Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food in a sanitary manner and in accordance with professional standards for food service safety. This failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen. The findings include: Review of the facility's Casper Report, last updated 05/04/2025, revealed 45 of 47 residents received their food from the kitchen. 1. Review of the facility's Chemicals policy, revised 02/2023, revealed the purpose of the policy was to ensure all chemicals would be properly stored. Per the policy, all chemicals would be in a separate/secured area. 2. Review of the facility's Equipment policy, revised 05/2014, revealed the purpose of the policy was to ensure that all food service equipment would be clean, sanitary, and in proper working order and areas would be maintained in a clean and sanitary condition. Per the policy, all equipment would be routinely cleaned and maintained in accordance with manufacturer's guidelines and training material. All staff members would be properly trained in the cleaning and maintenance of all equipment. All food contact equipment would be cleaned and sanitized after every use and all non-foods contact equipment would be clean and free of debris. The Dining Services Director would ensure that the physical plant would be maintained in a clean and sanitary manner. Review of the facility's attachment #1 Morning Daily Tasks to be completed revealed the opening dietary staff was to ensure equipment such as the microwave and can opener be cleaned, and the sink was cleaned and drained. Further morning dietary duties included to remove outdated/unmarked products from the refrigerators. In addition, the morning daily tasks included to wipe down the outside of stove, to include backsplash, top shelf, front of oven doors and knobs, remove stove burners and scrub and run through dishwasher. However, the cleaning schedule did not include that the stove grease trap and/or oven were scheduled to be cleaned. Review of the facility's attachment #2 Evening Daily Tasks to be completed revealed the closing dietary staff was to ensure equipment such as the stove to include the backsplash, top shelf, front of oven doors and knobs were wiped down and the stove trays were to be cleaned with no foil. Further dietary evening duties included to remove outdated/unmarked products from the refrigerators and to pull out counters/steam table/milk cooler to ensure to sweep and mop underneath. However, the cleaning schedule did not include that the stove grease trap and/or oven were scheduled to be cleaned. a. Observation during the initial kitchen tour, on 05/05/2025 at 7:10 PM, revealed the sanitation handwashing area to store a one gallon can of paint, one paint dish, one used paint brush and a screwdriver all stacked and stationed underneath the sanitation prep sink area. Further, the flooring surrounding the sanitation area was dirty/soiled/sticky and in need of cleaning. During interview on 05/05/2025 at 7:14 PM, with Dietary Aide (DA)1, she stated normal procedure for the storage of chemicals such as the gallon of paint and supplies should be stored downstairs; however, she had been painting a section in the kitchen approximately two weeks ago and just forgot to store it properly in the maintenance department. DA1 informed it should not be stored in the kitchen especially surrounding the handwashing station due to sanitation purposes. During interview on 05/05/2025 at 8:00 PM, with the Dietary Manager (DM), she stated any type of chemicals including paint should not be stored in the kitchen and/or cooking area due to the potential of a fire and safety concerns. b. Continued observation on 05/05/2025 at 7:40 PM, during initial tour, revealed the milk cooler to have a one (1) inch deep freezer-burnt build-up of solid ice particles circling the back and sides of the inside cooler, as well as a used, uncapped dirty writing pen and dirt/food particles on the floor of the cooler. c. Further observation on 05/05/2025 at 7:55 PM, during initial tour, revealed the heavy equipment such as the stove to have dried food substance and particles with scattered debris in the grease trap. Additional observation of the appearance inside the stove revealed a build-up of a gritty-greased, blackened substance that covered the entire bottom shelf. During an interview on 05/05/2025 at 8:00 PM, with the DM, she stated all the heavy equipment was to be cleaned throughout the day on both shifts and after each use. However, the DM was not able to convey a past cleaning schedule for the heavy equipment such as the inside of the stove and milk cooler. The DM stated that due to their appearance, the DM felt it had not been cleaned per the facility's cleaning schedule. During an interview on 05/06/2025 at 11:45 AM, during tray-line service with [NAME] 2, she stated it was important to sanitize the kitchen area, as well as all the cooking equipment to prevent residents and staff from getting sick and to prevent cross contamination. Cook2 also stated she was not sure the last time the oven had been cleaned. 2. Review of the facility's Food Storage: Cold Foods policy, revised 02/2023, revealed all food items would be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation during the initial tour of the kitchen conducted on 05/05/2024 at 7:26 PM revealed foods were stored open and unsealed, unlabeled, undated and/or past their expiration date. Observations included: a. Refrigerator 1 contained 11 chicken patties with an open date of 04/27/2025 and a used by date of 04/31/2025. b. Refrigerator 1 contained two large bags of mozzarella cheese with an open date of 04/10/2025: however, no discard date. Also, one bag of American cheese with an open date of 04/27/2025 and used by date of 05/04/2025. c. Refrigerator 2 contained a box of sixteen opened eggs, one cracked with yolk spilling out on the container. d. Refrigerator 3 contained a large bag of cut onion slices with an open date of 04/22/2025; however, no discard date. e. Dried storage revealed one bag of 12 hotdog buns expired on 04/16/2025. During an interview on 05/05/2025 at 7:40 PM with Cook1, she stated she threw out leftovers after three days and seven days for newly opened; however, she thought the leftovers were kept longer but was unable to say for sure. When asked why it was important to discard leftovers in a timely manner and per labeling, she stated to prevent people from getting sick. During an interview on 05/05/2025 at 8:00 PM with the DM (who toured with the survey team), revealed each kitchen staff member was responsible for cleaning the kitchen areas of which included the handwashing station, prep stations, surfaces, and floors between equipment, under the equipment and around the equipment in their work area every day after each meal. Continued interview revealed the refrigerators were to be checked one to two times daily per the dietary staff; however, she was unsure of the policy for how long the food items were held after being opened and/or how long it could be kept before disposal. Per the DM, there was a daily cleaning schedule for all staff; however, she indicated the need to start a closer tracking system to monitor the equipment to ensure staff were cleaning the cooking equipment after each meal service, checking to ensure food was being labeled, dated, rotated/discarded, and implementing proper food storage of the refrigerators and freezers. She further stated that she relied on all dietary staff to ensure the kitchen was clean, sanitary and a safe environment. During an interview on 05/08/2025 at 2:00 PM with the Administrator, she stated she expected the kitchen staff to follow facility policies and procedures, as well as the federal and state regulations, pertaining to the kitchen area. In addition, she stated it would be her expectations for the Dietary Manager and kitchen staff to monitor and date all food to ensure accuracy and to discard the outdates for the safety and well-being of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-three (23) sampled residents (Resident #34) was treated with respect and dignity. Observation on 12/20/2021 revealed Resident #34's catheter bag was not covered or blocked from view. The findings include: Review of the facility's policy titled Resident Rights dated 08/16/2018 revealed all residents have the right to be treated with respect and dignity. These rights would be promoted and protected by the facility. All residents would be treated in a manner and in an environment that promoted maintenance or enhancement of qualify of life. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the assessment revealed the resident had an indwelling catheter. Review of Resident #34's care plan dated 08/23/2021 revealed the facility had identified the residen t's nephrostomy catheters which were to divert urine due to bladder cancer. However, the plan did not address the drainage bag or privacy concerns. Observation of Resident #34 on 12/20/2021 at 10:05 AM revealed the resident was sitting in bed with two (2) nephrostomy urine bags laying on the bed. The nephrostomy drainage catheter bags were uncovered, and the resident's bed was visible from the hallway as the privacy curtain was not pulled. Observation of Resident #34 on 12/20/2021 at 1:29 PM, revealed the resident was sitting on the side of his/her bed, with two (2) nephrostomy drainage bags laying on the bed uncovered and visible from the hallway. The privacy curtain was not pulled. Interview with Resident #34, on 12/21/2021 at 8:25 AM, revealed he/she liked to carry his/her urine bags or lay them close to him/her. The resident stated he/she usually did not like bed covers over the urine bags and usually just left the bags laying on the bed. Resident #34 stated staff had not mentioned or offered to place covers over the urine bags. Interview with State Registered Nurse Aide (SRNA) #3, on 12/22/2021 at 1:06 PM, revealed Resident #34 would not wear a leg strap for the catheter bag. She stated Resident #34 had dignity bags, but he/she would remove the dignity bags when placed around the catheter drainage bags. The SRNA stated she knew they should try to cover the bags with the quilt if the resident would not wear the dignity bags. However, she stated she had not offered Resident #34 a privacy bag. The SRNA also stated she should pull the privacy curtain in the resident's room to provide privacy and dignity. Interview with SRNA #4, on 12/22/2021 at 1:17 PM, revealed Resident #34 did not want the dignity bag to cover the catheter drainage bags. He stated sometimes Resident #34 would let him pull the curtain but at times the resident wanted the curtain open to watch people. The SRNA stated he was aware he should pull the privacy curtain in residents' rooms to provide dignity and knew Resident #34's catheter drainage bags should be covered/in dignity bags. However, the SRNA stated he had not offered the dignity bags to the resident or applied them to the drainage bags. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 1:35 PM, revealed Resident #34 preferred to keep the urine drainage bags beside of him/her. She stated staff had not reported Resident #34 refusing to cover them up or refusing dignity bags and was unaware that he/she would not wear the leg straps. She stated she does not know if dignity bags have been offered and stated she had not offered a dignity bag to Resident #34 but knows she should have offered the dignity bags. Interview with Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed she was unaware until this week that Resident #34 was refusing to wear catheter leg straps to secure the catheter to the resident's leg. The DON stated before today, Resident #34's care plan had not included interventions for the use of dignity bags nor had the care plan addressed the resident's refusal to use the dignity bags. Per the DON, the resident's care plan should have included the use of dignity bags and privacy. Interview with Administrator, on 12/22/2021 at 4:24 PM, revealed the facility monitored the residents' care and audits staff providing resident privacy and catheter care. The Administrator stated she expected staff to pull privacy curtains. She stated if Resident #34 does not want to wear the catheter leg straps to secure the catheter then he/she can choose not to wear them, but it should be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to conduct an admission comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one (1) of twenty-three (23) sampled residents (Resident #95). A review of Resident #95's medical record revealed the resident was admitted on [DATE]; however, an admission MDS assessment for Resident #95 was not completed within fourteen (14) days of admission as required. Further, the admission MDS assessment was not completed as of 12/22/2021. the findings include: Interview with the Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed the facility did not have a policy for completing the Minimum Data Set (MDS) assessments; however, the facility followed the Resident Assessment Instrument (RAI) process to complete the assessments. A review of the Long-Term Care Facility Resident Assessment Instrument version 3.0 User's Manual revealed the admission assessment was a comprehensive assessment for a resident that the facility must complete within fourteen (14) days of admission. Review of Resident #95's medical record revealed the facility admitted the resident on 10/28/2021, with diagnoses which included Cerebrovascular Disease, Seizure Disorder, and a Urinary Tract Infection. Further review of the record revealed an admission assessment had not been completed for Resident #95. Interview with the Minimum Data Set (MDS) Nurse on 12/22/2021 at 10:05 AM, revealed she had been off work due to sickness and had not completed the resident's MDS assessment. Per the interview, she stated she was working on completing the assessment, on 12/22/2021. Interview with the Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed she was not aware Resident #95's MDS was late and was not completed. According to the DON, the MDS nurse was off sick, and a corporate nurse was helping while she was off work. Further interview with the DON revealed that due to the MDS nurse being off work, the facility became behind on assessments and a performance improvement plan was developed to complete assessments on current residents; however, the facility did not consider new resident admission assessments in the plan. The DON stated she was unaware Resident 95's admission assessment had not been completed. Interview with the Administrator, on 12/22/2021 at 4:24 PM, revealed she was aware of the late Minimum Data Set (MDS) assessments and incomplete assessments when the MDS nurse was off sick. The Administrator stated the facility had a corporate MDS nurse to assist with the residents' assessments that were late, but the facility did not develop a plan to ensure newly admitted residents were assessed, to prevent further late assessments. Per the Administrator, the facility had not considered discontinuing new admissions until the facility was able to complete the residents' MDS assessments, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy, it was determined the facility failed to revise the plan of care for one (1) of twenty-three (23) sampled residents (Resident #34). Staff interviews revealed Resident #34 often refused the leg straps to secure his/her catheter and dignity bags to cover the catheter drainage bags; however, the facility failed to revise the resident's plan of care to address the refusal of care. The findings include: Review of the facility's policy titled Comprehensive Care Plans last reviewed on 04/14/2021, revealed the care plan would include how the facility would assist the resident to meet their needs, goals and preferences. Person-centered care means the facility focused on the resident as the center of control and supported each resident in making his or her own choices. Care plans were ongoing and revised as information about the resident and the resident's condition changed. The resident had the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals were made, appropriate documentation would be entered into the resident's medical record. In the case of a resident's refusal or declination of care or treatment being declined, the risk the declination posed to the resident, and the efforts made by the Interdisciplinary Team (IDT) to educate the resident and representative as appropriate. The attempts to find alternative means to address the identified need/risk would be documented in the care plan. Review of the facility's policy titled Refusal of Care, Treatment, or to follow a Physician's order last reviewed on 05/08/2021 revealed if a resident refused care, treatment or to follow a physicians order, the unit manager, charge nurse, or director of nursing services would interview the resident to determine why the resident was refusing, try to address the resident's concerns and explain to resident the risk and consequences of the refusal. Further review revealed the facility would document the resident's refusal in the medical record and inform the resident's physician. In consultation with the resident's physician, the facility care plan team would assess the resident ' s needs and if possible and available, offer the resident alternative treatments while continuing to provide the resident other services outlined in the care plan. 1. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review of the assessment revealed the resident had an indwelling catheter. Continued review of the Minimum Data Set (MDS) revealed the resident was not assessed to reject care (Section E). Review of Resident #34's care plan dated 08/23/2021 revealed the facility had identified the resident's double nephrostomy catheters which was to divert urine due to bladder cancer. However, the plan did not address the refusal of care related to securing the catheter and the catheter dignity bags. Observations of Resident #34 on 12/20/2021 at 1:29 PM, revealed the resident was sitting on the side of his/her bed, with two (2) nephrostomy drainage bags laying on the bed uncovered and visible from the hallway. The catheter tubing was not secured. Interview with Resident #34, on 12/21/21 at 8:25 AM, revealed he/she liked to carry his/her urine bags or lay them close to him/her. The resident stated he/she usually did not like bed covers over the urine bags and usually just left the bags laying on the bed. The resident stated he/she has told staff he/she does not want to cover them up. Interview with State Registered Nurse Aide (SRNA) #3, on 12/22/2021 at 1:06 PM, revealed Resident #34 had dignity bags, but he/she would remove the dignity bags when placed around the catheter drainage bags. The SRNA stated Resident #34 would not wear a leg strap for the catheter bag. Interview with SRNA #4, on 12/22/2021 at 2:17 PM, revealed Resident #34 did not want the dignity bag to cover the catheter drainage bags. However, the SRNA stated he had not offered the dignity bags to the resident or applied them to the drainage bags. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 1:35 PM, revealed staff had not reported Resident #34 refusals to utilize his/her dignity bags. Per the LPN, she was unaware Resident #34 would not wear the leg straps to secure the catheter tubing. The LPN stated if a resident refused care she would talk to the resident and explain care, chart the refusal, and notify her supervisor for care plan changes. Interview with Director of Nursing(DON), on 12/22/2021 at 4:05 PM, revealed if a resident refused care then a Situation, Background, Assessment, Recommendation (SBAR) was completed, the care plan was revised and a behavioral meeting was held. She stated she was unaware until this week that Resident #34 refused to wear his/her catheter leg straps to secure the catheter to the resident's leg. The DON stated prior to today, Resident #34's care plan was not updated related to the catheter bags nor did the care plan address the resident's refusal to use his/her dignity bags. Per the DON, the resident's care plan should have been updated as per policy. Interview with Administrator, on 12/22/2021 at 4:24 PM, revealed that if Resident #34 did not want to wear his/her catheter leg straps to secure the catheter, then he/she could choose not to wear them. Continued interview with the Administrator revealed the resident's refusals should have been care planned. She further stated the potential outcome could be Resident #34 could hurt himself/herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure catheter tubing was secured for one (1) of twenty-three (23) sampled residents (Resident #34). Resident #34's catheter was not properly secured. The findings include: Review of the facility's policy titled, Catheterization last reviewed on 11/03/2020 revealed to hang the collection bag on the bed frame and to not hang it from the siderails and avoid letting it touch the floor. Per the policy, staff were to tape the catheter or apply a Velcro leg strap and never leave the room until the catheter was secured. Further review revealed the mechanical irritation caused by catheter movement could cause urethral and meatal tearing, accidental removal and serious complications. For the female resident, secure the catheter to the upper thigh. Continued review revealed the catheter in the male was secured to either the upper thigh (with a leg strap) or the abdomen (with tape). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the assessment revealed the resident had an indwelling catheter. Review of Resident #34's care plan dated 08/23/2021 revealed the resident had double nephrostomy catheters to divert urine related to bladder cancer. The care plan goals included treatment as ordered, keep a closed system as much as possible, manipulate tubing as little as possible during care, position bag below level of bladder and provide nephrostomy care every shift. However, the care plan did not address securing the catheter. Observations of Resident #34 on 12/20/2021 at 10:05 AM, revealed the resident was sitting in bed with two (2) nephrostomy urine bags laying on the bed. The nephrostomy catheter tubing was not secured. Interview with Resident #34, on 12/21/21 at 8:25 AM, revealed he/she liked to carry his/her urine bags or lay them close to him/her. The resident stated he/she usually leaves the bags laying on the bed. Interview with State Registered Nurse Aide (SRNA) #3, on 12/22/2021 at 1:06 PM, revealed Resident #34 would not wear a leg strap for the catheter bag. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 1:35 PM, revealed she was unaware that Resident #34 would not wear the leg straps. Interview with Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed if a resident refused care then a Situation, Background, Assessment, Recommendation (SBAR) was completed, the care plan was revised and a behavioral meeting was held. The DON stated she was unaware until this week that Resident #34 was not wearing catheter leg straps to secure the catheter to the resident's leg. Interview with Administrator, on 12/22/2021 at 4:24 PM, revealed that if Resident #34 does not want to wear the catheter leg straps to secure the catheter then he/she can choose not to wear them, but it should be care planned. She stated the potential outcome could be that Resident #34 could hurt himself/herself.

Based on observation, interview, and a review of the facility policy for storage of medication, it was determined the facility failed to ensure drugs/medications in one (1) of three (3) medication carts were locked when unattended by staff. Observation of the A hall medication cart on 12/22/2021 revealed the medication cart was left unlocked and unattended. The findings include: A review of the facility policy for storage of medication titled Medication Storage dated 2007, revealed medications were to be stored properly to maintain integrity and shall be accessible only to personnel authorized to administer medications. Further review of the policy revealed medication carts should remain locked when not in use or attended by persons with authorized access. Observation on 12/22/2021 at 1:55 PM revealed a medication cart was unlocked and unattended with no visible staff nearby. Approximately ten (10) seconds later, a nurse came out of a resident's room and approached the medication cart. Interview with Licensed Practical Nurse (LPN) #3, on 12/22/2021 at 1:57 PM, revealed the LPN did not lock the medication cart when she stepped away from the cart for a few seconds to go into a nearby resident's room. The LPN stated she should have locked the medication cart and not left the cart unlocked/unattended. Interview with the Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed it was facility policy to lock the medication carts when the carts were left unattended to prevent someone from tampering with the medications and ensure the integrity of the residents' medications. According to the DON, she monitored medication administration by making daily rounds and had identified no concerns with nurses locking the medication carts. Interview with the Administrator, on 12/22/2021 at 4:24 PM, revealed it was facility policy for medication carts to be locked when unattended. The Administrator stated she would expect the cart to be locked when unattended. Per the Administrator, she made daily rounds to monitor the medication carts and had not identified any concerns with medication carts being left unlocked and/or unattended.

Based on observation, interview and record review it was determined the facility failed to ensure resident privacy during care and treatment for four (4) of twenty-three (23) sampled residents (Resident #32, #22, #38, and #96). The facility failed to provide visual privacy for Resident #32 during wound care and a skin assessment on 12/21/2021. Residents #22, #38, and #96 were not provided privacy during blood glucose monitoring and insulin injections on 12/20/2021. The findings include: A review of the facility policy for privacy titled Resident Rights with a revised date of 08/16/2018, revealed all residents had the right to be treated with respect and dignity and the rights would be promoted by the facility. Further review of the policy revealed when providing care and services the stakeholders would respect the resident's individuality by providing the resident a dignified existence and that privacy and confidentiality were a basic right to all residents of the facility. 1. A review of the medical record for Resident #32 revealed the facility admitted the resident on 10/13/2021 with Intellectual Disabilities, Cerebral Infarction, Hemiplegia, and Hemiparesis of the right side. A review of the admission Minimum Data Set (MDS) assessment completed for Resident #32 dated 10/20/2021 revealed the resident was severely impaired for cognition and communication. Attempts to interview Resident #32 revealed the resident was nonverbal and not interviewable. Observation of a skin assessment and wound care for Resident #32 conducted on 12/21/2021 at 3:06 PM by Licensed Practical Nurse (LPN) #4 and the Director of Nursing (DON) revealed the LPN and the DON failed to close the blinds and pull the resident's privacy curtain to provide visual privacy prior to providing wound care to the resident's left ear and left foot. In addition, a head-to-toe skin assessment was conducted exposing the resident's skin which included the abdomen, back, buttocks, and groin area. Additional observation revealed the resident was in view of the facility's main entrance area of the front porch and of the facility parking lot via the resident's window. Interview with LPN #4 on 12/21/2021 at 3:22 PM revealed she was supposed to provide privacy by pulling the privacy curtain and closing blinds prior to providing care. The LPN stated she did not realize she did not pull Resident #32's privacy curtain or pull the blinds prior to providing care. Interview with the DON on 12/21/2021 at 3:25 PM revealed she thought the LPN had moved the curtain back during the assessment and treatment but had not realized Resident #32 was still in view of the front porch via the window. Further interview revealed she should have noticed the resident was not being provided privacy and ensured privacy by closing the curtain or the blinds. 2. Observation of finger stick blood sugar (FSBS) monitoring for Resident #22 on 12/20/2021 at 11:40 AM, Resident #38 on 12/20/2021 at 11:00 AM, and Resident #96 12/20/2021 at 12:10 PM by Licensed Practical Nurse (LPN) #3 revealed the LPN did not provide full visual privacy for the three (3) aforementioned residents by pulling the curtains and/or shutting the door or closing the window blinds prior to providing care. Additional observations revealed LPN #3 also administered an Insulin injection to Resident #22 on 12/20/2021 at 11:40 AM and did not provide full visual privacy for Resident #22 during Insulin administration in which his/her upper left arm was exposed. Continued observations revealed Resident #38's upper left abdominal quadrant was left exposed during insulin administration on 12/20/2021 at 11:55 AM by LPN #3. Interview with LPN #3 on 12/20/2021 at 12:17 PM revealed she was aware she had not provided privacy during the FSBS testing and subsequent insulin administration but should have provided privacy. Additionally, she stated that Resident Rights education had been presented during Skills Fair in mid-December. Interviews with Sampled Residents #38 and Resident #96 (spouses) (both with a brief interview for mental status (BIMS) scores of (12), which indicated they were cognitively intact) on 12/21/2021 at 8:45 AM revealed it did not bother them if nurses did not provide visual privacy while doing the FSBS and insulin injections. Interview with the DON on 12/22/2021 at 4:05 PM revealed it was her expectation for staff to provide full visual privacy for every resident, even if they were the only person in the room. She would expect the curtain/door shut if in Bed one (1) or curtain/blinds/door closed if in Bed two (2). She continued by stating it was the resident's right to have privacy afforded to them. Interview with the Administrator on 12/22/2021 at 4:24 PM, revealed staff were monitored for providing privacy to residents during procedures such as FSBS/Insulin injections and peri/catheter care by clinical/privacy audits. The Administrator stated if staff provided any sort of care, the curtain/door should be shut, no matter which bed the resident occupied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the policy Glucometer Cleaning and Disinfecting policy, dated 11/04/2019, revealed appropriate cleaning and disinfecting steps were needed to prevent the spread of bloodborne pathogens. Further review revealed to clean the Blood Glucose Monitor (BGM), gloves were recommended and to use a dampened soapy cloth or 70-80% isopropyl alcohol to remove visible dirt, body fluids, and blood. Continued review revealed to disinfect the BGM, staff was to use an environmental protection agency (EPA) registered disinfectant or germicidal wipe and follow product label instructions to disinfect and allow to air dry. Review of the facility product label, Microdot Bleach Wipes, (currently used by the facility to disinfect the BGM) revealed it was a combination cleaning/disinfecting product. Continued review revealed staff was to wear gloves and ensure the surface to be disinfected had a solution contact time of thirty (30) seconds. Additionally, the surface was to air dry. Review of the Manufacturers Guidelines website (www.assureus.com/general.html) for the type of BGM the facility used revealed the BGM was tested using four (4) different disinfecting wipes, one of which was the Super Sani-cloth Germicidal Disposable Cloth. Continued review of the website documentation revealed a facility could use a commercially available EPS-registered disinfectant wipe with the recommendation to create supporting documentation as to why the facility chose that product. Interviews with Licensed practical nurse (LPN) #3 on 12/20/2021 at 12:14 PM, LPN #4 on 12/21/2021, at 11:02 AM, and RN #1 on 12/22/2021 at 8:42 AM revealed they previously used Super Sani-cloth to clean/disinfect the BGM but had not had that product for several months. All stated they currently used the Micodot Bleach wipes to clean/disinfect the BGM and were trained on how to disinfect the monitor using this wipe. Observations during Medication Pass on 12/20/2021 and 12/21/2021 with (LPN) #3 revealed she failed to use a thirty (30) second contact time when cleaning the BGM with the Microdot Bleach wipe for Resident #22 on 12/21/2021, at 11:40 AM, Resident #38 on 12/21/2021 at 11:00 AM and Resident #96 12/21/2021 at 12:10 PM . On all three (3) occasions, LPN #3 allowed approximately ten (10) to fifteen (15) second contact time instead of thirty (30) seconds when disinfecting the BGM between uses. Interview with LPN #3 on 12/22/2021, at 11:05 AM, revealed she was aware there was a thirty (30) second kill time when using the disinfectant wipes. Continued interview revealed she thought she had used the required time. Additionally, LPN #3 stated they had recently had a Skills Fair, in which Glucometer disinfection was part of the education. Interview with the Director of Nursing (DON), on 12/22/2021, at 2:43 PM, revealed she was responsible for staff training at this time. Additionally, she stated the facility had not used the Super Sani-cloths in about three (3) months. Further interview revealed it was her belief that the decision to switch to the current product was a corporate decision and the product was appropriate to use on BGM and other points of care equipment. The DON stated LPN #3 failed to clean the BGM per facility policy/product guidance. Continued interview revealed the facility had presented a Skills Fair mid-December and BGM and covered the disinfection of the BGM. The DON stated the facility was not currently monitoring the disinfection of the BGM. Interview with the Administrator on 12/22/2021 at 5:24 PM revealed it was her belief that the Microdot Bleach Wipes the facility was used to disinfect the BGM and other point of care equipment was applicable to use related to the BGM Manufacturers Recommendations was to use an EPA registered product and the current product was EPA registered. Based on observation, interview, and a review of the facility policy Coronavirus (COVID-19) - Screening of Visitors and review of the facility policy and manufactures recommendations for sanitization of blood glucose monitors, it was determined the facility failed to have an effective infection control system to prevent the spread of infection by not consistently and adequately screening visitors at one (1) of one (1) designated visitor entrance to the facility and failing to sanitize blood glucose monitors in accordance with manufactures recommendations for three (3) of twenty-three (23) sampled residents. The findings include: 1. A review of the facility infection control policy titled Coronavirus (COVID-19) - Screening of Visitors with a revision date of 03/11/2021, revealed visitors would be screened for signs and symptoms for COVID-19, and visitors would be provided a copy of rules which a visitor would review and sign. Further review of the policy revealed visitors would wear appropriate Personal Protective Equipment (PPE) and use appropriate face covering or mask at all times for all persons. Further review of the policy revealed any provider, consultant, or vendor visiting the facility was subject to these requirements. There was no evidence the policy addressed what specific PPE was required for visiting other than mask. Observation of the screening process upon entry to the facility on [DATE] at 10:23 AM, revealed four (4) state surveyors and one (1) federal surveyor entered the building to conduct a survey and alert facility staff of the reason for the visit. Facility staff did not ensure adequate screening of the surveyors or advise the surveyors on any PPE requirements. A surveyor asked the Administrator upon entrance of the current status of the building regarding COVID-19 and was informed there was no residents/staff with COVID and no resident on precautions. The Administrator was also asked what kind of mask was required and the Administrator stated the facility preferred to have visitors wear a surgical mask. Surveyors were not instructed to wear any eye protection during the screening process and were escorted to an office area to begin the survey. A tour of the building was conducted on all residents by the surveyors on 12/20/2021 and at approximately 2:30 PM, a surveyor asked a staff member if eye protection was required. The staff member told the surveyor staff were required to wear eye protection and a mask. Observation of two (2) visitors, who were visiting a resident in the facility on 12/20/2021 at 3:15 PM, revealed the visitors were wearing a mask but was not wearing eye protection. Interviews with Visitors #2 and #3 on 12/20/2021 at 3:02 PM revealed they were screened at the kiosk by staff, given a mask to wear, and escorted to the resident's room but were not offered eye protection or told they would need eye protection. Observations in the front lobby of the facility on 12/22/2021 at 2:08 PM revealed two (2) ambulance employees entered the facility to transport a resident to a medical appointment. Facility staff failed to screen the ambulance employees into the building and the ambulance employees were not wearing eye protection. Interview with State Registered Nurse Aide (SRNA) #3 on 12/22/2021 at 2:00 PM revealed the SRNA was required to wear a mask and eye protection while working in the facility. According to the SRNA, she was not aware if visitors were to wear eye protection and was uncertain about the screening of the ambulance personnel. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 2:35 PM, revealed the LPN was working and greeted the surveyors when they entered the building. The LPN stated she was also on the phone arranging transportation for a resident. Further interview revealed she should have directed someone to screen the surveyors into the building. The LPN stated the surveyors should have been instructed on PPE and eye protection. Per the LPN, she did not instruct the surveyors on PPE and eye protection but should have. Interview with Registered Nurse (RN) #1 on 12/22/2021 at 2:56 PM revealed she was not aware that visitors had to wear goggles when visiting residents in the facility. The RN stated she was also not aware of the process or requirements for screening ambulance personnel. Interview with the Director of Nursing/Infection Preventionist (DON) on 12/22/21 at 3:20 PM revealed visitors were screened into the facility by whoever was available. Per the DON, the facility used to have a hospitality aide assigned to do the screening but now any available staff would screen individuals entering the facility. According to the DON, staff was wearing masks and eye protection because of the county positivity rate. The DON stated she monitored the screening process but was not aware staff were not consistently screening visitors or were confused about what PPE was required. The DON stated ambulance staff should be screened unless it was an emergency and then they could enter without screening. Interview with the Administrator on 12/22/2021 at 4:24 PM revealed the Administrator was not aware of the concerns with the screening process and should have ensured the surveyors were correctly screened when they entered the building to clear up any confusion regarding the required PPE. According to the Administrator, it was facility policy to wear masks and eye protection if the facility was in the orange or red zone of positivity. Per the Administrator, the facility was currently in the orange zone. The Administrator stated she had not discussed any screening protocols with the ambulance service or set any guidance other than what was in the screening policy which required all visitors to be screened. The Administrator stated she was not aware the policy did not clearly define the required PPE based on the current infection rates.