Based on observation and interviews, the facility failed to ensure staff followed the manufacturer's instructions for the 3 compartment sink to correctly sanitize dishware. Findings:In an interview on 08/27/2025 at 1:20PM, S4Dietary indicated he routinely washed dishes in the 3 compartment sink. S4Dietary explained that he would dip the dishes into the sanitization solution in the 3 compartment sink, remove the dishes from the sanitization solution, and would place the dishes on the side to air dry. S4Dietary further indicated he did not soak dishes in the sanitization compartment of the 3 compartment sink for any specific amount of time. Observation on 08/27/2025 at 1:26PM revealed the manufacturer's instructions were posted on the wall near the 3 compartment sink that indicated to expose all area's surfaces of the dishware in the sanitization solution for no less than one minute and then allow to air dry. In an interview on 08/27/2025 at 1:26PM, S5Dietary Manager indicated S4Dietary should have followed the manufacturer's instructions posted on the wall near the 3 compartment sink as mentioned above. In an interview on 08/27/2025 at 3:50PM, S1Administrator confirmed S4Dietary should have submerged dishware in the sanitization solution in the 3 compartment sink for no less than one minute as per the manufacturer's instructions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to: 1. Ensure a referral to home health was completed prior to a resident's discharge as ordered (Resident #1); and, 2. Clarify a resident's discharge order to ensure a resident had all the necessary supplies and equipment for Percutaneous Endoscopic Gastrostomy (PEG) tube (a feeding tube inserted directly into the stomach through a small incision in the abdomen) feeding before the resident was discharge home (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for discharge requirements. Findings: Review of the facility's Discharge and Plan policy with a revision date of 03/2025 revealed, in part, the facility should make referrals to local agencies, and support services that could assist in accommodating the resident's post-discharge preferences, as appropriate. 1. Review of Resident #1's Physician's Telephone Order dated 04/07/2025 revealed, in part, an order to discharge Resident #1 home with home health. Review of Resident #1's Transfer/Discharge Report dated 04/10/2025 revealed, in part, Resident #1 was discharged home on [DATE]. Review of Resident #1's record revealed no documented evidence, and the facility was unable to present any documented evidence, a home health referral was accepted for Resident #1 prior to Resident #1's discharge on [DATE]. Review of the facility's facsimile report revealed, in part, Resident #1 was not accepted by a home health agency until 04/11/2025. In an interview on 05/21/2025 at 3:40PM, S1Administrator indicated the facility had no documented evidence a home health agency had accepted a referral prior to Resident #1's discharge on [DATE]. 2. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 03/25/2025 revealed, in part Resident #1 had a feeding tube for nutritional needs. Review of Resident #1's April 2025 Physician's Orders revealed, in part, an order dated 04/04/2025 for Isosource 1.5 (liquid nutritional formula that is administered through a resident's PEG tube) at 75 milliliters an hour (ml/hr) per PEG tube pump (a device that was used to deliver nutrients directly in the gastrointestinal tract). Review of Resident #1's Physician's Telephone Order dated 04/07/2025 revealed, in part, an order to discharge Resident #1 home with home health to care for PEG tube. Further review of Resident #1's physician's discharge order revealed no evidence Resident #1's PEG tube feeding pump or PEG tube formula was ordered upon discharge. There was no documented evidence, and the facility was unable to present any documented evidence, the facility clarified Resident #1's physician's order to ensure Resident #1's PEG tube feeding pump and PEG tube feeding formula was ordered upon discharge. Review of Resident #1's Transfer/Discharge Report dated 04/10/2025 revealed, in part, Resident #1 was discharged home on [DATE]. Review of Resident #1's Physician's Orders, dated 04/11/2025 at 2:16PM, revealed an order for Resident #1's PEG tube pump and PEG tube formula of Isosource 1.5 at 75 ml/hr per PEG tube pump. Review of the facility's facsimile report dated 04/25/2025 revealed, in part, a referral was made to an infusion company for Resident #1's PEG tube feeding pump and Resident #1's PEG tube formula, with Resident #1's 04/11/2025 physician's orders attached. In an interview on 05/20/2025 at 11:11AM, S2Speech Therapist/Rehabilitation Director (ST/RD) indicated she participated in Resident #1's discharge planning meeting. S2ST/RD further indicated at the time of Resident #1's discharge she was still receiving intermittent PEG tube feeding via pump at night and would need to continue the feedings at home. In a telephone interview on 05/21/2025 at 9:58AM, a patient registration specialist with Resident #1's infusion company indicated a referral for Resident #1's PEG tube pump and PEG tube formula was first received from the facility on 04/25/2025 with Resident #1's physician's orders dated 04/11/2025. In a telephone interview on 05/21/2025 at 10:04AM, a nutrition care specialist with Resident #1's infusion company indicated Resident #1 did not receive a PEG tube feeding pump until 04/30/2025. The nutrition care specialist with Resident #1's infusion company further indicated Resident #1 did not receive 1 case of Isosource 1.5 until 05/01/2025. In an interview on 05/21/2025 at 3:40PM, S1Administrator indicated Resident #1's discharge referral orders were not followed up on to ensure Resident #1 received the necessary PEG tube equipment and formula upon discharge.

Based on interviews and record reviews, the facility failed to ensure transfer or discharge reports were completed for 3 (Resident #1, Resident #2, Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for transfer and discharge requirements. Findings: Review of the facility's transfer and d ischarge plan policy statement with a revision date of 03/2025, revealed, in part, the discharge summary should include the following: a. recapitulation of the resident's stay at the facility (a concise summary of the resident's stay and course of treatment in the facility); b. a final summary of the resident's status at the time of the discharge available for release to authorized individuals and agencies, with the consent of the resident or representative; and Review of Resident #1's record revealed, in part, Resident #1 was discharged on 04/10/2025. Review of Resident #1's t ransfer/d ischarge r eport dated 04/10/2025 revealed, in part, no chief complaint (reason for transfer), no relevant information including detailed instructions for ongoing care and no final summary of Resident #1's status at time of discharge. Review of Resident #2's record revealed, in part, Resident #1 was discharged on 05/07/2025. Review of Resident #2's t ransfer/d ischarge r eport dated 05/07/2025 revealed, in part, no chief complaint, no relevant information, no reason or location where Resident #2 was transferred/discharged and no final summary of Resident #1's status at time of discharge . Review of Resident #3's record revealed, in part, Resident #3 was discharged on 04/27/2025. Review of Resident #3's transfer/discharge report dated 04/27/2025 revealed, no chief reason for complaint, no relevant information, no location to where Resident #3 was transferred/discharged and no final summary of Resident #3's status at time of discharge. In an interview on 05/21/2025 at 3:40PM, S1Administrator indicated Resident #1, Resident #2 and Resident #3 did not have completed t ransfer/d ischarge r eports. S1Administrator further indicated the above mentioned transfer/discharge reports should have been completed.

Based on observations, interviews, and record reviews, the facility failed to ensure a notice of employees' rights against retaliation for reporting crimes against residents was posted in a conspicuous location. Findings: Review of the United States Social Security Act Title XI, Part A, Section 1150B(d)(3) dated 08/14/1935 and amended on 09/26/2024 revealed, in part, each long-term care facility shall post conspicuously in an appropriate location a sign specifying the rights of employees against retaliation for reporting crimes against residents of the facility. Further review revealed, such sign shall include a statement that an employee may file a complaint against a long-term care facility that violates the provisions against retaliation with respect to the manner of filing such a complaint. Observation of the facility's employee common areas on 03/18/2025 at 3:00PM revealed no conspicuous signage related to employees' rights against retaliation for reporting suspected crimes. In an interview on 03/18/2025 at 3:10PM, S6Licensed Practical Nurse (LPN) indicated there was no signage displayed for staff members indicating employees' rights against retaliation for reporting suspected crimes. In an interview on 03/18/2025 at 3:17PM, S2Chief Operations Officer (COO) indicated the facility could not provide any evidence of conspicuous signage related to employee rights and the prohibition and prevention of retaliation for reporting suspected crimes. In an interview on 03/18/2025 at 3:18PM, S4Compliance Executive Nurse indicated she was not aware of the above mentioned signage requirement. In an interview on 03/19/2025 at 1:38PM, S1Administrator confirmed the facility could not provide any evidence a sign was posted in a conspicuous location regarding employees' rights against retaliation. S1Administrator further indicated she was not aware such signage was required.

Based on interviews and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency within the required two hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Investigation and Reporting policy and procedure dated 03/04/2024 revealed, in part, an alleged violation of abuse, neglect, exploitation or mistreatment would be reported immediately to the State Survey Agency, but not later than 2 hours if the alleged violation involved abuse or had resulted in serious bodily injury. Review of the Louisiana Department of Health (LDH) Health Standards Incident Report #271580 revealed, in part, an allegation of abuse involving Resident #1: -Occurred on 02/19/2025; -Was discovered on 02/21/2025 at 9:39AM; and, -Was entered into the Statewide Incident Management System (SIMS) reporting system on 02/21/2025 at 11:05AM. In an interview on 03/18/2025 at 12:20PM, S1Administrator indicated she was made aware of Resident #1's allegation of abuse on 02/20/2025 at 9:15AM. S1Administartor further confirmed the discovery date and time of Resident #1's allegation of abuse was not accurately documented on the above mentioned LDH Health Standards Incident Report. In an interview on 03/18/2025 at 12:25PM, S3Assistant Chief Operations Officer indicated S8Certified Nursing Assistant was suspended on 02/20/2025 at 1:26PM pending the results of the investigation. In an interview on 03/19/2025 at 1:30PM, S1Administrator confirmed the facility did not report Resident #1's allegation of abuse to the State Survey Agency within two hours and should have.

Based on interviews and record reviews, the facility failed to complete a performance review within 12 months for 1 (S8Certified Nursing Assistant [CNA]) of 5 (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA) personnel records reviewed. Findings: Review of S8CNA's personnel record revealed, in part, S8CNA had a hire date of 03/10/2023. Further review revealed S8CNA's last performance review was dated 03/13/2024. There was no documented evidence, and the facility could not provide any documented evidence a performance review was completed for S8CNA within the past 12 months. In an interview on 03/18/2025 at 1:45PM, S5Human Resources Director indicated the facility could not provide any documented evidence S8CNA had a performance review completed in the past 12 months. In an interview on 03/19/2025 at 12:58PM, S1Administrator confirmed a personnel performance review had not been conducted for S8CNA within the past 12 months as required and should have been.

Based on interviews and record review, the facility failed to ensure monthly weights were documented for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for nutrition. Findings: Review of Resident #1's Care Plan revealed Resident #1 was care planned for monthly weight evaluation notifications as per the dietician's recommendations. Review of Resident #1's Weights and Vitals Report revealed no documented monthly weights for November 2024 and December 2024. In an interview on 03/13/2025 at 8:52AM, S4Dietitian stated she was not able to assess Resident #1's three month weight loss percentage on her 2/24/2025 nutritional assessment because there were no documented weights for November 2024 or December 2024 on Resident #1's Weights and Vitals Summary. In an interview on 03/13/2025 at 9:35AM, S3Compliance Executive Nurse (CEN) indicated it is the policy of the facility to obtain monthly weights on all residents. S3CEN confirmed there were no documented weights for Resident #1 for November 2024 and December 2024. S3CEN further indicated there should be documentation of monthly weights or a reason as to why the monthly weights were not obtained and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a Discharge/Transfer Minimum Data Set (MDS) assessment was completed and transmitted timely for 1 (Resident #66) of 3 (Resident #12, Resident #66, and Resident #80) residents reviewed for resident assessment. Findings: Review of Resident #66's record revealed, in part, Resident #66 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE]. Further review revealed Resident #66 was discharged from the facility and did not return to the facility. Further review of Resident #66's records revealed, in part, no documented evidence a transfer and discharge assessment was completed and/or transmitted since he was discharged . In a telephone interview on 09/13/2024 at 2:08 p.m., S3License Practical Nurse/Minimum Data Set (S3LPN/MDS) confirmed Resident #66's discharge MDS was not completed and transmitted and should have been. In an interview on 09/16/2024 at 11:03 a.m., S7Director of Nursing confirmed Resident #66 did not have a discharge MDS, and should have.

Based on record reviews and interviews, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #12) of 3 (Resident #12, Resident #66, and Resident #80) sampled residents reviewed. Findings: Review of Resident #12's MDS with an assessment referenced date (ARD) of 08/01/2024, revealed, in part, Resident #12 had a brief interview of mental status (BIMS) score of 15, which indicated she was cognitively intact. Further review revealed the bedrail was used less than daily documented as a physical restraint while Resident #12 was in bed. Review of Resident #12's care plan revealed, in part, there was no documentation, and the facility did not provide any documentation of Resident #12 being care planned for restraints. Observation on 09/13/2024 at 1:39 p.m. revealed Resident #12 did not have any bedrails on her bed. In an interview on 09/13/2024 at 1:39 p.m. with Resident #12 confirmed she did not have side rails on her bed. In a telephone interview on 09/13/2024 at 2:08 p.m , S3License Practical Nurse confirmed Resident #12's MDS was coded for restraints in error. In an interview on 09/16/2024 at 1:15 p.m., S7Director of Nursing indicated the facility did not use restraints.

Based on record reviews and interviews, the facility failed to complete performance reviews and provide in-service education based on the outcome of these reviews annually for 2 (S5Certified Nursing Assistant [CNA], S6Receptionist [Rec]) of 3 (S4CNA, S5CNA, S6Rec) ) sampled unlicensed personnel. Findings; Review of S4CNA's personnel record revealed, in part, a hire date of 03/27/2024. Further review of S4CNA's personnel record revealed no documented evidence and the provider did not present any documented evidence of an annual performance evaluation for S4CNA. Review of S5CNA's personnel record revealed, in part, a hire date of 10/03/2022. Further review of S5CNA's personnel record revealed no documented evidence and the provider did not present any documented evidence of an annual performance evaluation for S5CNA. Review of S6Rec's personnel record revealed, in part, a hire date of 04/24/2012. Further review of S5CNA's personnel record revealed no documented evidence and the provider did not present any documented evidence of an annual performance evaluation for S6Rec. In an interview on 09/10/2024 at 3:15 p.m., S2Human Resource Director (HR) confirmed S4CNA, S5CNA, and S6Rec had not had performance evaluations and they should have been conducted. In an interview on 09/10/2024 at 3:20 p.m., S1Director of Operations, confirmed personnel performance evaluations had not been conducted for S4CNA, S5CNA, or S6Rec, and they should had been conducted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interview, the facility failed to ensure staff placed a floor mat on the floor while a resident was in bed per a resident's plan of care as a safety precaution for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of Resident #3's February 2024 Physician Orders revealed, in part, floor mats for safety precaution with an order start date of 08/29/2023. Review of Resident #3's fall scale assessment dated [DATE] revealed a score or 75. A score of 75 indicated a high risk for falls. Review of Resident #3's care plan revealed, in part, Resident #3 was identified as having a potential for falls and injuries related to impaired mobility and the need for assistance with activities of daily living. Further review revealed a intervention included to place a floor mat at the bedside when Resident #3 was in bed. Observation on 02/29/2024 at 1:54 p.m. revealed S6Certified Nursing Assistant (CNA) and S7CNA transferred Resident #3 from the gerichair to the bed and did not place a floor mat at the bedside. Observation on 02/29/2024 at 2:03 p.m. revealed Resident #3 remained in the bed and there was no floor mat at the bedside. On 03/01/2024 at 2:08 p.m. the surveyor and S2Director of Nursing (DON) entered Resident #3's room. Observation revealed there was no floor mat at the bedside. In an interview on 03/01/2024 at 2:12 p.m., S2DON confirmed Resident #3 did not have a floor mat in place and should have per Resident #3's plan of care.

Based on record reviews, observation, and interviews, the facility failed to ensure a physician's order for pain medication was transcribed to the medical record for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) records reviewed. Findings: Review of Resident #1's physician progress notes dated 02/28/2024 revealed, in part, Resident #1 did not complain of pain at the time of visit; however, after the visit the nursing staff stated Tylenol did not relieve Resident #1's pain. Review of Resident #1's record revealed a copy of a physician's order dated 02/28/2024 for Tramadol 50mg (milligrams) tablets to take 1 every 8 hours prn (as needed) for pain. Review of Resident #1's March 2024 physician's orders revealed no documented evidence of an order for Tramadol 50mg (milligrams) tablets 1 tablet every 8 hours prn for pain. Review of the facility's pharmacy delivery sheet dated 02/28/2024 at 4:41 p.m. revealed, in part, Resident #1 received 30 Tramadol 50mg tablets. The pharmacy delivery sheet was signed as received by S5Licensed Practical Nurse (LPN). Observation of Resident #1's medications revealed a medication card with 30 pills of Tramadol HCL 50mg tablets. In an interview on 03/01/2024 at 11:52 a.m., Resident #1's Physician stated on 02/28/2024 at 4:39 p.m. he received a text message from S5LPN and she stated Resident #1's pain was not controlled with Tylenol. Resident #1's Physician stated he informed S5LPN he would order Tramadol 50mg to be used as needed for pain. In an interview on 03/01/2024 at 11:58 a.m., S5LPN confirmed on 02/28/2024 Resident #1's Physician notified her of an order for Tramadol 50mg as needed. S5LPN further stated she received Resident #1's Tramadol from the pharmacy on 02/28/2024; however, she did not enter the order into Resident #1's electronic record. In an interview on 03/01/2024 at 12:03 p.m., S2Director of Nursing (DON) stated S5LPN should have entered the order for Tramadol 50mg into the electronic record when it was received on 02/28/2024. S2DON further stated staff would not have known the medication was available for administration since it was not on the current physician orders.

Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form Centers for Medicare and Medicaid Services (CMS)-10055, was completed prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 2 (Resident #56 and Resident #25) of 3 (Resident #56, Resident #25, and Resident #189) residents reviewed for termination of Medicare Part A services. Findings: Review of the facility's Medicare Advanced Beneficiary Notice Policy revealed, in part, residents are informed in advance when changes will occur to their bills. 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial. b. The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review, form CMS-20052, completed by the facility revealed, in part, Resident #56's last day of Medicare Part A Services was on 05/20/2023. There was no documented evidence and the facility was unable to present any documented evidence Resident #56 had a signed CMS-10055 form prior to Medicare Part A services being terminated by the facility on 05/20/2023. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review, form CMS-20052, completed by the facility revealed, in part, Resident #25's last day of Medicare Part A services was on 10/02/2023. There was no documented evidence and the facility was unable to present any documented evidence Resident #25 had a signed CMS-10055 form prior to Medicare Part A services being terminated by the facility on 10/02/2023. In an interview on 10/26/23 at 2:50 p.m., S3Social Worker stated she was unaware of the SNF ABN form process. S3Social Worker further stated Resident #56 and Resident #25 did not sign an ABN CMS 100-55.

Based on observation and record review, the facility failed to ensure water accessible to residents did not exceed 120 degrees Fahrenheit for 2 (Room a and Room b) of 5 (Room a, Room b, Room c, Room d, and Room e) rooms observed for water temperature. Findings: Review of the facility's Safety of Water Temperatures policy and procedure revealed, in part, water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit. Further review revealed maintenance staff shall conduct periodic tap water checks. Observation on 10/23/2023 at 10:54 a.m. revealed the water from the sink in Room a was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. Observation on 10/24/2023 at 11:32 a.m. revealed the water from the sink in Room a was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. Observation on 10/24/2023 at 11:33 a.m. revealed the water from the sink in Room b was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. In an interview on 10/25/2023 at 11:20 a.m., S4Engineering stated he did not periodically check the temperature of the water in residents' rooms. S4Engineering further stated he did not keep water temperature logs. Observation on 10/25/2023 at 11:22 a.m. revealed S4Engineering measured the temperature of the water from the sink in Room a. Observation further revealed the water from the sink in Room a measured a temperature of 126.8 degrees Fahrenheit. Observation on 10/25/2023 at 11:26 a.m. revealed S4Engineering measured the temperature of the water from the sink in Room b. Observation further revealed the water from the sink in Room b measured a temperature of 123.8 degrees Fahrenheit. In an interview on 10/25/2023 at 11:28 a.m., S4Engineering stated the water in Room a and Room b was too hot, and S4Engineering needed to adjust the hot water heater. In an interview on 10/25/2023 at 11:35 a.m., S1Administrator stated the water temperatures in residents' rooms should be less than 120 degrees Fahrenheit.

Based on record reviews and interview, the facility failed to have documented evidence the Certified Nursing Assistant (CNA) Registry was performed prior to hire for 1 (S10CNA) of 5 (S10CNA, S11CNA, S12CNA, S13CNA, and S14CNA)personnel records reviewed for state registry verification reviews. Findings: Review of S10CNA's personnel record revealed a hire date of 03/10/2023. Further review of S10CNA's personnel record revealed the CNA Registry was checked on 04/05/2023. There was no documented evidence and the facility did not present any documented evidence of the CNA Registry check that was completed upon hire for S10CNA. In an interview on 10/24/2023 at 11:42 a.m., S8Facility Director stated there was no documented evidence the CNA Registry check was completed for S10CNA upon hire.

Based on record review, observation, and interview, the facility failed to: 1) Ensure the surface of the freezer floor was kept clean; 2) Ensure food was not stored on the freezer floor; and, 3) Ensure food available for use was dated, labeled, and not left open to air. Findings: Review of the facility's Food Receiving and Storage policy revealed, in part, all foods stored in the freezer are covered, labeled and dated. Further review revealed foods in the walk-in are stored off the floor. Observation on 10/23/2023 at 09:10 a.m. of the facility's walk in freezer revealed, in part, a softball size clear frozen substance and a softball size red frozen substance on the floor of the walk in freezer. Further observation revealed an open plastic bag of frozen crab balls that were not labeled or dated. In an interview on 10/23/2023 at 9:10 a.m., S16Dietary Aide stated something must have spilled onto the freezer floor and it went unnoticed by the staff. S16Dietary Aide stated the bag of frozen crab balls should have been labeled, dated, and sealed after it was opened. Observation on 10/25/2023 at 10:54 a.m. revealed, in part, the above mentioned frozen substances observed on the walk in freezer floor on 10/23/2023 remained on the freezer floor. Further observation revealed a large rack of frozen raw meat in clear plastic packaging was laying directly on the surface of the freezer floor and the corner of the packaging was touching the red frozen substance on the freezer floor. Further observation revealed a plastic bag of frozen spinach was laying directly on the surface of the freezer floor. In an interview on 10/25/2023 at 11:00 a.m., S8Facility Director confirmed the walk in freezer floor was unsanitary and should have been cleaned. S8Facility Director confirmed the package of frozen raw meat and spinach should not have been stored on the freezer floor and the opened bag of frozen crab balls should have been labeled, dated, and sealed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to: 1. Ensure a resident's pressure ulcer (a wound caused by pressure) wound assessments were completed at least weekly for 2 (Resident #48 and Resident #289) of 4 (Resident #3, Resident #17, Resident #48, and Resident #289) sampled residents investigated for pressure ulcers; and, 2. Ensure a resident's pressure ulcer wound care was performed per physician's orders for 1 (Resident #289) of 4 (Resident #3, Resident #17, Resident #48, and Resident #289) sampled residents investigated for pressure ulcers. Findings: 1.) Resident #48 Review of Resident #48's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2023 revealed, in part, Resident #48 had a diagnosis of a Stage IV Pressure Ulcer (a wound that extends into deep tissues including muscle, tendons, and ligaments) of the right hip, which was not present on admission to the facility. Review of Resident #48's Right Hip Stage IV Pressure Ulcer care plan initiated on 03/23/2023 revealed, in part, interventions for staff to measure Resident #48's right hip pressure ulcer at least once a week and record the measurements and appearance of Resident #48's right hip pressure ulcer. Review of Resident #48's Wound Assessments from 03/23/2023 through 10/26/2023 revealed, in part, Resident #48 did not have any documented weekly Wound Assessments for the weeks of 04/02/2023 through 04/08/2023, 04/23/2023 through 04/29/2023, 05/14/2023 through 05/20/2023, 07/23/2023 through 07/29/2023, and 08/27/2023 through 09/02/2023. There was no documented evidence and the facility was unable to present any documented evidence that Resident #48 had a weekly wound assessments for the weeks of 04/02/2023 through 04/08/2023, 04/23/2023 through 04/29/2023, 05/14/2023 through 05/20/2023, 07/23/2023 through 07/29/2023, and 08/27/2023 through 09/02/2023. In an interview on 10/26/2023 at 1:21 p.m., S2Director of Nursing (DON) confirmed wound assessments needed to be completed weekly. S2DON also confirmed Resident #48 had missing weekly wound assessments. Resident #289 Review of Resident #289's electronic medical record revealed Resident #289 had a diagnosis of Stage 2 ( a wound that has partial-thickness skin loss) pressure ulcer of the Right Heel with an onset date of 10/12/2023, an unstageable (a wound that is covered by dead tissue or slough) pressure ulcer of the head with an onset date of 10/12/2023, an unstageable pressure ulcer of the Right Hip with an onset date of 09/07/2023, and unstageable pressure ulcer of left heel with an onset date of 09/07/2023. Review of Resident #289's current comprehensive care plan for her wounds to her sacrum, right heel, left lateral leg, left elbow, left ear, and posterior head revealed, in part, an intervention to measure the wounds at least once a week and record the measurements and appearance of Resident #289's wounds. Review of Resident #289's Skin Observation Tool dated 10/13/2023 ofevealed, in part, Resident #289 admitted back to the facility with wounds to the top of the scalp, left elbow, left ear, right lower leg, left lower leg, and right heel. Further review revealed, no documented measurements, stage, or appearance of each wound. Review of Resident #289's Wound Assessments from 04/01/2023 through 10/26/2023 revealed, in part: - Resident #289 did not have any documented Wound Assessments upon return to the facility on [DATE] following a hospital stay for Resident #289's Sacrum Unstageable Pressure Ulcer, Resident #289's Right Heel Deep Tissue Injury, Resident #289's Left Lateral Deep Tissue Injury, Left Elbow Stage 3 Pressure Ulcer, Resident #289's Left Ear Stage 2, and Resident #289's Posterior Head Unstageable Pressure Ulcer; and -Resident #289 did not have any documented Wound Assessments for the week of 10/15/2023 through 10/21/2023 for Resident #289's Left Ear Stage 2 Pressure Ulcer, Resident #289's Left Lateral Leg Deep Tissue Injury, and Resident #289's Posterior Head Unstageable Pressure Ulcer. There was no documented evidence and the facility was unable to present any documented evidence Resident #289 had a readmission wound assessments completed on 10/12/2023 and a weekly wound assessment for the week of 10/15/2023-10/21/2023. In an interview on 10/26/2023 at 1:00 p.m., S5Wound Care LPN stated the only assessment completed for Resident #289 was the above stated assessment completed on 10/13/2023, which did not document the wound measurements, stage of the wounds, or the appearance of the wounds. S5Wound Care LPN further stated Resident #289 did not have a proper wound care assessment with measurements and staging until 10/19/2023 when the resident was seen by the contracted nurse practitioner. In an interview on 10/26/2023 at 1:41 p.m., S2DON stated she was unaware wound assessments should be completed weekly. S2DON further stated assessments of Resident #289 wounds should have been completed within 24 hours of Resident #289's readmission to the facility. S2DON further acknowledged the Skin Observation Tool completed on 10/13/2023 was not a sufficient wound assessment. 2.) Resident #289 Review of Resident #289's October 2023 Physician Orders revealed, in part, an order dated 10/14/2023, to cleanse left ear with normal saline, pat dry, apply silver alginate along ear pad with gauze, and apply ear cushion every day shift. S5Wound Care LPn further stated Resdient #289 did not have a proper wound care assessment with measurements and staging until 10/19/2023 when the resident was seen by the contracted nurse practitioner. In an interview on 10/25/2023 at 12:30 p.m., S5Wound Care LPN further stated she used calcium alginate on Resident #289 and she should have used silver alginate. In an interview on 10/26/2023 at 1:41 p.m., S2DON confirmed calcium alginate was not the same product as silver alginate and the above stated treatment was not appropriate for Resident #289s left ear wound.

Based on record review and interview, the facility failed to establish and maintain a method of communication with the contracted dialysis facility for 1 (Resident #67) of 1 (Resident #67) sampled residents reviewed for dialysis services. Findings: Review of the facility's Care of a Resident with End-Stage Renal Disease policy and procedure revealed, in part, agreements between the facility and the contracted dialysis facility include all aspects of how the resident's care will be managed, including how information will be exchanged between the facility and the dialysis facility. There was no documented evidence and the facility was unable to present any documented evidence that an agreement was established with the contracted dialysis facility in regards to communication of a resident's condition. Review of Resident #67's Minimum Data Set with an Assessment Reference Date of 09/13/2023 revealed, in part, Resident #67 had a diagnosis of End Stage Renal Disease and received dialysis services. Review of Resident #67's October 2023 Physician's Orders revealed, in part, an order for Resident #67 to receive dialysis on Mondays, Wednesdays, and Fridays at the contracted dialysis facility. Review of Resident #67's Dialysis Communication Forms from 04/01/2023 to 10/26/2023 revealed, in part, dialysis communication forms were completed for the following dates: 07/19/2023, 08/09/2023, 09/04/2023, 09/08/2023, 09/27/2023, 09/29/2023, 10/09/2023, 10/11/2023, and 10/20/2023. In a telephone interview on 10/25/2023 at 2:34 p.m., Resident #67's Contracted Dialysis Registered Nurse stated Resident #67's dialysis communication form was not always sent by the facility for the contracted dialysis facility to fill out. In an interview on 10/26/2023 at 12:45 p.m., S7Licensed Practical Nurse (LPN) stated communication between the contracted dialysis facility and the facility was completed by use of the Dialysis Communication Form. S7LPN confirmed Resident #67's Dialysis Communication Forms for the last 6 months were not completed for each dialysis visit. In an interview on 10/26/2023 at 1:15 p.m., S2Director of Nursing (DON) confirmed the facility's process to communicate with the dialysis facility regarding a resident's status was by use of the Dialysis Communication Form. S2DON stated a Dialysis Communication Form should be completed for each dialysis visit. S2DON further stated it was the responsibility of the facility to ensure the Dialysis Communication Form was completed and returned to the facility.

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of the facility's Payroll Based and Journal (PB&J) report for Fiscal Year 2023 Quarter 3 (April 1 thru June 30), revealed, in part, the facility triggered for no Registered Nurse (RN) hours provided on 04/10/2023, 05/29/2023, 06/01/2023, 06/23/2023, and 06/26/2023. Record review of facility written time sheets revealed, in part, a minimum of 8 hours was provided by S9Corporate Registered Nurse (RN) on 04/10/2023, 05/29/2023, 06/23/2023, and 06/26/2023. Further review revealed, in part, the S2Director of Nursing (DON) provided 8 hours on 06/01/2023. In an interview on 10/25/2023 at 9:20 a.m., S8Facility Director, stated at the time the above mentioned PB&J report was completed, the S9Corporate RN and S2DON were not clocking into the time clock. S8Facility Director further stated the PB&J report was incorrect due to the RNs not clocking in.

Based on record review, observations, and interviews, the facility failed to: 1. Ensure staff used fresh water and a clean towel when performing incontinence care for 1 (Resident # 3) of the 1 sampled residents observed incontinence care; 2. Ensure staff changed their gloves and performed hand hygiene between wounds, when coming into contact with items in the environment, and between procedures for 4 (Resident #3, Resident #17, Resident #48, and Resident #289) of 4 (Resident #3, Resident #17, Resident #48, and Resident #289) sampled residents observed for wound care; 3. Ensure staff disinfected reusable medical equipment after use for 2 (Resident #1 and Resident #84) of 5 (Resident #1, Resident #84, Resident #48, Resident #8, and Resident #79) residents observed during medication administration. Findings: 1. Resident #3 Review of the facility's Perineal Care Policy and Procedure revealed, in part, the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Further review of the policy and procedure revealed, the procedure for providing perineal care to a female resident included: wash perineal area, wiping from front to back, using fresh water and a clean towel continue to wash the perineum moving from inside outward. Discard dirty items into designated containers, remove gloves and wash and dry hands thoroughly before repositioning the covers and making the resident comfortable. Observation on 10/25/2023 at 9:40 a.m. revealed, in part S15Certified Nursing Assistant (CNA) entered Resident #3's room to provide incontinence care. Observation further revealed S15CNA put on clean gloves, removed Resident #3's brief, picked up two clean wash clothes and placed the towels in the sink in Resident #3's room and wet the towels. S15CNA removed the wet towels from the sink and placed the towels on the grab bars of Resident #3's bed. Further observation revealed S15CNA cleaned the front of Resident #3's genital area using both towels, S15CNA rinsed the towels in the sink, placed the towels on Resident #3's bed, and turned Resident #3 on her left side and wiped Resident #3's genital area from front to back with one of the towels three times, then S15CNA took the other towel and wiped Resident #3's peri-area from front to back two times. In an interview on 10/25/2023 at 9:59 a.m., S15CNA stated she should have not wiped Resident #3's peri-area with the same towel from front to back. In an interview on 10/26/2023 at 12:25 p.m., S2Director of Nursing (DON) stated the S15CNA should have not used the same towel wiping front to back while providing perineal care to Resident #3. S2DON confirmed using the same towel to provide peri-care could increase the risk of urinary tract infections. 2. Review of the facility's Handwashing/Hand Hygiene policy and procedure revealed, in part, personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to residents. Further review revealed alcohol-based hand rub or soap and water should be used in the following situations: before handling clean or soiled dressings; before moving from a contaminated body site to a clean body site during resident care; after contact with blood or bodily fluids; after handling used dressings; and, after removing gloves. Review of the facility's Wound Care policy and procedure revealed, in part, once the resident's soiled dressing was removed, gloves should be removed and hand hygiene should be completed. Resident #3 Observation on 10/25/2023 at 9:40 a.m. revealed S5Wound Care Licensed Practical Nurse (LPN) entered Resident #3's room to perform wound care while S15CNA was performing incontinence care. Observation further revealed S15CNA did not remove her gloves and perform hand hygiene following Resident #3's incontinence care. S15CNA then assisted S5Wound Care LPN by holding Resident #3's right buttocks clean wound dressing in place with her soiled gloves until S5Wound Care LPN secured the wound dressing. In an interview on 10/25/2023 at 9:59 a.m., S15CNA stated she should have changed her gloves and performed hand hygiene after providing incontinence care and before assisting with Resident #3's wound care. In an interview on 10/25/2023 at 1:10 p.m., S5Wound Care LPN stated S15CNA should have performed hand hygiene and changed her gloves after performing incontinence care to Resident #3 and before assisting with Resident #3's wound care. In an interview on 10/26/2023 at 12:25 p.m., S2DON stated S15CNA should have performed hand hygiene and changed gloves before touching Resident #3's clean dressing. Resident #17 Observation on 10/25/2023 at 9:20 a.m. revealed S15CNA provided incontinence care to Resident #17 and proceeded to assist the S5Wound Care LPN with repositioning Resident #17 for wound care without performing hand hygiene or changing gloves. Observation on 10/25/2023 at 9:25 a.m. revealed S5Wound Care LPN cleaned Resident #17's right buttocks unstageable wound and sacral unstageable wound with the same gauze without performing hand hygiene or changing gloves between cleaning each wound. Further observation revealed S15CNA, which still had not changed her gloves or performed hand hygiene after incontinence care, assisted S5Wound Care LPN by holding Resident #17's clean dressing in place to the sacral wound. In an interview on 10/25/2023 at 9:59 a.m., S15CNA stated she should have changed her gloves and performed hand hygiene after providing incontinence care and before touching the clean dressing on Resident #17's sacral area. In an interview on 10/25/2023 at 1:10 p.m., S5Wound Care LPN stated she should have performed hand hygiene and changed her gloves between cleaning Resident #17's right buttocks wound and Resident #17's sacral wound. S5Wound Care LPN further stated she should have not used the same gauze to clean both wounds. In an interview on 10/26/2023 at 12:25 p.m., S2DON stated S5Wound Care LPN should have performed hand hygiene and changed her gloves between cleaning Resident #17's wounds, and should have not used the same gauze to clean each wound. S2DON further stated S15CNA should have performed hand hygiene and changed gloves before touching Resident #3's clean dressing to the sacral wound. Resident #48 Observation on 10/25/2023 at 10:15 a.m. revealed S5Wound Care LPN provided wound care to Resident #48's right hip wound. Observation further revealed S5Wound Care LPN removed Resident #48's soiled dressing and did not change her gloves Or complete hand hygiene prior to cleaning Resident #48's wound. Observation then revealed S5Wound Care LPN changed her gloves but did not perform hand hygiene prior to drying Resident #48's right hip wound. S5Wound Care LPN removed her gloves again, did not perform hand hygiene, and then dressed Resident #48's right hip wound. In an interview on 10/25/2023 at 10:25 a.m., S5Wound Care LPN confirmed she did not remove her gloves and complete hand hygiene after she removed Resident #48's soiled dressing. S5Wound Care LPN also stated she should completed hand hygiene after gloves were removed. Resident #289 Observation on 10/24/2023 at 9:45 a.m. revealed S5Wound Care LPN applied gloves and removed Resident #289's right heel and right lower extremity dressings without changing gloves and without performing hand hygiene between removals. S5Wound Care Nurse then removed her gloves did not perform hand hygiene, reached into a box of gloves and applied the new gloves without performing hand hygiene. Observation revealed S5Wound Care LPN removed her gloves and without performing hand hygiene removed gloves from the box and applied new gloves then removed Resident #289's head dressing. Observation revealed S5Wound Care LPN performed wound care to Resident #286's left lower extremity and then without changing gloves or performing hand hygiene proceeded to perform wound care to Resident #289's right lower extremity. Observation revealed S5Wound Care LPN proceeded with the same gloved hands, without performing hand hygiene, and performed wound care to Resident #289's right lower extremity. Further observation revealed S5Wound Care LPN then performed hand hygiene and changed her gloves prior to having applied Resident #286's heel boot, and then without removing her gloves performed wound care to Resident #289's posterior head without performing hand hygiene. In an interview on 10/25/2023 at 12:30 p.m., S5Wound Care LPN confirmed she did not remove her gloves and complete hand hygiene after she removed Resident #289's soiled dressings. S5Wound Care LPN further stated she should have completed hand hygiene between each wound and after each glove change. In an interview on 10/26/2023 at 1:41 p.m., S2DON confirmed S5Wound Care LPN should have performed hand hygiene and changed her gloves after removing each of Resident #289's wound dressings. S2DON further stated S5Wound Care LPN should have completed hand hygiene after completing wound care on each wound. 3. Review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment revealed, in part, reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Observation on 10/25/2023 at 8:00 a.m. revealed S6LPN utilized an automatic wrist blood pressure cuff to obtain Resident #1's blood pressure. Further observation revealed S6LPN did not disinfect the blood pressure cuff after each use. Observation on 10/25/2023 at 8:10 a.m. revealed S6LPN utilized the same automatic blood pressure cuff to obtain Resident #84's blood pressure. In an interview on 10/25/2023 at 8:19 a.m., S6LPN confirmed she did not disinfect the automatic blood pressure cuff between Resident #1 and Resident #84. In an interview on 10/26/2023 at 9:45 a.m., S1Administrator stated staff should disinfect reusable resident equipment between each resident with germicidal wipes. In an interview on 10/26/2023 at 1:41 p.m., S2DON confirmed the blood pressure cuff should have been disinfected with germicidal wipes between Resident #1 and Resident #84.

Based on record review and interview the facility failed to immediately notify the responsible party of a change in skin condition to Resident's #1's right lower extremity for 1 (Resident#1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4 ) sampled residents. Findings: Review of S1Licensed Practical Nurse (LPN) nurse's wound assessment notes revealed in part: while performing wound care on 09/01/2023, S1LPN noticed a reddened area to Resident #1's Right foot. There was no documented evidence and the facility did not present any documented evidence of Resident #1's responsible party being immediately notified of Resident #1's change in skin condition. In an interview on 09/22/2023 at 2:45 p.m., S1LPN stated she did not have any documented evidence of the facility immediately notifying Resident #1's responsible party of the above mentioned change in skin condition until 09/05/2023.

Based on record review and interview the facility failed to immediately notify the responsible party when there was a significant change in the resident's level of consciousness, decreased blood pressure requiring transportation to a local hospital for 1(Resident#1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) of sampled Residents. Findings: Review of S3Licensed Practical Nurse nurse's notes revealed in part: on 06/21/2023 at 7:15 a.m. the shower aid returns Resident #1 to the room stating she noticed a change in Resident's #1 Level of Consciousness. Resident #1 was assessed vital signs Blood Pressure 61/33, Heart Rate 109, Respirations 34, and a Temperature of 96.6 F (Fahrenheit). Resident #1 was placed in a Trendelenburg position, the body was placed with the feet elevated above the head, and Resident #1 was escorted to a local hospital by Acadian ambulance service at 8:15 a.m. In an interview on 08-15-2023 the consumer stated on 06-20-2023 stated she arrived at the facility around looking for Resident #1 she was approached by the staff who directed her to S2 DON Office and she was notified at that time by S2 DON that Resident #1 was sent out to the hospital for a change in condition. The consumer stated she was never notified Resident #1 had a change in condition and was transported to a local hospital. In an interview on 08/16/2023 at 2:45 p.m., S1Administrator, S2 Director of Nurses (DON), and S3Licensed Practical Nurse stated they did not have any documented evidence of the facility immediately notifying the responsible party of Resident #1's decline in condition which required being transportation by the Emergency Medical Services to a local Hospital.

Based on record reviews and interviews, the facility failed to have a process in place to monitor vaccination status of employees, volunteers, and contractors. This deficient practice had the potential to affect any of the 79 residents who resided in the facility as identified on the facility's Resident Census and Conditions of Residents Form (CMS-672). Findings: Observation on 01/31/2023 at 09:45 a.m., S5Contracted Cleaner was utilizing an electrostatic mist sprayer in the dining room. In an interview on 01/31/2023 at 09:45 a.m., S5Contracted Cleaner stated he was there to disinfect the facility. In an interview on 01/31/2023 at 10:05 a.m., S3Infection Preventionist stated the initial case of COVID-19 identified in the facility was S10Priest who volunteers at the facility and performs mass for the residents and staff. In an interview on 02/02/2023 at 12:11 p.m., S6Hospice Nurse stated she was not vaccinated. In an interview on 02/02/2023 at 12:33 p.m., S3Infection Preventionsist (IP) confirmed she did not have an up to date COVID-19 vaccination status list for contracted employees or volunteers, including S5Contracted Cleaner or S6Hospice Nurse. In an interview on 02/02/2023 at 12:45 p.m., S3Infection Preventionist stated she did not know that contracted staff and vendors, including hospice staff, needed to be included in the COVID-19 vaccination status list. S3IP further stated she did not know she needed to verify COVID-19 vaccination status of contracted staff and vendors before allowing them to provide services. In an interview on 02/02/2023 at 3:49 p.m., S8Management stated she did not have COVID-19 vaccination information for S10Priest.

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infections by failing to ensure: 1. Staff perform hand hygiene and/or wore personal protective equipment (PPE) when handling medications for 1 (Random Resident #1) of 17 residents who received medications on Hall X; 2. Staff properly clean and stored PPE used in 2 (Room b and Room m) of 5 rooms observed on Hall Y that contained Covid-19 positive residents; 3. Staff perform hand hygiene after handling PPE used in Covid-19 positive residents rooms on Hall Y; and 4. 6 Certified Nurse Assistants (S7Restoritive CNA,S9CNA, S11CNA,S13CNA, S14CNA, and S15CNA) out of 7 CNAs observed, followed infection control practices in 8 rooms (Room c, Room e, Room f, Room g, Room h, Room i, Room j and Room n) that housed COVID-19 positive residents. This deficient practice had the potential to affect all 79 residents who reside in the facility as documented on the facility's CMS Form-672 Resident Conditions and Census of Residents. Findings: 1. Review of the facility's policy on Infection Control Guidelines for COVID-19 revised on 08/01/2022 revealed, in part, if hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol of isopropanol before preparing or handling medications. Observation on 02/01/2023 at 08:15 a.m., S4LPN (Licensed Practical Nurse) prepared Random Resident #1's medications and placed a Lasix 20milligram(mg) tablet and a Buspirone 15mg tablet into a medication cup. Further observation revealed S4LPN touched both medication cards to place them back inside the medication cart and touched the medication cart drawer to close it. S4LPN did not wash her hands and removed a Lasix 20mg tablet from the medication cup with her bare finger. S4LPN removed additional medication cards from the medication cart, placed a Buspirone 7.5mg tablet into the medication cup, and touched the medication cart drawer to close it. Further observation revealed, SLPN did not wash her hands and removed the Buspirone 15mg tablet from the medication cup with her bare finger. S4LPN placed an additional 4 tablets into the medication cup containing the Buspirone 7.5mg tablet and administered the medications to Resident #1. In an interview on 02/01/2023 at 08:15 a.m., S4LPN stated she removed the tablets from the medication cup because the medications were for a different resident. S4LPN confirmed she did not wash her hands or use a glove to remove the two tablets from the medication cup. SLPN confirmed she should not have used her unwashed bare finger to remove the tablets from Resident #1's medication cup. In an interview on 02/01/2023 at 10:55 a.m., S3Infection Preventionist (IP) confirmed S4LPN should have washed her hands prior to handling medications, and should not have used her unwashed and ungloved finger to remove the two tablets from the medication cup for Random Resident #1 during medication administration. 2, 3. Observation on 02/01/2023 at 10:00 a.m., revealed S15Certified Nursing Assistant (CNA) exited Room b, which contained a Covid positive resident, with face shield and a N95 mask on her face. Further observation revealed, S15CNA then approached the clean PPE cart located in the 200 hall and removed a gown and gloves without performing hand hygiene. Observation on 02/01/2023 at 10:23 a.m., revealed S15CNA entered and exited Room m with a face shield and a N95 mask on her face. S15CNA then removed her N95 mask with an ungloved hand, placed it in a plastic bag, and then placed the plastic bag on the clean PPE cart located in the hall way of the Hall Y. S15CNA then removed her face shield with an ungloved hand, did not clean the face shield, placed it in a plastic bag, and then placed the plastic bag on the clean PPE cart. S15CNA did not perform hand hygiene, placed a new N95 mask on her face, and proceeded down the hallway. In an interview on 02/01/2023 at 11:30 a.m., S15CNA stated she exited Room b and Room m with a contaminated mask and face shield on her face, removed them with an ungloved hand, did not clean them after removing them, and placed them on the PPE cart with clean PPE. S15CNA stated she should have worn gloves prior to touching PPE that had been worn in Room b and Room m, cleaned the PPE after use, and stored the PPE in a soiled area. S15CNA stated she removed a contaminated N95 mask from her face and a face shield and did not perform hand hygiene after and she should not have. S15CNA stated hand hygiene should have been performed before and after handling each PPE item that had been worn in Room b and Room m. In an interview on 02/02/2023 at 11:23 a.m., S3Infection Preventionist stated S15CNA should have cleaned her face shield and mask, placed them in a sealed bag, and placed them in the soiled area on the PPE cart. S3Infection Preventionist stated hand hygiene should have been performed before and after handling each item. S3Infection Preventionist confirmed both actions. 4. Review of the facilities Donning and Doffing PPE policy (putting on and taking off PPE) revealed, in part, gowns must be fastened in back of neck and waist, goggles or face shield should be worn, gloves should cover gown, and hand hygiene should be performed after taking off PPE. Review of the facilities Guidelines for COVID-19 policy revealed, in part, staff will have access to directions for proper PPE use posted. Review of Droplet and Contact Precautions signage posted on doors of Room c, Room e, Room f, Room g, Room h, Room i, and Room n revealed, in part, a gown, gloves, and procedure mask with eye protection were required to go into isolation rooms for resident's positive for COVID-19 and that staff should cleanse hands after leaving rooms. Review of Sequence for Putting on PPE signage posted on doors of Room c, Room e, Room f, Room g, Room h, Room i, and Room n revealed, in part a gown, gloves, mask, and goggles or face shield should be used. Review of the facility's Cleaning and Disinfecting of Resident Care Items and Equipment revealed, in part, reusable resident care equipment need to be cleaned between residents. Observation on 01/31/2023 at 10:34 a.m., revealed S7Restorative Certified Nursing Assistant (CNA) put on PPE to go into Room n (a room for resident on isolation for COVID-19). S7Restorative CNA had a N95 mask (a mask to keep individuals from breathing in infectious droplets) already on, put on a gown, but did not tie the gown closed in the back. S7Restorative CNA did not put on a face shield or protective eye wear. S7Restorative CNA then went into Room n without protective eyewear or face shield. In an interview on 01/31/2023 at 10:34 a.m., S7Restorative Certified Nursing Assistant (CNA) stated that she did not have protective eye equipment on because she had left her googles at home this morning and did not have any to wear. S7Restorative CNA then confirmed she should have been wearing either googles or face shield when entering into Room n. In an interview on 01/31/2023 at 10:56 a.m., S3Infection Preventionist (IP) stated that staff are required to wear gown, gloves, N95 mask, and protective eye wear or googles when going into isolation rooms for residents that are positive for COVID-19. Observation 02/01/2023 at 11:59 a.m., revealed S9Certified Nursing Assistant put on PPE and enter into Room c (a room for resident on isolation for COVID-19) to set up a lunch tray. S9CNA then exited into hall with N95 mask on and still in place. Observation 02/01/2023 at 12:10 p.m., revealed S11Certified Nursing Assistant put on PPE and enter into Room e (a room for resident on isolation for COVID-19) to set up a lunch tray. S11CNA then exited into hall with N95 mask on and still in place. Observation at 02/01/2023 at 12:15 p.m., revealed S11Certified Nursing Assistant (CNA) went into Room k (room for residents that are not on isolation precautions) wearing the same N95 masks that she was wearing previously when she was in Room e isolation room for residents positive for COVID-19. Observation at 02/01/2023 at 12:15 p.m., revealed S9Certified Nursing Assistant (CNA) went into Room l (room for residents that are not on isolation precautions) wearing the same N95 masks that she was wearing previously when she was in Room c isolation room for residents positive for COVID-19. In an interview on 02/01/2023 at 12:15 p.m., S11Certified Nursing Assistant (CNA) stated that she was wearing the N95 mask she currently has on in all residents' rooms, no matter if they were on isolation for COVID-19 or not on isolation for COVID-19. In an interview on 02/01/2023 at 12:15 p.m., S9Certified Nursing Assistant (CNA) stated that she was wearing her the N95 mask she currently has on in all residents' rooms, no matter if they were on isolation for COVID-19 or not on isolation for COVID-19. In an interview on 02/01/2023 at 12:16 p.m., S12Certified Nursing Assistant (CNA) stated that CNAs are supposed to have a N95 mask that they wear in just rooms for residents on isolation for COVID-19, and another N95 mask for out in the hall and non-isolation rooms. S12CNA stated they are supposed to wear different N95 masks with face shields over masks in each room for residents on isolation for COVID-19. In an interview on 02/02/2023 at 12:17 p.m., S11Certified Nursing (CNA) confirmed that she should not have been wearing the same N95 mask in Rooms k that she was wearing in rooms for residents on isolation for Covid-19. In an interview on 02/02/2023 at 12:17 p.m., S9Certified Nursing (CNA) confirmed that she should not have been wearing the same N95 mask in Rooms l that she was wearing in rooms for residents on isolation for Covid-19. Observation on 02/01/2023 at 12:26 p.m. revealed S13Certified Nursing Assistant (CNA) put on PPE and went into Room f (room for resident on isolation for COVID-19) without gloves and without face shield or goggles. S13CNA then exited Room f wearing the N95 mask. Observation on 02/01/2023 at 12:27 p.m., revealed S14Certified Nursing Assistant (CNA) put on PPE and went into Room g(a room for residents on isolation for COVID-19) without face shield or goggles. S14CNA then exited room with a N95 mask and reached into clean PPE cart in hallway for another gown without cleansing her hands. Observation on 02/01/2023 at 12:29 p.m., revealed S13Certified Nursing Assistant (CNA) put on PPE, and went into Room h (a room for residents on isolation for COVID-19) without a face shield or googles. Observation on 02/01/2023 at 12:32 p.m., S14Certified Nursing Assistant (CNA) put on PPE, and went into Room i (a room for residents on isolation for COVID-19) without a face shield or goggles. In an interview on 02/01/2023 at 12:35 p.m., S14Certified Nursing Assistant (CNA) stated that she is supposed to wear protective googles or face shields when going into rooms of residents on isolation for COVID-19, and that she was not wearing protective goggles of a face shield when going into Room g or Room i, both rooms for residents on isolation for COVID-19. In an interview on 02/01/2023 at 12:36, S13Certified Nursing Assistant (CNA) stated that she is supposed to wear protective googles or face shields when going into rooms of residents on isolation for COVID-19, and that she was not wearing them when going into Room f or Room h, both rooms for residents on isolation for COVID-19. S13CNA also stated that she did not wear gloves before going into Room f with the lunch tray.S13CNA stated she did not know the policy or proper procedure for putting on PPE when outside of resident room. Observation on 02/02/2023 at 4:19 p.m., S15Certified Nursing Assistant (CNA) exited out of Room j (a room for residents on isolation for COVID-19) with a wrist blood pressure cuff. S15CNA then placed the wrist blood pressure cuff into her scrub pocket without cleaning it. In an interview on 02/02/2023 at 4:20 p.m., S15Certified Nursing Assistant (CNA) stated that she should not have put the uncleaned wrist blood pressure cuff in her pocket that was used in Room j (a room for residents on isolation for COVID-19).