 then gripped the rack of clean utensils, shook it, and continued to clean the dirty side of the dish-washing area. EI #3 had not washed her hands. At 9:30 AM, EI #3 wiped her hands on her apron and retrieved a cart from the dining room with her unwashed hands. At that time, EI #3 washed her hands and put her hands back on the bar she handled with unwashed hands. An interview was conducted with EI #3 on 01/31/18 at 9:47 AM. EI #3 was asked how should clean dishes and silverware be handled and she answered with her hands. EI #3 was asked when should hands be washed during dishwashing and she answered before washing the dirty silverware and after. EI #3 was asked if she did that. EI #3 initially answered yes then added she had washed them before handling the dirty. EI #3 was asked what was the concern of handling clean dishes or silverware with unwashed hands and she answered bacteria contamination. EI #3 was asked if she usually worked both the clean and dirty side of dishwashing and she answered yes. An interview was conducted with EI #2, the Dietary Manager, on 02/01/18 at 1:32 PM. EI #2 was asked when should hands be washed during dishwashing and she answered after contact with dirty dishes. EI #2 was asked what was the facility's policy regarding staff handling both soiled and clean dishes and silverware. EI #2 answered after staff handled the soiled, they were supposed to go wash their hands before they handled the clean. EI #2 was asked what was the concern of staff handling soiled dishes or silverware, then handling the clean dishes without washing their hands. EI #2 answered it could cause germs to be transferred.