Based on observation, interview, review of the facility's documents, and review of the facility's policy, the facility failed to store food safely as determined by observations in the kitchen on 02/25/2025 at 10:30 AM and 02/27/2025 at 10:30 AM. The lunch tray carts contained pre-plated foods and drinks, which were not under refrigeration. Further, during the lunch meal service on 02/25/2025 at 12:12 PM Dietary staff touched different surfaces, but did not change gloves or wash hands. The findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 10/2023, revealed the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. Per the policy, the use of gloves did not replace hand washing/hand hygiene. The policy stated hand hygiene was indicated immediately after glove removal and after touching the resident's environment. Review of the facility's document Meal Delivery Times, not dated, revealed lunch service for the Providence and Honor/Mental Disabilities Units was from 12:05 PM to 12:15 PM and 12:15 PM to 12:40 PM, respectively. Review of the facility's document Food Guide 2013 Food Code Cooking Temperature and Holding Times, dated 2013, revealed cold food was held at 41 degrees Fahrenheit (F) or less. Observation during the initial kitchen tour on 02/25/2025 at 10:32 AM with the Certified Dietary Manager (CDM) revealed the food carts for the lunch set-up before the lunch meal revealed the carts contained juice, tossed salads, and cheese plates not stored in refrigeration. The tray carts were observed sitting in the kitchen from 10:32 AM and per interview would remain out of refrigeration until 11:45 AM. In an interview with the CDM on 02/25/2025 at 10:40 AM, the CDM stated the carts were set-up prior to meal service at 12:00 PM for lunch. The CDM stated the food carts were put into refrigeration 15 minutes before mealtime to get the food cold. Observation on 02/25/2025 at 12:12 PM revealed the Dietary staff set-up the tray line and served from both sides of the steam table to fill the room cart quickly. Observation of Dietary staff members revealed they wore gloves and touched other items with gloved hands as they served. One Dietary staff touched the cabinet handles, and one Dietary staff touched the nurse's desk, as she talked with the nursing staff and delivered the first cart with gloved hands. She returned to the dining room to continue serving wearing the same gloves. Observation on 02/25/2025 at 4:40 PM revealed the main Dining Room counter contained crumbs of food located under the clean stacked dishes, the lids, and plate holders for the plates. A brown dried substance was in the hand sink located on the counter. Observation on 02/26/2025 at 9:40 AM revealed the main Dining Room counter contained crumbs of food located under the clean stacked dishes, the lids, and plate holders for the plates. In additional interview with the CDM on 02/27/2025 at 10:30 AM, she stated her expectations for staff was to not touch cabinet pulls or the nurse's desk during meal service because of the potential for cross-contamination. She stated the food prepared on the tray carts for meals should be held in the refrigerator before meal service to prevent bacterial growth. She also stated the counter behind the steam table must be wiped off after the meal service. In an interview with the Director of Nursing (DON)/Infection Control on 02/27/2025 at 3:54 PM, she stated she expected Dietary staff to follow infection control guidelines and change gloves after touching other surfaces. She stated staff should remove gloves and use soap and water because bacteria live on all surfaces. After meals, she stated, the counter should be cleaned and standard precautions used even if it did not appear soiled. She stated if cold food was not kept at the proper temperature with refrigeration, bacteria could grow in the food. In an interview with the Administrator on 02/28/2025 at 8:33 AM, the Administrator stated preparation of cold food before the meal must be kept at the correct and safe temperature. The Administrator stated Dietary staff who changed tasks or touched other surfaces during meal service should remove their gloves, wash their hands, and put on new gloves. The Administrator stated there should be no crumbs on the counter left under the dishes, and the dishes should come up off the counter to use for meal service.

Based on observation, interview, review of the Food and Drug Administration article, and review of the facility's policy, the facility failed to ensure appropriate storage of residents' oral and topical medications, with multiple medications that were in use but exceeded the labeled expiration date. This occurred in 5 of 6 medication and treatment carts. The findings include: Review of the facility's policy, titled Medication Labeling and Storage, originally dated 2001 MED-PASS, revealed the facility stored all medications and biologicals in locked compartments under proper temperature, humidity, and light controls, and only authorized personnel had access to keys. Further review revealed the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Continued review revealed if the facility had discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy was contacted for instructions regarding returning or destroying these items. Review of the Food and Drug Administration (FDA) article Pharmaceutical Quality Resources, Expiration Dates - Questions and Answers, dated 01/21/2025, Expiration Dates - Questions and Answers | FDA revealed drug expiration dates reflected the period of time in which the medication was known to remain stable. Further review revealed the stability meant the medication retained strength, quality, and purity when it was stored according to its labeled storage conditions. Continued review revealed there were potential harms that could occur if expired medications were taken, including the medication not providing the intended benefit because it had less strength than intended. Additional review revealed when a drug degraded, it could yield toxic compounds that could cause unintended side effects. Observation of Medication Cart 1 and Medication Cart 2 on the Honor Unit on 02/26/2025 at 5:20 PM revealed the following expired medications: 1. ibuprofen 600 milligrams (mg), Resident (R) 34, expired 01/08/2025; 2. acetaminophen 500 mg, R39, expired 12/13/2024; 3. midodrine 10 mg, R16, expired 02/06/2025; 4. loperamide 2 mg, R13, ordered every 4 hours as needed for diarrhea for 3 days, dispensed 12/07/2023, no expiration date noted on blister card; 5. ondansetron 4 mg, R34, expired 01/11/2025; 6. Tab-a-Vite, R39, expired 11/05/2024; 7. magnesium citrate, R39, expired 12/05/2024; 8. naloxone 4 mg, R68, expired 02/08/2025; 9. olanzapine 5 mg, R22, expired 02/15/2025; 10. pantoprazole 20 mg, R33, expired 10/10/2024; 11. Almacone 15 milliliters (ml), R8, expired 2/12/2025; 12. polyethylene glycol 17 grams, R51, dispensed 10/30/2023, no expiration date found but marked good for one year from date dispensed; and 13. polyethylene glycol 17 grams, R11, expired 12/26/2024. Observation of Medication Cart 1 on the Purpose Unit on 02/27/2025 at 3:00 PM revealed the following expired medications: 1. Refresh lubricant eye drops, R59, expired 01/07/2025; 2. vitamin D3 5000 units, R6, expired 01/06/2025; and 3. Milk of Magnesia 30 ml, R6, expired 02/25/2025. Observation of Medication Cart 1, Medication Cart 2, and the Treatment Cart on the Providence Unit on 02/27/2025 at 3:35 PM revealed the following expired medications: 1. polyethylene glycol 17 grams, R43, expired 11/11/2024 per pharmacy sticker but commercial bottle marked expiration date 03/2026; 2. polyethylene glycol 17 grams, R53, expired 02/06/2025 per pharmacy sticker but commercial bottle marked expiration date 05/2026; 3. Tylenol, R53, expired 02/15/2025; 4. Senna 8.6 mg, R43, expired 01/05/2025; 5. nitroglycerin 0.4 mg, R53, expired 02/06/2025; 6. Tylenol 500 mg, R22, expired 02/06/2025; 7. ibuprofen 600 mg, R70, expired 12/20/2024; 8. Prostat 30 ml, R17, expired 10/25/2024; 9. polyethylene glycol 17 grams, R29, expired 06/05/2024; 10. polyethylene glycol 17 grams, R17, use by 12/04/2024; 11. ketoconazole cream topical, R62, expired 1/30/2025; and 12. Minerin Cream topical, unidentified resident, name marked out, expired 12/29/2024. During interview with Licensed Practical Nurse (LPN) 2 on 02/27/2025 at 3:40 PM, she stated expired medications must be discarded because they might not be as effective after that much time. During interview with LPN1 on 02/28/2025 at 11:17 AM, she stated staff went through medications usually before they expire. She also stated the nurses should be looking at medications and if not used in 30 to 60 days, they should call the physician. She stated she was not aware of anyone being assigned to audit carts on a regular basis. During interview with Registered Nurse (RN) 4 on 02/26/2025 at 5:05 PM, she stated usually the night shift nurses audited the carts for expired medications or those that were discontinued. In further interview she stated staff collected those in purple bags, and the pharmacy retrieved the purple bags when they made the next run. During interview with RN3 on 02/27/2025 at 3:00 PM, he stated he tried to keep up with expiring or discontinued medications as he worked. In further interview, he stated he was not sure if there was a protocol for anyone else to do it. He stated the reason for discarding expired medications was that they might not be as effective. During interview with Pharmacist 1 on 02/27/2025 at 11:12 AM, he stated they provided monthly visits, and they reviewed over the counter medications also, and removed those that were within 30 days of expiration. He stated the reviews were spot checks, that flipped through blister packs for those nearing expiration, not every card. In further interview, he stated the expectation was facility staff would audit medication carts for discontinued or expiring medications. He also stated he noted any expired medications in report notes, which were sent to the Director of Nursing (DON) or other corporate personnel that wanted them. During interview with the DON on 02/26/2025 at 4:58 PM, she stated the expectation was that cart audits would occur on night shift every week to remove discontinued or expiring medications or those belonging to residents who had discharged . During additional interview with the DON on 02/28/2025 at 2:08 PM, she stated she expected nursing staff to conduct cart audits in order to capture medications that needed to be removed from the cart for any reason, especially expiration. She stated the reason for checking expiration dates was so they did not give medications to residents that was ineffective or to make someone sick. She stated an example of giving a resident an expired medication was that it might not work, and the resident would have seizures. During interview with the Administrator on 02/28/2025 at 12:12 PM, she stated staff should be storing medication appropriately so they did not go bad, and staff did not give medication out of date, so it was safe for the resident. She stated medication could potentially be less potent if it was out of date and potentially could not work as well. She stated nurses should be checking medications for expiration on a regular basis. She also stated for quality assurance managers should be doing audits on a regular basis, at least weekly. She stated this would provide extra eyes for removing out-of-date medications from the carts.

Based on observation, interview, record review, and review of the facility's policies and isolation signage, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 18 sampled residents, Residents (R) 43, R58, R64, R68, and R78. Observation also revealed State Trained Nurse Aide (STNA) 1, STNA2, and STNA3 gave out lunch trays to residents without performing appropriate hand hygiene. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 12/2023, revealed members of the IPCP committee performed surveillance of staff adherence to IPCP practices. The policy stated the IPCP provided a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, with the responsibility of coordination and oversight by the Infection Preventionist (IP). Further review revealed infection prevention included educating staff members and ensuring they adhered to proper techniques and procedures for Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). Review of facility's policy titled, Standard Precautions, revised date 09/2022, revealed standard precautions were used in the care of all residents. The policy stated hand hygiene should be performed after contact with the resident, before performing an aseptic task, and after contact with items in a resident's room. Further review revealed gloves should be removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. The policy stated, after glove removal, hands should be washed or sanitized immediately to avoid transfer of microorganisms to other residents or environments. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 10/2023, revealed all staff were trained and regularly in-serviced on the importance of hand hygiene. Per the policy, all staff was expected to adhere to hand hygiene policies and practices, and hand hygiene was indicated after touching a resident's environment. Further review of the policy revealed the use of gloves did not replace hand washing/hand hygiene. Review of the facility's policy titled, Isolation-Initiating Transmission-Based Precautions [TBP], most recently revised 08/2019, revealed TBP were initiated when signs and symptoms of infection developed, the resident arrived on admission with symptoms of infection, or the resident had a laboratory confirmed infection and was at risk of transmitting to other residents. Further review revealed the Infection Preventionist (IP) or their designee posted appropriate signage at the door of the resident's room. Per the policy, the signage informed the staff of the type of Centers for Disease Control and Prevention (CDC) precautions, instructions for use of personal protective equipment (PPE), and/or instructions to see a nurse before entering the room. The policy stated the IP ensured PPE was maintained outside the resident's room, so anyone entering the room could apply the appropriate PPE. The policy also stated the precautions would remain in effect until either the IP or attending physician discontinued them based on specific criteria. Review of the facility's signage used for EBP placed outside of a residents room when indicated, revealed everyone must clean their hands before entering and when leaving the room and staff must wear gloves and gown for high contact resident care activities such as bathing, dressing, providing hygiene, and device or wound care. It also stated staff should not wear the same gown and gloves for more than one resident. Review of the facility's signage used for Contact Precautions (TBP) placed outside a resident's room when indicated, revealed everyone must clean their hands before entering and when leaving the room; staff must put on gloves and gown before entry and remove before exit; staff must not wear the same gown and gloves for the care of more than one resident; and staff must use dedicated or disposable equipment, and clean and disinfect reusable equipment before use on another person. Review of the facility's policy, Catheter Care, Urinary, original date 2001 from MED-PASS Inc, and revised August 2022, revealed the purpose of the procedure was to prevent urinary catheter associated complications, including urinary tract infections. Further review revealed, for infection control, to be sure the catheter tubing and drainage bag were kept off the floor. Per the policy, to prevent unobstructed urine flow, position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Observation on 02/25/2025 at 10:21 AM revealed no TBP signage was present on R78's door to instruct staff/guests before entering the room. However, a bin had been placed outside of R78's room that contained PPE. Continued observation revealed R78 had an indwelling catheter and pressure ulcers (wounds). Observation made on 02/27/2025 at 1:41 PM revealed a Contact Precautions sign had been placed on R78's door, and a bin of PPE was located outside the room. Further observation revealed staff providing care to R78 was wearing gown and gloves while providing care. Review of R78's admission Record revealed the facility admitted the resident on 01/03/2025 with diagnoses of paraplegia, methicillin resistant staphylococcus aureus infection (MRSA), and pressure ulcer. Review of R78's Physician Orders, dated 01/16/2025, revealed an order was placed for Contact Precautions with no end date given. Further review revealed an order for an indwelling urinary catheter, dated 01/04/2025, and an order for wound care for pressure ulcers, dated 02/20/2025. Review of the facility's Resident Matrix, dated 02/25/2025, revealed R78 was not identified as having TBP. During an interview with R78 on 02/27/2025 at 8:40 AM, she stated since being admitted to the facility she could not recall staff wearing gowns when providing hygiene care but did recall staff wearing gloves. During an interview with the Director of Nursing (DON) on 02/27/2025 at 4:15 PM, she stated she was not sure why Contact Precautions signage was not in place for R78 as ordered. 2. Observation on 02/25/2025 at 10:30 AM revealed Registered Nurse (RN) 1 was providing a bolus tube feed to R68, who was in EBP. The EBP signage was in place, and PPE was available outside the door. However, RN1 was wearing gloves, but no gown. Review of R68's Physician Orders, dated 06/11/2024, revealed R68 had an order for EBP because of the presence of a urinary catheter, G-tube, wound, and colostomy. 3. a. Observation on 02/25/2025 at 10:57 AM revealed there was EBP signage on R64's door. Observation on 02/27/2025 at 8:50 AM revealed a Contact Precautions sign had been placed on R64's door and above R64's bed. Then, at 9:00 AM, State Trained Nurse Aide (STNA) 9 removed both Contact Precautions signs. Observation on 02/27/2025 at 2:00 PM revealed a Contact Precautions sign again had been placed on R64's door and above R64's bed. Review of R64's Physician Orders, dated 12/20/2024, revealed an order was placed for Contact Precautions, with gown and gloves to be used for all direct contact and care, and with no end date given. Review of the facility's Resident Matrix, dated 02/25/2025 revealed R64 was not identified as having TBP. During a interview with STNA9 on 02/27/2025 at 9:00 AM, she stated after an inquiry made by the State Survey Agency (SSA) Surveyor about the Contact Precautions sign on R64's door, she spoke to the Assistant Director of Nursing (ADON) about the signage and was told it was an error, she could remove the sign, and she did remove the TBP signage. During an interview with the ADON on 02/27/2025 at 9:09 AM, she stated STNA9 asked her about the reason for the Contact Precautions sign because she was asked by the SSA, and she instructed STNA9 that the sign was likely placed in error and to remove the signage. The ADON stated the Director of Nursing (DON) was the IP and in charge of placing residents in TBP. During continued interview with the DON on 02/27/2025 at 4:15 PM, she stated she was the IP for the facility, but she and the ADON had been sharing responsibilities since 01/13/2025. She stated the ADON would have been responsible for ensuring the proper signage was placed on resident rooms for TBP, but she had placed the order for Contact Precautions. The DON stated as the IP she was responsible for auditing, which was done every Wednesday, which consisted of running a report, ensuring that the current rooms had the correct signage posted, and PPE was available. The DON/IP stated she was responsible for placing the orders into the system and discontinuing them once the isolation period had ended. She stated she did not know why Contact Precautions signage was not in place for R64 as ordered, as the expectation would be the sign should have been in place since the order date. The DON stated it was important to follow the proper TBP to ensure infections were not spread to staff and other residents, and staff should verify with her or the nurse if they were unsure of which resident was on precautions. She stated it was important for protecting self and residents. b. Observation of R64's room on 02/27/2025 at 11:51 AM revealed his room had posted signage for Contact Precautions that outlined the required PPE, and PPE supplies were stocked by the door. Further observation revealed the Environmental Services (EVS) Supervisor entered the room to restock paper towels in the bathroom and did not don (put on) a gown or gloves. During an interview with the EVS Supervisor on 02/27/2025 at 11:53 AM when she exited R64's room, she stated she did not have to don PPE since she was not providing contact care. She also stated she only had to use PPE if a resident was on isolation. She stated she did not realize contact precautions were isolation. She stated the reason for donning PPE was to prevent spreading infection. During an interview with RN3 on 02/27/2025 at 12:05 PM, immediately after administering insulin to R64, he stated the Contact Precautions for R64 were relatively new. When asked by the SSA Surveyor whether R64 had experienced staff donning PPE, he stated, Honestly? Probably not. During an interview with Licensed Practical Nurse (LPN) 1 on 02/28/2025 at 10:15 AM, she stated all staff should don the prescribed PPE if entering a room on Contact Precautions, regardless of why they were entering. During an interview with the Central Supply Manager on 02/28/2025 at 9:51 AM, he stated he was expected to gown up as directed with rooms that had Contact Precautions to prevent spread of an infection. During additional interview with the DON on 02/28/2025 at 2:08 PM, she stated her expectation was when staff entered a room that was under Contact Precautions, they would don PPE per CDC guidelines. She stated for Contact Precautions, that included gown and gloves, plus eye protection if providing wound care. During interview with the Administrator on 02/28/2025 at 12:12 PM, she stated for residents who were under Contact Precautions, she expected staff to gown as directed, regardless of the reason they entered. She further stated the importance of that was to prevent the spread of infection. 4. Observation on 02/25/2025 at 11:05 AM revealed R58 was resting in a low bed with a fall mat on one side, and her indwelling urinary catheter bag was resting on the floor. There was no Contact Precautions signage posted. Observation on 02/26/2025 at 4:23 PM revealed R58's urinary catheter bag was off the floor, but R58 was now on Contact Precautions. Review of R58's Physician Orders, dated 02/20/2025, revealed an order for Contact Precautions for the presence of escherichia coli in the urine. During additional interview with STNA9 on 02/25/2025 at 11:32 AM, she stated R58's catheter bag was on the floor because the bed was in low position. She stated the reason it should not be on the floor was for infection prevention. During additional interview with LPN1 on 02/25/2025 at 11:32 AM, she confirmed the catheter bag should not be on the floor and stated it had to be hung so that it could drain by gravity. She also stated keeping the catheter bag off the floor and in a position so the catheter could drain by gravity would help to prevent a urinary tract infection (UTI). During an interview with STNA2 on 02/26/2025 at 4:23 PM, she stated the Contact Precaution signage just went up today, and she understood it was secondary to extended-spectrum beta-lactamase (ESBL) in her urine. She also stated she thought if the urine was contained in the catheter bag, Contact Precautions were not required, but she donned a gown and gloves before entering the room for personal care. During an interview with the Physician Assistant-Certified (PA-C) on 02/28/2025 at 11:46 AM, she stated the catheter bag must hang lower than bladder but also off the floor to prevent infection. She stated R58 was prone to infections, and the propensity was likely due to being colonized due to a chronic catheter. She stated her expectation was staff should be following TBP as long as an infection was contagious. She stated as long as the resident was symptomatic and had not completed antibiotics, staff should be following the precautions, but she was not sure of the protocol beyond that time. During continued interview with the DON on 02/28/2025 at 2:08 PM, she stated it was not ever acceptable for a catheter bag to be resting on the floor. She further stated when a resident had a catheter and was in a low bed, the staff needed to find a way to prevent contact between the catheter bag and the floor. She stated if that was a problem, they should come to a leader for help. During continued interview with the Administrator on 02/28/2025 at 12:12 PM, she stated catheters should be hanging so the collection bag was not touching the floor, and that was important due to infection control. 5. Observation made on 02/25/2025 at 12:42 PM revealed lunch trays were given out by STNA1 while wearing gloves. Further observation revealed STNA1 wore the same gloves throughout tray pass and did not practice hand hygiene between trays, including two resident rooms with EBP signage in place. During an interview with STNA1 on 02/25/2025 at 12:50 PM, she stated she was not required to wear gloves, but wore them out of preference due to trays having moisture on them and not liking her hands wet. STNA1 stated she wore the same pair of gloves for all of the tray pass and did not change them or practice hand hygiene because she did not have time to change between every room. When asked about concerns for wearing the same gloves into a EBP room, she stated it was not a concern for EBP residents because she had gloves on. During continued interview with the DON on 02/27/2025 at 4:15 PM, she stated all staff attended training on hire that included infection prevention, hand washing, transmission-based precautions (TBP), and personal protective equipment. The DON stated it was her expectation that all staff would be performing hand hygiene between each tray being passed to residents, and if a resident was on a specific TBP, then it was expected that staff would adhere to the specific requirements. 6. Observation on 02/25/2025 at 12:45 PM revealed STNA2 was giving out lunch trays and never performed hand hygiene. STNA2 then began to assist R58, who was in contact isolation for extended spectrum beta-lactamase (ESBL) in the urine, without performing hand hygiene or donning PPE. Signage was posted on R58's door, and PPE was available outside the room. Further observation revealed STNA3 was also passing lunch trays without performing hand hygiene and began to feed R43, who was on EBP, without performing hand hygiene and without donning PPE. Signage was posted on R43's door, and PPE was available outside the room. Review of R43's Physician Orders, dated 02/10/2025, revealed an order for EBP for wounds. During an interview on 02/26/2025 at 4:16 PM with STNA8, she stated aides were made aware of which residents were on Contact Precautions by reviewing their Kardex's (aide care plans for residents). During an interview on 02/26/2025 at 4:22 PM with STNA7, she stated that Kardex's were used to communicate care of residents. She stated signage was also used to communicate what PPE should be used. During an interview on 02/28/2025 at 10:56 AM with STNA5, she stated she was told in report which residents required precautions and at what level. She stated if she did not know, she asked the nurse. She stated for EBP, PPE should be donned with any direct resident contact. STNA5 stated precautions being followed was important for infection control. She stated, it's the right thing to do to keep people from getting sick, and we don't want to spread things. During an interview on 02/28/2025 at 10:53 AM with RN2, she stated she knew what precautions to use by following the sign that was posted on the resident's door. RN2 stated if there was no sign on the door, then she would not know the resident required precautions. RN2 stated the facility implemented a new system this week to use stickers next to the name on the nameplates outside of the door so staff would know which resident in the room required precautions. RN2 stated it was important to know which precautions to use to prevent the spread of infection to other residents as well as staff. During an interview with the Administrator on 02/28/2025 at 11:00 AM, she stated the expectation was for all staff to adhere to the IPCP policies and protocols for TBP at all times to prevent the spread of infection, and the IP was ultimately responsible for ensuring policies and protocols were current and being followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to provide pharmaceutical services, to include procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one (1) of eighteen (18) sampled residents (Resident #273). Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed four (4) medications were not transcribed from the AVS to Resident #273's Medication Order Summary, or acquired from the pharmacy. These four (4) medications were 1) Albuterol Sulfate HFA Aerosol Solution Inhaler as needed (PRN) (a bronchodilator used to treat wheezing and shortness of breath); Amitriptyline HCL (an antidepressant that could be used for insomnia); Diltiazem HCL (a calcium channel blocker or cardiac medication that could be used to control high blood pressure and control chest pain or angina); and Prednisone (a corticosteroid used to reduce inflammation). Further review of Resident #273's Medication Administration Report (MAR), dated 06/02/2021 to 06/29/2021, revealed Resident #273 did not receive his/her ordered Albuterol Inhaler, Amitriptyline, Diltiazem, or Prednisone, according to physician orders, dated 06/02/2021. The findings include: Review of the facility's policy titled, Medication Reconciliation, no date, revealed the purpose of the policy was to ensure that a resident's medications were reconciled to ensure the resident was free from any significant medication errors. Continued review revealed medication reconciliation referred to the process of verifying that the resident's current medication list matched the physician orders for the purpose of providing the correct medications to the resident at all points throughout his/her stay. Further review revealed the pre-admission process included obtaining a current medication list from the hospital, from where the resident had been discharged . The policy stated, during the admission process, the admitting nurse transcribed orders in accordance with procedures for admission orders; ordered medications from the pharmacy; and verified medications received matched the medication orders. Review of the facility's policy, admission Notes, no date, revealed during the admission process, the admitting nurse ordered medications from the pharmacy. Review of Resident #273's admission Checklist revealed the checklist was incomplete and neither Registered Nurse (RN) #2 nor RN #4 dated, documented, or signed-off on the check list. Review of Resident #273's medical record revealed the facility admitted the resident, on 06/02/2021, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure, Dysphagia, Major Depressive Disorder, Arteriosclerotic Heart Disease, Osteoporosis, Atrial Fibrillation, and Physical Debility. Review of Resident #273's admission Minimum Data Set (MDS) Assessment, dated 06/09/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as having shortness of breath with exertion and when lying flat. Review of Resident #273's After Visit Summary (AVS) discharge orders from the hospital, dated 06/02/2021, and the Medication Order Summary, dated 06/02/2021, revealed discrepancies in transcription of four (4) medications: Albuterol Sulfate HFA Aerosol Solution Inhaler, two (2) puffs, every four (4) hours as needed, for wheezing; Amitriptyline HCL twenty-five (25) milligrams (mg), one (1) tablet at bedtime for insomnia; Diltiazem HCL sixty (60) mg, one (1) tablet, twice daily for cardiac issues; and Prednisone twenty (20) mg, three (3) tablets daily for ten (10) days. The medications listed above were not transcribed from the AVS to Resident #273's Medication Order Summary or acquired from the pharmacy. Review of Resident #273's Medication Administration Record (MAR), dated June 2021, revealed there was no documented evidence that Albuterol Sulfate HFA Aerosol Solution Inhaler; Amitriptyline HCL twenty-five (25) mg tablets; Diltiazem HCL sixty (60) mg tablets; and Prednisone 20 mg tablets were administered per physician orders. In addition, review of Resident #273's Medication Review Report, received from the pharmacy, on 07/14/2021 at 2:57 PM, revealed upon his/her admission to the facility, these four (4) medications, which were listed on his/her discharge medication list from the hospital's After Visit Summary (AVS), dated 06/02/2021, were not transcribed to his/her facility admission orders. Therefore, the medications were not listed on the Medication Review Report sent to the physician. Continued review of Resident #273's medical record revealed, according to the 06/08/2021 Physician Progress Note, the physician made no changes to the AVS medication orders. Per the progress note, the physician referred to the AVS for admission medication orders. The progress note stated the physician's recommendations were to continue short-term Prednisone and Albuterol for COPD, Amitriptyline for depression, and Diltiazem for coronary artery disease/congestive heart failure/atrial fibrillation. Interview with RN #2, on 07/09/2021 at 11:30 AM, revealed she started the admission for Resident #273. She stated Resident #273 arrived during a busy time of day, while she was still doing medication administration. RN #2 stated she left the facility before completing Resident #273's admission, but she passed it on to RN #4 for completion. She could not recall what part of the admission remained unfinished but believed she did not complete all the orders. Further interview revealed, per policy, the admitting nurse completed the admission and should not pass on this responsibility to another nurse, unless there were time constraints. RN #2 stated, A lot was going on during the time of Resident's #273's admission. Continued interview with RN #2, on 07/09/2021 at 11:30 AM, revealed there was an admission Checklist that assisted nurses to complete all admission tasks. RN #2 did not recall if Resident #273's checklist was completed or signed, because she passed it on to RN #4. RN #2 stated, per policy and procedure, the admitting nurse reconciled the discharge medications noted on the AVS. Then, she stated the admitting nurse called the provider and faxed the Medication Review Summary to him/her so that he/she could verify and sign the orders. She stated she did not fax the AVS to the physician. Per the interview, RN #2 stated the physician then faxed the orders back to the facility. In addition, the admitting nurse, she stated, sent the signed Medication Review Summary to the pharmacy where the medication was filled and delivered to the facility. Further interview revealed RN #2 stated there was not a two (2) nurse review of medications to check for accuracy, except she believed the DON did review new admission medication orders. RN #2 stated a review by the DON was important to ensure medication accuracy and resident safety. Telephone interview with RN #4, on 07/12/2021 at 7:43 AM, revealed she was asked to complete Resident #273's admission paperwork when she arrived to work, on 06/02/2021 at 7:00 PM, for the night shift. She stated RN #2 left the building when her shift ended, and RN #4 completed Resident #273's admission. RN #4 remembered having another admission at the same time she was asked to complete the medication reconciliation for Resident #273. She stated she asked Licensed Practical Nurse (LPN) #3 to complete the medication reconciliation, and she thought LPN #3 sent the orders to the physician and then to the pharmacy but did not remember the time. According to RN #4, per facility protocol, the admitting nurse was responsible for completing the entire admission. She stated it should not be passed to another nurse. Per the interview, RN #4 stated medication orders should be verified by two (2) nurses. She stated she did not remember if she verified the medication orders. RN #4 stated it was important to verify medication orders to ensure resident safety and to prevent harm to the resident. Interview with LPN #3, 07/09/2021 at 1:20 PM, revealed the admitting nurse completed the admission and should not pass on this responsibility to another nurse, unless there were time constraints. She stated the admitting nurse started the admission after a resident arrived, and then notified the physician. LPN #3 stated, per policy and procedure, two (2) nurses verified the admitting orders, and both nurses signed the admission Checklist. LPN #3 stated the rest of the process was as follows: 1) the admitting nurse faxed the Medication Review Summary to the physician for verification and signature; 2) the physician faxed the signed Medication Review Summary with the orders back to the facility; 3) the admitting nurse sent the signed Medication Review Summary to the pharmacy; and 4) the pharmacy filled the medications and delivered them to the facility. Further interview revealed the nurse on duty was responsible for all orders that came in during his/her shift, and if there was a change of shift, the nurse would stay to complete the task. LPN #3 responded that following this procedure was important for medication accuracy and resident safety. Interview with Kentucky Medication Aide (KMA) #1, on 07/09/2021 at 1:45 PM, revealed Resident #273 was scheduled to be admitted to the facility on [DATE]. Therefore, she stated, a nurse had inputted all of Resident #273's medications into the electronic health record (EHR); but, when Resident #273 did not arrive, on 06/01/2021, all his/her medications had to be taken out by marking them as discontinued. Per the interview, when Resident #273's orders were inputted back in on 06/02/2021, KMA #1 stated pending orders were still on the MAR. Further, KMA #1 stated Resident #273's MAR was confusing. According to KMA #1, pending orders were not active orders and were not used for medication administration. Interview with the Consultant Pharmacist, on 07/15/2021 at 1:50 PM, revealed he had no process in effect to ensure that medication orders had been reconciled correctly by the admitting nurse, according to the AVS and the physician's admitting orders. He stated pharmacy filled medications according to the signed medication orders found on the Medication Order Summary. Interview with the Nurse Practitioner (NP), on 07/15/2021 at 11:50 AM, revealed she generally relied on the nursing staff to notify providers of a resident's change in condition (CIC). She stated, had she known Resident #273 was not receiving medications listed on her AVS, she would have prescribed them, if she felt there was an indication for continuance. She stated the process when a resident presented from an acute care facility (hospital), was for the admitting nurse to correctly transcribe discharge orders from the AVS. Further interview revealed residents were seen by the provider within seven (7) days of admission, and she looked at the AVS then, if one was available. Per the interview, providers rounded twice weekly, and if a resident had a change in condition (CIC), the resident would be seen. She stated medication reconciliation and verification of medication orders was important for the safety and well-being of the resident. Telephone interview with the Physician, on 07/14/2021 at 3:33 PM, revealed she did rely on nursing staff to send the correct medications from the hospital Discharge Summary/After Visit Summary. She stated the process was the admitting nurse faxed reconciled medication orders printed from the Point Click Care (PCC) of the EHR to her for review and signature; she then sent them back via fax. Next, the Physician stated the admitting nurse sent the signed orders to the pharmacy, who filled and delivered the resident's medications to the facility. The Physician stated sometimes she might get an AVS sent with medication orders, but it was not a usual practice. She stated the facility's failure to order the Elavil (Amitriptyline), Albuterol, Diltiazem, and Prednisone could have contributed to complications for Resident #273, but not necessarily in this case. The physician stated she, or her NP, was in the facility two (2) times a week, when one of them would have seen the resident. Continued interview with the Physician, on 07/14/2021 at 3:33 PM, revealed if Resident #273 had not been progressing, or if there were issues from him/her not getting medications, the providers would have recognized the issue or been made aware prior to the visit. Per the interview, the Physician stated Resident #273 was progressing well on the medications he/she was receiving. She stated the Elavil would not impact the resident's overall well-being; Prednisone was not a long-term medication; and the Cardizem was for high blood pressure (hypertension), which was stable, and he/she had no cardiac issues during his/her stay. She stated Resident #273's baseline was diminished breath sounds bilaterally. If he/she had needed the PRN Albuterol, she stated, the nurse would have notified her, and she would have treated Resident #273 accordingly. The Physician further stated medication reconciliation was important to ensure the correct medication was given to treat the condition and to prevent harm to the resident. Interview with the Director of Nursing (DON), on 07/09/2021 at 10:45 AM, revealed the facility had a medication reconciliation policy in place, which provided for the reconciliation of admission orders. Per the interview, the DON stated Resident #273 arrived in the facility around 3:15 PM on 06/02/2021, with an AVS from the discharging hospital. She stated, per procedure, the admitting nurse notified the physician, via telephone, of the resident's admission; and, the AVS was used as admitting orders and were implemented immediately, until the facility provider saw the resident or made changes to the admitting orders. Further interview revealed the admitting nurse transcribed and reconciled the discharge medications noted on the AVS. Per facility procedure, she stated a second nurse must verify medications for accuracy. The DON reported the admitting nurse then faxed the Medication Review Summary, printed off of the EHR to the physician, who confirmed and signed the orders. The next steps, according to the DON, were 1) the physician faxed the orders back to the facility; 2) the admitting nurse sent the signed Medication Review Summary to the pharmacy; and 3) the pharmacy filled the medication orders and delivered them to the facility. The DON stated the nurse who received the medications from the pharmacy must verify the medications received matched the medication orders. Finally, she stated, per facility policy, the admitting nurse should complete and sign the admission Checklist. Continued interview with the DON, on 07/09/2021 at 10:45 AM, revealed a nursing mistake had occurred, on 06/02/2021, when Resident #273 was admitted , because a correct medication reconciliation was not done. According to the DON, RN #2, the admitting nurse, did not complete the admission and handed it off to the night shift nurse, RN #4. According to the DON, it was the policy and her expectation that when a nurse admitted a resident, she should complete all aspects of the admission before leaving the building; an admission should not be handed off to the next shift. The DON stated this was important because following the correct process helped to prevent errors and thus promoted resident safety. Additional interview with the DON, on 07/14/2021 at 9:50 AM, revealed that facility protocol was for the admitting nurse to complete the admission from start to finish. Further, if the admitting nurse's shift had ended, he/she should stay to complete all aspects of the admission process. The DON stated she would have expected RN #2 to have completed Resident #273's admission and completed his/her medication reconciliation before she left the building; she should not have passed it on to RN #4 to finish, as RN #2 had plenty of time before the end of her shift to complete it. Further, the DON stated it was the right of the resident to have medications available to them as necessary and to have staff provide safe medication administration, per facility policy and standards of practice. Interview with the Administrator, on 07/08/2021 at 1:30 PM, revealed Resident #273's admission Checklist had not been completed by the admitting nurse. According to the Administrator, the admitting nurse should have completed the admission Checklist, and medication orders were to be verified by a second licensed nurse. He stated he expected staff to always follow established procedures and facility policies.

Based on interview and record review, it was determined the facility failed to adhere to accepted professional standards and practices, by maintaining complete and accurately documented resident records, for one (1) of eighteen (18) sampled residents (Resident #273). Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed the resident was ordered oxygen therapy at two (2) liters per minute to maintain an oxygen saturation (SpO2) between eighty-eight (88) and ninety-two (92) percent. Further review revealed the physician ordered SpO2 monitoring every shift. Review of Resident #273's medical record revealed the facility failed to transcribe a physician's order for oxygen therapy and document its administration on the Medication Administration Record (MAR). Additionally, the facility failed to transcribe the physician's order related to SpO2 monitoring every shift and failed to document the SpO2 assessment on the Treatment Administration Record (TAR). In addition, the facility failed to complete and accurately document Resident #273's admission to the facility. The findings include: Review of the facility's policy titled, Medication Reconciliation, no date, revealed the purpose of the policy was to ensure that a resident's medications were reconciled to ensure the resident was free from any significant medication errors. Continued review revealed medication reconciliation referred to the process of verifying that the resident's current medication list matched the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his/her stay. Further review revealed the pre-admission process included obtaining a current medication list from the hospital. In addition, the policy stated, during the admission process, the admitting nurse transcribed orders in accordance with procedures for admission orders; ordered medications from the pharmacy; and verified medications received from the pharmacy matched the medication orders. Review of the facility's policy titled, admission Notes, no date, revealed during the admission process, the admitting nurse must document admission information in the nurses' notes admission form, as designated by facility protocol. Review of the facility's Chronic Obstructive Pulmonary Disease (COPD) - Clinical Protocol, revised September 2012, under Assessments and Recognition, revealed the nurse must assess and document pulse oximetry results. Review of Resident #273's medical record revealed the facility admitted the resident, on 06/02/202, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure, Dysphagia, Major Depressive Disorder, Arteriosclerotic Heart Disease, Osteoporosis, Atrial Fibrillation, and Physical Debility. Further review revealed Resident #273 was discharged to home from the facility on 06/29/2021. Review of Resident #273's admission Minimum Data Set (MDS) Assessment, dated 06/09/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as having shortness of breath with exertion and when lying flat. Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed the resident was ordered supplemental oxygen therapy at two (2) liters per minute to maintain SpO2 between eighty-eight (88) and ninety-two (92) percent. Review of Resident #273's admission MDS Assessment, dated 06/09/2021, under Section Q for Special Treatments, Procedures, and Programs, revealed the resident received oxygen therapy while not a resident and while a resident. Review of Resident #273's admission Information Sheet notes, dated 06/02/2021, revealed the resident would need oxygen therapy at two (2) liters per minute via nasal cannula. Review of Nursing Assessments dated 06/02, 06/03, 06/04, 06/05, 06/07, 06/09, 06/10, 06/11, 06/12, 06/13, 06/14, 06/15, 06/16, 06/17, 06/18, 06/19, 06/20, 06/21, 06/22, 06/24, 06/25, 06/26, 06/27, 06/28, and 06/29/2021 had the box checked, which stated Oxygen in use as ordered (see TAR for LPM and oxygen saturation). Review of Resident #273's Physician Progress Note, dated 06/08/2021, revealed the physician made no changes to the AVS medications orders. Per the progress note, the physician referred to the AVS for medication orders. Review of Resident #273's Twenty-Four (24) Hour Report sheets, provided by the Director of Nursing (DON), revealed nursing staff failed to document SpO2 every shift for twelve (12) of the twenty-eight (28) days the resident was in the facility, on 06/02, 06/03, 06/04, 06/05, 06/06, 06/10, 06/14, 06/17, 06/18, 06/19, 06/22, and 06/23/2021. Review of Resident #273's MAR, dated June 2021, revealed no order for oxygen therapy. There was no documentation the resident received oxygen therapy while he/she was at the facility, from 06/02/2021 to 06/29/2021. Review of Resident #273's TAR, dated June 2021, revealed a blank sheet with No order data found for Treatment Administration Record noted. Furthermore, there was no documentation on the TAR of the ordered oxygen liters per minute in use, or SpO2 monitoring while Resident #273 was at the facility, from 06/02/2021 to 06/29/2021. Review of Resident #273's admission Checklist form revealed the checklist was incomplete, and neither Registered Nurse (RN) #2 nor RN #4 dated, documented, or signed-off the checklist to complete the resident's admission documentation. Interview with RN #2, on 07/09/2021 at 11:30 AM, revealed she started the admission for Resident #273. She stated Resident #273 arrived during a busy time of day, while she was still administering medications. RN #2 stated she left the facility before completing Resident #273's admission or the admission Checklist form. RN #2 stated she passed the responsibility of completing Resident #273's admission documentation to RN #4 for completion. She could not recall what part of the admission remained unfinished but believed she did not document all the orders. Further interview revealed, per policy, the admitting nurse completed the admission and should not pass on this responsibility to another nurse, unless there were time constraints. RN #2 stated again that she was very busy during the time of Resident's #273's admission. Additionally, the interview revealed that oxygen therapy was documented on the MAR, and SpO2 monitoring was documented on the TAR; but, nurses usually documented the SpO2 on the Twenty-Four (24) Hour Report sheet. Continued interview with RN #2, on 07/09/2021 at 11:30 AM, revealed there was an admission Checklist form that assisted nurses to complete all admission tasks. RN #2 did not recall if Resident #273's checklist was completed or signed because she passed the admission completion to RN #4. RN #2 stated, per policy and procedure, the admitting nurse was responsible for completing the admission Checklist and documenting the admission. Telephone interview with RN #4, on 07/12/2021 at 7:43 AM, revealed she was asked to complete Resident #273's admission paperwork when she arrived to work, on 06/02/2021 at 7:00 PM, for the night shift. She stated RN #2 left the building after her shift ended and did not complete Resident #273's admission. RN #4 remembered having another admission at the same time she was asked to complete Resident #273's admission and admission Checklist. According to RN #4, per facility protocol, the admitting nurse was responsible for completing the admission documentation. She stated it should not be passed to another nurse. RN #4 stated following the process was important for accuracy of medical records and resident safety. Per the interview, RN #4 stated SpO2's were documented on the Twenty-Four (24) Hour Report sheets, but technically should be documented on the TAR. Interview with Licensed Practical Nurse (LPN) #3, on 07/09/2021 at 1:20 PM, revealed the admitting nurse completed the admission and should not pass on this responsibility to another nurse, unless there were time constraints. She stated the admitting nurse started the admission after a resident arrived, and then notified the physician. Per the interview, LPN #3 stated the nurse on duty was responsible for all orders that came in during his/her shift, and if there was a change of shift, the nurse would stay to complete the task. LPN #3 responded that it was important to follow the process for accuracy of medical records and resident safety. Further interview revealed SpO2's were documented on the Twenty-Four (24) Hour Report sheets and should be documented on the TAR. Interview with Kentucky Medication Aide (KMA) #1, on 07/09/2021 at 1:45 PM, revealed Resident #273 was on supplemental oxygen therapy at two (2) liters per minute via nasal cannula. KMA #1 stated SpO2's were documented on the Twenty-Four (24) Hour Report sheets and should be documented on the TAR. Interview with the Nurse Practitioner (NP), on 07/15/2021 at 11:50 AM, revealed it was her expectation that nursing staff documented vital signs if ordered. She stated accurate documentation was important for the safety and well-being of the resident. Telephone interview with the Physician, on 07/14/2021 at 3:33 PM, revealed she did rely on nursing staff to send her, for review, the correct medications as listed on the Discharge Summary/After Visit Summary. Further interview revealed she expected nursing staff to document accurately, follow orders as written, and assess and document vital signs as ordered. Interview with the Director of Nursing (DON), on 07/09/2021 at 10:45 AM, revealed the admitting nurse should complete and sign the admission Checklist and document the admission accurately. Further interview revealed she expected nursing staff to follow orders as written and to assess and document vital signs as ordered. Per the interview, she was aware there was a continued concern with missing documentation in the residents' medical records. Continued interview with the Director of Nursing (DON), on 07/09/2021 at 10:45 AM, revealed a nursing mistake had occurred, resulting in inaccurate documentation, when Resident #273 was admitted . According to the DON, RN #2, the admitting nurse, did not complete the admission documentation and handed it off to the night shift nurse, RN #4. The DON stated it was facility policy and her expectation that when a nurse admitted a resident, he/she should complete all aspects of the admission, including all documentation, before leaving the building; an admission should not be handed off to the next shift. This was important, the DON stated, to ensure accurate documentation, to prevent errors, and for the safety of the resident. Further interview revealed oxygen therapy was documented on the MAR, and SpO2 monitoring was documented on the TAR. However, she stated nurses usually documented the SpO2 on the Twenty-Four (24) Hour Report sheet. Additional interview with the DON, on 07/14/2021 at 9:50 AM, revealed it was her expectation that all facility policies were followed. Furthermore, she expected that when a nurse admitted a resident, he/she should complete all aspects of the admission, including all documentation. Per the interview, an admission should not be handed off to the next shift because following the correct process provided accurate documentation, prevented errors, and contributed to the safety of the resident. Interview with the Administrator, on 07/08/2021 at 1:30 PM, revealed Resident #273's admission Checklist had not been completed by the admitting nurse. According to the Administrator, the admitting nurse should have completed the admission Checklist. He stated he expected staff to always follow established procedures and facility policies.

Based on observation, interview, review of the facility's hand hygiene training program, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, between 07/07/2021 and 07/15/2021, revealed multiple staff members not wearing personal protective equipment (PPE) appropriately while in the facility in patient care areas. Observation, on 07/08/2021, revealed dietary staff scraped food from plates and stacked contaminated plates, cups, and utensils onto a table where a resident remained eating dessert. Additional observation, on 07/08/2021, revealed dietary staff failed to perform hand hygiene before and after serving meal trays. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, no date, revealed the purpose of the policy was to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and spread of communicable diseases and infection. Per the policy, standard/universal precautions would be used when caring for residents at all times regardless of their suspected or confirmed infection status. The policy recommendations for infection control revealed all staff must use personal protective equipment (PPE) according to facility policy. Furthermore, the policy stated hand hygiene must be performed in accordance with the facility's hand hygiene procedures. Review of the facility's policy titled, Interim COVID-19 Visitation Policy, undated, revealed the core principles of COVID-19 infection prevention would be adhered to, which included wearing a face mask, covering the mouth and nose, at all times. Review of the facility's hand hygiene training program titled, Stop Germs! Wash Your Hands! no date, revealed staff should perform hand hygiene before and after serving food, and before and after resident care. Observation of Licensed Practical Nurse (LPN) #1 and LPN #2, on 07/07/2021 at 4:15 PM, revealed both nurses sitting at the Pavilion Nurses' Station desk with their surgical masks below their noses. Both LPN #1 and LPN #2 pulled their masks up when the State Survey Agency (SSA) Surveyor passed the nurses' station. Interview with LPN #1, on 07/08/2021 at 10:15 AM, revealed at times her mask would slip below her nose, but when she realized it, she would adjust the mask. She stated if her mask was below her nose, it was not intentional. LPN #1 stated wearing a mask was important to prevent the spread of infection. She stated she received training regarding the facility's Infection Control Prevention (ICP) program upon hire, and she had received in-service training on COVID-19 and hand hygiene. LPN #1 stated, as part of the ICP program and the facility's policy, all staff was required to wear a mask while in the facility, regardless of vaccination status. Further interview revealed the Director of Nursing (DON) monitored staff compliance with ICP practices. Interview with LPN #2, on 07/08/2021 at 10:40 AM, revealed sometimes her mask slipped down below her nose, but if she was aware it had slipped, she would make an adjustment. She stated it was the facility's policy that all staff was required to wear a mask while in the facility, in patient care areas, and while providing care for the residents. LPN #2 stated wearing a mask was important to prevent the spread of communicable diseases and for the resident's safety. In addition, she stated she received education on ICP during new employee orientation and had received educational in-services throughout the year. She reported ICP training included proper hand hygiene techniques and the use of personal protective equipment (PPE). Observation of two (2) staff members standing at the Providence Hall Nurses' Station, on 07/07/2021 at 4:48 PM, revealed both staff members with their surgical masks below their noses. Both staff pulled their masks up when they saw the SSA Surveyor. Observation of Kentucky Medication Aide/State Registered Nurse Aide (KMA/SRNA) #1, on 07/08/2021 at 8:19 AM, revealed her face mask was worn below her nose. KMA #1 pulled her mask over her nose when she saw the SSA Surveyor. Interview with KMA/SRNA #1, on 07/08/2021 at 8:19 AM, revealed it was the facility's policy that all staff and visitors wear masks appropriately, and at all times while in the facility. Additional interview with KMA #1, on 07/09/2021 at 1:45 PM, revealed she received ICP and hand hygiene training upon hire. She stated she had received periodic in-services regarding COVID-19 updates. She further stated that all staff was monitored for compliance by the DON/IP and floor nurses. If they saw noncompliance, they would stop and educate. Observation, on 07/08/2021 at 12:10 PM, revealed a staff member walking down the hall without wearing a mask. The staff member also was not wearing a name badge. When the SSA Surveyor followed her for an interview, she turned down a hall and was not found. The SSA Surveyor notified the Director of Nursing/Infection Preventionist (DON/IP), who stated she would find the aide and address the issue of not wearing a mask while in a patient care area. Observation of Dietary Aide (DA) #2, on 07/08/2021 at 8:45 AM, revealed DA #2 was not wearing gloves, while she was in the dining room clearing trays. Observation in the dining room, on 07/08/2021 at 12:30 PM, revealed DA #2 removed dinner trays from the meal cart and set up meals for residents seated in the dining room. DA #2 contaminated her hands while assisting one (1) resident and then went back to get a tray for another resident, without performing hand hygiene. Observations, on 07/08/2021 at 1:10 PM, in the dining room, revealed DA #3 was not wearing a face mask. Further observation revealed DA #2 scraped and stacked contaminated plates, cups, and utensils on the table where a resident was still seated and eating his/her meal. Neither DA #1 nor DA #3 performed hand hygiene after removing gloves. Interview with DA #1, on 07/08/2021 at 2:20 PM, revealed she was trained on ICP practices upon hire and then had subsequent COVID-19 in-service training. She stated she trained new dietary staff, and she educated staff to wear gloves when serving food. She further stated staff was instructed to use alcohol-based hand rub (ABHR) after every third meal tray delivery. Per the interview, staff was not trained to scrape and stack dishes in the dining room after residents' meals. Additionally, staff should not place dirty plates, cups, or utensils on a table where residents were present. DA #1 stated gloves should be changed if contaminated and ABHR applied. Further, DA #1 stated following the facility's policies on ICP was important for infection control. Interview with DA #2, on 07/08/2021 at 2:43 PM, revealed she had been employed at the facility for two (2)weeks. She stated she was told about using PPE, but did not know she was required to wear a mask at all times. Per the interview, she was unaware that she needed to use ABHR when she removed her gloves. She stated she had not been trained to use ABHR when her hands were contaminated or after every three (3) tray passes. DA #2 stated she was taught to scrape and stack plates at the table but could see why it should not be done with residents at their tables because it could spread germs. Interview with DA #3, on 07/08/2021 at 2:50 PM, revealed he was trained on ICP practices upon hire and then had subsequent COVID-19 training. He stated he was trained to use ABHR and knew he was to wear a mask appropriately at all times while in the facility. He stated he was trained to wear gloves to pick up dirty trays and use ABHR after removing contaminated gloves because it was important for infection control. Interview with the Dietary Supervisor, on 07/08/2021 at 2:00 PM, revealed it was his expectation that masks were always worn in the patient care areas. The Supervisor stated dietary staff was to use alcohol-based hand rub (ABHR) appropriately when serving meals; staff serving food should wear gloves; and staff delivering meal trays should hand sanitize if they came in contact with a resident or a resident's environment, or after every third tray delivered. According to the Dietary Supervisor, staff should never scrape and stack plates at the same table where a resident remained seated and eating. He stated, They know better. It was his expectation that his staff follow all ICP policies. The Supervisor stated it was important for the health and safety of the resident and staff. Observation of Housekeeping Aide (HA) #1, on 07/08/2021 at 3:40 PM, revealed she was wearing her mask below her nose while cleaning in the hallway near residents. Interview with HA #1, on 07/08/2021 at 3:40 PM, revealed she was wearing her mask below her nose while cleaning in the hallway near residents, but stated she had asthma, and at times she found it difficult to breathe while wearing a mask. HA #1 was carrying a rescue inhaler for her asthma. She stated she tried to keep a face mask on when she was around residents. She stated she had received PPE and ICP training, as well as additional COVID-19 training. HA #1 said using PPE appropriately was important to stop the spread of infection. Interview with the Housekeeping/ Laundry Supervisor, on 07/08/2021 at 1:15 PM, revealed it was her expectation that the laundry and housekeeping staff wore masks at all times while in the facility. She stated it was important for staff to follow ICP practices to prevent the spread of infection. Observation of LPN #4, on 07/13/2021 at 2:40 PM, revealed she was sitting at the Rehabilitation Hall's Nurses' Station and was not wearing a mask. Observation of SRNA # 5, on 7/15/2021 at 9:45 AM, revealed she was wearing her mask below her chin while talking to Resident #58 who was not wearing a mask. Interview with SRNA #2, on 07/08/2021 at 11:10 AM, revealed he received some ICP training upon hire. He stated he was trained on how to properly don and doff PPE. SRNA #2 stated that the DON/IP monitored compliance, and if she saw something wrong, she would address it with the staff member. Per the interview, SRNA #2 believed several staff members were defiant and did not wear masks appropriately, but no one said anything. Interview with the DON/IP, on 07/08/2021 at 9:45 AM, revealed it was her expectation that all staff follow facility ICP policies and procedures related to hand hygiene and use of PPE. The DON/IP stated there was no specific facility policy on hand hygiene that listed when and what hand hygiene measures were required in specific situations. However, per the interview, she stated the facility trained staff members to follow the CDC's Stop Germs! Wash Your Hands! training program. According to CDC recommendations listed in the Stop Germs! Wash Your Hands! training guidelines, hands should be washed before and after serving food. Additional interview with the DON, on 07/15/2021 at 9:55 AM, revealed she did not know why staff was not following established ICP policies and procedures. She stated, I feel they are doing this to spite me. She stated it was her expectation that all staff wear their masks at all times. It was also her expectation that staff wear PPE appropriately and practice hand hygiene as indicated because doing so was important to prevent cross-contamination and prevent the spread of infection. Interview with the Administrator, on 07/08/2021 at 10:45 AM, revealed ICP guidelines were to be maintained at all times in the facility, and it was his expectation that staff followed all facility ICP practices related to wearing of PPE appropriately, and hand hygiene practices. He stated it was important to prevent the spread of infection and decreased the likelihood of cross-contamination.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. This affected Resident #19, Resident #21, Resident #23, Resident #34, Resident #62, and Resident #64. Observation during lunch meal, on 11/19/19, revealed staff were standing to assist Resident #19, Resident #21, Resident #23, Resident #34, Resident #62 and Resident #64 with dining. The findings include: Review of the facility Rights for Patients and Residents, Policy, undated, revealed every resident has the right to a dignified existence with services within the facility. Further, residents have the right to receive treatment, care and services that are adequate, appropriate, and in compliance with state and federal regulation. 1. Review of Resident #34's medical record revealed the facility admitted the resident on 03/19/14 with diagnoses to include, but not limited to Profound Intellectual Disabilities, Unspecified Mental Disorder, Cortical Blindness, Anxiety Disorder, Epilepsy, Cerebral Palsy, and Failure to Thrive (child). Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/17/19, revealed the facility assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed Resident #34 to require extensive physical assistance of one (1) staff member for eating. 2. Resident #64's medical record revealed the facility admitted the resident on 07/02/17 with diagnoses to include, but not limited to Profound Intellectual Disabilities, Pseudobulbar Affective Disorder, Blindness Both Eyes, and Weakness. Review of the Quarterly MDS Assessment, dated 11/01/19, revealed the facility assessed Resident #64 to have a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed Resident #64 to require limited physical assistance of one (1) staff member for eating. 3. Resident #23's medical record revealed the facility admitted the resident on 01/12/90 with diagnoses to include, but not limited to Cerebral Palsy, Aphasia, and Convulsions. Review of the Quarterly MDS Assessment, dated 11/12/19, revealed the facility assessed Resident #23 to have a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed Resident #23 to require extensive physical assistance of one (1) staff member for eating. 4. Resident #21's medical record revealed the facility admitted the resident on 01/05/11, with diagnoses to include, but not limited to Cerebral Palsy, Anxiety Disorder,and Chronic Pain Syndrome. Review of the Quarterly MDS Assessment, dated 11/03/19, revealed the facility assessed Resident #21 to have a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS Assessment, revealed the facility assessed Resident #21 to require extensive physical assistance with one (1) staff member for eating. 5. Resident #19's medical record revealed the facility admitted the resident on 01/21/19 with diagnoses to include, but not limited to Dementia, Alcohol Dependence, Anxiety Disorder, Vascular Dementia, Restlessness and Agitation. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/16/19, revealed the facility assessed Resident #27 to have a BIMS score of six (6) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed the resident to require total physical assistance with one (1) staff member for eating. 6. Resident #19's medical record revealed the facility admitted the resident on 08/18/19 with diagnoses to include, but not limited to Dementia. Review of the Quarterly MDS Assessment, dated 08/31/19, revealed the facility assessed Resident #19 to have a BIMS score of two (02) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed Resident #19 to require extensive physical assistance with one (1) staff member for eating. Observation during lunch meal, on 11/19/19, revealed staff were standing to assist Resident #19, Resident #21, Resident #23, Resident #34, Resident #62 and Resident #64 with dining. Interview with Licensed Practical Nurse (LPN) #2, on 11/21/19 at 9:45 AM, revealed the facility provided Resident Rights training a few times a year. Per interview, she ensured Resident Rights during meal services by interacting with the residents and talking to them at eye level. She further stated she ensured the residents were clean, had choices and were provided the level of assistance required as per their Care Plan. Additional interview, revealed on Tuesday 11/19/19, lunch meal service in the dining room was crowded and busy and she did stand to assist the residents with eating. However, she stated she should have found a seat and sat between Resident #34 and Resident #19, when assisting them because it would have been more resident centered and respectful than standing between them. Further, it was her responsibility to protect and promote each resident's rights to ensure quality of life. Interview with State Registered Nurse Aide (SRNA) #4 on 11/21/19 at 09:50 AM, revealed she worked on all units. She stated on 11/19/19 when she arrived to the dining room to assist residents with lunch, she did stand to assist Resident #64 and Resident #21 with eating. She stated this was a dignity issue for the residents and she should have sat down to assist the residents with eating instead of standing over them. Per interview, the facility provided training once a year on Residents Rights. Interview with Unit Manager/Registered Nurse (RN) #1, on 11/21/19 at 11:45 AM, revealed she had worked at the facility for six (6) years. She stated it was her expectation for staff to abide by residents rights. She further stated when she assisted Resident #23 and Resident #62 with lunch on 11/19/19 she did stand to feed the residents. Per interview, she should have found a chair to sit down when assisting the residents with the lunch meal. She further stated she did notice all other staff were standing and feeding the residents during mealtime that day. Interview with the Director of Nursing (DON), on 11/21/19 at 10:16 AM, revealed she expected staff to maintain each resident's dignity while providing all care. Additionally, she expected staff to sit beside residents to assist them during meals. Per interview, it was important to sit and not to stand over a resident when assisting with meals because staff should be at eye level, so they could speak to the residents as well as monitor them. Further, RN #1, LPN #2 and SRNA #4 should have found seats before assisting residents with their meal on 11/19/19, during the lunch meal. Interview with the Administrator, on 11/21/19 at 10:24 AM, revealed staff should be seated at all times when assisting a dependent resident with meals. Additionally, all staff was responsible to ensure Resident Rights were maintained for all residents during meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident receives hydration consistent with resident needs and preferences for nine (9) of thirteen (13) sampled residents (Resident #11, Resident #22, Resident #43, Resident #44, Resident #52, Resident #57, Resident #60, Resident #67, and Resident #70. During the Group Interview, conducted by the State Agency Representative, Resident #11, Resident #44, Resident #52, Resident #57, Resident #60, and Resident #70 complained ice and fluids were not being passed routinely between meals. In addition, Resident #67 who did not attend the Group Interview, complained ice and fluids were not passed routinely between meals. Furthermore, Task Care Records (document to be completed upon hydration pass at 10:00 AM, 1:00 PM, and 8:00 PM), for November 2019, revealed multiple gaps of missing documentation, indicating hydration pass was not completed. The findings include: Review of the facility Ice Pass Policy, undated, revealed ice was to be passed at least once a shift to residents to maintain adequate hydration, with the exception of residents on tube feeding or on fluid restrictions. Review of the staffing sheet dated 11/21/19, revealed a notation on the form stating, make sure to pass ice at 11:00 AM - 4:00 PM, 11:00 PM, and 3:00 AM, however, this did not include a space to indicate who was responsible for passing ice, nor did it match the Task Care Records in the electronic medical records, which indicated hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 08/14/17 with diagnoses to include Anxiety Disorder, Insomnia and Type 2 Diabetes Mellitus with Diabetic Neuropathy. The facility assessed Resident #11, in an 11/20/19 Quarterly Minimum Data Set (MDS) Assessment as having a Brief Interview for Mental Status (BIMS) of fourteen (14) out of fifteen (15) indicating no cognitive impairment. Review of Resident #11's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, there was no hydration recorded for November 9th, 10th, 11th, 17th, or 18th. 2. Review of Resident #22's medical record revealed the facility admitted the resident on 09/11/18 with diagnoses to include Acute Cystitis with Hematuria, Major Depressive Disorder, and Anemia Unspecified. The facility assessed Resident #22, in an Annual MDS Assessment, dated 09/04/19, as having a BIMS score of eleven (11) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #22's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 5th, 8th, 9th, 10th, 12th, 16th, 18th, or 19th. 3. Review of Resident #43's medical record revealed the facility admitted the resident on 06/25/19 with diagnoses to include Altered Mental Status Unspecified, Hyperlipidemia, and Hyperglycemia Unspecified. The facility assessed Resident #43 in a Quarterly MDS Assessment, dated 10/01/19, as having a BIMS score of four (04) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #43's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 12th, 13th, or 19th. 4. Review of Resident #44's medical record revealed the facility admitted the resident on 06/28/19 with diagnoses to include Urinary Tract Infection, Alzheimer's Disease and Anxiety Disorder. The facility assessed Resident #44, in a Quarterly MDS assessment dated [DATE], as having BIMS score of thirteen (13) of fifteen (15), indicating no cognitive impairment. Review of Resident #44's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 5th, 8th, 9th, 10th, 12th, 16th, 18th, or 19th. 5. Review of Resident #52's medical record revealed the facility admitted the resident on 09/22/17 with diagnoses to include Hereditary Lymphedema, Generalized Acute Peritonitis, and Encounter for Attention to Iliostomy. The facility assessed Resident #52, in a Quarterly MDS assessment dated [DATE], as having a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Review of Resident #52's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 5th, 8th, 9th, 10th, 12th, 16th, 18th, or 19th. 6. Review of Resident #57's medical record revealed the facility admitted the resident on 09/18/18 with diagnoses to include Paranoid Schizophrenia, Retention of Urine, and Anxiety Disorder. The facility assessed Resident #57, in a Quarterly MDS Assessment, dated 10/23/19 as having a BIMS score of three (03) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #57's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 2nd or 10th. 7. Review of Resident #60's medical record revealed the facility admitted the resident on 10/13/17 with diagnoses to include Adjustment Disorder with Depressed Mood, Hyperlipidemia, and Neuromuscular Dysfunction of Bladder Unspecified. The facility assessed Resident #60, in a Quarterly MDS assessment dated [DATE], as having a BIMS score of thirteen (13) out of fifteen (15), indicating no cognitive impairment. Review of Resident #60's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 1st, 12th, 13th, or 19th. 8. Review of Resident #67's medical record revealed the facility admitted the resident on 09/25/19 with diagnoses to include Hyperlipidemia, Repeated Falls, and Anxiety Disorder. The facility assessed Resident #67, per the admission MDS Assessment, dated 09/30/19, as having a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Review of Resident #67's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 1st, 12th, 18th, or 19th. Interview with Resident #67 on 11/19/19 at 11:30 AM revealed staff only provided ice and water/fluids upon request. 9. Review of Resident #70's medical record revealed the facility admitted the resident on 09/12/19 with diagnoses to include Chronic Kidney Disease Stage 2, and Type 2 Diabetes Mellitus. The facility assessed Resident #70, per the admission MDS assessment dated [DATE], as having a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Review of Resident #70's electronic medical record revealed a Task Care Record for November 2019, indicating hydration was to be passed at 10:00 AM, 1:00 PM, and 8:00 PM. However, no hydration was recorded for November 1st, 12th, and 13th. During Group interview on 11/20/19 at 10:00 AM, residents in attendance including Resident #11, Resident #44, Resident #52, Resident #57, Resident #60, and Resident #70, complained staff did not routinely pass ice, water, or fluids; however, ice or water would be provided if requested. Interview with Kentucky Medication Aide (KMA) #1, on 11/21/19 at 10:40 AM, revealed ice and fluids was supposed to be passed at 10:00 AM, again after lunch, and again before bed. She stated some residents had complained about ice not being consistently passed, and KMA #1 acknowledged there were times when ice and fluids were not passed between meals due to staff being too busy. Interview with Licensed Practical Nurse (LPN) #1, on 11/21/19 at 11:22 AM, revealed she was not aware of any complaints about residents not getting ice passed to them. She stated ice and fluids was passed every shift and it should be documented in the electronic medical record. Per interview, she did not know who was responsible for reviewing residents' fluid intake, but it was the unit nurse's jobs to ensure ice/water was passed. Interview with State Registered Nurse Aide (SRNA) #3 on 11/21/19 at 2:12 PM revealed SRNAs were supposed to pass ice and water at least once a shift routinely, and also upon residents' request. She stated if there were five (5) SRNAs working the units instead of six (6), staff may not get the opportunity to pass ice or water, unless it was requested by a resident. Interview with SRNA #4 on 11/21/19 at 2:37 PM revealed ice was to be passed at 10:00 AM, and again in the afternoon around 2:00 PM or 3:00 PM, but SRNA were not always able to do that, depending on staffing. She stated whenever staff checked on residents, they were to offer them drinks, and some residents were able to request ice or water. Interview with SRNA #5 on 11/21/19 at 2:59 PM revealed SRNAs tried to pass ice during the day shift at least twice a day, but sometimes there was not enough time to get this done. However, SRNA #5 was unaware of any residents complaining about staff not passing water or ice. Interview on 11/21/19 at 3:25 PM, with the Nurse Aide Manager, revealed ice was passed at 10:00 AM, 1:00 PM, and she thought at 6:00 PM. She stated staff was supposed to document in the electronic medical record when they passed ice, or fluids, but acknowledged there were dates in the Task Care Records for November 2019 where there was no documentation to indicate ice/water was passed. She stated staff needed to inform her if they were getting behind and she would pass ice/water if needed. Interview with the Director of Nursing (DON), on 11/21/19 at 4:08 PM, revealed she thought ice, and water were being passed routinely, as she often observed staff in performing the hydration pass. She further stated the facility had not experienced any dehydration issues. Per interview, the facility had been using agency staff, who may not have been recording when ice/water were passed. Further interview revealed when SRNAs were in resident rooms during rounds, they were to offer residents fluids, and nurses also gave extra fluids during medication pass. Continued interview revealed it was her expectation ice/water be passed between meals at least once a shift, and fluids documented in the Task Care Record. Interview with the Administrator, on 11/21/19 at 5:06 PM, revealed ice/water or other fluids should be passed every shift and as needed and documented in the electronic medical record. He stated he had not heard staff complain they were unable to pass ice/fluids and had not heard residents complain about this issue.