Based on interviews, record review, facility policy titled Administrative Abuse, and facility document review, the facility failed to ensure Resident #155 was not verbally abused by Certified Nurse Assistant (CNA) #1 on 01/13/2023. This deficient practice affected one (Resident #155) of one sampled resident reviewed for abuse. The facility implemented corrective actions to correct the identified deficient practice on 01/20/2023; thus, past noncompliance was cited. Findings included: A review of the facility's policy titled, Administrative Abuse, revised October 2017, revealed, . Residents have the right to be free from abuse, neglect . exploitation . Residents must not be subject to abuse by anyone, including, but not limited to: facility staff .VERBAL ABUSE is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident, or within their hearing distance regardless of the resident's age, ability to comprehend, or disability . A review of Resident #155's Facesheet revealed the facility admitted Resident #155 on 09/14/2020 with diagnoses that included dementia, chronic pain, generalized anxiety disorder, and mood disorder. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/2022, revealed Resident #155 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had a short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #155 was totally dependent on staff for bathing. A review of Resident #155's Care Plan(s), dated 04/12/2022, revealed Resident #155 had difficulty making decisions due to their diagnosis of dementia. The Care Plan directed staff to validate the resident's thoughts and feelings when confused or anxious and approach the resident from the front in a calm, unhurried manner . On 01/14/2023 at 1:00 AM the facility submitted an initial report via the Alabama Department of Public Health Online Incident Reporting System, which indicated notification of the state agency of a verbal abuse allegation. The report indicated CNA #2, who assisted CNA #1 with the provision of a shower for the resident, witnessed CNA #1 curse at the resident. A review of a Witness Statement form and handwritten statement, signed by CNA #1 on 01/16/2023, revealed CNA #1 admitted to cursing while showering Resident #155. CNA # 1 acknowledged his actions were wrong and he had a bad day. Attempts to contact CNA #1 during the survey were unsuccessful. According to CNA #2's handwritten statement dated 01/13/2023, she indicated she assisted CNA #1 in the provision of a shower for Resident #155. Per CNA #2, when the resident yelled out that they were cold, their arm and back hurt, CNA #1 told the resident to shut the [expletive F word] up. Per the CNA #2, every time the resident said something, CNA #1 would say to the resident that he did not give a [expletive F word], that he could care less and [expletive F word] you. In a telephone interview on 06/06/2023 at 5:10 PM, CNA #2 stated the incident occurred on the night shift when CNA #1 requested she assist him with showering Resident #155. CNA #2 reported that CNA #1 was rude, had no compassion and stated to shut the [expletive F word] up. In a telephone interview on 06/07/2023 at 5:52 AM, Licensed Practical Nurse (LPN) #3 stated she did not see or hear the abuse, but it was reported to her by a CNA. According to LPN #3, she immediately went to the shower room, removed CNA #1 from the shower room, and escorted the CNA out of the building. During an interview with the Administrator on 06/21/2023 at 1:28 PM, the Administrator stated the facility reviewed the abuse allegation in their quality assurance meeting and identified there had been an issue with verbal abuse. A review of the facility's Verification of Investigation, signed by the Administrator and dated 01/20/2023, revealed, the allegation of verbal abuse was substantiated. Per the investigation, CNA #1 verbally abused Resident #155 and was terminated on 01/20/2023. ********************************* ********************************* A review of a facility document titled, QA [quality assurance] Committee Meeting,' dated 01/19/2023, revealed the facility reviewed the verbal abuse of Resident #155 as part of their weekly quality assurance meeting and identified corrective actions related to the verbal abuse incident. The facility implemented the following corrective actions: 1. On 01/19/2023, staff education was provided for all staff regarding abuse with an emphasis on to never leave the resident alone with the person suspected of abuse, protection of the resident, and the reporting of suspected abuse immediately. 2. On 01/20/2023, the facility terminated CNA #1's employment. 3. On 01/20/2023, the facility terminated CNA #2's employment. 4. The facility implemented monthly audits with staff interviews for six months to ensure staff could recall appropriate interventions if abuse was suspected. Evidence was provided that indicated the audits were conducted monthly between January 2023 and May 2023 with no concerns identified. The survey team reviewed documentation to support the above corrective actions, including the facility's education records, employee files, and audit logs. Interviews with staff confirmed they were able to state what measures should be taken in the event of suspected abuse. Registered Nurse (RN) #13, the nurse manager and educator, conducted audits following the incident of verbal abuse involving Resident #155, was interviewed on 06/19/2023 at 4:14 PM. She confirmed she conducted the post-incident audits and indicated she quizzed various staff members, to include CNAs, housekeeping staff, dietary staff, and management staff, on what should be done in various abuse situations. The survey team determined necessary actions had been implemented on 01/20/2023 to correct the identified deficient practice and prevent recurrence; thus, past noncompliance was cited.

Based on interviews, record review, facility policy titled Administrative Abuse, and review of the facility's investigation file, the facility failed to implement two (protection and investigation) of seven components of their abuse policy when Resident #155 was verbally abused by Certified Nurse Assistant (CNA) #1 on 01/13/2023. Specifically, the facility failed to interview CNA #20 and Licensed Practical Nurse (LPN) #3, who had knowledge of the incident. Further, the facility failed to ensure CNA #2, who witnessed the verbal abuse did not leave Resident #155 alone, unattended with the alleged perpetrator, CNA #1, while she reported the allegation of abuse to the nurse. Findings included: A review of the facility's policy titled, Administrative Abuse, revised October 2017, revealed Policy . The facility has developed and implemented policies and procedures that prohibit abuse, ( .verbal, mental .) . These policies and procedures include the following seven components: . 5) Investigation 6) Protection .INVESTIGATION OF ALLEGED ABUSE, NEGLECT AND EXPLOITATION .Policy .The facility shall thoroughly investigate . all suspected or reported abuse . 8. Interview all employees who work near the resident during the times, which the incident occurred. 9. All interviews with . employees . are to be documented . RESIDENT PROTECTION DURING INVESTIGATION . Policy . The facility shall protect the resident(s) from further abuse, neglect . or mistreatment immediately when the suspicion is formed, or when the allegation is made, or when the event is witnessed and while the investigation is in process . A review of Resident #155's Facesheet revealed the facility admitted Resident #155 on 09/14/2020 with diagnoses that included dementia, chronic pain, generalized anxiety disorder, and mood disorder. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/2022, revealed Resident #155 had a BIMS (Brief Interview for Mental Status) score of zero of fifteen which indicated Resident #155 was rarely or never understood. The Staff Assessment for Mental Status (SAMS) for Resident #155 indicated the resident had a short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #155 was totally dependent on staff for bathing. A review of Resident #155's Care Plan(s), dated 04/12/2022, revealed Resident #155 had difficulty making decisions due to their diagnosis of dementia. The Care Plan directed staff to validate the resident's thoughts and feelings when confused or anxious and approach the resident from the front in a calm, unhurried manner. On 01/14/2023 at 1:00 AM the facility submitted an initial report via the Alabama Department of Public Health Online Incident Reporting System, which indicated notification of the state agency of a verbal abuse allegation. The report indicated CNA #2, who assisted CNA #1 with the provision of a shower for the resident, witnessed CNA #1 curse at the resident. According to CNA #2's handwritten statement dated 01/13/2023, she indicated she assisted CNA #1 in the provision of a shower for Resident #155. Per CNA #2, when the resident yelled out that he/she was cold, his/her arm and back hurt, CNA #1 told the resident to shut the [expletive F word] up. Per the CNA #2, every time the resident said something, CNA #1 would say to the resident that he did not give a [expletive F word], that he could care less and [expletive F word] you. In a telephone interview on 06/06/2023 at 5:10 PM, CNA #2 stated she should not have left Resident #155 alone with CNA #1 when she left to go and report the allegation of verbal abuse to the nurse (LPN #3). In an interview on 06/19/2023 at 9:08 AM, LPN #3 stated CNA #2 should have stayed with the resident and activated the call light in the shower room to get assistance to report the abuse. Per LPN #3, CNA #2 should not have left the resident unattended with CNA #1. In an interview on 06/19/2023 at 2:22 PM CNA #20 reported that she was on the hall when CNA #2 left the shower room and went to report the incident to LPN #3. CNA #20 said that CNA #2 told her that CNA #1 was cursing at resident. CNA #20 said she went to the shower room door and did not hear any cursing. During a follow-up interview on 06/21/2023 at 12:14 PM, CNA #20 stated that CNA #2 did not ask her to stay with the Resident #155, but did ask that she listen at the door. CNA #20 said the total time Resident #155 was in the shower room with CNA #1 after CNA #2 left the shower room was two minutes and she did not hear any further abuse. In an interview on 06/19/2023 at 10:30 AM, the Director of Nursing (DON) stated her expectation was that CNA #2 should have asked CNA #1 to leave the shower room and CNA #2 should have activated the call light to get assistance. The DON stated the first thing in their abuse policy was to protect the resident, then to report the abuse. In an interview on 06/19/2023 at 11:32 AM, the Social Services Director stated CNA #2 should not have left Resident #155 alone with CNA #1. In an interview on 06/19/2023 at 1:02 PM, the Administrator indicated CNA #2 should have stuck her head out of the shower room and hollered for help or activated the call light. The Administrator said to leave Resident #155 alone with CNA #1 could have resulted in further abuse. A review of the facility's investigation file revealed there was not a documented interview done with CNA #20 or LPN #3. In a follow-up interview on 06/21/2023 at 10:49 AM, the Administrator confirmed CNA #20 and LPN #3 were not interviewed during the investigation of the allegation of verbal abuse that involved Resident #155 and CNA #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility document review, the facility failed to transcribe physician's orders into the medical record for one (Resident #105) of 27 sampled residents Findings included: A review of the facility's standing orders signed by the Medical Director, Administrator, and Director of Nursing (DON) on 12/07/2022, indicated . The following orders have been approved by our staff physicians and nursing supervisors. The physician's signatures appear at the conclusion of these orders. The treatments or medications may be administered by the LPN [licensed practical nurse] or RN [registered nurse] and may be used an indefinite number of times unless stated otherwise. When used, the standing order must be transcribed as per facility protocol for all orders and entered into the EMAR [electronic medication administration record] . Per the standing order for .12. Rash/itching: Nystatin Powder or Selan AF [antifungal] cream under breast/abdominal folds/groin every shift & [and] PRN [as needed] . A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2022, revealed Resident #105 was admitted to the facility on [DATE]. According to the Staff Assessment for Mental Status (SAMS), Resident #105 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated the resident was totally dependent on staff for toilet use, personal hygiene, and bathing. Per the MDS, the resident was always incontinent of bladder and bowel and had moisture-associated skin damage. A review of Resident #105's Care Plan, reviewed on 02/11/2022, indicated Resident #105 was incontinent of bowel and bladder related to quadriplegia, impaired mobility, and contractures. The Care Plan directed staff to provide incontinence care every two hours and as needed, cleanse skin with soap and water after each incontinence episode, and monitor skin condition for signs of breakdown or redness. A review of Resident #105's Skin/Body Audit Record, dated 01/28/2023 and signed by Registered Nurse (RN) #24, revealed the resident was assessed to have bilateral redness of their breasts and redness on their buttocks. It was also noted the resident received antifungal powder. A review of the Physician Orders, for January 2023 and February 2023 revealed Resident #105 was ordered Diflucan (fluconazole, an antifungal medication to treat and prevent yeast infections) 100 milligrams (mg) tablet per feeding tube weekly for chronic yeast on 12/28/2022. There were no orders for an antifungal cream or antifungal powder were noted. A review of Resident #105's January 2023 and February 2023 eMAR [electronic Medication Administration Record] revealed no documentation of administration of an antifungal cream or antifungal powder. During an interview on 06/06/2023 at 12:51 PM, Nurse Practitioner (NP) #12 revealed Resident #105 had frequent yeast infections, contractures, and it was very difficult to keep the resident dry. NP #12 said the resident would sweat a lot, and their gluteal folds were kept moist, which caused yeast infections. Per NP #12, the resident was started on Diflucan. NP #12 said that due to the resident's skin being fragile and the moisture, the resident's skin was excoriated and had chronic yeast infections under the arms and breast. NP #12 indicated staff used Nystatin (antifungal) powder to treat the yeast infections. During an interview on 06/06/2023 at 1:37 PM, Certified Nurse Aide (CNA) #7 stated Resident #105's skin was always red and indicated staff put Nystatin powder and antifungal cream on the resident's skin. In a follow-up interview on 06/19/2023 at 9:59 AM, CNA #7 stated she was unsure if the treatment was documented in the resident's electronic health record (EHR). CNA #7 stated she normally got the antifungal cream or powder from the nurse, and the nurse would document the usage. During an interview on 06/06/2023 at 1:59 PM, Licensed Practical Nurse (LPN) #14 revealed Resident #105's skin was constantly red, and the resident had a long history of yeast infections. LPN #14 stated Resident #105 received antifungal medications, creams, and powder. During an interview on 06/19/2023 at 10:05 AM, RN #24, the nurse who completed the Skin/Body Audit Record for Resident #105 on 01/28/2023, stated the resident had fungal issues since admission, and nurses treated it with antifungal cream and powder. RN #24 stated there should have been an order for the antifungal cream and antifungal powder. During an interview on 06/19/2023 at 10:30 AM, the DON stated NP #12 felt Resident #105's skin issues were related to fungus and started treating it as such. The DON indicated there should be orders for the treatments. During an interview on 06/19/2023 at 10:49 AM, LPN #17, the treatment nurse, stated Resident #105 had chronic fungal infections of the skin. LPN #17 stated the facility had a standing order for Nystatin powder and antifungal cream. LPN #17 stated the standing order did not show up on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) unless the order was entered into the EHR. LPN #17 stated if a nurse administered something from the standing orders, they should enter the order into the EHR. LPN #17 confirmed staff had treated Resident #105 with Nystatin powder and antifungal cream but had not entered the order into the resident's EHR. In a follow-up interview on 06/21/2023 at 9:31 AM, the DON stated Resident #105 had previously had orders for the Nystatin powder and antifungal cream, but when the resident returned from the hospital in December 2022, staff continued the treatment, but did not re-enter the orders. During an interview on 06/21/2023 at 2:51 PM, the Administrator stated her expectation was that nurses would put in the orders if they provided treatments.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that expired medications were removed from the supply on one (1) of two (2) medication carts. Findings include: Review of the facility's policy titled Nursing Medications/Administrating, dated 5/13 with revision date of 7/14, revealed that before administering medication, staff should verify the expiration date. During observation of the front hall medication cart with Licensed Practical Nurse (LPN) #1 on 4/14/21 at 10:20 a.m., revealed one (1) bottle of Aspirin (ASA) 81 milligrams (mg), was opened on 7/15/2020 and expired on 1/21. Continued observation revealed a Cranberry Supplement 450 mg opened on 3/20/21; however, had a best buy date of 6/2020. During further observation, a bottle of Iron 325 mg with opened date of 9/4/19 and best buy date of 3/21. Interview with LPN #1, during the medication cart observation, on 4/14/21 at 10:20 a.m., confirmed three (3) expired medications were on the medication cart. Continued interview revealed that all nurses use this cart, and s/he was unsure of the facility policy for checking expired medication; however, s/he thought it was weekly. LPN#1 was unsure of the last time that these expired medications were given. Interview with LPN #2 on 4/14/21 at 10:40 a.m., revealed that s/he was unsure of the facility policy for checking medication carts for expired medication. Continued interview revealed that s/he usually checked the cart when s/he worked the night shift. During an interview with the Director of Nursing (DON) on 4/14/21 at 10:55 a.m., s/he confirmed that it was the responsibility of all nurses to check medication expiration dates prior to giving the medication. Continued interview revealed that if there was an expired medication, the nurses were expected to pull that medication from the cart, log the medication on the destruction sheet in the medication room, and place the medication in the destruction bin. Then the nurses were expected to obtain a new bottle from the stock medication and place the medication on the cart. S/he was unsure of last in-service provided regarding removing expired medication. Review of the bulleted document titled Inservice Topics that should be discussed, dated 4/5/21 at 2:00 p.m., revealed that the DON held a mandatory nurses meeting and discussed the topic medication destruction if take medication off cart or discontinued a medication. Review of the In-service Training/Attendance Record dated 4/5/21, revealed LPN #1's signature was recorded on the attendance sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure laboratory services were provided as ordered by the physician for one (1) of 40 sampled residents (Resident #50). Findings include: Review of the facility's policy titled Lab Services and Reporting dated 4/21 revealed that the facility was responsible for timeliness of the services. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with readmission on [DATE] with a diagnosis of Schizoaffective Disorder and Diabetes Mellitus-type 2 (DM2). Review of Resident #50's Physician's Order, 8/19/2020, revealed an order for Levemir 40 units (u) at bedtime, Metformin 500 mg daily and Novolog per sliding scales. Further review of the Physician's Orders, 4/15/2021, revealed an order for valproic acid (VPA) 500 milligrams (mg) twice a day (BID). Continued review of the Physician's Orders, dated April 2021, revealed lab orders for Glycated hemoglobin (HgbA1C) every four (4) months (April, August and December) and VPA every six (6) months (April and December). Review of Resident #50's Laboratory Report, dated 6/20/2020, revealed Resident #50's A1C was 12.1 (normal range below 6.5%) and VPA was 45 [normal range 50-100 micrograms per liter (mcg/ml)]. Further review revealed no evidence of A1C and/or VPA levels completed since June 2020. Interview with the Director of Nursing (DON) on 4/15/21 at 5:11 p.m., revealed that the labs were not drawn per the order. Continued interview revealed that the last time these labs were drawn was in June 2020. The DON confirmed that when s/he got here in January 2021, there was no way of tracking the labs, so s/he started a lab book, and since then there has been no concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide food that was palatable and at a safe and appetizing temperature. Residents #17, #29, and #52 complained that hot foods were served cold. Observation of a test tray from the dinner meal on 4/15/21 revealed point of service temperatures for hot foods were below one hundred thirty-five (135) degrees Fahrenheit (F) which was not in accordance with the facility's policy. Findings include: Review of the facility's policy Food and Nutrition Services Food Temperatures, dated 10/17, documented the food and nutrition service professional shall check test trays randomly. Temperatures should be taken periodically to ensure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit all during the portioning, transporting and serving process until received by the resident. According to the Food Service Director from the sister facility, temperatures are taken at the start of the tray line and midpoint of tray line. 1. In an interview with Resident #17 on 4/15/21 at 5:30 p.m, he/she stated the food was okay but could be better. When he/she got the food, it was usually cold. Review of Resident #17's Quarterly Minimum Data Set (MDS) assessment, dated 1/29/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. 2. In an interview with Resident #29 on 4/14/21 at 10:15 a.m., s/he stated the food could be warmer. S/he mentioned s/he didn't care much for the variety. Review of Resident #29's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a BIMS score of 15, indicating s/he was cognitively intact. 3. In an interview with Resident #52 on 4/13/21 at 1:40 p.m., s/he confirmed that the trays are delivered to the rooms barely warm. Review of the Resident #52's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident had a BIMS score of 15, which indicated the resident was cognitively intact. Review of the Grievance Reports, for the last six (6) months (December 2020 through April 2021), revealed no documented evidence that any grievances were filed regarding the temperature of the food. On 4/15/21, at 6:36 p.m., a test tray from the dinner meal was tested with the Food Service Director from the sister facility. The food items tested were coleslaw, fish sandwich and tater tots. The temperatures were as follows: Coleslaw 50 degrees Fahrenheit, tater tots 100 degrees Fahrenheit, and fish 100 degrees Fahrenheit. The Food Service Director from a sister facility took the food temperatures. When s/he tasted the food, s/he stated, I would like it to be heated up.

Based on observation, interview and facility policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. The sanitation concerns had the potential to affect all 56 residents who received meals from the kitchen. Findings include: Review of the facility's policy, Food and Nutrition Services Sanitation, dated 10/17, documented The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. An initial tour of the kitchen was conducted on 4/13/21 at 10:00 a.m. Concerns identified included: Observation revealed the window above the three-compartment sink was not able to be closed properly. There was an uneven gap at the bottom of the windowpane and the wood appeared to be warped. In addition, paint was chipping off the windowpane. The Food Service Director stated at 10:15 a.m. on 4/13/21 that s/he thought management was going to replace the window. The top shelf of the oven over the grill and stove was covered with black grime and was flaking off. The Food Service Director acknowledged that the cleanliness of the oven was a concern. The fryer was observed with a black coating around the inside walls. The grease was very dark and there were many food particles/crumbs floating around in the grease and on the sides of the inside portion of the grill. The Food Service Director stated, The fryer will be cleaned today. In an interview with the Food Service Director from the sister facility at 4/15/21 5:30 p.m., s/he stated the facility had planned on replacing the oven and fryer. On 4/15/21 at 11:30 a.m., the Administrator stated he/she heard the oven had been there for almost thirty (30) years and there was an order for a new oven but due to COVID-19 it hadn't arrived yet.

Based on record review, interview, and review of a facility policy titled, Pharmacy Destroying Drugs, the facility failed to ensure the required signatures were on one of 16 Non-Controlled Medication Destruction Sheets for the month of September, 2018. This affected one of 10 months of Non-Controlled Medication Destruction Records reviewed. Findings Include: A review of a facility policy titled, Pharmacy Destroying Drugs, with a revised date of 7/14, revealed, . 1. Non-controlled medications must be destroyed or prepared for destruction in the presence of two (2) licensed nurses or one (1) licensed nurse and pharmacist . On 2/28/19 at 2:48 p.m., the surveyor reviewed the facility's Non-Controlled Medication Destruction sheets for the months of March 2018 through January 2019. One of 16 of the September 2018 Non-Controlled Medication Destruction Sheets, dated 9/9/2018, did not contain the required two signatures. On 2/28/19 at 2:53 p.m., an interview was conducted with Employee Identifier (EI) #1, Assistant Director of Nursing (ADON)/Registered Nurse (RN). EI #1 said the Director of Nursing or Assistant Director of Nursing was responsible for ensuring the Non-Controlled Medication Destruction Sheets were filled out completely. After reviewing the September 2018 Non-Controlled Medication Destruction Sheet, dated 9/09/2018, EI #1 said it only had one signature, but should have had two. EI #1 was not sure why there was only one signature, but said two signatures should be on it to ensure that the drugs listed were properly destroyed and accounted for when they were destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, review of a facility policy titled Infection Control Isolation Precautions, and review of the Centers for Disease Control and Prevention (CDC)'s 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, CDC's Prevention Strategies for Seasonal Influenza in Healthcare Settings, and Fundamentals of Nursing, Ninth Edition, the facility failed to ensure: 1) staff wore gloves and a gown and performed proper hand washing while caring for Resident Identifier (RI) #49, a resident on Contact Precautions; further there was no isolation sign posted on RI #49's door and staff removed his/her personal cup from the room to fill it with ice from the hall; and 2) staff wore proper Personal Protective Equipment (PPE) and performed hand hygiene while caring for RI #11, a resident on Droplet Precautions. These deficient practices affected RI#49 and RI#11, two of three residents sampled for infections. Findings include: Review of the facility's policy titled INFECTION CONTROL ISOLATION PRECAUTIONS, dated 12/2018, revealed the following: Policy It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. This policy specifies the different types of precautions, including when and how isolation should be used for the resident. Definitions: . Contact Precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Droplet Precautions refers to actions designed to reduce/prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. 1) Review of the Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, pages 49-51, revealed the following: . II.E. Personal Protective Equipment (PPE) for Healthcare Personnel . II.E.1. Gloves. Gloves are used to prevent contamination of healthcare personnel hands when 1. anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; 2. having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route . Gloves can protect both patients and healthcare personnel from exposure to infectious material that may be carried on hands . II.E.2. Isolation gowns. Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW ' s (healthcare worker's) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious . The need for and type of isolation gown selected is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental . Review of Fundamentals of Nursing, Ninth Edition, copyright 2017, page 461, revealed the following: .Chapter 29: Infection Prevention and Control . The Isolation Environment. On the door or wall outside the room a nurse posts a card listing precautions for the isolation category in accordance to the health care facility policy. The card is a handy reference for health care personnel and visitors and alerts anyone who might enter the room accidentally that special precautions must be followed. RI #49 was readmitted to the facility on [DATE] with a diagnosis of Clostridium difficile (c. diff). A Physician's Order was written on 2/19/19 to place RI #49 on Contact Precautions for c. diff until further notice. RI #49's Care Plan for C. diff, dated 2/19/19, also documented an approach of Contact isolation as ordered. On 2/26/19 at 9:11 AM, the surveyor observed an isolation cart/drawers outside of RI #49's room, but there was no sign on the door to his/her room indicating any isolation precautions. On 2/26/19 at 10:09 AM, RI #49's room was again observed with no sign on the door indicating isolation precautions. On 2/26/19 at 12:16 PM, Employee Identifier (EI) # 2, a Certified Nursing Assistant (CNA), was observed removing a meal tray from the meal cart. She then carried the tray into RI #49's room, without putting on any PPE (no gown or gloves). She then exited RI #49's room after delivering the meal tray without washing her hands or using sanitizer. EI #2 then opened drawers in the isolation cart outside of RI #49's room, then walked down the hallway to a covered cart and removed a pair of gloves. After getting the pair of gloves, EI #2 went into another resident's room and placed a towel across his/her chest. After placing the towel across the other resident's chest, EI #2 returned to RI #49's room, knocked on the door, and entered his/her room with gloves in hand (no gown). At 12:26 PM, EI #2 exited RI #49's room with his/her meal tray and placed it back on the meal cart it was served from. Again, EI #2 did not wash or sanitize her hands. After placing RI #49's tray back on the cart, EI #2 entered four other residents' rooms and pushed the meal cart down the hallway, without washing hands. On 2/26/19 at 2:32 PM, EI # 3, another CNA was observed scooping ice from a cooler in the hallway and placing it into RI #49's personal cup. EI #3 took the cup into RI #49's room, gave the resident a drink from the cup with a straw, then placed the cup on RI #49's bedside table. EI #3 did not wear any PPE and did not wash hands before exiting the room. EI #3, CNA, was interviewed on 2/28/19 at 3:05 PM. EI #3 was asked if she filled RI #49's personal cup with ice from the cooler in the hallway. EI #3 said yes. However, EI #3 said personal items should not be removed from the room of residents on isolation. She further stated when she took the cup back into RI #49's room, she did not put on any PPE. EI #3 confirmed there was PPE available for use outside of RI #49's room. When asked if there was an isolation sign on RI #49's door, EI #3 said no. EI #3 also said she had not washed her hands, and had continued on to another resident's room to give them ice as well. EI #3 said she was aware RI #49 was on isolation for C. diff. When asked what the concern was in not wearing PPE and washing hands, EI #3 said she could spread C. diff to other residents. 2) Review of the CDC's Prevention Strategies for Seasonal Influenza in Healthcare Settings, last updated 10/30/2018, revealed the following: . 4. Adhere to Standard Precautions During the care of any patient, all HCP (health care professionals) in every healthcare setting should adhere to standard precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. Standard precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. Elements of standard precautions that apply to patients with respiratory infections, including those caused by the influenza virus, are summarized below.Hand Hygiene HCP should perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. Hand hygiene in healthcare settings can be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, use soap and water, not alcohol-based hand rubs. Gloves Wear gloves for any contact with potentially infectious material. Remove gloves after contact, followed by hand hygiene. Gowns Wear gowns for any patient-care activity when contact with blood, body fluids, secretions (including respiratory), or excretions is anticipated. Remove gown and perform hand hygiene before leaving the patient's environment. 5. Adhere to Droplet Precautions Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility. HCP should don a facemask when entering the room of a patient with suspected or confirmed influenza. RI #11 was readmitted to the facility on [DATE]. RI #11's Physician Orders for February 2019 included an order dated 2/22/19 for Droplet Precautions. RI #11's comprehensive care plans included a care plan for the diagnosis of influenza, dated 2/22/19. This care plan included an approach of droplet/contact isolation. On 2/27/19 at 11:53 AM, the surveyor observed EI #4, CNA, put on a mask, but no gloves when entering RI #11's room to deliver his/her meal tray. EI #4 placed the tray on RI #11's bedside table, opened containers from the tray, then removed the mask and washed hands in the bathroom before exiting the room. After exiting the room, EI #4 then re-entered the room without any PPE and walked over to RI #11's bedside.