**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility investigations and policies, the facility failed to ensure residents were protected from verbal and physical abuse for 2 of 14 sampled residents (Resident (R) 4 and R5). 1. On 07/17/2024, R4 reported to the Administrator that Kentucky Medication Aide (KMA) 3 had spoke to her like a dog, pointed her finger in the resident's face, and started cussing at her without cuss words. 2. On 10/19/2023, R7 hit R5 in the head with an open hand. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Per policy review, that included, but was not limited to, freedom from corporal punishment, verbal, mental, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the facility policy titled, Resident Rights, revised February 2021, revealed employees should treat all residents with kindness, respect, and dignity. 1. Review of R4's electronic medical record (EMR) revealed the facility admitted the resident on 06/20/2022, with diagnoses which included anxiety disorder, hypertension, and unspecified psychosis. Review of the Minimum Data Set (MDS) Assessment for R4, with an Assessment Reference Date (ARD) of 02/18/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the facility's Self-Reported Incident Form Initial Report, dated 07/17/2024, revealed an incident of verbal abuse occurred on 07/17/2024 at approximately 12:45 PM, which R4 reported to the facility's Administrator immediately. Per review of the report, upon notification by R4, an investigation was initiated. Continued review revealed KMA 3 was immediately suspended and vacated the facility until further notice pending the outcome of the investigation. Review revealed a change in condition, head-to-toe skin assessment, and rapid mood screening (RMS) were initiated for R4. Further review revealed due to the complex nature of the allegation, all witnesses prepared written statements and interviews were conducted. In addition, R4's physician, family/Power of Attorney (POA), Department for Community Based Services (DCBS), Adult Protective Services (APS), and the Ombudsman were all notified. Review of the facility's Final Report/5 Day Follow-Up, revealed all materials related to the investigation had been reviewed and it was found the allegation against KMA 3 involving (alleged verbal abuse of) R4 was verified. Per review, the evidence suggested KMA 3 had conducted herself in an unprofessional manner and used a tone and language that could be construed as an act of verbal abuse. Review of the Report, revealed at the time the allegation was made KMA 3 was placed under one-to-one (1:1) observation by the Director of Nursing (DON) while the medication cart was counted. Continued review revealed KMA 3 was then escorted out of the facility and placed on suspension until further notice. Review revealed a verbal education regarding abuse, verbal abuse, and abuse prohibition and reporting was implemented by the Administrator, DON, and Assistant Director of Nursing (ADON) during the investigative period for all 76 active employees. Further review revealed Social Services (SS) or the Administrator conducted routine check-ins with R4 for four weeks following the incident to monitor for any potential distress and to ensure her concerns were resolved. Finally, review further revealed since the allegation against KMA 3 had been verified, she was terminated from employment and did not return to the facility. Review of the facility's, Quality Assurance and Performance Improvement (QAPI) log of activity for the 08/27/2024 meeting revealed abuse - 1 incident; resolved was listed as a topic which was reviewed/discussed. Review of KMA 3's personnel file revealed a hire date of 10/20/2023, as a State Registered Nursing Assistant (SRNA). Per review, KMA 3 transferred on 12/03/2023, into the position of Kentucky Medication Aide after successfully passing the Medication Aide exam on 11/20/2023. Continued review revealed a background check, adult caregiver, nurse aide registry, sex offender and license verification had been performed. Further review revealed no documented evidence of disciplinary actions. Additional review revealed the KMA had received abuse training and was terminated on 07/22/2024. In interview on 05/13/2025 at 2:30 PM R4 stated things are pretty good here now. She stated she had only had problems with that one staff member before and that person was not there anymore. R4 reported that person lost her job over some stuff that went on. She further stated she hated anyone losing a job, but when you do bad that's what happens. R4 said that person talked to her real mean. Telephonic attempts were made to interview KMA 3 on 05/14/2025 at 9:36 AM, 3:42 PM, and 7:45 PM; however, were unsuccessful. Voicemail messages were left each time; however, a return phone call was never received. In interview on 05/13/2025 at 2:20 PM, Licensed Practical Nurse (LPN) 1 stated she relayed another incident to SSD and DON that occurred that same day the incident with KMA 3 and R4 occurred. She stated R3's daughter informed her that her mom (the resident) was told she was acting like a baby by the med tech that morning. LPN 1 said R3 had relayed that information to her daughter when she came to visit the resident at lunch. She reported she she immediately went to tell the Social Services Director (SSD) and the DON. LPN 1 stated she was unaware of the incident involving KMA 3 and R4 when she reported what R3's daughter told her. She further stated however, at that time she learned that KMA 3 had already been removed from the floor and the med carts were being counted. In interview on 05/13/2025 at 2:10 PM, the Receptionist stated she did remember an incident involving KMA 3 and R4. She stated KMA 3 had been a med tech in the facility, and on the day of the incident, R4 called from her personal phone to the facility phone asking about some meds. The Receptionist said after receiving the call, she went to find KMA 3 to let her know because she was the person passing meds. She explained KMA 3 asked her to go to R4's room with her so that no one would put words in my mouth. The Receptionist reported she was surprised when KMA 3 was the one that was verbally aggressive towards the resident. She further stated KMA 3 was cussing and pointing her finger towards the resident. The Receptionist additionally said she got KMA 3 out of the room and went straight to find the Administrator. In interview on 05/13/2025 at 2:40 PM, the SSD stated she was still new when this all happened and remembered very little. She said she did remember KMA 3 as not being kind and it was a form of verbal abuse. The SSD explained her role was to check with residents to make sure they were okay after the incident. She further stated she also checked with staff to see if they had witnessed anything like this occurring. In interview with R11, R1, and R2 on 05/13/2025 at 10:00 AM, they stated they felt well taken care of, staff treated them with respect, and they felt safe in the facility. R3 (Who reported the second incident to her daughter) was unable to be interviewed 05/13/2025 through 05/15/2025 during multiple attempts each day. In interview on 05/15/2025 at 11:19 AM, the DON stated staff abuse education was provided on hire, annually and as needed. The DON said the education was normally provided by her and/or the ADON, and might be provided in person or through a video with a posttest. She explained if she were to witness abuse taking place, she would intervene immediately to keep the resident safe and then report it to the Administrator. The DON stated if an incident of abuse was not reported, it would be possible to have a negative outcome for the residents. She said when the abuse allegation involving R4 was made, KMA 3 was removed from the floor, med carts were counted and then she (KMA 3) was escorted out of the facility. The DON said she thought KMA 3 had been out of the building before the second incident was reported. She further stated resident and staff interviews, as well as staff education were completed as part of the facility's investigation. The DON also stated the facility substantiated the allegation of verbal abuse and KMA 3 was terminated. In interview on 05/15/2025 at 11:48 AM, the Administrator stated he was the facility's abuse coordinator, and said all allegations of abuse by staff were handled immediately. He stated the accused staff had been suspended, and they were not allowed back on the premises pending the results of the investigation. The Administrator said residents involved in alleged incidents of abuse were monitored for physical/psychosocial effects related to incidents. He explained he expected staff to immediately report suspected abuse after intervening to keep the residents safe. The Administrator stated, when recalling his memory of the incident between KMA 3 and R4, multiple people had been trying to find him to report the incident. He said the facility's reaction to the allegation was immediate as R4 asked to speak with him as soon as KMA 3 left her room. The Administrator reported KMA 3 had been pulled from off the floor and suspended pending the investigation, and the med cart counted with supervision prior to the KMA being escorted out of the building. He stated as the first investigation was beginning, report of the second incident came in. The Administrator said he was unaware of any allegations regarding KMA 3 until that day, and she (KMA 3) had not seemed problematic, and had been very pleasant and welcoming. He further stated KMA 3 had been terminated for substantiated allegation of abuse against R4. In addition, the Administrator said the facility investigation concluded that KMA could have presented herself in a different manner towards R3; however, there had been no witnesses to verify it reached a level of abuse in that instance. Surveyor: [NAME], [NAME] 2(a). Review of the EMR admission Record for R5 revealed the facility admitted the resident on 05/29/2022 and discharged the resident on 03/29/2024. Continued review revealed R5 was admitted with the following diagnoses: mild neurocognitive disorder due to known physiological condition without behavioral disturbance, cognitive communication deficit, and unspecified psychosis not due to a substance or known physiological condition. Review of the Significant Change MDS with an ARD of 03/15/2024, revealed the facility assessed R5 to have a BIMS score of a 14 out of 15, indicating the resident was cognitively intact. (b). Review of the EMR admission Record for R7 revealed the facility admitted the resident on 09/15/2022 and discharged the resident on 11/04/2024, with diagnoses to include: dementia with agitation, schizophrenia, and Alzheimer's disease. Review of the Significant Change MDS with an ARD of 08/20/2024, revealed the facility assessed R7 to have a BIMS score of a zero out of 15, indicating the resident was severely cognitively impaired. Review of the facility's Initial Report dated 10/19/2023, revealed on 10/19/2023 at 11:55 AM, R7 made physical contact with R5's head with her open palm. Continued review revealed the incident was witnessed by SRNA 2. Review of the facility's investigation Final/5-Day Follow Up Report, dated 10/20/2023, revealed the facility concluded the incident was witnessed and therefore verified to have taken place. Review of the psychiatry initial consult dated 10/27/2023, for R7 revealed the resident had been evaluated to have struck another resident on 10/19/2023. Continued review revealed staff reported R7 had been more easily agitated recently. Review of the hospital emergency department note dated 10/19/2023, revealed R7 had been seen for allegedly slapping another resident, having frequent emotional outbursts, and episodes of aggression, which were not uncharacteristic for her. During an interview with SRNA 2 on 05/13/2025 at 4:32 PM, she stated she was unable to recall all of the details of the incident due to the amount of time that had elapsed. After reading her signed witness statement, SRNA 2 stated she did remember seeing R7 hit R5 in her head with an open hand. She further stated she recalled she immediately separated the two residents. SRNA 2 additionally said R7 was confused most of the time and had the mind of a child. During an interview with SRNA 5 on 05/15/2025 at 10:40 AM, she stated R7 always had some behaviors requiring increased supervision. During an interview with the DON on 05/15/2025 at 11:18 AM, she stated R7 usually did not have physical behaviors towards anyone; however, did have a diagnosis of schizophrenia and had delusions. She stated R7 would yell at nothing and was usually only aggressive towards her delusions. The DON said R7 was monitored by the nursing staff frequently, and stayed in her room or sat at the nursing station. She reported R7 was followed by psychiatric services and had been sent out of the facility for psychiatric evaluations a few times. The DON further stated she expected staff to keep residents safe and report any incident or allegation of abuse to her, their supervisor or the Administrator immediately. During an interview with the Administrator on 05/15/2025 at 11:50 AM, he stated R7 was known to be eccentric and have behaviors. He stated she had diagnoses of schizophrenia, delusions, and hallucinations, but was not usually physically aggressive. The Administrator further stated he expected staff to intervene immediately then report any abuse directly to their supervisor then they should call or text him immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a notice of discharge to the resident or resident representative along with a copy of the notice to the Office of the State Long Term Care Ombudsman following discharge for 1 of 4 sampled closed record reviews, (Resident (R) 13). R13 was discharged to home on [DATE]. However, the facility failed to provide a written notification of transfer/discharge to R13 or the Office of the State Long-Term Care Ombudsman. The findings include: Policies were requested; however, the facility did not provide policies which were in effect on 10/12/2022 for the State Survey Agency (SSA) to review. Review of R13's closed electronic medical record (EMR) admission Record revealed the facility admitted the resident on 09/30/2022, with diagnoses to include sepsis, type 2 diabetes mellitus and synovitis and tenosynovitis (inflammation) of the hand. Review of the Minimum Data Set (MDS) Assessment for R13 with an Assessment Reference Date (ARD) of 10/12/2022, located in the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognitive function. Additional review of R13's EMR revealed a Discharge Plan dated 10/12/2022. Further review revealed no additional documentation of discharge or discharge paperwork having been provided to the resident. Review of an electronic mail (e-mail) dated 05/14/2025, from the District Ombudsman, revealed she did not have anything from 2022 on (R13's) discharge. In interview on 05/14/2025 at 2:30 PM, the Regional [NAME] President of Operations, the facility's former Administrator, stated the transfer/discharge policy in effect for 09/30/2022 through 10/02/2022 was unavailable because of facility ownership changes. In interview on 05/15/2025 at 11:19 AM, the Director of Nursing (DON) stated discharge planning began at admission, with goals and plans shared with the team, and social services (SS) being involved. She stated that notification was documented in the resident's chart either in a progress notes or as a change in condition. The DON further stated paperwork was sent with the resident, sent to family, and she thought scanned into the resident's EMR. In an interview on 05/15/2025 at 11:48 AM, the facility Administrator stated the facility was responsible to notify the resident's family and ombudsman of transfers and discharges. He said under most circumstances written notification must be given. the Administrator further stated records should be retained and accessible; however, he was unaware of the specific length of time records should be kept.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to notify the resident and/or the resident's representative(s) of a hospital transfer in writing for two (2) of three (3) sampled residents, Resident #40, Resident #36, reviewed for hospitalization, out of the total sample of sixteen (16) residents. The findings include: The Survey Team requested a policy regarding the deficient practice; however, facility staff reported the facility had no such policy. 1. Review of Resident #40's record revealed a facility transfer form dated 10/26/2021 at 9:45 PM, which noted the resident had been sent to a local hospital due to a gastrointestinal (GI) bleed. Per review, there was no documented evidence related to facility staff having notified the resident and/or resident representative of the resident's transfer to the hospital. 2. Record review of a Resident #36's progress notes, revealed Resident #36 was sent to a local hospital on [DATE] due to an altered mental status. Further review of the record revealed there was no documentation related to notifying the resident and/or resident representative of the resident's transfer to the hospital. Interview on 12/01/2021 at 10:53 AM, with the Director of Nursing (DON), revealed they only notified the family member via telephone when a resident was sent out to the hospital. Per interview, the facility did not provide a letter to the resident or resident's representative for hospital transfers; however, they did notify the Ombudsman of this information, via electronic mail (email) on a monthly basis. Interview on 12/02/2021 at 6:15 PM, with the Administrator, revealed they only notify the family verbally when a resident was transferred to the hospital.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure all residents were provided proper nail care necessary for residents dependent on nail care for one (1) of sixteen (16) sampled residents, Resident 40). Observation revealed Resident #40's fingernails were not trimmed and there was a dark brown substance underneath all his/her fingernails. The findings include: Review of the facility's policy titled, ADL: Fingernail Care, with an effective date of 12/01/2006, revealed, for the Activity of Daily Living (ADL) facility staff were to trim and clean a resident's fingernails as needed or requested. Per review, the purpose of providing appropriate nail care for residents was To promote hygiene of hands and nails. Record review revealed the facility admitted Resident #40 on 11/01/2021, with diagnoses which included Lack of Coordination and Muscle Weakness. Review of the facility's five (5) Day Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed the facility had assessed Resident #40 with a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), which indicated moderate cognitive impairment. Continued review of the MDS Assessment revealed the facility had assessed Resident #40 as totally dependent regarding personal hygiene and requiring assist of one (1)person to complete his/her hygiene needs. Review of Resident #40's Comprehensive Care Plan, with a revision date of 09/21/2021, revealed the facility had care planned the resident to require assistance with all his/her ADL care. Per review, the interventions included for one (1) staff person to provide Resident #40 with the extensive assistance he/she required for grooming and/or personal hygiene. Observation on 11/30/2021 at 9:35 AM, revealed Resident #40 was lying on the bed in his/her room. Per observation, Resident #40's fingernails were approximately one quarter (1/4) inch to one half (1/2) inch long extending past the resident's fingertips. Continued observation revealed all of Resident #40's fingernails contained a dark brown substance underneath all of the nails. The Surveyor attempted to interview Resident #40 regarding his/her fingernails, at the time of observation, however, the resident did not respond when questioned. An additional observation on 12/01/2021 at 8:59 AM, revealed Resident #40 lying on the bed in his/her room with his/her hands under the covers. The Surveyor asked Resident #40 if he/she would show his/her hands to the Surveyor. Resident #40 removed his/her hands from under the covers, and observation revealed the resident's fingernails remained grown out and with the dark brown substance under all the nails. Interview at the time of observation revealed, Resident #40 stated staff never trim or clean my nails, while rubbing his/her fingertips over the elongated nails. Interview, on 12/01/2021 at 9:06 AM, with Certified Nursing Assistant (CNA) #1 revealed he/she was responsible for providing Resident #40's nail care needs. Per interview, nail care was typically completed on the resident's bath/shower day. CNA #1 stated Resident #40's bath day had been changed, so the CNA was unsure of when the last time was the resident had received a bath. Continued interview revealed all residents' nails were to be kept clean and trimmed to ensure they won't cut themselves. CNA #1 revealed the CNA had not provided any care to Resident #40 yet that day; however, had been assigned to the resident's care. Per the Surveyor's request, CNA #1 entered Resident #40's room at that time to look at the resident's nails. Further interview revealed the CNA stated, Oh, yeah, those are dirty and way too long. I will get them trimmed today. Observation at that time revealed CNA #1 asked Resident #40 if it was okay for the CNA to trim his/her nails, and the resident stated, Yes, please. Interview on 12/01/2021 at 9:14 AM, with Licensed Practical Nurse (LPN) #2 revealed the CNA's completed the nail care on residents, unless the resident was a Diabetic or on anticoagulant medication, in which case the nurses provided the nail care. Per interview, the CNA's were to complete nail care for residents as needed, particularly on the residents' bath days. LPN #2 further stated CNA's were to make sure residents' fingernails were not long and dirty, with debris underneath the nails. Interview on 12/01/2021 at 9:50 AM, with the Director of Nursing (DON) revealed the facility's expectations was for nail care to be completed by a CNA on each resident's bath day and as needed, unless the resident was Diabetic or on anticoagulants. Per interview, if a resident was Diabetic or on anticoagulants, then nail care was the nurse's responsibility. Further interview revealed it was ultimately the nurse's responsibility to ensure each resident's nails were kept clean and trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documentation, it was determined the facility failed to ensure two (2) of it's twenty-seven (27) rooms measured at least eighty (80) square feet per resident in multiple resident rooms, or one hundred (100) square feet in single resident rooms, resident rooms #13 and #15). The findings include: Review of the facility's wavier document dated 08/01/2018, from the Centers for Medicare and Medicaid (CMS) revealed the facility had been granted a waiver for resident rooms #13 and #15 for variations of the resident's room size. Further review of the waiver document revealed an expiration date of 02/21/2021 for the resident room waiver. Continued review of the facility's documentation revealed no documented evidence the facility submitted a waiver request for rooms [ROOM NUMBERS], prior to the expiration date, nor of a waiver having been granted for those rooms after the expiration on 02/21/2021. Observation on 12/02/2021 at 11:10 AM, of room [ROOM NUMBER] revealed the room measured approximately 28' (feet) W (wide) by 12' L (long), and room [ROOM NUMBER] measured approximately 28' W by 12' L. Per observation, each room contained four (4) residents' beds and two (2) wardrobe closets which measured approximately 10' by 2'. Further observation revealed both resident rooms were less than the required eighty (80) square feet per resident. Interview on 12/02/2021 at 1:17 PM, with the Administrator, revealed the facility had been provided no guidance on how long the resident room waivers lasted. Continued interview revealed the residents residing in rooms #13 and #15 were living in less than the required square footage. In addition, the Administrator revealed resident rooms #13 and #15 contained four (4) residents' beds in each room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review (should this say, facility policy review and not record review?), it was determined the facility failed to ensure resident rooms were equipped and/or located near a toilet and bathing facilities for twenty-six (26) of twenty-seven (27) rooms reviewed for variances. The findings include: Observation, on 11/30/2021 during the initial tour of the facility, resident rooms #1 through #12 were observed to accommodate fourteen (14) residents. Per observation, the rooms referenced did not have a private toilet room for the fourteen (14) residents' use. Continued observation revealed four (4) bathrooms with lavatories which the facility utilized to accommodate the residents residing in rooms #1 through #12. Observation of resident rooms #13 through #15, revealed the rooms accommodated eight (8) residents, with no private toilet rooms observed. Further observation revealed the facility utilized two (2) central bathrooms with two (2) lavatories to accommodate the eight (8) residents residing in rooms #13 through #15. Observation revealed resident rooms #17 through #26, were semi-private rooms that shared a toilet with an adjoining room; however, did not have a lavatory in each of the resident rooms. Per continued observation, residents were assisted to the bathrooms by staff; however, the layout of the bathrooms revealed residents who utilized wheelchairs for mobility were not accommodated. Further observation revealed the facility provided bedside commodes for residents' use which were being utilized by the residents. Interview on 11/30/2021 at 4:20 PM, with the Administrator, and provision of documentation revealed the facility had a waiver for the resident room sizes and for the lavatories not being located in or near each resident's room. Review of the letter dated 05/01/2006, provided by the Administrator, revealed the facility's waivers had been granted on 09/14/1977. Further interview revealed the Administrator stated the facility had not applied for a new waiver for the lavatories and was unaware of how often the waivers were required to be approved. Interview on 12/02/2021 at 7:50 AM, with the Maintenance Director revealed the facility did not have bathrooms located in the resident rooms on the facility's Front Hall, which were resident rooms #1 through #12. Continued interview revealed however, the facility provided bedside commodes and bathrooms located in the hallway for residents' use. Observation at the time of interview, revealed in order to reach a bathroom to use, a resident had to ambulate or wheel himself/herself in a wheelchair, down the hallway and turn a corner to access the bathroom. Continued observation revealed the Maintenance Director measured the distance between resident room [ROOM NUMBER] to the closest bathroom, with the results being approximately fifty-four (54) feet to the nearest bathroom. Further observation revealed the Maintenance Director measured the distance from resident room [ROOM NUMBER] to the closest bathroom as approximately twenty-three (23) feet.

**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 its infection prevention and control program adequately addressed the prevention of communicable diseases to the extent possible. The facility failed to properly screen visitors and staff for signs and symptoms of the COVID-19 virus prior to allowing the visitors and staff to enter the building. The facility also failed to educate visitors on the proper use of personal protective equipment (PPE) which was to be worn for Resident #94 who was on transmission-based precautions (TBP) due to possible exposure to the COVID-19 virus. The facility further failed to ensure its staff wore the proper PPE required when providing care for two (2) residents in isolation, Resident #194 and Resident #26. The facility additionally failed to ensure it staff wore appropriate eye protection when in resident care areas as required in a high transmission county, failed to complete the required fit testing necessary for the use of N95 masks (filtering facepiece respirators). The deficient practice occurred during the COVID-19 pandemic, and had the potential to affect all the facility's residents. The findings include: Review of the facility's policy titled, Supplemental Guidance for Placement of Admissions and Readmissions, with a revision date of 11/19/2021, revealed all newly admitted and readmitted residents required observation regardless of whether they had been vaccinated, partially vaccinated or were unvaccinated. Per review, the exclusion to observing newly admitted or readmitted resident was if the resident had been fully vaccinated and had received a vaccine booster. Continued review revealed the facility was to have an admission Observation Unit (AOU) which would be utilized for newly admitted or readmitted residents in order to segregate those residents for a ten (10) day observation period. Review revealed unvaccinated residents or residents who had been vaccinated with a prolonged close contact with someone who was COVID-19 positive within the prior fourteen (14) days residing in the AOU, were to be under person specific Airborne and Contact Precautions. Further review revealed the patient specific contact and airborne precautions included the use of gloves, gown, a N95 Respirator, and eye protection for everyone entering the resident's room. In addition, the resident's room was to have a patient specific precaution sign posted on the door. Review of the facility's policy titled, Use of Goggles, Face Shields and N95 Respirators on and Off Units, with a revision date of 09/24/2021, revealed when a COVID-19 outbreak occurred in the facility, the affected units were to be placed on Contact (plus) Airborne Precautions. Per review, staff were to wear goggles or a face shield, in addition to, an N95 respirator for which the staff member had to have been fit tested for. Further review revealed for the AOU and its rooms, staff were to follow the same practices as described above due to the increased risk of having a COVID-positive resident. Review of the Centers for Disease Control and Prevention (CDC) publication titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/10/2021, revealed healthcare (HCP) working in facilities located in counties with a substantial or high transmission rate were to wear PPE such as, eye protection (goggles or a face shield which covered the front and sides of the face) during all patient (resident) care encounters. 1. Review of Resident #194's record revealed the facility admitted the resident on 11/19/2021. Further review of the record revealed the admission Minimum Data Set had not been submitted yet, so cognitive status was not documented. Review of Resident #194's Physician's Orders, revealed an order with a start date of 11/19/2021, for the facility staff to initiate contact and airborne precautions due to the resident's recent hospitalization and possible exposure to COVID-19 during the hospitalization. Review of Resident #194's Care Plan revealed no documented evidence of the type of isolation precautions the resident was supposed to be on. Observation on 11/30/2021 at 9:33 AM, revealed Resident #194's room door was closed with a PPE bin located outside of the room door. Per observation, there was a sign on the door stating Resident #194 was on Airborne precautions. Continued observation revealed visitors and/or staff must see the nurse before entering Resident #914's room. Observation additionally revealed entrance into the resident's room required staff and visitors to don and wear an N95 respirator, gown, face shield, and gloves prior to entering. Observation on 11/30/2021 at 12:00 PM, revealed Nursing Assistant (NA) #1 delivered Resident #194's noon meal tray to the resident's room. Continued observation revealed however, NA #1 did not don the appropriate and required PPE prior to entering the Resident #194's room. Per observation, the NA entered the resident's room wearing only the facial mask he/she had been wearing prior to entering. Observation revealed NA #1 placed the meal tray on Resident #194's overbed table and then assisted the resident with repositioning in bed to eat his/her meal. Further observation revealed Resident #194 had a family member in the room, who was sitting by the resident's bed with no PPE on at all. Interview, at the time of observation, revealed the family member stated that the facility had screened them at the front door; however, had not educated them on what PPE needed to be worn while in the building or what PPE needed to be worn while visiting Resident #194 in his/her room. Observation further revealed the family member pulled a face mask out of their pants' pocket and stated they knew they had to wear a face mask when they entered the facility, but that was all that staff had told them. Observation on 12/01/2021 at 8:46 AM, revealed no evidence of the PPE isolation bin which had been located outside Resident #194's room previously. In addition, observation revealed the door signage had also been removed. Interview on 12/01/2021 at 8:49 AM, with Licensed Practical Nurse (LPN) #2, revealed Resident #194 was not on any type of isolation. Per interview, the LPN did not know the Resident #194's vaccination status. LPN #2 further stated residents who had not been vaccinated were on isolation for ten (10) days after being admitted . Interview on 12/02/2021 at 1:59 PM, with the Director of Nursing (DON) revealed Resident #194 had refused the vaccine when it was offered to him/her by the facility. Per interview, unvaccinated residents were on quarantine for ten (10) days after admission. The DON stated Resident #194 had been admitted on [DATE], and should have been taken off the quarantine isolation on 11/30/2021. Continued interview revealed The DON if a resident was on any type of isolation while on quarantine and had a visitor, the visitor was only required to wear a mask. Per the DON however, staff must wear full PPE when in the room of a resident who was on isolation while in quarantine. Further interview revealed visitors were given a face mask while being screened at the front of the facility. The DON additionally revealed visitors used to be provided an information sheet on what PPE to wear for the resident they were visiting; however, the DON believed visitors were no longer being provided those handouts. 2(a). Review of Resident #26's record revealed the facility admitted the resident on 11/04/2016, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) and Dependence on Supplemental Oxygen. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #26 dated 10/14/2021, revealed the facility had assessed the resident with a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #26's Physician's Orders revealed an order, with a start date of 12/21/2020, for Albuterol Sulfate Nebulization Solution (a breathing treatment) every two (2) hours as needed for wheezing or shortness of breath. Observation on 11/30/2021 at 9:58 AM, revealed a PPE bin located in front of Resident #26's room door. Per observation, there was also a sign on the resident's door with which had a STOP sign that stated, Aerosol Generating Procedure in Progress. Please do not enter. If you must enter, remember .Wear an N95 respirator, gown, face shield, and gloves upon entering this room. Keep room door closed. Continued observation revealed LPN #1 was in Resident #26's room administering a nebulizer treatment for the resident, wearing a facial mask. Interview at 10:03 AM during the previously noted observation, revealed LPN #1 stated she was in Resident #26's room to administer a nebulizer treatment which she had just completed for the resident. Further observation revealed LPN #1 walked out of Resident #26's room while stating there were no residents on isolation precautions at that time on that hall. Interview revealed LPN #1 stated the only PPE required for staff to wear was a regular facial mask. Observation further revealed LPN #1 walked to the nursing desk, where Registered Nurse (RN) #1 was sitting, and LPN #1 asked RN #1 why PPE bins were located outside of two (2) of the residents' rooms. RN #1 was observed and overheard telling LPN #1 the residents had been on isolation precautions; however, were no longer on the precautions, therefore the PPE bins were no longer needed and should have been moved. Observation on 11/30/2021 at 11:19 AM, revealed Resident #26 stated I can't breathe, to RN #1 who was in the resident's room wearing only a facial mask with no other PPE. Per observation, RN #1 stated Resident #26's pulse oximetry was 90% with the resident having six (6) liters of oxygen administered per minute via nasal cannula. Continued observation revealed RN #1 exited Resident #26's room to don a gown and gloves from the PPE bin located outside the resident's room door. The Surveyor attempted to interview Resident #26; however, the resident declined to be interviewed at that time. Further observation revealed RN #1 reentered Resident #26's room and informed the resident the RN would have LPN #1 provide pain medication for the resident to assist with his/her breathing difficulty. Interview on 12/01/2021 at 8:49 AM, with LPN #2 revealed she had been assigned to Resident #26's care that day. Per interview, the LPN stated Resident #26 was only on isolation when he/she was receiving a nebulizer treatment, due to that being an aerosol procedure. Interview on 12/02/2021 at 2:05 PM, the DON revealed Resident #26 was only on isolation precautions when he/she received an aerosol generating procedure (such as a nebulizer treatment). The DON stated, It's a policy that our corporation put into effect. It's an extra precaution. Further interview revealed during any aerosol generating procedure, staff must wear PPE to include a gown, N95 mask, goggles or face shield; however, only had to wear the PPE while the procedure was going on. 2(b). Review of the facility policy titled, IC405 Covid 19, dated 3/27/2020 and revised 06/07/2021, revealed, active screening was to be performed of all persons who entered the facility. Per review, all persons included employees, visitors, medically necessary personnel, contracted staff or vendors and volunteers. Review of the facility policy titled, Screening of Visitors and Employees, Return to Work Guidance for Employees, and Employee Workers Comp Procedures, dated 10/20/2021, revealed visitors with a temperature of 100 F [Fahrenheit] or higher or any listed signs or symptoms would not be permitted to enter the facility. Continued review revealed family visitors meeting any of the following would not be permitted entry into the facility: a fever or other symptoms as located on the screening form. Review of the facility policy titled, Screening Form Instructions for Screeners, dated 06/15/2021, revealed, visitors were to be screened for any symptoms and a temperature. Per review, the findings were to be recorded on the screening form for employees, and visiting healthcare personnel (HCP), and on the visitor's log. Upon entering the facility on 12/01/2021 at 7:40 AM, two (2) Surveyors had their temperatures obtained by the facility's Activities Director (AD); however no screening questions were asked of the Surveyors. Observation on 12/01/2021 at 7:54 AM and 8:00 AM, revealed a Surveyor entering the facility and the AD obtained that Surveyor's temperature; however, once again no screening questions were asked. 2(c). Review of the facility policy titled, SH408 Respiratory Protection and use of Respirators, dated 10/15/2009 and revised 11/01/2021, revealed the facility was to provide appropriate respiratory protection equipment, at no cost for its employees in accordance with the Occupational Safety and Health Administration (OSHA) standards. Per review, the OSHA standards included medically evaluating the employee for his/her ability to safely use a respirator, follow the fit testing guidelines and procedures in the Vita Learn Respirator Fit testing education to ensure employees were fit tested prior to using any N95 respirator, and employees were to follow the procedures for proper respirator use. Observation on 11/30/2021 at 10:03 AM, revealed LPN #1 had just completed providing a nebulizer treatment for a resident wearing only a face mask. Interview with LPN #1, at the time of observation, revealed the LPN had never been fit tested for an N95 mask and did not have to wear the N95 mask when caring for any resident he/she had been assigned to that shift. Observation during a medication (med) pass observation on 12/02/2021 at 3:12 PM, with LPN #1, revealed the LPN provided a nebulizer treatment for a resident. LPN #1 was observed to have on a regular face mask which the LPN then placed an N95 mask over and then applied a face shield. Interview, at the time of observation, revealed the LPN was unable to see through the face shield due to it fogging up. Further interview revealed LPN #1 again informed the Surveyor of not having been fit tested for the N95 mask the LPN was wearing over the face mask; however, had recently been told wearing an N95 mask was required when administering a nebulizer treatment. Interview on 12/01/2021 at 3:49 PM, with the Assistant Director of Nursing (ADON), who was also the facility's Infection Control Nurse revealed if a resident was receiving aerosol nebulizer treatments or were new admits to the facility, staff should adhere to the door signage for those residents. Continued interview revealed for those residents staff should wear a gown, gloves, N95 mask, and eye protection (a face shield or goggles), and ensure the resident's room door remained closed. Interview with the DON, on 12/01/2021 at 3:55 PM, revealed all staff received training on wearing N95 masks with a seal test prior to entering a resident's room during the pandemic. The DON demonstrated sealing her own mask across the nose bridge and adjusting the sides of the mask. Continued interview revealed the DON had taught the seal test procedure in order staff to do the seal test quickly prior to entering a resident room. The DON confirmed the facility had several different types of N95 masks and had not completed fit testing for staff. 3. Observation on 12/02/2021 at 7:14 AM, revealed LPN #1 was sitting at the nurse's desk in the facility's Back Hall area using the telephone. Per observation, a person outside the facility approached the exit door in the Back Hall area and motioned at the Surveyor to allow them entrance to the facility. The Surveyor informed LPN #1 that the Surveyors were not allowed to open exit doors and allow outside persons into the facility. Continued observation revealed the person outside again motioned at the Surveyor to let them in the door. The Surveyor informed Certified Nursing Assistant (CNA) #2, who had been walking down the hall, of the person outside the exit door which the Surveyor did not know and could not let in the door. Further observation revealed CNA #2 punched the entrance code for the exit door and allowed the person outside to enter the facility without being screened for the COVID-19 virus. Interview on 12/02/2021 at 7:40 AM, revealed LPN #1 stated the person standing outside the exit door had been a doctor. Per interview, the LPN had never seen a doctor use that exit door before to gain entrance into the facility. LPN #1 stated the doctor was let into the facility by another staff person while the LPN had been on the telephone. Further interview revealed that was why the doctor was not stopped for screening. Interview on 12/02/2021 at 7:42 AM, with CNA #2 revealed the CNA had not known who the person had been standing outside the exit door and, had thought the person was someone with the Surveyor. When the Surveyor reiterated telling CNA #2 he/she did not know the person outside the exit door, the CNA stated Oh. Interview on 12/02/2021 at 8:54 AM, with the DON, revealed the DON had been made aware of the doctor having been let into the facility without being screened. Per interview, the CNA had informed the DON the Surveyor had requested the CNA let the doctor in the building. The Surveyor then informed the DON of what had been told to the CNA regarding the Surveyor not knowing who the person was standing outside the exit door and that the Surveyor was not allowed to let the person into the facility. Further interview revealed nobody should use the exit door as an entrance to the facility. The DON further confirmed everyone must use the facility's business office door for entrance in order to be screened prior to entering the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and review of the Code of Federal Regulations (CFR), it was determined the facility failed to ensure two (2) of twenty-seven (27) rooms measured at least eighty (80) square feet (ft) per resident in multiple resident bedrooms or one-hundred (100) square ft in single resident rooms (Rooms #13 and #15). The findings include: Review of CFR 483.90(e)(1)(ii), implemented 11/28/17, revealed measurement of square footage measure at eighty (80) square feet per resident in multiple resident rooms and at least one-hundred (100) square feet in a single resident's room. room [ROOM NUMBER] measured 27' 9'' W by 11' 11 L and room [ROOM NUMBER] measured 27' 10 W by 11' 11 L, each room housed four (4) residents and contained two wardrobes that measured 10 foot by 2 foot, on 02/21/18. Both rooms housed four (4) residents which left less than eighty (80) square feet per resident. Observation on 10/14/19 revealed both rooms still contained the wardrobes and housed four (4) residents. Interview (Post Survey) with the Administrator, on 12/12/19 at 10:04 AM, revealed the facility had a waiver for the rooms and there were still four (4) beds in each room.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure recipes were being followed for meals being developed in the kitchen for the facility residents during supper meal preparation. The findings include: Review of the facility policy titled, Food: Quality and Palatability, last revised September 2017, revealed menu items are prepared according to the menu and standardized recipes. It further states the cooks prepare food in accordance with recipes. Observation during follow up visit to the kitchen on 07/18/18 at 8:25 AM, revealed [NAME] #1 was making cucumber salad for the residents' lunch meal without using a recipe and adding ingredients without a recipe. Interview with [NAME] #1 on 07/18/18 at 8:25 AM, revealed she normally makes the cucumber salad without a recipe and goes by what she knew for the cucumber salad. She stated she is supposed to use the recipes. Interview on 07/18/18 at 8:36 AM with the Dietary Manager, revealed she expected recipes to be followed for everything that is made in the kitchen for the residents. Interview on 07/19/18 at 3:19 PM with the facility Administrator, revealed she expects the kitchen staff to follow the facility policies and procedures related to using recipes.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 07/17/18, revealed food being stored in the freezer was open to air and unsealed and the kitchen's manual can opener was visibly dirty. Review of the Census and Condition, dated 07/17/18, revealed forty-seven (47) of forty-eight (48) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Food Storage: Cold Foods, last revised April 2018, revealed all foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Observation of Freezer #3 on 07/17/18 at 10:28 AM, revealed a box of dinner rolls open and unsealed. 2. Review of facility policy titled, Equipment, last revised September 2017, revealed all food service equipment will be clean, sanitary and in proper working order. Further review of the policy, revealed all equipment will be routinely cleaned and all food contact equipment will be cleaned and sanitized after every use. Observation of the kitchen on 07/17/18 at 10:33 AM, revealed the can opener had a build up of brownish/black colored crust like material on the cutting edge and area surrounding the cutting edge. Interview with the Dietary Manager on 07/18/18 at 8:36 AM, revealed she expected the can opener to be cleaned after each use and to be run through the dishwasher every shift. She stated she expected all food items stored in the freezer to be sealed completely and not left open to air. Interview with facility Administrator on 07/19/18 at 3:19 PM, revealed she stated she expects the staff to also follow the facility policy and procedures in regards to cleaning the kitchen equipment and sealing of foods in the freezers.