**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to involve the resident and resident representative in the development of the discharge plan and inform the resident and representative of the final plan in 1 of 3 residents (R2) reviewed for transfer and discharge in the sample of 3. This failure resulted in a disruption in R2's environment, causing reorientation issues and worsening confusion. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.R2's Care Plan does not address any plan for discharge.R2's 7/6/25 Progress Note by V9, Licensed Practical Nurse (LPN), documents V10 and V7, R2's Family, were looking for a facility for R2 with a locked memory unit but were still trying to decide between two facilities.R2's 7/17/25 Progress Note by V11, LPN, documents R2 will be discharging to another facility on 7/18/25. The note did not document any correspondence with family.R2's Progress Notes do not document V7 or V10 were involved in the development of the final plan or informed of the final plan.On 8/19/25 at 10:39 AM, V7 stated she is R2's Power of Attorney (POA), she did not sign any discharge paperwork for R2, and nobody told her R2 was discharging from the Facility. V4, Social Services Director, previously mentioned to the family that R2 would eventually need a higher level of care, but said there was no rush. V7 had not heard any more about it until on 7/18/25 when V8, R2's Family, got a call from V6, R2's Family, stating he saw R2 at a new Facility. V7 stated, (R2) is not a dog, you can't just dump them off like an animal, like they are trash; that's not fair. V7 stated every time R2 moves to a new facility, her dementia seems to get worse.On 8/19/25 at 8:15 AM, V1, Administrator, stated R2 had worsening dementia. V3, Director of Admissions, and V4 had talked to her family about placing her in a dementia unit. We found a facility with a dementia unit and planned to send R2 there when a bed was ready, but when there finally was a bed ready, nobody sent the family a notification that she was discharged . On 8/19/25 at 8:40 AM, V3 stated she spoke with V8 about R2's worsening dementia and R2 possibly being better off in a dementia unit. V8 stated she would discuss this with V7 and get back to her. V3 notified the accepting facility that R2's family was considering transferring there and would get back to them. V3 later heard R2 would be leaving the Facility on 7/18/25 and assumed someone else had talked to the family, but apparently nobody did. It was all a miscommunication. Apparently V6 was finishing up a stay at the accepting facility when R2 arrived. He saw her and called V7, and that is when it hit the fans.On 8/19/25 at 9:00 AM, V4 stated R2's discharge was a big miscommunication. She and V1 had been talking with R2's family regarding discharge, but R2 was discharged and the family was not made aware she would be transferring that day.On 8/19/25 at 11:18 AM, V1 stated there is no official transfer paperwork. It was just presumed that they had consent and it was ok to transport him in the van.On 8/19/25 at 11:25 AM, V1 stated typically discharges are initiated by the team/family/resident, then referrals are sent out to the facility, the facility is contacted to coordinate a date/time, the physician is contacted for orders, and the family is notified.The Facility's Discharge and Transfer Policy revised 4/2025 documents, Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in deciding where to go. If transferred to another health care facility upon order of a physician, a two-copy transfer form is completed. One copy is sent with the resident and the other is filed in the resident's record. Prior to resident being transferred or discharged , the facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident. This must be issued at least 30 days before the resident is transferred or discharged or as soon as practicable for immediate transfers or the resident has not resided in the facility for 30 days. The written discharge/transfer notice must contain the following information: a. The reason for transfer or discharge; b. The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged . Prior to the survey date of 8/19/25, the Facility had taken the following action to correct the non-compliance:On 7/21/25, V1, V2, and V4 were educated by V12 regarding discharge planning to ensure responsible parties were notified of discharges and transfers.On 7/21/25, an Ad Hoc QAPI Meeting including V13, Medical Director, was held to identify issue and discuss the development of a past non-compliance to address.V2 is reviewing discharges and transfers five days a week for 60 days, then three times a week for four weeks, then monthly to ensure compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to document notice of transfer requirement for 1 of 3 residents (R2) reviewed for transfer and discharge in the sample of 3. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.R2's Care Plan does not address any plan for discharge.R2's 7/17/25 Progress Note by V11, LPN, documents R2 will be discharging to another facility on 7/18/25.R2's Progress Notes do not document R2's discharge notice was given or family was contacted regarding R2's discharge.On 8/19/25 at 10:39 AM, V7, R2's Family, stated she is R2's Power of Attorney (POA) and was never notified of R2's discharge by the Facility.On 8/19/25 at 1:55 PM, V1, Administrator, stated he would expect the medical record to contain documentation that notification was made to the resident's representative and a discharge notice was given.The Facility's Discharge and Transfer Policy revised 4/2025 documents, Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Prior to resident being transferred or discharged , the facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident. This must be issued at least 30 days before the resident is transferred or discharged or as soon as practicable for immediate transfers or the resident has not resided in the facility for 30 days. The written discharge/transfer notice must contain the following information: a. The reason for transfer or discharge; b. The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged .Prior to the survey date of 8/19/25, the Facility had taken the following action to correct the non-compliance:On 7/21/25, V1, V2, and V4 were educated by V12 regarding discharge planning to ensure responsible parties were notified of discharges and transfers.On 7/21/25, an Ad Hoc QAPI Meeting including V13 was held to identify issue and discuss the development of a past non-compliance to address.V2 is reviewing discharges and transfers five days a week for 60 days, then three times a week for four weeks, then monthly to ensure compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 4 of 4 residents (R10, R22, R37, R112) reviewed for abuse in the sample of 45. Findings include: 1. R22's Face Sheet documents R22 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, morbid, obesity and pain. R22's Minimum Data Set (MDS) dated [DATE] documented R22 was severely cognitively impaired and ambulated via wheelchair. R22's Care Plan dated 6/5/24 does not address abuse. R112's Face Sheet documents R112 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, auditory hallucinations, and homicidal ideations. R112 was discharged from the Facility on 12/7/23. R112's MDS dated [DATE] documents R112 was severely cognitively impaired and ambulated with wheelchair and walker. R112's Care Plan dated 9/27/23 does not address abuse. The Facility's Initial Incident Description sent to the Illinois Department of Public Health (IDPH) on 12/6/23 documents, On Wednesday December 6th, 2023 at 1:30pm, it was reported that (R112) made contact with (R22)'s arm. Residents were immediately separated and (V1) immediately notified. R22's 12/6/23 Resident Incident Report reported by V6, Certified Nursing Assistant (CNA), and prepared by V12, Registered Nurse (RN), documents, This resident sitting in wheelchair in hallway as staff moving belonging from room [ROOM NUMBER] to new room [ROOM NUMBER]. Another resident going down the hallway passed this resident and hit this resident in the right arm/bicep with closed fist. R112's 12/6/23 Resident Incident Report reported by V6, CNA, and prepared by V10, Licensed Practical Nurse (LPN), documents, Staff reported that resident was with a staff member on North hall when she came upon a resident in a wheelchair and she reached out and hit her, they were immediately separated and checked for injuries. On 7/18/24 at 9:20 AM, R2 stated she did not recall the 12/6/23 incident and could not remember if another resident has ever hit her in the facility. On 7/18/24 at 10:16 AM, V6, CNA, stated R112 went by R22 in the hallway and punched her. She stated she separated the residents and reported the incident to her nurse. On 7/18/24 at 9:35 AM, V1, Administrator, stated R112 had a behavior and hit R22. The Facility's Final Incident Description sent to IDPH on 12/13/24 documents, On 12/6/2023 at approximately 1:30 PM, (R112) was walking with a staff member down north hall of the facility when they approached (R22) in the hallway and it was reported that (R112) with a closed fist made contact with (R22)'s right arm/bicep. Upon final investigation it found that (R112) did make contact with (R22)'s right arm. 2. R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, atrial fibrillation, and chronic kidney disease. R10's 7/18/24 MDS documents R10 was cognitively intact and ambulated via wheelchair and walker. R10's Care Plan dated 7/12/24 does not address abuse. R37's Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and cerebral infarction. R37's MDS dated [DATE] documented R37 was severely cognitively impaired and ambulated with walker. R37's Undated Care Plan with goal date of 9/6/24 documents R37 was verbally abusive at times, had threatened staff, yelled out, and had hallucinations and delusions. The Facility's Initial Incident Description sent to the State Survey Agency on 1/23/24 documents, On Tuesday January 23, 2024 at 10:45AM, it was reported that (R37) made contact with the back of (R10). Residents were immediately separated and (V1) immediately notified. R10's Resident Incident Report reported by V13, CNA, and prepared by V9, LPN, on 1/23/24 documents, This resident explained that another resident was in his bed. This resident attempting to tell other resident he is in the wrong room, other resident became agitated and began yelling and hit this resident with call light 4 or 5 times across upper back. Writer came to room in response to the call light and did separate residents. On 7/18/24 at 1:20 PM, R10 stated R37 came into his room and thought it was his own. He stated R37 was insistent he was in the right room and did not want to leave, then hit R10 a couple of times with the call light. On 7/18/24 at 9:27 AM, R37 was unable to respond appropriately to questions or provide any information regarding 1/23/24 incident. On 7/18/24 at 9:35 AM, V1, Administrator, stated R37 was in the wrong bed and hit R10 with the call light. On 7/18/24 at 9:54 AM, V13, CNA, stated R37 went into R10's room, believing it was his own, then yelled at R10 about being in his room and hit him with the call light. V13 stated she entered the room after she heard yelling and separated the residents and helped de-escalate R37. The Facility's Hand-Written Statement by V14, LPN, on 1/23/24 documents, Resident (R10) stated to this nurse that he was sitting in his w/c (wheelchair) with his blankets on. Resident (R37) came into his room and told him he was in the wrong room. (R10) replied that he was mistaken and this is his room. Directed him back to his room next door. (R37) then grabbed the call light cord and raised his arm with it to hit him. (R10) pulled his blankets over his head and leaned forward in his chair. (R37) hit him 4-5 times mid back with the chord {sic}. Staff immediately came in and moved him in his wheelchair out of the way. On skin assessment, resident has two small areas of redness to mid back. Not raised. On 7/18/24 at 10:42 AM, V14, LPN, stated she was called down to R10's room where R37 was in R10's bed. She stated she did not see R10 hit R37, but R10 told her R37 hit him and R37 had the call light balled up in his fist. On 7/18/24 at 2:02 PM, V9, RN, stated V13, CNA, called her down to R10's room where R37 thought R10 was an intruder and was hit him with the call light multiple times. She stated R10 was not seriously injured, but had a red mark on his back. The Facility's Final Incident Description submitted to the State Survey Agency on 1/30/24 documents, On 1/23/2024 at 10:45AM, (R37) had put himself in the bed of (R10). (R10) approached (R37) and told him that he is in the wrong room and bed and (R37) became agitated and started yelling and had contacted (R10) via call light cord lightly striking his back. Upon final investigation, (R37) did contact (R10) via call light. (R37) really believed he was in his own bed and simply reacted. On 7/19/24 at 11:25 AM, V1, Administrator, stated he expects the facility to keep residents free from abuse. The Facility's Abuse Prevention Policy revised 10/2022 documents, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Abuse: Will infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking.

Based on interview and record review the facility failed to ensure they had a qualified Infection Preventionist responsible for the facility's Infection Control Program at the facility. This has the potential to affect all 57 residents living in the Facility. Findings include: On 7/16/2024 at 9:00AM, V1, Administrator stated, (V3), Registered Nurse (RN)) was the Infection Control Specialist. On 7/19/2024 at 11:00AM, V3, Registered Nurse, RN, stated I took all the modules, but I did not pass the test. I am not taking it again. Facility job description dated 11/1/2019 states Under the direction of the Director of Nursing Services, the Infection Preventionist serves as a support person within the facility, providing guidance and education; assistance in problem solving related to resident care; monitoring compliance with state and federal regulations and coordinates the Infection Prevention and Control Program as set forth in the Resident Care Policy and Procedure Manual. Essential Duties: Maintains certification in Infection Prevention and Control.

Based on interview and record review the facility failed to investigate and provide treatment for bruises and abrasions to one of three residents (R2) reviewed for resident injury on the sample list of 11. Findings include: R2's Care Plan, not dated, documents, Positioning/Bowel and Bladder/Skin Integrity: Please encourage me to turn and reposition myself when in bed and reposition myself when up in my chair. Assist me if needed. I have a pressure re-distribution mattress on my bed and pressure re-distribution cushion in my wheelchair. Please look at my skin during showers and with any care and report any redness, bruising or open areas to my nurse/MD (Medical Doctor) right away. Please observe my skin weekly and notify MD with any decline or change in condition. R2's Minimum Data Set, undated, documents, that R2 was severely cognitively impaired, required assist from staff for activities of daily living, (ADL), does not document any skin concerns. R2's undated Face Sheet, documents diagnoses including Type 2 diabetes mellitus without complications, Sick sinus syndrome, old myocardial infarction, Atherosclerosis heart disease of native coronary artery without angina pectoris, dementia, R2's Weekly Skin Assessment, dated 11/24/2023, at 3:40PM, documents, No skin issues present. R2's Notes, dated 11/25/23, at 11: 23AM, documents, Nursing: Resident left the facility via family vehicle. will be gone until Monday. Resident's meds (medications) were sent with family. R2's Notes, dated 11/26/23 at 5:34PM, documents, Nursing: Resident returned to facility with family per family vehicle. R2's Notes, dated 11/27/23 at 1:32AM, documents, Nursing: Resident was out with family the last few days and arrived back to the facility this evening. Staff noticed bruising to resident's left foot this pm, on top of foot and toes. Resident was unsure what happened. Will continue to observe. R2's Weekly Skin Assessment, completed date 11/29/2024 at 4:11AM, documents, large dark reddish- purple Purpura to right wrist and Reddish colored bruising to left wrist. R2's Weekly Skin Assessment, completed date 12/06/2023 at 12:55AM, documents, bruise to right wrist-change condition, bruise left wrist resolved, sacrum abrasion still present, left lateral calf purpura still present, left lateral foot bruise still present, right thigh bruise still present, left thigh bruise still present. R2's Weekly Skin Assessment, completed date 12/15/2023 at 1:11AM, documents, bruise to right wrist still present, sacrum abrasion still present- abrasions to the right and left sacrum, left lateral calf purpura still present, left lateral foot bruise still present, right thigh bruise still present, left thigh bruise still present. Scab to the bridge of nose is resolved. R2's Weekly Skin Assessment, completed date 12/20/2023 at 11:33AM, documents, bruise to right wrist still present, sacrum abrasion still present- abrasions to the right and left sacrum, left lateral calf purpura still present, left lateral foot bruise still present, right thigh bruise still present, left thigh bruise still present. On 4/26/24 at 3:15PM V14, R2's family, stated, that he would like to know what happened when R2 fell and broke her pelvis. He stated he has tried to get information from the facility and they tell him he has to wait for a report. V14 stated, that he has some family members who work at the facility and the facility won't give them any information either. V14 stated, that (R2) had a fall back in June and the facility never explained what happened and (R2) had bruises on her face like she fell face first out of the wheelchair. V14 stated, that he did not get informed of any bruises his mother had in November on her legs and thighs. On 5/14/2024 at 11:08AM V2, Director of Nurses, stated, that she believes that the multiple bruises came from an outing with family. V2 stated, that R2 had a wound to her coccyx in the past, but that has healed. When asked about the abrasions to R2's right and left sacrum, V2 responded a shear. V2 stated, that usually they do nothing with it and that the CNA's, (certified nurse's assistant), apply barrier cream. V2 stated, that they don't usually document anything. V2 stated, that this information should be documented in the wound notes and she would get the documentation for me. V2 stated, that outside of the bruising to R2's right foot there is no other documentation of bruising and abrasions. On 4/26/2024 asked for an investigation of the bruises. As of 5/15/2024 the facility was unable to provide any investigation or explanation of these bruises and there were no fall reports around that time for R2. On 5/14/2024 at 1:10PM V8, Registered Nurse, (RN), stated, that when finding or being notified of bruising you go down and assess. V8 stated, that then you try to find out how it happens. V8 stated if you know what happened then good but if not then they fill out an incident report. V8 stated this is the responsibility of the nurse. On 5/14/2024 at 1:13PM V15, Licensed Practical Nurse, (LPN), stated, that she has worked at the facility for years. V15 stated, that she provided care for R2. V15 stated, that R2 was ambulatory. V15 stated, that R2 had poor safety awareness and was forgetful. V15 stated, that R2 had a wound in the past, but was not aware of any prior to discharge. V15 stated, that if there is a skin issue or injury an incident report is completed and they try to find out what happened/cause of the bruise and get treatment. On 5/14/2024 at 1:15PM V16, RN, stated, that she cared for R2, but it has been a while. V16 stated, that she does not remember any particulars as it relates to her. V16 stated the normal practice is when you are notified of a bruise you assess then you try to find out what happened. V16 stated, that you complete an incident report and if you can't find out what happened then V1 and V2 are notified. The report is given to them for further investigation. On 5/15/2024 at 5:33AM V17, LPN, stated, that she cared for R2. V17 stated, that she received in report that R2 had returned from outing with family and some bruising was found. V17 stated, that she did her own skin check and documented her finding. V17 stated, that she was not aware how R2 got the areas. V17 stated, that she did not complete an incident report because that would have been done by the nurse that found the areas. V17 stated she is aware of an area to R2's buttocks and it was an abrasion. V17 stated, that the area would open up and then it would close and open again. V17 stated, that they had tried barrier but that didn't work and she spoke with the previous Wound Nurse and applied a treatment similar to skin prep. V17 stated it worked but the area would reopen. On 5/15/2024 at 3:02PM V1, Administrator, stated, that he would expect his staff to follow the policy as it relates to incidents and injury. The facility's Accident & Incident Documentation & Investigation Resident Incident, dated 7/18, documents, POLICY: Accidents and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the LTC system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents. It continues PROCEDURE: 1. General Information: a. The Licensed Nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director as appropriate. b. The Licensed Nurse at the time of the incident is responsible for initiating / completing the Resident Incident Report, ensuring that all items identified on the form have been completed as applicable to the accident/incident. c. The Licensed Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth on the Resident Incident Report. d. If incident/accident is related to a visitor, refer to Accident & Incident Documentation & Investigation-Visitor Incident Policy. 2. Notification and Documentation in the Resident's Medical Record: a. The Licensed Nurse shall place the resident on the 24-Hour Report, document the incident, and notify the supervisor and Director of Nursing for follow through as needed. b. The Licensed Nurse may complete a Nurses' Notes, and update the Resident Care Plan as needed c. The Nurse's Notes could contain the following documentation on Date and time of incident: Clear, objective facts of what occurred; The last time the resident was seen by staff prior to the incident; An evaluation of the resident's condition at the time of the accident/incident could include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident; Any treatment provided; Any contacts made or attempted with the resident's physician, family, legal representative, or any other health care professional or person involved with the resident's care; The resident's outcome and any information concerning the incident; and on The Nurse's signature, date, and time of the charting. The Executive Director / Director of Nursing will notify the State Department of Health in accordance with reporting guideline's in the event the accident/incident is reportable. The Attorney General may need notification also. (Mississippi only).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's family/emergency contact of a change in condition and transfer to the hospital for 1 of 3 residents (R2) reviewed for notification of changes in the sample of 5. Findings include: R2's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses to include adjustment disorder with Mixed Anxiety and Depressed Mood, Hyperlipidemia, Gastro-esophageal Reflux Disease Without Esophagitis, Peripheral Vascular Disease, Nicotine Dependence, Hypothyroidism, Pain and Pneumonia. R2's Face Sheet documents V10 is R2's Responsible Party. R2's Progress Note dated 12/13/23 at 3:25 AM document, 12/12/23 at 7:20 PM EMTs (Emergency Medical Technicians) arrived at the facility after resident called 911 from his cell phone to say he was having chest pain. This nurse accompanied the emergency response team to the resident's room. He told them he called from his cell phone after having chest pain for 2 days. Resident did not report chest pain to the nursing staff anytime throughout the day. Resident answers questions appropriately and per his request was taken to (local hospital) for further evaluation. (Local hospital) called the facility at 10:20 PM to inform the facility that they would be discharging the resident back to the facility. Dx (diagnosis): Noncardiac Chest pain with a recommendation to follow up with his healthcare provider on 12/13/23 for further eval and treatment if needed. Resident arrived back at the facility at 11:27 PM. He denied pain/discomfort. He is resting comfortably with his call light within reach. Will continue to monitor throughout shift. On 12/29/23 at 12:33 PM, (V10) R2's Emergency Contact, stated, Nobody called and let me know when (R2) had to call 911 himself to go to the hospital for chest pains. That was a few weeks before I came to take him home for Christmas. On 1/3/24 at 8:14 AM during phone interview, V1, Administrator stated he cannot find any documentation that R2's emergency contact, V10, was contacted when he went to the hospital on [DATE]. He stated he would expect resident's family, responsible party and/or emergency contact to be notified when they are sent to the hospital. The facility's policy, Notification of a Change in Condition in Resident's Status, revised 11/17 documents, Policy: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident ' s condition, per standards of practice and Federal and /or State regulations. Procedure: 1. Guideline for notification of physician / responsible party (not all inclusive): j. Abnormal complaints of pain, ineffective relief of pain from current regimen. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition b. Physician/physician extender notification c. Notification of responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to feed residents in a manner which promotes resident's dignity for 1 of 4 residents (R51) reviewed for dignity in a sample of 36. Findings include: On 05/30/2023 during the lunch observation between 12:20 PM to 12:50 PM V3, Registered Nurse Staff Development Coordinator, set up R51's meal tray and stood up and fed R51 the entire meal. On 06/01/2023 at 12:55 PM, V2, Director of Nurses stated that she would expect the staff to be sitting down when feeding a resident. 06/05/2023 at 9:24 AM V2 stated that the facility does not have a policy for staff to be sitting down to feed a resident. R51's Minimum Data Set, dated [DATE], documented that R51 cognition was severely impaired and that she required supervision with physical assistance of 1 staff member.

Based on observation, interview, and record review, the facility failed to ensure nutrition was provided as ordered and per standards of practice for 1 of 2 residents (R10) reviewed for tube feeding management in the sample of 36. Findings include: R10's Physician's Order (PO), dated 12/02/19, documents Jevity 1.5 @ (at) 55 ml (milliliters)/hr. (hour) x 24 hours via g tube (gastrostomy tube). R10's Care Plan, dated December 3, 2019, documents I am NPO (Nothing by mouth). I have a diagnosis of Dysphagia. I have a PEG (Percutaneous Endoscopic Gastrostomy)- tube and receive Jevity per MD (medical doctor) orders. I receive Jevity 1.5 at 55ml/hr./24 hours. I have water flushes per tube per MD order. I am to receive medication per tube, all those compatible can be given at once with a 30 ml bolus of water at appropriate times. It also documents that it can be disconnected for no more than one hour a day during ADLs (Activities of Daily Living), therapy, or activities. On 5/30/23 at 9:30 AM R10 was up in wheelchair, out of room. The tube feeding container was not attached to the gastric tubing. On 5/30/23 at 12:40 PM V14, Licensed Practical Nurse, crushed R10's Baclofen 10mg tablet and placed in a cup. V14 then poured and unmeasured amount of water into the cup and entered R10's room. R10 was lying in bed. R10's gastric tubing not connected to feeding container. V14 grabbed a hold of the gastric tubing, opened the spout, and poured the mixture in the cup into the gastric tubing. The liquid stopped flowing. V14 then milked the tubing freeing sections of feeding caught in the tubing. V14 then allowed the liquid to free flow into tubing. V14 then connected the gastric tubing to the bottle of feeding and turned it on. The Jevity feeding bottle was not labeled with the resident's name, formula ordered and date. On 6/1/2023 at 12:45 PM V2, Director of Nursing, stated that she expects the feeding bottles to be filled in prior to administration of feeding. V2 stated that she would expect the staff to flush the g tube before and after administration of medication. V2 stated that the facility only checks placement every eight hours but that she would expect the nurses to follow the policy. V2 stated that R10 has an order to be off the feeding for an hour and that is what she expects. The facility's Tube Feeding policy, dated 7/2018 documents Procedure: 5c. Flush prior to administering medication, in between and after all medication with approximately 15cc of water. 7. Label the feeding bag with the resident's name, formula ordered and date. The facility's Enteral Tube Medication Administration Procedures, dated 2/18/2023, documents Procedure 2. Prepare medications for administration. 4. Wash hands and apply gloves. 5. Verify tube feeding placement per tube feeding policy. 6. Stop enteral feeding and flush tube with at approximately 15 ml of water prior to administration of water each dose unless fluid restriction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to utilize safe transfer techniques to prevent accidents for 4 of 5 residents (R1, R28, R30, R53) reviewed for accidents/supervision in the sample of 36. Findings include: 1. R1's Care Plan, dated 7/26/21, documents I am a total lift for transfers with two staff assist. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is totally dependent of 2 staff members for transfers. On 5/30/23 at 9:15 AM V11, Restorative Nurse, and V9, Restorative Aide, transferred R1 from her wheelchair to the bed using a full body mechanical lift. V11 operating the controls and V9 stood behind the wheelchair. V9 then moved the machine back and R1 started to sway in the sling. With V9 operating the controls V9 transported R1 from the wheelchair to the bed swinging without staff contact. 2. R28's Care Plan, dated February 3, 2017, documents Since having my stroke, I have left sided hemiplegia. I am not safe to get up on my own. I am a two person assist using the total lift with a TL2 purple edge sling. R28's MDS, dated [DATE], documents that R28 is totally dependent on 2 staff for transfers. On 5/31/23 at 130pm V12, Certified Nurse Aide/CNA, and V15, Nursing assistant (NA), assisted R28 to her bed from her wheelchair using a full body mechanical lift. V12 applied R28's sling straps to the lift. With V12 operating the controls V15 stood behind the wheelchair. V12 then moved the machine back transported R30 from the wheelchair at the far end of the room to the bed allowing R28 to swing freely in the sling without staff contact. 3. R30's Care Plan, Dated November 10, 2016, documents I am a two assist with total lift to transfer. R30's MDS, dated [DATE], documents that R30 is totally dependent on 2 staff for transfers. 05/30/23 at 2:18 PM V6, CNA, and V13, CNA, assisted R30 into the bed using a full body mechanical lift. V6 and V13 applied R30's sling straps to the lift. With V13 operating the controls V6 stood behind the wheelchair. V13 then moved the machine back and R30 started to swing in the lift. With V13 operating the controls transported R30 from the wheelchair at the far end of the room to the bed swinging without staff contact. 4. R53's Care Plan, dated August 28, 2022, documents I am a fall risk, and have a history of falls at home. I am a one person transfer with gait belt using a walker when I walk. R53's MDS, dated [DATE], documents that R53 requires extensive assist of 1 person for transfers. On 5/31/2023 at 11:31 AM R53's chair alarm was sounding. R53 transferred self to the toilet. V12 assisted R53 with toileting. V12 then grabbed R53 under her right arm and assisted R53 into the standing position. R53 noted to sway when standing and holding onto the bar. V12 then assisted R53 into the wheelchair. V12 did not apply a gait belt to R53 for the transfer. V12's gait belt was around her waist. On 6/1/2023 at 1:40 PM V2, Director of Nursing, stated that she expects the staff to apply a gait belt when assisting with a manual transfer. V2 stated that V12 should have applied the gait belt when transferring R53 from the toilet. V2 stated that when the staff are transferring a resident in a total mechanical lift both staff are to participate in the transfer. V2 stated that a staff standing behind a wheelchair or on the other side of the bed is not participating in the transfer. V2 stated that the resident should not be left unattended and left to swing in the lift. The facility's Transfer Belt/Gait Belts policy, dated 4/14, documents the policy is to promote safety in transferring residents, a gait belt is utilized when deemed appropriate. It also documents, A gait belt is used if indicated on care plan. The (Full Body Lift) Total Lift policy documents that the (Full Body Lift) total lift is to be used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R1's Care Plan, dated 7/26/21, documents I am incontinent of both bowel and bladder. I do wear incontinent protective undergarments. R1's MDS, dated [DATE], documents that R1 is always incontinent of bowel and bladder and totally dependent on 2 staff for toileting. R1's Bladder Continence Evaluation, dated 5/15/23, documents that R1 is incontinent of bladder and dependent on staff for toileting. On 05/30/23 at 2:00 PM V13, CNA, and V6, CNA, assisted R1 with incontinent care. R1 was incontinent and heavily soiled of urine. R1's lift pad and pants were soiled with urine. V6 and V13 assisted R1 into the bed using the mechanical lift. V6 and V13 removed R1's pants, opened the incontinent brief and rolled it between R1's legs. V6 using a premoistened washcloth wiped down the middle of R1's peri area. V6 and V13 assisted R1 onto her right side. V6 then using a premoistened wipe and wiped R1's rectal area. V6 and V13 then applied R1's incontinent brief. V6 and V13 did not clean R1'sinner labia, vaginal, peri, groin area, inner thighs, and buttocks. 3. R30's Care Plan, dated 11/10/2016, documents I am incontinent of urine/bowel and need assistance with peri-care after each incontinent episode. I do wear protective undergarments. I am also at risk for urinary tract infections due to my incontinence so monitor me for signs and symptoms of infection. R30's MDS, dated [DATE], documents that R30 is always incontinent of bowel and bladder and totally dependent on 2 staff for toileting. R30's Bladder Continence Evaluation, dated 5/15/2023, documents that R30 is moderately impaired cognitively. It documents that R30 is incontinent and dependent on staff for care. On 05/30/23 at 2:18 PM V13 and V6 assisted R30 with incontinent care. R30 was incontinent of urine. V6 and V13 assisted R30 into the bed using the mechanical lift. V6 and V13 removed R30's pants, opened the incontinent brief and rolled it between R30's legs. V6 using a premoistened washcloth wiped down the middle of R30's peri area. V6 and V13 assisted R30 onto her right side. V6 then using a premoistened wipe wiped R30's rectal area. V6 then using a premoistened wipe wiped R30's rectal area again. V6 and V13 then applied R30's incontinent brief. V6 and V13 did not clean R30's inner labia vaginal, peri, groin area, inner thighs, and buttocks. 4. R53's Care Plan, dated August 28, 2022, documents I am occasionally incontinent of bowel and bladder. R53's MDS, dated [DATE], documents that R53 is frequently incontinent of urine, occasionally incontinent of bowel and requires extensive assist of 1 person for toileting. On 5/31/2023 at 11:31 AM, V12, CNA assisted R53 with toileting. R53 transferred self to toilet. R53 was incontinent of urine. V12 removed R53's heavily soiled incontinent brief and applied a new one. R53 then voided on toilet. R53 with 2 squares of toilet paper wiped her vaginal area. V12 then took toilet paper and wiped R53's anal area. 5. On 06/01/23 at 1:25 PM, V17, CNA, and V15, CNA, entered R18's room to provide incontinent care. V15 and V17 washed hands with soap and water and donned gloves. R18 was wet as verified by V17 and V15. V17 cleansed R18 front peri area during cleansing of labia visible stool on the cleansing wipe. V17 did not obtain any additional wipes to cleanse R18. R18 then turned to left side facing wall. R18 was incontinent of loose stool which had leaked out of adult brief and leaked on the bed. V17 rolled soiled linens under R18 and cleansed R18. V17 did cleanse R18's thighs and buttock and when cleaning rectal area. R18 had visible stool on cleansing wipe. V17 did not cleanse rectal area after cleaning wipe visible with feces. R18 was never dried during incontinent care. R18's MDS, dated [DATE], documents R18 is totally dependent and requires two plus physical assistance for toileting. R18's MDS documents that R18 is always incontinent. 6. On 05/30/23 1:25PM, R35 was being pushed down hall towards her room by V6, CNA. V6 transferred R35 to toilet from wheelchair with gait belt. While R35 stand holding bar, V6 removed R35's pants. R35's adult diaper was urine soaked. While R35 was sitting on the toilet, V6 placed clean adult diaper around ankles and pulled up above thighs where wet clothing has been. then placed clean pants on and up to R35's thighs. After toileting R35, V6 assisted R35 to stand while R35 was holding bar. V6 took cleansing wipe and stood behind R35 and swiped from the front to the back and then pulled up R35's adult diaper and pants. R35's MDS dated [DATE] documents R35 requires extensive assistance of one person for toileting. R35's Care Plan, dated 3/12/ 2018, documents R35 has a history of urinary tract infection and urinary retention. On 6/1/2023 at 1:40 PM V2, Director of Nursing, stated that she expects the CNAs to clean all areas of incontinence. V2 stated that she would expect the CNA to perform incontinent care. The facility policy Incontinent Care dated reviewed 1/15 documents #10 wash the resident's entire perineal area, and all areas affected by incontinent with wash cloth, soap, warm water, peri-wash, or wipes. #11 When washing perineal area, wash the entire area moving from the front to back. #12 Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back. The Policy documents #14 Dry the perineal area front to back of all skin surface washed. #16 remove gloves and discard. Wash hands. Based on observation, interview, and record review, the facility failed to provide complete incontinent and perineal care for 6 of 6 residents (R1, R9, R18, R30, R35 and R53) reviewed for incontinent and perineal care in the sample of 36. Findings include: 1. 05/31/23 10:35 AM R9 was on the bedpan. V9, Certified Nurse Assistant, CNA, removed the bed pan from underneath of R9. V9 rolled R9 back over on to her back. V9 then cleansed R9's abdominal fold, left inner groin and down the center of R9's labia. She did not cleanse R9's right groin. V9 then assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock, and peri rectal area. V9 did not cleanse R9's right hip or buttock. R9's Minimum Data Set (MDS), dated [DATE], documented that her cognition was severely impaired, she was totally dependent upon 2 staff members for toileting and that she was always incontinent of bowel and bladder.

Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately during care, and cleaning soiled bed mattress and wheelchair seat pad for 6 of 6 residents(R9, R18, R33, R35, R48, R50) reviewed for infection control in the sample of 36. Findings include: 1. 05/31/23 10:35 AM, R9 was on the bedpan, V8, Certified Nurse Assistant (CNA) and V9, CNA, came into the room, both performed hand hygiene, both donned gloves. V8, with gloved hands, touched her hair, tucking her hair behind her right ear and the placed hand in shirt pocket, proceeded to the right side of R9's bed to assist with taking her off of the bed pan. V9 proceeded to uncover R9, open the disposable cleansing wipes with same gloved hands, removed the bedpan from underneath R9 and started to cleanse R9's abdominal fold, left inner groin and down the center of R9's labia with the same pair of gloves. V9, with the same soiled gloves, assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock and peri rectal area. 2. On 05/31/2023 at 10:20 AM, V8 took R48 into her room. V8 placed a gait belt on R48 and transferred her into her bed without the benefit of hand hygiene nor did she don gloves. 3. 05/31/2023 at 11:00 AM, V10, Registered Nurse (RN)/ Wound Nurse, performed hand hygiene, donned gloves, took a medicine cup of dakin's solution, packages of 4x4 gauze, a package of Melgisorb AG, cotton tip applicators, mepilex foam dressing, gloves and a barrier for the bed. V10 set all the wound dressing supplies on R50's overbed table, pulled R50's privacy curtain and then closed R50's door with her gloved hands. V10 went to R50's bedside, touched R50's right arm with the same gloved hands, explained what she was about to do. V10 pulled the blankets down to expose R50's buttocks and hips placed barrier down on the bed, unfastened R50's incontinent brief, that was wet, and removed the saturated wound dressing from R50's sacral coccyx area. V10 then doffed gloves, performed hand hygiene and donned a clean pair of gloves. V10, with her clean gloves opened the 4x4 gauze packages, placed gauze in medicine cup of dakin's solution, took 1 piece of dakins solution soaked gauze, wrapped it around a cotton tip applicator and cleansed the 9 o'clock tunnel, then took a 2nd gauze soaked with dakin's solution and used it to clean the wound bed. She then took the 3rd dakins soaked gauze and cleansed around the outside of of the wound all with the same gloved hands. V10 then doffed her gloves, performed hand hygiene with Alcohol Based Hand Rub, donned gloves, opened the Melgisorb AG package and took out the dressing, wrapped it around the cotton tipped applicator and placed it in the wound tunnel spreading it down into the wound bed. V10 took the foam dressing placed a 4x4 gauze pad on top of it and placed it over the wound. She then removed the barrier and reattached the soiled adult incontinence brief. 4. On 5/30/23 at 12:05 PM, V10, RN, entered R33's room to do the treatment on R33's legs. R33 right lower leg has multiple scattered scratches and scabs. R33's left leg has 2 scabbed venous ulcer areas with the approximate size of dimes. The areas around the wounds were red. The areas were cleansed and Bacitracin was applied, abdominal pad (ABD) and then gauze. During the dressing changes, V10 changed her gloves 3 times without hand hygiene in between. 5. On 06/01/23 at 1:25 PM during incontinent care, V17, CNA, rolled soiled linens under R18 and cleansed R18. R18's mattress was visibly wet from loose stool. V15 took soiled linens that were removed out from under R18 and swiped across the wet area on mattress. Then both CNAs placed adult diaper on R18. While R18 on mattress, V15 used cleansing wipes and cleansed the area on mattress that R18 has already been placed in. 6. On 05/30/23 01:25PM during incontinent care while R35 sitting on the stoo,l V6, CNA, removed wet pants and diaper which was soaked. V6 placed clean adult diaper around ankles and pulled up above thighs where wet clothing had been. V6 placed clean pants on and up to thighs. The pad in wheelchair wasvisible wet with urine. V6 did not clean pad in wheelchair prior to sitting R35 back in the chair. On 06/01/2023 at 12:55 PM, V2, Director of Nurses, stated that she would expect to staff to perform hand hygiene and change gloves during incontinent care and wound care. The facility policy Standard Precautions dated history 9/19 documents standard precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel. The policy documents standard precautions applies to blood; all body fluids, secretions, exertions except sweat, non-intact skin; mucous membranes. The policy documents #4 during delivery of healthcare, avoid unnecessary touching of surfaces in close contact proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands t surface. #2 Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patients intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. #6 environmental control- follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touches surfaces in patient care areas.

Based on observation, interview, and record review, the facility failed to properly store medication, and label Tubersol. This has the potential to affect all 57 residents living in the facility. Findings include: On 5/30/23 at 9:00 AM, The facility's Medication Storage Room was inspected. The refrigerator located in the medication room contained the following: 1. 3 open multidose vial of Tubersol (TB) without an open date. The Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. 2. R33's bottle of liquid Lorazepam Concentrate. 3. R6's bottle of liquid Lorazepam Concentrate. 4. R31's bottle of liquid Lorazepam Concentrate. On 5/30/2023 at 9:05 AM V8, RN, stated that the multidose vial of Tubersol was open and in use. V8 stated that the Tubersol should have an open date on it. V8 stated that the refrigerator should be locked. V8 stated that she unlocked the refrigerator and did not lock it back. On 5/23/2023 at 2:30PM, V2, Director of Nursing, stated that multi dose vials of Tubersol have a different expiration date from what's on the bottle once open and should be thrown away after this date. V2 stated that she believes it is 28 or 30 days. V2 stated that the TB vials are to be labeled with an open date when put in use. V2 stated that labeling the medication with a date open date lets the nurses know when the expiration date is. V2 state the Tubersol can be used on everyone as long as they have no allergies. The Resident Census and Condition of Residents form (CMS 672), dated 5/30/2023, documents that the facility has 57residents living in the facility. The facility's Medication Storage Policy, dated 11/10, documents Policy: All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R37's Physician's Order, dated 05/02/2022, documents, (1) Cleanse right heel with wound cleanser apply skin prep daily and prn until resolved (2) Vitamin C 500mg 1 po bid. The facility's Weekly Pressure Wounds dated 12/01/2022 through 05/17/2022, documents that R37's Suspected Deep Tissue Injury occurred on 05/02/2022. There was no assessment of the size of R37's pressure ulcer until 5/13/22. R37's Weekly Wound sheet, with an assessment date of 05/13/2022 documents, Wound location: 13-Right heel. Wound type: Suspected (Deep tissue injury). Wound measurement (length by width) 1.5 (by) 2.0 (centimeters) Depth: 0.5 (centimeters) It continues, Treatment(s) Skin Prep. It continues, Notes: Suspected DTI is now at healing stage 2. No (signs or symptoms) of infection or pain noted. Heal boot as tolerated. On 05/18/2022 at 10:00 AM, V35, LPN cleansed R37's open area to his right heel with dermal wound cleanser, applied hydrogel and the pressure ulcer was covered with a border dressing. There was no physician's order (PO) for this treatment. The facility's policy, Pressure ulcer/injury and skin conditions guide for wound evaluation documentation, dated 11/2017, documents, 1. Upon identification of a pressure ulcer/injury (arterial, venous or neuropathic,) regardless if developed in house or upon admission, the area is to be documented on the Wound Evaluation form or in electronic format. It continues, 4. Initiate appropriate treatment per treatment protocol and physician order. Based on interview, observation and record review, the facility failed to monitor and assess a new pressure ulcer and provide the Physician Ordered treatment for existing pressure ulcers for 3 of 7 residents (R6, R31, R37) reviewed for pressures ulcers in the sample of 33. Findings include: 1. R6's Face Sheet, print date of 5/19/22, documents R6 was admitted [DATE] and he has diagnoses of pressure ulcer to heel and type 2 diabetes mellitus. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact and requires extensive assistance from 1 staff member for bed mobility and transfers. R6's Physician Orders, dated 4/13/22, documents, Cleanse right heel ulcer with w/c (wound cleanser) ns (normal saline) apply Santyl and cover dressing daily and prn (as needed). R6's Weekly Wound document, dated 5/13/22, documents that R6 has a right heel pressure ulcer measuring 0.5 x 0.5 cm (centimeters). This Wound documents, Support and Specialty Devices: Heel Boots, Repositioning, Heels Elevated off the bed. On 5/16/22 at 3:14 PM, V13, Licensed Practical Nurse (LPN), entered R6's room to change his right heel pressure ulcer dressing. R6 was lying in bed on his back. R6 was not wearing his bilateral pressure offloading boots. V13 washed her hands, went to the treatment cart, and obtained the needed supplies, V13 placed supplies on the bedside table and then donned gloves. V13 raised R6's right leg exposing the heel pressure ulcer. The ulcer did not have a dressing on it. V13 cleansed the wound with wound cleaner and placed R6's foot back onto his bedding. V13 went to the restroom to wash her hands. V13 returned and stated, I guess I should not have put his foot back down on his dirty bedding. V13 proceeded to don gloves, raise R6's foot, place Santyl on the wound bed and place a bordered foam dressing. V13 removed her gloves, gathered supplies, left the room, put supplies on the dressing cart, walked down the hall to throw trash away in utility closet, returned to cart and then performed hand hygiene. On 5/16/22 at 3:14 PM, R6 stated, The girl didn't put my boots on. It depends who helps you if they get put on. R6 was unsure when his heel dressing came off. On 5/16/22 at 3:16 PM, V13 stated that R6 has 2 sets of heel boots ones for sitting up and ones for lying down. On 5/16/22 at 3:14 PM 2 sets of heel boots were observed on R6's floor next to the head of the bed. On 5/19/22 at 1:41 PM, V3, Assistant Director of Nurses (ADON), stated that R6's wound should have been cleansed again and that V13 knew better than to just dress the wound trapping in possible debris. 2. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's MDS, dated [DATE], documents R31 is cognitively intact, requires extensive assistance from 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. On 05/16/22 at 10:30 AM, V23 Nurse Practitioner and V13 entered R31 to apply a new dressing to R31's pressure ulcers. V23 donned gloves without hand hygiene, applied wound cleaner to a gauze pad, cleansed the pressure ulcer on the upper coccyx, flipped the gauze pad and cleansed the left buttock wound. With the same gloves, V23 applied Santyl with a q-tip then placed a heart shaped dressing to the upper coccyx. On 5/19/22 3:40 PM, V31 Regional Nurse stated that a Nurse Practitioner should know better, and she expects if an area is dirty to clean it again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. On 5/18/22 at 10:25 AM, R9 stated I liked to go eat in the dining room. I really wasn't too much into the activities, but I did go because I enjoyed talking to others in the dining room. I would like to go again. R9's Care Plan dated 3/2/22, documents (R9) is alert and oriented with confusion at times. (R9) does not have a diagnosis of dementia. (R9) is able to use his call light. (R9) is able to initiate conversations and express his needs well. (R9) is understood and understands others. (R9's) hearing and speech are adequate. It continues Please give (R9) a What's Up sheet every day, and a monthly calendar so he knows when things are. Please remind (R9) when activities are so he can decide to participate or not. Please encourage (R9) to participate in activities. 9. On 5/18/22 at 10:20 AM, R13 stated Oh yes, I liked getting out of my room. I liked to do a little of everything. I really miss eating in the dining room. I used to go in and talk to people. That was my social hour. I did like to play bingo too. R13's Care Plan dated 2/23/22, documents (R13) is alert and oriented and can make needs known. It continues Please give me a What's Up every day and a monthly calendar so he knows when things are. Please remind him when activities are so he can decide to participate or not. R13's MDS dated [DATE], documents R13 is cognitively intact. 10. On 5/18/22 at 9:30 AM, R39 stated I wasn't much for Bingo, but I did like to go to some of the other activities and to the dining room to eat. R39's MDS dated [DATE], documents that R39 is cognitively intact. On 5/18/22 at 9:55 AM, V19, Certified Nursing Assistant (CNA), stated Since COVID-19, we have not been able to take residents out of their rooms for dining or activities. I think it is because the area's percentage is high, and we won't be able to take them out of their rooms until it drops. The facility policy, Exhibit D Resident [NAME] of Rights, undated, documents, 19. To participate in other activities, including social, religious and community activities that do not interfere with the rights of other residents in the facility. Based on observation, interview and record review, the facility failed to promote residents' dignity by allowing them access to communal dining and group activities for 10 of 10 residents (R9, R11, R13, R18, R27, R37, R39, R50, R56 and R61) reviewed for dignity in a sample of 33. Findings include: 1. R50's Minimum Data Set (MDS), dated [DATE], documents that R50 is cognitively intact. On 5/16/2022 at 1:15 PM R50 stated that he is the president of Resident Council. R50 stated that all of the residents are in their rooms. R50 stated that he assumes it's because of the person testing positive for COVID but unsure. R50 stated that he overheard the nurses talking about it but have not been told directly what the reason is. R50 stated that he would like to be out of his room. On 5/19/2022 at 8:58 AM V28, [NAME] County Health Department COVID representative, stated that she was notified by the facility of their recent COVID outbreak. V28 stated that she gave the facility written guidance and told them specific pages to look at. V28 stated that she informed the facility that the residents that were fully vaccinated were still able to go about the facility to meals. V28 stated that she did not tell the facility to stop out of room activities for vaccinated residents. V28 stated that she informed the facility to continue visitation. V28 again stated that she did not tell the facility to stop out of room activities. On 5/19/2022 at 11:40 AM V2, Assistant Director of Nurses, ADON, stated that when she spoke with V28 she was instructed by her with the staff and felt it was not clear to her as to isolation for the residents. V2 stated that she was informed that she could always do more. V2 stated that she thought that keeping the resident in their rooms was the directive. 2. On 05/16/2022 from 9:51 AM until 12:00 PM, R18 was sitting up at nurse's station, playing with a paper facemask that was not on her face. R18 was not involved with any activities. On 05/17/2022 from 9:00 AM until 12:00 PM, R18 was sitting up across from the nurse's station. On 05/18/2022 at 10:30 AM, R18 sitting up to wheelchair, in the doorway of her room. On 05/18/2022 at 2:15 PM, R18 was lying in bed during the activity of hallway bingo. R18's Care Plan, dated 3/26/2022, documents Please remind me when activities are so I can decide to participate or not. 3. On 05/18/2022 at 9:51 AM, R27 stated that he wants to be able to get out of his room and talk to people. He also stated that he wants to go to activities and that he misses it. R27's MDS, dated [DATE], documented that his cognition was intact. 4. On 05/16/2022 from 11:17 AM to 12:30 PM, R37 was sitting up to the high back wheelchair up at nurse's station. He was not participating in an activity. On 05/17/2022 at 09:35 AM, V32, Activity Aide was going around with a coffee cart and did not stop in R37's room and provide him with coffee. At 9:41 AM, V32 left the hallway without offering coffee or activity to R37. On 05/18/2022 at 2:15 PM, R37 was in bed during the activity of hallway bingo. R37's Care Plan, dated 3/23/2022, documents, Activities/Psychosocial/Spirituality. Ask me if I would like to participate in activities at this time. It continues, Please remind me when activities are so I can choose to participate. Please encourage me to participate in activities. 5. On 05/17/2022 at 09:35 AM, V32 was going around with coffee cart did not stop by R61's room. At 9:41 AM, V32 left hallway without offering coffee or an activity to R61. On 05/18/2022 at 2:15 PM R61 was lying in bed, hallway bingo was being played. R61 stated that she would have liked to played bingo. R61's Care Plan, undated, documented Activities/Psychosocial/Spirituality. I enjoy card games, BINGO, watching TV mostly the Hallmark channel. 6. On 05/17/22 at 11:49 AM, V29, R11's daughter, stated, I don't think they should be locked down again. She (R11) can't see so those papers they hand out for them to do. They tell me she walks the halls. I tell them it's because she is bored and there is nothing for them to do. She is vaccinated and boosted. On 5/17/22 at 2:15 PM, V32 stated, We are doing room activities. I went around today and did resident education. They can read the education and do the games on the back. I don't know how much (R11) got out of it though with her dementia. With the coffee club, I hand out a paper with quotes and quizzes on it. We also have the ability to stream movies into the residents' rooms. We do one in the morning and one in the evening. Unfortunately, the system broke last week so that is not working. Tomorrow we will do coffee club in the morning and at 2:00 PM we will do bingo. They come to the doorway and play. I call all the numbers over the telephone system. We will have 6 games of bingo 5 regular games and one cover all. The residents that are more confused the aides will help. The more confused residents we do one to one's on. I will go in and talk to them or watch tv with them. The residents were enjoying being back out in the building. It took some residents awhile before they got back into the activities, so I hope this doesn't last long. V32 stated that coffee club is the snack cart that she goes around with in the morning. 7. On 05/16/22 at 12:31 PM, R56 was questioned about how she feels about being quarantined, R56 stated, I don't know how to feel. At first, I thought we would be locked down for 10 days and now I found out it is 14 days. I am vaccinated and boosted. They test me twice a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 5/16/22 at 9:50 AM, R41 was sitting in his wheelchair with Oxygen being administered at one and a half liters per nasal cannula. On 5/17/22 at 8:45 AM, R41 was sitting in his wheelchair with Oxygen on at one and a half liters per nasal cannula. R41's Physician Order dated 4/20/22, documents Oxygen two liters nasal cannula as needed to keep sats above ninety two percent. R41's Physician Order dated 4/20/22, documents BIPAP (bilevel positive airway pressure) nightly and as needed per instructions. R41's Physician Order dated 4/20/22, documents Iprat-Albut 0.5-3 (2.5) mg/3ml solution for Nebulizer, take 3ml by inhalation every six hours as needed for shortness of breath or wheezing. R41's Care Plan dated 4/14/22, documents (R41) has a diagnosis of Paroxysmal Atrial Fibrillation, COPD, Pulmonary Hypertension, Chronic Respiratory Failure with hypoxia or hypercapnia, Hypertension and Edema. Give all medications as ordered and monitor for any adverse effects of the medication. Routinely assess my vital signs, listen to heart, lung and abdominal sounds and report to nurse/physician if problems. R41's Care Plan does not document R41's use of Oxygen or Respiratory Care such as BIPAP. On 5/18/22 at 3:40 PM, V31, Corporate Nurse, stated the Care Plan tags are the hardest to clear because they always needed updated. The facility's policy, Comprehensive person-centered care plans, dated 03/2018, documents, Comprehensive Person-Centered Care Plan (CCP)-contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. 3. On 05/18/22 at 10:00 AM, R37 way lying in bed. R37 had bed rails up at the head of his bed. R37's Side Rail Evaluation, dated 6/23/2021, documents the need of assist rails for turning and repositioning in bed. R37's Care Plan, with a goal date for his Care Plan was 06/22/2022, does not document the need for bedrails. 4. On 05/18/22 at 10:08 AM R61 was lying in bed and had bilateral 1/4 bedrails up. R61's Bed rail evaluation dated 5/14/2021 documents the use of assist rails for both sides. R61's Care Plan dated 5/2/2022 does not address the use of bedrails. R61's Care Plan dated 5/2/2022 does not address the use of bedrails. Based on interview and record review, the facility failed to individualize and address the current needs of residents on the Care Plan for 5 of 16 residents (R7, R31, R37, R41, R61) reviewed for Care Plans in the sample of 33. Findings include: 1. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's Medication Record, dated May 2022, documents, Bactrim DS 1 tab (tablet) po (by mouth) bid (two times a day) x 10 days. Start date of 5/9/22. R7's Treatment Record, dated May 2022, documents, Cleanse wound to left lateral foot with WC (wound cleanser), apply Melgisorb AG and cover dressing daily and prn (as needed) until resolved. R7's Initial Weekly Wound document, dated 5/18/22, documents that R7 has an unstageable pressure ulcer on her left lateral foot measuring 1.0 x 0.7 x 0.2 cm (centimeters). This wound document also documents, Notes: 3/30 resident was noted to have blood filled blister with purple discoloration to surrounding tissue MD (Medical Doctor) and RR (Resident Representative) notified. Treatment order received 5/9 Blood blister opened and was reclassified as unstageable. MD and RR notified, Tx (treatment) orders. Treatment provided 5/17 and 5/18 FNP (facility Nurse Practitioner) notified and requesting orders. Resident did state pain when area is touched or bumped, refused pain medication from this nurse this AM and states that she has no pain when area is not touched. Currently on antibiotic will continue to observe. R7's Care Plan, goal date 5/16/22, fails to document R7's left lateral foot pressure ulcer. 2. On 5/1/6/22 at 11:01 AM, R31's indwelling urinary catheter drainage bag was observed with clear amber urine. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's Treatment Record, dated May 2022, documents 20 FR (French)/ 10 ml (milliliters) indwelling (urinary) catheter. change month et (and) PRN (as needed) (placed 3/24/22 per Urology). R31's Care Plan, dated 12/29/20, fails to document that R31 has an indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 5/18/22 at 10:25 AM, R9 stated I liked to go eat in the dining room. I really wasn't too much into the activities, but I did go because I enjoyed talking to others in the dining room. R9's Care Plan dated 3/2/22, documents (R9) is alert and oriented with confusion at times. (R9) does not have a diagnosis of dementia. (R9) is able to use his call light. (R9) is able to initiate conversations and express his needs well. (R9) is understood and understands others. (R9's) hearing and speech are adequate. It continues Please give (R9) a What's Up sheet every day and a monthly calendar so he knows when things are. Please remind (R9) when activities are so he can decide to participate or not. Please encourage (R9) to participate in activities. On 5/18/22 at 9:55 AM, V19, Certified Nurse's Aide, CNA, stated Since COVID-19, we have not been able to take residents out of their rooms for dining or activities. I think it is because the area's percentage is high, and we won't be able to take them out of their rooms until it drops. 7. On 5/18/22 at 10:20 AM, R13 stated Oh yes, I liked getting out of my room. I liked to do a little of everything. I really miss eating in the dining room. I used to go in and talk to people. That was my social hour. I did like to play bingo too. R13's Care Plan dated 2/23/22, documents Please give me a What's Up every day and a monthly calendar so he knows when things are. Please remind him when activities are so he can decide to participate or not. R13's MDS dated [DATE], documents R13 is cognitively intact. 8. On 5/18/22 at 9:30 AM, R39 stated I wasn't much for Bingo, but I did like to go to some of the other activities and to the dining room to eat. R39's Care Plan dated 4/4/22, documents Please give (R39) a What's Up every day and a monthly calendar so he knows when things are. Please remind (R39) when activities are so he can decide to go or not. Please encourage (R39) to attend out of the room activities. R39's MDS dated [DATE], documents that R39 is cognitively intact. On 5/19/2022 at 8:58 AM V28, [NAME] County Health Department COVID representative, stated that she was notified by the facility of their recent COVID-19 outbreak. V28 stated that she gave the facility written guidance and told them specific pages to look at. V28 stated that she informed the facility that the residents that were fully vaccinated were still able to go about the facility to meals. V28 stated that she did not tell the facility to stop out of room activities for vaccinated residents. V28 stated that she informed the facility to continue visitation. V28 again stated that she did not tell the facility to stop out of room activities. On 5/19/2022 at 11:40 AM V2, Assistant Director of Nurses, ADON, stated that when she spoke with V28 she was instructed by her with the staff and felt it was not clear to her as to isolation for the residents. V2 stated that she was informed that she could always do more. V2 stated that she thought that keeping the resident in their rooms was the directive. The facility's policy, Coronavirus (COVID19), 02/2022, documented, 3. Resident who are fully vaccinated may dine and participate in activities without face coverings or social distancing if all participating residents are fully vaccinated. If unvaccinated residents are present during communal dining or activities, then all residents should use face coverings when not eating and unvaccinated resident should physically distance from others. Based on observation, interview and record review, the facility failed to provide activities to promote psychosocial well-being for 8 of 8 residents (R9, R11, R13, R18, R27, R37, R39, and R61) reviewed for activities, in a sample of 33. Findings include: 1. On 05/16/2022 from 9:51 AM until 12:00 PM, R18 was sitting up at nurse's station, playing with a paper facemask that was not on her face. R18 was not involved with any activities. On 05/17/2022 at 9:00 AM, R18 was sitting up across from the nurse's station and was not involved with an activity. At 12:30 PM, R18 remained sitting up across from the nurse's station in her wheelchair not engaged in any activities. On 05/18/22 at 10:30 AM, R18 was sitting up in her wheelchair, in the doorway of her room drinking a cup of coffee. On 05/18/2022 at 2:15 PM, R18 was lying in bed while an activity of hallway bingo was occurring. R18's Care Plan, dated 3/26/2022, documents Please remind me when activities are so I can decide to participate or not. 2. On 05/18/2022 at 9:51 AM, R27 stated that he wants to be able to get out of his room and talk to people. He also stated that he wants to go to activities and that he misses it. R27's Minimum data set (MDS), dated [DATE], documented that his cognition was intact. 3. On 05/16/2022 from 11:17 AM to 12:30 pm, R37 was sitting up to the high back wheelchair up at nurse's station, he was not participating in an activity. On 05/17/2022 at 09:35 AM, V32, Activity Aide was going around with coffee cart and did not stop at his room. At 09:41 AM, V32 left the hallway without offering coffee or activity to R37. On 05/18/2022 at 02:15 PM, R37 was in bed during the activity of hallway bingo. R37's Care Plan, dated 3/23/2022, documents, Activities/Psychosocial/Spirituality. Ask me if I would like to participate in activities at this time. It continues, Please remind me when activities are so I can choose to participate. Please encourage me to participate in activities. 4. On 05/17/2022 at 09:35 AM, V32 was going around with coffee cart did not stop R61's room. At 9:41 AM, V32 left hallway without offering coffee or an activity to R61. On 05/18/2022 at 2:15 PM R61 was lying in bed, hallway bingo was being played. R61 stated that she would have liked to played bingo. R61's Care Plan, undated, documented Activities/Psychosocial/Spirituality. I enjoy card games, BINGO, watching TV mostly the Hallmark channel. 5. On 05/17/22 at 11:49 AM V29, R11's daughter, stated, I don't think they should be locked down again. She can't see so those papers they hand out for them to do she can't. They tell me she walks the halls. I tell them it's because she is bored and there is nothing for them to do. She is vaccinated and boosted. On 5/17/22 at 2:15 PM, V32 stated, We are doing room activities. I went around today and did resident education. They can read the education and do the games on the back. I don't know how much (R11) got out of it though with her dementia. With the coffee club I hand had out a paper with quotes and quizzes on it. We also have the ability to stream movies into the resident's rooms. We do one in the morning and one in the evening. Unfortunately, the system broke last week so that is not working. Tomorrow we will do coffee club in the morning and at 2:00 PM we will do bingo. They come to the doorway and play. I call all the numbers over the telephone system. We will have 6 games of bingo 5 regular games and one cover all. The residents that are more confused the aides will help. The more confused residents we do one's to one's on. I will go in and talk to them or watch tv with them. The residents were enjoying being back out in the building. It took some residents awhile before they got back into the activities, so I hope this doesn't last long. V32 stated that coffee club is the snack cart that she goes around with in the morning. On 05/18/22 at 2:26 PM, R11 is asleep in her bed during the hall bingo game. R11's Face Sheet, print date of 5/19/22, documents R11 was admitted on [DATE] and has a diagnosis of Dementia. R11's MDS, print date of 5/19/22, documents that R11 is severely cognitively impaired. R11's Care Plan, dated 12/7/20, documents, Activities/Psychosocial/Spirituality, Please give me a 'What's Up' every day and a monthly calendar so know when things are. Please remind me when activities are so I can decide to participate or note. It continues, I am seen for small group. I receive a daily work packet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 5/17/22 at 9:42 AM, V11, CNA, and V7, CNA assisted R3 to bed using a full body mechanical lift. V11 and V7 did not check to see if the full body mechanical lift sling straps were attached to the lift arm prior to R3 being lifted off her wheelchair. While R3 was transferred to her bed, V11 and V7 did not hold onto her as she was freely swinging in the air while V11 moved the wheelchair. V11 then pulled R3 towards the bed while V7 lowered R3 to bed and disconnected from the device. On 5/19/22 at 1:20 PM, V19, CNA, stated When I am transferring someone using a (full body mechanical lift), I usually use the blue strap at the top and the purple strap at the bottom. We always have two people doing this. Once the resident is hooked up, I will pull the resident back with the lift while the second person will hold the resident like a spotter towards the bed, then we will lower them. R3's Care Plan dated 5/9/22, documents (R3) has left sided hemiplegia and is not safe to get up on her own. (R3) is a two person assist using the total lift with a purple edged sling. It continues (R3) has a diagnosis of Arthritis, Hemaplegia left sided and Stroke Syndrome . (R3) is unable to walk or transfer herself. (R3) is a two person assist using the total lift with a purple edged sling. R3's MDS dated [DATE], documents R3 has a moderate cognitive impairment and is totally dependent of two staff members for transfers. 5. On 5/16/22 at 1:15 PM, V7, CNA, and V8, CNA, transferred R48 from her geriatric chair to her bed using a full body mechanical lift. V7 and V8 attached the full body mechanical lift sling straps to the lift arm and R48 was lifted off her wheelchair without V7 and V8 checking if the straps were securely connected. R48 was moved approximately 3 feet to her bed with no one holding her during the move as she was freely swinging in the air. R48 was then lowered to her bed. R48's Care Plan dated 4/18/22, documents (R48) is a fall risk due to history of falls and diagnoses of Convulsions, status post CVA (Cerebral Vascular Accident) and Osteoporosis. The Care Plan documents (R48) is an assist of two with total lift for transfers. R48's MDS dated [DATE], documents that R48 has a severe cognitive impairment and requires extensive assistance from two staff members for transfers. On 5/19/22 at 1:45 PM, V3, ADON, stated Yes, I would expect the staff to maintain contact at all times with the resident while transferring using a full body mechanical lift. The Facility's (Total Body Mechanical Lift Policy, dated 8/2016, documents 6. Attach the sling using color coded straps, position sling under resident with base of divided leg sling at base of spine, top of sling at top of head. Cross straps prior to hooking to hanger bar. 7. Place the straps of the sling over hooks of the swivel bar. 8. Match the corresponding colors on each side of the sling for an even lift of the resident. 10. Before and after transfer, observe all sling loops are securely connected. 11. Stand next to the resident, pump the lift handle or press the UP button on the hand control to slowly raise the lift to the height necessary to clear the surface to make sure the sling is properly connected to the hooks of the swivel bar. Maintain contact with the resident in order to guide or steady the resident during lift, as necessary. Based on observation, interview, and record review, the facility failed to implement fall interventions and provide safe transfers for 5 of 6 residents (R3, R7, R31, R37 and R48) reviewed for accidents/surpervision in the sample of 33. Findings include: 1. On 05/18/2022 at 09:47 AM R37 was in bed asleep and there was no bed alarm in place. On 05/18/2022 at 10:40 AM, V20, Certified Nurse's Aide, CNA, stated that R37 should have a bed alarm while he is in bed. R37's Incident report, dated 05/7/2022, documents, (R37's) visitors put him in bed and left the room leaving the bed in an up position, resident then rolled out of bed and received a new skin tear to his right elbow. He denied hurting anywhere. R37's Care Plan dated 5/7/2022, documents, I had a fall on this day, please educate my family of low bed protocol and proper bed positioning for safety. It continues, I have alarms to my bed and wheelchair for safety awareness. R37's Incident report dated 5/12/2022 at 3:31 AM, documented Staff heard resident yelling for help, when staff went into resident's room resident was (Found on floor) next to bed and nightstand. Resident could not explain occurred. Skin assessment performed. Cut to left eye, skin tear to left elbow and left knee were found. Resident helped into bed. proper footwear was not on. Poor lighting in room (due to) it being bedtime. bed lowered. (Range of Motion) performed and (within normal limits) Wounds were bandaged and steri strips applied. Neuros in place. (As needed) Tylenol given for any pain. Will continue to observe. Cut to left eye, skin tear to left elbow, abrasion on left knee. R37's Minimum Data Set (MDS) dated [DATE], documents that R37 requires extensive assist of 2 staff members to transfer in and out of bed and to be turned and repositioned in bed. On 05/19/2022 at 01:50 PM V3, Assistant Director of Nurses (ADON), stated that R37's bed was in the high position the night of 5/12/2022, when he fell out of bed and that it should have been in the low position. V3 also stated that she would expect the staff to make sure his bed was as low as it can go and that the staff should make sure all bed and chair alarms are in place. 2. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's MDS, dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. On 5/17/22 at 1:52 PM, V13, Licensed Practical Nurse, LPN, V15 CNA and V12 CNA/staff development, all entered R7's room to transfer her to bed. V13 and V12 hooked the mechanical lift sling to the machine. V12 raised R7 up out of her wheelchair using the remote. Once R7 was raised in the full mechanical lift sling. V13 moved to the left side of the bed. V12 pushed R7 over to her bed while in the sling. No staff members held the sling while being pushed to the bedside. 3. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's MDS, dated [DATE], documents R31 is cognitively intact, requires extensive assistance from 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. On 5/16/22 at 10:40 AM, V13 and V16 CNA entered R31's room to transfer her from the bed to her recliner using a full mechanical lift. V13 placed the right upper strap of the sling on the last loop on the strap, V16 placed the left upper strap of the sling on the second last loop on the strap. The bottom strap loops were placed correctly. V16 raised R31 up using the remote control, R31 was tilted to the right, V16 pushed the sling over to the recliner chair. During this time V13 was standing behind V16 holding the indwelling urinary drainage bag. V16 went behind the recliner and pulled the sling while V13 was operating the remote to lower R31 into her recliner chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for 4 of 7 residents (R7, R48, R51, R54) reviewed for incontinent care in the sample of 33. Findings include: 1. On 5/16/22 at 1:15 PM, V7, Certified Nursing Assistant (CNA) and V8, CNA, transferred R48 from her geriatric chair to her bed via full body mechanical lift. R48's pants were removed and R48 was turned to her side. V7 pulled some wipes out of the package and put them on her bed. V7 reached between R48's legs from behind and wiped from the vaginal area to anal area. Using the same gloves used to clean R48, V7 put some moisture barrier cream on the clean incontinence brief and spread it all over the clean incontinence brief with his hands. V7 then used same gloves to put on a new incontinence brief. R48 rolled over to her back and her vagina and both groins were wiped. R48 was not dried prior to putting on a new brief. V7 stated I got the new depends wet with the wipes, so now we need to put a new one on. R48's buttock was cleansed again due to moisture barrier cream from the previous incontinence brief all over her buttocks. V7 then applied the moisture barrier cream to R48's buttocks and then applied another incontinence brief. R48's Minimum Data Set (MDS) dated [DATE], documents that R48 has a severe cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfers and toilet use. R48 requires extensive assistance from one staff member for dressing, eating, bathing and personal hygiene. R48 is always incontinent of both bowel and bladder. 2. On 5/18/22 at 10:30 AM, R51 stated, I sh** my pants. I will have to tell them. On 5/18/22 at 10:45 AM, V13, Licensed Practical Nurse (LPN), rolled R51 to the right side to view his pressure ulcer. Incontinence brief was untaped and opened to see R51's buttocks. R51's coccyx area had a dry scabbed wound, appeared to be healing well, open to air. While the incontinence brief was opened, there was stool noted on R51's buttocks and anal area and on the incontinent brief. V13 closed the incontinence brief and retaped it, rolled R51 back over and covered him up with a blanket without cleaning R51 and then left the room. On 5/18/22 at 1:50 PM, V19, CNA, stated, (V13) came to us and said that (R51) needs cleaned up because he had messed his pants. She said the surveyor saw this too. I'm not sure why she didn't clean him up when she saw it, especially with you there. On 5/18/22 at 1:55 PM, V18, CNA, stated, If anyone sees that a resident is incontinent, they should clean them up right then and not wait until later. I always check on my residents and clean them if needed. R51's Care Plan dated 4/11/22, documents (R51) is incontinent of both bladder and bowel. (R51) needs staff to do perineal care and apply barrier cream after each incontinent episode. (R51) does wear incontinent products. It continues (R51) needs assistance to turn and reposition in bed and reposition in his chair every two hours and PRN. R51's MDS dated [DATE], documents R51 has a moderate cognitive impairment and is totally dependent on two staff members for transfers. R51 requires extensive assistance from two staff members for bed mobility and toilet use. R51 requires extensive assistance from one staff member for dressing, eating, personal hygiene and bathing. R51 is always incontinent of both bowel and bladder. 3. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's MDS, dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. This MDS documents that R7 has an indwelling urinary catheter which R7 does not at this time. On 5/17/22 at 1:35 PM, V13, LPN, stated, (R7) usually sits up all day. The girls will lay her down after meals and change her and then put her back in her chair. She will tell you she likes to sit up. She naps during the day in her chair. On 05/17/22 at 01:39 PM, V16, CNA, stated, (R7) has been up since this morning. Usually, we lay her down after lunch. She has not been changed since she got up this morning. On 5/17/22 at 1:52 PM, V13, LPN, V15, CNA, and V12, CNA/ staff development, all entered R7's room to transfer her to bed. V13 and V12 hooked the mechanical lift sling to the machine. V12 raised R7 up out of her wheelchair using the remote. Once R7 was raised in the full mechanical lift sling, R7's pants and the seat of her wheelchair was visibly saturated with urine. Upon lying down, V13 stated, (R7) I am so sorry the girls know better than this. R7 placed on the bed, the sheet immediately became wet, R7 was rolled to her left side, V15 began to take the sheet off and R7's pants. V13 and V12 both left the room. V26, CNA, entered the room. V26 donned gloves without hand hygiene. R7's pants and incontinent brief were removed. R7's pants were saturated with urine from the seat of the pants to the mid-thigh area. The incontinent brief was saturated with urine. V26 placed the saturated mechanical lift sling and pants in a bag. V26 placed the incontinent brief in a trash bag. With the same gloves, V26 wiped R7's rectal area, gluteal folds and buttocks with premoistened cloths. V26 failed to cleanse R7's hips, inner thighs or the back of R7's thighs. R7 was rolled over and V15 wiped the left and right groin and wiped the labia. V15 failed to cleanse the inner thighs or the pubic area. 4. R54's Face Sheet, dated May 2022, documents R54 was admitted on [DATE] with diagnoses of Hypertensive chronic kidney disease w (with) stg (stage) 1-4 unsp (unspecified). R54's MDS, dated [DATE], documents that R54 is severely cognitively impaired, totally dependent on 2 staff members for transfer, totally dependent on one staff member for toileting and personal hygiene and is always incontinent of bowel and bladder. R54's Care Plan, dated 5/3/22, documents, I am incontinent of both my bowels and bladder and need assistance of staff for pericare after each incontinent episode. Please apply barrier cream each shift and PRN (as needed). On 5/17/22 at 9:32 AM, V16, CNA, and V15 transferred R54 to bed. R54's pants and incontinent brief were removed. R54's incontinent brief was wet with urine. V16 washed hands and donned gloves, V16 cleansed the left groin, the right groin, retracted R54's foreskin and cleaned the meatus and surrounding area, V16 replaced the foreskin, V16 cleansed the scrotum and the buttocks. R54's scrotum was very red and irritated. V16 failed to cleanse the penis. V16 failed to apply barrier cream. On 5/18/22 3:40 PM, V31, Corporate Nurse, stated that all areas soiled should be cleansed. The Facility's Incontinent Care Policy dated 1/2015, documents To provide routine, preventive skin, perineal care to residents after an incontinent episode. It continues, Procedure: 7. Put on gloves before removing wet and/or soiled items. 10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire area moving from front to back. 14. Dry the perineal area front to back and all skin surfaces washed. 16. Remove gloves and discard. Wash hands. 17. Place a dry brief on the resident. 22. Wash hands.

Based on interview, observation and record review, the facility failed to provide respiratory care, including the changing of the humidified bottle and the dating and timing of both the humidified bottle and nasal cannula for 4 of 4 residents (R8, R23, R41, R46) reviewed for respiratory care in the sample of 33. Findings include: 1. On 5/16/22 at 11:05 AM, R8 had Oxygen being administered at 2 liters per nasal cannula. The humidified water bottle was empty and was dated 5/1/22. The nasal cannula was not dated. R8's Physician Order dated 3/10/21, documents O2 (Oxygen) at 2 Liters per Nasal Cannula continuous. R8's Care Plan dated 5/16/22, documents (R8) has a diagnosis of Diabetes Mellitus, Alzheimer's, Dementia, COPD (chronic obstructive pulmonary disease), Heart Failure, Depression and Anxiety that (R8) takes medications for. (R8) has accuchecks twice daily with routine insulin per physician order. (R8) also wears Oxygen per nasal cannula continuously. 2. On 5/16/22 at 9:50 AM, R41 was sitting in his wheelchair with Oxygen being administered at one and a half liters per nasal cannula. R41 stated he's out of water in his oxygen. Humidified water bottle for the oxygen is empty, dry and not dated. R41's Oxygen cannula was also not dated. On 5/17/22 at 8:45 AM, R41 was sitting in his wheelchair with Oxygen on at one and a half liters per nasal cannula. A new Humidified water bottle is now labeled with a date of 5/16/22. R41's Oxygen nasal cannula was still not labeled or dated. R41's Care Plan dated 4/14/22, documents (R41) has a diagnosis of Paroxysmal Atrial Fibrillation, COPD, Pulmonary Hypertension, Chronic Respiratory Failure with hypoxia or hypercapnia, Hypertension and Edema. Give all medications as ordered and monitor for any adverse effects of the medication. Routinely assess my vital signs, listen to heart, lung and abdominal sounds and report to nurse/physician if problems. 3. On 5/16/22 at 10:40 AM, R46 was sitting in her recliner with Oxygen being administered at three Liters per nasal cannula. The humidified water bottle was dry and not labeled or dated and R46's nasal cannula was also not dated. R46's Physician's Order dated 7/5/22, documents Oxygen continuous at one and a half liters per nasal cannula, may increase Oxygen with activity to maintain saturation greater than ninety percent. R46's Care Plan dated 4/11/22, documents (R46) has a diagnosis of Hypertension, Hypercholesterolemia, Depression and COPD that (R46) takes daily medications for. (R46) requires continuous Oxygen per nasal cannula per physician order and does get short of breath with exertion. On 5/17/22 at 2:10 PM, V13, Licensed Practical Nurse (LPN), stated There are tasks for each shift to get done on our daily sheets. For example oxygen tubing and water changes are done on Sunday Nights only. On 5/19/22 at 1:40 PM, V3, Assistant Director of Nursing (ADON), stated We don't really have a policy for changing the oxygen tubing and water, however, we do use the form that we use for each day for staff to check off. The nights are supposed to change the oxygen tubing and water on Sundays. 4. On 05/16/2022 at 10:20 AM, R23 was lying in bed, had an undated oxygen tubing and the oxygen concentrator did not have a humidified water bottle. R23's Face sheet, dated 05/19/2022, documents a diagnosis of Chronic obstructive pulmonary disease. R23's Care Plan, undated, documented, I am also on oxygen per nasal cannula. The Facility's Continuous Aerosol on Oxygen Policy dated 1/2015, documents To use continuous aerosol on oxygen to assist with secretion management while delivering oxygen. It continues Equipment needed: 1. Oxygen source. 2. Aerosol bottle (prefilled or refillable). 3. Disposable aerosol tubing. 4. Trach/Aerosol mask. 5. Drain bag. 6. Sterile water. &. Oxygen adapter. It continues Procedure: 3. Fill non-prefilled nebulizer with sterile water or assemble prefilled unit. It continues 8. Date individual components.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 05/18/22 at 10:00 AM, R37 was lying in bed, rails were up at the head of his bed. R37's side rail evaluation, dated 6/23/2021, documents the need of assist rails for turning and repositioning in bed. R37 last reduction of physical restraints was dated 6/23/2021. R37's Care Plan, with a goal date for his Care Plan was 06/22/2022, does not documents the need for bedrails. 5. On 05/18/22 at 10:08 AM, R61 was lying in bed, bilateral 1/4 bedrails were up. R61's Bed rail evaluation dated 5/14/2021 documents the use of assist rails for both sides. R61's most recent restraint (physical) reduction attempt was 5/14/2021. R61's Care Plan dated 5/2/2022 does not address the use of bedrails. The facility's policy, Restraint Evaluation and Restraint Reduction, dated 08/2013, documented, 2. All resident using a restraint are to be evaluated and re-evaluated approximately every quarter. It continues, 3. All residents who have evaluations which justify the use of restraints are to be using the least restrictive method possible as identified by the interdisciplinary team. Based on interview, observation and record review, the facility failed to evaluate and assess the use of side rails in a timely manner and explain the risk versus benefits of the use of side rails for 5 of 6 residents (R7, R31, R37, R54, R61) reviewed for side rails in the sample of 33. Findings include: 1. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's Minimum Data Set (MDS), dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. R7's Side Rail Evaluation, dated 5/18/22, documents that R7 had a side rail evaluation done 8/13/21 and then 5/18/22 both of these documents list the only risk of having a side rail physical contact. On 5/18/22 at 1:48 PM, R7 was observed in bed with bilateral half rails raised in up position. 2. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's MDS, dated [DATE], documents R31 is cognitively intact, requires extensive assistance from 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. R31's Side Rail Evaluation, dated 5/18/22, documents that R31 had a side rail evaluation done 8/13/21 and then 5/18/22 both of these documents list the only risk of having a side rail physical contact. On 5/16/22 at 10:30 AM, R31 was lying in bed with bilateral half side rails raised in the up position. 3. On 05/16/22 at 1:50 PM, R54 was sitting at the nurses station. R54 had a black purple bruising to his left eye, cheek and neck. On 5/16/22 at 1:51 PM, V2, Director of Nurses (DON), stated, (R54) rolled out of his bed. R54's Face Sheet, dated May 2022, documents R54 was admitted on [DATE] with diagnoses of Hypertensive chronic kidney disease w (with) stg (stage) 1-4 unsp (unspecified). R54's MDS, dated [DATE], documents that R54 is severely cognitively impaired, totally dependent on 2 staff members for transfer and requires extensive assistance of 2 staff members for bed mobility. R54's Care Plan, dated 5/3/22, documents, Safety Notes: I am not safe to get up on my own. It continues, Keep items that I frequently use within my reach on my right side while keeping the area free of clutter and safety hazards. It continues, 5/3/22 I have a low bed and landing strips dt (due to) my fall this day /bed side mat. R54's Care Plan fails to document the use of bed rails. On 5/18/22 at 1:42 PM, R54's Medical Record failed to document a bed rail assessment for R54. On 5/18/22 at 1:48 PM, R54 was lying in bed on his left side with bilateral half bed rails raised. On 5/19/22, the facility provided a Side Rail Evaluation, dated 5/18/22, this form fails to document the risks of using the side rails. On 5/19/22 at 1:50 PM, V3, Assistant Director of Nurses, stated that she did not realize that she was the one that was supposed to be doing the assessments so when she realized it she did them. V3 further stated that she did not realize the risks versus benefits need to be clearly written and that all risks of having a side rail must be listed.

Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 62 residents in the facility. Findings include: There was no consecutive 8-hour RN coverage in 24 hours on 1/2/22, 1/11/22, 1/15/22, 1/20/22, 1/30/22, 2/7/22, 2/8/22, 3/6/22, 4/20/22, 4/22/22, 4/23/22, 4/29/22, 5/3/22, 5/7/22, 5/8/22, 5/12/22, 5/17/22. On 5/18/2022 at 11:30 AM, the Nursing Working staffing schedule from 1/1/2022 through 5/18/2022 was reviewed with V3, Assistant Director of Nurses. V3 stated that the facility has had some staffing concerns. V3 stated that they are actively recruiting and currently using agency staff to fill shifts. V3 stated that she does not handle the RN schedules and that RN coverage would need to be discussed with V2, Director of Nurses. V3 stated that V2 is out on medical leave at this time and is not available. On 5/19/2022 at 10:27 AM, V2, Administrator, stated that the facility does not have a staffing policy. V2 stated that they follow state and federal guidelines for staffing. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility.

Based on observation, interview, and record review, the facility failed to properly store medication, label insulin and discard expired medications. This has the potential to affect all 62 residents living in the facility. Findings include: On 5/17/2022 at 9:15 AM, the North Apple Blossom Street Hall medication cart was inspected. The medication cart contained the following medications: 1. R10's Basaglar 100 unit/ml (milliliter) Kwikpen without open date. V9, Licensed Practical Nurse (LPN). Verified that the medication was open and in use. On 5/17/2022 at 9:17 AM, V9 stated that the Basaglar should have an open date. V9 stated that the the medication should not be used without the open date. V9 stated that there is a specific time that the medication can be used and this is why the open date is important so that the medication is not used past the ?? days. V9 stated that she would destroy the medication. On 5/18/2022 at 2:05PM, V3, Assistant Director of Nursing (ADON), stated that the insulin, tuberculin has a specific use time once open. V3 stated that the open date or the end date is important and one of them should be on the bottle to let the nurses know when it was open so that the medication won't be used passed its use by date. V3 stated that the expired medications are to be discarded. V3 stated that the nurse is to check the medication expiration date prior to administering medication. This is the triple check system. The Basaglar's Manufacturer instructions documents In-use Pen: Store the Pen you are currently using at room temperature [up to 86°F (30°C)] and away from heat and light. Throw away the Pen you are using after 28 days, even if it still has insulin left in it. On 5/17/2022 at 9:20 AM, the facility's medication storage room was inspected. The refrigerator, located in the medication storage room contained the following: 2. 1 box of Shingrid Zoster Vaccine Recomb adjunct with expiration of 5/7/22 3. Open unlabeled with date opened multi dose vial of Moderna COVID Vaccine. 4. Open unlabeled with date opened multi dose Tuberculin (TB) vial The medication room also had the following: 5. 4 bottles of Flonase 50 mcg (micrograms) with expiration date of 1/2022. On 5/17/2022 at 9:24 AM, V9 stated that the bottles of Flonase and the vial of TB is used for anyone that has an order and not allergic. V9 stated that if there was an order to give the medication she would have used this medication from the medication room and refrigerator. The facility's Medication Storage, policy, dated 11/10, documents Policy: All drugs, treatments, and biological must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. It also documents, Procedure: 12. The following medications must removed from from stock and disposed of properly on a continuous basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. On 5/17/22 at 9:42 AM, V11, CNA, and V7, CNA, assisted R3 to bed using a full body mechanical lift. V11 did not perform hand hygiene or don gloves prior to care done for R3. V7 did not perform hand hygiene prior to care done for R3. Neither CNA performed hand hygiene prior to leaving R3's room. 12. On 5/16/22 at 1:15 PM, V7, CNA and V8, CNA, performed perineal care for R48. V7 pulled wipes out of package and put on bed. V7 used the wipes to reach between R48's legs and wiped from her vaginal area to her anal area. Using the same soiled gloves, V7 applied barrier cream on the clean incontinent brief and spread it all over the brief with his hands. Using the same gloves, V7 put a new incontinence brief on R48. There was no hand hygiene done prior to donning of gloves to care for R48. During perineal care, there was no hand hygiene or glove changes done between the dirty and clean areas. On 5/19/22 at 1:30 PM, V19, CNA, stated When I go into a room to do perineal care, I wash my hands when I get into a room. I will make sure all supplies are set up in the room and once I touch a dirty field, I will change my gloves and use hand sanitizer. Once I do this three times, I will go and actually wash my hands. After cleaning the resident, they usually dry to air. I think our wipes dry quickly. The Facility's Hand Washing Policy dated 9/2019, documents Staff will use proper hand washing technique to prevent the spread of infection. The Facility's Proper Hand Washing and Glove Use Guideline, dated 2016, documents All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines. It continues Procedure: 4. Employees will wash hands before and after working with an individual resident. 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. 8. Staff should be reminded that gloves become contaminated just as hands do, and should be changed often. When in doubt, remove gloves and wash hands again. 9. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/22 documents that the facility has 62 residents living in the facility. Based on interview, observation and record review, the facility failed to appropriately use PPE (personal protective equipment), secure airflow from a COVID positive room from coming into the hallway, clean multi-use equipment, and perform hand hygiene to prevent/control the spread of COVID-19 and other contaminants. This has the potential to affect all 62 residents living in the facility. Findings include: 1. The Facility's undated document lists R2 as positive for COVID-19. R2's POC (point of care rapid test) Test Result Reporting, dated 05/07/2022, documented R2 was positive for COVID-19. R2's Health and Wellness Care Plan, dated 5/7/22, documents, I have tested positive for COVID-19 I am on droplet precautions per CDC (Center for Disease Control) guidelines. On 05/16/2022 at 10:04 AM, R2 was on isolation for being COVID-19 positive on 5/7/22. There were 2 doors frames covered with heavy see-through plastic that leads into her room. The outside barrier had a 4 inch gap at the top and on the open side and there was a wheelchair alarm clipped to the plastic barrier. The second doorway that leads into R2's main room also had a frame covered with heavy see-through plastic that had a 5 inch gap and did not reach to the ceiling. On 05/18/2922 at 3:20 PM, V3, Assistant Director of Nurses (ADON), stated that R2 and R21 were roommates when R2 became positive and R21 showed signs and symptoms of COVID-19. 2. The Facility's undated document lists R21 as exposed to COVID-19. R21's Health and Wellness Care Plan documents, Droplet isolation per CDC and state guidelines 5/7/22 Please keep door open due to fall risk. On 05/16/2022 at 10:36 AM, R21 was on isolation for exposure for COVID-19. The door frame into R21's room was covered with heavy see-through plastic that did not reach to the ceiling and was gapped open on the side. The gaps measured 4 inches. After V15, Certified Nursing Assistant (CNA), and V17, CNA, used the full mechanical lift for R21 in her room, V15 brought the mechanical lift out of the isolation room and did not clean it. V16, CNA, took the mechanical lift to R54's room. On 05/16/2022 at 11:00 AM, V15 stated that they clean the full mechanical lift with a spray bottle with cleaner in it and could not remember the name of the cleaner, but said it started with a V. Asked if the spray bottle was in R21's room, V15 stated, No, it's usually on the laundry cart. V15 stated that she did not clean the full mechanical lift. 05/18/22 03:12 PM, V30, Regional Clinical Operations Manager, stated that the plastic see through barriers should not gap at the top or on the sides. 05/19/22 03:17 PM, V3, ADON, stated that she would expect the staff to clean the full mechanical lift with the appropriate cleaner after being used on a COVID-19 quarantined resident. 3. On 5/16/2022 at 12:00 PM, V15, CNA, wore a KN95 mask with only one strap securing it in place and the 2nd strap hanging down. 4. On 05/17/2022 at 09:28 AM, V15, CNA, wore a KN95 mask with only one strap securing it in place and the 2nd strap was hanging down and entered R23's room, performed resident care and exited R23's room. V15 then entered R54's room to assist with a transfer with the 2nd strap hanging down. 05/19/22 03:17 PM, V3, ADON, stated that she would expect the staff to wear their facemask and personal protective equipment appropriately. The facility's Coronavirus (COVID19) policy and procedure, dated 2/2022, documents, 4. The infected resident if in a private room can remain in his/her current room on precautions with the door closed. If in a semiprivate refer to the resident and staff isolation/Quarantine guideline for placement. the exposed roommate can be kept in their room with the door closed, if safe to do so. Every effort will be made to minimize movement of the infected resident and suspected resident within the facility. It continues, 6. Personal Protective Equipment (PPE) including gloves, gown, face mask or respirator, eye protection (goggles or face shield) are to be utilized for any healthcare worker entering the resident's room for suspected or confirmed cases. It further documents, Environmental Cleaning, 3. Physical and recreational therapy equipment- Standard facility procedures will be followed for routine cleaning and disinfection of recreational and therapy equipment used by residents with Coronavirus. 5. On 05/18/2022 at 10:20 AM, V35, Licensed Practical Nurse (LPN), donned gloves without benefit of hand hygiene, removed R61's blankets and padded boot from right foot and removed R61's old dressing to right ankle. With clean gloves, V35 opened the applicator package, used the applicator, moved overbed table closer to her with her gloved hand and applied santyl ointment to the wound bed and covered wound with a border dressing without benefit of hand hygiene. 6. On 05/18/2022 at 10:00 AM, R37 was moving left leg upon right foot while V35, LPN, was trying to clean the open area to his right heel. V35, LPN, was trying to move R37's blanket out of the way and then moving R37's left foot with her gloved hands. V35 proceeded to perform wound care and dressing application without benefit of hand hygiene or changing her gloves after touching the dirty surfaces. The facility's policy, Standard Precautions, dated 09/2019, documented, 1. During delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surface. 2. Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. It continues, 6. Environmental control-follow procedures for routine care, cleaning and disinfection of environmental surface, especially frequently touched surfaces in patient care areas. The CDC COVID-19 Data Tracker: County Transmission, dated 5/9/2022 for the week of 5/16/2022, documented that the community transmission rate was high for [NAME] county where the facility was located. The Updated Interim Guidance for the Nursing home and other licensed Long Term Care facilities, dated 03/22/2022, documented, Universal PPE for HCP - Updated o If a resident is suspected or confirmed to have COVID-19 or is not up to date with COVID-19 vaccinations, and the resident is identified to be a close contact, HCP (health care provider) must wear an N95 respirator, eye protection, gown, and gloves. o If a resident is identified to be a close contact and is up to date with COVID-19 vaccinations, HCP must wear PPE according to community transmission levels listed below. o For those residents not suspected to have COVID-19, HCP should use community transmission levels to determine the appropriate PPE to wear. When community transmission levels are substantial or high o At a minimum, HCP must wear a well-fitted mask at all times and eye protection while present in resident care areas. o Facilities might consider having HCP wear N95 respirators at all times while in the facility. o HCP are not required to wear eye protection for COVID-19 when working in non-resident care areas (e.g., offices, main kitchens, maintenance areas) when there are substantial or high community COVID-19 transmission levels. HCP should wear eye protection when entering the resident care areas. 7. On 5/17/22 at 8:45 AM, V24, agency CNA, was collecting breakfast trays out of residents' rooms without wearing eye protection. On 5/17/22 at 8:48 AM, V24 stated that she was tested for COVID last week but not before her shift today, but she was screened at the front door. 8. On 5/17/22 at 8:50 AM, V11, CNA, was caring for residents on the north hall. V11 wore no eye protection and her K95 mask had one of the straps dangling in front of her neck not around her head. 9. On 5/17/22 at 11:37 AM, V25, unit aide, was in R163's lunch order with no eye protection on. 10. On 5/17/22 at 1:52 PM, V13, LPN, V15, CNA, and V12, CNA, staff development, all entered R7's room to transfer R7 to bed and perform incontinent care. V15 and V13 both donned gloves without hand hygiene. V26, CNA, entered the room and donned gloves without hand hygiene. R7's pants and incontinent brief were removed. R7's pants were saturated with urine from the seat of the pants to the mid-thigh area. The incontinent brief was saturated with urine. V26 placed the saturated mechanical lift sling and pants in a bag. V26 placed the incontinent brief in a trash bag. With the same gloves, V26 wiped R7's rectal area, gluteal folds and buttocks with premoistened cloths. On 5/19/22 at 1:40 PM, V3, ADON, stated that hand hygiene should be performed before donning and doffing gloves and that if gloves are soiled they should be changed.