Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure one (1) of three (3) residents reviewed for Pre-admission Screening and Resident Review (PASARR), (Resident #94) who had a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health or intellectual disability authority for review. Findings included: A review of the facility policy titled admission Criteria, revised in March 2019, revealed, Our facility admits only residents whose medical and nursing care needs can be met. The policy revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy did not address a resident who previously had a negative Level I screening and who was later identified with a newly evident or possibly serious MD, ID, or a related condition. A review of Resident #94's admission Record revealed the facility admitted the resident on 12/01/2022. A review of Resident #94's Nursing Facility Application for an admission date of 12/01/2022 revealed a PASARR level screening was included in the application. A review of the PASARR screening revealed the resident had no current or suspected mental health diagnoses, impairment, or intellectual disability. Further review of Resident #94's admission Record revealed the resident was diagnosed with psychotic disorder with delusions with an onset date of 10/10/2023, dementia with an onset date of 08/30/2023, major depressive disorder with an onset date of 02/27/2023, and adjustment disorder with mixed anxiety and depressed mood with an onset date of 02/27/2023. A review of Resident #94's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2023, revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses that included depression and psychotic disorder with delusions due to a known physiological condition. Further review revealed the resident had taken antipsychotic medications daily during the seven-day lookback period. Per the MDS, Resident #94 was not considered by the state level II PASARR process to have a serious mental illness or related condition. A review of Resident #94's care plan revealed a focus area initiated on 03/12/2023 for the risk of side effects due to psychotropic medication use. Further review of the resident's care plan revealed a focus area initiated on 05/08/2023 that indicated the resident exhibited delusions. A review of Resident #94's November 2023 PACS-Medication Administration Record (MAR) revealed staff documented Risperdal Oral Tablet (an antipsychotic medication) 0.25 milligrams (mg), was administered every morning and at bedtime through 11/28/2023, related to dementia with other behavioral disturbance. During an interview on 11/28/2023 at 2:21 PM, the Social Services Director (SSD) stated a PASARR level 1 screening included answering questions regarding mental illness and treatment related to diagnoses such as depression, anxiety, schizophrenia, and mood disorders. The SSD stated Resident #94's PASARR did not reflect any of those diagnoses and did not trigger a level II evaluation to refer the resident to the appropriate state-designated mental health or intellectual disability authority for review. Per the SSD, if there was a change in diagnosis after admission, the facility submitted a significant change notification to the state authority; however, most of the time, a new diagnosis did not affect a resident's level of functioning and would not trigger a level II PASARR. During a follow-up interview on 11/29/2023 at 4:26 PM, the SSD stated another PASARR did not have to be completed due to a new diagnosis of a depressive disorder or a psychotic unless the diagnosis affected a resident's level of functioning. The SSD then stated she was not aware Resident #94 had new diagnoses of a depressive disorder or a psychotic disorder since admission. During an interview on 11/29/2023 at 4:34 PM, the MDS Nurse stated the facility never completed another PASARR unless a resident had a significant change or a psychiatric stay. During an interview on 11/30/2023 at 12:01 PM, the Director of Nursing (DON) stated PASARRs had to do with a resident's mental health diagnosis and assessments of what they might need. She stated she expected PASARRs to be completed per the regulations. During an interview on 11/30/2023 at 1:03 PM, the Administrator stated he expected PASARRs to be completed per the regulations.

Based on interviews, record review, and facility policy review, the facility failed to develop an individualized, person-centered activities care plan for one (1) of twenty-three (23) sampled residents (Resident #56). Findings included: A review of a facility policy titled Care Plans, Comprehensive Person-Centered Policy, dated March 2022, revealed, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychological and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. The policy further revealed, 6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible. A review of Resident #56's admission Record revealed the facility admitted the resident on 05/07/2021. The admission Record revealed the resident had diagnoses that included cognitive communication deficit, contractures of the right and left shoulder and left hand, bilateral spastic hemiplegia, and functional quadriplegia. A review of Resident #56's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2023 revealed it was Somewhat important for the resident to listen to music they liked, be around animals such as pets, keep up with the news, do favorite activities, and participate in religious services or practices. Further review revealed it was important for the resident to go outside to get fresh air when the weather was good. A review of the care area assessment (CAA) summary revealed activities triggered and would be addressed in a care plan. A review of Resident #56's care plan, last reviewed by the facility on 09/26/2023 and printed on 11/30/2023, revealed no documented evidence the facility developed a care plan that addressed activities for the resident. During an interview on 11/30/2023 at 12:11 PM, the Director of Nursing (DON) stated there was no way to ensure Resident #56 was being provided with activities that were personalized if a care plan had not been created based on the resident's individualized interests. The DON stated she reviewed the resident's care plan, and it did not provide information about the resident's preferred likes and choices of activities of interest. She stated an activities care plan had not been completed. During an interview on 11/30/2023 at 1:11 PM, the Administrator stated the Activity Director notified him on 11/28/2023 that Resident #56 did not have a care plan for activities. However, he stated he felt activity staff were meeting residents' needs.

Based on interviews, record review, and facility policy review, it ws determined the facility failed to provide an ongoing program of activities designed to meet the resident's interests for one (1) of twenty-three (23) sampled residents, (Resident #56). Findings included: A review of a facility policy titled Activity Programs revised in August 2006, revealed, Activity programs designed to meet the needs of each resident are available on a daily basis. Policy Interpretation and Implementation 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. Residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interest of each resident. A review of Resident #56's admission Record revealed the facility admitted the resident on 05/07/2021. The resident had diagnoses that included cognitive communication deficit, contractures of the right and left shoulder and left hand, bilateral spastic hemiplegia, and functional quadriplegia. A review of Resident #56's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2023 revealed it was Somewhat important for the resident to listen to music they liked, be around animals such as pets, keep up with the news, do favorite activities, and participate in religious services or practices. Further review revealed it was important for the resident to go outside to get fresh air when the weather was good. A review of Resident #56's quarterly MDS with an ARD of 09/08/2023 revealed the resident had moderately impaired cognitive skills for daily decision-making per the staff assessment for mental status (SAMS). According to the MDS, Resident #56 usually made themselves understood (had difficulty communicating some words or finishing thoughts) and usually understood others (comprehending most conversations). The MDS revealed the resident required extensive assistance of two staff members with bed mobility and toileting. The MDS revealed the resident required total assistance from two staff members for locomotion, dressing, eating, personal hygiene, transfers, and bathing. The MDS revealed the resident required a Hoyer lift for transfers. During an interview on 11/30/2023 at 10:04 AM, the Activity Director stated that when providing resident activities, she considered the residents' activity preferences listed on the MDS, which was the only activity assessment completed. She stated Resident #56 had never attended a group activity but was unsure why. The Activity Director stated she had provided one-on-one visits for the resident but could not find any documented evidence. The Activity Director stated she was the only staff member responsible for providing one-to-one visits. She stated she had not designated how often the visits were to be provided. According to the Activity Director, she thought the staff provided care every day and interacted with the resident during care. She stated the resident received visits from family a couple of times a month. The Activity Director stated Resident #56 could see a television if the resident was positioned facing the television. During an interview on 11/30/2023 at 11:57 AM, the Assistant Activity Director stated she was also responsible for providing one-to-one resident activities. She stated Resident #56 liked music but did not have a radio in their room. The Assistant Activity Director stated once in a while, they took a CD player to the resident's room to play music. She stated they did not have a regular schedule for providing one-to-one visits and just provided them when they had downtime. The Assistant Activity Director stated she did not know whether Resident #56 would like to attend a group activity. She added she thought the resident had gone to a group activity, but not in a very long time. During an interview on 11/30/2023 at 12:11 PM, the Director of Nursing (DON) stated she did not have an opinion about when one-to-one resident activities should be provided or documented. She stated she felt it would depend on the wishes of the resident. After reviewing Resident #56's care plan, she stated the care plan did not provide information about the resident's activities of interest. She did not know what type of activities were being provided for Resident #56. She stated she felt the resident should be offered the opportunity to attend group activities of choice and did not know why the resident did not attend group activities. During an interview on 11/30/2023 at 1:11 PM, the Administrator stated he believed activity staff were meeting the resident's needs but were not documenting the activities that were provided. The Administrator stated he believed an activity assessment should have been completed for Resident #56 but did not think the regulations indicated how often one-to-one visits should take place.

Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure prompt treatment of a pressure ulcer for one (1) of five (5) residents reviewed for pressure ulcers (Resident #264). Findings included: A review of a facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised in April 2018, revealed, The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The policy revealed, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. A review of a document titled [name of medical facility] Medical Partners, dated 05/07/2022 (prior to Resident #264's admission to the facility), revealed a Physical Exam that indicated Resident #264 had a deep tissue injury to the right heel. The document indicated that Resident #264's family member reported the wound had been present for a couple of years. A review of Resident #264's admission Record revealed the facility admitted Resident #264 on 05/10/2022 with diagnoses that included chronic kidney disease, type two diabetes mellitus, idiopathic peripheral autonomic neuropathy, and hypertension. Further review of the admission Record revealed a diagnosis of unstageable pressure ulcer of the right heel with an onset date of 10/01/2022. A review of Resident #264's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2022, revealed Resident #264 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. The MDS further indicated that Resident #264 was admitted with an unstageable pressure ulcer. A review of Resident #264's Baseline Care Plan, initiated on 05/10/2022, indicated Resident #264 had a deep tissue injury to the bottom of the foot. Interventions directed staff to obtain/provide physician orders and treatments related to skin, provide a pressure-reducing mattress to the bed, and a pressure-reducing cushion to the wheelchair. A review of Resident #264's Care Plan revealed a Focus area initiated on 05/23/2022 that indicated the resident had a wound. Interventions directed staff to apply bilateral heel lift boots when in bed and up in a wheelchair, apply pressure relieving cushion to wheelchair and pressure relieving mattress to bed, refer to a dietitian as needed for recommendations to promote wound healing, and provide treatments as ordered. A review of a facility document titled Nursing - Admission/readmission Assessment for Resident #264 completed on 05/10/2022 and signed by Licensed Practical Nurse (LPN) #18 revealed Resident #264 had a small discolored deep tissue injury to the left heel. The nursing assessment indicated that povidone-iodine was applied to the wound, the nurse practitioner was notified, and the admission nurse was awaiting new orders. In an interview on 11/30/2023 at 11:01 AM, LPN #2 stated the admission nurse (LPN #18) had documented Resident #264's wound on the incorrect (left) heel and that the documentation was later corrected to the resident's (right) heel. A review of Resident #264's nursing Progress Note, dated 05/13/2022 at 6:20 PM, revealed documentation to indicate new orders were obtained for the wound to the resident's right heel from the wound care specialist for Betadine (povidone-iodine), abdominal pad dressing, and Kerlix gauze. A review of Resident #264's physician orders revealed an order for a pressure-reduction mattress with a start date of 05/10/2022 and an order for Betadine Solution 10% (povidone-iodine) to the right heel with a start date of 05/14/2022. A review of the physician order summary lacked evidence of a treatment order for the right heel prior to 05/14/2022. A review of Resident #264's Treatment Administration Record (TAR) for May 2022 revealed documentation to indicate a pressure reduction mattress was in place starting on 05/10/2022. The TAR documentation also indicated the right heel was treated with povidone-iodine, covered with an abdominal pad, and wrapped with Kerlix gauze daily starting 05/14/2022. The TAR lacked evidence of treatment to the right heel wound until 05/14/2022, four days after the resident was admitted with the wound. In a telephone interview on 11/30/2023 at 10:30 AM, LPN #17, a Unit Manager, stated it was important to get treatment orders immediately because the wound could get worse without treatment. LPN #17 stated Resident #264 had been admitted with a deep tissue injury but was unsure why no treatment was initiated on admission. In a telephone interview on 11/30/2023 at 11:36 AM, LPN #18 (admitting nurse for Resident #264) stated she could not recall Resident #264's admission. LPN #18 stated if the physician had declined to provide a treatment order, she would have documented it and notified the Director of Nursing and the treatment nurse. In an interview on 11/30/23 at 11:01 AM, LPN #2 stated the admitting nurse should have contacted the physician for a treatment order if a treatment was indicated. LPN #2 stated treatment to the wound should have started immediately and was unsure why she could not find documentation of the order or why any treatment was not started. In an interview on 11/30/2023 at 11:40 AM, the Wound Care Specialist stated that once a wound was identified, treatment should be initiated immediately. In an interview on 11/30/2023 at 12:17 PM, the Director of Nursing (DON) stated the expectation was that residents admitted with a pressure ulcer would be identified on admission with a head-to-toe skin assessment immediately. The DON stated the admitting nurse should notify the physician of the new admission and obtain needed orders. The DON said she was reviewing the documentation for Resident #264 to identify where the breakdown had occurred. In an interview on 11/30/2023 at 1:05 PM, the Administrator said he left decisions regarding pressure ulcers to the clinical team.

Based on interview, record review, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan in the care area of nutrition, for one (1) of thirty-two (32) sampled residents (Resident #26). The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised December 2016, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2017, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's policy titled, Nutritionally At Risk (NAR) Committee, last updated 12/30/2014, revealed its purpose was to monitor and intervene in the care of patients as it related to weight loss and weight gains. The criteria for NAR monitoring included: significant weight loss; if the resident consumed less than fifty (50) percent of meals and weight loss had been identified; recent acute illness; identified as being a total assist for feeding and meals; and received Speech Therapy services for swallowing and self-feeding issues; and documentation of the NAR Committee's recommendations. It further revealed a care plan would be developed with person centered interventions for residents identified to be nutritionally at risk. Review of Resident #26's Electronic Medical Record (EMR) revealed the facility admitted the resident on 03/01/2022. Further review revealed the facility discharged the resident on 03/08/2022 to an acute care hospital; and re-admitted the resident, on 03/21/2022. The resident's diagnoses included Activities of Daily Living and Mobility Deficits secondary to a Right Hemispheric Stroke with Left Hemiparesis and Dysphagia; History of Chronic Pain; Type 2 Diabetes; Gastroesophageal Reflux Disease; Osteoporosis; Hypertension; Hyperlipidemia; and Osteoarthritis. The record also stated Resident #26 was oriented to person only and often refused his/her meals. Review of Resident #26's admission Minimum Data Set (MDS) Comprehensive Assessment, dated 03/05/2022, revealed Resident #26's Brief Interview for Mental Status (BIMS) was unable to complete related to memory problems. Continued review revealed Resident #26 required cues and supervision for daily decision making. Resident #26 was totally dependent for eating and drinking. Review of a Nutrition Note, dated 03/27/2022, revealed the facility assessed Resident #26 as nutritionally at risk related to requiring a mechanically altered or therapeutic diet; being a total assist with meals; diagnoses of Cerebral Vascular Accident (stroke) and Type 2 Diabetes; a history of aspiration; an oral intake of approximately thirty-five percent (35%); and meeting only twenty-six to seventy-five percent (26-75%) of caloric needs. Review of Resident #26's active Physician's Orders, revealed House Nutritional Supplements were ordered with meals on 04/04/2022; Hi-Cal Snacks two (2) times daily were ordered on 06/09/2022; and weigh resident daily for three (3) days, beginning on 03/02/2022, and daily for three (3) days, beginning on 03/21/2022. Review of Resident #26's Dietary Progress Note, dated 03/21/2022, revealed the diet order was NAS (no added salt), CCHO (controlled carbohydrate) pureed with NTL (nectar thick liquids) and extra sauce/gravy. Review of Resident #26's Comprehensive Care Plan (CCP), dated 03/21/2022 and revised on 06/05/2022, revealed no documentation the facility developed a care plan with a focus on Nutrition which included nutritional monitoring, weight monitoring and ordered supplements and snacks for Resident #26. Review of Resident #26's Dietary Note, dated 06/07/2022, revealed Resident #26's current diet order was a pureed, NAS, CCHO diet and supplemental shakes with meals. Per the Note, the resident was a total assist for eating with aspiration precautions. The Note stated an added intervention of snacks two (2) times daily for increased calories and weight gain/stability was recommended and ordered. However, this order was not reflected on Resident #26's care plan as the facility had not developed a care plan for being nutritionally at risk. Interview with Licensed Practical Nurse (LPN) #8/MDS Coordinator (MDSC), on 08/12/2022 at 1:45 PM, revealed it was the MDS Coordinator's responsibility to develop the resident's care plan on admission/re-admission and to update the resident's care plan with new orders. She stated a list of new orders was printed off by Registered Nurse (RN) #3 and given to the MDSC at the morning IDT meeting. She stated, at the meeting, all new orders were reviewed and discussed; placed on the Community Board (CB), which could be viewed by all staff; and Unit Managers put the new orders into Point Click Care (PCC), a computer software program. She further stated a Nutritional at Risk Care Plan should have been developed for Resident #26. Interview with LPN #2/Unit 1 Manager, on 08/12/2022 at 2:14 PM, revealed Resident #26 should have had a care plan related to being Nutritionally at Risk. she said all orders from the Physician such as diet, snacks, supplements, and weekly or monthly weights for each resident should be included on the Comprehensive Care Plan. Interview with RN #2/Unit 2 Manager, on 08/12/2022 at 2:30 PM, revealed new orders were discussed in IDT meetings, and the Unit Manager for each unit put the new orders into PCC and on to the CB. She stated the MDSC developed and updated the residents' care plans with new orders. Interview with RN #6/Assistant Director of Nursing (ADON), on 08/12/2022 at 2:30 PM, revealed new orders were reviewed in the IDT meeting from a list which was printed off by RN #3. She stated the Unit Managers put the new orders for the residents on their unit into the PCC and on the CB. She stated it was the MDSC's responsibility to develop residents' care plans for new admissions and to update the existing resident care plans. Interview with the Director of Nursing (DON), on 08/12/2022 at 3:06 PM, revealed she tracked the monthly weights for residents and ensured they were obtained. She further stated a care plan should have been developed for Resident #26 because she was being followed by the NAR Committee. The DON stated care plans were developed for new residents by the MDSC on admission/re-admission and updated by the MDSC during the IDT meetings. The DON stated it was her expectation that resident care plans were developed, updated, and reviewed to reflect the resident's current care needs. Interview with the Administrator, on 08/12/2022 at 3:45 PM, revealed it was his expectation care plans for residents were developed on admission/re-admission and updated quarterly and as needed, to reflect the current care needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of the United States Pharmacopoeia Standards, review of a medication package insert, https://www.humalog.com/u100, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in two (2) of two (2) medication storage rooms and one (1) of three (3) medication carts. Observation of two (2) medication storage refrigerators located on Unit 1 and Unit 2, on [DATE], revealed the medication refrigerators' temperatures were not maintained between 36- and 46-degrees Fahrenheit (F). Further observation of Unit 1's medication storage refrigerator revealed vaccines and medications were stored improperly in the door of the refrigerator. Continued observations revealed a medication bottle that did not have a pharmacy label, was not dated with an open date, and did not have an expiration date; and one (1) open vial of Tubersol, which was not dated when opened. Observation, on [DATE], of the 400 Hall medication cart revealed one (1) unopened vial of Humalog insulin in the drawer, and its labeling stated to refrigerate the insulin until opened. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) document, Vaccine Storage and Handling, updated [DATE], revealed vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy (result), creating limited protection, and exposure to temperatures thirty-two (32) degrees Fahrenheit or colder could destroy potency. Per the document, 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. Per the document, exposure to any inappropriate conditions can effect potency of any refrigerated vaccine, but a single exposure to freezing temperatures (zero (0) degrees Celsius or thirty-two (32) degrees Fahrenheit or colder) could actually destroy potency. The document also stated liquid vaccines containing an adjuvant (substance which could increase potency of a drug) could permanently lose potency when exposed to freezing temperatures. Review of the United States Pharmacopoeia Standards (UPS) Chapter 1079: Good Storage and Distribution Practices for Drug Products, updated [DATE], revealed the standard provided guidance concerning storage of refrigerated medications. According to UPS standards, temperature-controlled storage environments must maintain appropriate conditions for temperature sensitive drugs and to ensure drugs were stored according to the manufacturer's instructions. USP standards reinforced that refrigerator storage temperatures should be maintained between thirty-six (36) and forty-six (46) degrees Fahrenheit, which was two (2) degrees and eight (8) degrees Celsius. Review of the facility's policy titled, Storage of Medications, revised [DATE], revealed drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls. Further review revealed medications requiring refrigeration would be stored in a refrigerator in the medication room. Per the policy, the nursing staff was responsible for maintaining medication storage. In addition, the policy stated compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals were locked when not in use. Review of the medication package insert for Humalog U-100 units/milliliter (insulin taken for Diabetes) at https://www.humalog.com/u100, revealed an unopened insulin vial should be stored in a refrigerator at thirty-six (36) to forty-six (46) degrees Fahrenheit or two (2) to eight (8) degrees Celsius. 1. Observation, on [DATE] at 3:24 PM, of the Unit 1 Medication Storage Room revealed it was locked. The thermometer was located on a shelf in the door of the refrigerator. The temperature of the refrigerator registered thirty-two (32) degrees Fahrenheit. The door to the freezer compartment would only open slightly as it was adhered to a large amount of ice build-up on the inside of the freezer compartment. Per the observation, stored on shelves on the door included: two (2) boxes of unopened Tubersol, a medication used to perform tuberculin skin tests, (TU) (5 TU/0.1 milliliters (ml)) 5 ml multi-dose vial; and seven (7) vials of Pneumococcal Conjugate Vaccine. Medications stored in the refrigerator compartment and unopened, which required refrigeration from thirty-six (36) to forty-six (46) degrees Fahrenheit included: one (1) bottle of Calcitonin Nasal Spray, used to treat postmenopausal osteoporosis; one (1) bottle of Omeprazole Oral Solution, used to treat gastrointestinal (GI) conditions; one (1) bag of Cephalexin IV, used to treat infections; multiple Acetaminophen suppositories, used to treat fever and pain; multiple Bisacodyl suppositories, used to treat constipation; two (2) bottles of Latanoprost Ophthalmic Solution, used to treat increased pressure in the eye; two (2) Humalog Kwik Pens, used to treat Diabetes (high blood sugar); one (1) Novolog Flex Pen, used to treat Diabetes; two (2) Basaglar Injection Pens, used to treat Diabetes; one (1) Insulin Glargine Pen, used to treat Diabetes; two (2) Ozempic Injection Pen, used to treat Type 2 Diabetes; and two (2) vials of Lorazepam 2.0 milligrams (mg)/milliliter, used to treat anxiety. In addition, one (1) bottle of Ibuprofen, used to treat fever, pain, and inflammation, with approximately thirty (30) tablets, which was located in a cupboard in the medication storage room. The Ibuprofen bottle was not labeled and did not have a visible expiration date. 2. Observation, on [DATE] at 3:42 PM, of the Unit 2 Medication Storage Room refrigerator revealed the temperature was at thirty-two (32) degrees Fahrenheit. Medications stored in the refrigerator compartment, unopened unless otherwise indicated, which required refrigeration from thirty-six (36) to forty-six (46) degrees Fahrenheit included: twelve (12) Acetaminophen suppositories; multiple Bisacodyl suppositories; one (1) opened Tubersol (5 TU/0.1 ml) 5 ml vial, where the packaging was dated, but there was not an opened date label; one (1) Trulicity Injection Pen, used to treat Type 2 Diabetes; one (1) bottle of Latanoprost Ophthalmic Solution; one (1) Novolog Flex Pen; one (1) Insulin Glargine Pen; one (1) Lansoprazole oral suspension, used to treat GI conditions; and twelve (12) Promethazine 25 mg suppositories, used to treat nausea. Review of the facility's form, Refrigerator Temp Log, dated 08/2022, for the medication storage refrigerators, revealed staff was to monitor the refrigerator temperature once daily and check for expired items and opened dates on items. Further review of the temperature log, for the Unit 2 medication storage refrigerator revealed there was no temperature logged for [DATE]. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 3:24 PM, revealed she did not know at what temperature the medication refrigerator should be maintained. She stated she was unaware that medications and vaccines should not be stored in the door of the refrigerator. Per the interview, LPN #9 stated the night nurse was responsible for monitoring the temperature of the medication refrigerators and the temperatures were monitored weekly. LPN #9 stated she was educated by nurse leadership on medication storage and labeling. Interview with Registered Nurse (RN) #1, on [DATE] at 3:45 PM, revealed the night shift nurse was responsible for monitoring the temperature of the medication refrigerators and temperatures were monitored once daily. She stated refrigerator temperatures should be maintained between thirty-six (36) and forty-six (46) degrees Fahrenheit. RN #1 stated she believed the Unit Managers (UM) audited the temperature log sheet for compliance. Per the interview, she stated storing medications according to manufacturer's recommendations was necessary for the safety of all residents and the stability of the medications. 3. Observation, on [DATE] at 9:54 AM, of the medication cart on the 400 Hall revealed one (1) unopened vial of Humalog U-100 units/ml. Per the label instructions, the insulin vial should be stored in a refrigerator prior to opening. Interview with LPN #7, on [DATE] at 9:55 AM, revealed the unopened vial of insulin should have been stored according to the manufacturer's instructions and stored in the refrigerator prior to opening. Interview with Unit 1 Manager/LPN #2, on [DATE] at 2:15 PM, revealed it was the responsibility of the nursing staff to ensure medications were stored according to the facility's policy. She stated she had been educated by the facility on medication storage and labeling. LPN #2 stated the night shift nurse was responsible for monitoring the temperature of the medication refrigerators, and then she audited the temperature logs to make sure the task had been completed. When asked at what temperature the medication storage refrigerator should be maintained, LPN #2 stated, Between thirty-six (36) and forty-two (42) degrees, I guess. Vaccines have different temperature requirements, but I'm not sure what that is. She stated she was not aware of any one (1) person in leadership who monitored the staff for medication storage and labeling compliance. Further interview revealed that all nurses were responsible for ensuring the refrigerator/freezers were maintained in proper working order, including defrosting the freezer. LPN #2 stated that she would defrost the freezer as needed. Continued interview revealed she was unaware that Unit #1's medication storage freezer compartment needed to be defrosted. Per the interview, she stated storing medications according to manufacturer's recommendations was necessary for the safety of all residents and the stability of the medications. Interview with Unit 2 Manager/RN #2, on [DATE] at 2:15 PM, revealed it was the responsibility of the nursing staff to ensure medications were stored according to the facility's policy. Per the interview, RN #2 stated the night shift nurse was responsible for monitoring the temperature of the medication refrigerators, and then she monitored the temperature logs to make sure the task had been completed. She stated the refrigerator should be maintained between thirty-six (36) and forty (40) degrees to forty-six (46) degrees Fahrenheit. Per the interview, defrosting was important to maintain the temperature. RN #2 stated storing medications according to the manufacturer's recommendations was necessary to ensure the medications were effective and safe to administer. Interview with the Director of Nursing (DON), on [DATE] at 3:03 PM, revealed it was her expectation that nurses followed the facility's policy regarding medication storage and labeling. She stated medications and vaccines should be stored according to manufacturer's recommendations and CDC guidelines to ensure the safety of all residents and to maintain medication effectiveness. Interview with the Administrator, on [DATE] at 3:30 PM, revealed it was his expectation that nurses followed the facility's policy regarding medication storage and labeling. He stated that it was important to follow manufacturer's recommendations to maintain medication and vaccine efficacy and ensure the safety of all residents and staff.

Based on interview and review of the facility's policy, it was determined the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to send and receive mail, and the facility was responsible for protecting and facilitating the resident's right to communicate with individuals and entities within and external to the facility. During the Resident Group Interview, on 08/09/2022 at 2:00 PM, the State Survey Agency (SSA) Surveyor interviewed the residents to see if they received mail at the facility, to include mail on Saturdays. The general consensus was residents did not receive mail on Saturdays, with the only exception being when mail or packages were delivered for special occasions such as residents' birthdays. Resident #29 stated and other residents agreed that staff did not generally deliver mail on Saturdays. Resident #29 stated during the week, mail was delivered by the Activities staff, but they were not available on weekends to deliver mail. Interview with the Director of Social Services, on 08/09/2022 at 4:14 PM, revealed she was not sure what the procedure was for delivery of mail on the weekends. The Director stated that no residents had brought up any concerns regarding this. Interview with the Activities Director, on 08/09/2022 at 4:38 PM, revealed resident rights were discussed in resident council. She stated the weekend receptionist had given out mail on Saturdays in the past if she was not extremely busy, especially if it was important mail. The Activities Director stated mail was not passed out every weekend. She stated no residents had complained to her about not receiving mail on Saturdays. Continued interview revealed there was no facility policy regarding mail delivery. Interview with the Weekend Receptionist, on 08/11/2022 at 4:33 PM, revealed one (1) of her duties was to sort mail, and place any resident mail in the Activities Mailbox. She stated she did not deliver mail on Saturdays and was uncertain whether or not anyone else delivered mail to residents on Saturdays. Continued interview revealed she used to work through the week, and the procedure had always been to place residents' mail in the Activities mailbox for Activities to deliver. Interview with the Administrator, on 08/11/2022 at 4:45 PM, revealed he knew the weekend receptionist sorted mail. He stated he believed the weekend supervisor delivered resident mail on Saturdays. Continued interview revealed when he learned mail was not being delivered to residents on Saturdays, he expected the receptionist to sort mail and the weekend supervisor to deliver the mail.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment. Residents complained during resident council of staff smoking outside on facility grounds. Observation revealed evidence of smoking off the Unit 2 exit, in the back parking lot, and at the back stairs. The findings include: Review of the facility's policy titled, Smoking Policy - Residents, not dated, revealed the facility was a no smoking facility. The policy stated smoking was only permitted if residents were off the premises. Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to a safe, clean, comfortable, and homelike environment. Interview with the Resident Group, on 08/09/2022 at 2:00 PM, revealed Residents #65, #88, #29, and #57 complained of staff that provided care for them smelled of smoke, and they, as residents, were not allowed to smoke. Resident #88 stated he/she had observed four (4) or five (5) staff smoking outside the after hours entrance (Unit 2 exit) and had complained, but could not remember who he/she had complained to. Resident #29 stated there were cigarette butts all around outside the emergency exit door where staff smoked. Resident #29 stated staff used to have to go a certain distance away from the facility to smoke. Observation, on 08/10/2022 at 3:41 PM, revealed the Unit 2 exit parking lot, directly around the emergency ramp, had in excess of forty-three (43) cigarette butts, with at least a dozen more in the bushes on each side of the door. Additional observation, on 08/10/2022 at 3:44 PM, revealed the back parking lot was littered with cigarette butts, and multiple cigarette butts also were observed at a back exit with stairs. Interview with the Director of Maintenance, on 08/11/2022 at 3:27 PM, revealed he had observed staff smoking around the building, at the picnic tables. He stated at night in this neighborhood, staff did not like to get too far away from the building. He stated it was posted at the entrance that this was a non-smoking facility. Continued interview revealed he tried to sweep things up around the ambulance (Unit 2) entrance. Further review revealed he was unaware of any resident complaints, and no residents had complained to him about staff smoking outside. Interview with State Registered Nurse Aide (SRNA) #4, on 08/11/2022 at 3:42 PM, revealed she had observed staff members smoking outside of the building, either in their cars or in smoking areas, to include the picnic table under the tree out back. She stated staff had a metal bucket to dispose of cigarettes at the picnic table. SRNA #4 stated she usually worked on Unit 1 which did not have an exit. She stated she did not know what happened on Unit 2. The SRNA stated she had not seen anyone smoking in the back parking lot. Interview with SRNA #10, on 08/11/2022 at 3:56 PM, revealed as a smoker, staff go off the premises down by the road to smoke. She stated she had never seen anyone smoking outside of the exits or in the back parking lot. She stated the building had been non-smoking since she had been at the facility. Interview with the Administrator, on 08/11/2022 at 4:45 PM, revealed he had not heard residents complain about staff smoking outside, although he had heard residents express their desire for the facility to be a smoking facility. He stated he had not seen staff smoking outside on the premises and would correct it immediately if he did. He stated he did not know who was responsible for producing the multiple cigarette butts observed outside. The Administrator stated, prior to admission, staff ensured that residents knew they were coming to a non-smoking facility. Continued interview revealed his expectation was that no one smoked on the premises, aside from one (1) designated area. He reiterated his expectation would be that nobody smoked on the premises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Director of Nursing and the Administrator's Job Descriptions, and review of the facility's policy, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and, failed to ensure infection prevention and control policies and protocols were adhered to for the safety and well being of residents, staff, and visitors. The Administration failed to ensure staff followed the Centers for Disease Control and Prevention (CDC) guidelines and the facility's policies for infection control and prevention (IPC); and COVID-19 testing was conducted per established local, state, and federal regulations. In addition, the Administration failed to ensure that all staff had received his/her primary vaccine series for COVID-19 per CDC guidelines because four (4) declination forms could not be found; and the Administration failed to ensure the facility tested two (2) newly-admitted residents immediately upon admission to the facility. Refer to F-880, F-886, F-888. The findings include: Review of the facility's Job Description for the Administrator, undated, revealed the Administrator's responsibilities included the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations governing nursing facilities to ensure residents were provided the highest degree of quality of care. Continued review revealed the Administrator was to ensure that all facility personnel followed established safety regulations to include infection control. Furthermore, the Administrator was responsible to plan, develop, organize, implement, evaluate, and direct the facility's programs. Review of the facility's Job Description for the Director of Nursing (DON), undated, revealed the DON oversaw and supervised the care of all residents. It stated the DON was responsible for the overall management of the entire nursing department. Per the Job Description, the DON's job duties included developing and implementing nursing policies and procedures and to ensure compliance. Furthermore the DON was responsible to ensure the safety of all residents. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed the Administrator was responsible for assuring the facility complied with federal, state, and local regulatory agency requirements. 1.a. Review of medical records revealed seven (7) residents had been placed untimely, on Quarantine Transmission Based Precautions (TBP) or Contact Precautions. b. Review of medical records revealed eight (8) residents had been placed on Quarantine TBP without documented evidence that it was warranted. c. Observations, from 08/08/2022 to 08/11/2022, revealed multiple infection prevention and control (IPC) breaches of protocol by staff. Twelve (12) observations involved staff not wearing or disposing of personal protective equipment (PPE) correctly; five (5) observations involved improper hand hygiene by staff; and five (5) observations involved incorrect disinfection of glucometers by staff. 2. During a COVID-19 outbreak, and with a high COVID-19 community transmission rate, the facility failed to test two (2) unvaccinated staff and five (5) staff whose COVID-19 vaccinations were not up to date prior to beginning his/her shift, allowing these staff to work a full shift before his/her bi-weekly COVID-19 test was performed. 3. Observation of the COVID-19 testing station, on 08/09/2022 at 4:30 PM, revealed multiple breaches in IPC protocol by the Quality Assurance/Infection Prevention (QA/IP) Nurse, who performed the testing. 4. Review of Resident #41's medical record revealed he/she received his/her first COVID-19 Rapid Test on 08/01/2022, five (5) days after admission on [DATE]. Review of Resident #210's medical record, whom the facility admitted on [DATE], revealed no COVID-19 Rapid Test results and none were provided by the facility's staff. 5. Review of the Facility COVID-19 Vaccine Acceptance/Declination Form, updated 01/24/2022, revealed twenty (20) employees declined the COVID-19 vaccination based on religious belief. Further review revealed five (5) of the twenty (20) employees did not date the acceptance/declination form. However, the facility did not provide documentation of declination for State Registered Nurse Aides (SRNA) #19, #20, and #21, and for Licensed Practical Nurse (LPN) #10. Interview with the Regional Director of Clinical Services (RDCS), on 08/10/2022 at 11:42 AM, revealed her role in the facility was to consult, train, and tell them what is expected. She stated the Administrator had ultimate oversight to ensure all the facility's policies and protocols, especially as they related to adherence to regulatory recommendations, were being addressed and followed. She stated staff following infection prevention and control (IPC) procedures was important to prevent the spread of infection. Interview with the Director of Nursing (DON), on 08/10/2022 at 11:42 AM, revealed she had been in her current role since 07/13/2022. She stated she had been monitoring to ensure that IPC policies and protocols were followed. She stated she had focused on understanding everyone's roles and providing direction and oversite for IPC compliance. The DON stated nursing leadership, to include the DON, Assistant DON, IP Nurse, and Unit Managers, actively monitored staff for IPC compliance. She stated there were no formal audits occurring, but if nursing leadership saw non-compliance, the staff was educated immediately. She stated IPC was important to prevent the spread of infection. The DON stated she was aware of issues related to the facility's failure to accurately document and track COVID-19 testing. Additional interview with the DON, on 08/12/2022 at 3:03 PM, revealed it was her expectation that all IPC policies and protocols were followed by all staff. Per the interview, the DON stated she and the Assistant DON/Staff Development Coordinator were responsible for educating staff on IPC policies and protocols. She stated the facility used the train the trainer method to train on IPC practices: first to train the facility's department heads, and then for the department heads to educate and train support staff and allied health employees. She stated each department had its own IPC in-service book. She stated there was immediate intervention by leadership if any breach in IPC practices was observed. Per the DON, leadership would provide reeducation of staff, if needed. The DON stated compliance with IPC protocols was important to prevent the spread of communicable diseases among residents and staff. She stated it was her expectation that staff followed all facility infection prevention and control practices. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed discussion of COVID-19 testing documentation and infection control were slated for the Quality Assurance Performance Improvement (QAPI) ad hoc meeting on 07/25/2022, but the meeting did not occur. According to the Administrator, there was a need to immediately address the COVID-19 testing documentation at the next ad hoc meeting. He stated ad hoc meetings had determined there were issues with IPC and COVID-19 vaccination and testing.

**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 maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Multiple breaches of infection prevention and control practices, as stipulated by the Centers for Disease Control and the facility's policies, was observed from 08/08/2022 to 08/11/2022. In addition, COVID-19 testing was not conducted per established local, state, and federal regulations. Furthermore, all staff had not received his/her primary vaccine series for COVID-19 per CDC guidelines because four (4) declination forms could not be found; and two (2) newly-admitted residents were not tested for COVID-19 immediately upon admission to the facility. Refer to F-880, F-886, F-888. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed the purpose of the policy was to ensure the facility developed, implemented, and maintained an ongoing facility wide QAPI program that was focused on care and quality of life for their residents. The objectives of the policy included: 1) provide a means to measure current and potential indicators for outcomes of care and quality of life; 2) provide a means to establish and implement performance improvement projects to correct identified deficiencies; and, 3) establish a system to monitor and evaluate corrective action. Further review revealed the facility's governing board was ultimately responsible for the QAPI program; and, the administrator was responsible for assuring that the QAPI program complied with federal, state, and local regulatory agency requirements. Per the policy, the QAPI committee oversaw implementation of the QAPI plan and identified and corrected quality deficiencies through 1) tracking and measuring performance; 2) establishing goals and thresholds for performance; 3) identifying and prioritizing quality deficiencies; 4) systematically analyzing underlying causes of systemic quality deficiencies; 5) developing and implementing corrective actions or performance improvement activities; and 6) monitoring effectiveness of the corrective actions and performance improvement activities. Review of the facility's QAPI Committee meeting documentation revealed a meeting had been held, on 04/27/2022, and attendees included but were not limited to the Administrator, the Medical Director, the Regional Director of Clinical Services (RDCS), the Director of Nursing (DON), the Infection Preventionist (IP), and the Unit I and Unit II Nurse Managers. Review of the Agenda revealed a mock survey, conducted on 04/06/2022 and 04/07/2022, had identified concerns related to infection prevention and control (IPC). The Medical Director voiced no concerns and/or recommendations regarding IPC. Review of the facility's QAPI Committee meeting documentation revealed a meeting had been held, on 05/25/2022, and attendees included but were not limited to the Administrator, the Medical Director, the RDCS, the DON, and the Infection Preventionist (IP). Review of the Agenda revealed IPC was not discussed. Review of the QAPI Committee meeting agendas, revealed the last QAPI meeting was held on 05/25/2022. 1.a. Review of medical records revealed seven (7) residents had been placed untimely on Quarantine Transmission Based Precautions (TBP) or Contact Precautions. b. Review of medical records revealed eight (8) residents had been placed on Quarantine TBP without documented evidence that it was warranted. c. Observations, from 08/08/2022 to 08/11/2022, revealed multiple infection prevention and control (IPC) breaches of protocol by staff. Twelve (12) observations involved staff not wearing or disposing of personal protective equipment (PPE) correctly; five (5) observations involved improper hand hygiene by staff; and five (5) observations involved incorrect disinfection of glucometers by staff. 2. During a COVID-19 outbreak, and with a high COVID-19 community transmission rate, the facility failed to test two (2) unvaccinated staff and five (5) staff whose COVID-19 vaccinations were not up to date prior to beginning his/her shift, allowing these staff to work a full shift before his/her bi-weekly COVID-19 test was performed. 3. Observation of the COVID-19 testing station, on 08/09/2022 at 4:30 PM, revealed multiple breaches in IPC protocol by the Quality Assurance/Infection Prevention (QA/IP) Nurse, who performed the testing. 4. Review of Resident #41's medical record revealed he/she received his/her first COVID-19 Rapid Test on 08/01/2022, five (5) days after admission on [DATE]. Review of Resident #210's medical record, whom the facility admitted on [DATE], revealed no COVID-19 Rapid Test results and none were provided by the facility's staff. 5. Review of the Facility COVID-19 Vaccine Acceptance/Declination Form, updated 01/24/2022, revealed twenty (20) employees declined the COVID-19 vaccination based on religious belief. Further review revealed five (5) of the twenty (20) employees did not date the acceptance/declination form. However, the facility did not provide documentation of declination for State Registered Nurse Aides (SRNA) #19, #20, and #21, or for Licensed Practical Nurse (LPN) #10. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/11/2022 at 4:12 PM, revealed she had been the QA/IP Nurse since April 2022 and was the facility's Assistant Director of Nursing (ADON) prior to accepting her new role. Per the interview, she stated the facility failed to comply with infection prevention and control (IPC) protocols when staff failed to don/doff PPE or wear it correctly, according to recommended guidelines; failed to perform hand hygiene; failed to place new admissions immediately in TBP; and, failed to have the proper PPE or signage on the door for the type of TBP. She stated, Nursing staff should be supervising their aides. We do expect our nurses to monitor infection prevention and control compliance and ensure their aides are following our policies and guidelines for infection control; and nursing leadership should be monitoring the nurses for compliance. The QA/IP Nurse stated she was not aware of formal IPC compliance audits being conducted. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed she had been in her current role since 07/13/2022. She stated she had been monitoring to ensure that IPC policies and protocols were followed. The DON stated she had focused on understanding everyone's roles and providing direction and oversite of IPC compliance. She stated nursing leadership, to include the DON, Assistant DON, QA/IP Nurse, and Unit Managers actively monitored staff for IPC compliance. Continued interview revealed there were no formal audits occurring, but if nursing leadership saw non-compliance, the staff involved was educated immediately. The DON stated she was aware of issues related to the facility's failure to accurately document and track COVID-19 testing. She stated she developed an agenda for an ad hoc QAPI Meeting, which was supposed to have taken place on 07/25/2022, but did not. She stated that IPC issues, including COVID-19 testing of residents, staff, and new admissions, and COVID-19 vaccination status were on the agenda to be addressed during the meeting. No explanation was provided as to why the meeting did not take place. Interview with the Medical Director (MD), on 08/12/2022 at 1:15 PM, revealed he attended ad hoc and monthly Quality Assurance and Performance Improvement (QAPI) meetings. He stated he had worked closely with the Administrator to assure the infection control process was adequate in preventing the spread of infection. He stated as MD, it was his expectation that staff was following IPC protocols, and leadership was monitoring compliance. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed the QAPI Committee had conducted monthly QAPI Meetings in the past, and planned to do so moving forward. However, he stated the last time the QAPI Committee met was at the end of April 2022. Per the interview, the Administrator stated discussion of COVID-19 testing documentation and infection control were slated for the ad hoc meeting on 07/25/2022, but the meeting did not occur. According to the Administrator, he stated there was a need to immediately address the COVID-19 testing documentation at the next ad hoc meeting. He stated ad hoc meetings had determined there were issues with IPC and COVID-19 testing. He stated, Infection control is discussed at every meeting for QA.

Based on observation, interview and record review, it was determined the facility failed to have documented evidence of COVID-19 vaccination exemptions for those employees who declined to be vaccinated or whose vaccination status was unknown, for State Registered Nurse Aides (SRNA) #19, #20, #21, and Licensed Practical Nurse (LPN) #10. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) memo titled, Long-Term Care and Skilled Nursing Facility Attachment A Revised, supplement to the QSO 22-07-ALL memorandum, revised 01/22/2022, revealed the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Per the memorandum, staff was considered fully vaccinated if it had been two (2) weeks or more since they completed a primary vaccination series for COVID-19. Furthermore, the policies and procedures must include a process for ensuring all staff, except for those that had been granted exemptions to the vaccination requirements of this section, had received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multidose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents Review of the facility's policy titled, COVID-19 Vaccine, not dated, revealed, if an employee refused the vaccine for medical contraindications or religious exemptions, it would be documented on the appropriate exemption form. Review of the facility's record of COVID-19 employee vaccination status, dated 08/08/2022, revealed the facility employed one hundred and twenty-three (123) staff. Eighty-four percent (84%) or one-hundred three staff were fully vaccinated; and sixteen percent (16%) or twenty (20) staff members had been granted a religious exemption from receiving the vaccination. Review of the Facility COVID-19 Vaccine Acceptance/Declination Form, updated 01/24/2022, revealed twenty (20) employees declined the COVID-19 vaccination based on religious belief. Further review revealed five (5) of the twenty (20)employees did not date the acceptance/declination form. However, the facility did not provide documentation of declination for State Registered Nurse Aides (SRNA) #19, #20, and #21, or for Licensed Practical Nurse (LPN) #10. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/11/2022 at 4:12 PM, revealed she had worked at the facility in the position of IP since July 2022. She stated prior to working in the role of IP, she was the Assistant Director of Nursing (ADON). The QA/IP Nurse stated the facility required that staff received his/her primary COVID-19 vaccination or requested a medical or religious exemption per CDC guidelines. She stated vaccination was important to prevent the transmission and spread of COVID-19. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed the Administrator kept records of the staffs' and residents' COVID-19 vaccinations. Interview with Administrator, on 08/10/2022 at 9:28 AM, revealed he had been in his position for two (2) years. He stated he had reported COVID-19 vaccination data to the CDC's National Healthcare Safety Network, most recently, on 08/08/2022. Additional interview with the Administrator, on 08/12/2022 at 9:40 AM, revealed he did not provide further information as to why the facility had not kept accurate records of employee COVID-19 vaccination declination forms. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed it was the Administrator's expectation that staff adhered to infection prevention and control protocols to help maintain the health and safety of all residents, staff, and visitors. The Administrator stated vaccination was important to help prevent the transmission of COVID-19 in the facility.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to serve and store food under sanitary conditions. Observations, on 08/08/2022 and 08/09/2022, revealed dry storage with dented cans; no label on a can; ingredient bins with food thickener, lids not closed; vents in dry storage with dust accumulation; vents in kitchen ceiling with dust and dripping water in front of the walk-in refrigerator and walk-in freezer. Further observations, on 08/11/2022, of the nourishment refrigerator on Unit 1, revealed it was not clean on the lower shelf; no identification on a frozen resident meal, and the boxed cookies were not dated. The findings include: Review of the facility's policy titled, Safe Dietary Practices, dated 10/2017, revealed all foods and fluids would be labeled by Dietary with two (2) dates; one (1) for the stock date and one (1) for the use by date, the manufacture's expiration date. The policy stated, if a food or fluid product did not have an expiration date, once it was opened, it must be labeled with a three (3) day discard date. Per the policy, all foods belonging to residents must be labeled with the resident's name, the item, and the use by date. Further review revealed it was housekeeping's responsibility to clean the nourishment refrigerators on a daily basis and, as necessary when soiled. Observation of the kitchen, on 08/08/2022 at 3:36 PM, revealed in the dry storage area: a dented spaghetti sauce #10 can on the shelf and a #10 can on the shelf with no label. Two (2) dry storage small ingredient bins, that contained food thickener, had the lids left open. In addition, observation of the intake and output vents in the ceiling of the dry storage area revealed an accumulation of dust and debris. Continued tour of the kitchen revealed vents in the kitchen ceiling with dust and dripping water in front of the walk-in refrigerator and near the walk-in freezer, between the walk-in freezer and production line. Additional observation of the kitchen, on 08/09/2022 at 9:45 AM, in the dry storage area, revealed five (5) packages of yellow cake mix, that had no box, label, or date; and a dented #10 spaghetti can and a #10 can with no label remained on the shelf. Further observation revealed two (2) gallons of lite mayonnaise and two (2) coleslaw dressing containers with no dates; one (1) barbeque sauce, sixty-four (64) fluid ounces, not dated; and one (1) outdated Silk milk shelf stable product, dated 12/06/2020. Additional observation of the kitchen, on 08/11/2022 at 12:00 PM, revealed a vent in front of the walk-in refrigerator dripping water onto the floor and the tray line. Observation of the Unit 1 Nourishment Room (for 100, 200, and 300 Halls), on 08/11/2022 at 10:15 AM, revealed frozen Grande Chicken and Ricotta Cheese Cannelloni with [NAME] Sauce with no resident identification and a to-go clear container of unknown food with no label, date, resident name, or room number. Inside the nourishment refrigerator, on the lower right shelves, was a dried stain of an unknown substance. The packaged cookies, fudge rounds, and oatmeal cookies were not dated, and four (4) packages of Teddy Grahams were outdated, as of 07/24/2022. Interview with [NAME] #1, on 08/12/2022 at 8:23 AM, revealed she checked the dry storage for stock dates and the condition of the cans. She stated that she took any dented cans or unlabeled food products to the Dietary Manager's office. [NAME] #1 stated it was important to date, rotate, and label foods to keep foods safe, so as not to make a resident sick. Continued interview revealed the lids on the ingredient bins should always be shut to prevent bugs and other things from getting into the food thickener. Interview with [NAME] #2, on 08/12/2022 at 8:31 AM, revealed dented cans were removed from the shelf and taken to the Dietary Manager's office, for the Manager to dispose of the cans. [NAME] #2 stated, if foods were not dated or labeled, staff would not know how long they had been on the shelf; and dented cans could allow bacteria to grow in the food product. [NAME] #2 stated the food thickener lid must always be closed to keep rodents and other pests out of it. Interview with Dietary Aide #1, on 08/12/2022 at 8:40 AM, revealed any cans or food products in dry storage that were dented or not labeled should be reported to the Dietary Manager. The aide stated dented cans could allow bacteria to grow, and food products with no date and/or no label or which were outdated, should be thrown away. Dietary Aide #1 stated food thickener for drinks must have the lid closed to protect against dust, bugs, or anything that could fall into it. Dietary Aide #1 stated food thickener that was not identified by a label or date should be thrown away. Interview with the Dietary Manager, on 08/12/2022 at 8:58 AM, revealed any dry storage dented cans should be taken to the office because dented cans could allow air into the can and get contaminated with bacteria. He stated the outdated soy milk could make a resident sick and had been thrown out. Further interview revealed food thickener ingredient bins must have a cover with a lid to prevent cross contamination from spills or debris from sweeping or mopping near the lower dry storage shelf. He stated all food items needed to be labeled and dated. Continued interview revealed the nourishment refrigerators were cleaned by nursing or housekeeping, and the cookie packages should be dated and rotated. The Dietary Manager stated the vents over the kitchen area should not contain dust or water condensation to prevent cross contamination of food in the production areas. Interview with the Maintenance Director, on 08/12/2022 at 9:36 AM, revealed he tried to walk through the dietary department daily. He stated the vent filters were changed monthly. Continued interview revealed he did not know the drips were coming down from the ceiling due to condensation on a hot surface hitting the hot attic. Interview with Licensed Practical Nurse (LPN)/Unit Manager #2, on 08/12/2022 at approximately 10:00 AM, revealed cleaning of the nourishment refrigerator was done by the night shift. LPN #2 stated food for residents was dated and timed with the resident's room number or name. Interview with the Registered Nurse (RN)/Director of Nursing (DON), on 08/12/2022 at 10:54 AM, revealed her expectations for Dietary Staff to follow the Health Department and State Regulation guidelines. Interview with the Administrator, on 08/12/2022 at 3:35 PM, revealed his expectations for Dietary Staff to follow food preparation guidelines and for foods to be labeled and stored with expiration dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13.a. Observation, on 08/09/2022 at 3:58 PM, revealed LPN #1, after performing a blood glucose check on Resident #34, returned to the medication cart and opened the top right drawer. He picked up an alcohol pad and wiped only the end of the glucometer and placed the glucometer back in the drawer. Interview with LPN #1, on 08/09/2022 at 3:59 PM, revealed he cleaned the glucometer after each use with an alcohol pad. b. Observation, on 08/11/2022 at 9:00 AM, revealed LPN #3 sanitized her hands and put on gloves before she cleaned the used glucometer with only one (1) Sani-Cloth. LPN #3 failed to take another disinfecting wipe and wipe the meter thoroughly per the manufacturer's instructions. Interview with LPN #3, on 08/11/2022 at 9:02 AM, revealed she cleaned the glucometer after each use with a Sani-Cloth and then let the glucometer sit for two (2) minutes to dry before using again. c. Observation, on 08/11/2022 at 9:05 AM, revealed LPN #5 cleaned the glucometer, after use, with a Sani-Cloth. LPN #5 then put the glucometer in a cup. She failed to take a second wipe and thoroughly clean the glucometer. Interview with LPN #5, on 08/11/2022 at 9:06 AM, revealed she cleaned the glucometer after each use with a Sani-Cloth and let the glucometer stay wet for two (2) minutes. d. Observation, on 08/11/2022 at 9:15 AM, revealed Registered Nurse (RN) #1 sanitized her hands and put on gloves. She then cleaned the glucometer with a Sani-Cloth and put the glucometer in a cup on the top of the medication cart. She failed to take a second wipe and thoroughly clean the glucometer. Interview, on 08/11/2022 at 9:17 AM, with RN #1 revealed she left the glucometer in the cup for at least two (2) minutes. She stated she did not take a second Sani-Cloth and thoroughly wipe the meter. e. Observation, on 08/11/2022 at 9:20 AM, revealed LPN #6 sanitized her hands and put on gloves. She then opened the top right medication drawer and took the glucometer out of the top drawer along with a Sani-Cloth. LPN #6 wiped the glucometer thoroughly and placed it in a plastic cup on top of the cart. Further observation revealed, after two (2) minutes, she failed to clean the glucometer with a second cloth. Interview with the DON, on 08/11/2022 at 4:00 PM, revealed she was not aware that staff were not using a second wipe to clean the glucometers as directed in the manufacturer's instructions. She stated an in-service would be implemented that evening on cleaning the glucometers correctly. Interview with the QA/IP Nurse, on 08/11/2022 at 4:46 PM, revealed staff was to clean the glucometer device with the appropriate wipe and let it sit for two (2) minutes. Interview with the ADON, on 08/12/2022 at 2:46 PM, revealed she did not include glucose meter cleaning in orientation. The ADON stated new staff started with a preceptor, and the preceptor instructed staff on how to clean the glucometers. She stated she did not do a follow up to assure new staff knew how to correctly clean glucometers. 14. Observation, on 08/10/2022 at 12:00 PM, revealed four (4) Dietary staff were not wearing masks over the nose in the kitchen during the lunch meal service. Interview with [NAME] #1, on 08/12/2022 at 8:23 AM, revealed she was trained on how to wear a mask. She stated staff must wear masks to protect against COVID-19. Interview with [NAME] #2, on 08/12/2022 at 8:31 AM, revealed staff was trained about wearing a mask. [NAME] #2 stated the mask was to be worn over the nose to protect themselves and others from getting sick. Interview with Dietary Aide (DA) #1, on 08/12/2022 at 8:40 AM, revealed the DA had received training on the proper way to wear a mask. She stated it was important to wear a mask to prevent infections. DA #1 stated she encouraged others in the department to wear their mask over the nose. Interview with the Dietary Manager, on 08/12/2022 at 8:58 AM, revealed staff received training concerning wearing masks correctly, which was to cover the nose. He stated it was important for staff to wear masks to protect self, other staff, and residents from the spread of COVID-19 and germs. Interview with Unit Manager (Unit 1), on 08/12/2022 at 2:15 PM, and Unit Manager (Unit 2), on 08/12/2022 at 2:30 PM, revealed infection control was important to prevent the spread of communicable diseases among residents and staff. Both stated it was their expectation that staff followed infection prevention and control practices as per the facility's policies. Interview with QA/IP Nurse, on 08/11/2022 at 4:12 PM, revealed she had been the QA/IP Nurse since April 2022 and was the facility's ADON prior to accepting her new role. Per the interview, the QA/IP Nurse stated the facility failed to comply with infection prevention and control (IPC) protocols when staff failed to don/doff PPE or wear it correctly, according to CDC recommended guidelines; failed to perform hand hygiene; failed to place new admissions immediately in TBP; and failed to have the proper PPE or signage on the door for the type of TBP. She stated staff was informed of TBP during the handoff report. She stated, Nursing staff should be supervising their aides. We do expect our nurses to monitor infection control compliance and ensure their aides are following our policies and guidelines for infection control; and nursing leadership should be monitoring the nurses for compliance. The QA/IP Nurse stated she was not aware of formal IPC compliance audits being conducted. She stated if there was a breech in IPC, staff should be corrected immediately. The QA/IP stated, You know, we expect the nurses to oversee and make sure they're doing that right. Per the interview, she stated that staff received IPC training and education upon hire. Furthermore, she stated the facility provided an infection control in-service training throughout the year and annually. Interview with the Regional Director of Clinical Services (RDCS), on 08/10/2022 at 11:42 AM, revealed her role in the facility was to consult, train, and tell them what is expected. She stated she had been working closely with the current DON since her hire in July 2022. Per the interview, the RDCS stated the Administrator had ultimate oversight to ensure all the facility's policies and protocols, especially as they related to adherence to current CDC recommendations, were being addressed and followed. She stated IPC was important to prevent the spread of infection. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed she had been employed at the facility in her current role since 07/13/2022. She stated she had been monitoring to ensure that IPC policies and protocols were followed. Further interview revealed she had focused on understanding everyone's roles and providing direction and oversite of IPC compliance. The DON stated that staff was trained on IPC policies and protocols upon hire and in-services were given by the ADON/SDC throughout the year. She stated nursing leadership, to include the DON, ADON/SDC, QA/IP Nurse, and UM's actively monitored staff for IPC compliance. She stated there were no formal audits occurring, but if nursing leadership saw non-compliance, the staff was educated immediately. She stated IPC was important to prevent the spread of infection. Interview with the DON, on 08/12/2022 at 3:03 PM, revealed it was her expectation that all IPC policies and protocols were followed by all staff. Per the interview, the DON stated she and the ADON/SDC were responsible for educating staff on IPC policies and protocols. She stated they used the train the trainer method to train IPC practices to the facility's department heads to educate and train support staff and allied health employees. She stated each department had its own IPC in-service book. Continued interview revealed there was immediate intervention by leadership if any breach in IPC practices was observed. Per the interview, the DON stated leadership would provide reeducation of staff, if needed. The DON stated compliance with IPC protocols was important to prevent the spread of communicable diseases among residents and staff. Also, she stated it was her expectation that staff followed all the facility's infection prevention and control practices. Interview with the Medical Director (MD), on 08/12/2022 at 1:15 PM, revealed he attended ad hoc and monthly Quality Assurance and Performance Improvement (QAPI) meetings. He stated he had worked closely with the Administrator to assure the infection control process was adequate in preventing the spread of infection. He stated as MD, it was his expectation that staff was following IPC protocols, and leadership was monitoring compliance. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed infection control was important to prevent the spread of communicable diseases among residents and staff. Furthermore, he stated it was his expectation that staff followed all the facility's infection prevention and control practices, including staff wearing masks correctly in the Dietary Department. Based on observation, interview, record review, review of the Centers for Disease Control and Prevention guidelines, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Review of the facility's testing results revealed from 07/11/2022 to 08/05/2022, seven (7) staff members tested positive for COVID-19. Observations throughout the survey revealed multiple breaches in Infection Prevention and Control (IPC) practices and protocols. These observations included: staff with masks below their noses and chins; failure to perform hand hygiene; failure to don (put on) PPE prior to entering transmission-based precaution (TBP) rooms; failure to doff (remove) PPE prior to exiting TBP rooms; failure to dispose of contaminated linen, and trash according to facility policy. Furthermore, the facility failed to place newly admitted residents in quarantine, placed residents in quarantine without a documented reason, and failed to place residents in ordered contact precautions. Continued observation revealed staff failed to perform hand hygiene between each resident encounter and after resident care was provided. Additional observations revealed staff left dirty laundry on the floor of a resident's room. These failures had the potential to affect all residents, but specifically, Residents #9, #19, #22, #32, #41, #48, #74, #94, #97, #101, #110, #162, #210, #212, and #360. The findings include: Interview with Licensed Practical Nurse (LPN) #2/Unit 1 Manager (UM), on 08/09/2022 at 8:40 AM, revealed she knew of no policy on quarantine of residents. However, she stated all new admissions were placed in Quarantine TBP for fourteen (14) days, and personnel were required to wear an N-95 respirator, face shield/goggles, gown, and gloves when giving care to these residents. Review of the CDC's, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/2022, revealed new admissions and readmissions should be placed in quarantine, even if they had a negative COVID-19 test upon admission. Review of the Centers for Disease Control and Prevention's (CDC) Infection Control Basics, Standard Precautions for All Patient Care, dated 01/26/2016, revealed Standard Precautions were used to prevent the transmission of infectious organisms. In addition to standard precautions, staff was to use appropriate personal protective equipment (PPE) as a barrier to exposure whenever there was an expectation of possible exposure to infectious material. Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, not dated, revealed hand hygiene reduced the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Continued review revealed multiple opportunities for hand hygiene could occur during a single care episode. Further review revealed the clinical indications for the use of 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. Review of the CDC's guideline titled, How to Safely Remove Personal Protective Equipment (PPE), no date, revealed all PPE should be removed before exiting the patient room except a respirator, if worn. Per the recommendations, there were two (2) examples to doff PPE:1) remove gloves, goggles or face shield, gown, and finally the mask or respirator; and 2) remove gown and gloves, goggles or face shield, then mask or respirator. Per the CDC, if hands became contaminated during PPE removal, healthcare personnel (HCP) were to immediately perform hand hygiene. Finally, wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. Review of the CDC's How to Use Your N95 Respirator, dated 03/16/2022, revealed the N95 mask must form a seal to the face to work properly. Per the recommendation, surgical masks were not to be worn with other masks or respirators. Review of the CDC's, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, last reviewed 03/02/2011, revealed blood glucose meters should be cleaned and disinfected after every use per the manufacturer's instructions. Review of the facility's policy, Isolation - Initiating Transmission Based Precautions, revised 08/2019, revealed the purpose of the policy was to initiate TBP's when a resident developed signs and symptoms of transmissible infection; arrived for admission with symptoms of an infection; or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. Per the policy, if a resident was suspected of or identified as having a communicable infectious disease, nursing supervisors would notify the Infection Preventionist (IP) for evaluation of appropriate transmission based precautions. TBP's were utilized when a resident met the criteria for transmissible infection, and the resident had risk factors that increased the likelihood of transmission. Further review revealed when TBP's were implemented, the IP identified the type of precaution needed, the duration, and the PPE that must be used. It stated the IP provided and or oversaw the education of the staff, resident, representative, and or visitors regarding the precautions and the use of PPE. In addition, the IP ensured the proper PPE was maintained outside the resident's room so that anyone entering the room could apply the appropriate equipment and ensured the suitable linen hamper and waste container, with an appropriate liner, were placed in the resident's room. Review of the facility's policy, Isolation - Notices of Transmission-Based Precautions, revised 08/2019, revealed the purpose of the policy was to alert personnel and visitors of TBP's. Per the policy, when TBP's were implemented, the IP determined the appropriate notification to be placed on the resident's room so personnel and visitors were aware of the need for and type of precaution. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2019, revealed the single most effective means of preventing transmission of infection from one (1) person to another was proper hand hygiene. It stated facility personnel were required to wash their hands after each direct or indirect resident contact, for which hand washing was indicated by acceptable standards of practice. Also, it stated hand hygiene should be performed after touching inanimate sources that were likely to be contaminated; between resident contacts; between tasks and procedures to prevent cross contamination; and when otherwise indicated to avoid transfer of microorganisms to other residents and environments. Additionally, it stated hand hygiene should be performed when in contact with a resident, or the equipment or environment of a resident, who was on contact precautions. Review of the facility's policy titled, Linen Handling, no date, revealed the purpose of the policy was to ensure that all linen should be handled, transported, and processed according to best practices for IPC. Per the policy, all laundry was handled as potentially contaminated until it was bagged properly. Additionally, linen should be bagged or placed in containers at the location where it was used. It stated soiled linen should be handled as little as possible and within minimum agitation to prevent microbial contamination of the air and of the staff handling the linen. It stated contaminated laundry was placed in a bag or container at the location where it was used and not sorted at the location of use. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, revealed resident-care equipment would be cleaned and disinfected according to current CDC recommendations for disinfection. Review of documentation provided by the facility titled, COVID Guidance, no date, revealed staff was to wash hands after touching blood, body fluids, secretions, excretions and contaminated items, and between residents. Per the policy, good hand hygiene was essential to prevent the spread of infection. It stated linens must be handled and transported in a manner that prevented contamination and that avoided the transfer of microorganisms to other residents and environments. Further review of the guidance revealed Standard Precautions assumed all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes might contain transmissible infection agents. It stated Standard Precautions applied to all patients regardless of suspected or confirmed infection status and included hand hygiene and the use of gloves, gown, mask, eye protection or face shield. Per the guidance, TBP's, including Contact Precautions and Droplet Precautions were used when the route of transmission was not completely interrupted using Standard Precautions. Review of the facility's staff COVID-19 testing results revealed the facility identified one (1) staff on 07/11/2022; one (1) staff on 07/12/2022; one (1) staff on 07/13/2022; one (1) staff on 07/20/2022; two (2) staff on 08/02/2022; and one (1) staff on 08/05/2022, as being positive for COVID-19. Review of the facility's manufacturer instructions titled Cleaning and Disinfecting Procedures, not dated, revealed to: 1) thoroughly wipe the entire surface of the meter with disinfecting wipes listed to clean any possible dirt, dust, blood, and other body fluids; and 2) take another disinfecting wipe and wipe the meter thoroughly. Review of the facility's Listed Wipes sheet, not dated, revealed Sani-Cloth was the wipe the facility used. 1. Observation, on 08/08/2022 at 3:10 PM, of the 100 Hall revealed personal protective equipment (PPE) bins outside of Rooms #105 and #108. Further observation revealed there were no signs on either door indicating the type of transmission based precautions (TBP) in use. Interview with the Director of Nursing (DON), on 08/08/2022 at 3:10 PM, upon entrance to the facility, revealed there were no residents on transmission based precautions (TBP), and there were no current COVID-19 positive residents or staff. 2. Observation of Unit 1 and Unit 2, on 08/09/2022 at 8:00 AM, revealed thirteen (13) residents (Residents #19, #22, #32, #41, #48, #74, #94, #97, #101, #162, #210, #212, and #360 had been placed on TBP. a. Review of Resident #19's medical record revealed the facility admitted the resident, on 02/25/2022, with diagnoses that included Parkinson's Disease, Dementia with Lewy Bodies, Muscle Weakness, Hypertension, Dysphasia, Malignant Neoplasm of the Prostate, and Hyperlipidemia. Further review revealed the resident was placed on TBP on 08/09/2022, but there was no order or documented reason in the medical record for Quarantine Precautions. Review of the Care Plan, last reviewed on 06/16/2022, revealed the resident was care planned for being at risk for COVID-19, with goals to include limiting the resident's exposure to potential sources of COVID-19. Interventions, dated 07/21/2022, included Quarantine Precautions: gown, gloves, N95 respirator, and eye protection, but the fourteen (14) day quarantine period had ended on 08/04/2022. b. Review of Resident #22's medical record revealed the facility admitted the resident, on 09/28/2017, with diagnoses that included Cerebral Palsy. Further review revealed the resident was placed on TBP on 08/09/2022. There was an order in the medical record for TBP, dated 08/08/2022, for Contact Precautions due to extended spectrum beta-lactamase (ESBL) in the urine diagnosed on [DATE]. Continued review revealed orders for Resident #22 to have antibiotic therapy on 08/05/2022. c. Review of Resident #32's medical record revealed the facility admitted the resident, on 05/10/2022, with diagnoses that included Chronic Kidney Disease, Idiopathic Peripheral Autonomic Neuropathy, and Type 2 Diabetes Mellitus. The resident was placed in TBP on 08/09/2022, for no documented reason. Additionally, there was no order in the medical record for Quarantine Precautions, and review of the care plan, dated 05/10/2022, revealed the resident was not care planned for TBP. d. Review of Resident #41's medical record revealed the facility admitted Resident #41, on 07/27/2022, with diagnoses that included Acquired Absence Of Left Leg Below Knee, Sepsis, Weakness, Type 2 Diabetes Mellitus, and End Stage Renal Disease. Further review revealed the resident was placed on TBP on 08/09/2022. On 08/08/2022 at 11:00 PM, an order was entered in the medical record for Quarantine Precautions. Review of the Care Plan, dated 07/27/2022, revealed Resident #41 was care planned for being at risk for COVID-19 on 08/08/2022, with goals to include limiting the resident's exposure to potential sources of COVID-19. Interventions included Quarantine Precautions: wearing a gown, gloves, N95 respirator, and eye protection. e. Review of Resident #48's medical record revealed the facility admitted the resident, on 08/26/2020, with diagnoses that included Hemophilia and Hematopoiesis Following Cerebral Infarction Affecting Right Dominant Side and Dysphasia. The resident was placed on TBP on 08/09/2022. However, there was no order entered in the medical record or documented reason for Quarantine Precautions. Review of the Care Plan, dated 07/21/2022, revealed the resident was not care planned for TBP. f. Review of Resident #74's medical record revealed the facility admitted the resident, on 10/26/2016, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Atherosclerotic Heart Disease, and Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant Side. The resident was placed on Quarantine TBP on 08/09/2022. However, there was no order in the medical record or documented reason for Quarantine Precautions. Review of the care plan, last reviewed 06/16/2022, revealed the resident was not care planned for TBP. g. Review of Resident #94's medical record revealed the facility admitted the resident, on 03/18/2021, with diagnoses that included Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Muscle Weakness, ESBL Resistance, and Contact with an Exposure to COVID-19. The resident was placed on Contact Precautions on 08/09/2022. However, there was an order in the medical record, dated 08/01/2022, for Contact Precautions for ESBL in the urine diagnosed on [DATE]. Review of the care plan, last reviewed 08/05/2022, revealed the resident was care planned for Contact Precautions, initiated 08/02/2022. Interventions, dated 08/02/2022, included contact precautions related to ESBL; signs for contact precautions per the facility's policy; disposable nursing equipment to be used per the facility's policy; wear PPE per the facility's policy; and use biohazard waste disposal per the facility's policy as indicated. h. Review of Resident #97's medical record revealed the facility admitted the resident, on 04/28/2022, with diagnoses that included Chronic Respiratory Failure With Hypoxia, Atherosclerotic Heart Disease, and Type 2 Diabetes Mellitus Without Complications. Review of the care plan, no date, revealed the resident was not care planned for TBP. i. Review of Resident #101's medical record revealed the facility admitted the resident, on 06/14/2022, with diagnoses that included Encounter for Surgical Aftercare Following Surgery on the Digestive System and Contact with and Suspected Exposure to COVID-19 on 07/21/2022. Further review revealed the resident was placed on Quarantine TBP on 08/09/2022, nineteen (19) days from the exposure. However, there was no order in the medical record or documented reason for Quarantine Precautions. j. Review of Resident #162's medical record revealed the facility admitted the resident, on 08/05/2022, with diagnoses that included Chronic Venous Hypertension, Methicillin Resistant Staphylococcus Aureus Infection, and Muscle Weakness. Further review revealed the resident was placed in Contact/Droplet Precautions on 08/09/2022; however, there was an order for Contact/Droplet Precautions dated 08/05/2022. k. Review of Resident #210's medical record revealed the facility admitted the resident, on 08/08/2022, with diagnoses that included Type 2 Diabetes Mellitus and Adult Failure To Thrive. Further review revealed the resident was placed in Quarantine TBP on 08/09/2022, but there was an order for Quarantine Precautions, dated 08/08/2022, for fourteen (14) days requiring a gown, gloves, N95 respirator, and eye protection. l. Review of Resident #212's medical record revealed the facility readmitted the resident, on 07/30/2022, with diagnoses that included Coronary Artery Disease and Diabetes Mellitus. Resident #212 was not in Quarantine Precautions on 08/08/2022, even though it had been only ten (10) days since he/she returned to the facility. The resident was discharged on 08/09/2022. m. Review of Resident #360's medical record revealed the facility admitted the resident, on 07/28/2022, with diagnoses that included Malignant Neoplasm of Lower Lobe of the Lung, Secondary Malignant Neoplasm of the Brain, and Secondary Malignant Neoplasm of the Bone. Further review revealed the resident was placed on Quarantine TBP on 08/09/2022, instead of on admission, on 07/28/2022. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/09/2022 at 4:30 PM, revealed when asked why thirteen (13) residents were now in TBP but were not at the time of the State Survey Agency's (SSA) entrance on 08/08/2022, she stated, The facility realized they were not in compliance and fixed it. 3. Observation of Unit 1 and Unit 2, on 08/10/2022 at 8:00 AM, revealed two (2) residents (Residents #9 and #110) had been placed on TBP's. a. Review of Resident #9's medical record revealed the facility admitted the resident, on 04/03/2022, with diagnoses that included heart failure and COPD. Further review revealed the resident was placed on Quarantine TBP on 08/10/2022, but there was no order in the medical record or documented reason for Quarantine Precautions. Review of the care plan, last reviewed 06/16/2022, revealed the resident was not care planned for TBP. b. Review of Resident #110's medical record revealed the facility admitted the resident, on 10/25/2021, with diagnoses that included COPD, Pneumonitis, and Type 2 Diabetes Mellitus. Further review revealed the resident was placed on Quarantine TBP on 08/10/2022, but there was no order in the medical record or documented reason for Quarantine Precautions. Review of the care plan, no date, revealed the resident was not care planned for TBP. Interview with Licensed Practical Nurse, (LPN) #9, on 08/08/2022 at 3:18 PM, revealed she had just arrived at the facility, and she did not think any residents on the 100 Hall were on TBP. Interview with Kentucky Medication Aide (KMA) #6, on 08/09/2022 at 8:35 AM, revealed that residents on TBP were new admissions to the facility. She stated, per IPC polices, an N95 mask, face shield/goggles, gown, and gloves were required for Quarantine TBP. Continued interview with LPN #2/Unit 1 Manager (UM), on 08/09/2022 at 8:40 AM, revealed she received IPC education and training upon hire, annually, and frequent in-service updates. She stated following the facility's policy was important for the safety of residents and staff and to prevent the spread of infectious disease. 4. Observation of KMA #6, on 08/08/2022 at 3:20 PM, at the medication cart on 200 Hall, revealed her mask was below both nares. Interview with KMA #6, on 08/08/2022 at 3:25 PM, revealed the mask was too big and it would not stay up. She stated it was the facility's policy to wear a mask at all times while in the facility. KMA #6 stated she received IPC training upon hire and through frequent in-service updates. She stated following the facility's policies was important to keep germs from spreading. 5. Observation of room [ROOM NUMBER], on 08/08/2022 at 3:33 PM, revealed the Speech Therapist (ST) was sitting on the resident's bed. She was not wearing a mask. The ST exited the room without wearing a mask and without performing hand hygiene. Further observation, on 08/08/2022 at 4:47 PM, revealed the ST with her mask below her chin. The ST pulled the mask up over her nose when she saw the SSA Surveyor. Interview with the ST, on 08/08/2022 at 3:33 PM, revealed she did not perform hand hygiene. She stated there was nowhere to sit when providing care in the resident's room other than the resident's bed. The ST stated she should not have sat on the bed due to IPC concerns. She also stated she was working with the resident, and it was difficult to communicate while wearing a mask. Further interview revealed she should have used hand hygiene when exiting the room. The ST stated it was the facility's policy to wear a mask at all times while in the facility. She stated she received IPC training upon hire and through frequent in-service updates. The ST stated adhering to IPC requirements was important to prevent the spread of infection. 6. Observation of the Laundry Supervisor, on 08/10/2022 at 12:20 PM, revealed she had one (1) face mask strap hanging free, and the mask was below both nares. Interview with the Laundry Supervisor, on 08/10/2022 at 12:20 PM, revealed she was trained on how to don (apply) and doff (remove) PPE by the QA/IP Nurse, Sometime this year. However, she did not recall when. She stated, I know I am supposed to always gown up and wear goggles and gloves if I go into any isolation room. I do hand hygiene when I come out of a patient room, out to smoke, go to lunch, push a patient in the hall, or leave the floor for any reason and return. I know I should probably do it normally. She stated, I know I just went into a room without doing it [placing mask securely over the mouth and nares]. I was trained to put both straps on, but I just didn't do it. 7. Observation of KMA #6, on 08/09/2022 at 8:10 AM, revealed she was in a Quarantine TBP room without wearing PPE. Interview with KMA #6, on 08/09/2022 at 8:11 AM, revealed she did not know why the resident was on Quarantine TBP's. She stated, according to the facility's policy, an N95 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH Memo, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidelines, review of the Kentucky Department for Public Health's (KDPH) Long-Term Care Facility COVID-19 bi-weekly County Indicator Map, review of the BinaxNOW Covid-19 Ag Card Instructions, and review of the facility's policies, it was determined the facility failed to conduct COVID-19 testing, twice weekly, for unvaccinated staff based on the community's COVID-19 transmission levels and the facility's COVID-19 outbreak status. The facility failed to conduct testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests; and failed to follow established standard precautions to prevent the transmission of infectious organisms. Also, the facility failed to test newly-admitted residents immediately upon admission to the facility, affecting two (2) of thirty-two (32) sampled residents (Resident #41 and Resident #210). The findings include: Review of the Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH Memo, revised 03/10/2022, revealed Long Term Care (LTC) facilities must:1) conduct testing based on parameters set forth by the Secretary; 2) conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests; and 3) document that testing was completed and the results of each staff test and document in the residents' records that testing was offered, completed, and the results of each test. Further review revealed, the CDC recommended testing employees twice a week, even if they only work once a week, if they were unvaccinated or not up to date with COVID-19 vaccinations. Review of the CDC's, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes & Long-Term Care Facilities, Section, New Infection in Healthcare Personnel or Residents, updated 02/11/2022, revealed because of the risk of unrecognized infection among residents, a single new case of COVID-19 infection in any health care personnel (HCP) or a nursing home onset of COVID-19 infection in a resident should be evaluated as a potential outbreak. Review of the facility's staff COVID-19 testing results revealed the facility identified one (1) staff on 07/11/2022; one (1) staff on 07/12/2022; one (1) staff on 07/13/2022; one (1) staff on 07/20/2022; two (2) staff on 08/02/2022; and one (1) staff on 08/05/2022, as being positive for COVID-19. Review of the CDC's website, http://cdc.gov, on COVID-19 Testing, updated 08/11/2022, revealed, All instructions for performing the test must be followed. Instruction for proper Infection Prevention and Control (IPC) guidelines included that the user should follow IPC protocols and discard the specimen collection swab and test kit in the trash, clean all surfaces that the specimen might have touched, and wash hands. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Testing Criteria for Health Care Personnel, not dated, revealed all healthcare personnel (HCP) in the facility would be tested for SARS-COVID-19-2 virus based on CDC guidelines and recommendations and vaccination status. Further review revealed routine testing of healthcare personnel was based on the extent of the virus in the community and vaccination status. Per the policy, the county positivity rate was monitored every week. If the county positivity rate increased to a higher level of testing, increased frequency of testing began as soon as that data was assessed. Review of the Kentucky Department for Public Health's (KDPH) Long-Term Care Facility COVID-19 Bi-Weekly County Indicator Map, from 07/05/2022 to 08/12/2022, revealed that the (County's), Kentucky community transmission rate was high (red zone) requiring testing two (2) times a week of all unvaccinated and not up to date for COVID vaccinated staff. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, revised 08/2019, revealed hand washing was the primary means in preventing the transmission of infections. Per the policy, all health care workers would utilize hand hygiene frequently and appropriately. Further review revealed health care workers would use hand hygiene after contact with excretions or secretions, mucus membranes, or specimens. Review of the BinaxNOW Covid-19 Ag Card Instructions, revised 02/2022, for specimen collection and handling of test specimens, revealed appropriate personal protective equipment (PPE), including gloves, were to be worn when running each test and handling specimens. Further review revealed that users should wear suitable protective clothing, gloves, and eye/face protection when handling the specimen contents to reduce the risk of biohazard contamination, including treating all specimens, as well as the used test kit components as potentially biohazardous materials. Also the instructions stated that users should follow standard precautions when handling the test kit and its contents and should wash hands thoroughly after handling contaminated specimens. 1. Review of the facility's employee staffing and COVID-19 testing records for not up to date employees revealed:1) State Registered Nurse Aide (SRNA) #13 worked the evenings of 07/06/2022 and 07/20/2022, but was not tested until his/her shifts ended on 07/07/2022 and 07/21/2022; 2) SRNA #19 worked 07/17/2022 and 07/23/2022, but was not tested until his/her shift ended on 07/23/2022; 3) SRNA #15 worked the evenings of 07/19/2022 and 07/25/2022, but was not tested until his/her shifts ended on 07/20/2022 and 07/26/2022; 4) Physical Therapist (PT) #1 worked 07/11/2022 and 07/25/2022 but was not tested until his/her shifts ended on 07/12/2022 and 07/26/2022; 5) SRNA #16 worked the evening of 07/25/2022 but was not tested until his/her shift ended on 07/26/2022. Review of the facility's employee staffing and COVID-19 testing records for unvaccinated employees revealed:1) SRNA #14 worked 07/06/2022 but was not tested until 07/09/2022; and 2) SRNA #18 worked the evenings of 07/17/2022 and 07/23/2022, but was not tested until his/her shift ended on 07/23/2022. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/11/2022 at 4:45 PM, revealed she tested staff two (2) times per week if the staff member was unvaccinated or not up to date with his/her COVID-19 vaccination. She stated, If the employee does not work more than one day per week, I only test once per week. According to CDC, we should be testing employees twice a week even if they only work once a week, if they were not up to date with COVID-19 vaccination. Per the interview, the QA/IP Nurse stated she came early each morning to catch the night shift before they went home; however, she stated she did not come in to test employees on weekends. The QA/IP Nurse stated weekend staff were tested when there is a house supervisor. She stated the facility did not always have a house supervisor. She stated she would try to test those who were missed on the weekend before his/her next shift. She stated testing, according to CDC recommendations, was important for the safety of the residents and staff. Additional interview with the QA/IP Nurse, on 08/12/2022 at 9:50 AM, revealed she restated that night shift staff were usually tested for Covid-19 after they had worked their shift, and weekend staff were tested by house supervisors if they were present. Per the interview, the QA/IP Nurse stated that ideally the employee should be tested before the shift started to prevent exposing a resident or other staff to a potentially infected staff member. The QA/IP Nurse stated she did not want to answer whether testing after instead of before an employee's shift could expose the residents to the risk of possible COVID-19 exposure. Interview with the Administrator, on 08/12/2022 at 9:28 AM, revealed the County was in the red zone indicating a high COVID-19 community transmission rate. Per the interview, the Administrator stated the QA/IP Nurse was responsible for COVID-19 testing. He stated, We test by committee, meaning when the QA/IP was not available, supervisors would test staff as required. 2. Observation of the COVID-19 testing station, on 08/09/2022 at 4:30 PM, revealed six (6) contaminated COVID-19 rapid tests sitting on a bedside table located in the QA/IP's office. There was one (1) opened box containing multiple unused COVID-19 tests and two (2) folders, which contained papers also on the bedside table. There was no barrier covering the table, gloves, alcohol-based hand rub (ABHR) or disinfectant wipes on or near the testing station. The QA/IP Nurse picked up the contaminated COVID-19 rapid tests and moved them to place the tests together. Further observation revealed one (1) contaminated COVID-19 rapid test laying on top of paperwork on the QA/IP's work desk. Per the observation, she was not gloved when she touched the contaminated tests and did not perform hand hygiene after she handled the tests. Interview with the QA/IP Nurse, on 08/09/22 at 4:30 PM, revealed she had worked at the facility in the position of IP since July 2022. Prior to working in the role of IP, she stated, she was the Assistant Director of Nursing (ADON). The QA/IP Nurse stated she received IPC training upon hire and had been trained through in-services. The QA/IP Nurse stated she performed COVID-19 point-of-care (POC) testing earlier in the day, and she had placed the testing cards on the table so she could document the results. Per the interview, she stated that she had completed the CDC's Nursing Home Infection Preventionist Training Course on 12/23/2019. Further interview revealed she should have had a barrier cloth on the table to prevent contamination of the surface. She stated she had disinfectant wipes near the table, but observation during the interview revealed there were no disinfectant wipes in the vicinity of the table but were located behind the QA/IP Nurse's desk. She stated performing tests according to manufacturer's recommendations was necessary for the safety of all residents and staff. Additionally, she stated she followed established standard precautions to prevent the transmission of infectious organisms. She stated testing residents and staff according to CDC recommendations was important for the health and safety of all residents, staff, and visitors. 3. Review of COVID-19 tests results documented in the medical record for two (2) newly admitted residents, Resident #41, admitted on [DATE], and Resident #210, admitted on [DATE], revealed the results were not in their medical records. Multiple requests were made to the Administrator, Director of Nursing (DON), and the QA/IP Nurse to obtain COVID-19 testing results on 08/08/2022. However, documentation was not provided until 08/11/2022. According to the test results, Resident #41 received his/her first COVID-19 Rapid Test on 08/01/2022, five (5) days after admission. No COVID-19 Rapid Test results were provided for Resident #210. Interview with Unit Manager (UM) #1, on 08/09/2022 at 3:57 PM, revealed COVID-19 testing was done immediately on admission, and if it was negative, a rapid test was obtained again in five (5) days. She stated testing new residents for COVID-19 upon admission was a new protocol that began with the current DON. Previously, residents needed a negative COVID-19 test at the hospital before admission. Continued interview revealed that the facility utilized Point of Care (POC) Rapid COVID-19 testing. She stated test results were not entered into the electronic medical record (EMR) because recently hired nursing staff were not aware they could enter results. She stated nursing staff was still being trained on how to enter the POC Rapid test results into the EMR. Interview with the Regional Director of Clinical Services (RDCS), on 08/10/2022 at 11:42 AM, revealed her role in the facility was to consult, train, and tell them what is expected. She stated she had been working closely with the current Director of Nursing (DON) since her hire on 07/13/2022. The RDCS stated the former DON, who resigned in 06/2022, was tracking all COVID-19 testing and vaccinations for staff and residents. She stated they had been testing and vaccinating per CDC guidance. Per the interview, the RDCS stated, The infection control binder is a mess with handwritten notes and unorganized. She stated further that she did not know when the breakdown happened. Further interview revealed she first realized there was an issue with testing documentation after the former DON left, and while she was training the current DON and QA/IP Nurse. She stated during the time the former DON was responsible for testing, the facility had been testing based on an old QSO memo. The RDCS stated she educated the new QA/IP Nurse to test based on the 03/22/2022 QSO memo. Per the interview, the RDCS stated she revised the staff and resident testing plan because she couldn't make heads or tails of the Covid book. She stated the facility came up with a vaccination and positive COVID-19 status list, which she stated was up to date. The RDCS stated the Administrator had the ultimate oversight to ensure all facility policies and protocols, especially as they related to adherence to current CDC recommendations, were being addressed and followed. She stated following IPC standards was important to prevent the spread of infection. Continued interview revealed testing residents and staff according to CDC recommendations was important for the health and safety of all residents, staff, and visitors. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed she had been employed at the facility in her current role since 07/13/2022. She stated she had been monitoring to ensure the QA/IP Nurse had been testing staff per CDC guidelines and that IPC policies and protocols were followed. She stated she had focused on understanding everyone's roles and providing direction and oversite of IPC compliance. The DON stated she was aware of issues related to the facility's failure to accurately document and track COVID-19 testing per CDC guidelines. She stated she developed an agenda for an ad hoc QAPI Meeting, which was supposed to have taken place on 07/25/2022, but did not. She stated that IPC issues, including COVID-19 testing of residents, staff, and new admissions, and COVID-19 vaccination status were on the agenda to be addressed during the meeting. No explanation was provided as to why the meeting did not take place. Additional interview with the DON, on 08/12/2022 at 3:03 PM, revealed the QA/IP Nurse was trained to perform COVID-19 tests and should follow manufacturer's testing protocols and Standard Precautions, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Per the interview, the DON revealed it was her expectation that nurses followed the facility's policies regarding IPC policies and protocols. She stated it was important to follow IPC policies and testing protocols to prevent the spread of infectious disease. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed it was the Administrator's expectation that all staff followed the facility's IPC policies and complete COVID-19 testing according to the manufacturer's recommended protocols. The Administrator stated adhering to IPC protocols helped maintain the health and safety of all residents, staff, and visitors, and testing was important to help prevent the transmission of COVID-19 in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident, that includes measurable objectives and timeframes to meet a resident's needs related to Restorative Nursing. Although Resident #69 was discharged from Physical Therapy (PT), on 07/30/19, with recommendations for the Restorative Nursing Program (RNP) to include routine exercise to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) and exercises to maintain bed mobility; there was no documented evidence the facility developed or implemented a Plan of Care related to therapy recommendations. Furthermore, although Resident #111 was discharged from Occupational Therapy (OT), on 03/11/19, with recommendations for the RNP related to a right wrist splint and an exercise plan, there was no documented evidence the facility developed or implemented a Plan of Care related to therapy recommendations. (Refer to F-688) The Findings include: Review of the facility's Care Plan (CP), Comprehensive Person Centered Policy, dated Dec. 2016, revealed a person center care plan will include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, the care plan process will include a resident's personal preferences. Further, the CP will describe the services to be provided to maintain or attain the residents highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. 1. Review of Resident #69's Clinical Record, revealed the facility admitted the resident on 07/09/19 with diagnoses including Dementia, Osteoarthritis (OA) Bilateral Knees, Gout, Chronic Obstructive Pulmonary Disease, Muscle weakness, Need for assistance with Personal Care, and Difficulty Walking. Review of the Physician's Orders, dated 07/10/19, revealed orders for Resident #69 to have Physical Therapy (PT) five (5) times per week for four (4) weeks for therapeutic exercise, therapeutic activity, manual therapy and gait. Review of the admission Minimum Data Set (MDS) Assessment, dated 07/16/19, revealed the facility assessed Resident #69 as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Further, the facility assessed the resident as requiring extensive assistance of two (2) staff for all Activities of Daily Living (ADLs). Per the MDS Assessment, the resident had no Limitations in Functional Range of Motion (ROM) to his/her bilateral upper extremities (BUE), but had Limitations in Functional ROM to bilateral lower extremities (BLE). Review of Resident #69's Comprehensive Care Plan (CCP), initiated on 07/18/19, revealed the resident required assistance with ADLs related to Dementia, fluctuating ADLs, hearing problems, limited ROM- bilateral knee Osteoarthritis with contractures, pain, vision problems, and weakness. The goals stated the resident would not have a decline in ADLs and would participate in care to the highest ability; and the resident would have acceptable pain management and reduced risk of limitations of ROM. The interventions included: monitor for declines in ADLs and refer to therapy services as needed; Restorative Nursing Program (RNP) as indicated; observe for pain and give analgesics as ordered; and therapy referral and treat as indicated. All interventions were initiated on 07/18/19. Review of the Physical Therapy (PT) Discharge summary, dated [DATE], revealed recommendations for Resident #69 to transition to a RNP to maintain gains in PT. Review of the Functional Maintenance Program, dated 07/30/19, revealed the resident would benefit from the following activities to maintain current functional status: bed mobility, and routine exercise BUE and BLE. However, there was no documented evidence the CCP was developed and implemented related to the RNP related to interventions to maintain current functional status: bed mobility, and routine exercise BUE and BLE as per the PT Discharge summary dated [DATE]. Review of the State Registered Nurse Aide (SRNA) [NAME] (Care Plan), dated 08/23/19, revealed no documented evidence of a RNP related to bed mobility, or routine BUE and BLE exercises for Resident #69. 2. Review of Resident #111's Clinical Record, revealed the facility admitted the resident on 04/14/17 with diagnoses including, but not limited to Abnormal posture, Muscle Weakness, Legally blind, Cervical Spina Bifida, Paraplegia, Contracture of the knees, and Need for assistance with Personal Care. Review of the CCP, dated 06/13/18, revealed the resident required assistance with Activities of Daily Living (ADL) related to chronic illness, fluctuating ADLs, limited ROM, spina bifida, history of lower extremity paraplegia, vision problems, and weakness. The goal revealed all needs would be anticipated and met by staff. Interventions initiated on 06/13/18 included: Restorative Program if indicated; assist with morning (AM) and night (PM) care; assist of two (2) staff for bed mobility; monitor for declines in ADLs; and refer to therapy services as needed. Further review of Resident #111's CCP, revealed a problem of Contracture/limited ROM to left knee and right hand, dated 01/04/19. The goal revealed the resident would have reduced risk of limitation of ROM. Interventions initiated 01/04/19 included: apply splint as ordered; assess skin under splint for redness, skin integrity and circulation every two (2) hours; ensure correct alignment of splints/braces; ROM provided as indicated; Therapy referral and treat as indicated; and use positioning devices as needed to promote comfort and proper alignment. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #11 as having a BIMS of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff with bed mobility and total assist of two (2) staff for transfers. Further review revealed the facility assessed the resident as having Functional Limitations in ROM of one (1) upper extremity and Functional Limitations in ROM of both lower extremities. Per this MDS Assessment, the resident received no RNP. Review of Resident #111's Occupational Therapy (OT) Discharge summary, dated [DATE], revealed the nursing staff received education related to Resident #111's Right Upper Extremity wrist splint and the importance of wearing the splint. Further review revealed a Restorative Nursing Plan related to the Right wrist splint and an exercise plan was developed to be utilized after OT discharge. Additional review revealed no documented evidence the CCP was developed and implemented related to the RNP for the Right wrist splint and exercise plan related to the OT recommendations after the resident was discharged from OT on 03/11/19. Physician orders, dated 06/01/19 through 08/31/19, revealed no documented evidence of Physician's Orders for Restorative Nursing Program order or for a splint to the right wrist. Interview with State Registered Nurse Aide (SRNA) #1, on 08/23/19 at 10:05 AM revealed she was often assigned to the hallway for Resident #69 and #111. Additionally, she knew how to provide care to each resident by using their [NAME] (Nurse Aide Care Plan) before assisting a resident. However, per interview the [NAME] did not include which residents were on RNP or had contractures; and she was not aware of another resource the facility provided to denote which residents were on RNP. Per interview, the [NAME] should include if a resident was receiving a RNP or had contractures or required a splint. Interview with SRNA #2, on 08/23/19 at 10:39 AM, revealed he worked on first and second shift and was assigned to Resident #69 and #111. He stated he used the [NAME] (Care Plan) on the computer to guide him in the level of assistance and as well as devices a resident needed. Per interview, the [NAME] should have all devices (splint/braces) listed and should also state if a resident had contractures and required ROM or was on the RNP. However, he stated this information was not always on the [NAME]. Further interview revealed there was a RNP binder at each nurse's station with Plans of Care for those Residents who received RNP by the Restorative SRNAs and Resident #69 and Resident #111's information was not in the binder and therefore these residents were not in the RNP. Interview with Licensed Practical Nurse (LPN) #1, on 08/23/19 at 11:00 AM, revealed she was assigned to Resident #69 and #111's hallway. Per interview, the CCP should be a current, accurate reflection of the residents because it was used by the interdisciplinary team (IDT) and direct care givers to ensure residents received safe quality care to meet their needs. She stated if Resident #69 and Resident #111 had recommendations from therapy upon discharge for the RNP, the CCP should be developed and implemented with interventions specific to the recommendations. Continued interview revealed there was a RNP binder and certain residents were provided a Plan specific to their needs at least five to seven (5-7) days a week by a Restorative SRNA. Additionally, she stated it was important the CCP was implemented related to RNP and residents were provided necessary care and devices to ensure they contractures did not worsen and to ensure they kept moving to improve quality of life. Interview with the facility Occupational Therapist and Physical Therapist , on 08/23/10 at 9:35 AM, revealed upon a residents discharged from skilled therapy a Therapy/ Nursing Communication Form was completed for devices. Per interview, this form was given to the direct care nurse who entered the device (ordered) in the Electronic Medical Record. Additional interview revealed a Functional Maintenance Program form was completed for each resident discharged from skilled therapy with recommendations for the resident on how to maintain gains from therapy. Per interview, the Assistant Director of Nursing (ADON) was then responsible to take that information and implement a RNP Plan of Care for these residents as soon as possible. Interview with the ADON, on 08/23/19 at 2:02 PM, revealed she was responsible to develop the RNP Plan of Care. Further, the ADON stated she based the RNP on the therapy recommendations for residents who were discharged from skilled therapy to maintain their gains from therapy or to assist with getting them back to their functional baseline. Additional interview revealed Resident #69's RNP was not developed because the resident historically was combative and refused care. However, she further stated there was no documented evidence, the ADON developed a RNP and attempted approaches with the resident nor was there documented evidence the resident was not receptive or did not participate in the RNP. Continued interview revealed Resident #111's RNP was not implemented because his/her referral from therapy was lost and there was no documented evidence of recommendations for the RNP. Interview with the MDS Coordinator, on 08/23/19 at 2:23 PM, revealed she gathered information/data from the Medical Record to ensure she developed/implemented and revised the Care plans. Further, she attended a morning meeting with department heads (except therapy) which reviewed all new orders, changes in conditions, incidents, illness, and progress notes in the last twenty-four (24) hours. Continued interview revealed it was important to ensure the CCP was developed and implemented related to restorative nursing interventions based on therapy recommendations to ensure quality of care. Per interview, the ADON developed the RNP CCP. Interview with the Director of Nursing (DON), on 08/23/19 at 3:12 PM, revealed if there were recommendations in place for RNP from therapy, the facility was responsible and accountable to develop and implement the RNP Plan of Care. Additionally, the DON stated this was very important to ensure residents maintained quality of life, current function, and to prevent further issues such as muscle weakness. Interview with the Administrator, on 08/23/19 at 3:45 PM, revealed he expected the CCP to be developed and implemented related to therapy recommendations upon a resident's discharge from therapy. Per interview, this was important to ensure residents received restorative nursing to ensure their individualized needs were met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for two (2) of eight sampled residents reviewed for limited Range of Motion (ROM) out of a total of twenty-six (26) sampled residents (Resident #69 and Resident #111). Resident #69 was discharged from Physical Therapy (PT), on 07/30/19 with recommendations for a Restorative Nursing Program (RNP) to include routine exercise to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) and exercises to maintain bed mobility; however, there was no documented evidence the facility outlined or implemented a RNP Plan of Care after discharge from skilled therapy in order to maintain his/her functional status and gains achieved in therapy. Further, Resident # 111 was discharged from Occupational Therapy (OT), on 03/11/19 with recommendations for a RNP related to a right wrist splint and an exercise plan. However, there was no documented evidence the facility outlined or implemented a RNP Plan of Care after discharge from skilled therapy related to the hand splint or an exercise plan in order to maintain his/her functional status and gains achieved in therapy. (Refer to F-656) The findings include: Review of the facility Restorative Nursing Service (RNS) Policy, revised July 2017, revealed residents would receive Restorative Nursing care as needed to promote optimal safety and independence. Additionally, RNS consisted of nursing interventions that may not be accompanied by formalized rehabilitation services. Per Policy, the RNS program was available anytime during the residents stay at the facility. Continued review revealed the goals and objectives of restorative were individualized and resident centered, and would be outlined in the resident's Care Plan. Further, RNS goals included developing, maintaining, or strengthening a resident. 1. Review of Resident #69's Medical Record, revealed the facility admitted the resident on 07/09/19 with diagnoses including Dementia, Osteoarthritis (OA) Bilateral Knees, Gout, Chronic Obstructive Pulmonary Disease, Muscle weakness, Need for assistance with Personal Care, and Difficulty Walking. Observation of Resident #69, on 08/21/19 at 11:30 AM, 08/22/19 at 9:00 AM, and 08/23/19 at 10:00 AM, revealed the Resident was lying in bed on his/her back in bed with covers from the waist down. Additionally, the resident's knees were noted to be slightly raised/bent from bed surface. Review of Resident #69's Physician's Orders, dated 07/10/19, revealed orders for Physical Therapy (PT) five (5) times per week for four (4) weeks for therapeutic exercise, therapeutic activity, manual therapy and gait. Review of Resident #69's admission Minimum Data Set (MDS) Assessment, dated 07/16/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for all Activities of Daily Living (ADLs). Per the Assessment, the resident had no Limitations in Functional Range of Motion (ROM) to his/her bilateral upper extremities (BUE), but had Limitations in Functional ROM to bilateral lower extremities (BLE). Further, per the MDS Assessment, the resident last had therapy on 07/11/19. Review of Resident #69's Comprehensive Care Plan (CCP), initiated 07/18/19, revealed the resident required assistance with ADLs related to Dementia, fluctuating ADLs, hearing problems, limited ROM- bilateral knee Osteoarthritis with contractures, pain, vision problems, and weakness. The goals revealed the resident would not have a decline in ADLs and would participate in care to the highest ability; and the resident would have acceptable pain management and reduced risk of limitations of ROM. Interventions included: monitor for declines in ADLs and refer to therapy services as needed; Restorative Nursing Program (RNP) as indicated; observe for pain and give analgesics as ordered; and therapy referral and treat as indicated. All interventions were initiated on 07/18/19. Review of Resident #69's Physical Therapy (PT) Discharge summary, dated [DATE], revealed recommendations for the resident to transition to a RNP to maintain gains in PT. Review of Resident #69's Functional Maintenance Program, dated 07/30/19, revealed the resident would benefit from the following activities to maintain current functional status: bed mobility, and routine exercise BUE and BLE. However, there was no documented evidence the CCP was developed and implemented related to the RNP with interventions to maintain current functional status: bed mobility, and routine exercise BUE and BLE. (Refer to F-656) Review of Resident #69's State Registered Nurse Aide (SRNA) [NAME] (Care Plan), dated 08/23/19, revealed no documented evidence of a RNP related to bed mobility, or routine BUE and BLE exercises. Review of the Restorative Binder, dated August 2019, for the 600 hall where Resident #69 resided, revealed no documented evidence of a RNP Plan of Care for Resident #69. Review of Resident #69's Progress Notes, dated 07/09/19 through 08/23/19 revealed no documented evidence of a RNP Plan or or exercise routine. 2. Review of Resident #111's Medical Record, revealed the facility admitted the resident on 04/14/17 with diagnoses including, but not limited to Abnormal posture, Muscle Weakness, Legally blind, Cervical Spina Bifida, Paraplegia, Contracture of the knees, and Need for assistance with Personal Care. Review of Resident #111's CCP, dated 06/13/18, revealed the resident required assistance with Activities of Daily Living (ADL) related to chronic illness, fluctuating ADLs, limited ROM, spina bifida, history of lower extremity paraplegia, vision problems, and weakness. The goal stated all needs would be anticipated and met by staff. Interventions initiated on 06/13/18 included: Restorative Program if indicated; assist with morning (AM) and night (PM) care; assist of two (2) staff for bed mobility; monitor for declines in ADLs; and refer to therapy services as needed. Additional review of Resident #111's CCP, revealed a problem of Contracture/limited ROM to left knee and right hand, dated 01/04/19. The goal stated the resident would have reduced risk of limitation of ROM. Interventions initiated 01/04/19 included: apply splint as ordered; assess skin under splint for redness, skin integrity and circulation every two (2) hours; ensure correct alignment of splints/braces; ROM provided as indicated; Therapy referral and treat as indicated; and use positioning devices as needed to promote comfort and proper alignment. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff with bed mobility and total assist of two (2) staff for transfers. Continued review revealed the facility assessed the resident as having Functional Limitations in ROM of one (1) upper extremity and Functional Limitations in ROM of both lower extremities. Per the MDS Assessment, the resident received no RNP. Review of Resident #111's Occupational Therapy (OT) Discharge summary, dated [DATE], revealed the nursing staff were educated on Resident #111's Right Upper Extremity wrist splint and the importance of wearing the splint. Additional review revealed a Restorative Nursing Plan related to the Right wrist splint and an exercise plan was developed to be utilized after OT discharge. Review of the Resident's Right to Refuse Routine Care document, dated 05/07/19, revealed the resident was educated that the Medical Director did not have a clinical indication for continued use of the right wrist splint. Additionally, the resident insisted on continuing to wear the splint. Further review revealed no documented evidence the CCP was developed and implemented related to the RNP for the Right wrist splint and exercise plan related to the OT recommendations after the resident was discharged from OT on 03/11/19. (Refer to F- 656) Review of Resident #111's Physician orders, dated 06/01/19 through 08/31/19, revealed no documented evidence of Physician's Orders for Restorative Nursing Program order or for a splint to the right wrist. Review of Resident #111's Nurse's Progress Notes, dated 03/01/19 to 08/22/19 revealed no documented evidence of interventions related to the right wrist splint; no documented evidence of an exercise plan, and no documented evidence of a RNP Plan of Care. Review of the Restorative Binder, dated August 2019, on the hall where Resident #111 resided, revealed no documented evidence of a RNP Plan of Care for Resident #111 related to the right hand splint or an exercise program. Review of the Treatment Administration Record (TAR) dated August 2019, revealed no intervention for a hand splint. Review of Resident #111's Quarterly MDS Assessment, dated 08/10/19, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Additionally, the facility assessed the resident as requiring extensive assistance of one (1) staff with eating, dressing, locomotion, and hygiene; extensive assistance of two (2) staff with bed mobility; and total assistance of two (2) staff with toileting, transfers, and bathing. Per the MDS Assessment, the resident had Limitations in in Functional (ROM) to one (1) upper extremity and Limitations in Functional ROM to both lower extremities. Further, the resident received no RNP. Interview with Resident #111, on 08/21/19 at 9:22 AM, revealed he/she had been in the facility since 2010. Additional interview revealed he/she received therapy a few months ago and worked on strengthening his/her arms and legs. Continued interview revealed the resident wore a splint to his/her right wrist/hand and he/she thought the splint was used to help with discomfort in the right wrist. Further interview revealed he/she was not on a formal exercise plan. Observation of Resident #111, on 08/21/19 at 9:22 AM, revealed the resident was in bed lying on his/her back, on a low air loss mattress, in high fowlers position. The upper quarter bilateral side rails were raised up. Additional observation revealed the resident had a right wrist/hand splint in place. Interview with the facility Occupational Therapist (OT), on 08/23/19 at 9:35 AM, revealed Resident #111 was seen by an outside facility (hand clinic) around March 2019, related to right wrist nerve damage and complaints of pain. Per interview, a right wrist splint was made for the resident; however, there were no specific instructions from the outside facility related to the brace. Per the OT, a splint like Resident #111's should have been worn four to six (4-6) weeks and then modified or discontinued. However, the OT stated there was no follow up appointment after the brace was implemented. Further interview revealed the resident should have been picked back up by therapy for a contracture management splint that was more long term in nature. Interview with State Registered Nurse Aide (SRNA) #1, on 08/23/19 at 10:05 AM, revealed she had worked at the facility for two (2) years and had worked on every shift. Per interview, she was often assigned to Resident #69 and #111. Additionally, she stated she used the [NAME] (Nurse Aide Care Plan) as a guide for providing care before assisting a resident. However, review of the the Kardexes (Care Plan) with SRNA #1 revealed the Kardexes did not specify which residents were to receive RNP or which residents had contractures and required ROM. She stated she was unaware of any other resource the facility provided to indicate which residents were on the RNP. She stated she did provide ROM to all residents as much as she could during ADL care. SRNA #1 stated she received ROM training last year and had not received training related to donning and doffing devices such as splints. However, she stated she did assist Resident #111 with applying and taking off his/her splint upon request of the resident. Interview with SRNA #2, on 08/23/19 at 10:39 AM, revealed he had worked at the facility for twelve (12) years and worked on first and second shift. Per interview, he was assigned to Resident #69 and Resident #111's hallway. He stated he provided ROM to all residents during routine ADL care including while turning and repositioning residents, while providing incontinence care and while dressing the residents. Additionally, he stated he used the [NAME] (Care Plan) on the computer to guide him in the level of assistance and as well as devices a resident needed. Per interview, the [NAME] should have all devices (splint/braces) listed and should also state if a resident had contractures and required ROM or was on the RNP; however, he stated this information was not always on the [NAME]. Continued interview revealed there was a RNP binder at each nurse's station with Plans of Care for those Residents who received RNP by the Restorative SRNAs and Resident #69 and Resident #111's information was not in the binder and therefore the residents were not in the RNP. SRNA #1 stated he had training during orientation on ROM and therapy staff or the nurses applied and removed all splints and braces. Interview with Licensed Practical Nurse (LPN) #1, on 08/23/19 at 11:00 AM, revealed she had worked at the facility for three (3) years, and was assigned to Resident #69 and Resident #111's hallway. Additionally, ROM was provided to all residents by nurses, SRNAs, therapy and restorative SRNAs. Further, it was important ROM was provided to residents to ensure they could continue to use their extremities, keep moving, prevent pain, and ensure quality of life. Per interview, if a resident had recommendations from therapy, the CCP should be developed and implemented with interventions specific to the recommendations. Continued interview revealed there was a RNP binder and certain residents were provided a Plan specific to their needs at least five to seven (5-7) days a week by a Restorative SRNA. Continued interview with LPN #1, on 08/23/19 at 11:00 AM, revealed splints would need a Physician's Order and the Order would be transferred to the Treatment Administration Record (TAR) in order for the nurses to apply and take off the splints. She stated there should have been a Physician's Order for Resident #111's hand splint with specific instructions on how long the splint should be worn. She stated she sometimes helped Resident #111 with the hand splint, but the resident usually took care of the splint himself/herself. Per interview, only the nurses or therapy donned and doffed braces/splints. Additionally, she stated it was important for the Interdisciplinary Team (IDT) to be on same page to ensure braces/splints were put on in the right way and were worn a specific amount of time because improper placement or wearing a brace/splint too long could hurt a resident. Interview with the facility Occupational Therapist and Physical Therapist , on 08/23/10 at 9:35 AM, revealed when a resident was discharged from skilled therapy a Therapy/ Nursing Communication Form was completed for devices. Per interview, the form was given to the direct care nurse and who entered the device (ordered) in the Electronic Medical Record. Additionally a Functional Maintenance Program form was completed for each resident discharged from skilled therapy with recommendations for the resident on how to maintain gains from therapy. Per interview, the Assistant Director of Nursing (ADON) was then responsible to take that information and implement a RNP Plan of Care for the residents as soon as possible. Interview with the Assistant Director of Nursing (ADON), on 08/23/19 at 2:02 PM, revealed she had worked at the facility for over five (5) years. Per interview, direct care staff provided ROM to residents when they turned and repositioned them during ADL care. Further interview revealed Restorative SRNAs received specific training on ROM, including applying and removing splints/braces, and ambulating residents. Additionally, she stated she was responsible to develop the RNP Plan of Care. Further, the ADON stated she based the RNP on therapy recommendations for residents who were discharged from skilled therapy to maintain their gains from therapy or to assist with getting them back to their functional baseline. Per interview, the facility did not have a timeframe for when a RNP should be developed and implemented after recommendations from therapy, but it should be less than a month. Further interview revealed initiation of a new resident in the RNP meant a resident on the current caseload would have to be removed to ensure the caseload was manageable. Continued interview revealed the facility did not have guidelines to determine when a resident was removed from the RNP; and the RNP caseload was approximately thirty (30) residents. Continued interview with the (ADON), revealed the facility had two (2) Restorative SRNAs, Monday through Friday and one (1) Restorative SRNA who worked on the weekend. However, she stated Restorative SRNAs were often pulled from RNP duties to cover direct care call-ins and the residents were not receiving the RNP approached per their Plan of Care routinely because of this. Per the ADON, only the Restorative SRNAs were responsible to implement the RNP Plan of Care and document care provided on a weekly note. The ADON stated she reviewed the RNP documentation monthly. Further, the ADON she was aware the RNP was not being provided to residents' per facility policy. Per interview, she met with the Director of Nursing (DON) last week to implement a plan on how to ensure the RNP was maintained per policy moving forward. Per the ADON, the facility policy on RNP should be followed to meet resident's needs. Further, interview with the (ADON), revealed Resident #69's RNP was not implemented because the resident historically was combative and refused care. However, she stated there was no documented evidence, the ADON developed a RNP and attempted approaches with the resident nor was there documented evidence the resident was not receptive or did not participate in the RNP. Further interview revealed Resident #111's RNP was not developed because his/her referral from therapy was lost and there was no documented evidence of recommendations for the RNP. However, she stated it was important to maintain ROM and to maintain functional status to prevent overall decline and to maintain residents' dignity and quality of life. Interview with the Director of Nursing (DON), on 08/23/19 at 3:12 PM, revealed she had worked at the facility since July 1, 2019. Per interview, she expected the RNP to be maintained per the facility policy. She stated if there were recommendations in place for RNP, the facility was responsible and accountable to develop and implement the RNP Plan of Care. Additionally, the DON stated the RNP was very important to residents to ensure they maintained quality of life, current function, and to prevent further issues such as muscle weakness. Further, the RN gave caregivers the opportunity to assess and report changes in condition. Continued interview with the DON, revealed she expected consistent guidelines for implementation of a RNP; a cycle of eight to twelve (8-12) weeks on RNP, then transition to a maintenance program, and to refer to therapy with any decline. Per interview, all residents should be provided ROM and exercises to maintain their level of function either in a RNP or maintenance program. Further, she was made aware the RNP was not maintained per the facility policy last week related to Restorative SRNAs being pulled from RNP duties to cover call-ins as direct care staff and a plan was in place to ensure staffing for the RNP. Interview with the Administrator, on 08/23/19 at 3:45 PM, revealed he had been at the facility since December 2018. Additionally, he stated he expected the RNP to meet the needs of many residents. Continued interview revealed he expected the facility policy and therapy recommendations to be followed, and the RNP caseload to be managed and to not exceed capacity. Per interview, he expected the RNP to be maintained to ensure the best care was provided to residents per their individualized care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #64's Medical Record, revealed the facility admitted the resident on 01/04/19, with diagnoses including Vascular Dementia, Anxiety Disorder, Lack of coordination, Muscle weakness, Abnormalities of gait, and Need for assistance with personal care. Review of Resident #64's Comprehensive Care Plan (CCP), revealed the Resident needed assistance with Activities of Daily Living (ADL) related to chronic illness, fracture left femur, pain and weakness, initiated 01/15/19. The goal stated the resident would have no decline in ADLs and participate in care to the highest ability and have no decline in limited Range of Motion (ROM). Interventions included but were not limited to setup assistance with eating. Additional interventions included encourage resident to participate in care to promote independence. Further, review of the SRNA [NAME] (SRNA Care Plan), dated 08/23/19 revealed the Resident required setup assistance with meals and a divided plate. Observations of the lunch meal, on 08/20/19 at 12:08 PM, revealed Resident #64 was sitting at a U shaped assist table facing the wall with three (3) other residents. Additional observation revealed Resident #64 requested coffee at 12:11 PM and the State Inspector informed Licensed Practical Nurse (LPN) #6 of Resident #64's request. LPN #6, stated Resident #64, was a total feed and {he/she} would have to wait until someone could assist him/her to have coffee. Continued observation, at 12:13 PM, revealed Resident #64 asked the State Inspector if staff knew he/she requested coffee, and the State Inspector replied she had informed the facility staff of his/her request for coffee. Observation at 12:14 PM, revealed the facility Director of Nursing (DON) who was also in the dining room, overheard the State Inspector and Resident #64's conversation and asked LPN #6 to get Resident #64's coffee. Again, LPN #6 stated the resident could not have coffee and it would be on his/her tray when the tray arrived. The DON acknowledged LPN #6 and did not question the statement or get the resident's coffee. Further observation at 12:23 PM, revealed Resident #64 was served coffee with a lid and straw setup. Resident #64 held the coffee mug independently, and drank the beverage independently with his/her left hand. Observation, on 08/21/19 8:00 AM, revealed Resident #64 was at an independent table in the dining room drinking coffee independently from a coffee mug with a lid and straw setup. Resident #64 stated the coffee was good this morning. Further observation revealed no noted difficulties with eating and no facility staff were assisting the resident with greater than fifty (50) percent of the meal consumed. Interview with Resident #64, on 08/21/19 at 9:20 AM, revealed he/she did not know why there was a delay in getting coffee yesterday during lunch. Additionally, he/she stated the facility was usually pretty good with getting requested items to him/her timely. Further, the resident had no concerns with dining services other than having to wait for coffee yesterday. Interview with SRNA #2, on 08/23/19 at 10:39 AM, revealed he had worked at the facility for twelve (12) years and worked on first and second shift; and was assigned to the hallway for Resident #64. Per interview, Resident #64 was independent with meals after setup, and often ate meals in his/her room. Interview with SRNA #1, on 08/23/19 at 10:05 AM, revealed she had been employed by the facility for two ( 2) years and had worked every shift. SRNA #1 stated the staff utilized the care plan to know what kind of care the residents' needed and the care plan was on the computer/online. Per interview, the care plan provided instructions about Activities of Daily Living, which would include assistance with meals. Continued interview revealed Resident #64 required setup only with meals as he/she could eat and drink independently. Per interview, Resident #64 dined at a regular table in dining room. Further interview revealed residents should be given coffee if they were not on fluid restriction, and were able to drink it as long as it was suitable for their diet because it provided hydration. Additionally, SRNA stated she would be upset to see a resident not able to get requested services as this was important to ensure resident rights. SRNA #1 further stated the facility provided training on care for the residents, which did include assistance with meals and resident rights upon hire and annually. Interview with Licensed Practical Nurse (LPN) #1, on 08/23/19 at 11:00 AM, revealed she had been employed by the facility for three (3) years. Continued interview revealed staff was educated by the facility related to resident rights. Continued interview revealed, one of the rights would be for the residents to have the right to have beverages as they request and at the same time as residents who were able to assist themselves. Per interview, it was important to maintain resident rights, as this was the residents home and residents who were not independent with Activities of Daily Living, could still make decisions and choices to enhance their quality of life. Interview with the Assistant Director of Nursing (ADON), on 08/23/19 at 2:02 PM, revealed she had been employed by the facility for five (5) years in December. She stated she expected resident rights to be maintained, and all staff was in-serviced on resident rights. Further interview revealed residents had the right to choices and preferences. Per interview, residents should be provided a drink upon request. She stated it was important to maintain resident rights as this was their home they should be afforded all rights unless their requests infringed on the rights of other residents. Interview with the Director of Nursing (DON), on 08/23/19 at 2:45 PM, revealed she started as Director of Nursing at the facility in July 2019. Per interview, the facility did provide training for staff during orientation and annually competencies, to include resident rights and dignity and how to assist resident with meals. Continued interview revealed staff should be sitting while assisting residents with dining. Per interview, it would be against policy and a dignity issue for staff to assist residents with dining while standing. The DON stated, resident rights should always be honored and maintained. Per interview, honoring resident rights was important, as residents come to long term care losing some independence, and adjustments should be made to ensure the residents have options and choices while at the facility. Interview with the Administrator, on 08/23/19 at 2:52 PM, revealed he had been employed by the facility since since December of 2018. Per interview, the facility did have policy for assisting residents with dining and it was his expectation staff follow the facility's policy. Per interview, staff should sit when assisting to provide person centered care, dignity and respect. Per interview it would be against policy to stand while assisting residents with dining. Further, Resident #64 should have been given coffee at his/her request and assistance as necessary. The Administrator stated he expected Resident Rights to be honored for all residents related to dignity during meal service. Continued interview revealed training was provided to staff regarding policies at orientation and annually and as needed. Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. There were four (4) residents affected, (Resident #14, Resident #31, Resident #39 and Resident #64). Observation of the lunch meal, on 08/20/19, revealed Resident #39, Resident #14, and Resident #31 were assisted with dining by staff while staff was standing. Additional observations of the lunch meal, on 08/20/19, revealed Resident #64 requested coffee and was denied related to his/her level of assistance; however, the resident's Comprehensive Care Plan and further observations during survey revealed the resident was independent with drinking from a cup after set up. The findings include: Review of the facility's Policy titled, Assistance with Meals, revised July 2017, revealed facility staff will serve resident trays and will help residents who require assistants with eating. Continued review revealed residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals. Review of the facility's Policy titled, Resident Rights, revised December 2016, revealed residents have a right to be treated with respect, kindness and dignity, and communication to and access to people and services, both inside and outside the facility . 1. Record review for Resident #14 revealed the resident was admitted by the facility on 05/10/17, with the diagnoses to include: Weakness, Type 2 Diabetes Mellitus, Essential Hypertension and Hypothyroidism. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/15/19, revealed the facility assessed Resident #14 to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed Resident #14 to require extensive physical assistance with one (1) staff member for eating. Observation of the noon meal, on 08/20/19 at 12:34 PM, revealed Resident #14 was at a U shaped assist table. Continued observation revealed State Registered Nursing Assistant (SRNA) #8 was assisting Resident #14 with his/her meal. Further observation revealed SRNA #8 was standing across the table while assisting the resident with his/her meal. Interview with SRNA #8, on 08/23/19 at 11:15 AM, revealed she had been employed by the facility for one (1) year. Continued interview revealed the facility has a policy for assisting residents with dining and for resident rights. Per interview, she usually sat while assisting residents in the dining room. She stated she would sit on the stools so she could be at eye level, to make the residents feel better and so they don't feel different than everyone else. Per interview, it would be important for the residents dignity and it would be the way she would want to be treated. Further interview revealed she should not have been standing, and should have followed the facility's policy like she normally did and sat while she assisted Resident #14 with dining during the whole meal. 2. Record Review for Resident # 31 revealed the resident was admitted by the facility on 05/27/19 with diagnoses to include: Abnormal posture, Age related debility, Unspecified Dementia with Behavioral Disturbance and Hypothyroidism. Review of Resident #31's Quarterly MDS Assessment, dated 08/12/19, revealed the facility assessed the resident to have a BIMS of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review revealed the facility assessed Resident #31 to require extensive physical assistance with one (1) staff member for eating. Observation of the noon meal, on 08/20/19 at 12:35 PM, revealed Resident #31 was assisted with dining by Quality Assurance Nurse (QA) #1. Continued observation revealed QA #1 stood to the left side of Resident #1 at the U shaped table while he assisted with the resident's meal. Interview with QA #1, on 08/23/19 at 11:00 AM, revealed he had been employed by the facility for five (5) years. Continued interview revealed the facility did have a policy for assisting residents with dining and resident rights. Per interview, if possible staff should attempt to assist residents with dining at eye level and sit while assisting most of the time, to facilitate communication with the resident and for the resident's dignity. Per interview, the facility reviewed trainings on resident rights and assisting with meals annually at competencies and at orientation. 3. Record Review for resident #39 revealed the resident was admitted by the facility on 01/07/19 and re-admitted on [DATE], with diagnoses to include: Dysphagia, History of Falling, Abnormal Posture and Vascular Dementia without Behavior Disturbance. Review of Resident #39's Quarterly MDS Assessment, dated 06/15/19, revealed the facility assess the resident to have a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed the facility assessed Resident #39 to require extensive physical assist of one (1) staff member for eating. Observation of the noon meal, on 08/20/19 at 12:12 PM, revealed Resident #39 was being assisted with his/her meal by SRNA #8. Continued observation revealed SRNA #8 stood while assisting the resident from 12:12 PM to 12:16 PM. Further observation revealed at 12:16 PM, SRNA #8 pulled a chair over to the table and sat down to assist the resident. Interview with SRNA #8, on 08/23/19 at 10:28 AM, revealed you should sit while assisting residents with feeding and be at eye level so as not to be intimidating to the resident. SRNA #8 stated, for Resident #39 it would be important because at times he/she could be a handful and it may set him/her off if he/she felt intimidated. Per interview, staff should know the resident's needs and care plan. She stated staff should know the residents that require physical assistance with meals and staff should be sitting with the residents when assisting with meals. Interview with the Unit Manager for Unit Two (2), on 08/23/19 at 10:45 AM, revealed it would be her expectation staff follow the policy and regulations related to resident rights and assistance with meals. Per interview, the policy is in place for the residents' dignity and staff should be at the residents' eye level for assisting with meals to make a bond with the residents. Continued interview revealed all residents should be provided with the same services and provisions unless medically or behaviorally indicated. Interview with the Assistant Director of Nursing, on 08/23/19 at 10:59 AM, revealed she had been employed by the facility for five (5) years. Per interview, the facility did have a policy in regards to assisting residents with meals. Continued interview revealed it was her expectation for staff to follow the facility's policy. Further interview revealed residents should be assisted with meals while staff was seated and at the residents eye level so residents' did not feel intimidated, and because it was more personal. Per interview, it could be a dignity issue if the staff was standing over the resident while assisting them with dining.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to provide a safe, clean, comfortable, and homelike environment affecting seven (7) residents, (Resident #1, #14, #19, #31, #34, #60 and #64). Observations of the lunch meal, on 08/20/19 at 11:30 AM, revealed Residents #1, #14, #19, #31, #34, #60 and #64 were sitting at U shaped assist tables facing the walls. Continued observation revealed the tables were without tablecloths, table runners or centerpieces. The findings include: Review of the facility's Policy titled, Homelike Environment, dated 2001, revised May 2017, revealed Residents are provided with a safe, clean, comfortable homelike environment. Continued review revealed staff shall provide person centered care that emphasizes the residents' comfort, independence and personal needs and preferences, with inviting colors and decor. Review of the facility's Policy titled, Resident Rights, dated 2001, revised December 2016, revealed residents' rights include the right to a dignified existence, and to be treated with respect, kindness and dignity. Observation of the Dining Room, on 08/20/19 11:30 AM, revealed Resident #1, Resident #14, Resident #19, Resident #31, Resident #34, Resident #60, and Resident #64 were seated at a U shaped assist table. Continued observation revealed the residents were all facing away from the dining room and towards the wall. Further observation revealed there were no tablecloths, table runners or centerpieces on the tables. 1. Record review revealed Resident #1 was admitted by the facility on 06/09/18 with a readmission date of 03/16/19 with diagnoses to include: Contracture, unspecified joint, Dysphagia, Abnormal Posture, Long Term Use of Anticoagulants and Personal History of other Malignant Neoplasm of the Kidney. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/12/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15), indicating the resident to be moderately impaired for decision making. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive physical assist by one (1) staff for eating. 2. Record review revealed Resident #14 was admitted by the facility on 05/10/17 with diagnoses to include Weakness, Type 2 Diabetes Mellitus, Essential Hypertension and Hypothyroidism. Review of Resident #14's Quarterly MDS Assessment, dated 08/15/19, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident to require extensive physical assistance with one (1) staff member for eating. 3. Record review revealed Resident #19 was admitted by the facility on 02/20/19 with diagnoses to include Type 2 Diabetes Mellitus, Essential Hypertension, Unspecified Dementia without Behavior Disorder and Post-Traumatic Stress Disorder, Unspecified. Review of Resident #19's Quarterly MDS Assessment, dated 05/30/19, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review revealed the facility assessed the resident to require extensive physical assistance with one (1) staff member for eating. 4. Record review revealed Resident #31 was admitted by the facility on 05/27/19 with diagnoses to include Abnormal posture, Age Related Debility, Unspecified Dementia with Behavioral Disturbance and Hypothyroidism. Review of Resident #31's Quarterly MDS Assessment, dated 08/12/19, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive physical assistance with one (1) staff member for eating. 5. Record review revealed Resident #34 was admitted by the facility on 01/29/04, with a readmission date of 10/05/12, with diagnoses to include Dysphagia, Oral phase, Abnormal Posture and Cognitive Communication. Review of Resident #34's Quarterly MDS Assessment, dated 06/13/19, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed the resident to require the support of one (1) staff member physical assist for eating. 6. Record review revealed Resident #60 was admitted by the facility on 07/14/17 with diagnoses to include Muscle Weakness, Dysphagia, Abnormal Posture and Hypothyroidism. Review of Resident #60's Annual MDS Assessment, dated 07/06/19, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive physical assist with one (1) staff member for eating. 7. Record review revealed Resident #64 was admitted by the facility on 01/04/19 with diagnoses to include Vascular Dementia with Behavior Disturbance, Difficulty Walking and Anxiety Disorder. Review of Resident #64's Quarterly MDS Assessment, dated 07/13/19, revealed the resident was assessed by the facility to have a BIMS score of eight (8) out of fifteen (15), indicating the resident to be moderately impaired. Continued review revealed the resident did not have a documented upper extremity impairment. Further review of the MDS Assessment, revealed the facility assessed the resident to require one (1) staff physical assistance with eating. Interview with State Registered Nursing Assistant (SRNA) #8, on 08/23/19 at 10:28 AM, revealed all residents who are assisted with meals should have the same provisions and services as other residents, such as table cloths and tables. Per interview, the U assist tables could be seen as institutional, but they were using them because the smaller tables were not as tall for the wheelchairs. Per interview, the U shaped tables faced the wall and not the rest of the dining room and could be seen as isolating the residents. Continued interview revealed the tables should have been arranged for the residents to be able to face the dining room and the table should have tablecloths and centerpieces. Per interview, the facility did provide training related to resident rights and providing a homelike environment and the staff was trained to view the facility as the resident's home. Interview with the Quality Assurance Nurse, on 08/23/19 at 11:00 AM, revealed all residents should have the same care and services and be provided the same goods in a safe homelike environment. Continued interview revealed the facility may need to provide a variety of tables to provide for resident needs and preferences. Further interview revealed residents should not be singled out for a different type of furniture solely based on the type of assistance they required such as with meals. Per interview, the facility did have a policy related to dignity and resident rights. Interview with the Assistant Director of Nursing (ADON), on 08/23/19 at 10:59 AM, revealed the facility did have a policy related to homelike environment and resident rights. Continued interview revealed residents who were assisted with dining should receive the same goods and services as residents who were independent diners. Further interview revealed she was not aware of any reason the residents who were assisted with dining during the lunch meal, on 08/20/19, were assisted using institutional U shaped tables without table linens or centerpieces. Interview with the Director of Nursing (DON), on 08/23/19 at 2:45 PM, revealed all residents should be provided with the same provisions and services whether they were assisted or independent for dining. Continued interview revealed it would be her expectation for staff to follow the facility's Policy for homelike environment and for dignity and respect. Per interview, having a consistent environment that was the same for all residents was important to provide a homelike environment and should be done unless there was a medical or behavioral reason. Interview with the Administrator, on 08/23/19 at 2:52 PM, revealed he had been employed by the facility since December 2018. Continued interview revealed residents that need assistants with dining should receive the same provisions and services as residents that were independent, to make everyone feel equal. Continued interview revealed it could be a possible dignity issue if the dependent residents did not receive the same services. Further interview revealed the facility had a policy and all residents should be afforded a homelike environment and person centered care.