**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff for one (Resident (R) 1) of 22 sampled residents. Abuse was substantiated when staff yelled at R1 and hooked a back scratcher on the resident's bottom lip to pull on the resident's mouth. The findings include: Review of the facility's policy titled Abuse Prohibition Standard of Practice, revision date 07/2022, revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of R1's admission record revealed the facility admitted R1 on 06/14/2022, with diagnoses of neurogenic bowel, neuromuscular dysfunction of bladder, other psychoactive substance abuse with unspecified psychoactive substance-induced disorder, and unspecified viral hepatitis C without hepatic coma. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2025, revealed a Brief Interview for Mental Status (BIMS) score of 13/15, indicating R6 was cognitively intact. Per the MDS, R1 displayed no behaviors. Review of R6's Electronic Health Record (EHR) on 04/22/2025, revealed a Miscellaneous Note, dated 02/08/2025 at 3:17 AM, which stated that R6 displayed some aggression towards staff at 10 PM, with the note stating that R6 threw water on staff. Further review of the Miscellaneous Note revealed no information as to what might have led to this incident. Review of a facility investigation, dated 02/10/2025 at 10:00 AM and completed by the former Director of Nursing (DON), revealed that on the evening of 02/07/2025, R1 was asleep in his bed when he was abruptly awakened by two Certified Nursing Assistants ((CNA) 4 and CNA5), who were standing over his bed, talking loudly and attempting to wake him up. Per the investigation, CNA4 took R6's bamboo back scratcher from his over-bed table and lightly touched his lip. CNA4 may have also brushed R6's stomach with the back scratcher. R6 was startled, and when he felt the backscratcher on his lip, he threw a half-filled cup of water on CNA4. Continued review of the investigation revealed CNA4 then left R6's room and brought CNA5 into the room to scold him for the water he threw on CNA4. CNA4 told R6 she was going to report him for his actions. Licensed Practical Nurse (LPN) 3 was standing at R6's doorway during this time. Per the investigation, LPN3, CNA4, and CNA5 claimed they tried to wake R6 up because he appeared to be unresponsive. LPN3 told CNA4 and CNA5 to stop after R6 woke up. The facility's investigation showed that, based on the information provided by R6 regarding CNA4, the facility substantiated the allegation of abuse. During an interview on 04/22/2025 at 11:34 AM, R6 stated LPN3 came into his room [ROOM NUMBER] minutes prior to the incident because R6's roommate was on intravenous (IV) antibiotics, and while in the room, LPN3 said, hey to R6. R6 continued that, when the incident occurred, he had been asleep but woke up when CNA4 took his back scratcher and hooked it on the bottom of his lip, pulled at his mouth, and was hollering at him. Then, he woke up and slung the cup of water on CNA4. R6 stated when he woke up, CNA4 and CNA5 were on the left side of his bed with LPN3 at the foot of his bed. Further interview with R6 revealed CNA4's actions made him mad. During an interview with CNA5 on 04/22/2025 at 2:31PM, CNA5 stated R6's call light went off and CNA4 answered it. CNA5 stated CNA4 tried to ask R6 if he needed anything, but he would not wake up, and that's when CNA4 got me. We tried to scratch his belly and forehead, smacked the bed, hollered at him, and he still wouldn't wake up. CNA5 stated that when R6 did wake up, he threw water on CNA4. CNA5 indicated that when trying to wake a resident, she would normally say their name two to three times and rub on the resident's leg, and if that does not work, she will get another staff member. During an interview on 04/23/2025 at 3:38PM, LPN3 stated prior to the incident, she was hanging R6's roommate's IV and she woke R6 up while she changed the IV. LPN3 stated she was at the nurses' desk when CNA5 came to her and stated that they were unable to wake R6 up. When she got there, CNA4 had the back scratcher in her hand and R6 stated I'm tired of getting picked on by these girls. Attempts to contact CNA4 on 04/22/2025 at 2:27PM and 04/23/2025 at 12:36PM, were unsuccessful, as the call could not be completed as dialed. Attempts to contact the former Director of Nursing (DON) on 04/24/2025 at 9:29AM and 04/24/2025 at 2:09PM were also unsuccessful, as the voice mailbox could not accept any more messages. Interview with the former Administrator on 04/24/2025 at 9:33AM, revealed he was the Administrator at the time of this incident. The former Administrator described the incident in which abuse was substantiated as, It was just one aide aggravating a resident, also stating that There was no injury at all. Continued interview with the former Administrator revealed his statement that CNA4 and R6 had some playfulness prior to that incident, and I think they thought it was funny. He did not elaborate on what playfulness was or what his expectations were. Further interview with the Administrator revealed that the facility failed to report the incident to the State Survey Agency or other required agencies (Refer to F609.)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an alleged violation involving abuse was reported immediately, but not later than two hours, for one (Resident (R)1) of four residents reviewed for abuse, out of a total sample of 22 residents. Staff failed to immediately report an allegation of abuse to the Administrator, as well as the State Survey Agency (SSA) and Adult Protective Services (APS). The findings include: Review of the facility's policy titled Abuse Prohibition Standard of Practice, revision date 07/2022, revealed alleged violation(s) will be reported to the Administrator and/or designee immediately. Further review revealed alleged violations were to be reported to the SSA and APS. However, the policy did not include the time frames specified in the regulation. Review of a facility investigation dated 02/10/2025 at 10:00 AM, and which was completed by the former Director of Nursing (DON), revealed that on the evening of 02/07/2025, R1 was asleep in his bed when he was abruptly awakened by two Certified Nursing Assistants ((CNA) 4 and CNA5), who were standing over his bed, talking loudly and attempting to wake him. Per the investigation, CNA4 took R6's bamboo back scratcher from his over-bed table and lightly touched his lip and may have also brushed R6's stomach with the back scratcher. R6 was startled, and when he felt the backscratcher on his lip, and he threw a half-filled cup of water on CNA4. Continued review of the investigation revealed CNA4 then left R6's room and brought CNA5 into the room to scold the resident for the water he threw on CNA4. CNA4 told R6 she was going to report him for his actions. The facility's investigation concluded, that based on information provided by R6 regarding CNA4, abuse was substantiated. (Refer to F600.). Further review of the facility investigation revealed the initial allegation of abuse was not received by the Administrator until 02/10/2025 at 10:00 AM, three days after the incident occurred. In addition, once the Administrator was notified of the allegation, the facility failed to immediately notify the SSA, as the Office of Inspector General was not notified until 02/10/2025 at 2:57 PM. During an interview with CNA5 on 04/22/2025 at 2:31PM, she said that after the incident on 02/07/2025, she texted Unit Manager (UM)1 about the incident. CNA5 stated she no longer had the texts, and did not remember specifically what she texted to UM1. However, she indicated that the report to the UM was more about the resident throwing water on CNA4, rather than the suspected abuse in which the CNA pulled the resident's lip with the backscratcher and yelled at him. During an interview with LPN3 on 04/23/2025 at 3:38PM, she confirmed that CNA5 texted UM1 what happened, and UM1 said OK, figure out what's going on in the morning. During an interview with UM1 on 04/24/2025 at 10:41AM, UM1 stated CNA5 texted her in the middle of the night, and she did not see the text until she woke up the next morning. Further interview with UM1 revealed that she sent a message to the former DON, and he said the resident was just mad, that's not anything. Continued interview with UM1 revealed she expected her staff to call her and keep calling until she was awake. During an interview with the former Administrator on 04/24/2025 at 9:33AM, he confirmed that he did not receive the report until a couple days after the incident. The former Administrator stated, It was just one aide aggravating a resident. The former Administrator stated that once he was aware of the allegation, he had two hours to report it to OIG, However, the SSA was not notified of the abuse allegation until almost five hours after the Administrator was made aware of it. The Administrator confirmed that the facility had not reported the abuse allegation to APS, saying that he was under the impression OIG informed APS. Continued interview with the Administrator revealed staff were supposed to notify the Administrator or the Director of Nursing (DON) immediately, and that was specified in the abuse policy of the facility.

Based on interview, record review and policy review, the facility failed to ensure that an allegation of abuse/mistreatment was reported immediately to the administrator and failed to ensure that the allegation was reported to the appropriate state agencies for one (1) of one eighteen (18) sampled residents (Resident #31). On 03/19/2021, Resident #31 reported to Licensed Practical Nurse (LPN) #1 that someone had jumped on the resident (spoke in a harsh manner toward the resident). The LPN failed to immediately report the allegation to the administrator. Further, the facility failed to have evidence that the allegation was reported to the appropriate agencies. The findings include: Review of the facility policy titled Abuse Prohibition Standard of Practice, with a revision date of May 2020, revealed the purpose of the policy was to ensure reporting and investigating of alleged violations. The policy further stated that alleged violations would be reported to the administrator immediately and that the administrator would oversee the center in conducting an internal investigation. Observation of and interview with Resident #31 on 04/20/2021 at 11:10 AM revealed the resident was sitting on the side of the bed in his/her room. The resident stated that he/she had been at the facility a little over a month and that approximately two (2) weeks after arriving at the facility, a nurse had been rude to him/her and had talked mean to the resident. The resident stated that facility staff had discussed the incident with him/her and that he/she had not seen the staff person since the incident. The resident went on to say that, he/she felt safe in the facility, was not harmed by the incident, and had no further concerns. Review of the medical record for Resident #31 revealed the facility admitted the resident on 03/02/2021 with diagnoses that include Diabetes, Hypertension, and Osteoarthritis. Review of the nursing progress notes revealed no notes related to the incident that Resident #31 reported. Further review of the record for Resident #31 revealed an admission Minimum Data Set (MDS) assessment with a reference date of 03/04/2021. The assessment noted that Resident #31's Brief Interview for Mental Status (BIMS) score was 14 indicating that the resident's cognition was intact. Review of a Grievance/Concern Form dated 03/19/2021 revealed Resident #31 reported to LPN #1 that a woman came in [his/her] room and jumped on [him/her]. The grievance/concern form further stated that Resident #31 reported that the woman came to his/her room twice and the woman was wearing a red shirt. The form stated that the resident indicated that the woman that Resident #31 was referring to was not LPN #1, State Registered Nursing Assistant (SRNA) #1, or SRNA #2. The form further noted that Registered Nurse (RN) #1 was assigned to investigate the concern. The summary of the investigation noted that RN #1 spoke with Resident #31 and the resident denied having any issues or anything that caused him/her distress and when the resident was asked about the previous evening, the resident stated, it was good. The summary of the investigation further noted that a search of the building during the previous shift found no female wearing red. Under the portion of the form that stated Resolution of Grievance/Concern, RN #1 signed the form and noted that the grievance/concern was not confirmed and no issues were found. The date of the resolution was 03/19/2021. The Grievance/Concern Form further noted that the resident was notified of the resolution on 03/22/2021 through a meeting. Further review of the information provided regarding the incident revealed no evidence that the incident was reported to the State Survey Agency or Adult Protective Services. Interview with LPN #1 on 04/22/2021 at 10:24 AM revealed that she was working when Resident #31 made the statement that someone had jumped on the resident. LPN #1 stated that the incident occurred late, approximately 11:00 PM or 12:00 AM. She stated that she went into the resident's room and the resident reported the incident. LPN #1 stated she asked the resident to describe the woman and she said the woman was wearing a red shirt. LPN #1 stated she brought all of the staff that were working to Resident #31 and asked if it was any of the staff working and the resident reported that it was not any staff working. LPN #1 stated that she did not report the incident immediately because Resident #31 has episodes of confusion at times and LPN #1 did not think anything really happened. LPN #1 further stated that she did not look at any residents to see if they were wearing red shirts or ask any other residents about the incident. Interview with RN #1 on 04/22/2021 at 10:43 AM revealed she was the unit manager for the unit where Resident #31 resided. RN #1 stated she remembered that LPN #1 reported the incident to her in the morning on 03/19/2021 when she arrived at the facility at approximately 7:30 or 8:00 AM. She stated that LPN #1 works evening shift and the incident had occurred sometime during the night shift while LPN #1 was on duty. RN #1 stated she told LPN #1 to fill out a grievance form related to the incident. RN #1 stated she asked LPN #1 to clarify what jumped on meant and that it had been a verbal incident and that the person that did it was wearing red. RN #1 stated that LPN #1 told her that she checked with all of the staff that was working during the evening and no one was wearing red and the resident had said it was not any of the staff that were working. RN #1 stated that she then went and spoke to the resident and the resident did not recall or report an incident. RN #1 stated that she then went to the Director of Nursing (DON) and reported the incident to her when the DON arrived at the facility between 8:00 AM and 8:30 AM. Interview with the DON on 04/22/2021 at 10:58 AM revealed she was familiar with the incident but she did not investigate the incident. The DON stated that the expectation for the staff was that any allegation of abuse, which includes verbal abuse, would be reported immediately to the administrator or to the DON. Interview with the Social Services Director (SSD) on 04/22/21 at 11:22 AM revealed she spoke to Resident #31 on 03/19/2021 after becoming aware that the resident reported an incident. The SSD stated that the resident did not recall the incident. She stated that she reported that information back to the administrator. The SSD stated she then spoke to the resident again on 03/22/2021 and notified the resident of the resolution of the grievance. Interview with the Administrator on 04/22/2021 at 11:09 AM revealed she was the abuse coordinator for the facility and was responsible for investigating and reporting allegations of abuse. The Administrator stated that when she arrived at the facility on the morning of 03/19/2021, the grievance form was on her desk. The Administrator stated that when she reviewed the grievance, she felt like they needed more information so she requested that the SSD speak with Resident #31. The Administrator stated that the SSD reported that the resident did not recall the incident. The Administrator stated that if the nurse felt like there was an allegation of abuse, then it should be reported to her immediately. The Administrator stated that she spoke to LPN #1 and because she found no staff that met the description given by Resident #31, she did not feel there was an allegation of abuse and therefore did not report it to the State Survey Agency and Adult Protective Services. The Administrator stated she did not know if LPN #1 had interviewed any other residents regarding the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan related to use of a BiPAP (Bilevel Positive Air Pressure) machine for one (1) of eighteen (18) sampled residents (Resident #5). Resident #5 had a diagnosis of Obstructive Sleep Apnea and had a physician's order for the use of a BIPAP machine while sleeping. However, the facility failed to include the use of the BIPAP machine on the resident's plan of care. The findings include: Review of the facility's policies revealed that there was no Comprehensive Care Plan policy. Interview with Administrator on 04/22/2021 at 1:22 PM revealed the facility had no policy related to respiratory care. The Administrator stated the facility developed resident care plans following the Resident Assessment Instrument (RAI) process. Review of Resident #5 medical record revealed the facility last readmitted the resident on 02/07/2021 with diagnosis of Obstructive Sleep Apnea, Malignant Neoplasm of Cerebral Meninges and Type 2 Diabetes Mellitus without complications. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of ten (10) out of fifteen (15) indicating the resident has moderate cognitively impairment. Review of the Resident #5's physician's order written on 10/22/2020 revealed an order for a BIPAP machine at hour of sleep and during naps. Orders for BIPAP settings were IPAP (Inspiratory Positive Air Pressure) 16 cm EPAP (expiratory Positive Air Pressure) 8 cm rate of 24/min and FIO2 (Fraction of Inspired Oxygen) 24%. Review of Resident #5's care plan revealed the facility had not addressed the resident's Obstructive Sleep Apnea or the use of the BIPAP machine. Observation of Resident #5 on 4/22/21 at 10:57 AM revealed Resident #5 was resting in bed utilizing a CPAP (Continuous Positive Air Pressure) machine instead of a BIPAP machine. Interview with LPN #3, on 04/22/2021 at 11:32 AM, revealed an outside respiratory company comes to the facility to set up resident respiratory machines. The LPN stated I check the machine to make sure it's working, that's all. LPN #3 stated Resident #5 currently was using a C-PAP machine. However, LPN #3 stated Resident #5's physician's order was for a BIPAP machine. Interview with Education Manager on 04/22/21 at 5:31 PM revealed that a care plan for Resident #5's respiratory care was not done. The Education Manager (who is in training for completing MDS assessments) stated she would be responsible for developing Resident #5's care plan. The Education Manager stated I would had developed a care planned for respiratory. This is done usually when we get a discharge report from the hospital or an order from the doctor. The Education Director stated she did not know why the resident did not have a care plan addressing respiratory care completed. Interview with Director of Nursing (DON) 04/22/21 at 5:53 PM revealed the facility should have developed a care plan for Resident #5 addressing respiratory care and the BIPAP machine use. The DON stated We recently have been going thru all care plans to make sure they are correct. We do this once a month as a team (Interdisciplinary Team) which consist of DON, unit managers, MDS, Education Trainer. The DON stated that she hadn't noticed anyone not having a care plan for oxygen use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards and physician orders for one (1) of eighteen (18) sampled residents (Resident #5). Resident #5's physician ordered the resident to utilize a BIPAP (Bilevel Positive Air Pressure) machine when sleeping; however, observation and interviews with staff revealed the resident was utilizing a CPAP (Continuous Positive Air Pressure) machine instead of a BIPAP machine. The findings include: Review of the facility's policies and interview with the Director of Nursing (DON) on 04/22/2021 at 3:10 PM revealed the facility had no policy on CPAP/BIPAP machines or on respiratory care. Interview with Administrator on 04/22/2021 at 4:57 PM revealed the facility had no policy on following physician orders. Observation of Resident #5 on 04/22/20 revealed Resident #5 in bed using a CPAP machine. The CPAP machine in use was a Res Med Air sense 10 with settings of 6.7 pressure. An interview was attempted with the resident; however, the resident was very hard of hearing. The resident did state he/she used the machine when he/she napped. Review of Resident #5 medical record revealed the facility last readmitted the resident on 02/07/2021 with diagnosis of Obstructive Sleep Apnea, Malignant Neoplasm of Cerebral Meninges and Type 2 Diabetes Mellitus without complications. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of ten (10) out of fifteen (15) indicating the resident has moderate cognitively impairment. Review of the Resident #5's physician's order written on 10/22/2020 revealed an order for a BIPAP machine at hour of sleep and during naps. Orders for BIPAP settings were IPAP (Inspiratory Positive Air Pressure) 16 cm EPAP (Expiratory Positive Air Pressure) 8 cm rate of 24/min and FIO2 (Fraction of Inspired Oxygen) 24%. Interview with Licensed Practical Nurse (LPN) #2, on 04/21/2021 at 3:36 PM, revealed Resident #5 currently utilized a C-PAP machine with settings of 6.7 pressure. However, the LPN stated the current physician order for Resident #5 was for a BIPAP machine. The LPN stated an outside respiratory company had set up the resident's CPAP machine. She stated she did not question the discrepancy between the CPAP verses the BIPAP machine. Interview with LPN #3, on 04/22/2021 at 11:32 AM, revealed an outside respiratory company comes to the facility to set up resident respiratory machines. The LPN stated I check the machine to make sure it's working, that's all. LPN #3 stated Resident #5 currently was using a C-PAP machine. However, LPN #3 stated Resident #5's physician's order was for a BIPAP machine. The LPN stated Resident #5 dealt with her own machine. and that she did not questioned the order. The LPN stated Respiratory set up the machine and checked it monthly. Interview with Customer Service Representative at Specialized Service (with the respiratory company) on 04/22/21 at 11:32 AM , revealed a Respiratory Therapist set up the resident's CPAP machines. Interview with Respiratory Therapist via phone on 04/22/2021 at 1:50 PM revealed the process for setting up oxygen involves receiving an order in the cooperate office and they tell us what to do. We do BIPAP, C-PAP or whatever needs to be done. We do monthly checks unless the resident needs something else. The Respiratory Therapist stated the C-PAP gives continuous one positive pressure where BIPAP gives two, an inhale pressure and an exhale pressure. Regarding Resident #5, the Therapist stated I did not initially set up the C-PAP machine but have been seeing Resident #5 since December 2020. The Therapist stated since the COVID pandemic she would stand at the resident's doors to check to complete the monthly checks. She stated she had not checked Resident #5's machine. The Therapist was asked If Resident #5 was on C-PAP or BIPAP and the Therapist stated she was currently not for sure but would try and get order from cooperate office. Interview with Resident #5's Physician, on 04/22/21 at 2:41 PM, revealed Resident #5 should be on BIPAP machine with settings of Peep (Positive and Expiratory Pressure) 8 Respiratory Rate 24, and FIO2 24. The Physician stated this is what Resident was discharged with from his/her pulmonologist. The Physician revealed Resident #5's pulmonologist is no longer at the facility. Interview with DON on 04/22/21 at 3:10 PM revealed when a resident needs oxygen, we get an order from the physician and contact the oxygen company. The company will then set the oxygen up. Don't really know if staff know the difference between BIPAP/CPAP. The DON stated will have to interview staff to see. Respiratory therapist is supposed to be here today. The DON stated staff are expected to follow physician orders. The DON stated he/she did not know why the respiratory company set up a CPAP instead of BIPAP for Resident #5. The DON stated Respiratory Therapist comes in monthly to check on Residents oxygen. Continued interview with the Respiratory Therapist on 04/22/21 at 4:16 PM revealed that Resident #5 is currently on auto pap (CPAP Machine) with a setting of 6-16. The Therapist stated that when the resident goes to sleep the machine will give pressure from 6-16. The Therapist stated The machine will give the resident what is needed. When therapist was questioned whether auto pap was the same as BIPAP, therapist revealed auto pap is not BIPAP. The Therapist stated she took Resident #5 as a Patient in December of 2020 but had not reviewed her/his machine due to COVID. The Respiratory Therapist revealed there was no progress notes or documentation related to the CPAP machine. Interview with Regional Director of Operation on 04/22/2021 at 4:17 PM revealed the facility has been using the respiratory company since 2018. The Director stated there is no contract with this company. Interview with Education Manager on 04/22/2021 at 5:31 revealed she was not aware that Resident #5 was on the wrong type of respiratory machine, (CPAP instead of BIPAP). Interview with Administrator on 04/22/21 at 6:00 PM revealed the facility depended on Respiratory to make sure correct oxygen was given to our residents. Per the Administrator, the facility expectation was for staff to follow physician orders. The Administrator stated I was not aware that respiratory was not looking at the CPAP/BIPAP machine. I expect all staff to be educated on respiratory basis training. Nursing staff was not really trained on oxygen.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to maintain kitchen equipment in a clean and sanitary condition. Observation on 02/12/19 and 02/14/19 revealed the drip pan underneath the range top had an excessive buildup of dried and burned food debris. In addition, the drip pan underneath the range grill contained an excessive amount of oil. The findings include: Review of the facility's policy titled Equipment, revised September 2017, revealed non-food contact equipment would be clean and free of debris. Observation at 9:45 AM on 02/12/19 revealed the drip pan underneath the range top was heavily soiled with a buildup of burned and dried food debris. Further observation at 10:30 AM on 02/14/19 revealed the drip pan underneath the range grill contained approximately two (2) gallons of liquid oil. Interview with a Dietary employee at 10:35 AM on 02/14/19 revealed the drip pans were supposed to be wiped/cleaned daily, and thoroughly cleaned every week. Further interview revealed the drip pans should not have that much food debris and oil.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain an infection prevention and control program to ensure a safe, sanitary, and comfortable environment was maintained and that prevented the development and transmission of communicable diseases and infections for one (1) of thirty-eight (38) sampled residents. Nursing staff were observed on 02/12/19 and 02/13/19, to enter the room of Resident #1, who was on contact precautions, without donning personal protective equipment (PPE). On 02/13/19, Licensed Practical Nurse (LPN) #1 was observed to leave Resident #1's room and go into the hallway with an isolation gown on and was observed to remove the gown in the hallway. The findings include: Review of the facility's policy, Infection Control Program and Standard of Practice, revised November 2017, revealed the standard of practice was to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. The policy further stated all isolation precautions and handwashing techniques for staff and residents would comply with the Centers for Disease Control and Prevention's (CDC) long-term care facility guidelines. Review of the CDC long-term care guidelines revealed healthcare personnel caring for residents on contact precautions were to wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated surfaces/areas in the resident's room. Review of Resident #1's medical record revealed the facility admitted the resident on 07/20/18 with diagnoses of Colon Cancer, Parkinson's Disease, and Enterocolitis due to Clostridium Difficile (C-Diff). Continued review of the medical record revealed Resident #1 was discharged from the hospital on [DATE] with a primary diagnosis of Acute C. Difficile colitis. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 01/31/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required limited assistance of two (2) or more persons to complete the task of transferring and extensive assistance of one (1) person for toileting. Review of Resident #1's comprehensive care plan, dated 01/25/19, revealed Resident #1 had a diagnosis of a C-Diff infection and interventions implemented included contact precautions, proper handwashing, and to educate family and residents on infection control procedures. Review of the SRNA assignment sheet, undated, revealed Resident #1 was on contact precautions related to C-Diff. Observation of Resident #1 on 02/12/19 at 11:35 AM, revealed PPE was located outside the resident's room and signage was posted for visitors to report to the nurses' station prior to entry. Interview with Resident #1 revealed he/she was aware that precautions were in place related to the diagnosis of C-Diff. Observation during the noon meal on 02/12/19 at 12:45 PM, revealed State Registered Nurse Aide (SRNA) #6 entered Resident #1's room to deliver a meal tray without donning PPE. She then exited the room and continued to pass lunch trays to other residents. Observation on 02/13/19 at 11:47 AM, during wound care for Resident #1 revealed upon the surveyor's arrival to the resident's room Registered Nurse (RN) #1 and LPN #1 were both already in the resident's room; however, neither nurse was wearing PPE. Further observation revealed after observing the surveyor putting on PPE, RN #1 and LPN #1 both put on PPE. Observation during wound care for Resident #1 revealed LPN #1 was observed to leave the resident's room with the isolation gown on and removed the gown in the hallway. Interview with SRNA #6 on 02/14/19 at 9:50 AM, revealed she worked primarily as a restorative aide. She stated she did deliver Resident #1's lunch tray on 02/12/19 without putting on PPE. She stated she was not sure what kind of precautions the resident was on and that she would usually ask one of the nurses but had failed to do so. She also stated that when she opened the resident's door and entered she observed Therapy in the room, so she just placed the tray on the bedside table. Interview with LPN #1 on 02/13/19 at 12:15 PM, revealed she and RN #1 had not put on PPE because Housekeeping had just sterilized the room. However, she stated it was expected that whenever a resident was on precautions/isolation, all staff would put on appropriate PPE prior to entering the room. Interview with the Director of Nursing/Infection Control Nurse on 02/14/19 at 10:21 AM, revealed PPE should be worn every time you enter the room of a resident on contact precautions. She stated all staff are educated during orientation and annually regarding infection control procedures. She added there had also been specific education provided to the staff on Resident#1's unit related to the resident's contact precautions.

Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to provide drinks consistent with resident preferences related to coffee choices for five (5) of thirty-eight (38) sampled residents that attended the resident council meeting. The residents stated they preferred caffeinated coffee; however, the facility only served decaffeinated coffee. The findings include: Review of the facility's policy titled Dining and Food Preferences, revised September 2017, revealed the individual tray assembly ticket would identify all food items appropriate for the resident based on the resident's diet order, allergies, intolerances, and preferences. During a resident council meeting on 02/13/19 at 10:30 AM, five (5) residents stated they preferred to drink caffeinated coffee; however, the facility only served decaffeinated coffee, and they were never given a choice of caffeinated or decaffeinated coffee. One (1) resident stated he/she quit drinking the facility's coffee, and started drinking soft drinks in order to get the caffeine. Another resident stated everyone who drank coffee should have a choice between caffeinated or decaffeinated. Interview with the Dietary Manager (DM) at 2:20 PM on 02/14/19 revealed the facility only served decaffeinated coffee. However, the DM stated she had ordered one (1) case of caffeinated coffee on 01/18/19, but it was kept in the kitchen, and if a resident preferred regular coffee they had to come to the kitchen and ask for it. However, the facility had taken no action to ensure residents were aware that they could request caffeinated coffee. The DM stated decaffeinated coffee was the only kind of coffee routinely served to the residents.