**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User Manual, and review of the facility's policy, the facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected the resident's status for 2 of 18 sampled residents, Resident (R) 28 and R57.Review of R28's admission MDS, with an Assessment Reference Date (ARD) of 05/14/2024, inaccurately documented the resident was admitted with a catheter.Review of R57's two quarterly MDS, with an ARD of 02/28/2025 and 05/29/2025, both documented active diagnoses of pneumonia and septicemia without any evidence of treatment for the diagnoses. Additionally, R57's annual MDS, with an ARD of 12/11/2024, quarterly MDS, with an ARD of 02/28/2025, and quarterly MDS, with an ARD of 05/29/2025, incorrectly coded the COVID-19 and influenza vaccine status.The findings include:Review of the RAI 3.0 Manual Version 1.19.1, dated 10/2024, revealed the RAI process required that the assessment accurately reflected the resident's status, and a registered nurse conducted or coordinated each assessment with the appropriate participation of health professionals. Further review revealed the definition of active diagnoses was physician documented diagnoses in the last 60 days that had a direct relationship to the resident's current functional status, medical treatment, and nursing monitoring during the seven-day look back period. Continued review revealed for septicemia to be coded there had to be documented evidence of inflammation due to sepsis and evidence of a microbial process in the medical record.Review of facility's policy titled, MDS 3.0 Completion, dated 02/01/2024, revealed the facility conducted accurate and standardized assessments of each resident according to the federal regulations, using the RAI specified by the State. Per the policy, responsibility of sections would be clearly assigned based on discipline, and persons completing the assessment must attest to the accuracy of the section they completed.1. Review of R57's admission Record revealed the facility admitted the resident on 12/08/2023 with diagnoses of chronic obstructive pulmonary disease (COPD), abscess of lung with pneumonia, and severe sepsis.a. Review of R57's Physician Progress Note, dated 01/08/2025, revealed active diagnoses of COPD, high blood pressure, type 2 diabetes, and morbid obesity.Review of R57's quarterly MDS, with an ARD of 02/28/2025, revealed the facility assessed the resident with active diagnoses of pneumonia and septicemia.Review of R57's Physician Progress Note, dated 02/28/2025, revealed active diagnoses of COPD, high blood pressure, type 2 diabetes, and morbid obesity.Review of R57's Physician Progress Note, dated 04/17/2025, revealed active diagnoses of COPD, high blood pressure, type 2 diabetes, and morbid obesity.Review of R57's quarterly MDS, with an ARD of 05/29/2025, revealed the facility assessed the resident with active diagnoses of pneumonia and septicemia.In an interview with R57 on 07/08/2025 at 9:14 AM, she stated she had a history of lung infection and sepsis prior to admission to the facility but could not recall any infections requiring antibiotics or hospital treatment for some time.In an interview with the MDS Coordinator on 07/09/2025 at 3:07 PM, she stated she had the responsibility for completing assessments, gathering data, reviewing hospital records, verifying diagnoses, and entering information obtained into the MDS assessment. She stated diagnoses were added to assessments when there had been active treatments or a diagnosis within the past 30 days prior to the reporting date. She stated she could not provide a reason for adding diagnoses of pneumonia and septicemia on R57's past two quarterly MDS without being active diagnoses. However, she stated it could had been due to being three months behind and going back and reviewing charts, then adding information.b. Review of R57's annual MDS, with an ARD of 12/11/2024, as well as two quarterly MDS, with ARDs of 02/28/2025 and 05/29/2025, revealed staff documented that R57 did not receive the influenza vaccine during the year's influenza vaccination season. For each of these three MDS assessments, staff documented that the vaccine was offered and declined. However, review of R57's vaccination records revealed the resident received the influenza vaccine on 10/04/2024.Further review of these three MDS assessments revealed they documented that R57's COVID-19 vaccination status was not up to date. However, review of R57's vaccination records revealed R57 received the COVID-19 vaccine on 11/21/2024.In an interview with the MDS Coordinator on 07/09/2025 at 2:15 PM, she stated those three MDS assessments did not accurately reflect R57's immunization status. She stated she used the facility's immunization records for coding the MDS, noting that these records included both electronic and paper documents (which the facility was in the process of uploading). She stated the facility was going to an all-electronic system, and the immunization records were currently in several different places. The MDS Coordinator stated the MDS errors occurred because of the multiple locations where the records were stored, adding, to confirm the resident's immunization status, I was not looking in the right place. 2. Review of R28's, admission Record revealed the facility initially admitted the resident on 04/07/2025 with diagnoses including Alzheimer's disease, acute kidney failure, and Crohn's disease. Review of R28's admission MDS, with an ARD of 04/11/2025, revealed the resident was assessed for an indwelling catheter. Review of R28's Nursing admission Evaluation and Baseline Care Plan, dated 04/07/2025, revealed the resident was assessed for urinary incontinence. Further review revealed the section that addressed the presence of a urinary catheter was marked No.Review of R28' s Comprehensive Care Plan Report, initiated on 04/09/2025, revealed a focus for alteration in elimination related to incontinence with interventions for assistance with daily toileting needs, incontinence care every shift and as needed, and peri-care after incontinent episodes as needed.Review of R28's Skilled Nursing Documentation, dated 04/07/2025, revealed documentation that specified the absence of genitourinary (GU) appliances.Review of R28's hospital Discharge summary, dated [DATE], revealed no documented evidence of an indwelling catheter. Review of R28's Nursing Assessment re-admission Evaluation, dated 06/10/2025, revealed the resident was assessed for urinary incontinence. Further review revealed the section that addressed the presence of a urinary catheter was marked No.Review of R28's admission MDS, (following a hospitalization) with an ARD of 06/14/2025, revealed the resident was assessed for an indwelling catheter. Review of R28's Skilled Nursing Documentation, dated 06/23/2025, revealed documentation that specified the absence of genitourinary (GU) appliances. Observation of R28 on 07/08/2025 at 4:12 PM revealed the resident asleep in bed; an indwelling urinary catheter was not observed. Additional observation on 07/09/2025 at 2:27 PM revealed R28 in a wheelchair near the North Hall nurse's station; an indwelling urinary catheter was not observed. In an interview with the North Hall Unit Manager (UM) on 07/08/2025 at 4:19 PM, she stated R28 did not have an indwelling urinary catheter.In an interview with the MDS Coordinator on 07/09/2025 3:10 PM, she stated prior to completion of a resident's MDS, she verified diagnoses, obtained hospital records, reviewed medical records, and assessed the resident. She further stated she reviewed medications and reviewed nursing documentation. The MDS Coordinator stated she clarified any questionable documentation with the appropriate staff. The MDS Coordinator stated in order to assess a resident's bowel and bladder function, she reviewed the Certified Nurse Aide's charting, talked to the resident, talked to nursing, and reviewed any other documentation related to incontinence. The MDS Coordinator stated it was her responsibility to ensure the accuracy of a resident's MDS. She further stated MDS accuracy was important because it guided a resident's care. When asked about R28's bowel and bladder assessment, the MDS Coordinator stated the resident was incontinent and wore a brief; however, she was not aware the resident was coded for an indwelling urinary catheter. In an interview with the Director of Nursing (DON) on 07/09/2025 at 4:25 PM, she stated the accuracy of MDS reporting was important to provide an accurate picture of a resident's current status, drove the care plan, and thus the treatment for a resident. She stated the MDS Coordinator was responsible for entering accurate information and verifying that other disciplines entered accurate information.In an interview with the Administrator on 07/09/2025 at 4:30 PM, she stated the MDS reflected a resident's status and guided the care of a resident. She stated the facility had used a contracted service for MDS reporting prior to the current MDS Coordinator, who began in 01/2025, and believed there was a back log of information upon filling the position. She stated it was very important to ensure accuracy of information on the MDS to ensure proper care, reporting, and reimbursement.

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area from each resident's bedside. Observation on 07/07/2025 at 10:40 AM, revealed the call light for the resident room, bed 1 and bed 2, where Resident (R) 387 and R18 resided was not working. During an interview with R387, the resident stated their call light had not worked since Saturday, 07/05/2025.The findings include:During an interview on 07/09/2025 at 9:31 AM with the Director of Nursing (DON), she stated there was no facility call light policy.Review of R387 admission Record revealed the facility admitted the resident on 07/03/2025 with diagnoses of stroke, diabetes mellitus type 2, and congestive heart failure (CHF).Review of R387's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating R387 was cognitively intact. Review of R18's admission Record revealed the facility admitted the resident on 03/03/2025 with diagnoses of autistic disorder, intellectual disability, and depression. Review of R18's admission MDS, with an ARD of 06/16/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating R18 was severely cognitively impaired. Observation on 07/07/2025 at 10:40 AM, revealed the call light for R387 and R18's room for bed 1 and bed 2 was not working. During an interview on 07/07/2025 at 10:40 AM with R387, he stated the call light had not worked since Saturday (07/05/2025). He stated he let staff know, but he could not remember the name of the staff member. He stated the staff member he informed told him they would make maintenance aware. He stated he was not offered an alternative way to call out for assistance.The State Survey Agency (SSA) Surveyor was unable to interview R18 due to his cognitive status and being nonverbal. During an interview on 07/07/2025 at 10:50 AM with Licensed Practical Nurse (LPN) 3 and Registered Nurse (RN) 3, they stated they were not aware of the call light for R387 and R18 not working. Both stated they were unsure how long it had not been working. During an interview on 07/09/2025 at 9:06 AM with the Maintenance Director, he stated the call light system was not capable of running reports of call light histories. He stated he was not aware of the call light not working since Saturday. He stated he received work orders after they were entered into the TELS system (facility's software) for him to fix. During continued interview on 07/09/2025 at 9:31 AM with the DON, she stated her expectation was that call lights were answered timely. She stated she did not know if/when they were checked, and she would need to check with maintenance. She stated she had not done any call light audits, but she had only been at the facility a couple of months. She stated it was important to have working call lights, and they be answered timely to keep residents safe and to meet their needs. During an interview on 07/09/2025 at 10:30 AM with the Administrator, she stated there were not call light audits or a policy on them. She stated it was her expectation that call lights were answered as quickly as possible. She stated call lights were checked to make sure they worked prior to every admission. She stated if any issues were found with malfunctioning call lights, then it should be entered into TELS for maintenance to fix promptly. She stated if call lights were not working, an alternative device to call for assistance should be offered for resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's documents and policy, the facility failed to provide a safe, clean, comfortable and homelike environment for the long hall on the North Unit. Observations on 07/07/2025, 07/08/2025, and 07/09/2025 revealed a lingering odor of urine throughout the area. During the Resident Council meeting on 07/08/2025 at 2:00 PM, Residents (R) 52, R54, and R65 stated the area smelled of feces, and it needed air freshener. The residents also stated they had to cover their faces because of the odor. This had the potential to affect the 30 residents residing on the long hall of the North Unit.The findings include:Review of the facility's policy titled, Safe and Homelike Environment, dated 02/01/2024, revealed housekeeping services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Per the policy, general considerations to minimize odors were for staff to dispose of soiled linens promptly and report lingering odors and uncleaned bathrooms to the housekeeping department. Review of the facility's policy titled, Resident/Patient Room Cleaning, dated 02/01/2025, revealed cleaning and disinfecting must be performed in a manner that minimized the chance of dirt/germs contacting a surface that had already been cleaned or disinfected.Review of the facility's document Floor Plan, undated, revealed 30 residents resided on the long hall of the North Unit.Review of the facility's document Grievance Form, dated 05/01/2025, revealed the Resident Council attendees voiced concern that resident bathrooms were dirty and needed to be cleaned twice daily instead of once daily. Observation on 07/07/2025 at 10:44 AM during the initial tour of the long hall of the North Unit revealed the odor of urine, starting from room [ROOM NUMBER] to room [ROOM NUMBER]. This odor of urine lasted throughout the day. Observation on 07/08/2025 at 8:00 AM, 10:15 AM, and until 1:15 PM of the long hall of the North Unit revealed a very strong odor of urine.Observation on 07/09/2025 at 7:39 AM of the long hall of the North Unit revealed the odor of urine.Observation on 07/09/2025 at 8:05 AM of the long hall of the North Unit revealed urine odor was present, and at 8:45 AM the urine odor was stronger toward the end of the hallway. Observation on 07/09/2025 at 10:25 AM of the long hall of the North Unit revealed the urine odor remained in the hallway near the nurse's station. Observation on 07/09/2025 at 1:20 PM of the long hall of the North Unit revealed the urine odor remained in the hallway.Review of R52's admission Record revealed the facility admitted the resident on 01/10/2023 with diagnoses of major depression and anemia. Review of R52's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/08/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating intact cognition.Review of R54's admission Record revealed the facility admitted the resident on 01/16/2023 with diagnoses of major depression, post-traumatic stress disorder, and anxiety. Review of R54's quarterly MDS, with an ARD of 07/07/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Review of R65's admission Record revealed the facility admitted the resident on 05/03/2024 with diagnoses of cerebral palsy, depression, and anemia.Review of R65's quarterly MDS, with an ARD of 04/16/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating intact cognition. In an interview with the Resident Council attendees on 07/08/2025 at 2:00 PM, all seven residents in attendance stated their concern with the odor of urine in the long hallway of the North Unit. Resident 52 stated it smells like poop and pee in the hallway. R54 stated when she went into the hallway, she had to cover her face due to the smell, and R65 stated he asked for air freshener, and no one brought it. Review of R49's admission Record revealed the facility admitted the resident on 09/20/2023 with diagnoses of hypertension and cerebral vascular accident (stroke) with left hemiparesis. Review of R49's quarterly MDS, with an ARD of 04/16/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating severe cognitive impairment. In an interview with the Environmental Services (EVS) Manager on 07/09/2025 at 8:50 AM, she stated R49 missed the urinal in his room when he urinated, and the urine got into the wax on the floor. She stated he tried to empty his own urinal into the trash can. The EVS Manager stated they controlled the odors in the hallway and concentrated on cleaning certain rooms, in the mornings. She stated these were focus rooms, with residents who urinated around the floor. She stated the housekeeping staff checked the residents' focus rooms morning and night. She stated other male residents also missed the toilet or bedside commode. She stated housekeeping tried to daily mop, clean high touch areas, strip and wax the floor in these rooms to control the odor. She stated the housekeepers on the North Unit had been instructed on those special focus rooms and how to clean them. In an interview with Certified Nurse Assistant (CNA) 4 on 07/09/2025 at 4:30 PM, she stated Resident (R) 49 refused bath/showers, tried to urinate in the room using a urinal and poured the urine into his trash can. She stated he refused changes and showers. In an interview with the Director of Nursing (DON) on 07/09/2025 at 1:24 PM, she stated her expectation was to provide residents with a home like environment. She stated staff tried to encourage showers and the use of urinals.In an interview with the Administrator on 07/09/2025 at 1:14 PM, she stated there was a resident on the North Unit who did not want to be changed, and staff would change out the mattress and try to encourage more brief changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, the facility failed to notify the resident and the resident's representative of the bed hold notice and the transfer or discharge and the reasons for the move in writing and in a language in manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer as well as a statement of the resident's appeal rights and the contact information for the state long term care ombudsman. The deficient practice was identified for 4 out of 18 residents investigated for transfer and or discharge, Resident (R) 18, R24, R29, and R37.The findings include:Review of the facility's policy titled, Bed Hold Notice Upon Transfer, revised 03/05/2025, revealed, At the time of transfer for hospitalization or therapeutic leave the facility will provide to the residents and/or resident representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. The policy also revealed, In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies, as stipulated in the State's plan. Per the policy, The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.Review of the facility's policy titled, Transfer and Discharge (including AMA), revised 03/20/2025, revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. the effective date of transfer or discharge. c. the specific location (such as name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the state. e. The name, address (mailing and email) and telephone number of the State entity which received such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing requests. h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long Term Care Ombudsman. i. For nursing facility residents with an intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.1.Review of R18's admission Record revealed the facility admitted R18 on 03/03/2025 with diagnoses of autistic disorder, mild cognitive impairment, and intellectual disability.Review of the facility's Census revealed R18 was sent to the hospital on [DATE] and 04/06/2025.Review of R18's Bed Hold Notice, dated 04/02/2025, revealed it was left blank with a handwritten note reading ER visit only.Review of R18's Bed Hold Notice, dated 04/09/2025, revealed R18's Representative was notified verbally by the facility's Business Office Manager (BOM). The State Survey Agency (SSA) Surveyor requested, from the facility's staff on 07/08/2025 and 07/09/2025, R18's Transfer/Discharge Notice for the 04/02/2025 and 04/06/2025 hospital transfers, but neither was produced. Also, the SSA Surveyor was unable to find the forms in R18's electronic medical record (EMR). During an interview on 07/09/2025 at 11:32 AM with R18's Representative, he stated he emailed the facility to ask if R18 would be able to return to the facility for rehabilitation, but he had never received a Bed Hold Notice or Transfer/Discharge Notice via email or mail.2. Review of R24's admission Record revealed the facility admitted the resident on 12/23/2024 with diagnoses of diabetes, chronic kidney disease, and personality and behavior disorder.Review of the facility's Census revealed R24 was sent to the hospital on [DATE], 06/05/2025, and 06/22/2025.Review of R24's Bed Hold Notice for the transfer on 02/26/2025 revealed R24's Representative and the BOM signatures with no signature date.Review of R24's Bed Hold Notice for the transfer on 06/05/2025 revealed R24's Representative and the BOM signatures with no signature date.Review of R24's Bed Hold Notice for the transfer on 06/22/2025 revealed R24's Representative and the BOM signatures with no signature date and a handwritten note stating, ER Visit.The SSA Surveyor requested, from the facility's staff on 07/08/2025 and 07/09/2025, R24's Transfer/Discharge Notice for the 02/26/2025, 06/05/2025, and 06/22/2025 hospital transfers, but none was produced. Also, the SSA Surveyor was unable to find the forms in R24's EMR. However, the facility did provide the SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form for the three dates, which included medical information.During an interview on 07/08/2025 at 7:14 PM with R24's Representative, she stated she had never been given any copies of Bed Hold Notice or Transfer/Discharge Notice. She stated the only thing she had ever received in the mail from the facility were bills. She stated she was asked to sign the Bed Hold Notice on 07/08/2025 for the three transfers over the last six months. She stated the BOM had her sign them today as she was walking out of the front door after visiting with R24.3. Review of R37's admission Record revealed the facility admitted the resident on 09/28/2022 with diagnoses of hypertension, depression, and Parkinson's disease.Review of the facility's Census revealed R37 was sent to the hospital on [DATE].Review of R37's Bed Hold Notice for the transfer on 03/08/2025 revealed R37's signature and the BOM's signature with no signature dates.The SSA Surveyor requested, from the facility's staff on 07/08/2025 and 07/09/2025, R37's Transfer/Discharge Notice for the 03/08/2025 hospital transfer, but it was not produced. Also, the SSA Surveyor was unable to find the form in R37's EMR. During an interview on 07/09/2025 at 8:31 AM with R37, he stated he did not recall receiving a written copy of a Bed Hold Notice or Transfer/Discharge Notice when he was sent to the hospital.4. Review of R29's admission Record revealed the facility admitted the resident on 10/18/2019 with diagnoses of cerebral infarction with hemiplegia and hemiparesis, heart disease, Alzheimer's, and type 2 diabetes. Review of R29's Change in Condition evaluation, dated 04/08/2025, revealed the resident had a complaint of chest pain and was sent out to the local hospital emergency room (ER) for evaluation and treatment.Review of R29's Progress Notes, dated 04/08/2025, revealed R29 returned to the facility via ambulance free of pain, with no new orders.Review of R29's EMR did not reveal a Transfer/Discharge Notice or Bed Hold Notice had been completed, signed, or mailed. The SSA Surveyor requested, from the Administrator on 07/09/2025, R29's Transfer/Discharge Notice for the 04/08/2025 hospital transfer, but it was not produced. The Administrator provided a copy of the Bed Hold Notice to the SSA Surveyor. Review of the Bed Hold Notice for R29 revealed the form had been completed and signed by R29 on 07/09/2025, the same date as requested. During an interview with R29 on 07/08/2025 at 9:16 AM, he stated he made his own medical decisions and did not recall signing any forms when transported to the hospital on [DATE]. He also stated he did not recall being informed about the bed hold policy. He stated he was told by staff he would be sent to the hospital. He stated, after being seen, the ambulance returned him to the facility, and he was placed back in the same room. During a follow up interview with R29 on 07/09/2025 at 4:00 PM, he stated a staff person came to his room and told him his signature was needed on a form they had forgotten to have signed. He stated he was unsure why the form needed to be signed on this date [07/09/2025] when his visit to the hospital had been months ago. During an interview on 07/08/2025 at 3:20 PM with the BOM, she stated she did not provide a written copy of the Bed Hold Notice to the resident or their representative each time a resident was sent out of the facility. She stated the resident, or their representative, signed a bed hold agreement upon admission. She stated she notified the majority of the representatives and made them aware verbally, but not all of them. During an interview on 07/08/2025 at 3:30 PM with the Director of Nursing (DON), she stated the E Interact Transfer Form was completed via point click care (PCC, a software) and sent with the resident to the hospital. She stated a written copy was not provided to the resident's representative unless the representative was present at the time of the transfer. During an additional interview on 07/09/2025 at 9:31 AM with the DON, she stated she was not aware that Bed Hold Notices and Transfer/Discharge Notices were supposed to be sent to both the resident and their representative. During an interview on 07/08/2025 at 3:45 PM with the Administrator, she stated if the resident was unable to sign the Bed Hold Notice, then an email was sent to the representative, or the notice was sent via certified mail. During an additional interview on 07/09/2025 at 10:30 AM with the Administrator, she stated it was her expectation that bed hold and transfer notices were completed timely, so the facility knew if they needed to hold the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect and dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (2) of twenty-two (22) sampled residents (Resident #2 and Resident #271). Observation, on 12/14/2021, revealed Nurse Assistant (NA) #1 failed to knock prior to entering Resident #271's room. When Resident #271 asked NA #1 when she would make his/her bed, NA #1 walked out without responding to Resident #271. Observation, on 12/14/2021 at 12:17 PM, during the lunch meal service, revealed Resident #271 and Resident #2 were both in room [ROOM NUMBER] and NA #1 started assisting Resident #2 with meal service. However, Resident #271 received his/her tray approximately forty-five (45) minutes after his/her roommate (Resident #2) received a meal tray. On 12/14/2021, State Registered Nurse Aide (SRNA) #1, was interviewed as to why Resident #271 had not received his/her meal tray. In front of Resident #2, SRNA responded, All of the feeders are taken care of first. Observation, on 12/15/2021 at 12:00 PM, revealed Resident #2 (Resident #271's roommate) received a meal tray and was assisted by therapy. However, Resident #271 did not receive his/her lunch meal tray until approximately one (1) hour later, even though they were both in the same room during meal service. Observation on 12/15/2021 at 5:36 PM, revealed Resident #271, had not received his/her dinner meal tray; however, Resident #2 who was in the same room, received his/her meal and was feeding himself/herself. The findings include: Review of the facility's Resident Rights policy, dated 11/28/2017, revealed residents had a right to a dignified existence and access to persons and services inside and outside of the facility. The facility must treat each resident with respect and dignity and, care for residents in a manner which promoted enhancement of his/her quality of life. The facility must provide a homelike environment for each resident. Review of Resident #271's clinical record revealed the facility admitted the resident on 12/10/2021, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Nutritional Anemia, Hearing loss, and Stage II ulcer of the sacral region. Further review revealed the resident was homeless before he/she entered this facility. Record review revealed Resident #271's admission Minimum Data Set (MDS) Assessment had not been completed due to the resident being a new admission. There was no Brief Interview for Mental Status (BIMS) completed for the resident. However, observation on 12/15/2021, revealed the resident communicated with the State Survey Agency (SSA) Representative and the resident was able to make wants and needs known. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/06/2021, with diagnoses that included Fusion of the spine, Cervical Disc Disorder, Type 2 Diabetic, and Muscle Weakness. Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 12/09/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. The MDS Assessment further revealed the resident required one (1) person physical assistance for bed mobility, and supervision, cueing, encouragement, and one (1) person physical assist for eating. Resident #2 was wheelchair-bound. 1. Observation on 12/14/2021 at 12:13 PM, revealed Nurse Assistant (NA) #1 entered Resident #271's room (room [ROOM NUMBER]) and did not knock on the door prior to entering. At that time, Resident #271 asked her when she would make his/her bed. NA #1 walked out without responding to Resident #271. Further observation revealed NA #1 returned a few minutes later with linen, tossed it on Resident #271's bed and turned to walk out. Resident #271 asked, Aren't you supposed to make that for me? NA #1 told the resident she would be back later. Interview with SRNA #1, on 12/15/2021 at 11:40 AM, revealed residents were to be treated with dignity and respect, and staff were to honor residents' requests and assist residents with their needs to the extent possible. SRNA #1 stated staff should always knock on residents' doors before they entered the room because that was their home. Interview with Resident #271, on 12/15/2021 at 12:20 PM, revealed he/she watched as NA #1 stood outside the room and talked and did not work. The resident stated NA #1 would come into his/her room many times and not speak to him/her at all. Resident #271 further stated if he/she asked NA #1 to do something, she would take a very long time to do it and did not communicate the process. Interview with NA #1, on 12/16/2021 at 1:55 PM, revealed she had been at the facility for three (3) months, and had passed all of her check-offs and was ready to take the SRNA test. NA #1 explained staff should show residents dignity and respect and should always be nice and help the residents. She further stated staff should always knock before entering residents' rooms, but sometimes she did not knock because she was used to the residents. Continued interview with NA #1, on 12/16/2021 at 1:55 PM, revealed staff was not to change linens when trays were passed out. Per interview, staff could only change linens during meal service if the resident or the bed was wet or soiled. She stated she should have talked with Resident #271 to explain how things would be done when she delivered the linen to the resident on 12/14/2021. Further interview revealed Resident #271 had complained several times that Resident #2 (Resident #271's roommate) got better care and more attention. NA #1 stated she explained to Resident #271, that Resident #2 required more help. Additionally, NA #1 stated she did not engage with Resident #271 because the resident was usually asleep, and she did not want to bother him/her. Interview with Registered Nurse (RN) #7, on 12/17/2021 at 9:41 AM, revealed residents should be treated like, we would want to be treated. RN #7 stated staff should take their concerns to heart and always address them. She stated, she had actually watched NA #1 avoid areas and residents in order to not have to provide care for them. Further interview revealed she was not in a supervisory position, but as an RN, she was responsible for the care staff delivered. She stated she had voiced concerns related to NA #1 to both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) on more than one occasion. Interview with the DON, on 12/17/2021 at 2:59 PM, revealed it was not appropriate for staff to take linens in the resident's room and drop it on the bed and walk out without an explanation as to what would take place. She stated this did not show respect for the resident. 2. Observation on 12/14/2021 at 12:17 PM, revealed NA #1 entered room [ROOM NUMBER] and talked with Resident #2, (Resident #271's roommate) and asked the resident if he/she needed a fork. Resident #2 explained he/she was unable to use a fork on his/her own. Further observation revealed NA #1 assisted Resident #2. SRNA #1 then entered the room and told NA #1 that she provided care for Resident #2. However, Resident #271, who was also in room [ROOM NUMBER] at the time, had not received a meal tray and at no time did either staff member inform Resident #271 when his/her tray would be there, nor did they talk to Resident #271. Resident #271 was noted to be standing in his/her room waiting for lunch to be delivered. Observation on 12/14/2021 at 12:20 PM, revealed Resident #271 had not received the meal tray at the time of the observation. The SSA Representative asked Resident #271 when he/she would receive his/her meal tray and the resident responded, This is how it is every day. Interview on 12/14/2021 at 12:20 PM, with SRNA#1, revealed Resident #271 had not received his/her meal tray yet as All of the feeders are taken care of first. SRNA #1 stated this in front of Resident #2. When SRNA #1 was asked if it was appropriate to refer to the residents as feeders, she stated, Ah, yeah. Observation on 12/14/2021 at 1:00 PM, revealed Resident #271 still had not received his/her lunch tray. Interview with SRNA #1, on 12/14/2021 at 1:00 PM, revealed Resident #271's meal trays came from a different cart and maybe that was why the resident had not received his/her tray yet. She further stated, meal trays would be delivered first for some residents who ate in the dining room, but if the resident was not in the dining room, the tray would be left on the cart and delivered to the resident when all the other trays for their area had been passed out. However, further interview revealed Resident #271 ate in his/her room. Observation on 12/14/2021 at 1:03 PM, revealed Resident #271 received his/her lunch tray, which was approximately forty-five (45) minutes after his/her roommate (Resident #2) received a meal tray. Per observation, Resident #271 was able to feed self. Interview with the Assistant Director of Nursing (ADON), on 12/14/2021 at 1:03 PM revealed the delay in Resident #271 receiving his/her meal tray could have happened because the resident was scheduled for meals in the dining room. However, she was not sure if this was the case for this resident. She stated the residents made the choice as to where they wanted to eat. Further interview with the ADON, revealed it was not appropriate for staff members to refer to a resident as a feeder. Interview on 12/14/2021 at 1:05 PM, with Resident #271, revealed staff had never asked him/her if he/she wanted to eat in the dining room. The resident stated, nobody had talked to him/her about preference for location for dining. Interview with Resident #271, on 12/15/2021 at 12:20 PM, revealed he/she had just met with the Dietary Aide and finally got his/her menu straightened out. Resident #271 stated, I go last for everything, eating, everything. He/she stated this made him/her feel bad and he/she did not feel like he/she was treated equally to the other residents. 3. Observation on 12/15/2021 at 12:00 PM, revealed Resident #2 (Resident #271's roommate) received a meal tray and was assisted by therapy. Further observation revealed residents in room [ROOM NUMBER] received their lunch meal trays at 12:36 PM. Residents in room [ROOM NUMBER] received their lunch meal trays at 12:40 PM, and residents in room [ROOM NUMBER] received their lunch meal trays at 12:45 PM. At 1:03 PM, Resident #271 who was in room [ROOM NUMBER] and residents in room [ROOM NUMBER] had not received their lunch trays. SRNA #1 was observed to walk down to the North Long Hall to obtain Resident #271's meal tray to deliver to room [ROOM NUMBER], and to obtain meal trays for the residents in room [ROOM NUMBER]. Resident #271 received the lunch meal tray approximately one (1) hour after Resident #2 (Resident #271's roommate) received his/her lunch tray. Interview with SRNA #1, on 12/15/2021 at 1:03 PM, revealed she delivered the last trays to rooms [ROOM NUMBERS]. SRNA stated she did not know why residents in these rooms received their food so late. She stated rooms [ROOM NUMBERS] were on the South Hall, but the carts that come to South Long hall were completely full and the trays for rooms [ROOM NUMBERS] were on the cart for the North Long Hall. 4. Observation of Resident #271, on 12/15/2021 at 5:36 PM, revealed the resident had not received his/her dinner meal tray. However, Resident #2 who was Resident #271's roommate had received his/her meal and was self feeding. Further observation revealed other residents on the South Hall had received their meal trays. Interview with Registered Nurse (RN) #7, on 12/17/2021 at 9:41 AM, revealed residents on the South Long Halls including Resident #271 were to receive their meal trays first. RN #7 stated the correct process to deliver trays was to ensure both residents in a room received their meal trays at the same time and if this did not occur, it could be a dignity issue. Further interview revealed she was unaware Resident #271 was not receiving the meal tray at the same time as his/her roommate. Interview with the Dietitian/Kitchen Manager, on 12/17/2021 at 1:30 PM, revealed food trays were delivered to the units on five (5) different carts. The first cart went to the North dining room as some residents were assigned to eat in there. She further stated if the resident was not at the dining room when trays were delivered, the trays were to be taken straight to the resident in their room. Per interview, the tray was not to be left or put back on the cart because of temperature concerns. Further interview revealed Resident #2 was documented to be in the dining room for meals, and this was why that resident received his/her tray first. Per interview, staff was to ensure Resident #2 was up, dressed and down in the dining room for meals. The Dietitian/Kitchen Manager further stated, when there were two (2) residents in one (1) room, both were supposed to receive their food at the same time. Further interview with the Dietitian/Kitchen Manager, on 12/17/2021 at 1:30 PM, revealed trays were set up for delivery for Rooms 209, 210, 211, 212 and 213 on the South Long Hall Cart. She stated rooms [ROOM NUMBERS] were to receive their trays with rooms, 216 to 225, which were delivered on the Short South Hall Cart. When observations of tray pass on 12/15/2021 were explained to the Dietitian/Kitchen Manager, she stated she could not explain how or why that would happen. Interview with the Director of Nursing (DON), on 12/17/2021 at 2:59 PM, revealed residents should be treated with dignity and respect. Further, it was not appropriate to refer to residents as feeders as this was a dignity issue. Continued interview revealed she expected staff to treat residents with dignity at all times including during meal service. Further, staff should knock on residents' doors to obtain permission to enter. The DON stated she had worked with staff in the past on customer service. Interview with the Administrator, on 12/17/2021 at 4:46 PM, revealed it was his expectation for staff to treat the residents with dignity and respect during all interactions as the facility was their home. Further, all staff should knock and announce before they entered a resident's room, because we would not want someone just walking into our house. He further stated staff should ensure residents were treated respectfully during meal service. Continued interview revealed he expected staff not to use any old nursing home terms such as feeder.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation on 12/15/2021, revealed the North Unit resident nourishment refrigerator contained foods which were not labeled or dated and were not marked with resident identification. Additionally, there was the appearance of black dots on the bottom shelf of the refrigerator. Further, there was the appearance of blue frost, white substance and a brown hair on the bottom shelf of the freezer. The findings include: Review of the facility's policy titled, Foods Brought by Family/Visitors, dated 10/2017, revealed the nursing staff will discard perishable foods on, or before the use by date. Perishable foods will be labeled with the resident's name, the item and the use by date. Observation on 12/16/2021 at 8:40 AM, of the North Unit resident refrigerator, revealed the appearance of black dot like particles, on the bottom shelf. The refrigerator also contained a four (4) ounce strawberry yogurt, and a 1.5 ounce of sharp cheddar cheese bar, neither of which was labeled, dated, or marked with a resident's identification. Continued observation of the nourishment freezer revealed the freezer had a hue of blue frost, a white substance and a brown hair adhered to the bottom shelf. Interview with Registered Nurse (RN) #7, on 12/17/2021 at 10:37 AM, revealed the Dietary staff brought nourishments and stocked the refrigerator at night. She stated she did not know who was responsible to clean the nourishment refrigerator. Interview with Housekeeper #1, on 12/17/2021 at 10:40 AM, revealed she was not responsible to clean the resident nourishment refrigerator located behind the nurses station. Interview with State Registered Nurse Aide (SRNA) #7, on 12/17/2021 at 10:45 AM, revealed dietary staff was responsible for cleaning out the nourishment refrigerators. Interview with the Registered Dietitian (RD), on 12/17/2021 at 10:30 AM and 2:05 PM, revealed food was delivered to the resident refrigerators on the night shift and foods were rotated at that time. Continued interview revealed food should be labeled with food type, date, and resident identification. Further interview revealed Dietary staff was not responsible for cleaning out the nourishment refrigerator as that was the nursing staff's responsibility. Interview with SRNA #3 and SRNA #8, on 12/17/2021 at 2:22 PM, revealed food received from families was to be labeled with the resident's name and put into the resident's personal refrigerator or the unit resident refrigerator. Interview with the Assistant Director of Nursing (ADON), on 12/17/2021 at 2:25 PM, revealed dietary staff was responsible to clean resident refrigerators on the unit and to rotate the foods in the refrigerator. Interview with the Director of Nursing (DON), on 12/17/2021 at 2:43 PM, revealed Dietary staff was responsible for cleaning the resident unit refrigerators and rotating foods. Further, staff should label and date the food as well as mark the food items with resident identification, prior to placing the food items in the resident unit refrigerator. Interview with the Administrator, on 12/17/2021 at 5:00 PM, revealed it was his expectation for staff to keep the resident nourishment refrigerators clean and food was to be labeled, dated and include a resident identification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Guideline, review of the facility's education manuals, 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 and sanitary environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. The facility also failed to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the CDC, and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for four (4) of twenty-two (22) sampled residents (Resident #7, #218, #368, and #369). 1. Observation on 12/14/2021, revealed two (2) visitors, escorted by a staff member, entered Resident #218's (recent treatment for COVID-19 and Clostridium Difficile (C-Diff), infection of the large intestine) room. The visitors were not wearing appropriate Personal Protective Equipment (PPE), although there was signage on the door specifying Droplet Precautions and Airborne Precautions. In addition, observation on 12/15/2021, revealed a Healthcare Services Group Manager-in-Training exited Resident #218's room wearing a N-95 mask and eye protection. She walked down the hall before she removed the PPE. 2. Observation on 12/14/2021, revealed Registered Nurse (RN) #3, State Registered Nurse Aide (SRNA) #4, and the Assistant Director of Nursing (ADON) entered Resident #7's (possible C-Diff) room without donning appropriate PPE or performing hand hygiene, although there was signage on the resident's door specifying Contact Precautions. Observation on 12/15/2021, revealed SRNA #5 entered Resident #7's room without donning PPE to refill the resident's water cup. SRNA #5 exited the room with Resident #7's water cup, then entered the resident's room with the same water cup, again without donning PPE. 3. Observation, on 12/14/2021, revealed Nursing Assistant #3 entered and exited both Resident #368's room and Resident #369's room, who were in Droplet and Contact Isolation, without using correct hand hygiene or wearing the appropriate PPE (gloves, gown, and N 95 respirator or mask with goggles). The findings include: Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers Guideline, reviewed 01/08/2021, revealed hand hygiene reduced the spread of infection and disease to patients (residents). Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further review revealed the clinical indications for hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when hands were visibly soiled, and before preparing or handling medications. 2. Review of Resident #7's EMR, revealed the facility admitted the resident on 09/15/2021 with diagnoses that included Hypertension, Diabetes Type 2, Manic Depression and Major Orthopedic surgery. Review of Resident #7's admission Minimum Data Set (MDS) Assessment, dated 09/22/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated the resident had intact cognition. Additional review revealed the resident required limited assistance for toilet use and was frequently incontinent of bowel with no toileting program in place. Review of Physician's Orders revealed no orders for isolation and/or treatment for infection. Interview with the Director of Nursing (DON), on 12/17/2021 at 4:50 PM, revealed nurses were directed to place Resident #7 in TBP while awaiting results of a stool specimen. Observation of Resident #7's door, on 12/14/2021 at 11:01 AM, revealed signage for Contact Precautions. The sign included instructions to clean hands before entering and leaving the room, don (put on) gloves and gown prior to entering the room and discard gloves and gown upon exiting the room. Further, the signage instructions included: use dedicated or disposable equipment, or clean and disinfect reusable equipment before use on another person. Observation on 12/14/2021 at 12:30 PM, revealed RN #3 entered Resident #7's room without donning Personal Protective Equipment (PPE) or performing hand hygiene. Interview with RN #3, on 12/14/2021 at 12:30 PM, revealed she knew the importance of contact isolation, and had been provided training on the types of PPE to wear in Transmission Based Precautions (TBP). Additionally, she stated she should have worn PPE when entering Resident #7's room related to the potential for C-Diff, but since she was just delivering supplies, she chose not to don the necessary PPE. Observation on 12/14/2021 at 12:49 PM, revealed SRNA #4, in Resident #7's room, with no PPE. Further, SRNA #4 exited the room without performing hand hygiene. Interview with SRNA #4, on 12/14/2021 at 12:49 PM, revealed she was not aware Resident #7 was in TBP. Additionally, she was not aware she was supposed to wear PPE when she was in Resident #7's room because the resident just had C-Diff. Further, she stated staff caring for residents with C-Diff were not required to wear PPE. Observation on 12/14/2021 at 3:50 PM, revealed the ADON was in Resident #7's room without PPE. The ADON exited the resident's room without performing hand hygiene and carried a clear garbage bag out of the room. She then walked down the hallway with the clear garbage bag to the soiled closet. When she exited the soiled closet, she used hand sanitizer in the hallway and re-entered Resident #7's room without PPE. Interview with the ADON, on 12/14/2021 at 4:05 PM, revealed all staff were trained upon hire, monthly and as needed on TBP and PPE usage. Additionally, she expected all staff to don and doff PPE per guidelines when entering a room with TBP. Per interview, she should have donned PPE prior to entering Resident #7's room. Further interview revealed residents who required TBP and PPE were discussed in morning Clinical Meeting, Monday through Friday with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Nurse and Registered Dietician (RD). Continued interview revealed during the 12/14/2021 Clinical Meeting, Resident #7 was discussed, and the Interdisciplinary Team (IDT) determined the resident had potential C-Diff and required a transfer to a private room and contact isolation until labs confirmed the infection, since he/she had symptoms of C-Diff. Interview with Resident #7, on 12/15/2021 at 3:59 PM, revealed he/she had multiple diarrhea stools, and was moved to a private room and was placed on Transmission Based Precautions (TBP), on 12/14/2021 due to a poop infection. Observation on 12/15/2021 at 4:04 PM, revealed SRNA #5 entered Resident #7's room without donning PPE to refill the resident's water cup. SRNA #5, exited the room with Resident #7's water cup, then entered the resident's room with the water cup, again without donning PPE. Interview with SRNA #5, on 12/15/2021 at 4:04 PM, revealed he received training on infection control and was knowledgeable on types of TBP and what PPE to wear. However, he had not been instructed on the facility's protocol on proper handling of water cups/refilling water glasses for residents in isolation. Further, he stated he should have worn PPE when entering Resident #7's room and should not have removed the water cup out of isolation into the hallway. 3. A. Review of Resident #369's medical record revealed the facility admitted the resident on 12/08/2021 with diagnoses that included History of Respiratory Distress and Percutaneous Endoscopic Gastrostomy (PEG) placement. Resident #369 resided on the Rehab Unit. Review of Resident #369's Physician's Orders, dated 12/08/2021, revealed no orders for isolation and no orders for treatment of infection. B. Review of Resident #368's medical record revealed the facility admitted the resident, on 12/10/2021, with diagnoses that included Anemia and Osteomyelitis. Review of the admission MDS Assessment, dated 12/17/2021, revealed the facility assessed the resident as having a BIMS score of fifteen (15) of fifteen (15) indicating intact cognition. Resident #368 resided on the Rehab Unit. Review of Resident #368's Physician's Orders, dated 12/08/2021, revealed no orders for isolation and no orders for treatment of infection. However, continued interview with Infection Control Preventionist, on 12/14/2021 at 4:15 PM, revealed Resident #369 and Resident #368 were in TBP because of their recent admissions. Observation on 12/14/2021 at 12:15 PM, of Resident #368's and Resident #369's doors, revealed both had signage for Droplet Precautions that included hand sanitizing before entering and after exiting the room and fully cover the eyes, nose, and mouth before room entry with a N95 or mask with goggles. Further observation revealed both doors had signage for Contact Precautions that included instructions to clean hands before entering and leaving the room; don gloves and gown prior to entering the room and discard gloves and gown upon exit of the room; and, use dedicated or disposable equipment, or clean and disinfect reusable equipment before use on another person. Further observation revealed both doors had a third sign which included instructions for the correct sequence to don (put on) and doff (remove) Personal Protective Equipment (PPE). Continued observation on 12/14/2021 at 12:15 PM, revealed Nurse Assistant (NA) #3 walked up the South Hall pushing an unsampled resident in a wheelchair. While pushing the wheelchair, NA #3 was observed to stop in front of Resident #369's room as the call light was ringing. NA #3 did not perform hand hygiene, but donned only a hospital mask with no other PPE and entered Resident #369's room. NA #3 stood in the middle of the resident's room and asked the resident what he/she needed. The observation revealed NA #3 then, without doffing (removing) the mask or performing hand hygiene, exited Resident #369's room. Continued observation on 12/14/2021 at 12:15 PM, revealed after NA #3 exited Resident #369's room, she immediately entered Resident #368's room as the call light was ringing; however, the NA did not perform hand hygiene or don PPE prior to entering. NA #3 had on the same hospital mask. NA #3 stood in the middle of the resident's room and asked the resident what he/she needed. The call light went off. Further observation revealed NA #3 then, without doffing the mask or performing hand hygiene, exited Resident #368's room. NA #3 then proceeded to push the unsampled resident down the hall in the wheelchair. Interview with NA #3, on 12/14/2021 at 12:45 PM, revealed she was in a hurry but should have donned PPE prior to entering residents' rooms with signage posted for TBP, which included a gown, mask, face shield, and gloves. She further stated it was important to wear appropriate PPE to protect the residents and staff from anything that could be contagious. Continued interview revealed she failed to perform hand hygiene prior to entering and prior to exiting Resident #369's and Resident #368's rooms. Interview with RN #2 on 12/15/2021 at 10:30 AM, revealed she worked on the Rehab Unit. She stated staff were required to wear a gown, gloves, face shield or goggles into residents' rooms that were on TBP. She stated signage was placed on the residents' doors to identify those residents who were on TBP. Per interview, staff was also to practice good hand hygiene prior to entering and prior to exiting resident rooms. Continued interview revealed Resident #368 and Resident #369 did not have known infections, but it was standard protocol to place new admissions in precautions. Interview with Resident #369, on 12/15/2021 at 11:40 AM, revealed he/she did not know why SSA Surveyors were wearing PPE into his/her room. He/she stated staff did not wear PPE into his/her room. Further, he/she was unaware of the the signs on his/her door, and staff did not explain to him/her the meaning of the signs. Additional interview with the Infection Control Preventionist (ICP) on 12/17/2021 at 4:34 PM, revealed signs were placed on the residents' doors listing the required PPE to wear prior to entering a room with TBP. The ICP stated if staff did not wear the appropriate PPE, this could cause the spreading of microorganisms amongst residents and staff. Further interview revealed it was important for staff to practice good hand hygiene before entering or exiting a resident's room for infection control purposes. Interview with the Director of Nursing (DON), on 12/17/2021 at 4:50 PM, revealed NA #3 should have asked another staff member to answer the call lights or return the unsampled resident to his/her room and then answer the call lights. Further interview revealed it was her expectation for all staff to follow the facility's practice of wearing appropriate PPE in TBP rooms and to practice good hand hygiene prior to entering and exiting a resident's room and any time it was appropriate for infection control. Continued interview revealed staff needed to advise visitors of the need to utilize PPE when appropriate and also inform residents why they were placed on TBP with signage on their doors. Interview with the Administrator, on 12/17/2021 at 5:00 PM, revealed it was his expectation for staff to don/doff PPE according to the signage on the TBP resident room doors in order to prevent potential spread of infections. Further, it was his expectation staff practice hand hygiene as per policy for infection control. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised September 2021, revealed the facility followed infection prevention and control practices recommended by the Centers for Disease Control and Prevention. Further review revealed the facility would follow transmission-based precautions where indicated and appropriate use of Personal Protective Equipment (PPE). Additional review revealed administrative practices were in place to mitigate the spread of COVID-19 including education of residents and visitors; and, staff training. Review of the facility's policy titled, Infection Control Program, Version #:2 Effective Date:12/27/2016, revealed the purpose of the policy was to provide a safe sanitary and comfortable living environment to help prevent development and transmission of infection. Further review revealed the infection control program included prevention, surveillance, and control measures to protect residents and personnel from healthcare associated infections and determines when procedures such as isolation needed to be implemented. Review of the Clinical Practice Guidelines for Clostridium Difficile Infection (CDI) in Adults and Children, Centers of Disease Control, dated 2017, revealed Contact Precautions should be utilized for patients with known or suspected CDI. 1. Review of Resident #218's Electronic Medical Record (EMR) revealed the facility admitted the resident on 12/13/2021 with diagnoses that included Atrial Fibrillation, Adult Failure to Thrive, Type 2 Diabetes, Anxiety, and Insomnia. Review of Resident #218's Discharge summary, dated [DATE], revealed the resident was admitted to the hospital on [DATE] with diagnoses that included COVID-19, Urinary Tract Infection (UTI), Clostridium Difficile (infection of the large intestine), Diabetes Mellitus, Failure to thrive, Paroxysmal Atrial Fibrillation, Malnutrition, and Deep Vein Thrombosis. Further review of the Summary revealed the resident was asymptomatic for COVID-19, and there was no indication for therapeutics. Continued review of the Summary, revealed Clostridium Difficile was treated with oral Vancomycin (antibiotic medication), and the toxin stool test was negative which indicated colonization rather than actual infection. Interview with the Infection Control Preventionist, on 12/14/2021 at 4:15 PM, revealed it was standard protocol, with no Physician's Order required, to place new admissions on Transmission Based Precautions (TBP), which was the reason Resident #218 was on TBP. Observation on 12/14/2021 at 10:35 AM, revealed two (2) signs on Resident #218's door: Droplet Precautions and Airborne Precautions. Per the signage, Droplet Precautions included hand sanitizing before entering and after exiting the room and fully cover the eyes, nose, and mouth before room entry with a N95 or mask with goggles. Additional observation revealed the Airborne Precautions sign stated, Everyone must: Put on a fit-test N-95 or higher-level respirator before room entry. Observation on 12/14/2021 at 10:35 AM, revealed the Business Office Manager (BOM) escorted two (2) of Resident #218's family members into his/her room. Further observation revealed both family members were wearing medical masks and no other Personal Protective Equipment (PPE). Interview with the BOM, on 12/14/2021 at 10:36 AM, revealed she had spoken with Registered Nurse (RN) #2, prior to escorting the visitors into Resident #218's room and was informed the visitors could enter the room. Further interview revealed RN #2 did not direct the BOM to instruct the visitors to wear PPE. Interview with RN #2, on 12/14/2021 at 10:37 AM, revealed she told the BOM that Resident #218's family could visit, but the nurse did not elaborate on instructions given to the BOM as far as PPE upon entering the room. Interview with Resident #218's Visitor #1, on 12/14/2021 at 10:41 AM, revealed his parent had recently been admitted to the facility. Further, he stated he was not informed by anyone in the facility on what PPE to wear when entering his parent's room. Interview with Resident #218's Visitor #2, on 12/14/2021 at 10:42 AM, revealed he was not provided education by the facility on what PPE to wear when entering his grandparent's room. Observation of Resident #218's door, on 12/14/2021 at 4:00 PM, revealed three (3) signs were on his/her door: Droplet Precautions, Airborne Precautions and Contact Precautions. Continued interview with the Infection Control Preventionist, on 12/14/2021 at 4:15 PM, revealed she had added three (3) signs to Resident #218's room for extra precautions because Resident #218 had recently returned from the hospital. Observation on 12/15/2021 at 9:25 AM, revealed a Healthcare Services Group Manager-in-Training exited Resident #218's room wearing a N-95 mask and eye protection. The Manager walked down the hall about fifty (50) feet before she removed the N-95 mask and eye protection. She then utilized the hand sanitizer on the wall. Interview with the Healthcare Services Group Manager-in-Training, on 12/15/2021 at 10:55 AM, revealed she was taught how to keep from spreading COVID and the proper procedures to prevent the spread of COVID during orientation. However, she stated she exited Resident #218's room while wearing a mask and eye protection.