An observation was conducted on 4/15/24 at 12:16 p.m. in the Unit 7 dining room. Four residents were sitting at a table for lunch. One resident had their tray and was eating, and the other three residents did not have a tray. At 12:18 p.m. the second resident was served their lunch tray, at 12:23 p.m. the third resident was served their lunch tray and at 12:27 p.m. the fourth and final resident at the table was served their lunch tray. (Photographic evidence obtained.) Review of a facility policy titled Dignity, dated February 2021, showed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Under policy interpretation and implementation, (1.) Residents are treated with dignity and respect at all times. 5. (e.) provided with a dignified dining experience. (8.) Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice not labeling or referring to the resident by his or her room number, diagnosis, or care needs. (12.) Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents keep urinary bags covered. Based on observations, interviews and record review, the facility 1) failed to provide access to quality care related to a dignified meal service for three residents (# 69, #43, and #89) out of 13 residents reviewed for dining, and 2) failed to ensure a catheter was stored in a privacy bag for one resident (#43) out of 29 sampled residents. Findings included: On 4/15/24 at 10:00 a.m. Resident #69 was observed in his room in bed. The resident was observed with food on his chest area and beard from his breakfast meal, and a small flying insect on his beard. The resident stated he fed himself. He stated the staff clean him up When they get around to it. During the interview, the resident confirmed he did not know he had food pieces on his beard, chest, and clothing. He said, I am blind I can't see. The resident stated he had oatmeal for breakfast. He did not know how long ago. The food remnants were noted to be mushy in texture. An interview was conducted with Staff I, Certified Nursing Assistant (CNA) on 4/15/24 at 10:12 a.m. She stated breakfast was served at 7:45 a.m. and Resident #69 ate independently. She stated the CNAs clean the residents up as soon as they are done with the meal. She observed Resident #69 with food on himself and stated she would clean the resident. Resident #69 was readmitted to the facility on 2/2023 with diagnoses to include Type 2 Diabetes Mellitus (DM), unspecified malnutrition, blindness right and left eye category 5, Cerebral Vascular Accident (CVA), dysphagia and dehydration. A care plan for Resident #69, dated 5/31/23, revealed the resident had an alteration in visual function with interventions to provide Activities of Daily Living (ADL) tasks as needed and to provide verbal cues to locate objects or navigate in the environment. A self-care focus showed the resident had a grooming deficit related to generalized weakness, DM, CVA ,and chronic pain. Interventions included to provide hands on assistance with grooming. On 4/15/24 at 12:40 p.m., Resident # 69 was observed in his bed after lunch. The resident was observed with food spilled all over his shirt, chest area and his left shoulder as he leaned to the side of the bed. During an observation on 4/16/24 at 02:00 p.m., Resident #69 was observed in his room, he was noted licking a bowl. The resident's tray was removed from the room. The resident said, I can't see in this bowl. I am trying to feel for the pudding. The resident was observed with a towel on his chest area with food dropped on himself during the meal. The resident's beard and nails were observed with redness from meal sauce and brown color from the pudding. It was noted the other residents had finished their meal and trays had been removed from the halls. Resident #69 was not cleaned up from lunch which was served at 12:00 p.m. Review of a document titled, Documentation Survey Report, also known as CNA task log, dated April 2024, showed daily entries of 05 under eating, indicating the resident required set up or clean up assistance - Helper sets up or cleans up. Under personal hygiene, the documentation showed 01 documented daily indicating the resident was dependent - Helper does all of the effort, meaning resident does none of the effort to complete the activity. On 4/17/24 at 1:03 p.m., an interview was conducted with Staff K, CNA. She stated she assisted residents who eat in their rooms and cleans them up when she removes trays or right after they were done with their meals. She stated the residents should not wait hours to be cleaned up after meals. An interview was conducted on 4/17/24 at 1:06 p.m. with Staff G, CNA regarding Resident #69 being observed with food after the meal. She said, [Resident #69] refuses care. He has [small flying insects] on his beard and on himself all the time. She stated if the resident refused care, they let the nurse know. She stated she had not notified the nurse of any refusals that day. During dining observation on 4/17/24 at 12:40 p.m., Resident #43 was observed laying on his bed. His roommate was presented with his tray while this resident was not. An immediate interview was conducted with Staff G, CNA. She said to this surveyor, [Resident # 43] is a feed, that's why I didn't pass his tray. During a dining observation on 4/17/24 at 12:41 p.m., The Regional Nurse Consultant (RNC) asked Staff J, Registered Nurse (RN) if they needed help passing trays. She said, Yes, Resident #69 is not a feed. He needs cues. His roommate [Resident #43] is a feed. During a facility tour on 4/15/24 at 10:11 a.m., Resident #43 was observed in his bed. The resident was not interviewable. His catheter was observed hanging below his bed, visible to bystanders. His catheter was not stored in a privacy bag. (Photographic evidence was obtained.) On 4/18/24 at 10:50 a.m., an interview was conducted with the Assistant Director of Nursing (ADON) she stated, It is bad to leave the resident soiled after a meal. She stated if a resident refused care, she would have another staff try. She stated she would step away and come back and try again. She said regarding Resident #69, it is care planned. Sometimes you have to leave him and come back. Sometimes he refuses, but not all the time. The ADON stated the CNAs should report to the nurses and there should be documented re-attempts. She stated they should not wait a long time before returning to the resident. She stated the CNAs should document if a resident refused care and the attempts they made should be documented. A follow -up interview was conducted on 4/18/24 at 12:35 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated Resident #69 refuses care. She asked, How long was he waiting? When notified breakfast was served at 7:30 a.m. and at 10:12 a.m. the resident still had food on him, she said, Oh, okay. The DON stated regarding the catheter not being in a privacy bag I'm surprised. What room was that?

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a grievance was filed related to a resident's room changed for one resident (#87), out of eight residents sampled. Findings Include: During an observation made on 04/15/2024 at 10:45 AM., Resident #87 was observed laying down in her bed with her call light within reach. The Resident said she would like to have a room change because she doesn't get along with her roommate. She said she spoke to the Social Services Assistant multiple times about wanting to move to another room, but nothing has been done about it. During an observation made on 04/16/2024 at 12:00 PM., Resident #87 was observed sitting up in her wheelchair with a blanket placed over her lap. She stated she and her roommate got into a verbal fight last night and she really wants her room to change. She said she was not made aware of the facility grievance process. Review of the medical record showed Resident #87 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, unspecified, major depressive disorder, recurrent, mild, acute kidney failure unspecified. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident had a Brief Interview Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. During an interview on 4/17/2024 at 4: 37 p.m., with Staff P, Social Service Assistant, SSA, she stated Resident #87 spoke with her about wanting to have a room changed a few times because she was not getting along with her roommate. She stated Resident #87 told her a few weeks ago that she and her roommate do not get along with each other and she wants a room change. Staff P stated she told Resident #87 when a room becomes available, she will work on moving her to another room. During an Interview on 4/17/2024 at 4:37 p.m., with the Social Service Director, SSD, she stated her assistant told her about Resident #87 wanting to have a room change but they did not have any rooms available at this time. Resident #87 has an infection, and we were not able to change her out of that room but when a room becomes available, we told her that we will do our best to change her to another room. She stated Resident #87 likes to fixate on things and will not let some things go once she gets it in her head. We did not document the conversation we had with the resident about the room change and the reason we were not able to move her out of the room she is in at this time. My assistant should have put a progress note in the system showing that she spoke with the resident about the room change and a grievance should have been filed on the resident's behalf if we were not able to accommodate her need. Review of the facility policy titled, Grievance/ Complaint, Filing, ,revised April 2017, showed the following: Policy statement: Resident and their representatives have the right to file grievance, either orally or in writing, to the facility staff or to the agency designated to hear grievance (e.g., thee State Ombudsman) The administrator and staff will make prompt effort to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation: 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Action on such issues will be responded to in writing, including a rationale for the response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to report an allegation of verbal/psychosocial abuse for two residents (#210 and #211) out of twelve residents. Findings included: Review of the facility's policy Identifying Types of Abuse revised date 09/2022 showed, Mental and Verbal Abuse 1. Mental abuse is the use of verbal and non-verbal conduct which cause (or has the potential to cause) the resident to experience humiliation, intimidation, fear , shame, agitation and degradation. 2. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Psychosocial Outcomes 1. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not to be immediately apparent. 2. Abuse may result in psychological, behavioral, or psychosocial outcomes including, but not limited to, the following: a. Fear of a person or place of being left alone, of being in the dark, and/or disturbed sleep and nightmares. During an interview on 04/15/24 12:00 p.m., Resident #210 stated Staff A, CNA this weekend started using the F bomb and stated she was just not doing it over the weekend. Resident #210 stated Staff A, CNA also was on her phone with the earbuds talking to someone about threesomes. Resident #210's Family Representative (FR), present during the interview, also stated I didn't even go to work today, I came in because I am worried about my mom and her care. Resident #210's FR stated when she and Resident #210 reported Staff A, CNA over the weekend to Staff E, Licensed Practical Nurse (LPN) , Staff A, CNA ,after being reassigned, came back into Resident #210's room and asked what she did wrong. Resident #210 stated she felt very uncomfortable and even a little threatened. Resident #210's FR informed Staff A they felt very uncomfortable and Staff A left the room. During an interview on 04/15/24 at 12:15 p.m., Resident #211's family member stated he was certainly grateful for Resident #210 and the FR who spoke up to ensure Staff A, CNA was no longer able to work with Resident #211. Resident #211's family member stated he was not present during the time Staff A, CNA was being disrespectful and verbally aggressive towards Resident #211 but all the information could be obtained by speaking with Resident #210 and Resident #210's FR. Review of the admission Record showed Resident #210 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of femur subsequent encounter for closed fracture with routine healing, cerebellar ataxia in diseases classified elsewhere, polyneuropathy, heart failure and spinal stenosis. Review of the Brief Interview For Mental Status (BIMS) Evaluation dated 04/15/24 showed Resident #210 had a BIMS score of 14 (cognitively intact. During a second interview on 04/15/24 at 2:50 p.m. Resident #210 stated the incident occurred on Sunday 04/14/24. Resident #210 recalled it all started when the roommate (Resident #211) had to go to the bathroom. Resident #210 stated she heard Staff A, CNA yell at Resident #211 saying Don't do that, you are going to make me have to clean {expletive} off the call light pull string. Resident #210 stated Staff A, CNA took Resident #211's wheelchair, shoved it out of the bathroom door and It hit my bed. Resident #210 stated she heard Staff A, CNA state, I don't feel like this {expletive} crap today. Resident #210 stated her FR walked in to visit about that time and was also present in the room. Resident #210 stated Staff A, CNA was on the phone and was talking about :threesomes and cussing. Resident #210 stated both she and Resident #210's FR talked with Staff E, LPN about it and she stated Staff A, CNA would not be coming back into the room. Resident #210 stated after lunch Staff A, CNA came back in to the room to pick up the lunch tray and began interrogating and asking why she was reassigned. Resident #210 stated, It was like she was going to get one more dig in. Resident #210 stated the FR spoke up and informed Staff A the conversation was getting very uncomfortable and Staff A, CNA left the room. Review of the facility's actual working schedule for 04/14/24 revealed Staff A, CNA was assigned to both Resident #210 and Resident #211 for the 6:45 a.m.-3:15 p.m. shift. During an interview on 04/15/24 at 3:12 p.m., the Staffing Coordinator (SC) identified Staff A, CNA as the CNA assigned to Resident #210 and Resident #211's room on 04/14/24. Review of the facility's reportable's for April 2024 showed no reportable for the date of 04/14/24. During an interview on 04/15/24 at approximately 3:20 p.m., the Administrator stated there were no additional reportable's for April. During an interview on 04/15/24 at 3:30 p.m., Staff A, CNA stated she provided care for Resident #210 and #211 on Sunday 04/14/24 until she was reassigned from the room. Staff A, CNA stated she really did not know why she got reassigned and no one gave her any specific reason for the reassignment. Staff A, CNA stated Staff E, LPN came to her and told her she would no longer be working with Resident #210 and Resident #211. Staff A, CNA stated she tried to inquire about why she was reassigned but no one would give her answers. Staff A, CNA stated no one told her she could not go back into Resident #210 and Resident #211's room. Staff A, CNA stated later in the day she was picking up lunch trays and went back into Resident #210 and Resident #211's room when the residents and Resident #210's family representative (FR) acted as if they were stunned and uncomfortable. Staff A, CNA stated the response gave her an uncomfortable feeling as well. Staff A, CNA stated at the time of tray pick, she asked Resident #210 and Resident #210's FR if there was a problem, but Resident's 210's FR stated this was making them very uncomfortable, so she left the room. Staff A, CNA stated no one ever told her she was not allowed to go back into the room, so she apologized to Resident #210 and Resident #210's FR but she still did not understand why everyone felt so uncomfortable. Staff A, CNA stated she tried to inquire a couple more times with staff as to why she was reassigned but no supervisor ever gave her any other information. Staff A, CNA stated she still knows nothing about why her room assignments got changed. During an interview on 04/15/24 at 3:46 p.m., Staff E, Licensed Practical Nurse (LPN) stated on Sunday 04/14/24 she was addressed by both Resident #210 and Resident #211 about Staff A, CNA being on her phone with ear buds and cursing. Staff E, LPN stated she decided to just go ahead and remove Staff A,CNA from Resident #210 and Resident #211's room and replace her with another CNA. Staff E, LPN stated she reported this to the supervisor Staff F, Registered Nurse (RN) who stated she would have a talk with Staff A, CNA. Staff E, LPN stated later Sunday afternoon Staff A, CNA took it upon herself to go back into Resident #210 and Resident #211's room . Staff E, LPN stated she never told Staff A, CNA why she was reassigned because she reported it to the supervisor on duty Staff F, RN. Staff E, LPN stated Staff F, RN was the supervisor and told her she would take care of it. Staff E, LPN stated she reported to Staff F, RN the information about Staff A, CNA cursing and all the actions that Staff A, exhibited towards Resident #210 and Resident #211. Staff E, LPN stated when she spoke with Resident #210 and Family Representative (FR) she was informed Staff A, CNA was cussing, using the F word and talking about threesomes. Staff E, stated she apologized for Staff A, CNA's behavior and informed Resident #210 and Resident #211 that Staff A, CNA would not go back into the room. Staff E, LPN stated she told all this information to Staff F, RN. Staff E, LPN stated that she would have reported this incident but respecting the chain of command she reported it to Staff F, RN who was the supervisor to take the information from there. During an interview on 04/15/24 at 4:20 p.m., Staff F, RN stated on Sunday 04/14/24 Staff A, CNA was reassigned from Resident #210 and Resident #211's room . Staff F, RN stated Staff E, LPN reported concerns that Resident #210 and Resident #211 had about Staff A, CNA. Staff F, ,RN stated she heard there were personality conflicts and since personalities do not always mesh Staff A, CNA's assignment was reassigned. Staff F, RN stated it was reported to her Resident #210 and Resident #211 were unhappy, so Staff E, LPN tried to smooth things over by removing Staff A, CNA from Resident #210 and Resident #211's room. Staff F, RN stated Staff A, CNA was Loud with a Big Personality but stated that is just Staff A, CNA's personality. Staff F, RN stated Staff E, LPN told her about a wheelchair that may have been pushed out of the bathroom while assisting Resident #211 and hit the wall or something and the Residents didn't care for that behavior. Staff F, RN stated she did not follow up with Resident #210 and Resident #211 about Staff A, CNA because she was under the impression Staff E, LPN took care of it. Staff F, RN stated she was never told about Staff A, CNA ever being on the phone or using any profanity. Staff F, RN stated she was a mandated reporter so if Staff E, LPN would have reported anything to her about Staff A, CNA using profanity directed towards residents that behavior would have required her to report it. Staff F, RN stated Staff E, LPN stated that she took care of it. During an interview on 04/15/24 at 4:35 p.m., with the Administrator and the DON, the DON stated she just spoke with Staff F, RN about 20 minutes before meeting with the survey team. The DON stated Staff F, RN just reported to her that Staff A, CNA was reassigned from Resident #210 and Resident #211's room on Sunday 04/14/24 because the Residents didn't care for Staff A, CNA. The DON stated Staff F, RN told DON Staff E, LPN talked with both Resident #210, Resident #210's Family Representative(FR) and Resident #211 and answered a ton of questions and everything seemed fine after that. The DON stated the chain of command for reporting would be for Staff E, LPN to report to Staff F, RN and then Staff F, RN should report to the DON who also identified herself as the Risk Manager. The DON stated if anything was reported to her related to abuse then Staff A, CNA would have been suspended immediately and an investigation would have been initiated. The DON stated that she had not even heard of any concerns related to Staff A, CNA and Residents #210 and #211 until 20 minutes prior to meeting with the survey team. During an interview on 04/15/24 at 4:45 p.m., Resident #211 stated on Sunday 04/14/24 Staff A, CNA was cussing. Resident #211 stated she could hear Staff A, CNA talking to someone on the phone. Resident #211 stated she could hear Staff A, CNA Talking about me. Resident #211 stated It didn't make me feel very good but what could I do? Resident #211 stated, I am blind with 1% vision in one eye and only about 7% in the other eye (legally blind). Resident #211 stated, I was afraid when Staff A, CNA was acting like that. Review of the admission Record revealed Resident #211 was admitted to the facility on [DATE] with diagnoses that included acute bronchitis, weakness, unspecified falls, unspecified visual loss, depression and anxiety disorder. Review Resident #211's care plan showed the following: Focus: Resident has experienced a traumatic event that could lead to manifestation of Post Traumatic Stress Disorder (PTSD) or other psychosocial issues change in health status, loss of past roles. The goal included: Resident will have minimum negative changes in thinking and mood through next review. The Interventions included: Allow resident to make decisions, encourage resident participation in activities of choice, encourage resident to express emotions in a safe, private environment, provide reassurance and reorientation to facility, staff, and current situation as needed and refer to counseling/psych as needed. Focus: Resident #211 has an alteration in visual function diagnoses of glaucoma, diagnosis legally blind. Resident #211is at increased risk for falls with visual deficiencies at risk for malnutrition with visual deficiency. The goal showed, Resident will remain safe in the surrounding environment thru the next review date with assist form staff. The interventions included: administer medication as ordered, administer eye gtts (drops) as ordered, provide adequate lighting, provide assist with ADL tasks as needed, maintain a safe environment; notify resident of changes in environment as needed, provide verbal cues to locate objects or navigate in the environment, read written material to resident as needed. Review of the Brief Interview For Mental Status (BIMS) Evaluation dated 04/15/24 showed Resident #211 had a BIMS score of 13 (cognitively intact). During an interview on 04/16/24 at 4:35 p.m., The Regional Nurse Consultant (RNC) stated she thought Staff A, CNA's behavior was unprofessional and inappropriate, but she did not see it as abuse. The RNC stated she would have handled it differently than this administration and would have fired Staff A, CNA for the behavior. During an interview on 04/17/24 at 8:23 a.m., the DON stated all the staff know they are to report accurate information up the chain, so as the Risk Manager she is able to obtain accurate information to report an allegation and it can be handled properly. The DON stated she believed this was not abuse just a case of bad customer service. Review of facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised date 2021 showed, Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation 3. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to one resident (#45) out of ten residents sampled. Finding Include: On 4/15/2024 at 10:30 AM., Resident #45 was observed laying down in his bed dressed in a red shirt and newspapers spread out all over his bed. Resident #45 was not able to communicate his needs. On 04/16/204 and 4/17/2024, at 11:00 AM., Resident #45 was observed laying down in his bed, dressed in the same red shirt for 3 days in a row. The same newspapers were observed for 3 days spread out all over his bed. Resident #45 was not able to communicate his needs. Review of the medical record showed Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include but not limited to Autistic Disorder, Chronic Kidney Disease Stage 3, other mechanical complication of other Urinary Devices and Implants, Sequelae, and Down Syndrome, unspecified. Review of a Quarterly Minimum Data Set (MDS) ARD/ Target Date 2/20/2024, showed in section C0100 no was answered indicting Resident #45 is rarely/never understood and a Brief Interview for Mental Status should not be conducted. Further review of section C100 showed Resident #45 was severely cognitively impaired. Review of Resident #45's care plan showed the following: Focus: Resident having a self-care deficit with dressing, grooming, bathing related to r/t: cognitive deficit, diagnoses of down syndrome, autism, generalized weakness, limited endurance visional limitations, Resident requires staff assistance/ cueing to participate with ADL's (Activity of Daily Living). Date initiated: 08/08/2018 and revised on: 01/26/2023. Interventions for providing hands-on assistance with dressing, grooming, bathing as needed, observed for decline in ADL function; report to the physician as indicated. Date initiated 08/08/2024 and revised on 01/26/2024. Review of the medical record showed no documentation to support Resident #45 had an ADL decline or behaviors with refusing ADL care. During an interview on 04/17/2024 at 11:00 AM., with Staff M, Certified Nursing Assistant, (CNA), she stated she stated at the facility two weeks ago and she was caring for Resident #45. She stated she had not completed full ADLs on Resident #45 because she really doesn't know all his care needs. She stated she had emptied his catheter and did not change the resident shirt from the night because she thought the night shift staff took care of dressing the resident. She stated she did not know what type of care the resident needed. She stated, I usually work on the other hall. During an interview on 04/17/2024 at 11:20 AM., with Staff N, License Practical Nurse (LPN), she stated when she first starts her shift at 7:00 AM., she does rounds to ensure all her residents are safe, and their beds are in low positions. If a resident is awake, she asks them if they are experiencing any pain. She said she checks on residents who are incontinent to make sure they are dry and clean. She stated she had been assigned to Resident #45 for the last three days but was not aware that he had the same shirt on for three days in a roll. She stated it was an oversight on her behalf and she will assist the resident immediately with his care. She stated her expectations are CNA's should make sure that ADL care is provided to their residents every day and residents are provided with clean clothes. If a CNA is experiencing problems with a resident they should notify her so she can assist them by using a different approach to provide care for the resident. She stated Resident #45 has not had any behavior reported to her during the days she has worked with him as his nurse. During an interview on 04/18/2024 at 2:00 PM., with the Director of Nursing, DON, she stated her expectation is that residents have ADL's performed on them every day. If staff are dealing with a resident refusing ADL care, then they report it to their nurse so the nurse can document the resident's behavior and provide further assistance. She stated no resident should be left in the same shirt for three days. Review of the facility policy titled, Activities of Daily Living (ADL's) Supporting, revised 03/2018 showed the following: Resident will be provides with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) has a debilitating diseases with known functional decline; (2) has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/or (3) refuses care and treatment to restore or maintain functional abilities and: a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; and b) he or she has been offered alternative intervention to minimize further decline; and c) the refusal and information are documented in the resident's clinical record. 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. 4. If resident with cognitive impairment or dementia care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure proper orders and documentation were in the medical record for two residents (#10 and #255) out of twenty-nine sampled residents. Findings included: Review of Resident #10's care plan showed she was receiving hospice services. Review of Resident #10's physician orders did not show an active order in place for hospice services. There was a previous order for hospice, dated 5/31/22, which was discontinued on 6/6/22. Review of admission records showed Resident #10 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including dementia, psychotic disturbance, anxiety, and malnutrition. Review of Resident #10's hard chart and electronic medical record showed no documentation or notes from hospice services. An interview was conducted on 4/17/24 at 10:05 a.m. with Staff Q, Licensed Practical Nurse (LPN). She said Resident #10 was receiving hospice services. She pulled out the resident's hard chart and showed the hospice team and contact information noted on Resident #10's chart. When asked if the resident had an order for hospice she said Oh it's there she has been on hospice a long time. Staff Q reviewed Resident #10's medical record and confirmed there was no order for hospice services. Staff Q said maybe Resident #10 was disenrolled from hospice because she didn't meet the criteria any longer. When asked where notes are from hospice visits, Staff Q said she isn't sure hospice leaves any notes. An interview was conducted on 4/17/24 at 10:21 a.m. with Staff H, LPN/Unit Manager (UM). She said Resident #10 is hospice but she wasn't sure where hospice notes are. She said they may be in the Director of Nursing's (DON) office. An interview was conducted on 4/17/24 at 10:28 a.m. with the DON. She confirmed Resident #10 was on hospice. The DON said hospice notes should be scanned into the medical record. She reviewed the record and was unable to find any hospice notes or documentation for Resident #10. The DON also confirmed there was no physician order for hospice for Resident #10. The DON checked the facility's previous charting system in case the information didn't transfer to the new system. She said she could only find the order that was discontinued in 2022. The DON said an order should be in Resident #10's medical record. She also said hospice notes should be in the record, so the resident's nurses are able to view them. Review of lab results for Resident #255 showed he had a critically low hemoglobin level on 4/9/24. The Lab Results Report showed the lab was collected on 4/9/24 at 7:02 p.m. and the facility's laboratory servicing company was notified of the critical lab result on 4/9/24 at 8:57 p.m. The lab results showed they were faxed to the facility on 4/9/24 at 9:08 p.m. Review of the admission Record showed Resident #255 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the kidney, history of transient ischemic attach and cerebral infarction, and anemia. Review of Resident #255's progress notes did not show any documentation a provider was notified of the critical lab values on 4/9/24. There was a progress note dated 4/10/24 at 7:08 a.m. showing the lab called about critical lab results for Resident #255, the resident's primary care nurse practitioner (NP) was notified, and she gave orders for the resident to be sent to the hospital. An interview was conducted on 4/18/24 at 10:50 a.m. with the DON. The DON reviewed Resident #255's medical record and noted the order for STAT (immediate) labs was placed on 4/9/24 at 10:42 a.m. When asked why it took almost 8 ½ hours for STAT labs to be drawn, the DON stated, STAT labs have been challenging at times. She said STAT labs should have results within 4-6 hours of being ordered. The DON confirmed there was no documentation showing a provider was notified of the critical lab values. She said she knows the nurse spoke with the NP but there should be documentation in the record. An interview was conducted on 4/18/24 at 11:25 a.m. with Staff R, Medical Records. She confirmed all facility records for Resident #255 had been scanned into his electronic medical record and there are no additional closed records or hospice notes. An interview was conducted on 4/18/24 at 11:59 a.m. with Resident #255's primary care NP. She said she didn't know what the deal was with the labs, but STAT orders should be drawn within 4 hours and results are typically back within two hours after that. Review of a facility policy titled Hospice Program, revised July 2017, showed the following: Policy Statement Hospice services are available to residents at the end of life. Policy Interpretation and Implementation 9. In general, it is the responsibility of the hospice to manage the resident's care as it related to the terminal illness and related conditions, including: . c. Providing medical direction, nursing, and clinical management of the terminal illness. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriate based on the individual resident's needs. Review of a facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, reviewed November 2018, showed the following: Options for Physician Notification 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis,etc. Review of a facility policy titled Charting and Documentation, revised July 2017, showed the following: Policy Statement All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure foot care was provided when needed for one resident (#69) out of one residents sampled. Findings included: During a facility tour on 04/15/24 at 10:10 a.m., Resident #69 was observed in his bed. His toe nails were observed with dark nail beds and black residue around the toe nails. An immediate interview was conducted with the resident who did not know what was wrong with his feet or toenails. He asked this surveyor what they looked like. He said, Lady, I am blind. I have not seen my feet or nails. He stated he did not know if the staff were applying anything to his feet. Review of a Primary Care Physician (PCP) progress note, dated 02/07/24, showed Resident #69 had a follow up visit chief complaint, At risk patient with long thickened painful nails. Patient is seen today for treatment of painful and thickened toenails bilateral feet. Patient has pain secondary to thickening and dystrophy of the infected (mycotic) nail plate. Thickening and dystrophic nail has been present for many months. Debridement of the nails has helped previously to control pain and inflammation of periungual nail borders. The patient has a reoccurrence of pain as the nail grows and becomes thickened . The plan note showed Nursing staff to contact me immediately if any erythema, purulence, or other signs of infection be present, otherwise patient is to be seen in 6-8 weeks. Review of the Electronic Medical Record (EMR) for Resident #69 did not show the physician had been contacted or had seen this resident since the visit in February. Review of April 2024 physician orders for Resident #69 conducted on 04/15/24 at 11:00 a.m. showed the resident did not have active treatment orders for his skin condition. Review of the admission record showed Resident #69 was admitted to the facility on [DATE] an initial admission date of 05/13/22 with diagnoses of Type 2 Diabetes Mellitus (DM), unspecified malnutrition, blindness right and left eye category 5,and Cerebral Vascular Accident (CVA). Review of a care plan for Resident #69, dated 05/31/23, revealed the resident had an alteration in visual function, with interventions to provide ADL tasks as needed and to provide verbal cues to locate objects or navigate in the environment. A self-care focus showed the resident had a grooming deficit with .grooming related to generalized weakness, DM, CVA and chronic pain. Interventions included providing hands-on assistance with dressing, grooming, and bathing. Review of Resident #69's weekly skin assessments for the months of March and April 2024 showed four documents were completed indicating the resident's skin condition was normal. On 04/13/24 skin condition is normal, dry, flaky, and fragile. On 04/06/24 skin condition is normal, dry, flaky, and fragile. On 03/30/24 skin condition is normal. On 03/23/24 skin condition is normal, dry, flaky, and fragile. On 03/16/24 skin condition is normal, dry, and fragile. On 04/18/24 at 09:18 a.m., an interview was conducted with Staff L, Registered Nurse (RN) she observed Resident #69's feet and stated the resident should be getting skin prep. She stated she would review his chart. Staff L followed up with this surveyor at 09:54 a.m. and stated they just ordered a cream for his feet. She stated the physician ordered Ammonium Lactate External Cream 12% to be applied to bilateral legs and feet every shift. She stated Resident #69 was on the list to be seen by the podiatrist next time he was in the building. Staff L, RN reviewed the electronic medical record and confirmed she could not find podiatry notes for this resident. An interview was conducted on 04/18/24 at 10:02 a.m., with Staff H Licensed Practical Nurse (LPN) She stated the resident was seen by his PCP on 02/7/24. The UM stated she did not know if he had been seen by a podiatrist since his admission. She stated she had not seen the resident's feet and did not know the condition they were in. She stated she was not aware there were any concerns. On 04/18/24 at 10:59 A.m. an interview was conducted with the Assistant Director of Nursing (ADON). She said, As a nurse they [nurses] should do skin checks and report any concerns, or the CNAs to report any skin impairments. The ADON reviewed residents skin assessments with surveyor and noted they indicated normal skin. She stated if a resident had any kind of skin impairment, it should be documented. She stated she would assess the resident herself. On 04/18/24 at 12:59 p.m. an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON stated the resident should have been seen by podiatrist. She said, There should be notes. She reviewed the skin assessments with surveyor showing normal skin assessments were documented without any noted impairments. She stated she would follow-up. Review of a facility policy titled, Fingernails/Toenails, Care of, dated February 2018, showed the purpose of this procedure are to clean the nail bed, to keep nails trimmed, to prevent infections. Under general guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulator impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding etc. 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not accommodate dietary preferences related to alternate meal requests for four residents (#351, #18, #352, and #86) out of 13 sampled residents. Findings included: 1. On 04/15/24 at 10:31 a.m. an interview was conducted with Resident #351 who stated food was not palatable. He said sometimes the food is cold. He described the supper last night, which was lima beans, carrots, and what he described as broth (but was supposed to be soup), fruit from a can, and no bread/crackers. He stated dietary comes by to get choices, but they never bring what he wants. He said follow up is nonexistent. On 04/15/24 at 12:52 p.m. resident #351 said, The food {expletive}. I don't like anything. He stated the food has no seasoning/salt. He described the lunch as very bland. The resident stated he was not offered an alternative even though he doesn't like the options. During the interview the roommate stated nobody asked if he wanted an alternate meal choice and he didn't know he could ask for an alternative. Review of the admission record showed Resident #351 was admitted to the facility on [DATE] with a diagnoses of dehydration, and dysphagia. Review of Resident #351's admission Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 12, intact cognition. Review of April 2024 physician orders for Resident #351 showed the resident received a regular texture diet, thin consistency, large portions with breakfast and fortified foods with meals for nutrition. Review of Resident #351's care plan, dated 03/29/24, under the nutrition focus showed the resident has an alteration in nutrition related to a variable PO (by mouth) intake. The goal, revised on 04/12/24, showed honoring resident's food preferences. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. 2. On 04/17/24 at 12:42 p.m. Resident #18 was observed during lunch service. The resident stated to Staff G, Certified Nursing Assistant (CNA) that was not what he wanted. He said, I don't want the soup. I wanted two sandwiches. I ordered this last night. During the observation, the resident's tray was noted without sandwiches. Resident #18 stated he put in his request the night before. Resident#18 said, It happens all the time. During the interview Staff H, Licensed Practical Nurse (LPN)/ Unit Manager (UM) stated she would get him a sandwich. She said, It should have been on the tray if he asked the night before. Review of the admission Record for Resident #18 showed the most recent admission date of 10/19/22 and an initial original admission date of 03/01/19, with a diagnoses morbid severe obesity and Type 2 Diabetes Mellitus. Review of Resident #18's MDS, dated [DATE], revealed in Section C-Cognitive and Patterns BIMS score of 15, intact cognition. Review of the April 2024 physician orders for Resident #18 did not show the resident's dietary orders. Review of resident #18's care plan, initiated on 08/25/20 under the focus of nutrition showed the resident has an alteration in nutrition related to a therapeutic diet with a history of changing dislikes and preferences often. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. 3. An interview was conducted with Resident #352 on 04/15/24 at 12:48 p.m. Resident #352 stated he doesn't like the food as it's not food he normally would eat. He said, When I request food as an alternate choice, I do not get what I want. Review of Resident #352's meal ticket, dated 04/29/24 sic (04/15/24), revealed the resident was served mushroom gravy, steamed summer squash, pureed black-eyed peas, dinner roll buttered, mechanical/altered ground orange gelatin (photographic evidence was obtained). During the observation, the resident stated this is not what he ordered and he did not like any of these meal items. Review of the admission Record showed Resident #352 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease stage 4. Review of the April 2024 physician orders for Resident #352 showed the resident received a mechanical soft texture diet, thin consistency, no straws for nutrition. Review of Resident #352's care plan, dated 04/15/24, under the focus of nutrition showed the resident has an alteration in nutrition related to a variable oral (PO) intake. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. 4. An interview was conducted on 04/15/24 at 10:50 a.m. with Resident #86. Resident #86 stated she generally likes the food; however, she doesn't ask for an alternate if she doesn't like the option. Resident #86 stated, She did not know she could ask for an alternate option. Review of the admission Record for Resident #86 showed an admission date of 08/25/23 with diagnoses to include noninfective gastroenteritis and colitis and constipation. Review of Resident #86's Quarterly MDS, dated [DATE], revealed in Section C-Cognitive and Patterns a BIMS score of 99, indicating the resident was not interviewable. Review of the April 2024 physician orders for Resident #86 showed the resident received a regular texture diet, thin consistency, and super cereal with breakfast for nutrition. Review of Resident #86's care plan, dated 08/26/23, under the focus of nutrition showed the resident has an alteration in nutrition related to a variable PO intake. Interventions included providing diet as ordered, providing alternate as needed, and honor food preferences. An interview was conducted on 4/18/24 at 6:09 p.m. with the Dietary Manager (DM). The DM stated she was responsible for interviewing residents and collecting their food preferences. The DM stated during the 3pm-11pm shift, the CNAs collect the food preferences from the residents. The DM stated she gives the food preferences interview to the Registered Dietitian (RD-1), who puts the information into the meal tracker system. The DM stated the meal tracker system is a new system. She stated the meal tracker system is not interfaced completely, therefore, there have been some issues with residents not getting their preferences and alternate choices. The DM stated she was aware there was an issue, which was identified a month and a half ago. She stated she was aware residents have been reporting they were not receiving the options they wanted, despite being asked the day prior by staff. She stated she brought this concern up during their morning staff meetings. She said, I am keeping the food preferences and substitute paper from the residents who are saying they are not getting the food choices they want. The DM stated she was monitoring their process. Review of the facility's policy titled, Dining and Food Preferences, dated October 2019, showed it is a center policy that individual dining, food, and beverages preferences are identified for all residents/patients. Under action steps, (6.) The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal pan into the plan of care, (7.) The individual tray assembly ticket will identify allergies, food and beverage preferences or special requests, and adaptive equipment as appropriate, (8.) Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value, (9.) The alternate meal and/or beverage will be provided in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure four dependent residents (#45, #43, #69, and #72) were provided with activities out of ten residents sampled. Findings Include: Multiple observations were made on 4/15/2024 at 10:00 a.m., 1:00 p.m., and 4:00 p.m., showing Resident #45 laying down in his bed dressed in a red shirt and newspapers spread out all over his bed. Resident # 45 was not able to communicate his needs. During an observation made on 04/16/204 at 10:30 a.m., and at 3:00 p.m., and on 4/17/2024 at 11:00 a.m. Resident #45 was observed laying down in his bed, dressed in the same red shirt for 3 days in a row. The same newspapers were observed for 3 days spread out all over his bed. Resident # 45 was not able to communicate his needs. Review of the medical record showed Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Autistic Disorder, Chronic Kidney Disease Stage 3, other mechanical complication of other Urinary Devices and Implants, Sequelae, and Down Syndrome, Unspecified. Review of a Quarterly Minimum Data Set (MDS) ARD/ Target Date 2/20/2024, showed in section C0100 no was answered indicting Resident #45 is rarely/never understood and a Brief Interview for Mental Status should not be conducted. Further review of section C100 showed Resident #45 was severely impaired. Review of Resident #45's care plan showed the following: Focus: The resident is at risk for decreased social interaction/ activity participation, due to severe cognitive impairment, fluctuating responses to external stimuli do to (d/t) down syndrome, autistic, limited verbalization, impaired physical mobility, dependent on staff for all needs. Interventions: to provide cues and assist to complete tasks while in activity programs as needed. Activity staff to provide in room [ROOM NUMBER]:1 visit, including sunshine visits, various tactile activities. During an interview on 4/18/2024 at 2:00 p.m., with the Activities Director, he stated he creates his activity program from the information he gathers from residents upon admission and from resident council meetings. He stated room visits are done every day for wellness checks around 4 or 4:15 p.m. every day. He stated he had not provided any activities or room visit for Resident #45 all week because he was too busy. During multiple facility tours on 04/15/24 from 09:58 a.m. to 2:30 p.m. Resident #72 was observed in the dining room sitting at a table by himself. The resident was not interacting with anyone. The resident was not participating in any activities. On 04/15/24 at 02:21 p.m. Resident #72 was observed still sitting in the dining room at the same spot. The resident was observed growing restless, noted standing, looking around and then sitting down. Resident was noted to be confused. Review of the admission record showed Resident #72 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of resident #72's Care Plan, dated 03/20/24, showed a focus indicating Resident #72 was at risk for decreased social interaction/activity participation related to dementia with interventions to include assist with television programs, provide monthly activity calendar in room, encourage social interactions with staff and peers and to encourage family/loved ones to ring music, television etc. for stimulation. A focus in the care plan showed Resident 372 has severe cognitive deficits and does not respond to verbal or tactile stimuli with interventions for activities' staff to provide in room [ROOM NUMBER]:1 visits, music etc. Resident #72 has an alteration in communication ability related to does not communicate needs at all, does not speak English; primary language is: Polish Interventions: included to ask resident yes/no questions, provide interpreter as needed, ask family to interpret as able and for staff to anticipate need and verify with resident as able. On 04/15/24 at 02:35 p.m. an interview was conducted with Staff G, Certified Nursing Assistant (CNA). She stated the resident spoke Polish. She said, He is hard to understand. I did not ask him if he wanted to leave the dining room or if he needed to use the restroom. He is sometimes resistive. Residents should be checked on at least every 2 hours. On 04/15/24 at 2:40 p.m. an interview was conducted with Staff J, Registered Nurse (RN). She confirmed seeing Resident #72 in the dining area all morning. She stated she had seen him since 11 a.m. On 04/15/24 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON). She stated their residents should be attended to at least three times per shift. During multiple tours on 04/16/24 and 04/17/24 Resident #72 was observed in the dining room seated at a table by himself without interaction. The resident was not engaged in any activities. During multiple tours on 04/15/24, 04/16/24, and 04/17/24, Residents #69 and #43 were observed laying in their beds without a television or radio on. The residents were observed in their room without activities or social interactions. Review of the admission record showed Resident #69 was admitted to the facility on [DATE] an initial admission date of 05/13/22 with diagnoses of blindness right and left eye category 5, and Cerebral Vascular Accident (CVA). Review of a care plan, dated 05/16/22, revealed Resident #69 was at risk for decreased social interaction/activity participation related to being legally blind. Activity preferences indicated Resident #69 had impaired physical mobility and enjoyed listening to fishing shows, national geographic, music and family visits. Interventions included providing assistance with television programs of choice. Providing monthly activity calendar in room, encourage social interactions with staff and peers and to encourage family/loved ones to bring in music, television for increased stimulation. Review of the admission record showed Resident #43 was admitted to the facility 11/21/23 an initial admission date of 04/30/23 with diagnoses of dementia. Review of a care plan, dated 02/28/24, showed Resident #43 was capable of pursuing his own activities with motivation and encouragement. Resident prefers to watch television, spend time with families and listening to music. Interventions included determining which individual activities [Resident #43] preferred and provide any related materials, to provide monthly calendar in room, invite to daily activities of choice and encourage resident to voice needs and concerns related to independent leisure tasks as needed. On 04/18/24 at 1:20 p.m. an interview was conducted with the Activities Director. He stated a lot of times he tried to conduct 1:1 activities in the afternoons. He stated the wellness check in the activity's calendar meant 1:1 activities. He stated he would see the ones who would like an activity brought to them such as magazines or books or just a conversation. The Activities Director said, I have a spreadsheet with listed name of the residents. I don't write the specific names of the residents who participated. I am not charting an individual's participation. I just tally the count. He stated he had an assistant but would normally be by himself on Mondays and Tuesdays. He stated the assistant worked weekends by herself. The Activities Director said, It can be a lot. The Activities Director confirmed he had not checked on Residents #69, #43 and #72 all week. He said, [Resident #69] enjoys just being in his room watching TV or listening to the radio. It should be on. You are right. I did not check on him this week. [Resident #43] does come out. When is out, he participates in activities with encouragement. I have not seen him this week. A family member visits and gets him out. I have not seen him this week. I did not get around to see him. I could have asked the CNAs to get him up. I did not get to it. [Resident #72] is in the dining room a lot. I have not seen him participate in any activities. I tried to get him into Polish activities like music. I have not figured him out yet. I know he has a language barrier. He sits and watches people. It is not realistic to engage all the residents. I have quite a few that do not come out of the rooms. I try my best. Review of the facility policy titled, Activity Programs, revised June 2018, showed Activity programs are designed to meet the interest of and support the physical, mental and psychological well-being of each resident. 1. The activity program is provided to support the well-being of residents and to encourage both independence and community interaction

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a relicensure and complaint survey that was conducted on 4/15 - 4/18/24 and was cited at F880. On 6/11/24 a revisit survey was conducted, and the facility was recited at F880. The facility had developed a Plan of Correction with a completion date of 5/18/22. During the revisit survey the facility failed to 1. ensure staff members observed transmission-based precautions correctly related to the use of Personal Protective Equipment (PPE) for one (#1) out of 18 residents diagnosed with COVID-19, failed to appropriately dispose of PPE after assisting one (#2) out of 18 residents with transferring, failed to appropriately clean and disinfect a mechanical lift used for multiple residents, and 2. failed to ensure the catheter drainage bag of one (#45) out of three residents sampled for the implementation of privacy bags was stored in a clean and sanitary manner. Findings included: 1. The facility developed a plan of correction that included: The facility identified residents on transmission based precautions on 4/16/2024 and 4/17/2024 verified signage and Personal Protective Equipment (PPE) on door. The facility developed a plan of correction that included: Staff education PPE for transmission-based precautions provided by DON/Designee 5/10/2024. Isolation audits before and after resident contact will be completed daily for 1 week, weekly for 4 weeks, and monthly for two months or until the QAPI committee determines substantial compliance. On 6/11/24 at 10:02 a.m., an observation was made on one of four hallways of room [ROOM NUMBER] with an open lidded trash bin, containing blue precaution gowns, and a three-drawer storage unit located outside the room and in the hallway. The observation revealed room [ROOM NUMBER] was posted (on the door) for Enhanced Barrier Precautions (EBP). Photographic evidence was obtained. On 6/11/24 at 10:04 a.m., an observation was made of a healthcare professional dressed in gray scrubs standing against the bed of Resident #1. The observation revealed the door to Resident #1's room was posted with a red sign showing Droplet Precautions and in the hallway next to the doorway of the room was a trash bin containing blue precaution gowns and a three-drawer storage unit containing procedural masks and blue precaution gowns. The staff member was standing next to an over-bed table which a clipboard and a tablet which the staff member was observed utilizing with bare hands. Photographic evidence was obtained. During an observation on 6/11/24 at 10:04 a.m., Staff A, Certified Nursing Assistant was seen leaving room [ROOM NUMBER] (across hall from Resident #1's room). The staff member was observed [NAME] up a blue precaution gown, walked across the hallway, and disposed the gown into the trash bin next to Resident #1's room. The door to room [ROOM NUMBER] was posted with a red sign Droplet Precautions with a trash bin inside the room next to the door. A few moments later Staff A and Staff B, CNA, dressed in gown, gloves, and masks then entered room [ROOM NUMBER]. On 6/11/24 at 10:15 a.m., Staff B pushed a mechanical (Hoyer) lift from room [ROOM NUMBER] into the hallway. The staff member stated the lift had been cleansed with hand sanitizer prior to bringing it into the hallway and had to get bleach wipes from the nurse for Staff A to clean it. Staff C, Registered Nurse (RN), removed a bleach wipe from the medication cart and handed the wipe to Staff B, who hung it on the handle of the lift. Staff A was seen in the room making Resident #2's bed. On 6/11/24 at 10:18 a.m., the healthcare professional, Staff D, dressed in gray was observed into the bathroom of room [ROOM NUMBER] as running water could be heard. The staff member came out of the bathroom, wiped her hands with a brown paper towel, she placed the clipboard and tablet in her arms and held them against her torso while she spoke with Resident #1. Staff D, left room [ROOM NUMBER] and revealed self as a (named) physician's Registered Nurse (RN) and not a staff member of the facility. Staff D reported not knowing the room was posted for Droplet Precautions and should have been wearing (a) gown and gloves. Staff D stated next time I'll pay attention. On 6/11/24 at 10:24 a.m., Staff C stated it was not appropriate to clean the mechanical lift with hand sanitizer. The staff member stated the lift should have been left in the room, staff members should have gotten a bleach wipe to clean it (before leaving room) as they could not leave bleach wipes in the hallway. Staff C reported not seeing if Staff D had been wearing PPE or not but should have been. On 6/11/24 at 10:26 a.m., Staff A came out of room [ROOM NUMBER] dressed in a blue PPE gown, took the gown off in the hallway, crossed the hall, and placed it in the trash bin outside of room [ROOM NUMBER]. An interview was conducted with Staff A on 6/11/24 at 10:28 a.m., the staff member stated the reason for throwing PPE away in the bin across the hall (next to room [ROOM NUMBER]) was they did not have a bin in room [ROOM NUMBER]. The staff member viewed the trash bin next to the door in room [ROOM NUMBER] and stated they did not use that one for isolation, they used the one outside of room [ROOM NUMBER]. The facility revealed an outbreak of COVID was ongoing and currently had 18 positive residents. The floor map, provided by the facility, where observations were made had 12 rooms, which had 6 rooms with Droplet precautions, one room with consequent Contact, one room with Enhanced Barrier precautions, and three additional rooms with Enhanced Barrier Precautions (EBP). The map showed 9 out of the 12 rooms had assigned precautions. Review of the list of COVID positive residents included Resident #1 and Resident #2. Review of Resident #1's admission Record showed the resident was admitted on [DATE] and diagnoses included acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, and acute pulmonary edema. The physician order summary for the resident revealed an order for Maintain Droplet Precautions for COVID+ for 10 days, every shift for COVID + for 10 days, started on 6/3 and to end on 6/13/24. Review of Resident #2's admission Record showed the resident was admitted on [DATE] and diagnoses included chronic diastolic (congestive) heart failure, localized edema, and nasal congestion. The review of Resident #2's physician order summary revealed an order for Droplet isolation for COVID 19 one time only until 6/13/24, started on 6/3/24 and Enhanced Barrier precaution for Infection control intervention related to (r/t) wounds, started on 4/18/24. The facility provided signage for Droplet Precautions and Enhanced Barrier Precautions. The Droplet sign revealed STOP ATTENTION STOP Please carefully review the instructions Below. EVERYONE MUST: Clean their hands, including before entering and when leaving the room with Alcohol-based Hand Rub (ABHR). PPE Requirements: Gown and (&) Gloves, Face Shield or Goggles, N95 or higher-level respirator must be worn at all times while in patient room. The Enhanced Barrier sign revealed STOP ENHANCED BARRIER PRECAUTIONS STOP EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care of use: central line, urinary catheter, feeding tube, tracheostomy, (and/or) Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an interview, on 6/11/24 at 12:44 p.m., the Infection Preventionist (IP) stated N95's (mask), gown, gloves, and eye protection were to be worn for Droplet precautions and glasses were not considered eye protection, a face shield or goggles should be worn. The IP stated the observation of Staff D wearing a surgical mask and no other PPE (in room [ROOM NUMBER]) was not appropriate, PPE should be thrown away inside the room, and trash bins were inside the room. The IP reviewed photos taken of the trash bins in the hallway outside of room [ROOM NUMBER] and 49 then stated they should not be in the hallway, staff should remove everything (PPE) before coming into the hallway and while outside to use hand sanitizer. The IP stated the expectation was for staff to take off PPE while in the room and garbage bins were to be inside the room to dispose of the PPE. Regarding the process for cleaning the mechanical lift, the staff member stated staff were to remove PPE, leave the lift in the room, get wipes, don PPE, clean the lift, and then remove it from the room. The IP stated hand sanitizer was absolutely not to clean equipment. The IP reported educating (staff) on COVID outbreak, the education contained don/doffing PPE and did not put in writing but did tell them to doff (remove) inside the room and all trash bins were to be kept in the room. The IP stated the facility had completed audits for use of PPE. During an interview on 6/11/23 at 3:20 p.m., the Director of Nursing (DON) stated she had spoken with the Medical Director regarding Staff D, his nurse who was observed on the unit. The DON stated Staff D needed to wear PPE appropriately according to Transmission Based Precautions (TBP). She said all garbage cans were to be inside the rooms. Originally the garbage cans were outside the room because the facility did not have enough when the EBP were started. The only explanation for trash bins outside in the hallway was to get residents or lifts out of the room. The DON stated hand sanitizer was not appropriate to use to clean a mechanical lift. The policy- Infection Control, revised October 2018, revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The interpretation and implementation of this policy included the following: 1. The facilities infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, in the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control for infections in the facility; b. Maintaining safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission based precautions; e. Maintain records of incidents and corrective actions related to infections; and f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. 3. The quality assurance and performance improvement committee, through the infection control committee, shall establish, review, and revised infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 5. The administrator or governing board, through the quality assurance and performance improvement and the infection control committees, has adopted the infection control policies and practices. Inquiries concerning our infection control policies in the facility practices should be referred to the infection preventionist or director of nursing services. The policy, Isolation-Categories of Transmission-based Precautions, revised September 2022, revealed Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The interpretation and implementation of the policy showed: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2. Transmission based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door, and on the front of the chart so that the personnel and visitors are aware of the need for in the type of precaution. a. The signage informs the staff of what type of centers for Disease Control and prevention (CDC) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. a. If reuse of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. The section of policy, Droplet Precautions explained Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets [larger than five microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 3. Are worn when entering the room. 4. Gloves, gown and goggles are worn if there is a risk of spraying respiratory secretions. The policy - Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, showed resident care equipment, including reasonable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 6. Reusable resident care equipment is decontaminated and/ or sterilize between residents according to manufacturer's instructions. 9. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident. 2. On 6/11/24 at 11:16 a.m., Resident #45 was observed in bed with multiple magazines/newspapers, an empty catheter privacy bag was hanging from the side of bed facing the door. The observation revealed the resident's catheter bag appeared to be lying on the floor on the opposite side of the bed. The resident did not engage verbally with this writer. The resident's room was posted for Droplet precautions and resident was included on list of COVID+ residents. On 6/11/24 at 11:30 a.m., Staff E, Occupational Therapist (OT) was observed dressed in PPE in hallway standing next to the door of the room next to Resident #45. The catheter bag for Resident #45 was observed lying in the same area previously viewed at 11:16 a.m. on 6/11/24. The OT stated it did appear the catheter bag was on the floor, the staff member entered the room and picked the drainage bag off the floor and moved it, saying it must have fallen. Staff E stated it (drainage) bag appeared to be on the floor but had a privacy bag. An interview was conducted on 6/11/24 at 12:03 p.m. with Staff F, Licensed Practical Nurse/Unit Manager (LPN/UM) and Staff G, Certified Nursing Assistant (CNA). Staff F stated Resident #45 moved around a lot and (the drainage bag) must have fallen off during that time. Staff F reported no the catheter bag should not be on the floor. Review of Resident #45's admission Record revealed the resident was admitted on [DATE]. The review revealed the resident's diagnoses included COVID-19, Autistic disorder, sequela other neuromuscular dysfunction of bladder, and other mechanical complication of other urinary devices and implants. A review of Resident #45's care plan on 6/11/24 at 12:13 p.m., revealed: -Resident #45 had an alteration in elimination as evidence by (AEB): is incontinent of bowel, cognitive impairment related to (r/t) diagnosis (dx) of autism, Down Syndrome. Has a suprapubic catheter r/t urinary retention neurogenic bladder. Requires staff assist with toileting/incontinence care needs, has history (hx) recurrent Urinary Tract Infections (UTI). Hx of Nephrolithiasis/Chronic Kidney Disease. This history showed the care plan changes prior to completion of last review, dated 2/28/24. The history showed Staff H, MDS Coordinator, revised the above focus on 6/11/24 to include Noted to touch and reposition foley catheter bag. Photographic evidence obtained. The interventions related to the resident's suprapubic catheter revealed care instructions and to Maintain closed drainage system and keep drainage bag below level of the bladder, provide catheter privacy bag. - Resident had a self-care deficit and at times refused Activities of Daily Living (ADL) care with changing clothes, continent care, can try to hit when ADLs are being done, refuses to have anyone but sister shave (pronoun), (and) prefers to stay in bed, revised on 1/26/23. This focus did not show a behavior related to repositioning catheter bag to the floor. -Resident prefers to deviate from plan of care regarding refusal of ADL care, may try to hit staff providing care, refusing medications, refusing to get out of bed (OOB) and was not capable of understanding risks of deviating from the plan of care, revised 12/11/23. - Use of indwelling suprapubic urinary catheter related to dx of urinary retention secondary to neurogenic bladder, created and revised on 3/5/23. The interventions instructed staff to keep drainage bag below urinary bladder., monitor position of bag and tubing during transfers to avoid tugging and pulling, watch for kinks in tubing which may obstruct urinary flow and to monitor for signs/symptoms of UTI. The focus or interventions did not reveal the resident had history of placing drainage bag on floor. - Resident has the potential to exhibit following behaviors: may strike out at care during are d/t dx of autism and has been noted to put finger in mouth to try to throw up, revised on 1/25/23. Review of this focus did not show the resident had a behavioral history of touching or repositioning catheter drainage bag to the floor. Review of Resident #45's physician orders did not reveal an order instructing staff to monitor for any behaviors. The orders revealed the resident was not receiving any psychotropic medications related to any mental illness or intellectual disability. Review of Resident #45's Behavioral task documentation showed in the past 30 days (5/13 to 6/9/24) the resident had one episode of kicking/hitting and two episodes of rejection of care. The behavioral symptoms did not address the resident touching or repositioning catheter drainage bag to the floor. Review of the most recent written Daily Skilled Note, effective 6/7/24, showed Resident #45 had not exhibited any behaviors. The comments reported the resident was alert, staff anticipated needs, the resident was resting comfortably in bed, and mood (was) pleasant. Review of Resident #45's progress notes dated 5/13 to 6/11/24 did not reveal the resident had exhibited the behavior of touching or repositioning catheter drainage bag on the floor. A care plan meeting note, dated 5/15/24, showed the resident's responsible party/family attended the meeting via telephone conference and the resident's plan of care was discussed and the care plan remains current. The note did address the resident's resistiveness to get out of bed but did not mention the resident was noted to touch and reposition catheter drainage bag. An interview was conducted with Staff H, Registered Nurse/MDS Coordinator, on 6/11/24 at 3:34 p.m. State H stated Resident #45 had a history of playing with magazines and had to look back at it (care plan). Staff H reported adding that the resident touched and repositioned the foley catheter bag because the resident had taken it or played with the catheter or maneuvered it. Staff H stated Staff E said the bag was in a privacy bag and he must have done it (moved it to the floor). Staff H reported believing Staff E had seen the resident do it. During an interview on 6/11/24 at 4:34 p.m., the Director of Nursing stated the facility was able to purchase drainage bags with privacy flaps. The policy - Urinary Catheter Care, revised August 2022, showed the purpose of this procedure was to prevent urinary catheter-associated complications, including urinary tract infections. The procedure of infection control related to the use of catheter revealed staff were to use aseptic technique when handling or manipulating the drainage system and to be sure the catheter tubing and drainage bag were kept below level of bladder. Review of Cleveland Clinic's guidance on the care of urine drainage bags, last reviewed on 12/3/20, located at https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care, revealed Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor. The policy - Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of clear and quality of life. 2. Providing means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Established systems through which to monitor and evaluate corrective actions. The implementation of the policy revealed: 1. The QAPI committee overseas implementation of our QAPI plan, which is a written component describing the specifics of the QAPI program, how the facility will conduct its Q API functions, and the activities of the QAPI committee. 2. The Q API plan describes the process for identifying and correcting quality deficiencies key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. The coordination of the policy showed: 1. The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/ or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as liaison between the QAPI committee and individuals, services, and/or departments regarding QAPI activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation was made on 4/15/24 at 10:51 p.m. of Resident #89 going to lunch in the dining room. The resident had black debris under her fingernails. When asked if staff helped her clean her hands or nails, she said no. The resident was observed eating her lunch with her hands and nails dirty. Her nails remained dirty on 4/16/24. (Photographic evidence obtained) An observation was made on 4/16/24 at 8:58 a.m. of Staff B, Licensed Practical Nurse (LPN) during medication administration. Staff B, LPN donned PPE to enter a room on isolation precautions. When exiting the room, she went to the medication cart with PPE still on, prior to performing hand hygiene, opened the drawer and placed items in the cart. She then removed her PPE in the hall and threw it in the trash can placed in the hallway. An observation was made on 4/16/24 at 9:13 a.m. of Staff N, LPN during medication administration. Staff N administered an inhaler to a resident, exited the room, opened the medication cart, and placed the inhaler inside without performing hand hygiene. An interview was conducted on 4/16/24 at 2:58 p.m. with the Assistant Director of Nursing (ADON). The ADON said PPE should be removed inside the room and placed in the trash before exiting. She said the health department came to the facility a week prior and told them PPE should be removed and thrown away in the room. She said changes could not be implemented overnight and they needed to get big trash cans for the rooms. The PPE trash cans remained in the hallway on 4/17 and 4/18/24. The ADON confirmed staff should perform hand hygiene after each resident, prior to touching the medication cart. Review of the facility's policy Handwashing/Hand Hygiene, dated August 2019, showed, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets, and/or other written material provided at the time of admission and/or posted throughout the facility. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .o. Before and after eating or handling food. Based on observation, interviews, and record review, the facility failed to ensure an effective infection control program was implemented related to 1) the use of personal protective equipment (PPE) for two of three designated transmission based precaution (TBP) rooms, 2) no hand hygiene provided to residents prior to meals for four of four hallways, and 3) the Infection Preventionist (IP) conducting appropriate surveillance for influenza. Findings included: During an interview on 04/15/24 at 1:20 p.m., Resident #209's Family Representative (FR) stated Resident #209 tested negative for influenza and the droplet precautions sign was placed on the door for his roommate who went out to the hospital. Resident #209's FR stated she did not know why the droplet precaution sign remained on Resident #209's door when he tested negative for influenza. (Photographic evidence obtained). An observation on 04/15/24 at 1:25 p.m., revealed Staff A, Certified Nursing Assistant (CNA) walked into Resident #209's room, past Droplet Precaution sign and PPE, and entered the room without donning PPE. Staff A, CNA was observed taking Resident #209 out of the room and began to wheel him down the hall. An immediate interview on 04/15/24 at 1:25 p.m., was conducted. Staff A, CNA stated Resident #209 was good and not on precautions because he did not have a blue band on his wrist to show that she needed to don a gown and glove to assist him. During an interview on 04/15/24 at 1:30 p.m., Staff B Licensed Practical Nurse (LPN) stated Resident #209 had an active order for droplet precautions and Staff A, CNA should have appropriately donned PPE for any droplet precaution rooms. Staff B, LPN stated Resident #209 should not be out of his room and being wheeled down to the hall to the shower room right now due to being on droplet precautions. Review of the admission Record showed Resident #209 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, anemia, Type II Diabetes, ventricular tachycardia, and acute chronic systolic (congestive) heart failure. A physician order, dated 04/12/24 revealed, Follow Droplet isolation related to active Flu A + status. All cares to be provided in room only. During an interview on 04/16/24 at 3:00 p.m., the Infection Preventionist (IP) stated blue bands were used in the facility to only alert therapists and our staff a resident is on enhance precautions because of a peripherally inserted central catheter (PICC) line or other catheters. The IP stated the blue bands are only used for enhanced precaution rooms. The IP stated blue bands had nothing to do with droplet precautions and all PPE should be worn in droplet precaution rooms. An observation on 04/15/24 at 12:30 p.m., revealed seven residents sitting in the front dining room located near the facility lobby. Staff C, CNA was observed passing hydration to the residents. Staff C, CNA was not observed providing hand hygiene to the residents during the passing of hydration. Additional observations of tray pass in the facility revealed the following: - On 04/17/24 at 12:00 p.m., there was no hand hygiene offered during tray pass to residents who resided in rooms 18 to 30. - On 04/17/24 at 12:15 p.m., there was no hand hygiene offered during tray pass to residents who resided in rooms 1 to 17. - On 04/17/24 at 12:22 p.m., there was no hand hygiene offered to 13 residents during hydration pass in the front dining room near the lobby. - On 04/17/24 at 12:30 p.m., there was no hand hygiene offered during tray pass to residents who resided in rooms 41 to 52. - On 04/17/24 at 12:40 p.m., there was no hand hygiene offered to 13 residents during tray pass in the front dining room near the lobby. During an interview on 04/17/24 at 1:15 p.m., Resident #210 stated No staff never offer hand hygiene. Resident #210 stated, I actually had my daughter bring me some hand hygiene wipes from home. Review of the admission Record showed Resident #210 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of the neck of left femur, subsequent encounter for closed fracture with routine healing, cerebellar ataxia in disease, polyneuropathy, heart failure, and spinal stenosis. Review of the Brief Interview For Mental Status (BIMS) evaluation, dated 04/14/24, revealed Resident #210 had a BIMS score of 14 (cognitively intact). During an interview on 04/17/24 at 1:20 p.m., Resident #65 stated, No, I have never been offered any hand sanitizer from staff and actually I have never heard staff offer hand hygiene to anyone. Review of the admission Record showed Resident #65 was admitted to the facility on [DATE] with diagnoses that included Sepsis, Hyperlipidemia, Cystitis without hematuria and urinary tract infection. Review of Resident #65's quarterly Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns revealed a BIMS of 11 (moderately impaired). During an interview on 04/17/24 at 5:16 p.m., Resident #205 stated, No and they never do. regarding hand hygiene. A review of the admission Record showed Resident #205 was admitted to the facility on [DATE] with diagnoses that included Syncope and collapse, hyperthyroidism, dehydration, hypokalemia, depression and Parkinson's. Review of Resident #205's quarterly Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns revealed a BIMS of 13 (cognitively intact). During an interview on 04/17/24 at 1:25 p.m., Staff C, CNA stated she did not carry around hand sanitizer to provide to residents for hand hygiene. Staff C, CNA stated if Residents needed hand hygiene, they could use the sink or any of the two hand sanitizer stations located on the walls of the dining room. Staff C, CNA stated she was picky about her hands, and she washed, and hand sanitized all the time. Review of the facility's policy Influenza, Prevention and Control of Season, revised date March 2022, showed, Infection Precautions 1. Contact and Droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgement. Review of the facility's policy Handwashing/Hand Hygiene, dated August 2019, showed, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets, and/or other written material provided at the time of admission and/or posted throughout the facility. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .o. Before and after eating or handling food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident #250) of twenty residents receiving respiratory (nebulizer) medication was assessed and monitored for self-administration of a respiratory nebulizer treatment. Findings included: An observation of Resident #250 on 11/02/2021 at 12:10p.m. revealed the resident holding respiratory equipment of a nebulizer mouthpiece to her mouth with her left hand, and the nebulizer machine was running. No staff member was in the room or nearby while the resident received the nebulizer medication. An interview was conducted with Resident #250 at that time, and the resident said the nurse had given the medication to her earlier and she did not remember what time. An immediate interview was conducted with the resident's nurse Staff B, Licensed Practical Nurse (LPN) on 11/02/2021 at 12:15p.m. Staff B (LPN) confirmed the resident was self-administering a respiratory (nebulizer) treatment and revealed the resident did not have a physician order to self-administer the respiratory treatment. Staff B (LPN) stated I did not give her that, I have no idea where she got it from. I signed off the medication, for 12:00 p.m., because we sign it off before we give it here, and I was going to go in her room and give it to her, but she is already getting the medication now. A subsequent interview was conducted with Resident #250, on 11/02/2021 at 12:26 p.m. During the interview the resident revealed she was given the respiratory (nebulizer) treatment on the previous shift and stated, I got it from the nurse last night, I forgot to take it. A record review for Resident #250 revealed a profile sheet which indicated she was admitted on [DATE] with multiple diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Essential (Primary) Hypertension and Diabetes Mellitus Type II. Review of the active Physician Orders revealed an order dated 10/23/2021, which read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG[milligrams]/3ML[milliliters] 1 vial inhale orally every six hours for COPD. Further record review revealed no active order to self-administer medications. Review of the Minimum Data Set (MDS) dated [DATE], identified in Section C, a Brief Interview for Mental Status (BIMS) score of 13, on a 0-15-point scale, indicating Resident #250 was cognitively intact. On 11/02/21 at 12:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, The nurse must be in the room with the resident during administration of a medication, and until the medication is completed. The DON confirmed Resident #250 did not have a physician order to self-administer a respiratory (nebulizer) treatment. Review of the facility's policy titled Oral Inhalation Administration, Pharm script Policy #9.8 with revision date of 08/2020, Page 156, 158 and 159, read under Policy Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer medications that are orally inhaled. IV. NEBULIZERS: 12. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. 18. Administer Therapy until medication is gone (mist has stopped or until the designated time of treatment has been reached.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility failed to ensure a clean and sanitary living environment was provided during three (11/02/21, 11/03/21 and 11/04/21) of four days observed, and for two (#39 and #84) of two residents in room [ROOM NUMBER]. Findings included: During a facility tour on 11/02/21 at 10:48 a.m., Resident #39 and #84's room (room [ROOM NUMBER]) was observed with brown stains on wall by trash can with an appearance of human waste matter. The floor around Resident #39's bed was noted with sticky dirt and debris around the fall mats, which were positioned on both sides of the bed. The area in front of Resident #39's bed side table was noted with black spots, stains and dust. A subsequent observation on 11/02/21 at 1:26pm revealed no change in the cleanliness of the resident room. Photographic evidence was obtained. On 11/03/21 at 09:19 a.m., room [ROOM NUMBER] was observed with the same brown stains on wall, dirt on the floors, stains on floors and an overflowing trash can. A tour of a bathroom inside room [ROOM NUMBER] revealed a toilet with yellow streak stains and a base covered with brown and yellow debris. The bathroom floors were noted sticky and with dried yellow liquid. A piece of rusted metal pipe extended to the front of the toilet next to Resident #84's walker. A trash can underneath the hand washing sink was noted with overflowing trash. A loose pipe was observed underneath the sink on the floor. Photographic evidence was obtained. A review of the clinical record for Resident #39 revealed she was readmitted to the facility on [DATE] with a primary diagnosis of other osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing. A quarterly MDS (minimum data set) dated 09/20/21, section C showed a BIMS (brief interview for mental status) score of 14, indicating intact cognition. Section G revealed Resident #39 was totally dependent for ADLs (activities of daily living). A review of the clinical record for Resident #84 revealed admission to the facility on [DATE] with a primary diagnosis of unspecified fracture of shaft tibia, subsequent encounter for closed fracture with routine healing. A quarterly MDS dated [DATE], section C showed a BIMS score of 15, indicating intact cognition. Section G showed Resident #84 was totally dependent for ADLs. On 11/03/21 at 09:18 a.m., an interview was conducted with Staff F, Housekeeping. Staff F was observed sweeping the hallway floors outside room [ROOM NUMBER]. Staff F stated that he cleans resident rooms every day. Staff F stated that he was sweeping floors but would be cleaning resident rooms later. Staff F confirmed there are at least four housekeeping staff on duty daily. On 11/03/21 at 09:22 a.m. an interview was conducted with Resident #39. She stated the stains on the wall in front of her bed had been there a while. Resident #39 said, too bad I have to look at that every day. On 11/04/21 at 08:47 a.m., room [ROOM NUMBER] was observed in the same condition as the previous observations on 11/02/21 and 11/03/21 showing the same brown stains on the walls, bathroom floors and the bedside floor areas with dirt, dust, and debris. An interview was conducted with Resident #84 on 11/04/21 at 10.22 a.m. Resident #84 stated she uses the bathroom inside her room every day. Resident #84 stated staff assist her with transfers and said she did not know why the floors are never cleaned. On 11/04/21 at 12:25 p.m., Resident #39 was observed laying in her bed, waiting for lunch. The room was noted dirty, with trash overflowing, bathroom floors stained, and drops of brown matter were observed near the trash can, noted extending towards the doorway. An interview was conducted on 11/04/21 at 12:30 p.m. with Staff B, CNA (certified nurse's aide). Staff B looked at room [ROOM NUMBER] and said, this room is not clean. At 12:34 pm, Staff C, CNA who was standing outside the door also proceeded to look at room [ROOM NUMBER]. Staff C said, looks like [bowel movement]. The housekeeper should clean it. Staff C stated she saw the stained walls before and forgot to say something. On 11/04/21 at 12:33 p.m., an interview was conducted with Staff E, CNA who worked that hallway during the three days of observation. Staff E said, I would not have my family use that restroom. On 11/04/21 at 12:35 p.m., an interview was conducted with Staff D, LPN (licensed practical nurse). Staff D observed the bathroom and said, the brown stains on wall and floors looks bad. Staff D stated she thought the expectation was that Housekeeping should clean resident rooms daily. A follow-up was conducted on 11/04/21 at 01:00 p.m. with the Housekeeping Director (HD). The HD observed room [ROOM NUMBER] and stated, this is absolutely unacceptable, looks like feces on walls and on the floor. The HD stated the CNAs should be wiping off the immediate bowel movement and then Housekeeping staff can disinfect it. The HD stated the resident rooms are cleaned daily, and said, No residents should use a restroom that looks like that. I will clean it myself right after lunch. The HD stated the expectation is for the resident living areas to be cleaned daily. On 11/05/21 at 08:24 a.m. an observation of room [ROOM NUMBER] confirmed the room and bathroom was clean. A follow -up interview was conducted on 11/05/21 at 08:40 a.m., with the director of nursing (DON). The DON stated she was informed to the condition of room [ROOM NUMBER], and said it was cleaned right away. The DON said, Residents should live in a clean room. Review of an undated facility policy titled, [company name] Daily resident/patient room cleaning, showed that room cleaning tasks should be performed in the following order: 1. Straighten up resident's room. 2. Dust all surfaces, and spot clean all necessary areas. 3. Dust mop the floor and sweep trash and debris to the door and pick it up with the dust pan. 4. Empty and clean the trashcan and put in a new liner if necessary. 5. Wet mop the room using disinfectant. Under title, Restroom Cleaning the policy showed the restroom cleaning tasks should be performed in the following order: 2. Dust mop the room and spot clean all necessary areas, such as walls. 3. Disinfect the sinks, mirrors, all lights, fixtures, and pipes. 4. Disinfect and clean all parts of the toilet. 5. Damp mop the room using disinfectant. Under title, Method of cleaning, the policy showed to: Move furniture around and clean behind not commonly used furnishings. Restrooms: pay close attention to the sink and commode. Check overall condition of the room Remove all debris from floors, counters, and edges. Remove all trash and replace liners as needed. Mop floors using disinfecting neutral floor cleaner or disinfectant cleaner. Review of an environmental specialist job description titled, Environmental specialist, with a revised date 06/2020, showed that the goal is to create a clean and orderly environment for the residents that will become a critical factor in maintaining and strengthening their reputation. Responsibilities included to: Ensure all clean and soiled rooms are cared for and inspected according to standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to conduct a comprehensive, accurate assessment for one (#20) of 50 sampled residents related to skin conditions which included discolorations. Findings included: Observation on 02/11/20 at 3:47 p.m. revealed Resident #20 lying in her bed, she was frail and elderly. A visitor was at the bedside. The visitor was attempting to feed the resident, but she was not interested. She had multiple discolorations noted on both arms, and legs, neck area, and one on her lower lip. The visitor stated that she had recently returned from the hospital. A review of the admission Record for Resident #20 showed that she was admitted on [DATE] and was readmitted on [DATE] from the hospital. The admission showed her diagnoses included but were not limited to chronic obstructive pulmonary disease (COPD). myocardial infarction (MI), adult failure to thrive, dehydration, pulmonary fibrosis, and depression. Review of the February 2020 physician orders showed weekly skin checks dated 01/30/20, low air mattress to promote skin integrity and she was on Aspirin 81 mg (milligrams) daily. Record review of the Nursing Comprehensive Evaluation on 01/30/20, readmission from the hospital, showed in the skin integrity section: coccyx deep red non-blanchable. In the Skin discoloration section, it was noted that the lower extremities had no discoloration. Review of the Weekly Skin Check / Nurse dated 02/06/20 showed [Resident #20] has continue breakdown of coccyx. Will continue to apply house cream and encourage resident to turn often. Resident will often refuse to let staff change and turn her. Record review of the potential for skin impairment care plan initiated on 12/10/19 showed resident had impaired mobility but was able to turn and reposition self with minimal assistance and she had fragile skin. Interventions included but were not limited to observe skin for signs and symptoms of breakdown during care and report to physician. During an interview on 02/13/20 at 5:00 p.m. the Director of Nursing (DON) reviewed the Weekly Skin Check dated 02/06/20 and the Nursing Comprehensive Evaluation dated 01/30/20 and confirmed neither showed Resident #20 had any discolorations on her arms, legs, neck and mouth. She stated that the only documentation found was regarding her coccyx area. We went to the resident's room and the DON inspected the resident's skin and stated that, yes, she would expect to see these areas documented on her readmission and/or weekly skin evaluations. She stated that we need the documentation so we can tell if she has any new areas, and if new areas appear so we can investigate as to where they came from. Record review of the facility's policy showed, Pressure Ulcer Risk Assessment, revised October 2010, showed routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Monitoring: Staff will maintain skin alert, performing routine skin inspections daily or every other day as needed. Nurse are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin assessments at least weekly to identify changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to review and revise the Comprehensive Patient Centered Care Plan related to smoking based on the resident's assessment for one (#19) of three sampled residents of 15 total smokers. Findings included: A review of the Current Facility Smokers list was provided by the facility on 2/11/20. The list showed Resident #19 was to be supervised while smoking and the staff was to maintain her supplies. Observation on 02/11/20 at 4:09 p.m. revealed Resident #19 was in the smoking area without supervision present. She stated that she smokes and was allowed to keep her supplies with her. She stated that she was also allowed to smoke without supervision. At 4:45 p.m. Resident #19 was observed again in the smoking area. A staff member was on the porch but took another resident into the facility and left Resident #19 unsupervised in the smoking area. A review of the admission Record for Resident #19 showed that she was admitted to the facility on [DATE]. Diagnoses included but not limited to bipolar, hypertension, and anxiety. Record review of the Smoking Evaluation dated 01/14/20 showed the resident may smoke unsupervised in designated smoking area. Record review of the smoking care plan, initiated on 12/6/19, showed Resident #19 had been assessed as able to smoke with supervision due to poor safety awareness. The resident had been informed of the facility smoking policy. The goals included the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices. The interventions dated 12/06/19 included but were not limited to: maintain smoking materials in designated area (with facility staff); accompany the resident to the designated smoking area and provide supervision; provide assistance with lighting the cigarette; and provide redirection if resident was observed in any unsafe smoking practices. During an interview on 02/13/20 at 5:00 p.m. the Director of Nursing (DON) reviewed the 01/14/20 smoking evaluation and smoking care plan. She stated that the evaluation and care plan did not match. Resident #19 needed supervision with smoking on admission but had come a long way. The care plan needed to have been updated to her current status. The 3 to 11 (3:00 p.m. -11:00 p.m.) supervisor that performed the January (1/2020) evaluation should have communicated the change with the MDS (Minimum Data Set) coordinator so she could update the smoking care plan. Record review of the facility's policy, Smoking Policy-Residents, dated April 2007, showed it is the policy of this facility to establish and maintain safe resident smoking practices. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. Smoking restrictions may be imposed on residents at any time if the Attending Physician and/or Director of Nursing determine that the resident is not able to smoke safely without supervision. Smoking restrictions shall not be assessed against any resident for the mere convenience of the staff, but for the safety and well-being of the resident. Any resident with restricted smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period. Smoking privileges shall be reviewed quarterly by the Director of Nursing Services, the Attending Physician, and/or the Care Planning Team. All reclassifications of smoking privilege shall be so noted on the care plan. Reclassifications deemed necessary for the safety and well-being of the resident may be made at any time by the Attending Physician and/or the Director of Nursing Services. Residents with independent smoking privileges shall not be permitted to store any types of smoking articles, to include cigarettes, tobacco, etc. within his/her sleeping area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Current Facility Smokers list, dated 2/2020, showed Resident #62 was an independent smoker and was to use a smoking apron while smoking. The staff was to maintain his supplies. Resident #62 was observed on 2/11/20 at 3:07 p.m. in the smoking area alone. He was smoking a brown cigarette. Facility staff were not present. He stated he keeps his own smoking materials. The resident did not have on a smoking apron. Resident #62 was observed on 2/12/20 at 10:25 a.m. sitting in the hallway. He self-propelled himself to the smoking area. He had his own smoking materials. He lit a cigarette while in the smoking area. He did not have a smoking apron on. A review of the admission Record for Resident #62 showed that he was admitted on [DATE]. Diagnoses included but were not limited to Cerebral Vascular Accident (CVA), Chronic Obstructive Pulmonary Disease (COPD) and seizures. Record review of the Nursing Comprehensive Evaluation dated 12/21/19 showed Resident #62 may smoke unsupervised in designated smoking areas. He must wear a smoking apron at all times. He must request smoking materials from the staff. Record review of the smoking care plan, initiated on 10/9/19, showed he desires to smoke. The resident had been assessed as able to smoke unsupervised with a smoke apron. He verbalized understanding of the smoking policy and requirements of independent smoking. The goals included the resident will demonstrate safe smoking practices and will adhere to the smoking policy daily. Interventions dated 10/09/19, included but were not limited to maintain smoking materials in designated area (with the staff); provide assistance with lighting cigarette; apply/remove smoking apron; provide redirection if resident was observed in any unsafe smoking practices; seek the assistance of managers / supervisors if needed; observe for decline in hand dexterity; and assist to hold cigarette, as needed. During an interview on 2/13/20 at 5:00 p.m. the DON reviewed the 12/21/19 Nursing Comprehensive Evaluation as well as the smoking care plan. She stated that the Evaluation showed Resident #62 may smoke unsupervised with a smoking apron and the materials were to be kept by the staff. The care plan showed he was to use a smoking apron and the materials were to be kept in a designated area. The DON stated that the facility staff was to keep his materials because he kept stating that his cigarettes were being taken by others. So, to solve that problem the facility staff was keeping his materials. The DON stated that the care plan needed to be updated related to the materials. She also stated that Resident #62 was supposed to wear a smoking apron when he was smoking. She also stated that each resident had their own apron that they kept with them. 4. Record review of the facility's policy titled, Smoking Policy-Residents, dated April 2007, showed it is the policy of this facility to establish and maintain safe resident smoking practices. Smoking Restrictions: Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. Smoking restrictions may be imposed on residents at any time if the Attending Physician and / or Director of Nursing determine that the resident is not able to smoke safely without supervision. Smoking restrictions shall not be assessed against any resident for the mere convenience of the staff, but for the safety and well-being of the resident. Any resident with restricted smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period. Review of Smoking Restrictions: Smoking privileges shall be reviewed quarterly by the Director of Nursing Services, the Attending Physician, and / or the Care Planning Team. All reclassifications of smoking privilege shall be so noted on the care plan. Reclassifications deemed necessary for the safety and well-being of the resident may be made at any time by the Attending Physician and / or the Director of Nursing Services. Smoking Articles: 1. Residents with independent smoking privileges shall not be permitted to store any types of smoking articles, to include cigarettes, tobacco, etc. within his/her sleeping area. Residents may be issued a smoking apron and/ or adaptive / safety devices when deemed necessary for their independent smoking protection. 2. Residents without independent smoking privileges shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc., either on his or her person or within his/her living or sleeping area, at any time other than when the resident is under direct supervision. This facility shall provide reasonable means of providing direct supervision to those residents wishing to smoke. Staff members, guardians, visitors, and volunteer workers may assist in providing this service to residents. Any person (s) providing smoking supervision to residents must be instructed in smoking regulations prior to rendering such service. Based on observation, resident record review, staff and resident interview and facility policy review, it was determined the facility failed to ensure that three residents (#7, #13 and #62) of 15 residents who smoke were free from smoking hazards. Findings included : 1. An observation of Resident #7 was conducted on 2/11/20 at 12: 48 p.m. on the smoking patio. Resident #7 was observed smoking a cigarette for approximately ten minutes and then dropping his cigarette butt on the ground instead of the ashtray, which was on the table near the resident. At the beginning of the observation, a staff member was observed at the far end of the patio briefly talking on a cell phone. The staff member ended the call an entered the building. There was no other staff present on the smoking patio. Review of the facility posted smoking times revealed Resident #7 was smoking outside of a designated smoking time. Review of the list of Current Facility Smokers updated 2/2020, revealed that Resident #7 was listed as a supervised smoker. Review of the medical record for Resident #7 revealed diagnoses on the admission Record of Type II Diabetes Mellitus with Diabetic Neuropathy and Other Hereditary and Idiopathic Neuropathies. A quarterly nursing comprehensive evaluation was completed 1/26/20 which included a smoking evaluation. Review of the resident observation section of the smoking evaluation revealed that Resident #7 did not have the ability to light a cigarette safely with a lighter, does not smoke safely, does not utilize ashtray safely and properly, is not able to extinguish a cigarette safely and completely, and does not have the physical dexterity to smoke safely. The summary of the evaluation indicated that the resident must be supervised by staff, volunteer or family member at all times when smoking and the resident must request smoking materials from staff. Review of a care plan, initiated 11/21/19, with a focus of (Resident #7) desires to smoke. Resident has been assessed and requires supervision when smoking. Goals were listed as, Resident will demonstrate safe smoking practices thru the next review date and Resident will adhere to the smoking policy daily thru the next review date. Interventions included : Maintain smoking materials in designated area, accompany resident to designated smoking area and provide supervision, provide assistance with lighting cigarette, observe for decline in hand dexterity, assist to hold cigarette as needed. An interview was conducted with the Director of Nursing (DON) on 2/13/20 at 6:00 p.m. She reviewed the smoking assessment and care plan for Resident #7 and verified that Resident #7 was to be supervised when smoking. 2. Review of the record for Resident #13 revealed a nursing progress noted, dated 2/5/20 at 2143, which stated Today upon arrival at work, I noticed (Resident #13) sitting outside in the smoking area. (Resident #13 then asked me for a light, to which I responded that I was not aware if he was a supervised smoker or not. (Resident #13) has a pack of cigars. I mentioned that I did not know that (Resident #13) smoked. (Resident # 13) responded by saying 'I smoke cigars sometimes but I had to get away from (another resident) . Review of an admission nursing comprehensive evaluation, dated 9/21/19, revealed a smoking evaluation which indicated that Resident #13 did not use tobacco products. Review of a nursing comprehensive evaluation, dated 2/5/20 , revealed a smoking evaluation which indicated that Resident #13 did not use tobacco products. Review of all current care plans for Resident #13 revealed no care plan related to smoking. An interview was conducted with the DON, on 2/13/20 at 6: 05 p.m. She reviewed the nursing progress note from 2/5/20 and stated that she was not aware of this event and was not aware that Resident #13 smoked. She stated that a new smoking evaluation and care plan needed to be completed. An interview was conducted with Resident #13, on 2/14/20 at 11: 23 a.m. He stated he occasionally smokes a cigar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to monitor for behaviors, effects and side effects related to psychotropic medications for one resident (#5) of five sampled residents. Findings included: Resident #5 was observed sleeping during the morning hours on 2/11/20. On 2/11/20 at 3:32 p.m. the resident was lying on her right side in bed. A review of the admission record revealed that Resident #5 was admitted on [DATE] and readmitted from the hospital on [DATE]. Record review showed diagnoses included but were not limited to lung and bone cancer, anxiety, depression, and mood disorder. Review of the physician orders and Medication Record Administration (MAR) for February 2020 showed the resident was receiving Trazodone HCL 50 mg (milligrams) at bedtime for depression with a start date of 12/28/19, Lexapro 20 mg daily for depression with a start date of 12/29/19, and Lorazepam 2 mg / ml (milliliters) give 0.5 ml every 4 hours as needed for anxiety with a start date of 2/3/20. The physician orders lacked orders to monitor for behaviors, or for effects and side effects. Review of the care plan, initiated on 1/21/20 showed Resident #5 had alteration in mood related to anxiety and depression. The interventions included but were not limited to observe for changing in mood state, report to physician as needed. Review the record showed a care plan initiated on 8/8/19 for the potential of adverse side effects related to the use of psychotropic medications due to antidepressants, antianxiety. Interventions included but were not limited to observe for effectiveness of psychotropic medications, observe for adverse side effects related to psychotropic medication use and report to physician if noted and observe for changes in mood/behavior and report to physician if needed. During an interview on 2/13/20 at 5:00 p.m. the Director of Nursing (DON) reviewed Resident #5's physician orders. She stated that the resident was prescribed Trazodone, Lexapro and Lorazepam. She stated that psychotropics were to have behavior monitoring performed. She verified that no behavior monitoring was being performed for the resident. She stated that she would expect to find the behavior monitoring. She stated that the resident was being monitored prior to hospitalization and when she returned the monitoring was not ordered. During an interview on 2/14/20 at 11:14 a.m. the consultant pharmacist stated that he visited the facility monthly. On his visit he reviewed the resident's medication orders and Medication Administration Records. He stated that he would expect to see behavioral monitoring for residents on psychotropics. He stated that he would expect to see monitoring for Lexapro, Lorazepam and Trazodone. Record review of the facility's policy, Behavior Assessment and Monitoring, revised April 2007, showed Assessment: the nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including: onset, duration and frequency of problematic behaviors or changes in behavior, cognition, or mood; any precipitating or relevant factors. Management: The staff will identify and discuss with the practitioner situations where nonpharmacological approaches are indicated, and will institute such measures to the extent possible. Monitoring: If the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing assessments of changes in the individual's behavior, mood and function The staff will document the following information about specific problem behaviors: number and frequency of episodes; preceding or precipitating factors; interventions attempted; and outcomes associated with interventions. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling.

Based on observation, interview and record review the facility failed to follow infection control practices related to adequately cleaning blood glucose meters for two residents (#7 and #99) of two residents observed for glucose monitoring. Findings included: 1. An observation on 2/11/20 at 4:55 p.m. revealed Staff A, Licensed Practical Nurse (LPN) removed the blood glucose meter from the top drawer of the medication cart and set it on the top of the cart. She also placed a lancet and alcohol wipes on top of the cart also (no barrier). Staff A stated that she had one more blood glucose monitoring to perform. She donned two gloves and entered Resident #7's room with the supplies. She placed the items on the overbed table. She cleaned the right ring finger with an alcohol wipe. She pricked his finger with a lancet. A drop of blood was added to the strip and placed in the meter. She removed her gloves. She informed the resident the results were 208. She placed the lancet into the biohazard container. She placed the blood glucose meter on the top of the medication cart. She washed her hands. She drew the required amount of insulin. She donned her gloves and administered the insulin. Staff A, LPN removed her gloves and washed her hands. She moved the blood glucose meter with her bare hand. She administered the rest of Resident #7's medications. She washed her hands. She opened the top drawer of the medication cart and placed the uncleaned blood glucose meter inside. When asked about cleaning of the machine she stated that she would clean it with an alcohol wipe. She removed the uncleaned machine from the drawer and cleaned it with multiple alcohol wipes. She stated that she would clean it and leave it out to air dry for 2-3 minutes. She put it back in the drawer after a few moments. 2. An observation on 2/11/20 at 6:00 p.m. revealed Staff B, Registered Nurse (RN) had two blood glucose meters sitting on top of her medication cart in plastic cups. She stated that after she cleans the meters, she places them in the cup to dry. She placed a barrier/Styrofoam plate on the medication cart and placed the blood glucose meter on it, including alcohol wipes and a lancet. She entered Resident #99's room and placed a paper towel on the over bed table and placed the items on the barrier on the bedside table. She washed her hands and donned gloved. Staff B used the alcohol wipe to right forefinger of Resident #99. She then used the lancet. The results showed 261. She placed the lancet in the biohazard container. She removed her gloves and placed the meter into a cup on the medication cart. She administered the required Humulin R insulin, 2 units, in the abdomen post the use of an alcohol wipe. She placed the used syringe in the biohazard container. Staff B, RN wiped the meter with bleach wipes and placed in the cup on the medication cart. Staff B stated that she wipes the meter with a bleach wipe and leaves it in the cup for about 3 minutes before replacing in the drawer. During an interview on 2/11/20 at 6:20 p.m. the Director of Nursing (DON) stated that they were supposed to use bleach wipes after blood glucose meter use. They were to wipe the meter and put it in a cup until it is dry. She stated that she will educate the nurses about using a bleach wipe not an alcohol wipe to clean the meters. The DON stated that she had not reviewed the directions or contact time on the bleach wipe container. They instructed the nursing staff to wipe the blood glucose meter and leave it in a cup until it dries. A review of the directions for the bleach wipes showed a 30 second contact time is required to kill all the bacteria and viruses on the label except a 1-minute contact time is required to kill Trichophyton mentagrophytes and a 3-minute contact is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains wet the entire contact time. Allow surface to air dry and discard used wipe and empty canister. The DON stated that the nurses needed to wipe the meter top to bottom and front to back and leave the bleach wipe wrapped around the meter until it dries to meet the direction requirements. She stated that they would instruct the nurses again. Record review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, revised October 2011, showed always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Record review of Brand Name Bleach Wipe showed: apply towelette and wipe desired surface to be disinfected. A 30 second contact time is required to kill all the bacteria and viruses on the label except a 1-minute contact time is required to kill Trichophyton mentagrophytes and a 3-minute contact is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains wet the entire contact time. Allow surface to air dry and discard used wipe and empty canister. Contact time: allow surface to remain wet for 30 seconds to kill bacteria and viruses on the label except a 1-minute contact time is required to kill Trichophyton mentagrophytes and a 3-minute contact time is required to kill Clostridium difficile spores.