**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop a comprehensive person centered care plan, which addressed the type of feeding assistance needed for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for comprehensive person centered care plans.Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Sequelae of Cerebral Infarction, Dysphagia, Need for Assistance with Personal Care, Specified Forms of Tremor, Hereditary and Idiopathic Neuropathy, and Muscle Weakness. Review of Resident #1's most recent comprehensive person centered care plan revealed no documented evidence of feeding assistance interventions. An observation was made on 09/03/2025 at 8:32 a.m. of S3CNA providing feeding assistance to Resident #1. Resident #1 noted to have bilateral upper extremities resting on bed while S3CNA delivered food and hydration to Resident #1's mouth without his assistance. An interview was conducted on 09/03/2025 at 8:35 a.m. with S3CNA. S3CNA confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/03/2025 at 8:45 a.m. with S2LPN. S2LPN confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 8:45 a.m. with S4CNA. S4CNA confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 8:50 a.m. with S5LPN. S5LPN confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 9:25 a.m. with S6TD. S6TD stated she had provided Occupational Therapy services to Resident #1. S6TD stated Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 9:50 a.m. with S7CCC. S7CCC stated she was responsible for Resident #1's comprehensive person centered care plan. S7CCC confirmed Resident #1 did not have any interventions care planned for feeding assistance and should have. An interview was conducted on 09/04/2025 at 11:20 a.m. with S1DON. S1DON confirmed residents requiring feeding assistance should have a comprehensive person centered care plan that reflected individualized feeding interventions to ensure the resident received proper care and support.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable infection by failing to ensure staff performed appropriate infection control practices during and after incontinence care for 1 (#5) of 1 (#5) resident observed for catheter care. Findings: Review of the facility's undated policy titled, Hand Hygiene revealed the following, in part:Policy: Hand hygiene is the single most important procedure in preventing infection.Staff should change gloves before touching a patient, before a clean/aseptic technique, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. Review of Resident #5's clinical record, revealed she was admitted to the facility on [DATE]. Review of Resident #5's current care plan, revealed clean catheter with soap and water every shift. On 07/22/2025 at 9:30 a.m., an observation was made of catheter care performed by S4CNA and S5CNA on Resident #5. S4CNA and S5CNA donned clean gloves. S4CNA cleaned the catheter tubing and, without changing her gloves and performing hand hygiene, she picked up two clean soapy washcloths, performed perineal care to Resident #5, disposed of wash clothes, touched Resident #5, and touched draw sheet. Then, S5CNA used a wet wipe to wipe resident's buttocks three times and removed the dirty brief. Then without changing their gloves, both S4CNA and S5CNA touched the clean brief, draw sheet, gown, pillow between Resident #5's legs, neck pillow, a pillow under her left arm, sheet, and call light. Both CNAs then removed dirty gloves and performed hand hygiene. On 07/22/2025 at 9:52 a.m., an interview was conducted with S4CNA. She stated she did not change her gloves and perform hand hygiene once she touched Resident #5's dirty catheter and she should have. She stated she should change gloves and perform hand hygiene any time she goes from a dirty to a clean area. On 07/22/2025 at 10:00 a.m., an interview was conducted with S5CNA. She stated she did not change her gloves and perform hand hygiene once she touched Resident #5's catheter and she should have. She stated she should change gloves and perform hand hygiene any time she goes from a dirty to a clean area. On 07/22/2025 at 1:25 p.m., an interview was conducted with S1DON. She stated she expected all staff to change gloves and perform hand hygiene when going from dirty to clean while performing catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain accurate documentation for 2 (#66 and #122) of 22 (#1, #2, #3, #5, #7, #8, #10, #11, #32, #37, #44, #48, #50, #51, #58, #62, #68, #72, #75, #96, #97, and #113) sampled residents. The facility failed to ensure:1. Resident #66's oxygen use was accurately documented; and2. Resident #122's death note was accurately documented.1.Review of Resident #66’s clinical record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Dementia. Review of Resident #66’s Physician Orders revealed in part, the following: [DATE] Check Oxygen (O2) saturation routinely, every shift Notify Medical Doctor (MD) if less than 90%. Review of Resident #66’s [DATE]-[DATE] Medication Administration Record (MAR) revealed in part, the following: No evidence of documentation of oxygen saturation every shift, on the following dates: [DATE] day shift, [DATE] day shift, [DATE] day shift, [DATE] day shift, [DATE] day shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift, [DATE] day shift, and [DATE] day shift. On [DATE] at 2:01 p.m., a telephone interview was conducted with S3LPN. S3LPN stated Resident #66 at times would refuse getting her O2 checked. Review of the nurses’ notes of the aforementioned dates revealed no nurses’ notes related to Resident #66's refusal of treatment or oxygen saturation. On [DATE] at 2:16 p.m., an interview was conducted with S1DON. S1DON confirmed there was no documentation for the aforementioned dates of Resident #66’s oxygen saturation and no nurses’ notes documenting Resident #66’s refusal of treatment and there should have been. 2. Review of the facility’s undated policy titled “Death of a Resident” revealed in part, the following:Upon the death of a resident, nursing documentation must include:1. Date and time of death of resident.2. Pertinent details related to death event.3. Physician notification.4. Family notification, name of person to whom body was released. Review of Resident #122’s clinical record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #122 expired while on hospice care on [DATE]. Review of nurse's notes dated [DATE] revealed in part, the following:[DATE] at 1:58 p.m. - expired. On [DATE] at 2:30 p.m., an interview was conducted with S1DON. S1DON reviewed Resident #122’s physical and electronic medical record. She stated a death note should consist of at least the following: notification to the hospice nurse, assessment of resident, notification to the family, name of person who called time of death, time of death, notification to the coroner, body release number, and who the body was released to. She confirmed a death note which simply stated expired was not sufficient and a complete death note should have been present in Resident #122’s medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, and #3) residents reviewed. Findings: Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #1 had a diagnosis of Generalized Edema with an onset date of 05/25/2018. Review of Resident #1's current Physician Orders revealed the following: Start Date: 09/03/2024 Furosemide 20 mg give one tablet orally one time a day related to Generalized Edema Review of Resident #1's MAR dated September 2024 revealed the following; in part, Resident #1 received Furosemide 20 mg by mouth daily as prescribed. Review of Resident #1's Quarterly MDS with an ARD of 09/07/2024 revealed Generalized Edema was not coded as an active diagnosis. On 10/03/2024 at 11:30 a.m., an interview was conducted with S2CCC. S2CCC confirmed Resident #1's MDS with an ARD of 09/07/2024 was not coded for the diagnosis of Generalized Edema. On 10/03/2024 at 11:40 a.m., an interview was conducted with S1DON. S1DON stated she was not sure if the MDS for Resident #1 should have been coded for Generalized Edema diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#108) of 4 (#27, #65, #75, and #108) residents reviewed for falls. Findings: Review of the clinical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Repeated Falls, Difficulty in Walking, Reduced Mobility, Cognitive Communication Deficit, and Alzheimer's Disease. Review of the most recent MDS with an ARD of 06/10/2024, revealed Resident #108 had a BIMS of 3, which indicated severe cognitive impairment. Review of the most current Care Plan revealed the following: Problem: At high risk for falls . 06/14/24 unwitnessed fall in room . Intervention: 06/15/2024- Replaced wheelchair cushion with a cushion to improve positioning. Remains high fall risk. On 07/10/2024 at 11:20 a.m., an observation was made of Resident #108 sitting in his wheelchair by the nurse's station when he fell out of his wheelchair and onto the floor. No cushion was observed in the resident's wheelchair. On 07/10/2024 at 11:55 a.m., an observation and interview was conducted with S6LPN. She stated Resident #108 was considered a high fall risk. S6LPN reviewed Resident #108's care plan and verified one of the interventions for falls was to replace his wheelchair cushion with a cushion to improve positioning. S6LPN verified there was no cushion on Resident #108's wheelchair and should have been according to his care plan. On 07/10/2024 at 1:20 p.m., an interview was conducted with S7IP. She stated she is responsible for completing and investigating incident reports and updating resident care plans after an incident occurs. She reviewed Resident #108's care plan interventions listed. S7IP confirmed the cushion should have been in Resident #108's wheelchair since it was listed as a care plan intervention for falls. On 07/10/2024 at 2:59 p.m., an interview was conducted with S2DON. She confirmed Resident #108's care plan had a fall intervention to replace his wheelchair cushion with a cushion to improve positioning, and it should have been implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#108) out of 4 (#27, #65, #75, and #108) residents reviewed for falls. Findings: Review of Resident #108's clinical record revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Repeated Falls, Difficulty in Walking, Reduced Mobility, Cognitive Communication Deficit, and Alzheimer's Disease. Review of Resident #108's Nurse's Note dated 07/07/2024 revealed, in part, the following: Notified by CNA at 4:30 a.m., when making rounds that resident was laying on floor, upon entering room resident laying on right side at side of bed, bedside chair also at bedside, assessed range of motion, able to move arms and legs, denies pain, unable to state how he got there, assisted to bed via two staff, noted dime size skin tear to back of right hand, no skin flap present . Review of Resident #108's care plan revealed it was not revised to include fall interventions for falls after 06/17/2024. The care plan did not include interventions to address Resident #108's fall that occurred on 07/07/2024. On 07/10/2024 at 1:20 p.m., an interview was conducted with S7IP. She stated she was responsible for completing and investigating incident reports and updating resident care plans after an incident occurs. She stated care plans and interventions should be revised within 24 hours of the incident occurring. She verified she was aware Resident #108 had a fall on 07/07/2024, and confirmed she had not revised or implemented any further interventions for falls on his care plan and should have. On 07/10/2024 at 2:59 p.m., an interview was conducted with S2DON. She stated when a resident had a fall, the care plan and interventions were to be revised with updated interventions after each fall. S2DON confirmed Resident #108 had a fall on 07/07/2024 and after reviewing his care plan, confirmed no revisions had been made to his fall interventions after 06/17/2024 and should have been.

Based on interviews, and record reviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice and the resident's preferences for 1 of 1 (#56) residents sampled for dialysis services. The facility failed to ensure staff maintained ongoing communication with the dialysis center to ensure Resident #56 received meals during dialysis treatments. Findings: Review of Resident #56's medical record revealed an admission date of 11/12/2018 with diagnoses that included, in part, End Stage Renal Disease, Dependence on Renal Dialysis, and Type II Diabetes Mellitus without Complications. Review of Resident #56's care plan revealed in part, Potential for Altered Nutrition related to therapeutic diet, ESRD (End Stage Renal Disease), and Diabetes Mellitus Type II. On 07/08/2024 at 3:43 p.m., an interview was conducted with Resident #56. She stated she felt tired and weak following her dialysis treatments. She stated she was a diabetic, and she was sent to dialysis 3 days per week from 9:30 a.m. to almost 3:00 p.m. or later with no juice, snacks, or supplements. She stated she has told her nurses and Administrative staff she needed a snack during the time she was gone, but the facility has not provided any snacks. On 07/09/2024 at 9:30 a.m., an interview was conducted with S4LPN. She stated the facility did not send Resident #56, a diabetic resident, to her dialysis treatments on Mondays, Wednesdays, and Fridays with snacks, meals, juice or supplements. She stated since COVID-19, Resident #56's Dialysis Center does not allow the residents to come with food. She stated she did not communicate with Resident #56's Dialysis Center to determine if those restrictions were still in place, and she should have. She stated she was aware of the complaints from Resident #56 about being sent to dialysis with no juice, snacks or supplements during her treatments. On 07/10/2024 at 2:40 p.m., an interview was conducted with the Area Clinical Manager of the Dialysis Center Resident #56 attends for treatment. She stated residents can come with snacks, supplements, juice, or appropriate meals to the Dialysis Center. She stated the COVID-19 restrictions have been lifted, and the facility should be aware of that. On 07/10/2024 at 12:05 p.m., an interview was conducted with S9LPN. She stated she was responsible for communication with the Dialysis Centers. She stated since March of 2020 no snacks were allowed at the Dialysis Centers. She stated Resident #56, a diabetic resident, has not been sent with snacks, juice, or supplements to her Dialysis treatments. She stated she has not communicated with Resident #56's Dialysis Center regarding any restrictions for juice, snacks or supplements being sent for residents during treatments in the last 8 months, and she should have. On 07/10/2024 at 11:58 a.m., an interview was conducted with S2DON. She confirmed Resident #56, a diabetic resident, had not been sent to her dialysis treatments with snacks, supplements, or juice. She stated S9LPN was responsible for all communication with the Dialysis Centers. She stated residents were not allowed to bring snacks to the Dialysis Centers to her knowledge. She confirmed she had not communicated with Resident #56's Dialysis Center to confirm if the restrictions were lifted and she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 4 (#38, #45, #62 and #119) residents out of a total of 24 sampled residents. The facility failed to ensure: 1. Resident #38 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #45 was coded correctly for anxiety; 3. Resident #62 was coded correctly for hospice; and 4. Resident #119 was correctly for discharge. Findings: 1. Review of Resident #38's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Anxiety, Depression, Schizophrenia and Schizoaffective Disorder. Review of Resident #38's Form 142 revealed resident was approved for admission by Level II Authority for a temporary period effective 02/19/2024 through 05/10/2024. Sign and dated on 02/26/2024 by Agency Representative. Review of Resident #38's OBH-Level II Evaluation Summary & Determination Notice dated 02/26/2024 revealed: The individual has a serious mental illness. Review of Resident #38's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2024 revealed Section A1500 PASRR was coded as 0. No. Further review revealed the following: Section A1510A: Serious Mental Illness was blank and Section A1510B: Intellectual Disability was blank. On 07/09/2024 at 1:50 p.m., an interview was conducted with S8MDS. She stated she was responsible for completing resident MDS assessments. She reviewed Resident #38's Level II PASARR dated 02/26/2024 indicating Resident #38 had a serious mental illness. She reviewed Resident #38's Annual MDS with an ARD of 03/05/2024 and confirmed Section A1500, A1510A and A1510B was not coded as yes and should have been. 2. Review of Resident #45's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder (09/28/2023). Review of Resident #45's Annual MDS with an ARD of 04/23/2024 revealed Anxiety was not coded as an active diagnosis in Section I. On 07/10/2024 at 8:45 a.m., an interview was conducted with S8MDS. She stated she was responsible for completing resident MDS assessments. She stated when a MDS assessment was performed, all diagnoses should have been coded accurately. She reviewed the Annual MDS for Residents #45 with an ARD of 04/23/2024 and confirmed the MDS was not coded accurately for Anxiety in Section I. 3. Review of Resident #62's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #62's Annual MDS with an ARD of 05/21/2024 revealed Hospice was not coded in Section O. Review of Resident #62's Physician Orders dated July 2024 revealed the following: Order date: 04/13/2023- Admit to Hospice for terminal diagnosis. On 07/10/2024 at 3:51 p.m., an interview was conducted with S8MDS. She stated she was responsible for completing resident MDS assessments. She reviewed Resident #62's Physician Orders and confirmed Resident #62 was admitted to Hospice on 4/13/2023. She reviewed the Annual MDS with an ARD of 04/23/24 and confirmed the MDS was not coded accurately for Hospice in Section O and should have been. 4. Review of Resident #119's Clinical Record revealed she was admitted to the facility on [DATE] and discharged on 05/29/2024. Review of Resident #119's Discharge MDS with an ARD of 05/29/2024 revealed Section A2105 Discharge Status: Short Term General Hospital. Review of Resident #119's Nurse's Note dated 05/17/2024 included the following, in part: Discharge home with nephew. On 07/10/2024 at 3:17 p.m., an interview was conducted with S8MDS. She reviewed Resident #119's Discharge MDS with an ARD of 05/29/2024. She confirmed Resident #119 was coded as being discharged to the hospital and should have been coded as being discharged home. On 07/10/2024 at 4:30 p.m., an interview was conducted with S2DON. She reviewed the aforementioned findings and confirmed Residents' #38, #45, #62, and #119 MDS assessments should have been coded correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#9 and #27) of 6 (#9, #20, #27, #45, #69 and #71) residents reviewed for unnecessary psychotropic medications. Findings: Resident #9 Review of Resident #9's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #9's July 2024 Physician's Orders revealed the following: Start date: 09/22/2023-Vistaril 50 mg by mouth every 8 hours as needed for anxiety. Further review revealed the PRN medication had no stop date or duration. Review of Resident #9's July 2024 Medication Administration Record (MAR) revealed the following: Start date: 09/22/2023-Vistaril 50 mg by mouth every 8 hours as needed for anxiety. Further review revealed the PRN medication had no stop date or duration. On 07/10/2024 at 4:15 p.m., an interview was conducted with S2DON. She reviewed Resident #9's Physician orders and MAR dated July 2024. She confirmed Vistaril was ordered PRN longer than 14 days with no end date or duration documented. Resident #27 Review of Resident #27's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #27's July 2024 Physician's Orders revealed the following: Start date: 03/26/2024-Diazepam 5 mg tablet by mouth every 6 hours as needed; and Start date: 07/04/2024-Xanaz 0.25 mg tablet by mouth every 6 hours as needed. Further review revealed the above PRN medications had no stop date or duration. Review of Resident #27's July 2024 Medication Administration Record (MAR) revealed the following: Start date: 03/26/2024-Diazepam 5 mg tablet by mouth every 6 hours as needed; and Start date: 07/04/2024-Xanaz 0.25 mg tablet by mouth every 6 hours as needed. Further review revealed the above PRN medications had no stop date or duration. On 07/10/2024 at 4:15 p.m., an interview was conducted with S2DON. She reviewed Resident #27's Physician orders and MAR dated July 2024. She confirmed Valium was ordered PRN for longer than 14 days with no end date or duration documented. She confirmed Xanax was ordered PRN with no end date or duration.

Based on observations and interview, the facility failed to store, prepare, and distribute foods in accordance with professional standards for food service safety. There were 108 residents who received meals prepared by the kitchen. On 07/08/2024 at 8:15 a.m., an observation was conducted of the kitchen meal prep area. Lemon pepper seasonings, 28 ounces, was found to be open and unlabeled. The following items were found to be open, unsealed and unlabeled: 25 lbs. bag of lima beans 25 lbs. bag of flour 25 lbs. bag of panko crumbs 5 lbs. bag of white rice 6 lbs. box tea bags On 07/08/2024 at 8:20 a.m., an observation was conducted of the walk in cooler with the following items opened and unlabeled: 1 gallon container of slaw dressing 1 gallon container of mayonnaise 1 gallon container of salad dressing On 07/08/2024 at 8:30 a.m., an interview was conducted with S5DM. She confirmed all opened food items should be sealed and labeled with an open dated. She confirmed the above items were not labeled with an open dated and should have been. She further confirmed the rice, flour, lima beans, panko crumbs and tea bags should have been stored in a sealed container and were not.

Based on record review, observations, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 114 residents who were served meals from the kitchen. Findings: Review of the facility's Food Service Operation Standards for Purchasing, Cooking and Storage revealed: Policy: The facility stores, preparers, distributes and serves food under sanitary condition to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Procedure: 4. Preparation a. All potentially hazardous food should be prepared so they will spend less than a total of 4 hours in the temperature danger zone of 40 degrees -140 degrees 7. Holding: a. Holding equipment should keep hot foods at 140 degrees or above and cold foods at 40 degrees or below. On 03/04/3024 at 10:18 a.m., a review of the facility's daily food temperature monitoring log, cooking holding, storage dated 12/01/2023-03/04/2024 revealed food temperatures were not being completed 270 of 273 total meals served. On 03/04/2024 at 10:18 a.m., an interview was conducted with S1DM. She confirmed the dietary staff had not preformed or recorded foods temperatures prior to serving 270 of 273 total meals to the residents on the dates of 12/01/2023-03/04/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain a resident's privacy and dignity by staff failing to close privacy curtains while care was being performed for 1 (#2) of 2 (#2 and R1) residents reviewed. Findings: Review of the policy Titled, Conduct of Nursing Personnel revealed the following, in part: It is the policy of this facility that all nursing care personnel conduct themselves in a manner that promotes dignity and respect to residents. Policy Interpretation and Implementation: 12. Close room doors and/or cubicle curtains when providing nursing care to the resident. Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] and had diagnoses which included Incontinence, Contractures, and Cognitive Communication Disorder. Review of the Quarterly MDS with an ARD of 07/25/2023 for Resident #2 revealed, in part, she had a BIMS of 2, which indicated she was severely cognitively impaired. Further review revealed, she required maximum assistance with ADL care. On 10/02/2023 at 12:50 p.m., an observation was made of incontinent care performed by S1CNA and S2CNA on Resident #2. Resident #2's roommate was in bed watching television while Resident #2 was exposed. Without pulling the privacy curtain, S1CNA and S2CNA exposed Resident #2's perineal area and performed incontinent care. Resident #2 was visualized in her bed by her roommate throughout care performed by S1CNA and S2CNA. On 10/02/2023 at 1:32 p.m., an interview was conducted with S1CNA. She confirmed she did not pull the privacy curtain during incontinence care for Resident #2. She stated residents' privacy should always be maintained, and the privacy curtain should have been pulled. On 10/02/2023 at 1:33 p.m., an interview was conducted with S2CNA. She confirmed the privacy curtain should have been pulled during incontinence care for Resident #2, and it was not. On 10/02/2023 at 1:35 p.m., an interview was conducted with S3CNAS. She stated she would have expected S1CNA and S2CNA to close the privacy curtain in the room to ensure Resident #2 was not visible to her roommate during care. She stated she expected the CNA staff to provide privacy at all times for residents. On 10/02/2023 at 2:00 p.m., an interview was conducted with S4ADON. She stated she would have expected the CNAs to use the privacy curtains as to not expose a resident to their roommate or anyone in the hallway during incontinence care. On 10/02/2023 at 2:05 p.m., an interview was conducted with S5DON. She stated she would have expected the CNAs to use the privacy curtains as to not expose a resident to their roommate or anyone in the hallway during incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced appropriate infection control practices, hand hygiene, and proper glove use for 2 (#2 and R1) of 2 (#2 and R1) residents observed for incontinence care. Findings: Review of the facility's policy titled, Incontinent Care: Bladder revealed the following, in part: Procedure: 2. Perform handwashing or use alcohol gel. 8. Put on disposable gloves. 9. For female perineal care: b. Wash the mons pubis, rinse, and dry. 11. Remove and discard gloves. 12. Perform handwashing or use alcohol gel. Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Contractures, and Cognitive Communication Disorder. Review of Resident #2's Quarterly MDS with an ARD of 07/25/2023 revealed she had a BIMS of 2, which indicated she was severely cognitively impaired. It further revealed, she required total assistance with ADL care and was always incontinent. R1 Review of the Clinical Record revealed R1 was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Epilepsy, and Incontinence, and UTI. Review of R1's Quarterly MDS with an ARD of 08/29/2023 revealed he had a BIMS of 9, which indicated he was moderately cognitively impaired. It further revealed, he required total assistance with ADL care. On 10/02/2023 at 12:50 p.m., an observation was made of incontinent care performed by S1CNA and S2CNA on Resident #2. Without performing hand hygiene, S1CNA and S2CNA donned clean gloves and pulled back Resident #2's bed linens. S1CNA unfastened and removed Resident #2's soiled brief then cleaned Resident #2's perineal area. S1CNA did not remove her soiled gloves or perform hand hygiene and proceeded to place a clean brief on Resident #2, reposition the pad underneath her, straighten her gown, touch the resident's linens, reposition her in bed, adjust the pillow behind her head, and adjust bed linens. S1CNA removed her gloves and kept them in her hand, and without discarding the soiled gloves or performing hand hygiene entered R1's room. On 10/02/2023 at 1:00 p.m., an observation was made of incontinent care performed by S1CNA and S2CNA on R1. S1CNA entered R1's room with dirty gloves from Resident #2 in her hand and discarded them in the trash can in R1's room. Without performing hand hygiene, S1CNA donned clean gloves. S1CNA unfastened and removed R1's soiled brief then cleaned his perineal area. S1CNA removed soiled gloves, donned clean gloves without performing hand hygiene, placed a clean brief on R1, and redressed the resident. S1CNA removed her gloves, and without performing hand hygiene, bagged the trash, touched the door handle, exited the room and placed the soiled brief in the trash bin in the hall. In an interview following the above observation, S1CNA confirmed that she entered R1's room with soiled gloves in her hands, and should not have. S1CNA confirmed that she did not use hand hygiene prior to or after providing care to R1, and should have. S1CNA confirmed that she did not perform hand hygiene prior to opening the door, and discarding the soiled diaper in the trash. S1CNA confirmed she should have changed gloves and performed hand hygiene after soiling gloves. On 10/02/2023 at 1:33 p.m., an interview was conducted with S2CNA. She confirmed hand hygiene should be performed before and after incontinent care. She confirmed she did not perform hand hygiene prior to donning gloves and assisting with incontinent care on R1, and should have. On 10/02/2023 at 1:35 p.m., an interview was conducted with S3CNAS. She stated she would expect staff to perform hand hygiene prior to and after completing incontinence care. She stated she would expect staff to change gloves and perform hand hygiene after performing perineal care, prior to applying a clean brief, and prior to touching the resident or their personal items. She stated the CNA staff should not exit a resident's room with soiled gloves and without performing hand hygiene. On 10/02/2023 at 2:00 p.m., an interview was conducted with S4ADON. She stated she would expect staff to perform hand hygiene prior to and after completing incontinence care. She stated she would expect staff to change gloves and perform hand hygiene after performing perineal care, prior to applying a clean brief, and prior to touching the resident or their personal items. She stated the CNA staff should not exit a resident's room with soiled gloves and without performing hand hygiene. On 10/02/2023 at 2:05 p.m., an interview was conducted with S5DON. She stated she would expect staff to perform hand hygiene prior to and after completing incontinence care. She stated she would expect staff to change gloves and perform hand hygiene after performing perineal care, prior to applying a clean brief, and prior to touching the resident or their personal items. She stated the CNA staff should not exit a resident's room with soiled gloves and without performing hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#72) of 2 (#28 and #72) sampled residents records reviewed for PASRR. Findings: Review of the Clinical Record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses which included: Unspecified Dementia without Behavioral Disturbance. Further review revealed additional medical diagnosis of Schizophrenia on 03/16/2022. An interview was conducted on 08/01/2023 at 1:40 p.m. with S2SSD. She stated she was responsible for PASRRs for all residents at this facility. She reviewed the PASRR Level I for Resident #72 and diagnoses. She confirmed on 03/16/2022, Resident #72 was diagnosed with Schizophrenia and she should have sent in a Resident Review Form to the Office of Behavioral Health to assess the need for a PASRR Level II. She stated she did not realize Resident #72 had a diagnosis of Schizophrenia until review with surveyor. An interview was conducted on 08/01/2023 at 1:45 p.m. with S1DON. She stated S2SSD was responsible for completing PASRRs. She confirmed Resident #72 did not have a new PASRR performed after a new diagnosis of Schizophrenia.