**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure resident care plans were implemented for one (1) of nineteen (19) sampled residents, Resident #14, related to use of a palm guard. Observations from 08/30/3031 through 09/03/2021, revealed no palm guard in place to the resident's right hand as per the Comprehensive Care Plan. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2019, revealed the Comprehensive Care Plan was an interdisciplinary communication tool. Per review, the Comprehensive Care Plan described the services provided to a resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. In addition, review revealed the Comprehensive Care Plan was to reflect the care a resident received. Review of the facility's policy, Splints and Orthotic Devices, undated, revealed an orthotic device was used to support a joint or body part, reduce pain, or position the joint in a functional position. Per review, the rationale for use of orthotics included joint range of motion, reduced pain, reduced effects of disease, and reduced risk for skin breakdown or joint deformity. Review of the clinical record for Resident #14 revealed the facility re-admitted the resident on 04/09/2021 with diagnoses including Cerebral Palsy and Contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues causing joints to shorten and stiffen preventing movement). Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/09/2021 revealed the facility assessed Resident #14 as severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident with impairment of functional ROM in his/her upper extremities. Review of Resident #14's Comprehensive Care Plan revealed the facility care planned the resident for safety, dated 07/02/2019. Per review of the safety care plan Resident #14 had limited range of motion (ROM) due to contractures and the diagnosis of Cerebral Palsy. Continued review revealed goals included for Resident #14's joint contractures to be free from injury and skin breakdown. Further review revealed the interventions included the following: therapy evaluation and treatment as needed; staff were to follow Physical Therapy (PT) and Occupational Therapy (OT) recommendations as indicated; and for staff to place a palm guard to his/her right hand. In addition, review revealed the nurse aides and nurses were responsible for ensuring the listed interventions on the Comprehensive Care Plan for Resident #14 were implemented. Review of an OT Therapist Progress Note, dated 03/12/2021, revealed Resident #14's goal was upgraded on 03/12/2021, for the resident to tolerate upper extremity splints for six (6) hours with the use of a palm guard. Per review, this goal was to enhance maximum ROM and joint alignment to prevent deformity and pain for Resident #14. Continued revealed Resident #14's prior level of function, on 02/26/2021, was four (4) hours, and his/her current level of function on the 03/12/2021 Note, was documented as four (4) to five (5) hours. Further review revealed the OT noted Resident #14's caregiver was educated on putting on and taking off his/her palm guards. Review of the OT Therapist Progress and Discharge summary, dated [DATE], revealed the goal for the caregiver to put on and take off Resident #14's palm guard was met on 07/23/2021. Per review, the caregiver was educated on how to put on and take off the palm guard splint, as the resident required assistance with the splint. Further review revealed the OT noted Resident #14's caregiver was aware of his/her need for assistance with the palm guard splint, and understood the resident's diagnosis and prognosis. Review of the facility's Nurse Aide Care Sheet, dated 08/31/2021, for Resident #14 revealed the resident was to have a splint to his/her right upper extremity at all times, which could be removed for bathing. Observations of Resident #14, on 08/30/2021 at 6:21 AM, and at 12:45 PM; on 08/31/2021 at 12:05 PM, at 2:10 PM, and at 4:04 PM; on 09/01/2021 at 8:27 AM, at 10:13 AM, at 10:54 AM, at 1:40 PM, and at 2:05 PM, revealed the resident's hands were contracted. In addition, the observations revealed no visual evidence Resident #14 of his/her OT recommended and care planned palm guard in place to his/her right hand. Interview with Certified Nurse Aide (CNA) #1, on 09/01/2021 at 3:29 PM, revealed Resident #14 was unable to do anything for himself/herself. Per interview, Resident #14 did not have anything for his/her hands. The CNA revealed Resident #14's hands were tight, and therapy was responsible for providing range of motion (ROM) exercises, and for placing anything in the resident's hands. Further interview revealed the CNA had access to Resident #14's care plan and was supposed to anticipate the resident's care needs. In addition, she stated if there were any changes in Resident #14's condition, she reported it to the nurse. Continued observations of Resident #14, on 09/01/2021 at 3:33 PM and 09/02/2021 at 8:28 AM, revealed the resident continued to have no visual evidence of his/her palm guard in place as per the care plan interventions. Interview, on 09/02/2021 at 11:33 AM, with Licensed Practical Nurse (LPN) #1 revealed therapy worked with Resident #14's contractures. She stated Resident #14 did not have anything scheduled to be placed on the resident's hand, and she had not seen the resident with a palm guard in his/her hand. However, she stated as the nurse she was responsible for ensuring Resident #14's palm guard was in place. Per interview, she had not seen Resident #14 with a palm guard in place to his/her hands since she had been employed at the facility, which had been about ten (10) months. The LPN stated the Comprehensive Care Plan intervention for the palm guard to the resident's right hand was to protect his/her skin integrity. Further interview revealed if the care plan intervention for the palm guard was not followed, the resident's palm could be cut by the resident's fingernails. Observation during the interview, revealed Resident #14's hands were contracted, and his/her right hand fingers were folded and tightly closed to the palm. Additional observation of Resident #14, on 09/02/2021 at 2:13 PM, revealed no visual evidence of the palm guard in place to his/her right hand as per the care plan interventions. On 09/03/2021 at 8:35 AM, interview with the Therapy Program Director revealed Resident #14's care plan included an intervention for a palm guard. She stated the palm guard was a type of splint which wrapped around the hand and was held in place with a Velcro strap. Per interview, therapy evaluated Resident #14 and made recommendations. The Therapy Director stated therapy turned over care of Resident #14's palm guard to the nursing department when the resident was discharged from therapy on 07/23/2021. Continued interview revealed the resident tolerated four (4) hours of use of the palm guard. She stated the nursing department was responsible to set up the actual schedule of when to use Resident #14's palm guard once the resident had been discharged from therapy. According to the Therapy Director, if Resident #14 was not assisted to wear the palm guard as per the care plan, the resident could experience skin breakdown, risk of infection. She stated Resident #14 could also experience becoming septic and possibly hospitalized if his/her nails were not cut and allowed to pierce the skin on his/her palms. The Therapy Director revealed the Comprehensive Care Plan was to ensure the facility provided good care and prevented hospitalization of a resident. Additionally, the Director stated if Resident #14's care plan interventions were not provided, it could lead to further functional decline in the resident. She stated staff were educated to follow residents' Comprehensive Care Plans and to perform the interventions. An additional observation on 09/03/2021 at 8:59 AM, revealed Resident #14 had no visual evidence the palm guard was in use as per the care plan interventions. Interview with the Director of Health Services (DHS), on 09/03/2021 at 10:56 AM, revealed therapy was responsible for entering the order for the use of a palm guard for Resident #14 when he/she was discharged from therapy services. Per interview, the palm guard noted on Resident #14's Comprehensive Care Plan was also be entered as an order to ensure the intervention was provided. The DHS stated if it was placed as an order it carried over to Resident #14's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for documentation of application. She stated however, the Comprehensive Care Plan intervention was not entered in the computer separately. The DHS revealed the purpose of the palm guard care plan intervention for Resident #14 was to maintain his/her skin integrity. Further interview revealed the purpose of Comprehensive Care Plans was to note care an individual resident required and interventions for staff to follow. Per the DHS, if staff did not provide the care Resident #14 required, it could result in the resident experiencing skin breakdown. Interview, on 09/03/2021 at 1:32 PM, with the Area Executive Director (ED) revealed the nurse aide or the nurse was responsible for ensuring Resident #14's palm guard were applied as per the resident's Comprehensive Care Plan interventions. She stated there should be a Physician's Order for Resident #14's palm guard, in order for staff awareness of the need for the palm guard. Per interview, the ED revealed the facility had not identified communication issues between therapy services and the nursing department regarding the use of therapeutic devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure quality of care for one (1) of nineteen (19) sampled residents, Resident #14, related to use of a palm guard. Observations each day of the survey revealed no palm guard present on the resident per care plan intervention and therapy recommendation. The findings include: Review of the facility policy Splints and Orthotic Devices, undated, revealed orthotic devices were used to support a joint or body part, inhibit abnormal tone, reduce pain, or position the joint in a functional position. Orthotic devices were used for joint range of motion, to reduce pain, reduce effects of disease, and reduce risk for skin breakdown or joint deformity. Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2019, revealed the comprehensive care plan (CP) was an interdisciplinary communication tool that described the services provided to a resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CP should reflect the care a resident received. Review of the clinical record for Resident #14 revealed the facility re-admitted the resident on 04/09/2021 with diagnoses of Cerebral Palsy and Contracture of the right wrist and hand. Review of Resident #14's comprehensive care plan (CP), dated 07/02/2019, revealed the resident with limited range of motion (ROM) due to contractures and cerebral palsy. Interventions included therapy evaluation and treatment as needed, follow physical therapy (PT)/ occupational therapy (OT) recommendations, and a palm guard to his/her right hand with the nurse aides and nurses responsible for the intervention. Review of an OT Therapist Progress note, dated 03/12/2021, revealed Resident #14's goal was upgraded on 03/12/2021 to tolerate upper extremity splints for six (6) hours with use of a [NAME] guard to enhance maximum ROM and joint alignment to prevent deformity and pain. The caregiver was educated to put on and take off the palm guards. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #14 as severely cognitively impaired. The resident had impairment with functional ROM in his/her upper extremities. Review of the OT-Therapist Progress and Discharge summary, dated [DATE], revealed the resident required assistance to put on and remove the splint and the caregiver was educated how to put on and take off the [NAME] guard splint. Review of the nurse aide care sheet, dated 08/31/2021, revealed Resident #14 had a splint to his/her right upper extremity at all times and may be removed for bathing. Observations of Resident #14, on 08/30/2021 at 6:21 AM, 08/30/2021 at 12:45 PM, 08/31/2021 at 12:05 PM, 08/31/2021 at 2:10 PM, 08/31/2021 at 4:04 PM revealed no palm guard in place and the resident's hand contracted. Continued observations on 09/01/2021 at 8:27 AM, 09/01/2021 at 10:13 AM, 09/01/2021 at 10:54 AM, 09/01/2021 at 1:40 PM, and 09/01/2021 at 2:05 PM, on 09/01/2021 at 3:33 PM revealed the resident's hand contracted and no palm guard in place. Further observations on 09/02/2021 at 8:28 AM, on 09/02/2021 at 2:13 PM, on 09/03/2021 at 8:59 AM revealed his/her hands contracted, and the resident did not have a palm guard in place. Interview, on 09/01/2021 at 3:20 PM, with Certified Nurse Aide (CNA) #1 revealed Resident #14 did not have anything for his/her hands. The CNA stated the resident could not do anything for him/herself and staff had to anticipate the resident's needs. She revealed the resident's hands were tight, and therapy was responsible to provide ROM and put anything in place for the resident's hands. She revealed she had access to the resident's care plan and if there were any changes to the resident, she reported the changes to the nurse. Interview with Licensed Practical Nurse (LPN) #1, on 09/02/2021 at 11:33 AM, revealed therapy worked with Resident #14's contractures. She stated the resident did not have anything scheduled for his/her hand and she had not seen the resident with a palm guard, although as the nurse she was responsible for ensuring the resident had his/her palm guard in place. The nurse revealed she had not seen the resident with a palm guard since she was employed at the facility, about ten (10) months. The LPN stated without the palm guard, the resident's nails could cut his/her palm. Observation during the interview, revealed the Resident #14's hands were contracted with his/her fingers folded closed to the palm. On 09/03/2021 at 8:35 AM, interview with the Therapy Program Director revealed therapy evaluated Resident #14 and then turned over care of the palm guard to the nursing department when therapy discharged the resident on 07/23/2021. She stated the nursing department was responsible to set up the actual schedule when to use the palm guard. She revealed if the resident did not wear the palm guard he/she could have skin breakdown, risk of infection, or if the resident's nails were not cut, the resident could get wounds which could lead to becoming septic and hospitalization. Additionally, the Director stated if the resident did not have the palm guard care provided, he/she could have further functional decline. She revealed staff were educated regarding positioning related to the palm guard. Interview, on 09/03/2021 at 10:56 AM, with the Director of Health Services (DHS) revealed when therapy discharged Resident #14 from therapy services, the therapy department was responsible to enter an order for use of a palm guard. The DHS revealed an order for the palm guard ensured the intervention was provided, as it carried over to the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for documentation. The DHS revealed the purpose of the palm guard for Resident #14 was for skin integrity and not providing the care could lead the resident to have skin breakdown. Interview with the Area Executive Director (ED), on 09/03/2021 at 1:32 PM, revealed the nurse aide or the nurse was responsible to apply Resident #14's palm guard. She stated there should be an order for the resident's palm guard, for staff to be more aware the palm guard was needed. The ED revealed the facility had not identified communication issues between therapy and nursing related to use of therapeutic devices.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure unused kitchen equipment was removed and disposed of when no longer in use. Observation revealed the outside delivery area of the facility contained six (6) commercial coffee makers/dispensers, two (2) commercial beverage dispensers, an ice chest, a commercial toaster, a countertop microwave, three (3) empty milk crates, a portable gate, a mop and bucket full of liquid, and a wood pallet. The findings include: Review of the facility's policy entitled, Garbage and Refuse, dated 05/31/2016, revealed all garbage and refuse was stored and disposed of daily. Observation, on 09/01/2021 at 8:49 AM, revealed the facility's outside delivery area contained the following: a mop bucket filled with liquid and a mop; six (6) commercial coffee makers/dispensers; two (2) commercial beverage dispensers; three (3) black, empty milk crates; a countertop microwave oven; a blender base; a yellow rolling collapsible gate; a horizontal ice chest; a commercial toaster with rust on the top; a hose sprayer; and two (2) black rubber mats. Continued observation revealed there were brown leaves and pine cones located in the spaces between all the equipment and in the corners of the area. Further observation revealed a wood pallet with rough edges observed leaning against the exterior wall by the delivery door. An additional observation, on 09/02/2021 at 1:59 PM, revealed the following items still present in the same area: a mop and bucket full of liquid; three (3) empty, black milk crates; six (6) commercial coffee makers/dispensers; two (2) commercial beverage dispensers; a commercial toaster; horizontal ice chest; and wood pallet. Interview, on 09/02/2021 at 2:54 PM, with the Director of Food Services (DFS) revealed most of the kitchen equipment stored outside the delivery door had been there before he started employment at the facility one (1) year and eleven (11) months ago. Per interview, nothing had been added to that area with the rest of the equipment in the last six (6) months. The DFS revealed the facility used the delivery door for the vendors delivering food or other items to the facility. According to the DFS, he was aware the outside area had coffee machines, tea machines, and a cooler stored there. He stated it was not the time of the year or season for brown leaves or pinecones to be there. Further interview revealed it was his understanding the vendors who supplied the equipment, which was stored outside the delivery door, had been contacted to come pick up the equipment. The DFS revealed however, the vendors had not came to pick the unused equipment up and remove it from the facility's premises. He further revealed he was not aware of who the vendors were that needed to come pick the unused equipment up. In addition, the DFS stated the unused equipment left outside could be a potential trip hazard and was an invitation for pests to be located there. Interview on 09/03/2021 at 10:56 AM, with the Director of Health Services (DHS) revealed she was not aware of unused kitchen equipment being stored outside the delivery area until yesterday (09/02/2021). She stated the maintenance department was responsible for the equipment. Per interview, staff in the facility's morning meeting had not previously discussed the unused kitchen equipment stored outside the delivery door. The DHS revealed she was unsure how long the equipment had been stored outside the delivery door. Further interview revealed the equipment left outside the delivery door could be in the way of people making deliveries or in facility staff's way. Interview with the Maintenance Director, on 09/03/2021 at 11:19 AM, revealed the unused kitchen equipment stored outside the delivery door had been there since he began his employment at the facility two (2) years ago. The Maintenance Director revealed he was unsure who was responsible for ensuring the equipment was removed from that area. Per interview, he had been told the previous company which had operated the facility had been contacted prior to his employment regarding removal of the equipment. The Maintenance Director revealed he was unsure if there were any potential issues with the equipment being stored outside the delivery door, as the equipment was stationary and there was a clear path for people to walk through. Interview, on 09/03/2021 at 1:32 PM, with the Area Executive Director (ED) revealed she had noticed the unused kitchen equipment stored outside the delivery door after she started working at the facility. Per interview, the previous facility operator had used different vendors for equipment supplies than the facility currently used. The ED revealed the facility had been waiting for the equipment to be picked up by the previous vendors. Further interview revealed the equipment was visible through the window and was an eyesore. The ED further stated she did not want the facility's residents to see it.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure performance reviews were completed every twelve (12) months, for six (6) of six (6) nurse aides personnel files reviewed. The findings include: Review of the facility's policy, Quarterly Wage Investment Timeline, undated, revealed employee eligibility for increases was dependent on disciplinary actions incurred resulting from performance and performance improvement plans, etc. Review of the facility's Skills Check-Off sheets revealed the facility evaluated employees on Hand Washing, and Guidelines for Donning and Doffing Personal Protective Equipment (PPE). The facility did not provide a policy specific to Nurse Aid performance evaluation. The facility failed to provide documented evidence of performance evaluations of nurse aides for six (6) of six (6) nurse aide files sampled. Interview, on 09/03/2021 at 9:40 AM, with the Staff Development Coordinator (SDC) revealed the nurse aide employment anniversary was utilized to meet training and educational timeframe's. She stated the nurse aides were educated to ensure they were competent to do their job, in order for residents to receive the care they required and deserved. Per interview, she provided input into the nurse aides' annual and other evaluations, although she did not conduct the evaluations herself. According to the SDC, the Director of Health Services (DHS) or Executive Director (ED) completed the nurse aide evaluations. She stated the evaluations determined if the aide performed their duties properly, and in order to identify anything necessary areas of improvement for the aide. Further interview revealed the only skills check off the facility used was for hand washing, and donning and doffing PPE. On 09/03/2021 at 10:56 AM, interview with the DHS revealed the facility had not performed annual nurse aide evaluations as per the regulation. She stated the facility completed staff competencies and check offs of staff regarding hand washing and PPE, with infection control as the focus. She stated the purpose of the nurse aide evaluations was to ensure the aides knew the tasks they were responsible to perform. The DHS further revealed if the nurse aide evaluations were not completed the aides could perform tasks improperly which could lead to other issues, such as improper skin integrity or infection for a resident. Interview with the Area Executive Director (ED), on 09/03/2021 at 1:32 PM, revealed the facility's corporate policy for nurse aide evaluations was the quarterly wage increases with a focus on positive reinforcement. Per interview, she addressed any concerns regarding an employee's performance. The ED stated prior to receiving the quarterly pay increase, employee personnel files were reviewed for counseling and coaching needs. According to the ED, the facility used non-certified nurse aides to provide resident care. Continued interview revealed the non-certified nurse aides received a lot of hands on monitoring on the floor by the DHS and Assistant Director of Health Services (ADHS); however, there was no documentation of the nurse aide evaluations. Further interview revealed the purpose of the nurse aide evaluations, per the regulation, was to ensure staff were competent and capable to care for residents, and for the residents to receive the care they deserved and required. She further revealed the facility's Quality Assurance (QA) Committee had not discussed how the new corporate policy for quarterly wage increases met the regulatory requirement for nurse aide evaluations.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed undated and opened containers of salad dressing, and in the freezer unopened vegan trays, and meat and cheese packages. Additional observation of the freezer revealed a container of strawberries covered with a gray substance. Further observations revealed the freezer temperature log was incomplete for the dates of 08/20/2021 through 08/30/2021. The findings include: Review of the facility's policy, Food Labeling and Dating, dated March 2019, revealed any food product removed from its original container, or with a broken seal, or had been processed in any way, would be labeled. Per review, the label was to include the item's name, the date and time the food was labeled, the used by date, and initials of the person labeling the item. Review of the facility's policy titled, Refrigerators, dated May 2017, revealed refrigerators would have a functioning thermometer present in a visible location, which were monitored daily. Per review, the temperature checks were documented on the refrigerator monitoring log, and there was documentation of follow up for any out of range readings noted. Tour of the facility's kitchen area, on 08/30/2021 at 6:18 AM, with the Dining Services Assistant, revealed observations of a Caesar dressing container which was opened but not labeled and dated. Continued observations revealed a package of lunch meat and package of cheese in the refrigerator which had been opened, but not dated. Per observation, the refrigerator also contained strawberries with a gray, fuzzy material on them, moldy in appearance. Further observation revealed two (2) Styrofoam containers with food items stored in them in the freezer, which had not been dated or labeled as per facility policy. Observation further revealed the facility's temperature log for the freezer contained documentation noting the latest entry completed on 08/20/2021. Interview with the Kitchen Director, on 08/30/2021 at 6:35 AM, revealed all temperature logs were to be filled out every morning and evening because if something was not working right, the facility needed to know and have it repaired or replaced. He stated the strawberries should have been thrown away as they were moldy. Per interview, the Styrofoam containers contained vegan meals and should have been labeled as per policy. According to the Kitchen Director, the Caesar dressing which was open and not dated should have been dated. He stated the importance of having food items labeled and dated gave kitchen staff an idea of when they could discard those items. He revealed if the food was in the cooler too long it could make a resident sick. Further interview revealed the Kitchen Director acknowledged, after reviewing the freezer log, it had not been filled out since 08/20/2021; however, the Kitchen Director stated it should have been completed daily. In addition, he stated if the freezer log was not completed as required staff would not be able to tell if the freezer was operating as it was supposed to. Interview with the Director of Health Services (DHS), on 09/03/2021 at 10:56 AM, revealed if the facility's refrigerator contained food which was moldy or had undated opened food it could affect the residents negatively. She stated the persons responsible for labeling and dating items were the ones who opened the items. Per interview, if someone opened food items they were to label and date the items. According to the DHS, the kitchen staff were ultimately responsible for ensuring opened food items were labeled and dated as per facility policy. She stated the temperature log for the refrigerators and freezers was used to ensure staff determined equipment was running at the right temperature. Further interview revealed if the refrigerator or freezer temperatures were out of range it could cause food to thaw. She further revealed the kitchen staff was responsible for making sure the refrigerator and freezer temperature logs were completed every day. Interview with the Area Executive Director (ED), on 09/03/2021 at 1:32 PM, revealed there was a potential for using an outdated item if containers were not date and labeled when opened. Per interview, whoever put away the food in the kitchen area was responsible for dating it. She stated the purpose of the refrigerator and freezer temperature logs was to ensure food was maintained at the correct temperature and everything was working properly. According to the Area ED, the potential problem with a temperature log not being filled out completely was food might not be stored at the proper and safe temperature. Further interview revealed the facility's cook was the one responsible for keeping the refrigerator and freezer logs up to date. She revealed the morning cook made sure the morning temperatures were completed and noted, and the evening cook made sure the evening temperatures were noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility-wide assessment, CMS Form 672, and policy review it was determined the facility failed to accurately determine the number of residents in the facility with respiratory diagnoses or care needs. Review of the facility's resident population included three (3) residents with tracheostomy care and ten (10) resident who required a closed unit and isolation for COVID-19 care. Review of the facility's assessment found the facility failed to include the residents for the determination of the competent care to meet the needs of the resident population. The findings included: Review of the Facility Assessment Tool, dated 08/18/2017, revealed Long Term Care (LTC) facilities conducted the assessment to document and annually review a facility-wide assessment, which included both their resident population and the resources the facility needed to care for their residents. The purpose included to determine the necessary resources to care for residents competently with day-to-day operations and emergencies. The facility used the assessment to make decisions about scheduling the proper staff to provide the required care for the required residents. The intent of the facility assessment included to evaluate the LTC resident population and identify the resources needed to provide the necessary person-centered care and services. The use of the competency-based approach ensured the focus allowed the facility to provide resident care, which allowed the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The facility did not provide a facility assessment policy or procedure guide. Review of the Resident Census and Condition of Residents Form CMS-672, dated 03/02/2021, revealed under section E, Special Care, the facility included tracheostomy for three (3) residents. Review of the Facility Matrix, dated 03/02/2021, revealed the facility noted ten (10) residents in the facility who required a closed unit and private rooms to provide transmission based precautions (TBP) with dedicated staff for residents with or under surveillance for COVID-19. Review of the Quality Assurance and Performance Improvement (QAPI) attendance record, dated 01/13/2021, revealed two (2) Directors of Health Services (DHS), two individual (2) Executive Directors (ED), one Assistant DHS, and the Clinical Support Nurse. The Medical Director (MD) area did not include a name. Review of the Facility Assessment, dated 12/01/2020, revealed the facility's QAPI team reviewed the assessment on 01/13/2021. Review of the Assessment revealed the persons involved with review and completion of the assessment included the ED, DHS, and MD. Review of section 1.3, Diseases, Conditions, Physical, and Cognitive Disabilities, of which the facility could accept residents, included respiratory and infectious disease. The facility identified Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, and Asthma. The facility did not identify residents with tracheostomy or COVID-19. Review of Section 2.1, revealed the facility indicated the ability to care for residents included Tracheostomy. However, the facility marked the numeric percentage as zero (0) percent. Review of Resident #29's clinical record revealed the facility admitted the resident on 02/13/2021 with the diagnosis of Respiratory Failure. Resident #29's Physician's Orders revealed the care need to suction for a Tracheostomy. Review of Resident #4's clinical record revealed the facility admitted the resident on 04/23/2015 with respiratory failure. Further review revealed Resident #4's Minimum Data Set (MDS) dated [DATE], revealed the facility's assessment included tracheostomy status. Review of Resident #142's clinical record revealed the facility admitted the resident on 07/30/2014 with a diagnosis of Tracheostomy status. Continued review of Resident #124's MDS, dated [DATE], revealed the diagnoses included tracheostomy status. The facility listed the resident's condition as a medically complex for the resident's primary medical condition category. Interview with the MD, on 03/04/2021, at 1:15 PM, revealed the facility accepted residents with tracheostomy care requirements. He stated the facility required competent staff to care for tracheostomies because of the higher level of risk and the acuity of the resident. He stated the facility housed residents on a closed unit with active COVID-19. The MD stated he did not participate in the development of the facility's assessment, but the facility did review it with him. However, he stated the facility's assessment should include tracheostomy residents and COVID-19 resident care. Interview with the DNS (Director of Nursing), on 03/04/2021 at 1:20 PM, revealed the facility's assessment reflected the resident population. She stated the facility determined the type of residents to include based on their review of clinical documentation, diagnoses lists, and the facility matrix. She stated the facility considered residents with tracheostomy and COVID-19 as high acuity, which required more care than a resident without a tracheostomy. She stated the facility assessment for respiratory care should include tracheostomy and COVID-19. The DNS stated on 01/13/2021, the facility held a QAPI meeting at which time she and the ED reviewed the assessment for accuracy and the review deemed the assessment was accurate. However, she stated the assessment needed to be accurate to show what care the facility could provide competently. She stated the ED's and DHS's responsibility included to ensure the assessment remained accurate. Interview with the ED, on 03/05/2021 at 9:16 AM, revealed the facility's process for completion of the assessment included to gather facts about the facility's population and care capabilities. She stated the facility's QAPI team reviewed the information, then forwarded to the corporate office for review by corporate level staff, who returned the assessment to the facility if revision was necessary. She stated the facility obtained information for the assessment through medical review of the residents and the facility involved the ED, DHS, MD, MDS, and interviews with staff to obtain an accurate assessment. The ED stated the facility did not have a policy for facility assessment and further stated an accurate assessment to ensure care, resources, and staffing needs were met to provide the necessary care of the resident. She stated the ED responsibilities included to ensure an accurate facility assessment reflected the resident population and the assessment needed to be updated.

Based on observation, interview and policy review, it was determined the facility failed to ensure safe, operating conditions of the fryer and freezer in the kitchen. Observation on 03/02/2021 at 8:28 AM, revealed two (2) boxes in close proximity to the ceiling of the walk-in freezer. Observation on 03/03/2021 at 1:35 PM, revealed liquid substance on the floor under fryer and four (4) boxes in the walk in freezer within close proximity to the ceiling. The findings include: Review of the document titled, Emergency Operations Plan, Hazardous Materials or Chemical Spills, undated, revealed hazardous materials included substances which were flammable and combustible. The policy revealed the proper steps for facility staff members during a hazardous materials emergency. Review of the document titled, Fryer, undated, revealed the cleaning process for the fryer which included draining the fryer, using cleaning solution, rinsing the fryer twice after cleansing solution, and replacement of oil after the fryer has dried. Review of the documents titled, Aides Cleaning List, dated December 2020 through March 2021, revealed daily and weekly tasks for work areas, equipment, and cleanliness of the kitchen. Review of the documents titled, Cooks Cleaning List, dated January through March 2021, revealed daily and weekly cleaning schedule with staff initials for sanitation, equipment, and the kitchen environment. The records revealed the cook swept and mopped the kitchen daily. The weekly tasks included changing the oil in the fryer, dated completed on 03/02/2021. Review of the policy titled, Storage Guidelines, undated, revealed the guidelines used for storage of dry goods and food in the refrigerator and freezer. The facility did not provide the requested policy for oil disposal. Observation on 03/02/2021 at 8:28 AM, revealed two (2) boxes in close proximity to the ceiling of the walk-in freezer. Observation on 03/03/2021 at 1:35 PM, revealed liquid substance on the floor under fryer and four (4) boxes in the walk in freezer within close proximity to the ceiling. Interview with the Director of Food Services (DFS), on 03/03/2021 at 1:35 PM, revealed the liquid substance on the floor behind the fryer was either water or oil. He stated he was unaware there was liquid on the floor prior to the identification by the State surveyors. The DFS stated there was no schedule for cleaning under or behind the fryer. He stated staff used a lift or dolly to move the stove in order to clean behind it. Upon further interview, the DFS revealed the assisted living DFS assisted him with delivery of food to the walk-in freezer and placed smaller boxes on the top shelf. The DFS stated adding the task to clean behind the fryer would be an important addition to the cleaning schedule. Interview with the assisted living DFS, on 03/02/2021 at 2:00 PM, revealed boxes in the walk-in freezer were to be at least eighteen (18) inches from the ceiling to prevent a fire hazard and ensure the sprinkler system to cover items if triggered. He stated if there was a fryer fire, the oil on the floor would make it difficult to extinguish and it created a fall hazard. The DFS stated the facility did not have an oil disposal policy. Interview with the Cook, on 03/03/2021 at 2:15 PM, revealed she was educated during training regarding the process used to change fryer oil. She stated she changed the oil out yesterday, did not spill the oil, and did not notice any oil on the floor upon completion of the task. The [NAME] stated she mopped the floor daily and had not noticed oil on the floor. She stated oil on the floor could make the floor slick. Interview with the Chief Engineer, on 03/05/2021 at 9:08 AM, revealed he performed daily rounds throughout the facility that included assessment of the kitchen to check for leaks, proper storage of flammables, and to ensure the sprinkler system was free from obstructions. The Chief Engineer stated he did not have a checklist for the kitchen assessment. He stated boxes stored in close proximity to the ceiling created a fire hazard. The Chief Engineer stated he was not aware of oil under the fryer in the kitchen floor until the DFS notified him during the survey. Interview with the Executive Director (ED), on 03/05/2021 at 9:53 AM, revealed she performed daily rounds to ensure safety of the residents and staff, and to identify possible regulatory violations. She stated she would speak to staff at that moment, follow up later, and/or discuss the issue in the morning meeting. The ED stated an assessment of the issue would reveal if the incident was isolated or systemic, required immediate intervention, and whether staff required further education. The ED stated boxes close to the ceiling could interfere with the effectiveness of the sprinkler system. She stated the facility needed to ensure proper cleaning schedules to address oil under the fryer in the kitchen. The ED stated she had been to the kitchen once in the two (2) weeks of employment at the facility.

Based on interview, record review, and policy review, it was determined the facility failed to provide adequate notice of discharge, or specific reasons for discharge from the facility for one (1) of twenty-one (21) sampled residents (Resident #343). Resident #343 was discharged from the facility while the resident was an inpatient in an acute care facility. However, the facility failed to document specific reasons for the resident's discharge. The facility also failed to provide the resident or a family member a written notice of the discharge. The findings include: Review of the facility's policy and procedure titled, Guidelines for Transfer and Discharge, dated 05/03/17, revealed procedures should include for non-emergency transfers or discharges to record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being discharged in the medical record and on a discharge form or a letter. Give a copy of the discharge notice to the resident and his/her legal representative. Provide the resident with a statement of the right to appeal the action to the state agency designated for such appeals, along with the name, address, and phone number of the State Long-term Care Ombudsman. Assist the resident with such appeal, and the Ombudsman, representative, consultations, as desired. The physician should document the medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physician's order for discharge should be attached to the discharge notice. Record review revealed the facility admitted Resident #343 on 04/15/15. Current diagnoses included: Multiple Sclerosis with Lower Extremity Paresis, Urinary Incontinence, and Recurrent Urinary Tract Infections (UTI). Additional diagnoses included Chronic Systolic and Diastolic Congestive Heart Failure, Lumbar Spinal Stenosis, Heart Disease, Morbid Obesity, Depression with Anxiety, and history of Gluteal Decubiti. Review of the Quarterly Minimum Data Set (MDS), signed and dated 10/04/19, revealed the facility assessed Resident #343's Brief Interview of Mental Status (BIMS) as fifteen (15), and determined the resident was interviewable. Continued review of the MDS revealed the facility assessed Resident #343 to require the extensive assistance of two plus (2+) persons with bed mobility, transfers, dressing, and toilet use, and the resident was totally dependent on one (1) person for bathing. Review of the Resident Progress Notes, dated 11/05/19 at 6:49 PM, revealed the results of the resident's urine culture indicated two (2) organism growths. The Physician was notified and orders were received to transfer Resident #343 to a local Emergency Department (ED). Continued review of the Resident Progress Notes dated 11/05/19 at 7:31 PM revealed Resident #343 was transferred to the ED via the Emergency Medical Services (EMS), and the transfer/discharge/bed hold forms were sent with the resident. Review of the Resident Progress Notes, dated 11/05/19 at 11:20 PM, revealed Resident #343 had been admitted to the hospital with the diagnosis of Urinary Tract Infection (UTI). Continued review of the Resident Progress Notes, dated 11/07/19 at 1:36 PM, revealed Discharge Planning Communication with Resident #343 to inform the resident of the intent of the facility to discharge him/her. Telephonic interview with Physician #12, on 10/01/2020 at 2:52 PM, revealed he did not recall anything about Resident #343. Review of the clinical record revealed no documented evidence by the physician for Resident #343's discharge, or an order for discharge from the facility. Review of the clinical record revealed no documented evidence that a written Notice of Discharge was sent to Resident #343, or the resident's Emergency Contact/Responsible Party (RP). Further review revealed no specific reasons listed as to what resident needs could not be met. Telephonic interview with Resident #343, on 10/01/2020 at 10:08 AM, revealed he/she received a call from a social worker at the facility, who stated, She hated to tell me this, but you are not going to be able to return to the facility. I told her I had only been in the hospital for two (2) days with a UTI. When I asked her why, she told me she did not know why. Further interview revealed with Resident #343 revealed, The Assistant Director of Nursing (ADON) had been with the Social Worker when she called me, so I asked her why as well. She told me the facility could no longer meet my clinical needs, and I asked, what clinical needs? The ADON could not give me an answer. The resident stated that he/she had not received any paperwork or a written notice of discharge. Interview with ADON #13, on 10/02/2020 at 8:13 AM, revealed she did not recall anything about Resident #343, or the resident's discharge from the facility. Review of the Discharge Summary and Recapitulation of Stay, dated and signed on 11/19/19 at 10:56 AM, by Social Worker #10, revealed the reason for discharge was met skilled care goals. Telephonic interview with Social Worker #10, on 10/01/2020 at 10:47 AM, revealed she would not disclose or acknowledge any information about Resident #343's case due to the Social Worker Code of Ethics. Telephonic interview with Resident #343's Emergency Contact/RP, on 09/30/2020 at 2:47 PM, revealed the facility phoned him and stated the facility could no longer meet his family member's needs. However, the facility did not identify the specific needs. He stated he had not received any paperwork in regards to Resident #343's discharge from the facility. Interview with Clinical Support Registered Nurse #8, on 09/30/2020 at 4:02 PM, revealed the Chief Nursing Officer (CNO) assessed Resident #343's care at the time of discharge, and decided the facility could not provide the care the resident needed. However, she was unsure what care the resident needed. Interview with the facility's Administrator- In-Training, on 10/01/2020 at 9:00 AM, revealed the CNO was not available for interview. Interview with the Assistant [NAME] President of Clinical Quality, on 10/01/2020 at 8:58 AM, on 10/02/2020 at 9:39 AM; and, on 10/02/2020 at 1:56 PM, revealed the facility made some decisions in regards to not being able to meet Resident #343's medical and psychosocial needs. He stated the specific needs the facility could not meet should have been documented in the resident's clinical record. He stated the facility had not given the resident a thirty (30) day notice because it had been determined the facility could not meet the resident's needs. He was unable to state whether or not the physician should have been involved in Resident #343's discharge. Telephonic interview with the previous Executive Director revealed Resident #343 had an unplanned discharge from the facility. He stated the facility could not meet the resident's needs because of staffing challenges at the time and that the resident required a two (2) to three (3) person staff assist with his/her Activities of Daily Living (ADLs). He stated Resident #343 should have received a discharge notice when the facility discharged him/her. Interview with the Interim Executive Director, on 10/02/2020 at 2:58 PM, revealed when a resident was discharged from the facility, a discharge notice had to be given; a copy given to the resident; and, a copy of the notice was kept on file in the resident's Electronic Medical Record (EMR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to develop and implement the care plan for two (2) of twenty-one (21) sampled residents (Residents #27 and #37). The findings include: 1. Review of the facility's policy Comprehensive Care Plan Guideline, revised 05/22/18, revealed the purpose of the policy was to ensure appropriateness of services that would meet the resident's needs, severity and stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. The policy revealed a comprehensive care plan would be developed within seven (7) days of completion of the admission comprehensive assessment. Care Plan problem areas should identify the relative concerns; goals should be measurable and attainable; and interventions should be reflective of the individual's needs and risk influence as well as the resident's strengths. The policy further revealed pertinent care plan approaches were communicated to the nursing staff, per the assignment sheet or Care Tracker profile dependent on the campus' preference. Review of the clinical record revealed the facility admitted Resident #27 on 12/24/18 with diagnoses which included Nondisplaced Intertrochanteric Fracture of the Left Femur, Dementia with Behavioral Disturbance, History of Falling, and Age-related Osteoporosis. Review of the Care Plan, revised 09/29/2020, revealed the plan stated the resident would safely wander around the facility and remain safe from any harm. Review of interventions revealed the resident would wear a wander guard device and nursing staff would collaborate with each other to help monitor the resident. Observation, on 09/29/2020 at 9:14 AM, revealed Resident #27 seated on the side of the bed. Further observation and interview with Licensed Practical Nurse (LPN) #2 revealed a wander guard bracelet should be attached to the resident's wheelchair; however, she could not locate a bracelet on the wheelchair or the resident. Observation, on 09/29/2020 at 12:25 PM, revealed Resident #27 exited the restorative dining room unsupervised and propelled to the opposite end of the South Hall. Further observation, on 09/29/20 at 12:29 PM, revealed the resident propelled back down the South Hall towards the dining room. Interview with Certified Nursing Assistant (CNA) #3, on 10/01/2020 at 2:01 PM, revealed it was important to supervise residents to ensure their safety. He further revealed the purpose of the wander guard bracelet was to protect a resident from elopement. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 2:57 PM, revealed care plans were individualized to include interventions to meet a resident's preferences and care needs. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 10:25 AM, revealed the care plan was a systematic intervention to meet a resident's needs. She stated Resident #27's care plan was not implemented if the interventions were not followed. Interview with the Minimum Data Set (MDS) Coordinator, on 10/02/2020 at 3:07 PM, revealed care plans were resident centered to address any issues and ensure interventions were in place to prevent potential harm. She stated the interdisciplinary team (IDT) reviewed progress notes, new orders, falls, and behaviors during the daily clinical care meeting (CCM) and she revised the care plan as needed. The MDS Coordinator revealed Resident #27 exhibited behaviors, including crying and wandering. Interview with the Interim Director of Health Services (DHS), on 10/02/2020 at 1:17 PM, revealed the MDS Coordinator or Social Services Director (SSD) was responsible for developing care plans to ensure interventions were individualized to resident care needs. She stated the IDT reviewed clinical records in the daily CCM and revised care plans as needed. The DHS revealed she was not aware of any issues related to care plan development or implementation. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed staff should follow and update care plans as needed to provide for residents' psychosocial, emotional, and physical needs. The ED revealed the goal of the facility was to make the care plan individualized and least intrusive as possible. He further stated the facility tried to find creative ways to provide a safe environment for certain residents. The ED stated he was not aware of any concerns related to care plans. 2. Review of the facility's policy, CCP guideline, revised 05/22/18, revealed CCPs were to remain accurate, current, and updated. The facility was to ensure the approach met the resident care needs to meet the resident's level of condition, impairment, disability, or disease according to Federal and State guidelines. Review of the clinical record revealed the facility admitted Resident #37 on 04/23/15 with the diagnoses of Quadriplegia, Chronic Respiratory Failure, and Tracheostomy. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident with severe cognition, total dependence with two (2) staff for all activities of daily living (ADL) needs including transfers and mobility. Further review revealed the resident had a Tracheostomy. Review of the facility's resident posted information, undated, revealed Resident #37 liked listening to music; liked being outdoors when the weather allowed; and, liked going to the activity room at 1:00 PM on Monday, Wednesday, and Friday for Mindful Moments. Review of the CCP, reviewed 09/22/2020, revealed the care plan for Resident #37 included Activities, which included to seat resident with younger residents, outdoors when the weather allowed, coordination of care with staff on attendance of activity, provide 1:1 as needed, and provide transport to activity. Further interventions included to attend music, spiritual, outdoor activity, social special events, animal, and sensory activity. Staff responsibilities included the transfer of the resident into the wheelchair on Monday, Wednesday, and Friday, and take to activities. The ADL care focus included interventions for transfers included the use of the specialty chair as ordered, and mechanical lift with total assist for all transfers. Review of the Resident First Meeting notes, dated 03/06/2020 at 10:09 AM, revealed a goal included to have staff dress the resident and transfer to the wheelchair at least every Monday, Wednesday, and Friday to socialize, and watch television (TV). Record review revealed on 06/12/2020, the TV required appropriate placement in order to allow the resident to watch TV. Further review revealed, on 09/17/2020, the facility removed the resident from isolation, but they had not changed the position of the TV. Observations, on Tuesday, 09/29/2020 at 9:40 AM and 3:30 PM; on Wednesday, 09/30/2020 at 8:43 AM, 10:40 AM, 12: 14 PM, 2:00 PM, AND 3:35 PM; on Thursday, 10/01/2020 at 10:59 AM, and 2:30 PM; and, on Friday, 10/02/2020 at 9:30 AM and 2:35 PM revealed Resident #37 in bed, staff did not have the TV or radio on for activities or stimulation, and the resident was not transferred into the wheelchair. Review of Physician Summary Orders revealed the physician ordered for Resident #37, tracheostomy (trach) care every shift, change humidifier water three (3) times a week with distilled water, oxygen saturation level check weekly while off oxygen, number four (4) SHILEY 4 (type of trach cannula) change monthly and PRN; change the inner cannula daily; change dressing to trach daily; oxygen at three (3) liters per minute per collar; trach suction as needed and after breathing treatment; and, oxygen monitoring per respiratory contracted orders. Continued review of the CCP for Resident #37 revealed the facility did not develop a focus care plan for the presence of the resident's Tracheostomy. Interview with Certified Nursing Aide (CNA) #3, on 10/02/2020 at 3:03 PM, revealed care plans explained the care required for each resident. He stated the care plan should be specific to the resident and the tasks necessary to care for the resident came from the care plan. CNA #3 stated the facility expected staff to follow the care plan. He stated the resident could decline if the care plan did not address the resident needs or staff did not follow. In addition he stated staff did not implement the care plan because the resident remained in bed, was not engaged in activity, and staff did not initiate activity in the room with music or TV. Interview with Licensed Practical Nurse (LPN) #3, on 10/02/2020 at 2:39 PM, revealed staffs' responsibilities included to follow resident care plans daily. She stated this ensured residents remained safe with the interventions specific for the resident. She stated when staff did not follow care plans ,the resident may become depressed or decline. LPN #3 stated the facility initiated a CCP upon a resident's admission and the MDS staff ensured the care plan interventions reflected the resident's care needs. She stated residents may suffer if staff did not follow the care plan or the interventions did not reflect specific care interventions for the resident. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 2:35 PM, revealed the facility prepared care plans with admissions and upon review and all resident care plans required specific interventions to meet the care needs of the residents. RN #1 stated the facility expected staff to follow the care plan at all times. She further stated staff did not initiate sensory activities and the resident remained in bed, therefore staff did not implement the resident's care plan. Interview with MDS Coordinator, on 10/02/2020 at 3:08 PM, revealed she obtained a resident's information to develop and revise the resident's CCP through observation, interview of staff and residents, review of orders, new treatments and review of clinical data. She stated the CCP focused on interventions to prevent harm and to implement care which spelled out the care the resident required to meet their goal. The MDS Coordinator stated residents with trachs required interventions specific to the resident because not every resident with a trach was the same. She stated upon review, the CCP needed to provide specific interventions, such as emergency supplies, and the size of the trach cannula to use which would provide the individuated components for each resident. She stated the facility expected staff to follow residents' care plans for ADL care and all the components required specific indicators for each resident. She stated the care plan provided directions for resident care to maintain physical, mental, and emotional health for dependent residents and if care needs were not specific and not implemented the resident may require hospitalization or die. Interview with the Director of Health Services (DHS), on 10/02/2020 at 4:06 PM, revealed she expected staff to provide the care plan interventions to ensure cognitive impaired residents received the appropriate care, services, and staff were to help provide activities. She stated the facility provided individualized care plans to meet each individual need for safe care. Further interview revealed she had not initiated care plan audits but, she expected staff to follow the care plan and MDS Coordinator should ensure the care plan reflected the resident's individual care needs. She stated residents could decline when care plans were not followed. Interview with the Executive Director, on 10/02/20 at 4:36 PM, revealed he ensured staff met the resident care needs with monthly review by the department supervisor. He stated he expected staff to follow resident care guides and orders to meet the needs of the resident. He further stated his responsibilities included to ensure staff provided the care ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy it was determined the facility failed to provide Activity of Daily Living (ADL) transfers for dependent residents for one (1) of two (2) bedfast residents of a total resident sample of twenty-one (21) (Resident #37). Observations revealed the resident remained in bed during times ordered by the physician to be out of bed. The findings include: The facility did not provide an ADL policy or a policy for transfers upon request. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15 with the diagnoses of Quadriplegia, Spastic Cerebral Palsy, and contractures. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with severe cognition, total dependence for transfers and bed mobility with two (2) person assist, impaired functional range of motion to both sides of the arms and legs, and used a wheelchair. Review of the Physician Order's, dated September 2020, revealed an order for staff to transfer the resident into a wheelchair Monday, Wednesday, and Friday for two (2) hours from 1:30 PM to 3:30 PM. Observation, on Tuesday, 09/29/2020 at 2:39 PM; Wednesday, 09/30/2020 at 2:00 PM, 2:50 PM, and 3:40 PM; Thursday, 10/01/2020 at 3:01 PM, and on Friday, 10/02/2020 at 2:35 PM, revealed Resident #37 in bed in his/her room. Review of the Progress Notes, dated 03/04/2020 at 2:45 PM, revealed the care plan meeting note included discussion of the resident's goal to have staff dress the resident, and transfer him/her to the wheelchair at least every Monday, Wednesday, and Friday. Interview with Certified Nursing Aide (CNA) #3 on, 10/02/2020 at 3:03 PM, revealed Resident #37 required a mechanical lift with two (2) staff to transfer into the wheelchair and the resident was dependent for all required ADL care. He stated he could not think of a reason why the resident could not be out of bed daily. CNA #3 stated staff used to get him/her up for activities, but this had not occurred for several months. He stated the transfer to the wheelchair provided pressure relief to areas affected while in bed, allowed for a change of scenery; and, getting out of the bed was good for the resident's emotional wellbeing. CNA #3 stated his care task listed getting the resident up once a week. Additionally, CNA #3 stated he had not transferred the resident to the wheel chair today. Review of CNA Task List, dated 09/28/2020, revealed Resident #37's documented ADL care needs included nothing by mouth, check and change, elbow brace, heel protectors, turn every two (2) hours, and a mechanical lift for transfer. The CNA tasks did not include when to transfer the resident into the wheelchair. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 2:35 PM, revealed Resident #37's care included physician orders to transfer the resident into the wheelchair. She stated the resident's care included to be up a couple times a week. Continued interview revealed the resident required a transfer to another surface for socialization, relief from pressure points in bed, respiratory status, and it was good for the residents to be out of bed. RN #1 stated being in bed all the time could cause depression and change of skin status. She stated staffs' responsibilities included to follow physician orders to ensure the resident maintained a healthy status for his/her body and mind. She stated staff did not follow physician orders for ADL care, which included to transfer the resident, because the resident remained in bed at the time of the interview. Interview with the MDS Coordinator, on 10/02/2020 at 3:08 PM, revealed residents who were dependent on all ADL care needs required staff to complete the related task. She stated when residents required full assist with transfers, the facility's expectations of staff included to transfer the resident as ordered. She stated the importance of staff to follow the order to transfer a resident from one area to another included prevention of skin breakdown, to move the resident to a different location for social and emotional care, and to ensure the staff completed the order. She stated when dependent residents' care plans were not followed the resident may end up in the hospital. She stated the facility assessed the resident as dependent with two (2) staff required for transfer by a lift. She stated staffs' expectations included to transfer the resident when the physician or family requested. Interview with the Nurse Executive, on 10/02/2020 at 4:06 PM, revealed when she cared for Resident #37 the resident's care included transfer to the wheelchair for activity. She stated the transfer to the wheelchair helped Resident #37 decrease the risk of skin integrity issues, changed his/her venue, and provided activity for the resident. She stated she audited resident care, how staff followed care plans or orders, with walking rounds, and she had not identified issues with Resident #37's care. She stated she expected staff to transfer the resident into the wheelchair as ordered. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed he ensured staff met the resident care needs with monthly reviews conducted by the Department Supervisor. He stated he expected staff to follow resident care guides and orders to meet the needs of the resident, which included transfer of the resident. He further stated his responsibilities included to ensure staff provided the care ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy, it was determined the facility failed to ensure individualized activities were implemented for one (1) of twenty-one (21) sampled residents (Resident #37). Observations revealed signage in Resident #37's room that stated he/she enjoyed music. However, the resident's environment was silence. The findings include: Review of the facility's policy, Individual Program Planning, dated 06/02/16, revealed programs were provided to residents who were not able to attend group programs. The program included interventions to meet the resident's social, emotional, physical, and cognitive functioning needs and ensured the resident had consistent recreation opportunities. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15 with the diagnoses of Quadriplegia, Chronic Respiratory Failure, and Tracheostomy. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with severe cognition impairment, extended or total dependent care needs, required oxygen seven (7) days a week, and received treatment for anxiety. Review of the facility's resident posted information, undated, revealed the resident liked listening to music; liked being outdoors when the weather allowed; and, liked going to the activity room at 1:00 PM on Monday, Wednesday, and Friday for Mindful Moments. Review of the Resident First Meeting notes, dated 03/06/2020 at 10:09 AM, revealed the notes included to dress the resident daily, socialize, and watch television (TV). On 6/12/2020, the facility notes for the meeting included concern over the location of the TV in regard to the resident's bed because the resident could not see the TV. Observations, on Tuesday, 09/29/2020 at 9:40 AM and 3:30 PM; on Wednesday, 09/30/2020 at 8:43 AM, 10:40 AM, 12: 14 PM, 2:00 PM, and 3:35 PM; on Thursday, 10/01/2020 at 10:59 AM, and 2:30 P; and, on Friday, 10/02/2020 at 9:30 AM and 2:35 PM revealed Resident #37 in bed and the TV and radio were turned off. Review of Progress Note, dated 09/17/2020 at 2:39 PM, revealed the resident was off isolation, and the facility's maintenance staff needed to change the TV placement. Interview with Certified Nursing Aide (CNA) #3, on 10/02/2020 3:03 PM, revealed Resident #37 liked music and to watch TV. He stated staffs' responsibilities included to turn on the TV or radio to provide stimulation, and to ensure the resident did not feel alone. CNA #3 stated this should be done daily and turned off later in the evening, which would give Resident #37 a sense of day and night. He further stated the CNA's task card did not specify to turn on the TV or music. However, CNA #3 stated all staff should be mindful and ensure either the TV or radio was on during the day. He stated the activity personnel could not be in the resident's room all the time so it was up to the staff to initiate the activity. CNA #3 stated without stimulation the resident could become depressed. Review of the CNA Task List, dated 09/28/2020, revealed Resident #37 documented care needs included nothing by mouth, tracheostomy (trach mask), perimeter mattress, elbow brace, heel protectors, and turn every two (2) hours. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 2:35 PM, revealed Resident #37's care included for staff to stimulate and socialize the resident. She stated the resident had access to a TV to watch and listen; and, a radio for music for his/her enjoyment. She further stated staff were expected to ensure the resident was stimulated and not in an isolated environment. RN #1 stated lying in a quiet environment listening to himself/herself breathe would make anyone depressed. Interview with the Life Enrichment Director (LED), on 10/02/2020 at 3:47 PM, revealed activities for cognitive impaired residents included sensory stimulation of music, smells, and sensory bins. The LED stated Resident #37 had a smart TV to ensure staff used the unit for music as well for TV shows and movies. He stated staff were expected to turn on the radio and TV daily to ensure the resident was stimulated and felt involved. The LED further stated the reason activities were included with resident care was to enrich the resident's life, wellbeing and provide personal contact with interests. He further stated if the resident did not have the TV or music on in the room the resident could become sensory deprived. Interview with the Nurse Executive, on 10/02/2020 at 4:06 PM, revealed resident activity information was located on the resident's wall by the door. She stated staff were to implement the activity or care listed and she expected staff to use the information to provide stimulation to prevent isolation. The Nurse Executive stated without stimulation the resident could become depressed and may further impair the resident. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed he expected staff to follow the activity plan for the residents when residents were unable to attend activities, when possible. He stated the activity provided to the resident helped to meet the psychosocial needs for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to supervise and ensure placement of a wander guard bracelet for one (1) of two (2) sampled residents (Resident #27), at risk for elopement, of a total resident sample of twenty-one (21). The findings include: Review of the facility's policy Elopement Risk Assessment and Prevention, revised 05/01/17, revealed the policies assisted to define the mechanisms and procedures for monitoring and managing residents at risk for elopement and help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. Wandering referred to a cognitively-impaired resident's ability to move about inside the facility aimlessly and without an appreciation of personal safety needs and who may enter into a dangerous situation. Further review of the policy revealed facilities with wander alert detection systems should place a wander alert bracelet on the resident. Activity programs should include plans for diversion and redirection during periods of increased wandering and exit seeking. Review of the facility's policy General Safety Practices, undated, revealed it was the policy of the facility to promote safety first when performing maintenance tasks. Review of the clinical record revealed the facility admitted Resident #27 on 12/24/18 with diagnoses to include Nondisplaced Intertrochanteric Fracture of the Left Femur, Dementia with Behavioral Disturbance, History of Falling, and Age-related Osteoporosis. Observation on 09/29/2020 at 9:10 AM revealed Resident #27 beating on the North Hall exit door, pushed the handle until the door alarmed, and asked to open the door. Interview with Licensed Practical Nurse (LPN) #2, during the observation, revealed Resident #27 was an elopement risk and occasionally went to the doors and tried to get out. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #27 exhibited the behavior of wandering. Review of the Quarterly Elopement Risk Review, dated 06/11/2020, revealed Resident #27 had a history of exit seeking and exhibited periods of pacing, agitation or wandering toward an exit. Approaches to prevent elopement included observing for elopement attempts. Review of the clinical record revealed a Physician's Order, dated 12/23/19, to check placement of the wandering system bracelet/device every shift twice a day. The order stated the bracelet was located on the right back bottom of the wheelchair. Observation, on 09/29/2020 at 9:14 AM, revealed Resident #27 seated on the side of the bed with a wheelchair at bedside. Further observation and interview with LPN #2 revealed a wander guard bracelet should be attached to the resident's wheelchair; however, she could not locate a bracelet on the wheelchair or the resident. Observation, on 09/29/2020 at 12:25 PM, revealed Resident #27 exited the restorative dining room unsupervised and propelled to an office at the end of the South Hall. Further observation, on 09/29/2020 at 12:29 PM, revealed the resident propelled back down the South Hall in the direction of the dining room. Observation of Resident #27, on 09/30/2020 at 2:35 PM, revealed the resident propelled to an exit door at the end of the North Hall and pushed on the handle to exit. Observation of the South Hall, on 10/01/2020 at 2:32 PM, revealed an unsecured utility closet located across from the beauty shop containing two (2) breaker boxes and a transformer. Further observation revealed an unsecured utility closet adjacent to room [ROOM NUMBER] which contained a fire alarm system panel. Interview with the Chief Engineer, on 10/01/2020 at 4:03 PM, revealed he accidentally left the utility room doors unsecured. He stated the rooms should be secured to prevent access to residents. Interview with Certified Nursing Assistant (CNA) #3, on 10/01/2020 at 2:01 PM, revealed it was important to supervise residents at risk of elopement because they could potentially fall or leave the building. He further revealed the purpose of the wander guard bracelet was to protect a resident from elopement. Interview with the Certified Medication Technician (CMT), on 10/02/2020, at 10:03 AM, revealed staff kept an eye on Resident #27 because he/she wandered around the building. The CMT stated she supervised the resident by checking on him/her every 15 or 20 minutes. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 2:57 PM, revealed nursing staff was responsible for verifying placement/function of wander guard bracelets. She stated it was important to verify placement because a resident could potentially elope and be injured. The LPN stated it took a village to keep an eye on Resident #27 because he/she roamed the building. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 10:25 AM, revealed staff kept a close eye on Resident #27 because he/she was a wanderer. RN #1 stated it was not okay for the resident to be unsupervised on the South Hall because he/she could easily follow someone who did not know him/her out of the building. Interview with the Interim Director of Health Services (DHS), on 10/02/2020 at 1:17 PM, revealed all staff were responsible for room rounds and supervision of residents to ensure their safety. She stated she was not aware of any issues related to the wander guard bracelets or supervision of residents. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed staff were expected to check on residents every two (2) hours. Further interview revealed the level of supervision would depend upon the resident's needs. The Director stated he was not aware of any issues related to wander guard bracelets, supervision of residents, or unsecured utility rooms. The ED revealed the ultimate goal of the facility was resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide Tracheostomy care and services for one (1) of two (2) sampled residents (Resident #37) with tracheostomy (trach) care needs, of a total resident sample of twenty-one (21). Observations revealed the facility did not have an AMBU (Artificial Manual Breathing Unit) at the resident's bedside. The findings include: Review of the facility's policy, Tracheostomy Care, revised 05/11/16, revealed the staff were to return the oxygen delivery device to the tracheostomy (trach) after each portion of the trach care session which required access to the device. Staff were to educate and prepare the resident for the care to be provided. Review of LinCare Tracheostomy Care, undated, included to educate and explain the procedure to the resident, suction the airway per the facility artificial airway procedure, and maintain a resuscitative bag for immediate use. The facility did not provide policies for emergency care, assessment of a resident with a trach, or trach suctioning procedures. Review of Lippincott Nursing Tracheostomy Care, dated 10/2018, revealed an artificial manual resuscitation bag at the resident's bedside for immediate use, as part of the listed equipment to be at the bedside at all times. Suctioning of the resident included to ensure correct suction depth to prevent trauma, insert slowly, remove the catheter slowly with the suction activated, and less than ten (10) seconds for the total procedure. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15 with the diagnoses of Quadriplegia, Chronic Respiratory Failure, and Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing). Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with severe cognitive impairment, extended or total dependent care needs, required oxygen seven (7) days a week, and received treatment for anxiety. Observation, on 09/29/2020 at 2:39 PM; 09/30/2020 at 8:49 AM; 10/01/20 3:01 PM and, 10/02/20 at 10:02 AM, revealed the facility did not have a AMBU bag in or at the bedside of Resident #37's room. Interview with Licensed Practical Nurse (LPN) #2, on 09/30/2020 at 8:49 AM, revealed she could not locate an AMBU in Resident #37's room. She stated the room previously had one at the bedside and the other resident in the room, who also had a trach, had an AMBU at his/her bedside. She stated she did not know if a resident with a trach needed an AMBU at the bedside at all times. However, LPN #2 stated staff used the AMBU to give resident air and provide respiratory support when indicated. Interview with Registered Nurse (RN) #1, on 10/02/2010 at 2:35 PM, revealed staff interactions with Resident #37 included to talk to the resident to ensure he/she felt as a part of the care process and that he/she mattered. She stated she observed Resident #37's room to be without an AMBU bag. She stated the resident should have an AMBU at the bedside. RN #1 stated if the resident's oxygen went low and equipment was not immediately available, then the resident might not recover. Interview with the Nurse Executive (NE), on 09/30/2020 at 9:05 AM, revealed the facility did not follow standards of care from Lippincott Nursing Care, which the Nurse Executive cited was used as the facility's procedures for their standard of care. In addition, the NE stated education provided by the contracted respiratory company included an AMBU for immediate use at the residents' bedsides. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed observations of trach care was done by the NE. He stated the observations were reviewed monthly by the head of the department and this ensured residents care and services were met. He further stated he did not receive any reported care issues for resident with tracheostomy care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy, Tracheostomy Change, revised 05/11/16, revealed the resident should be assessed for the following indications that the tracheostomy change was needed: abnormal breath sounds, reduced airflow through the tube, and/or respiratory distress, trach pulled out. Explain the procedure to the resident; perform hand washing and put on gloves; put on a mask and protective eyewear as indicated. Assist the resident to Fowler's or semi-Fowlers position; and hyperextend the neck by putting a pillow under the shoulders (if resident can tolerate). Check the cuff on the new trach by inserting air with syringe, to make sure it inflates, and listen for air leaks. Then deflate cuff entirely. Undo the trach collar, holding on to trach; remove old trach tube; insert the new trach tube immediately as the patient is inhaling; remove obturator immediately while holding the tube in place with your fingers; insert the inner cannula (if trach tube has one); inflate the cuff with syringe; apply trach collar; and suction as needed. Apply split sponge dressing; assess lung sounds; discard supplies in appropriate receptacles and wash hands. Document the size of trach tube, color and amount of secretions, resident's response to procedure, and any abnormalities noted, if any. Review of the clinical record revealed the facility readmitted Resident #36 on 12/13/19 with diagnoses to include Spastic Quadriplegic Cerebral Palsy and Chronic Respiratory Failure with Hypoxia. Further review of the clinical record revealed a Physician's Order, dated 07/16/19, for a #5 Shiley (type of cannula) tracheostomy tube with obturator to be kept at bedside - taped to wall in a bag at all times for emergency replacement purposes as needed for tracheostomy dislodgement. Interview with Licensed Practical Nurse (LPN) #2, on 09/29/2020 at 2:26 PM, revealed the facility's respiratory provider changed tracheostomy tubes every 30 days. Interview with Registered Nurse (RN) #1, on 09/30/2020 at 9:00 AM, revealed in the event of an accidental decannulation she would ensure the stoma was patent, check the resident's oxygen saturation, and insert a tracheostomy tube in the stoma; however, she could not describe the procedure for insertion of the tube or use of the obturator. The nurse revealed she was new to the facility and was not trained on accidental decannulation. Review of the Respiratory Services Inservice, dated 02/13/2020, revealed RN #1 did not attend the training. Further review of the training material revealed no content related to accidental decannulation. Interview with the Interim Director of Health Services (DHS), on 10/02/2020 at 1:17 PM, revealed the facility trained staff upon hire, to include skills competency. She stated the facility and the respiratory services provider trained and assessed staff for competency of tracheostomy care and skill(s) in February. However, RN #1 was hired in March and missed the inservice. She stated she had no concerns with the care RN #1 provided and stated there were resources and other staff available in the event of an emergency. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed he was not aware of any concerns related to staff education/competency. Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide training and ensure competent nursing staff for the provision of tracheostomy care and emergency interventions for two (2) of twenty-one (21) sampled residents (Residents #36 and #37). The findings include: 1. Review of the Lippincott Nursing Tracheostomy Care, dated 10/2018, revealed suctioning of a tracheostomy (trach) included to ensure correct suction depth to prevent trauma, to insert catheter slowly, and remove slowly with suction activated while using less than ten (10) seconds for the total procedure. Furthermore, the oxygen mask was to be replaced to the tracheostomy at all times except when care required access to the stoma or when the trach was removed. The resident was to be monitored to ensure oxygen levels were maintained, not in distress, and that emergency supplies were available to treat the resident. Review of the LinCare Tracheostomy Care, undated, revealed staff were to monitor the resident during the procedure, assess the respiratory status before and after the session, to suction the airway per the artificial airway procedure, and maintain a resuscitative bag for immediate use. The facility did not provide policies for emergency care, assessment of a resident with of a trach, or trach suctioning procedures. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15, with the diagnoses of Quadriplegia, Chronic Respiratory Failure, and Tracheostomy. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with oxygen requirements seven (7) days a week. Observation, on 10/01/2020 at 11:00 AM, revealed Licensed Practical Nurse (LPN) #2 set up a sterile tray for trach care and suctioning with her back to the resident and table in front of her. The LPN reached over the sterile field several times to obtain supplies on the dresser. The LPN was observed providing care with her body turned away from the resident and rotated her upper body back and forth to provide care. The LPN removed the oxygen trach mask and pinned it to the side of the bed. Continued observations revealed with one (1) hand, the LPN repeatedly pulled the gauze dressing placed under the trach while she twisted around to the resident, and dislodged the trach to the edge of the stoma. LPN #2 did not reach in and clean the edges of the stoma, instead swiped around the edge of the face plate. The LPN did not inform the resident, proceeded to push the suction catheter into the resident's trach tube, the resident gagged and began a long episode of coughing. Further observation revealed the resident turned a deep red to purple color while his/her tongue protruded. The LPN did not replace the oxygen mask to the resident, did not attempt to sooth the resident at this time and resumed one (1) other suction episode in the same manner. LPN #2 removed one side of the trach tie, did not hold the face plate, and the trach dislodged to the tip of the stoma. The LPN did not monitor the resident's oxygen level throughout the procedure and did not complete a respiratory assessment after the procedure. Interview with LPN #2, on 10/01/2020 at 11:30 AM, revealed she provided care and treatment for Resident #37 every time she worked. She stated she attended an in-service education provided by the respiratory service provider for trach care. LPN #2 stated Resident #37 did not appear distressed with the procedure and she did not self-identify concerns for the provided care with the exception of not ensuring the trach plate was held down. The LPN stated she had access to a pulse oximeter. She stated she did know the facility's policy for trach care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations, on 10/2/2020 at 8:00 AM, revealed observations of medication pass with Registered Nurse (RN) #2, revealed staff did not wash or sanitize hands before initiation of medication preparation and before entering resident rooms after handling equipment on the medication cart. Equipment included drawers to the cart, medication packages, containers, computer keyboard, and computer mouse. Furthermore, observations revealed staff held water cups by the lip of the cup and handed the residents the cup of water to drink. In addition, staff obtained vital signs for multiple residents with the assigned vital sign machine and pulse oximeter. Continued observation revealed staff did not clean the devices with a disinfectant agent after use with a resident and used the devices with the next resident. Review of the policy, Medication Administration-General Guidelines, revised 1/17, revealed when administering medications staff washed or sanitized their hands at the beginning of the medication pass, prior to handing medications, after contact with the resident. Interview with RN #2, on 10/02/2020 at 8:00 AM, revealed the facility provided and the RN completed education for general infection control and to prevent the spread of COVID-19 virus. The RN stated staff's responsibilities included to wipe the vital sign unit and pulse oximeter with the disinfection wipe after each resident. The RN stated the disinfection process was to prevent the spread of the virus and any other bacteria to other residents. RN #2 stated the facility expected all staff to follow standard infection control practices. Further interview revealed proper HH included to sanitize or wash hands before medication prep, and when staff entered and exited resident room. The RN stated the facility expected staff to follow proper HH practices because HH prevented the transmission of infections more than any other practice for infection control. RN #2 stated they forgot to clean the equipment between residents. The RN stated when staff did not follow infection control (disinfection and proper HH) staff put residents at risk for infection which could lead to a risk of loss of life. The RN further stated they did not follow the facility's policy for infection control. Interview with the Nurse Executive, on 10/02/2020 at 4:06 PM, revealed she expected staff to clean all equipment after each use with a resident to prevent the spread of infection. She stated she expected staff to follow the infection control practice for HH to prevent the spread of infection. The Nurse Executive stated when staff did not follow HH or ensure the disinfection of equipment used for residents, it could result in the spread of the COVID-19 virus. She stated the facility audited medication pass which had not identified infection control issues with HH and equipment cleaning. She stated she expected staff to follow policy and when they did not follow policy the residents were not safe. She stated her responsibilities included to make sure residents remained safe. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed that the staff who cared for the residents should consider the need for good infection control. Based on observation, interview, and facility policy review it was determined the facility failed to implement an effective infection control program related to hand hygiene (HH), unlabeled personal hygiene products, and storage of clean linens in one (1) of one (1) shower room on the North Hall. In addition, the facility failed to implement an effective infection control program to prevent the spread of bacteria and communicable diseases, which includes COVID-19 infection control guidelines in relation to maintain clean equipment used for multiple residents and HH. Observations revealed staff did not wash hands after contact with residents, and failed to sanitize the equipment used to obtain vital signs, and the pulse oximeter. The findings include: 1. Review of the facility's policy Infection Prevention and Control Program (IPCP), revised 11/10/17, revealed the purpose of the policy was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy revealed the campus shall designate a member of the clinical team to monitor the campus IPCP program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP. The policy revealed designee responsibilities included monitoring compliance with infection control practices and procedures; and ensuring timely infection control education and training at orientation, regularly scheduled in-services, and as needed in response to identified problems. Review of the facility's policy Guideline for Handwashing/Hand Hygiene, revised 03/12/2020, revealed handwashing was the single most important factor in preventing transmission of infections. The policy stated HH was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Health Care Workers shall use HH at times such as: reporting to work; before/after eating; after smoking, toileting, blowing nose, coughing, sneezing, etc; before/after preparing/serving meals, drinks, tube feedings, etc; before/after having direct physical contact with residents; and after removing gloves, worn per Standard precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc. Review of the facility's policy, Medication Administration-General Guidelines, revised 1/17, revealed when administering medications staff washed or sanitized their hands at the beginning of the medication pass, prior to handing medications, after contact with the resident. Review of Centers for Disease Control and Prevention (CDC), and the COVID-19 Standard Infection Control Practices, 2019, revealed standard infection control practices to decrease the transfer of the COVID-19 virus included to clean and disinfect equipment used between residents with an approved agent for viral pathogens prior to use on another resident Observation of the North Hall Shower Room, on 09/29/2020 at 9:53 AM, revealed a stack of clean towels/washcloths stored in a handwashing sink and a white uniform jacket lying on top of the linens. There were soiled towels on top of the trash can and a soiled washcloth on the floor. Further observation revealed the following opened, unlabeled personal hygiene items stored on top of a heating unit: one (1) 30 oz. bottle of hair conditioner, two (2) 1.5 oz. cans of shaving cream, one (1) 700 ml bottle of hair conditioner, one (1) 8 oz. bottle of shampoo and body wash, one (1) 21 oz. bottle of lotion, one (1) 2.6 oz. tube of deodorant, one (1) 13 oz. bottle [NAME] moisture conditioner, one (1) 16.8 oz. bottle of lotion, one (1) 16 oz. bottle of lotion, one (1) bottle of cocoa butter lotion. Further observation of the shower room revealed one (1) 3 oz. bottle of antifungal body powder, one (1) 5.6 oz. tube of protective ointment, and one (1) 3.4 oz. tube of deodorant stored on a shelf. In addition, there was one (1) unlabeled tube of protective ointment on top of the toilet tank and two (2) unlabeled brushes containing hair on the sink. Interview with the Certified Medication Technician (CMT) Preceptor during observation revealed personal hygiene items should not be shared and should be labeled with the resident's name/room number. She further revealed clean linens should not be stored in the handwashing sink due to infection control issues. The CMT stated sharing personal hygiene items and improper storage of clean linens could spread germs. Observation of Registered Nurse (RN) #1, on 09/30/2020 at 8:34 AM, revealed the nurse entered room [ROOM NUMBER] and assisted a resident with his/her sweater. The RN failed to perform HH, exited the room, and walked to the nurses' station. The nurse collected papers at the nurses' station, pulled a cell phone from her pocket, made a phone call, and placed the phone back in her pocket. She used the computer at the desk, left the nurses' station, failed to perform HH, entered room [ROOM NUMBER], and closed the door. Observation of Restorative Dining, on 09/29/2020 at 11:57 AM, revealed the CMT pushed Resident #27's wheelchair to the dining room, failed to perform HH, removed clothing protectors from a storage cabinet, and passed them out to seven (7) residents. The CMT placed a clothing protector on Resident #21, failed to perform HH, removed Resident #39's facemask, and performed HH. Further observation of dining revealed the CMT placed a clothing protector on a resident, removed his/her facemask, failed to perform HH, and passed out silverware/napkins to resident tables. Interview with Certified Nursing Assistant (CNA) #3, on 10/01/2020 at 2:01 PM, revealed personal hygiene items should be labeled with the resident's name and stored in their room. However, staff forgot to return them to the resident's room once in a while. He stated personal hygiene items should not be shared because it was an infection control issue. Further interview with CNA #3, on 10/01/2020 at 2:49 PM, revealed HH should be performed before/after leaving a resident's room, before and after contact with a resident, and between each tray during tray pass. He stated it was important to perform HH to prevent the spread of germs and infection. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 2:57 PM, revealed staff should perform HH before/after resident care, after touching anything dirty or soiled, and after contact with resident equipment. She stated HH was the first line to prevent the spread of infection. The LPN revealed she constantly reminded CNA's to make sure they performed HH. LPN #3 stated she was not aware of any issues. Further interview with LPN #3 revealed she noticed personal hygiene items left in the shower room every once in a while. She stated the purpose of labeling hygiene items was to ensure they were not used for another resident because of the potential for passing germs and infection. Interview with Registered Nurse #1, on 10/02/2020 at 10:25 AM, revealed she noticed personal hygiene items lined up on top of the air conditioning unit in the shower room. She further revealed staff were responsible for ensuring the items were labeled with the resident's name. According to RN #1, personal hygiene items should not be shared because of the potential for cross contamination with skin infections. Interview with the Interim Director of Health Services (DHS)/Infection Preventionist, on 10/02/2020 at 1:17 PM, revealed personal hygiene items should be labeled with the resident's name and stored in the resident's room. She stated she monitored the shower room once or twice a week and had not identified any concerns. Further interview with the DHS revealed she monitored restorative dining at least weekly to ensure staff were performing HH and ensure residents received the correct diet/adaptive equipment. She stated every once in a while she had to remind someone about HH but it was not a huge issue. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed the facility conducted random audits for infection control to ensure staff donned/doffed personal protective equipment (PPE) and performed HH appropriately. The ED stated he was not aware of any concerns related to infection control.

Based on interview, record review, and facility policy review it was determined the facility failed to implement an effective immunization program for influenza vaccine for two (2) of five (5) sampled residents (Resident #20 and #27) of a total resident sample of twenty-one (21). The findings include: Review of the facility's policy Guidelines for Influenza and Pneumococcal Immunizations, revised 05/01/17, revealed each resident/responsible party would be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request unless medically contraindicated. The policy revealed it would be documented if the resident refused immunization or did not receive the immunization as a result of a medical contraindication (including the nature of the resident's medical contraindications), unavailability, or a precaution that delayed the administration and a later date for administration had been planned. The campus would document vaccinations given in the resident's Electronic Health Record (EHR). Review of Resident #20's clinical record revealed the facility did not administer an annual influenza vaccine for the 2019 flu season. The facility did not provide a copy of Resident #20's influenza informed consent/declination form for the 2019 flu season. Review of Resident #27's clinical record revealed the facility did not administer an annual influenza vaccine for the 2019 flu season. The facility did not provide a copy of Resident #27's influenza informed consent/declination form for the 2019 flu season. Interview with the Interim Director of Health Services (DHS) and Infection Preventionist, on 10/02/2020 at 1:17 PM, revealed she was responsible for monitoring residents' immunization status. She stated the facility audited immunization records in July and identified concerns with flu vaccines and consents. According to the DHS, the facility needed to reconcile immunization administration(s) with the resident clinical record(s). Interview with the Interim Administrator, on 10/02/2020 at 4:31 PM, revealed the informed consent/declination form(s) and immunization administration records should be documented in the clinical record. He revealed the facility had identified gaps in immunization records during the transition to new management.

Based on interview, record review, and policy review, it was determined the facility failed to maintain accurate documentation of the freezer and refrigerator temperatures for one (1) of one (1) walk in cooler; one (1) of one (1) walk in freezer; and two (2) of two (2) reach in coolers. The findings include:: Review of the facility's policy titled, Storage, and dated 05/31/16, revealed refrigerated storage temperatures will be recorded on the Refrigerator Log at least twice daily and frozen storage temperatures will be recorded on the Freezer Temperature Log at least twice a day. Review of the, Cooler/Freezer Temp Log, dated September 2020 revealed on 09/29/2020 at 9:19 AM, the Temp Log had already been completed in entirety through 09/30/2020. Interview with [NAME] #18 on 09/29/2020 at 9:22 AM revealed he had documented the temperatures of the coolers, and freezer this morning, 09/29/2020, and he must have just mixed up the dates. Interview with the Dietary Director, on 10/02/2020 at 10:00 AM, revealed his expectation of the Cooks were to monitor and accurately log the refrigerators, and freezer temperatures twice a day. He stated Management reviewed the Temp Log daily. Further interview revealed the purpose of checking the temperatures of the refrigerators and freezer was to ensure the equipment was in working order, and all of the food products were stored within safe temperatures zones. He stated if the refrigerators and freezer were not monitored appropriately the food products could spoil and possible make residents ill.