Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure health information was maintained in a private and confidential manner for 1 of 12 sampled residents, Resident (R) 16. On 04/08/2025, R16's Medication Administration Record (MAR) was observed unattended and exposed to public view. The findings include: Review of the facility's policy titled, HIPAA [Health Insurance Portability and Accountability Act] Privacy Addendum, dated 03/05/2018, revealed the facility shall not disclose any protected health information. Review of R16's Face Sheet revealed the facility admitted R16 on 03/18/2025 with diagnoses to include heart failure, stroke, and bipolar disorder. Observation, on 04/08/2025 at 12:01 PM, revealed an unattended medication cart on the 300 Unit between the kitchen and porch. Further observation revealed R16's Medication Administration Record (MAR) was visible on the computer screen and in plain view. Registered Nurse (RN) 1, who was in charge of the medication cart, was not in the hall. During interview with RN1 on 04/08/2025 at 12:04 PM, she stated she should not have left the resident's MAR pulled up on the computer screen because health information should be kept confidential. During interview with the Director of Nursing (DON) on 04/10/2025 at 4:13 PM, she stated staff should always keep their computers closed when they were not with the computer. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated she addressed each issue regarding resident privacy when they were brought to her attention. She stated she first established a time frame using a matrix. She stated the time frame for each incident varied according to the severity of the issue. She stated she then involved the Staff Development person to educate staff and followed-up to assure the issues were resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 12 sampled residents, Resident (R) 28. The findings include: Review of the facility's policy titled, Discharge, last revised 09/29/2022, revealed for all discharges and transfers, including to an acute care facility, the Office of the State Long-Term Care Ombudsman was to be notified. Review of R28's Face Sheet in the electronic medical record (EMR) revealed the facility admitted the resident on 01/14/2025 with diagnoses to include dementia, stroke, and chronic kidney disease. Further review of the EMR revealed the facility transferred R28 to the hospital on [DATE], but there was no documented evidence the Ombudsman had been notified in writing. During interview with the Social Services Director (SSD) on 04/10/2025 at 1:47 PM, she stated she did keep a list of notifications to the Ombudsman of discharges from the facility. She stated they had a conversation about the discharges every time the Ombudsman was at the facility. During telephone interview with the Ombudsman on 04/10/2025 at 2:02 PM, she stated she was not notified of residents who were discharged . She stated, when she came to the facility every month or two, she asked for a list of current residents and those that had been discharged . During interview with the Director of Nursing on 04/10/2025 at 4:13 PM, she stated it was the responsibility of the SSD to notify the Ombudsman of all transfers/discharges. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated her role was to assure the facility's policies were followed and to review the polices and address any issues.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC)document, and review of the facility's policies, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 12 sampled residents, Resident (R) 2 and R16. Observation on 04/08/2025 revealed staff did not perform correct hand hygiene when providing care to R2. Observation on 04/08/2025 revealed staff did not correctly dispose of a gown worn during the care of R16, who was in Enhanced Barrier Precautions (EBP). The findings include: Review of the facility's Infection Prevention and Control and Surveillance Program policy, dated 11/01/2017, revealed staff was required to adhere to standard precautions and use personal protective equipment (PPE) according to infection control precautions. Review of the facility's Hand Hygiene policy, revised 04/01/2024, revealed alcohol-based hand sanitizers should be used immediately upon removal of gloves. The policy further stated alcohol-based hand sanitizers should be used when moving from a soiled body site to a clean body site of the same resident. Review of the CDC's document Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated July 12, 2022, revealed Enhanced Barrier Precautions (EBP) was an infection control intervention designed to reduce transmission of resistant organisms that employed targeted gown and glove use during high contact resident care activities. Per the document, signage needed to be posted, indicating the type of precautions and required PPE. It also stated to position a trash can inside the resident's room and near the exit for discarding PPE after removal, prior to exit of the room, or before providing care for another resident in the same room. 1. Observation on 04/08/2025 at 9:56 AM revealed R2 was lying in bed. Registered Nurse (RN) 1 was in the room getting medications. R2 asked to be cleaned, and the nurse called Certified Nurse Assistant (CNA) 1. CNA1 and RN1 cleaned R2's bowel movement. Per observation, CNA1 removed gloves and left the room to get linen. CNA1 opened the door then sanitized hands. Per observation of RN1, after cleaning R2's bowel movement, she cleaned the perineal area without changing gloves. During interview with CNA1 on 04/08/2025 at 10:13 AM, CNA1 stated staff should sanitize each time gloves were removed because there could be a hole in the gloves, and it could spread infection. During interview with RN1 on 04/08/2025 at 10:19 AM, she stated she should have changed her gloves when moving from R2's back to front. She further stated it could cause the resident to get an infection. 2. Observation on 04/08/2025 at 4:44 PM revealed a yellow gown (PPE) was on a chair outside R16's room, and there was no EBP sign on the door. During interview with RN1 at the time of the observation, she stated she must have placed it there. She stated she should have put it in a container in the room. She stated she had been trained in infection control, she just forgot. During interview with the Infection Preventionist (IP) on 04/10/2025 at 10:11 AM, she stated R16 was on EBP and she usually placed a sign on the resident's door indicating what type of precaution and what was required to care for residents, such as PPE and/or laundry restrictions. She stated the sign fell, and she had not replaced it. She stated she expected staff to either wash or sanitize their hands after changing gloves. She stated she would also expect staff to wash or sanitize their hands and change gloves when going from a dirty area to a clean area. During interview with the Director of Nursing (DON) on 04/10/2025 at 4:13 PM, she stated the IP trained staff to follow precautions to prevent the spread of infection. She stated anytime the resident was in infection control precautions, staff should remove their PPE prior to leaving the room. She further stated staff was taught to wash or sanitize their hands after they removed their gloves. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated her role in infection control was to be notified of any issues from staff, the IP, or the DON. She stated she expected staff to follow the facility's infection control policies, and her role was to assure the facility's policies were followed. She stated she reviewed the policies and made changes if needed. She stated, if there were problems, the Staff Development Coordinator educated staff.

Based on observation, interview, and facility policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 22 current residents. The findings include: Review of the facility's Food Storage policy, revised 07/11/2024, revealed, Raw meat is to be stored in drip proof containers. Any expired or outdated food products should be discarded. Observation in the kitchen on 04/08/2025 at 9:07 AM, revealed the front refrigerator had a container of cottage cheese that expired on 03/31/2025. Continued observation at 9:09 AM revealed a package of hamburger lying on the middle shelf, and it was not in a container. There were two uncovered melons on the shelf below. During telephone interview with the Dietitian on 04/10/2025 at 2:02 PM, she stated all meat should be stored in a container on the bottom shelf. She further stated if the meat juice dropped on the melons, it could put the residents at risk for illness. She stated she would expect staff to store the meat in a container on the bottom shelf. She also stated staff should dispose of expired food because a resident could potentially become ill if they ate expired food. During interview with the Director of Nursing (DON) on 04/10/2025 at 4:13 PM, she stated staff was to check the refrigerators for any expired foods and to store foods correctly. She stated eating expired food could cause a resident to become ill. She further stated staff should store meat so it could not drip onto other foods. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated she was not aware of the issue with the food. She stated when she was informed of issues and errors were made, she educated staff to prevent recurrence.

Based on observation, interview, and review of the facility's procedure on mechanically altered diets, it was determined the facility failed to ensure pureed food was blended to a smooth consistency to meet the needs of residents who required a pureed diet, during one (1) of one (1) meal service observed. The failure had the potential to affect three (3) residents who required pureed diets out of twenty-two (22) facility residents. The findings include: Review of the facility's Mechanically Altered Diet Explanation procedure, revised 05/06/2019, revealed, Puree all foods to the consistency of smooth, moist mashed potatoes or pudding-like consistency. Observations of the lunch meal, on 05/09/2022 between 12:14 PM and 12:40 PM, revealed Ezer (a Certified Nurse Aide who received kitchen and housekeeping training) #2 preparing to puree meatloaf for a resident who required pureed meats. At 12:24 PM, Ezer #2 cut a piece of meatloaf from the pan and placed it into the food processor to blend. No moisture was added to the food processor at this point. She blended the meatloaf for a couple of minutes then plated the meatloaf. Chunks of vegetables as well as pieces of unblended meat were visible in the finished product. During the observation, Ezer #2 was asked if the meatloaf was blended enough. Ezer #2 stated that it was, then retrieved Ezer #6 to verify the texture. Ezer #6 noticed the chunks of vegetables and meat and suggested Ezer #2 add some vegetable broth to the meatloaf to help blend it to a smoother consistency. Ezer #6 pointed out to Ezer #2 the importance of a smooth, consistent, pureed texture to prevent aspiration and choking. Ezer #2 acknowledged Ezer #6's comments, then added some vegetable broth to the meatloaf and re-blended it to a smooth, consistent texture. Interview with Ezer #2, on 05/09/2022 at 12:40 PM, revealed she received culinary training provided by the Support Services Manager (SSM) during orientation. She stated she also shadowed an Ezer in the kitchen of the cottage before performing the kitchen tasks herself. She stated she completed the ServSafe training on the computer, which covered kitchen sanitation and textures. Ezer #2 stated she demonstrated pureed texture to the SSM during kitchen orientation. Interview with Ezer #3, on 05/10/2022 at 10:13 AM, revealed the Ezers received classroom training and shadowed other Ezers who were cooking and working in the kitchen. He stated pureed texture was supposed to be smooth, with no chunks of food. Interview with Ezer #10, on 05/10/2022 at 10:22 AM, revealed classroom kitchen training was provided and she also shadowed others who were cooking. She stated pureed texture was supposed to be smooth and consistent. Interview with the SSM, on 05/10/2022 at 12:34 PM, revealed she oversaw the culinary orientation provided to the Ezers. She stated the daily prep sheet described menu items, ingredients needed, the recipes, and the different preparations for textures of the food items. She stated the texture training included a return demonstration during the hands-on training in the kitchen. The SSM also stated she supervised Ezer #2 and two (2) other Ezers in training during the hands-on kitchen training on 04/22/2022. She stated she observed Ezer #2 correctly blend and prepare the mechanical soft and pureed texture diets. Continued interview revealed Ezer #2 also shadowed a seasoned Ezer before being assigned as a kitchen Ezer. Interview with the Director of Nursing (DON), on 05/11/2022 at 12:28 AM, revealed the pureed diet texture should be smooth with no chunks. The DON stated improper consistency could lead to choking or aspiration. Interview with the ED, on 05/11/2022 at 12:12 PM, revealed pureed foods should be blended until smooth and consistent, with no chunks.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety in two (2) of three (3) kitchens (Faith Cottage and Hope Cottage kitchens). The failed practices had the potential to affect all twenty-two (22) residents. Observations, on 05/09/2022, of the Faith Cottage kitchen, revealed a box of food stored on the floor; a dented can of food on the shelf for use; and, expired cans of food on the shelf for use. Observations, on 05/09/2022, of the Hope Cottage kitchen, revealed an opened package of raw beef stored next to an opened package of shredded cheese; and expired food items and dented cans of food available for use. In addition, a kitchen staff member, while handling food, used antibacterial hand sanitizer instead of washing hands with soap and water. The findings include: Review of the facility's policy titled, Food Storage, updated 03/09/2020, revealed, Upon delivery all food items should be inspected for safe transport and quality upon receipt. Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. Further review of the policy revealed, All products should be inspected for safety and be dated upon receipt, when open, and when prepared. Raw meat is to be stored in drip-proof containers separately from cooked meats and other raw foods. The policy also stated, Dented or bulging cans should be placed on the Damaged Goods Shelf and returned for credit. All foods should be stored away from the walls, off the floor, and clear of ceiling sprinklers, sewers/waste disposal pipes and vents. Review of the facility's policy titled, Handwashing and Glove Use, updated 02/01/2014, revealed, Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the dietary department must be followed. Note: Antimicrobial hand gel cannot be used in place of proper hand washing techniques with soap and warm water. Review of the facility's Culinary Orientation packet, on 05/09/2022, revealed no references to using hand sanitizer gel in place of handwashing in the kitchen. The instructions indicated handwashing must occur prior to putting on gloves and whenever gloves were changed. 1a. Observations in the Skilled 1-Faith Cottage (unit) on 05/09/2022 at 10:17 AM, revealed one (1) unopened box of strawberry nutrition shakes stored on the floor between the stand-up freezer and pantry shelving. Interview with Ezer (a Certified Nurse Aide who received kitchen and housekeeping training) #1, on 05/09/2022 at 10:32 AM, revealed the box on the floor between the stand-up freezer and pantry shelving was an unopened box of strawberry nutritional shakes. Ezer #1 stated nothing should be stored on the floor of the pantry. 1b. Observations in the Skilled 2 - Hope Cottage kitchen, on 05/09/2022 at 11:41 AM, revealed the refrigerator in the pantry contained an opened five-pound (5-lb.) roll of raw ground beef that was stored on a cookie sheet in the bottom drawer. The ground beef was next to an opened bag of shredded mozzarella cheese and a sealed bag of mashed potatoes. Interview with Ezer #2, on 05/09/2022 at 12:40 PM, revealed meat should be thawed and stored on a tray by itself and not with other food products. She noted that the raw ground beef was on the cookie sheet next to the open bag of cheese and sealed bag of potatoes in the pantry refrigerator. Ezer #2 stated the meat could cross-contaminate the cheese and should be stored on its own. Interview with the Support Services Manager (SSM), on 05/09/2022 at 1:17 PM, revealed she oversaw the Ezer training in the cottage kitchens. She stated nothing should be stored on the floor. The SSM stated raw meat, such as ground beef, should be thawed and stored in the bottom drawer of the refrigerator, on a cookie sheet, by itself, and should not be touching other food items. She stated raw meat could cross-contaminate food items stored with it. Interview with Ezer #3, on 05/10/2022 at 10:13 AM, revealed raw meat should be thawed in the lowest drawer of the refrigerator, away from any other food items. He stated unsafe thawing of raw meats could introduce foodborne illness to the residents. Interview with the Executive Director (ED), on 05/11/2022 at 12:12 PM, revealed raw meat should be stored in the bottom of the refrigerators away from other food items to prevent cross-contamination. Interview with the Director of Nursing (DON), on 05/11/2022 at 12:28 PM, revealed raw ground beef should be thawed and stored in the bottom drawer of the refrigerator away from other food items. She stated the meat drippings could contaminate other foods. The DON stated the improper thawing of meat could introduce foodborne illness to the residents of the facility. 2a. Observations in the Skilled 1-Faith Cottage kitchen and pantry, on 05/09/2022 at 10:17 AM, revealed one (1) six-pound can of pears that was dented along the seal and bottom of the can; three (3) three-pound cans of cream of potato soup, with a printed expiration date of 04/29/2022; one (1) three-pound can of vegetable soup, with a printed expiration date of 02/03/2022; and two (2) forty-six (46)-ounce containers of prune juice, with a printed expiration date of 03/16/2022. There was no shelf designated for storage of dented cans for disposal. Observations of the main pantry on 05/10/2022 at 3:31 PM, revealed a designated dented can removal shelf. Interview with Ezer #1, on 05/09/2022 at 10:32 AM, revealed the Ezers were responsible for the kitchen when assigned. She stated she was assigned to the kitchen that day. Ezer #1 stated opened items should be dated and that she checked daily for dates and expired items. She stated the printed expiration date determined when an item should be thrown out. Continued interview revealed if an item was past the printed expiration date, it should be tossed out. At this time, she acknowledged the two (2) expired juice containers and four (4) expired cans of soup. She threw away the expired juice and pulled the expired cans to be returned to the main pantry storage area for disposal. She stated dented cans should be returned to the main kitchen pantry for return or disposal. Ezer #1 stated dented cans were handled by the Support Services Manager (SSM). 2b. Observations in the Skilled 2 - Hope Cottage kitchen, on 05/09/2022 at 11:41 AM, revealed the cottage had two (2) refrigerators (one in the kitchen area and one in the pantry). Observations of the refrigerator in the kitchen area revealed a five (5)-pound container of cottage cheese with no opened date and a printed expiration date of 04/20/2022. In addition, there were two (2) opened packages of processed summer sausage. The opened date on the first package was 03/15/2022, and the opened date on the second package was 04/07/2022. Observation, on 05/09/2022 at approximately 11:41 AM, of the pantry, revealed six (6) dented cans, including one (1) three (3)-pound can of brown gravy, one (1) fifteen (15)-ounce can of mixed beans, one (1) ten and a half (10.5)-ounce can of cream of chicken soup, one (1) ten and a half (10.5)-ounce can of chicken noodle soup, one (1) six (6)-pound can of chili hot dog sauce, and one (1) forty-six (46)-ounce can of tomato juice. Further observation of the pantry revealed one (1) expired forty-six (46)-ounce container of grape juice, with a printed expiration date of 04/09/2022. There was no shelf designated for storage of dented cans for disposal. Observation, on 05/09/2022 at approximately 11:41 AM, of the refrigerator in the pantry revealed an unopened five (5)-pound container of cottage cheese with a printed expiration date of 04/22/2022. Follow-up observations, of the pantry in the Skilled 2 - Hope Cottage, on 05/11/2022 at 1:51 PM, revealed the dented cans discovered on 05/09/2022 remained in the pantry. At 2:00 PM, the ED (Executive Director) and the DON (Director of Nursing) were notified of the dented cans remaining in the pantry of the Hope Cottage. Interview with Ezer #2, on 05/09/2022 at 12:40 PM, revealed dented cans were not to be used and were to be thrown out if found in the pantry. She stated, if expired food items were found in the pantry or refrigerator, they should be thrown out. She stated opened food items should be labeled when opened and be kept in the refrigerator for three (3) days, then thrown away. At this time, she acknowledged the dented cans, expired items, and opened food items in the pantry and refrigerators. Interview with the Support Services Manager (SSM), on 05/09/2022 at 1:17 PM, revealed that all canned goods should be checked for dents upon arrival so they could be returned. She stated each shift was supposed to check the canned goods in the pantry and remove dented cans. She stated dented and expired cans should not be used when preparing meals for the residents. She stated the Ezers received training about removing expired food items and dented cans from the pantry and refrigerators. Continued interview revealed expired food items should be thrown away. She stated that after packaged food was opened, it should be thrown away seven (7) days later. The SSM stated, if the food item was homemade or dairy, it should be thrown away three (3) days after being opened. Interview with Ezer #3, on 05/10/2022 at 10:13 AM, revealed the Ezers received classroom training and shadowed other Ezer's who were cooking and working in the kitchen. He stated all staff members who worked in the kitchens checked daily for expired food items and dented cans. Ezer #3 stated if a can was slightly dented, it would be kept and used, but if it was a large dent it would be returned or disposed. He stated most of the dented cans should be screened out at the main pantry when they were delivered. He stated the printed expiration date on a package determined when an item needed to be thrown away if it was unopened, and, if the food item was opened. He stated the kitchen Ezer would check for expired items in the pantry and the refrigerators at the end of the shift and throw them out. He stated serving food from dented cans or expired items could introduce foodborne illness to the residents. Interview with Ezer #10, on 05/10/2022 at 10:22 AM, revealed the lead Ezers checked the pantries and refrigerators for expired foods and beverages twice a week when the food orders were placed. She stated expired food items were disposed of when found and dented cans were returned to the main pantry for disposal. Interview with the Director of Nursing (DON), on 05/11/2022 at 12:28 PM, revealed dented cans should not be used or stored in the pantries. She stated dented cans should be returned or discarded. She also indicated expired items should be discarded. She stated opened food items should be labeled with the opened date. The DON stated the type of food item determined how long it was good in the refrigerator after opening. Continued interview revealed a binder was kept in the kitchens that was used to determine how long an opened food item was good. She indicated dented cans and expired food and beverage items could introduce foodborne illness to the residents. Interview with the Executive Director (ED), on 05/11/2022 at 12:12 PM, revealed the facility used the ServSafe program to train the Ezer's in the kitchens. She stated opened food was expected to be labeled with the opened date, and printed expiration dates should be checked, with the expired items discarded. 3. Observations of the lunch meal service in the Skilled 2 - Hope Cottage kitchen, on 05/09/2022 between 12:14 PM and 12:40 PM, revealed Ezer #2 was performing kitchen duties in the cottage, including plating food for the meal service. Ezer #2 used antibacterial hand sanitizer instead of washing with soap and water in between glove changes on three (3) occasions during the meal service and while pureeing a resident's meal. Interview with Ezer #2, on 05/09/2022 at 12:40 PM, revealed she had started employment with the facility two (2) weeks prior and had completed the ServSafe kitchen training during orientation. She stated this training covered infection control and hand hygiene. Ezer stated hand hygiene training included using antibacterial hand sanitizer and handwashing while working in the kitchen. She stated that during meal service, hand sanitizer was to be used between each plate and between glove changes, with handwashing to be performed after the third glove change. Interview with the Support Services Manager (SSM), on 05/09/2022 at 1:17 PM, revealed hand hygiene training was provided to all staff members who worked in the kitchens. She stated handwashing should be performed immediately upon entering the kitchen and in between glove changes. She stated antibacterial hand sanitizer should not be used in place of handwashing while working with food in the cottage kitchens. Interview with Ezer #3, on 05/10/2022 at 10:13 AM, revealed hand hygiene should be completed immediately upon entering the kitchen and in between glove changes, as well as before and after assisting a resident with personal care. He stated staff could use antibacterial hand sanitizer in place of handwashing if needed, but that handwashing was always preferred. Ezer #3 stated the training included the use of hand sanitizer and that other staff had advised the use of hand sanitizer while working in the kitchen. Interview with the Director of Nursing (DON), on 05/11/2022 at 12:28 PM, revealed staff working with food in the kitchen should always perform handwashing and were not to use hand sanitizer. She stated the hand sanitizer could get into the food and that improper hand hygiene in the kitchen could introduce foodborne illness to the residents. Interview with the Executive Director (ED), on 05/11/2022 at 12:12 PM, revealed handwashing should be performed in the kitchen by staff members handling food prepared for residents.

Based on interview, review of manufacturer's directions for use, review of the Centers for Disease Control and Prevention (CDC) guidance, and the Occupational Safety and Health Administration (OSHA) requirements and the RB Sigma website, it was determined the facility failed to implement infection control procedures that included a respiratory protection program compliant with OSHA respiratory protection standards, including medical evaluations, training, and fit testing for the use of N95 respirators. This failed practice had the potential to affect all twenty-two (22) residents and occurred during the COVID-19 pandemic. The findings include: Review of the CDC's, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/2022, indicated, Source control options for HCP [healthcare personnel] include: A NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent or higher-level respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators. (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated). Review of Occupational Safety and Health Standard 1910.134, titled, Respiratory Protection indicated the following: - 1910.134(c)(1) - In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions of this section, as applicable: Procedures for selecting respirators in the workplace; Medical evaluations of employees required to use respirators; Fit testing procedures for tight-fitting respirators; Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance. - 1910.134(f) - Fit testing. This paragraph requires that, before an employee may be required to use any respirator with negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. - 1910.134(f)(2) - The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. Review of the RB Sigma (medical supply company) website https://www.rbsigma.com, on 05/11/2022, revealed the N95 model RBS-95-DM002, which was the model used at the facility, was no longer available. The model RBS-FFR95-1013 was the only Sigma model listed as being NIOSH-approved. Review of the CDC website, https://www.cdc.gov, on 05/11/2022, revealed the guideline titled, NIOSH-approved N95 Particulate Filtering Facepiece Respirators, indicated the information was updated weekly. Further review revealed the only N95 respirator that had been approved for RB Sigma was the model RBS-FFR95-1013. Review of the RB Sigma N95 Filtering Facepiece Respirator - User Instructions RBS-FFR95-1013 indicated, Before occupational use of this respirator, a written respiratory protection program must be implemented meeting all the local government requirements. In the United States, employers must comply with OSHA 29 CFR 1910.134 which includes medical evaluation, training, and fit testing. Interview with the Director of Nursing (DON), on 05/11/2022 at 3:23 PM, revealed all staff members were to wear N95 masks and that none of the staff had been fit tested for the masks that were in use. The DON stated the facility had a fit testing kit available, but had not used it. The DON was unable to answer why the staff had not been fit tested on the current N95 masks that were in use. Interview with Ezer #4 and Ezer #5, on 05/11/2022 at 3:53 PM, who were both working the Best Friends House (100 Hall cottage), revealed both Ezer's were wearing N95 masks. Also, Ezer #4 and Ezer #5 stated they had not been fit tested for the masks they were wearing. Both stated they had been fit tested by the health department at the beginning of the COVID-19 pandemic for a different mask. They stated they had not received any training on how to properly wear the N95 mask. Interview with Registered Nurse (RN) #1 and RN #2, on 05/11/2022 at 3:57 PM, who were both working in the Hope House (200 Hall cottage), revealed they were wearing N95 masks. The RNs stated they had not been fit tested for the masks they were wearing. RN #2 stated they did not need to be fit tested for the current mask and that she had been fit tested for the duck bill type of N95 mask. RN #1 stated they did not have to be fit tested for the current mask because the bands went over the ears instead of around the head. Interview with Ezer #2, on 05/11/2022 at 3:59 PM, revealed she was working in the Hope House. She stated no fit testing or training had been provided for the N95 mask she was wearing. Interview with Ezer #6, on 05/11/2022 at 4:01 PM, revealed she was working in the Hope House. Ezer #6 stated she had not been fit tested for the N95 mask she was wearing. She stated that no training had been provided to her on how to properly wear the N95 mask. Interview with Ezer #7, Ezer #1, Activity Coordinator (AC), Ezer #8, Licensed Practical Nurse (LPN) #1, and Ezer #9, on 05/11/2022 at 4:05 PM, revealed they were working in the Faith House (300 Hall cottage). They stated they had not been fit tested for the N95 masks they were wearing. Also, they all stated no training had been provided to them on how to properly wear the N95 mask. Interview with the Executive Director (ED), on 05/11/2022 at 4:39 PM, revealed her expectations for education/training, before staff used an N95 mask, was that the facility would provide training for the proper donning/doffing (putting on and removal) of the mask. The ED stated the facility had done fit testing previously with a different brand/style but had not done any fit testing with the current N95 masks. The ED stated they had just gone back to using the N95 masks due to a recent outbreak, and they had previously been using surgical masks. The facility's policy for N95 use was requested. The ED stated the facility's infection control policies and procedures were all they had. However, review of the policies and procedures did not address the requirements before use of the N95 masks.

Based on interviews and review of the facility's policy, it was determined the facility failed to ensure the individual assigned the responsibilities of the Infection Preventionist (IP) had received specialized training in infection control and prevention. This had the potential to affect all twenty-two (22) residents residing in the facility. The findings include: Review of the facility's policy titled, Infection Preventionist, dated 11/28/2017, revealed, 1. This facility will designate one (1) or more individual(s) as the infection preventionist(s) (IP)(s) who is responsible for the facility's IPCP [Infection Prevention and Control Program]. The infection preventionist will: Have completed specialized training in infection prevention and control. On 05/09/2022 at 9:24 AM, the entrance conference was conducted with the Executive Director (ED) and the Director of Nursing (DON). Interview, at this time, revealed the DON identified herself as the designated Infection Preventionist (IP) for the facility. Interview with the DON, on 05/11/2022 at 1:03 PM, revealed she was the IP, but she had not completed any training regarding infection prevention. The DON stated she was aware that she needed to complete the training, but had not completed it yet. The DON stated the facility's wound treatment nurse had previous infection prevention training but was not the designated IP. The DON indicated she became the DON in January 2022. Interview with the Director of Clinical Support (DCS), on 05/11/2022 at 3:00 PM, revealed that the previous DON had been trained on infection prevention, but she did not check to make sure the current DON had completed the training prior to becoming the designated IP. Interview with the ED, on 05/11/2022 at 4:39 PM, revealed her expectations for the IP would be for her to take the available infection prevention course and become certified.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on the Skilled 2 Cottage Kitchen, on 07/16/19, revealed the refrigerator contained a five (5) pound Sysco Pimento Cheese container and a thirty-two (32) ounce container of whipping cream; both of which had been opened and not marked with an open date. In addition, there was a foil container of left over food, dated 07/12/19, which was not labeled with the resident's name and was expired as per facility policy. In addition, observation on 07/16/19, on the Skilled 2 cottage, revealed the back room storage refrigerator contained a thirty-two (32) ounce container of Hidden Valley Honey Mustard Dressing which had been opened and was not marked with the open date; one (1) box of four (4) count frozen Outshine fruit bars which had been opened and was not marked with the open date; and five (5) containers of Chobani Strawberry Greek four (4) ounce yogurts with an expiration date of 06/20/19. The findings include: Review of the facility Food Safety Requirements- Use and Storage of Food and Beverage Brought in for Residents, Food Procurement, effective date 02/28/17, revealed it is the policy of the facility to provide safe and sanitary storage, handling and consumption of all foods including those brought to the resident by family and visitors. Any person working in the kitchen is responsible to adhere to food safety requirements. Continued review of the Policy, revealed for food brought in for residents, foods requiring refrigeration will be received by the facility designee, dated upon receipt, and discarded after three (3) days. Further review of the Policy, revealed the facility will store and label food according to state and local laws and regulations, which would include when food, food products or beverages are delivered to the nursing home. The facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. 1. Observation on the Skilled 2 Cottage Kitchen, on 07/16/19, at 11:30 AM, revealed the refrigerator contained a five (5) pound Sysco Pimento Cheese container which had been opened and was not marked with the open date. Additionally, there was a thirty-two (32) ounce container of whipping cream which had been opened and was not marked with the open date. Further, there was a foil container of left over food, dated 07/12/19, which was not labeled with the resident's name and was expired as per facility policy. 2. Observation on 07/16/19 from 11:30-11:45 AM, on the Skilled 2 cottage, revealed the back room storage refrigerator contained a thirty-two (32) ounce container of Hidden Valley Honey Mustard Dressing which had been opened and was not marked with the open date; one (1) box of four (4) count frozen Outshine fruit bars which had been opened and was not marked with the open date; and five (5) containers of Chobani Strawberry Greek four (4) ounce yogurts with an expiration date of 06/20/19. Interview with State Registered Nurse Aide (SRNA) #2, on 07/16/19 at 12:05 PM, revealed all food brought into the facility by family should be dated, and should only be kept in the facility for three (3) days. Continued interview revealed other foods supplied by the facility should be dated upon arrival and should be discarded at expiration date for the safety of the residents to prevent foodborne illnesses. Per interview, facility staff did receive training related to expectations regarding food handling safety. Interview with the Dietary Manager (DM) on 07/18/19 at 5:30 PM, revealed staff should follow policy related to food storage including labeling foods with the dates foods were opened or brought in by resident families. The DM further stated, staff should ensure expired food items were discarded in order to prevent food borne illness. Per interview, all staff handling food had been trained related to food handling and preparation and were expected to know the rules and regulations related to marking food items with names and dates. Per interview, as Dietary Manager, it was her responsibility to be aware of the food inventory in the refrigerators of each cottage. Interview with the Staff Development Coordinator, on 07/19/19 at 10:00 AM, revealed staff should follow facility policy related to food storage and labeling. Further interview revealed expired foods should be discarded and not accessible for use. Continued interview revealed the SRNAs took turns preparing food in the cottages, and they were all trained in proper food storage, labeling and food safety. Per interview, this education began at orientation and continued annually, and as needed. Interview with the Director of Clinical Support/Acting Administrator, on 07/19/19 at 11:30 AM, revealed it was her expectation for all staff to follow facility policy related to safe food handling practices. Continued interview revealed prepared food brought in from families should be labeled with the resident's name and date it was brought in, and should be discarded after three (3) days. Per interview, all food should be marked with an open date and should be discarded when expired for resident safety and to prevent food borne illnesses.