**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy, and review of Federal Regulations regarding Advance Directives, it was determined the facility failed to have a policy on Advance Directives which allowed two (2) of thirty (30) sampled residents, Residents #25 and #42 to have insufficient documentation concerning their directives for medical care. The findings include: Interview with the Social Service Director (SSD) on [DATE] at 10:30 AM, revealed the facility did not have a policy detailing how Advance Directives were to be obtained or what they should contain. Review of the facility's policy titled, Resident Rights, not dated, revealed the facility was to comply with the requirements specified in 42 CFR Part 489, Subpart 1, to provide information to all adult residents concerning the right to formulate an advance directive. Review of 42 CFR 489.100, Subpart 1, Advance Directives, revealed advance directives was defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Further review revealed skilled nursing facilities (SNF) must maintain written policies and procedures concerning Advance Directives with respect to all adult individuals receiving medical care, by or through the provider and were required to document in a prominent part of the individual's current medical record whether or not the individual had executed an Advance Directive. 1. Review of Resident #25's medical record revealed the facility admitted the resident on [DATE], with a primary diagnosis of Heart Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed the resident to continue to have a BIMS score of fifteen (15). Additional review of Resident #25's medical record revealed a one (1) sheet Medical Directive Acknowledgement form dated [DATE], which contained a check mark noted beside the sentence stating, I have chosen to formulate the following directives for care. Continued review of the medical record and the Medical Directive Acknowledgement form revealed a separate box located at the bottom of the form that was checked as Yes by the area noting Use of CPR (Cardiopulmonary Resuscitation) in the event of cardiac or respiratory arrest, with the word verbal noted by Resident #25's name. Review of the form also revealed it did not list in detail Resident #25's directives beyond his/her CPR status (Such as use of Intravenous Fluids [IVF] or feeding tubes, or intubation). Further review of the Medical Directive Acknowledgement form revealed it contained an additional check mark documented by the, Durable Health Care Power of Attorney, which noted the method by which the resident had expressed his/her wishes for future care. Per review, the Resident Signature line contained no documented resident signature; however, the Facility Representative Acknowledgement area contained the facility's Social Services Director (SSD) signature and a signature was noted on the Physician Acknowledgement line. Further review on the line noted as Responsible Party/Surrogate Acknowledement Resident #25's Power of Attorney (POA), as noted on his/her admisison record, was printed, with documentation noting verbal rather than a written signature of the POA. In addition, record review further revealed no documented evidence noted in Resident #25's medical record verifying the resident had a Durable Health Care POA in place; and no evidence of a copy of a Durable Health Care POA located in his/her medical record. 2. Review of Resident #42's medical record revealed the facility admitted the resident on [DATE], with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #42 to have a BIMS score of fifteen (15), indicating the resident was cognitively intact. However, review of the latest Annual MDS assessment dated [DATE], revealed the facility assessed Resident #42 to have a BIMS score of eleven (11), indicating the resident was now assessed to have moderately impaired cognition. Record review further revealed Resident #42 was listed as being his/her own responsible party after the [DATE] MDS Assessment. Additional review of Resident #42's medical record revealed a one (1) sheet Medical Directive Acknowledgement form dated [DATE], which contained a check mark noted beside the sentence stating, I have chosen to formulate the following directives for care. Review of the Facility Representative Acknowledgement area revealed it contained the facility's SSD's signature and a signature was noted on the Physician Acknowledgement line. Review on the line noted as Responsible Party/Surrogate Acknowledement there was a printed name on the line with the word verbal documented beside the name. However, review of Resident #42's medical record revealed the person's name printed beside the word verbal on the Medical Directive Acknowledgement form was not listed in the resident's record as one (1) of his/her emergency contacts. Further review of the Medical Directive Acknowledgement form revealed it contained check marks by the Directives for Care and by the Durable Health Care Power of Attorney which indicated the methods by which the resident expressed his/her wishes for future care. Review of the form revealed there was also a box which read, To be completed only by a resident who had decisional capacity and Use of CPR in the event of cardiac or respiratory arrest which had No checked beside them. Record review further revealed no documented evidence noted in Resident #42's medical record verifying the resident had a Durable Health Care POA in place; and no evidence of a copy of a Durable Health Care POA located in his/her medical record. Additionally, there was no documented evidence of specific directives for Resident #42's care if he/she suffered a catastrophic incident. Interview with the MDS Coordinator on [DATE] at 4:52 PM, revealed she defined Advance Directives as a resident's code or CPR status. She stated if a resident had more specific wishes regarding the aspects of his/her care, the Physician would have to write an order clarifying those wishes. Per the MDS Coordinator, if the Physician wrote such orders they would be found in the facility's electronic health record (EHR) for the resident. She further stated the SSD handled the facility's Advance Directives process for residents with them and their families. Interview with the SSD on [DATE] at 10:30 AM, revealed the facility's process for giving Advance Directives information to residents began with their admission to the facility. She stated if the resident came to the facility from the hospital, the facility used the hospital information and then discussed the resident's code status and living will information with the resident and his/her family. Continued review revealed she also gathered relevant documents at the time of that discussion to present to the resident and his/her family. The SSD further stated she defined Advance Directives as a resident's desired code or CPR status. Further interview revealed Advance Directive were to be considered separately from a living will which detailed resident's wishes regarding use of a feeding tube or a ventilator (Even though this differed from the definitions in the Code of Federal Regulations). The Administrator was out of town and unavailable for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the comprehensive care plan (CCP) after each assessment following falls with interventions to prevent falls, for one (1) of thirty (30) sampled residents (Resident #42). Resident #42's CCP was not revised/updated for twelve (12) of the twenty-one (21) falls he/she experienced from 04/29/2022 through 10/14/2022. Refer to F-0689 The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed it was the facility's policy to review and update a resident's care plan when the desired outcome had not been met. Review of Resident #42's medical record revealed the facility admitted him/her on 04/23/2020, with diagnoses including Chronic Obstructive Pulmonary Disease, Polyneuropathy, Chronic Pain, Dizziness, History of Falls, Ataxic Gait, and Unspecified Dementia. Review of Resident #42's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating mild cognitive impairment. Review of the facility's Event Log from 04/01/2022 to 10/14/2022, revealed Resident #42 experienced twenty-one (21) falls between 04/29/2022 through 10/14/2022. While conducting the review of Resident #42's falls from 04/29/2022 through 10/14/2022, the State Survey Agency (SSA) Surveyor noted a pattern of several falls occurring around toileting. However, review of the facility's documentation revealed no documentation noting any patterns determined for Resident #42's falls. Review of Resident #42's CCP, initially dated 04/24/2020, and most recently revised 08/27/2022, revealed Resident #42 would have no avoidable falls and/or no falls with injury before the next review of the CCP. Review of Resident #42's CCP for fall prevention interventions, dated 04/24/2020 to 04/28/2020, revealed the interventions included: answering the call light as promptly as possible each shift; offering toileting before and after meals and at bedtime; assisting the resident with clothing management; monitoring the condition of the resident's shoes; encouraging the use of nonslip socks/shoes; instructing the resident to ask for assistance before transfers; keeping the bedside table and call light within reach; placing a wheelchair pad alarm to alert staff; and using Meclizine (an antihistamine used to treat dizziness) to treat dizziness as ordered. Review of Resident #42's CCP for fall prevention, dated 01/19/2022 to 03/25/2022, revealed the interventions included: installing padded flooring to the resident's room; keeping the bed in the lowest position; and providing a hand bell for the resident to use in addition to the call bell. 1. Review of Resident #42's medical record revealed he/she experienced a fall on 04/29/2022 at 7:32 AM, when the resident stood up and tried to turn the wheelchair alarm off, fell into the wheelchair, and tipped the wheelchair over which resulted in the resident sustaining an abrasion to the right middle finger. Continued review revealed no new care plan interventions were noted following this fall. 2. Review of Resident #42's medical record revealed the resident experienced a fall on 05/02/2022 at 4:15 AM, when the resident attempted to go to the bathroom while the room was dark. Continued review revealed no new care plan interventions were noted following this fall. 3. Review of Resident #42's medical record revealed the resident experienced a fall on 05/02/2022 at 10:55 AM, when the resident slid on the mat in the bathroom and scraped his/her back. Continued review revealed no new care plan interventions were noted following this fall. 4. Review of Resident #42's medical record revealed the resident sustained a fall on 05/15/2022 at 6:00 PM, when the resident stood in front of the commode in the bathroom and fell. Continued review revealed no new care plan interventions were noted following this fall. 5. Review of Resident #42's medical record revealed the resident sustained a fall on 05/22/2022 at 8:08 AM, when he/she slid off the bed while trying to get up. Continued review revealed no new care plan interventions were noted following this fall. Per continued review of Resident #42's CCP revealed on 05/24/2022, the care plan had been modified to add the intervention of placing Dycem (a non-slip material used for stabilization and to prevent sliding) in the wheelchair seat to prevent falls. Additional review of Resident #42's CCP revealed on 05/25/2022, the care plan was modified to add the intervention of installing grab bars on top of the bathroom counter to assist the resident with balance. Per review of Resident #42's CCP, on 05/25/2022, the CCP was modified to add the intervention of consulting the pain pump management team about a medication review due to the resident's dizziness. Further review of Resident #42's CCP revealed on 06/02/2022, the CCP was modified to add the intervention of placing a stop sign at the bathroom door to remind the resident to ask for assistance with toileting. 6. Continued review of Resident #42's medical record revealed the resident experienced a fall on 06/03/2022 at 10:15 PM, while ambulating from the bathroom to the wheelchair. Continued review revealed no new care plan interventions were noted following this fall. 7. Review of Resident #42's medical record revealed the resident sustained a fall on 06/09/2022 at 7:30 PM, when he/she was making the bed and got his/her feet tangled in the blankets and fell. Continued review revealed no new care plan interventions were noted following this fall. 8. Review of Resident #42's medical record revealed the resident experienced a fall on 06/22/2022 at 5:29 AM, when trying to get back into bed. Continued review revealed no new care plan interventions were noted following this fall. 9. Review of Resident #42's medical record revealed the resident sustained a fall on 06/25/2022 at 7:50 AM, while attempting to transfer independently onto the toilet seat. Continued review revealed no new care plan interventions were noted following this fall. Additional review of Resident #42's CCP revealed on 07/10/2022, the care plan was modified to add an intervention of using a perimeter defined mattress to the resident's bed for positioning. 10. Review of Resident #42's medical record revealed the resident experienced a fall on 08/14/2022 at 5:04 AM, when he/she independently changed his/her briefs. Continued review revealed no new care plan interventions were noted following this fall. 11. Review of Resident #42's medical record revealed the resident experienced a fall on 08/21/2022 at 6:35 PM, when he/she reached for clothing in a drawer. Continued review revealed no new care plan interventions were noted following this fall. 12. Review of Resident #42's medical record revealed the resident experienced a fall from his/her wheelchair on 10/14/2022 at 1:20 PM, while looking for a light on the floor. Continued revealed no new care plan interventions were noted following this fall. Observation on 10/19/2022 at 11:53 AM, revealed Resident #42 in his/her room, sitting in his/her wheelchair, slumped forward and leaning to the right side. Interview with Resident #42 on 10/18/2022 at 3:36 PM, revealed he/she fell frequently due to dizziness, resulting in the facility placing a foam mat in the resident's room to prevent injuries. Continued interview revealed Resident #42 believed the dizziness was due to his/her pain medication. Resident #42 stated however, he/she needed the pain medication or his/her pain was unbearable and limited his/her ability to perform activities of daily living (ADL) and participate in activities. Further interview revealed there were some staff who did not answer his/her call light in a timely manner; however, the resident was unable to recall any names. Interview with Licensed Practical Nurse (LPN) #7 on 10/20/2022 at 5:45 PM, revealed she was aware Resident #42 had experienced multiple falls. She stated Resident #42's care plan interventions for fall prevention included having him/her wear nonskid socks, having a padded floor in the resident's room, and placing alarms in the resident's wheelchair, until the resident refused these alarms. Interview with the Assistant Director of Nursing (ADON), who also acted as the facility's Falls Coordinator, on 10/22/2022 at 11:15 AM, revealed the only other thing the facility could suggest for Resident #42 was a bubble due to his/her noncompliance with previously attempted interventions. The ADON stated she looked at the falls incident reports and worked with the facility's interdisciplinary team (IDT) to develop resident-specific interventions to prevent falls. She stated her expectation was for staff to provide increased supervision of Resident #42 by performing every two (2) hours checks of the resident to see if he/she needed assistance going to the bathroom. She stated however, she was unsure if this expectation was communicated in the resident's care plan, and made no attempt to look it up to determine if the checks were noted on the resident's care plan. Per the ADON, she provided education for staff regarding ensuring residents' care plans were being followed. Interview with the Director of Nursing (DON), on 10/22/2022 at 11:15 AM, revealed she was aware of Resident #42's history of falls and was able to access the CCP and read the interventions in place. She stated the care plan was an important communication tool for staff to know what each resident needed. Per the DON, tracking residents' falls was the responsibility of the ADON, Further interview revealed the facility had a committee that analyzed residents' falls, and the ADON would be able to give more details on the findings of that group, since that committee was her responsibility. The Administrator was out of town and was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of thirty (30) sampled residents, Resident #42. Resident #42 experienced twenty-five (25) falls from 04/14/2022 through 10/21/2022. The findings include: The State Survey Agency (SSA) Surveyor requested the facility's policy on Falls; however, the facility did not provide the policy as requested. Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to a safe environment. Review of Resident #42's medical record revealed the facility admitted the resident on 04/23/2020, with diagnoses that included History of Falling, Polyneuropathy, Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Dizziness, Ataxic Gait, and Unspecified Dementia. Review of Resident #42's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15), indicating he/she was moderately cognitively impaired. Review of Resident #42's initial care plan dated 04/23/2020, revealed it included interventions for fall prevention. Continued review revealed the interventions were noted as answering call lights as promptly as possible each shift, offering toileting before and after meals and at bedtime, and assisting the resident with clothing management. Review additionally revealed other interventions which were monitoring condition of resident's shoes, applying Dycem (a non-slip material used for stabilization and to prevent sliding) to the wheelchair seat, encouraging use of nonskid socks, installing a grab bar on the bathroom counter, instructing resident to ask for assistance prior to transfers, keeping the bed in the lowest position. Further review revealed the interventions also included keeping the bedside table and call light within reach, use of perimeter defining mattress and padded flooring, following up with the pain pump provider for a medication dose reduction due to dizziness, and placing a wheelchair pad alarm to alert staff. Review of the facility's Event Log for the time period of 04/01/2022 through 10/17/2022, revealed Resident #42 experienced twenty-five (25) falls. Review revealed the falls occurred: on 04/14/2022 while attempting to transfer to the wheelchair; on 04/21/2022 at 9:15 AM when getting out of bed to go to the bathroom; on 04/26/2022 at 6:20 AM when he/she refused to lie down on the bed and slid onto the floor; on 04/29/2022 at 7:32 AM when he/she stood up and tried to turn the wheelchair alarm off, fell back into the wheelchair, and tipped the wheelchair over, which resulted in an abrasion to his/her right middle finger; on 05/01/2022 at 4:40 AM when he/she attempted to transfer from the wheelchair to the commode and did not use the call bell to obtain assistance; on 05/02/2022 at 4:15 AM when he/she attempted to go to the bathroom while the room was dark; on 05/02/2022 at 10:55 AM when he/she slid on the mat in the bathroom and scraped his/her back; on 05/03/2022 at 10:00 PM when he/she was discovered with his/her pants down around the ankles trying to get back into bed; on 05/04/2022 at 4:55 PM when he/she was making the bed without assistance; on 05/15/2022 at 6:00 PM when he/she was standing in front of the commode and fell; on 05/22/2022 at 8:08 AM when he/she slid off the bed while trying to get up; on 05/24/2022 at 3:00 PM, cause unknown cause, and Dycem was applied to his/her wheelchair; on 06/01/2022 at 2:45 PM when he/she attempted to transfer to the toilet and fell backwards into the wheelchair, which flipped over; on 06/03/2022 at 10:15 PM while ambulating from the bathroom to get to the wheelchair; on 06/04/2022 at 1:06 PM when he/she used the call light three (3) times for assistance and no one came, so he/she went to the bathroom on his/her own and fell; on 06/08/2022 at 5:20 PM, cause unknown when he/she was found in the floor and refused help to get up; and on 06/09/2022 at 7:30 PM when he/she was making the bed and got his/her feet tangled in the blankets and fell. Further review of the facility's Event Log, for the same timeframe of 04/01/2022 through 10/17/2022, revealed Resident #42 additionally experienced falls: on 06/22/2022 at 5:29 AM when he/she was trying to get back into bed; on 06/25/2022 at 7:50 AM when he/she fell while attempting to transfer independently onto the toilet seat; on 07/22/2022 at 12:50 PM when he/she was found with one (1) knee on the metal base of the bedside table, and was noted to have been drowsy; on 08/14/2022 at 5:04 AM when he/she fell while independently changing his/her brief; on 08/21/2022 at 6:35 PM when he/she fell while reaching for clothing in a drawer; on 09/30/2022 at 1:30 PM when he/she fell while the Pain Management Nurse was assisting him/her from the wheelchair to the bed; and finally on 10/14/2022 at 1:20 PM when he/she fell out of the wheelchair while looking for a light on the floor, a total of twenty-four (24) falls. Review of Resident #42's Progress Note dated 10/21/2022, revealed the resident sustained a fall on 10/21/2022 at 10:00 AM, while attempting to get clothes out of his/her closet. This fall was the twenty-fifth (25) fall Resident #42 experienced for the timeframe of 04/01/2022 through 10/17/2022. Observation on 10/19/2022 at 11:53 AM, revealed Resident #42 sitting in his/her wheelchair in his/her room, slumped forward and to the right side of the wheelchair. Interview with Resident #42 on 10/18/2022 at 3:36 PM, revealed the resident fell frequently due to dizziness, which resulted in the facility placing a foam mat in the resident's room to prevent injuries. Resident #42 stated he/she believed the dizziness he/she experienced was due to the pain medication he/she was prescribed. Further interview revealed Resident #42 needed the pain medication, or he/she experience unbearable pain which limited his/her ability to perform activities of daily living (ADL) and participate in activities. Interview with Licensed Practical Nurse (LPN) #7 on 10/20/2022 at 5:45 PM, revealed she was aware of the multiple falls Resident #42 had experienced. Per LPN #7, Resident #42 did not like to ask for staff assistance and had disabled the position change alarms on his/her wheelchair. Continued interview revealed Resident #42 also had removed the nonskid socks utilized. The LPN stated in her experience, when Resident #42's room door was kept open, Resident #42 was more likely to be compliant with interventions that prevented falls. She stated this was because staff performed more frequent incontinence checks and reminded the resident to ask for assistance. Interview with the Social Services Director (SSD) on 10/22/2022 at 10:30 AM, revealed Resident #42 had a history of being resistant to care and had experienced multiple falls. Continued interview revealed the facility had installed a padded floor and alarms in Resident #42's room, as well as other standard interventions such as nonskid socks and keeping the bed in the lowest position. The SSD revealed she though alarms irritate residents. Further interview revealed Resident #42 became groggy when his/her pain pump was refilled; however, the SSD did not recall that being discussed in the care plan meetings. Interview with the MDS Coordinator on 10/20/2022 at 4:33 PM, revealed Resident #42 attempted to do things independently when he/she was not strong enough to transfer without assistance, and that resulted in falls. Continued interview revealed the padded floor which had been implemented for Resident #42 had been the best intervention the facility had implemented as it helped prevent the resident from sustaining significant injury with any of the falls. She stated the facility had attempted other interventions, such as a dose reduction on some Resident #42's medications and giving the resident a handbell in addition to the call light to alert staff when he/she needed assistance. The MDS Coordinator further stated Resident #42 had refused some interventions, including the use of position change alarms. Interview with the Assistant Director of Nursing (ADON) on 10/22/2022 at 11:15 AM, revealed due to Resident #42's noncompliance with previously attempted interventions, the only other thing the facility could suggest for the resident was a bubble to prevent further falls. Continued interview revealed she had educated Resident #42 on the importance of using his/her call light for assistance and had educated staff on the importance of answering the resident's call light in a timely manner. Per the ADON, her expectation was for staff to perform every two (2) hour checks of Resident #42 to see if the resident needed assistance going to the bathroom. Further interview revealed however, she was unsure if that expectation was communicated in Resident #42's care plan. Interview with the Director of Nursing (DON) on 10/22/2022 at 11:21 AM, revealed Resident #42 had refused help from staff in the past. Per the DON, this included a previous incident on an unspecified date during which Resident #42 threw a trash can at staff members when they tried to assist him/her up off the commode. Continued interview revealed Resident #42 had also fallen while rummaging through drawers in his/her room. According to the DON, Resident #42's current care plan interventions for fall prevention included the resident having a padded floor in his/her room, maintaining his/her bed in the lowest position, installing wireless position change alarms, applying nonskid socks to the resident's feet, providing one (1) person assistance with toileting as allowed by the resident, and keeping the call light in his/her reach. Further interview revealed Resident #42 had a grab bar installed on the bathroom counter in his/her room, a nonskid pad on his/her wheelchair seat, nonskid material to the door handle in his/her bathroom, and a perimeter defining mattress. The Administrator was out of town and not available for interview.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to keep staff food and drink items in the designated staff area and not in the residents' food nourishment room. The findings include: Review of the facility's policy titled, Food Brought in From Outside/Home, not dated, revealed the residents had the right to have foods brought in by family or visitors, and the facility had the responsibility to ensure the residents' safety. The State Survey Agency (SSA) Surveyor requested, from the Director of Nursing (DON), the facility's policies titled, Break Room Policy and Drink and Food but did not receive them. Observation of the nourishment room located on the 200 Hall, on 10/19/2022 at 6:19 PM, revealed six (6) used Styrofoam cups, with lids and straws, and two (2) bottles of soda that belonged to the staff. The cups were placed around the sink and next to the ice maker. Observation of the nourishment room located on the 100 Hall, on 10/20/2022 at 10:00 AM, revealed three (3) used Styrofoam cups, with lids and straws, that belonged to the staff. The cups were placed around the sink. Interview with Certified Medical Tech (CMT) #2, on 10/21/2022 at 10:54 AM, revealed staff had a break room that was located next to the residential dining room. She said that the nourishment room on the 100 Hall also had a refrigerator for the staff. According to CMT #2, some employees left their drinks and bottles in the nourishment room because they were not allowed to bring the drinks to the nurses' station while working, but they were allowed to leave them in the nourishment room. Interview with Certified Nursing Assistant (CNA) #4, on 10/21/2022 at 11:15 AM, revealed the staff had a break room where they could keep their drinks and food. She said staff members were also allowed to put their drinks and food in the room with the nourishment refrigerator. CNA #4 stated that there was a potential of cross contamination if one (1) of the employees was sick. Interview with the Activities Assistant, on 10/21/2022 at 11:35 AM, revealed the facility had a break room for their employees where they could put their drinks and food. She said she always had her cup with her or in the fridge. She stated there was a possibility of cross contamination if staff members placed their cups and food in the nourishment room. Interview with Licensed Practical Nurse (LPN) #5, on 10/21/2022 at 11:40 AM, revealed the staff was provided with a break room where they could take their drinks and food. She stated the facility had a policy addressing food and drinks. She said the nurses oversaw the nourishment rooms. According to LPN #5, staff members were allowed to keep their cups and food in the nourishment rooms. She stated there was a potential of harm for a resident because of cross contamination. Interview with the Director of Nursing (DON), on 10/21/2022 at 12:05 PM, revealed staff had a break room and had to adhere to the policy addressing food and drinks. The DON stated no one was allowed to use their food or drinks at the nurses' station. She stated the staff could not use the refrigerator that was assigned for the residents. The DON stated she saw staff members putting their drinks and food in the nourishments room. The DON admitted she did not tell staff Yes or No whether they could put their food and drinks in the nourishment room. Per the interview, she stated the potential of harm for residents could be cross contamination. The Administrator was out of town and was not available for interview.

Based on interviews, record review, document review, review of the Certified Nursing Assistant (CNA) Job Description, and review of the facility's policy, it was determined the facility failed to accurately maintain medical records on food and fluid consumption for one (1) of thirty (30) sampled residents (Resident #7). The findings include: Review of the facility's policy titled, Documenting of Food Consumption, not dated, revealed nursing personnel shall record each resident's intake of meals immediately following mealtime. The policy further stated intake of meals shall be recorded by food categories, and documentation of consumption by food categories provided in-depth information on a resident's food intake patterns. Per the policy, the Food Service Manager and/or Consultant Dietitian, along with nursing personnel, would monitor intake routinely or according to the resident's individual care plan. Review of the facility's document titled, Certified Nursing Assistant Job Description, not dated, revealed CNA's were to report and document nutritional and fluid intake. Further review revealed CNA's performed and documented resident care activities according to written and verbal instructions from the charge nurse. Review of the facility's Competency Based Orientation packet for CNA's and the CNA Skills Checklist revealed CNA's were responsible for documentation of resident consumption per the facility's policy. Review of Resident #7's Point Click Care (a software to record certain resident information) records revealed CNA #9 charted the resident consumed 75 to 100% of his/her food and drank 360 milliliters (ml) of fluids, on 10/20/2022 during his/her lunch time. It was also recorded that Resident #7 was given a Magic Cup (120 ml, a nutritional product) at 2:00 PM. It was recorded that CNA #8 signed the copy of the charting that this Magic Cup was given between breakfast and lunch. Observation, on 10/20/2022, during lunch time, revealed Resident #7 consumed about 35% of his/her food and drank a small Styrofoam cup of liquid filled with ice. After lunch, the CNA, who assisted the resident with his/her food agreed with the observation. According to the Staff Development Coordinator, the Styrofoam cup was eight (8) ounces or 240 ml. Interview with CNA #9, on 10/21/2022 at 8:20 AM, revealed she recorded Resident #7 ate 75 to 100 % of his/her food and drank 360 ml of fluids on 10/20/2022 during his/her lunch time. She stated she did not see the resident's tray after he/she finished eating, and she did not observe the resident eating his/her food. She said the amount of food and drink was reported to her. CNA #9 stated she did not remember who told her how much Resident #7 ate or drank for lunch on 10/20/2022. She also stated that two (2) years ago she was told that a small Styrofoam cup contained 360 ml. Further interview with CNA #9, on 10/22/2022 at 10:10 AM, revealed she received training on how to record information correctly when she was hired. Interview with Licensed Practical Nurse (LPN) #5, on 10/21/2022 at 9:12 AM, revealed CNA #9 should not have charted the food the resident consumed if she did not see it. She stated she expected CNA's to document correct information. She stated there was a potential of harm for the resident if inaccurate information was recorded because the resident could lose weight, could become malnourished, and skin integrity could be jeopardized. Interview with the Registered Dietitian (RD), on 10/21/2022 at 9:21 AM, revealed Resident #7 did not have significant changes during the last assessment. She said it was normal for this resident to intake forty-four percent (44%) of his/her food. She stated it was care planed for Resident #7 to intake nine hundred forty (940) ml of fluids with meals and additional intake between his/her meals. She said her expectations were that CNA's and nurses charted correct information about residents' intake because it was a base for her assessments of residents. The RD stated Resident #7 did not lose weight. Per the interview, there was a potential harm for a resident if the charting was incorrect. She stated the potential for harm included weight loss, skin integrity problems, dehydration, and anything nutrition related. Review of Resident # 7's clinical chart confirmed his/her weight did not fluctuate, and he/she did not lose weight. Interview with LPN #6, on 10/22/2022 at 10:15 AM, revealed the Staff Development Coordinator trained her on reporting accurate information. After the training, she stated, the staff had to check off on the training that was completed. Interview with the Staff Development Coordinator, on 10/22/2022 at 10:20 AM, revealed CNA's were trained by more experienced CNA's on how to chart food and liquids intakes. She said CNA's also were trained on how to document intake information in Point Click Care. She said her expectation was that CNA's would document each meal and fluid intake with one-hundred percent (100%) of accuracy. The Staff Development Coordinator said there was a potential for harm for a resident such as weight loss, impaired skin integrity, and dehydration if there was inaccurate intake information recorded. She said if the CNA was not sure of the milliliters in the size of the cup, he/she would be able to look it up on the kiosk. Interview with the Director of Nursing (DON), on 10/20/2022 at 4:15 PM, revealed CNAs were responsible to accurately document tasks performed. She stated, if a resident did not eat because he/she was sleeping, she expected CNAs to record this information; and, in this instance, it would be incorrect to record the resident refused food. The DON stated she expected the staff to record findings correctly. Further interview with the DON, on 10/21/2022 at 9:40 AM, revealed the nursing staff relied on the information CNAs charted. She said her expectation was that the charting information would be accurate. She said there was a potential for harm for a resident such as dehydration, malnutrition, and impaired skin integrity if charting was not recorded correctly. The Administrator was out of town and was not available for interview.

Based on interview and review of the facility's policy, it was determined the facility failed to provide residents with activities on Saturday and Sunday. The facility census was sixty-two (62). The findings include: Review of the facility's policy titled, Activity Procedures, undated, revealed the facility was to offer residents the opportunity for improving or maintaining physical functioning abilities in a recreational setting. Per the policy review, participation in exercise could also help maintain or increase cognitive abilities and feelings of self-worth and positive self-esteem. Interview with Resident Council members on 10/18/2022 at 3:14 PM, revealed the facility was not providing any scheduled activities for residents on Saturdays and Sundays. Interview with the Activities Director on 10/20/2022 at 2:00 PM, revealed the facility had provided supervised activities for the residents on weekends prior to the COVID pandemic. She stated, after COVID, the facility considered bringing activities back on weekends. Continued interview revealed she waited for the Administrator's direction regarding a starting date for provision of weekend activities. The Activities Director further stated she and the Activities Assistant on Fridays, provided residents with packets that contained coloring books and puzzles before the weekend. In an additional interview with the Activities Director on 10/21/2022 at 8:20 AM, revealed the President of the Resident Council brought the concerns of no scheduled activities on weekends to the Administrator's attention. She stated the concerns were not discussed during the Resident Council meetings; however, it had been a private conversation between the Administrator and the President of the Resident Council. Further interview revealed the Activities Director and her assistant were planning to leave early during the week so they could come back and provide activities on the weekends. Interview with the Director of Nursing (DON) on 10/20/2022 at 2:51 PM, revealed she had not heard that residents were complaining about activities not being provided on weekends, that issue had not been discussed with her. She stated she would talk to the Administrator, and they would get something in place for weekend activities. Further interview revealed facility staff could put the packets with coloring books and puzzles on the nurse's stations while the situation was being resolved. The Administrator was out of town and not available for interview.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to date and change weekly oxygen tubing as required for four (4) of thirty (30) sampled residents, Residents #28, #29, #37, and #54. The findings include: Review of the facility's policy titled, Respiratory Care Services Policy & Procedure, Oxygen Equipment: Supply Change, undated, revealed nasal cannulas and oxygen supply tubing were to be replaced every seven (7) days and as needed (PRN) per facility protocol. 1. Review of Resident #54's medical record revealed the facility admitted the resident, on 01/22/2019, with diagnoses to include Heart Failure, Coronary Artery Disease (CAD), Asthma, and Respiratory Failure. Review of Resident #54's Quarterly Minimum Data Set (MDS) Assessment, dated 09/03/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #54's Care Plan, dated 08/22/2022, revealed the resident received oxygen at two (2) liters per minute (LPM) per nasal cannula. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation, on 10/18/2022 at 11:45 AM, revealed the oxygen tubing in use for Resident #54 was dated 10/05/2022. The staff replaced it with new tubing and placed oxygen per nasal cannula (N/C) on the resident. 2. Review of Resident #29's medical record revealed the facility admitted the resident, on 03/03/2021, with diagnoses to include Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Diabetes, and Pulmonary Fibrosis. Review of Resident #29's Quarterly Minimum Data Set (MDS) Assessment, dated 07/23/2022, revealed a BIMS score of fifteen (15) of fifteen (15), which indicated the resident had intact cognition. Review of Resident #29's Care Plan, dated 03/03/2021, revealed the resident received oxygen at three (3) LPM per nasal cannula. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation, on 10/18/2022 at 12:10 PM, revealed Resident #29's oxygen tubing was dated 10/05/2022, with no date on the humidifier bottle. 3. Review of Resident #37's medical record revealed the facility admitted the resident, on 03/22/2022 with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Diabetes, and Chronic Respiratory Failure with Hypoxia. Review of Resident #37's Quarterly MDS Assessment, dated 08/17/2022, revealed the resident had a BIMS score of twelve (12) of fifteen (15), which indicated the resident had moderate cognitive impairment. Review of Resident #37's Care Plan, dated 03/22/2022, revealed the resident received oxygen at three (3) LPM per nasal cannula or mask. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation, on 10/19/2022 at 9:15 AM, revealed Resident #37's oxygen tubing was dated 10/05/2022. 4. Review of Resident #28's medical record revealed the facility admitted the resident, on 08/12/2022, with diagnoses to include Atrial Fibrillation (AF), Peripheral Vascular Disease (PVD), and Shortness of Breath. Review of Resident #28's admission Minimum Data Set (MDS) Assessment, dated 08/12/2022, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident had intact cognition. Review of Resident #28's Care Plan, dated 09/23/2022, revealed the resident received oxygen at three (3) LPM per nasal cannula. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation of Resident #28, on 10/20/2022 at 2:00 PM, revealed oxygen therapy at 3 LPM per nasal cannula, but the oxygen tubing was not dated. The resident stated, at that time, that he/she had been on oxygen since admission, and this therapy was not new. Interview with the facility's contracted Respiratory Service Technician, on 10/19/2022 at 9:30 AM, revealed his company was a contracted service and oxygen tubing with nasal cannulas and humidifier water bottles were changed every two (2) weeks. He revealed he added a date sticker on the tubing line. He also reported he left extra tubing and bottles in the supply closet at the facility for as needed (PRN) use. Interview with the Director of Nursing (DON), on 10/22/2022 at 12:03 PM, revealed she was not aware of the facility's policy stating that oxygen tubing was to be changed weekly. She stated since she was made aware of this, the facility was in the process of adding oxygen tubing change to the Treatment Administration Record (TAR). She stated it was important to change oxygen tubing timely due to the risk of contamination from bacteria, which could cause infection and/or decreased airflow. The Administrator was out of town and not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of medication package inserts, review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, and review of the facility's policy, it was determined the facility failed to store all drugs and biologicals under proper temperature control. Observation of the two (2) medication refrigerators revealed one (1) had temperatures outside the recommended range for drug storage. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed proper vaccine storage and handling played critical roles in efforts to prevent vaccine-preventable diseases. Vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy, creating limited protection, and exposure to temperatures thirty-two (32) degrees Fahrenheit or colder could destroy potency. Per CDC recommendations, vaccine temperatures should be monitored and documented at least twice daily if the refrigerator did not have a temperature monitoring device, which read minimum and maximum temperatures. Further review revealed best practices for storage of vaccines was to ensure that vaccines were not stored on the top shelf, floor, or door of the refrigerator as the temperature in these areas might differ significantly from the temperature in the body of the unit. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, revised 07/21/2022, revealed the facility should ensure that medications were stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines. Further review revealed the listed range for refrigeration was thirty-six (36) to forty-six (46) degrees Fahrenheit. Review of the facility's Refrigerator Temperature logs, dated 10/15/2022 through 10/21/2022, revealed the Medication room [ROOM NUMBER] refrigerator was checked once per day. Additional review revealed, on two (2) of the seven (7) day period, the temperature was documented as thirty-four (34) degrees Fahrenheit. Observation, on 10/21/2022 at 11:56 AM, revealed the Medication room [ROOM NUMBER] refrigerator had a temperature of thirty-two (32) degrees Fahrenheit and contained the following medications labeled as requiring temperatures between thirty-six (36) and forty-six (46) degrees Fahrenheit: 1) one (1) Latanoprost 0.005% eye drops (used to treat increased pressure in the eye) 2) two (2) Novolog FlexPens (a fast acting insulin used to treat high blood sugar; 3) one (1) Magnesium Citrate bottle (laxative); 4) one (1) container of prefilled Prevnar syringes (pneumonia vaccine); 5) one (1) vial of tuberculosis testing solution; 6) one (1) container of prefilled Pneumovax syringes (vaccine to prevent pneumonia); 7) one (1) container of Engerix B prefilled syringes (vaccine to prevent Hepatitis B); 8) eight (8) Bisacodyl suppositories (laxative); 9) one (1) Acetaminophen 650 milligram (mg) suppository (pain reliever, fever reducer); 10) Promethazine 25 mg suppositories (treated nausea); 11) Lispro insulin; 12) Lantus insulin; 14) Novolin N insulin; 15) Novolin R insulin; 16) Novolin 70/30 insulin 10 mg; 17) Tresiba FlexTouch (a long acting insulin); and 18) Basaglar KwikPen (a long acting insulin). Observation, on 10/21/2022 at 11:56 AM, revealed the Medication room [ROOM NUMBER] refrigerator had a temperature of thirty-two (32) degrees Fahrenheit (freezing point)and contained Glargine insulin (the Basaglar KwikPen and Lantus) and Humulin insulin (the Lispro and Novolin insulins). Review of the package inserts for Glargine insulin at https://pi.lilly.com/us/basaglar-kwikpen-us-ifu.pdf and https://products.sanofi.us/lantus/lantus.html#Section-15.2, revealed the insulin should not be frozen. In addition, the inserts stated if the insulin had been frozen not to use it. Review of the package inserts for the Lispro insulin at https://www.drugs.com/pro/insulin-lispro.html#s-34069-5; for the Novolin-N insulin at https://www.drugs.com/pro/novolin-n.html#s-34069-5; for the Novolin-R insulin at https://www.drugs.com/pro/novolin-r.html#s-34069-5; for the Novolin 70/30 insulin at https://www.drugs.com/pro/novolin-70-30.html#s-34069-5; and for the Tresiba insulin at https://www.drugs.com/pro/tresiba.html#s-34069-5, revealed they should not be frozen. In addition, the inserts stated if the insulin had been frozen not to use it. Interview with Certified Medical Technician (CMT) #2, on 10/21/2022 at 11:30 AM, revealed she believed night shift staff performed temperature checks on the medication refrigerators. She stated she was not able to locate the temperature logs. Interview with CMT #1, on 10/21/2022 at 11:55 AM, revealed the Maintenance Department performed temperature checks on the medication refrigerators. She stated she was not able to locate the temperature logs. Interview with a Maintenance worker, on 10/21/2022 at 12:34 PM, revealed he checked the temperatures on the medication refrigerators every morning when he arrived at the facility. He stated he adjusted the temperature if he found it to be outside of a range of thirty-two (32) to forty (40) degrees Fahrenheit. Interview with the Director of Nursing (DON), on 10/26/2022 at 11:06 AM, revealed her expectation was for the Maintenance staff to check the temperatures on the medication refrigerators to make sure the temperatures were in the correct range. The DON stated she was unable to state what that range should be without looking it up online. After looking it up, she stated the temperature should be thirty-six (36) to forty-six (46) degrees Fahrenheit. Also, the DON stated temperature regulation of the medication refrigerators was important to ensure the medications were still effective and had not been damaged by improper storage. The Administrator was out of town and was not available for interview.

Based on interview and review of the facility's Mail Distribution policy, it was determined the facility failed to ensure residents had the right to send and receive mail. In addition, the facility failed to ensure residents were able to receive letters, packages and other materials delivered to the facility for residents on Saturdays and Sundays. The total census was sixty-two (62). The findings include: Review of the facility's policy titled, Mail Distribution, undated, revealed it was the intent of the policy that the facility developed a system of resident mail transport, which involved the Activities Department and the person who received the mail, i.e., the Receptionist. Continued review revealed it also included provisions whereby the Activities Department was informed of the arrival of, or was given, the mail. Further review of the policy revealed the Activities Director or Designated Volunteer was to deliver the mail to the residents within twenty-four (24) hours. Interview with Resident Council members, on 10/18/2022 at 3:14 PM, revealed the facility was not delivering residents' mail on Saturdays and Sundays. Interview, with the Activities Director, on 10/20/2022 at 2:00 PM, revealed she and the Activities Assistant were responsible for delivering the mail to the residents during the week. She stated the Business Office employees were responsible for picking the mail up from the post office during the week. However, they were off on weekends, and therefore, no one delivered the mail to the facility or to the residents. The Activities Director stated she was aware of the facility's policy which noted the residents' right to have mail delivered, including on the weekends. Interview, with the Social Service Director, on 10/20/2022 at 2:00 PM, revealed no one was checking for residents' mail on Saturdays because the Business Office was closed. Interview, with the Accounts Receivable Clerk, from the Business Office, on 10/20/2022 at 2:35 PM, revealed she picked up the mail from the post office during the week. However, during the weekends the mail was not picked up because she was off. Interview, with the Director of Nursing (DON), on 10/20/2022 at 4:00 PM, revealed she was aware residents did not receive their mail on the weekends because no one was there to pick it up from the post office and deliver it to the facility. She further stated she would ensure the Activities Department delivered the residents' mail to them on weekends. The Administrator was out of town and not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, 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; to help prevent and control the development and transmission of communicable diseases; 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. Multiple observations, from 10/18/2022 to 10/20/2022, revealed staff members were not providing assistance with COVID screening; not wearing required personal protective equipment (PPE) or wearing it incorrectly, in a Contact Precautions room; not performing correct hand hygiene; not disinfecting reusable medical equipment or not disinfecting it with the correct contact time; and inappropriate handling of trash in a Contact Precautions room. In addition, the facility failed to post instructional signage about COVID-19 for visitors to see at the facility's entrance and throughout the facility. The findings include: Review of the facility's policy titled, Standard Precautions, not dated, revealed Standard Precautions would be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard Precautions protocol included: handwashing; use of gloves when indicated, discarded in the proper receptacle, and hand hygiene when gloves were removed; use of gowns, when indicated, that fit at the neck, were tied at the neck into a shoelace bow, and overlapped at the back, completely covered clothing, and tied at the waist string into a shoelace bow; reusable resident care equipment that was not used for the care of another resident until it had been appropriately cleaned; and, environment surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces that were properly cleaned. Review of the Micro-Kill Germicidal Bleach Wipes canister label revealed directions that stated thirty (30) second contact time was required to kill bacteria and viruses and to reapply as necessary to ensure the surface remained wet for the entire contact time. Review of the facility's policy titled, Contact Precautions, not dated, revealed Contact Precautions were to be used, in addition to Standard Precautions, for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the residents' environment. Contact Precautions protocol included: to wear gloves when entering the room if any contact was to be made with the resident or items in the room, remove gloves before leaving the room, and wash hands or use waterless antiseptic agent (alcohol based hand rub (ABHR)) after removal of gloves. Additional protocol included to wear a gown when entering the room, if you anticipate your clothing will have substantial contact with the resident, the environment, or resident items. The policy also stated to wear a gown if the resident was incontinent, had diarrhea, an ileostomy, a colostomy, or wound drainage not contained by the dressing. It also stated to remove the gown before leaving the room. Further protocol for resident care equipment revealed, if the use of common equipment or items was unavoidable, then adequately clean and disinfect them before use on another resident. Review of the facility's policy titled, Facility Visitation, Communal Activities, Dining, and Resident Outings Guidelines, effective September 23, 2022, revealed the facility shall follow current guidelines and recommendations related to resident visitation as recommended by the Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS) through Memo QSO-20-39-NH, revised 09/23/2022. Review of the Centers for Medicare and Medicaid Services (CMS) document Ref: QSO-20-39-NH, revised 09/23/2022, Core Principles of COVID-19 Infection Prevention revealed: facilities should provide guidance (e.g., posted signs at entrances) about recommended actions for visitors who had a positive viral test for COVID-19, symptoms of COVID-19, or have had close contact with someone with COVID-19. Further review revealed instructional signage should be placed throughout the facility on visitor education for COVID- 19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, and hand hygiene). Review of the facility's document Nursing Home COVID-19 Visitor Screening Log revealed a slot for a staff member's initials indicating screening was performed by facility staff. 1. Observation, on 10/18/2022 at 10:20 AM, revealed, upon entry to the facility by the State Survey Agency (SSA) Surveyor Team the screening for COVID-19 was self-performed without assistance or instructions of front desk staff. Continued observation revealed the front lobby area, the front door, and throughout the facility had no signage for COVID/Visitation Precautions. Additional observation, on 10/19/2022 at 8:00 AM, revealed the front desk personnel were sitting at the desk. The front desk personnel provided no instruction in screening or assistance, so the survey team members self-screened again by utilizing the sign-in sheet, temperature check, and hand hygiene. Further observation revealed no signage on the front door or lobby area offering guidance to visitors for COVID symptoms or exposure. One (1) sign was noted to the left of the front door facing toward the inside of the facility above the hand hygiene station attached to the wall to the left of the entrance. Observation revealed this signage was out of eye sight range upon entry to the facility. Interview with the Accounts Receivable Clerk, on 10/21/2022 at 11:30 AM, revealed she opened the door for visitors and if possible would screen them using equipment and the sign in sheet. When asked if visitors were informed of signs and symptoms of COVID-19 to prevent them from entering the building, she stated there was a sign for them to read at the front door. During the interview, the SSA Surveyor observed a visitor enter the building without the front desk staff utilizing the in-person screening process. The front desk staff then looked at the screening document after the visitor had entered the building and left the lobby. Interview with the Accounts Payable/Payroll Clerk, on 10/21/2022 at 11:30 AM, revealed visitors were observed by staff to screen themselves without assistance. 2. Observation, on 10/18/2022 at 11:15 AM, of room [ROOM NUMBER]A, for Resident #62, revealed an isolation cart with personal protective equipment (PPE) with Contact Precautions signage on the door. Continued observation revealed, on 10/18/2022 at 11:45 AM, there was a visitor in the room with Resident #62. The visitor was not wearing any PPE. 3. Observation, on 10/19/2022 at 8:30 AM, of room [ROOM NUMBER], for Resident #28, revealed an isolation cart containing gowns and masks, but no gloves. In addition, the room door did not have signage indicating what type of isolation. Certified Nursing Assistant (CNA) #12 entered room [ROOM NUMBER] without a gown. The CNA came out of the room, and donned (put on) a gown. However, the gown did not cover the back. Further observation revealed CNA #12 did not don gloves before entering the room. upon exiting the room, CNA #12 did not perform hand hygiene. 4. Observation, on 10/19/2022 at 10:30 AM, revealed CNA #8 entered room [ROOM NUMBER] A, a contact isolation room. CNA #8 provided assistance to Resident #62, who was on contact precautions, without wearing a gown, gloves, or mask. 5. Observation, on 10/19/2022 at 6:45 PM, revealed an unknown staff member delivered a tray to Resident #62, in room [ROOM NUMBER]A, who was in contact precautions. Further observation revealed the staff member handled and adjusted the overbed table. However, no PPE was used, only hand sanitizer was used upon exiting the room. The staff member then obtained another tray and took it to another room. 6. Observation, on 10/20/2022 at 8:33 AM, revealed CNA #8 went into a contact isolation room to pick up the breakfast tray. She got the tray and placed it on the tray rack in the hallway. No PPE was used, and no hand hygiene was done when exiting the room. She continued to the next room, picked up the lunch tray, and placed it on the cart in the hallway. 7. Observation, on 10/20/2022 at 11:00 AM, revealed CNA #3 wheeled a Hoyer lift (a mechanical device used to assist staff in lifting and transferring residents) up the hallway into the storage room without disinfecting it. Per the observation, no disinfecting wipes were available for immediate use in the lift's bag/storage space. Interview with CNA #3, on 10/20/2022 at 11:05 AM, revealed she had not disinfected the Hoyer lift after use and prior to storage. She stated other staff would have no way of knowing the Hoyer lift had not been disinfected prior to its use on other residents. CNA #3 stated she knew disinfecting was important to stop the spread of germs, and she should have disinfected the lift prior to storage. 8. Observation, on 10/20/2022 at 11:07 AM, revealed a housekeeper, unidentified, came out of a contact precautions rom, 216A. The housekeeper got supplies from the cleaning cart outside the room. However, she did not change gloves and perform hand hygiene before retrieving items from the cart to take back into the room. Per the observation, the housekeeper only performed hand hygiene when she came out of the room for the third time. 9. Observation, on 10/20/2022 at 11:14 AM, revealed Certified Medication Technician (CMT) #2 went into room [ROOM NUMBER] (contact precautions for bed 216A) carrying a medication cup for the resident in bed 216B. Further observation revealed no gown or gloves were donned before entering the room. 10. Observation, on 10/20/2022 at 11:35 AM, revealed CMT #2 in room [ROOM NUMBER]B (Resident #23, who was on contact precautions). The CMT was in the room to administer medications to Resident #23. She put material from Resident #23's medication pass into Bed A's trash can (not on contact precautions). She then dumped towels from a trash bag in room [ROOM NUMBER] onto the floor and cleaned the floor under Resident #23's wheelchair. Additional observation, on 10/20/2022 at 7:15 PM, revealed Licensed Practical Nurse (LPN) #1 in room [ROOM NUMBER]B performing wound care. At completion of the wound care, the SSA Surveyor removed the PPE, but there was no trash can at the door. The resident, who resided in bed 210A (non-isolation) stated, Put that in my trash can, everyone else does. Observation of the trash can, which sat between the resident in bed 210A's bed and the oxygen concentrator revealed gowns were in the trash can. Interview with LPN #1, on 10/20/2022 at 7:30 PM, revealed placing trash from a contact isolation resident into another resident's trash could cause cross-contamination and possibly make the roommate ill. 11. Observation, on 10/20/2022 at 11:40 AM, revealed CNA #8 in Isolation room [ROOM NUMBER] with a gown on, but it was not tied at the neck or waist. After exiting room [ROOM NUMBER], CNA #8 entered room [ROOM NUMBER] without performing hand hygiene. CNA #8 then entered room [ROOM NUMBER], with no hand hygiene observed. CNA #8 then entered room [ROOM NUMBER], but exited the room abruptly without hand hygiene. 12. Observation, on 10/20/2022 at 6:20 PM, revealed CNA #8 went into residents' rooms with a rolling cart, which had a pulse oximeter and a thermometer. CNA #8 entered, with the cart, into room [ROOM NUMBER]B, and took the resident's temperature, which required touching the forehead. The thermometer did not have a cover, but touched the forehead directly. She did not disinfect the thermometer and only wiped the pulse oximeter after use for eight (8) seconds with Micro-Kill Germicidal Bleach Wipes (the label stated contact time was thirty (30) seconds). Per the observation, no hand hygiene was performed. The rolling cart was then taken into other residents' rooms. Interview with CNA #6, on 10/20/2022 at 12:00 PM, revealed education from the facility consisted of hand hygiene (HH) with a visual audit and isolation precautions. She stated other training was done by computer, and she knew all equipment should be disinfected between residents, and supplies to disinfect equipment were available. Interview with CNA #7, on 10/20/2022 at 4:20 PM, revealed training consisted of HH checkoffs, and staff did have in-services for isolation requirements and to disinfect equipment before and after use for each resident. Interview with CNA #13, on 10/20/2022 at 7:05 PM, revealed training consisted of videos for HH and use of PPE. CNA #13 stated she did not recall any audits or being instructed to disinfect equipment between resident use. Interview with CNA #14, on 10/20/2022 at 7:20 PM, revealed training consisted of HH, correct use of PPE, and being fit tested for N-95 respirators. He stated he self-screened for COVID every time he came to work. When asked about disinfecting resident shared equipment, he stated the only piece of equipment disinfected was the pulse oximetry unit, not the vital sign equipment. Interview with the Infection Preventionist (IP) Nurse, on 10/21/2022 at 9:20 AM, revealed she had worked at the facility for two (2) years and also was the Assistant Director of Nursing (ADON). She stated staff was educated to perform HH between residents and disinfect the equipment. She stated her expectation for staff members was to follow trainings and self-report if they had issues with performing a task or understanding the process. She stated staff should wash with soap and water after three (3) HH's with ABHR. Additionally, she stated, if during the screening process a visitor was symptomatic, he/she would be encouraged to test for COVID-19. Continued interview with the IP Nurse, on 10/21/2022 at 9:20 AM, revealed the only isolation residents was on Contact Precautions. The IP Nurse stated staff should follow the signage on the door. She stated HH audits were performed, but they were not recorded. She stated the front desk staff should screen visitors in for better source control of COVID. She stated staff from the East Hall should do the screening when the front desk personnel were not available. The IP nurse stated there were no COVID positive residents in the facility at present. Interview, with the Director of Nursing (DON), on 10/22/2022 at 11:00 AM, revealed she had held the position since December 2021, and her responsibility was to provide oversight of the Nursing Department. Continued interview revealed she provided assistance with IP. but she was not certified. Additional interview revealed her expectation for the staff was to follow the training protocol which was provided per the program annually. Further interview revealed staff was to abide by the signage for contact precautions, proper HH/PPE, and the supply cart should not be taken into an isolation room. The Administrator was out of town and was not available for interview.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety. On 10/29/19, during the initial tour, the ice cream freezer was observed to have a thick layer of frost on all sides of the freezer as well as a black sediment along the tracks where the top slid to provide access to the freezer. The frost on the sides was also observed to have some of the black sediment present. The findings include: Review of the cleaning schedule, undated, revealed the ice cream freezer was not on the schedule to be cleaned. Observation of the kitchen on 10/29/19 at 11:04 AM, during the initial tour with the Dietary Manager, revealed the ice cream freezer had a thick layer of frost on all sides and a black residue was present on the tracks where the top lid slid to open. Further observation revealed the black residue was also on the layer of frost next to the track. No food containers were observed to have any black residue on them. Observation of the ice cream freezer on 10/31/19 at 9:41 AM revealed the freezer still had a thick layer of frost with black residue on the tracks and frost present. Interview with the Dietary Manager on 10/31/19 at 10:19 AM revealed the ice cream freezer was not on the regular cleaning schedule and therefore had not been cleaned lately. Per the Dietary Manager, she was not sure why the freezer was not scheduled for cleaning other than just an oversight. She then stated it would be added to the regular cleaning schedule. Interview with the Administrator on 10/31/19 at 2:19 PM revealed the freezer should have been clean and should have been on the cleaning schedule. She further stated this was just an oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate medical record was maintained for one (1) of thirty-one (31) sampled residents (Resident #54). On 07/09/18, Resident #54's physician prescribed Norvasc (medication to treat high blood pressure and/or chest pain) daily. Observation revealed the facility administered the medication to the resident as ordered; however, the facility failed to ensure the resident's October physician's order summary and Medication Administration Record (MAR) accurately reflected the physician's order. The findings include: Review of the facility's Medication Administration-General Guidelines, dated 12/18/12, revealed medications were administered in accordance with written orders of the physician. The Director of Nursing stated in interview on 10/24/18 at 3:45 PM, that the facility did not have a policy regarding accurate medical records. Review of the medical record revealed the facility admitted Resident #54 to the facility on [DATE] with diagnoses of Chronic Kidney Disease (Stage 5), Enterocolitis due to Clostridium Difficile, Dependence on Renal Dialysis, Acute on Chronic Diastolic Heart Failure, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Observation of medication administration on Wednesday, 10/24/18 at 8:25 AM, revealed Licensed Practical Nurse (LPN) #2 administered Norvasc to Resident #54. Review of Resident #54's October 2018 physician's order summary revealed an order initiated on 07/06/18 for Amlodipine (Norvasc) twice daily, but to hold the medication on days the resident had dialysis. According to the order summary, the resident was scheduled for dialysis on Monday, Wednesday, and Friday every week. Review of Resident #54's Medication Administration Record (MAR) for October 2018 also revealed the resident's medication should be held on days the resident had dialysis; however, the facility had documented that Norvasc had been administered to the resident twice every day. Interview with Licensed Practical Nurse (LPN) #1 on 10/24/18 at 2:27 PM revealed she was certain that the order to hold Norvasc on dialysis days had been changed, and that the medication was required to be administered daily. She also stated she was not aware the physician's order and MAR still read to hold on dialysis days. Further review of the medical record for Resident #54 revealed a physician's order was written on 07/09/18, to administer Norvasc twice daily and there was no order to hold the medication on days the resident had dialysis. Review of the resident's August 2018 physician's order summary revealed the 07/09/18 order had been transcribed to the August 2018 order summary; however, the revised order was not transcribed to the September and October 2018 order summaries, or the October 2018 MAR. Continued interview with LPN #1 on 10/24/18 at 2:48 PM, revealed physician order summaries were reviewed initially by a nurse for accuracy. A second nurse and the physician then reviewed the summary together before the physician signed the orders. LPN #1 further stated Resident #54's medical record did not show the correct order on the monthly physician order summary or the MAR; however, the facility had been administering the medication based on the most recent physician order. Interview with LPN #3 on 10/24/18 at 4:00 PM, revealed she had reviewed the order summary for August and had corrected the summary with the new order for Norvasc that was received on 07/09/18. She stated the process was to compare the current monthly summary with the previous monthly summary and all supplemental orders. LPN #3 stated a contracted pharmacy printed the physician order summaries and the MARs for the facility based on physician orders provided to them. She stated the new order should have been carried over to September and October; however, the facility started utilizing a new pharmacy during that time, which could have contributed to the error. LPN #3 also stated she should have caught the error when she reviewed the September order summary. Interview with the Director of Nursing (DON) on 10/24/18 at 3:45 PM, revealed the process for auditing monthly physician order summaries for accuracy was not in a policy form or written as a process. She stated the summaries were reviewed for accuracy by two (2) nurses prior to going into the resident's medical record and signed by the physician. The DON agreed the medical record was inaccurate; but the resident had received the correct medication at the correct time.

Based on interview and review of the facility policy, it was determined the facility failed to protect residents' rights to manage their personal funds. Interview with Resident Council members revealed the facility managed the residents' money they won from Bingo and residents did not have access to their money on weekends. The findings include: Review of the facility's policy, Resident Trust Fund, (undated) revealed residents shall have access to their personal funds within a reasonable period of time when requested, and the same day if possible. The policy stated the facility's banking hours were from 8:30 AM to 4:00 PM Monday through Friday, and typically closed on holidays. Further review of the policy revealed if funds were needed at a time after business office hours, arrangements would be made by the office or the Administrator upon request. A group interview was conducted at 3:00 PM Central Daylight Time (CDT) on 10/23/18 with six (6) facility residents. The residents stated during the interview that for the past few months, the facility had not allowed residents to keep money they won when playing Bingo because someone had been taking the residents' money. The residents stated the facility kept the money locked in the front office; however, the front office was locked on the weekends, and the residents did not have access to their personal money. Interview with the Accounts Payable/Payroll Clerk at 10:30 AM CDT on 10/25/18 confirmed that the business office was closed on weekends. Interview with the Administrator at 1:15 CDT on 10/25/18 revealed several months ago, residents' Bingo money came up missing. Since that time, the facility had been depositing the residents' Bingo money into an account in the business office. The Administrator also stated the business office was closed on the weekends, and residents were aware that they should request money on Fridays, prior to the weekend.

Based on observation, interview, and a palatability test of a lunch meal, it was determined the facility failed to ensure that food served to residents was palatable. Interview with residents and a palatability test of a lunch test tray on 10/24/18 at 11:20 AM CDT, revealed the facility failed to season food to ensure food served to residents was palatable. The findings include: Interview with the Dietary Manager (DM) at 3:25 PM CDT on 10/24/18 revealed the facility did not have a policy related to food palatability. A group interview conducted at 3:00 PM on 10/23/18 with six (6) facility residents revealed the food served at the facility was not seasoned. The residents further stated that they only received one (1) packet of salt on their meal trays, which was not enough salt to season their food. A test tray was requested to conduct a palatability test for the lunch meal on 10/24/18. At 11:20 AM CDT on 10/24/18, the palatability test was conducted with the facility Dietary Manager (DM). The green beans served had not been salted/seasoned and tasted bland. Interview with the DM confirmed the green beans needed salt and seasoning.