Based on observation, interview and record review, the facility failed to treat three Residents (R4, R12, R31) with dignity and respect out of 18 residents reviewed for dignity. This deficient practice resulted in a lack of personal dignity and feelings of embarrassment based on the reasonable person. Findings include: On 10/29/24 at 12:15 p.m., the lunch meal observation was observed in the Glacier Hill Cottage. During this time, Certified Nurse Aide (CNA) A and CNA B were observed assisting two residents with their meals (later identified as R4 and R12). CNA B started to assist R12 by standing next to R12 with a spoon and continued to place food in their mouth. CNA A then replaced CNA B to assist R12 and continued to stand while quickly placing food in R12's mouth with the spoon. CNA B then walked over to R4 and began to assist R4 with lunch in a standing position, placing the spoon in her mouth. On 10/30/24 at 12:25 p.m., the lunch meal observation was observed in the Grass Creek Cottage. During this time, CNA C was observed assisting R31 with their meal by placing the meal in front of R31, sitting down, and donning gloves. CNA C continued to wear gloves during the meal observation with R31 and would make clicking noises to R31 or humming while assisting her with the meal. An interview was conducted with the Director of Nursing (DON) on 10/30/24 at 1:07 p.m. The DON confirmed that these observations were not providing the residents with a dignified dining experience. Review of the facility's Resident Rights Interpretation and Implementation Policy, undated, read in part, .Policy: It is the policy of this facility that all residents be treated with kindness, dignity, and respect. Policy Interpretation and Implementation: Our staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement care plans for three Residents (R24, R83, and R86) of 18 residents reviewed for care planning. This deficient practice resulted in the potential for unidentified and unmet individualized resident care needs. Findings include: Resident #24 (R24) A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R24 was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene. A progress note dated 10/24/24 documented R24 was lethargic and had a 101.1 degrees Fahrenheit axillary (under arm) temperature. The Nurse Practitioner (NP) ordered lab tests including a urinalysis (UA). The UA resulted in a urine culture that revealed a urinary tract infection with the organism Escherichia coli (bacteria found in the intestine). A physician note dated 10/28/24 documented R24 had not had a bowel movement (BM) in 5 days and was experiencing abdominal pain. The physician documented R24 had a history of constipation. A review of the care plans for R24 revealed no care plan for the urinary tract infection and no care plan for the constipation to provide staff with appropriate interventions to address the individualized needs and care goals for R24. Resident #83 (R83) R83 was admitted on [DATE] with diagnoses which included a fracture of the left femur (leg), pain in the right shoulder, pain in the left shoulder, pain in the left knee, and other chronic pain. The admission MDS assessment dated [DATE] documented R83 was at risk of developing pressure ulcers (wounds caused by pressure), was taking an opioid (medication for pain), was on a scheduled pain medication regime and the verbal descriptor scale indicated very severe, horrible pain with indicators of pain or possible pain observed daily. The MDS assessment of 8/3/24 revealed the resident had a fall in the last month with a related fracture. The Care Area Assessment Summary (CAA) of the 8/3/24 MDS specified several care areas were triggered and would be addressed in the care plan including falls, pressure ulcers and pain. The care plan was reviewed and did not include a care plan for falls, pressure ulcers or pain to provide staff with appropriate interventions to address the individualized needs and care goals for R83. During an interview on 10/30/24 at 10:05 AM, Registered Nurse (RN) G agreed the care plan was not completed for R83. RN G stated R83 was scheduled to move to another unit and said, It is my intent to get that caught up before I pass them on (to the new unit). Resident #86 (R86) R86 was admitted on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunction), gastrostomy (tube feeding through the stomach), and pressure ulcer. The MDS assessment of 10/7/24 documented R86 had an unstageable pressure ulcer due to coverage of the wound bed by slough (dead tissue) and/or eschar (dry, black, crusty tissue). The physician orders indicated R86 was to have nothing by mouth and received all nutrition via the tube feeding. Pain medication had been ordered to be given as needed. The monthly medication administration record showed pain medication was given seven times during the month. The 10/7/24 MDS CAA specified several care areas were triggered and would be addressed in the care plan including pressure ulcers and pain. Upon review of the care plan for R86: - there were no care plans for pain, - it did not include nursing care interventions for the specialized tube feeding required, - it included a focus listed as The resident has (SPECIFY) pressure ulcer (SPECIFY LOCATION) or potential for pressure ulcer development r/t (related to) and was incomplete. - it had no goals or interventions listed for the existing pressure ulcer. During an interview on 10/30/24 at 11:00 AM, the Director of Nursing stated they would expect nursing interventions to be included with the tube feeding care plan and the other areas to be completed. The facility policy titled Comprehensive Care Plans and dated as effective 10/2024 read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to transport two Residents (R39 and R41) in a safe manner and per standards of care out of 18 residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in the potential for injury. Findings include: Resident #41 (R41) On 10/29/24 at 11:10 AM, Registered Nurse (RN) D was observed pushing R41 in their wheelchair without footrests from Orchard Hill dining area to R41's room halfway down the hall. Certified Nurse Assistant (CNA) E stopped RN D after noticing RN D was not using R41's wheelchair footrests. CNA E then put R41's footrests on their wheelchair. R41 was noted to have a plastic boot-like shoe to both their right and left feet that were barely off the floor during transport. On 10/30/24 at 10:35 AM, an interview was conducted with RN D who was asked about yesterday and pushing R41 back to their room from the dining area then to their room. RN D replied, Yes, we are supposed to use foot pedals, and I was just taking them back to their room to do a blood sugar check. I should have used the foot pedals. Resident #39 (R39) On 10/30/24 at 10:33 AM, CNA F was observed pushing R39 in their wheelchair without footrests from the Orchard Hill dining area down the hall to their room. R39 visibly had footrests stored on the back of their wheelchair readily available. On 10/30/24 at 10:34 AM, an interview was conducted with CNA F who was asked about propelling R39 in the wheelchair without footrests. CNA F replied, I am new down here. Yes, I should have used their [NAME] pedals to transport them back to their room. On 10/30/24 at 1:50 PM, an interview was conducted with the Director of Nursing (DON) who was asked about two different staff transporting residents without footrests. The DON replied, That is unacceptable. It is the standard of practice to use foot pedals.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% during the medication administration task. Two medications errors were observed for one Resident (R47) out of 26 medication administration opportunities for 11 total residents reviewed. This deficient practice resulted in a medication error rate of 7.69% and the potential for additional medication errors for facility residents. Findings include: During an observation on 11/16/22 at 8:44 a.m., Registered Nurse (RN) A attempted to prepare multiple medications, which included, but were not limited to: 1. [Name Brand] long-acting insulin, 18 units administered via insulin pen, and 2. [Name Brand] nasal spray, two puffs in each nostril one time daily for nasal congestion. 1. Insulin Administration Review of R47's Physician Order Summary, revealed: [Name Brand] (Insulin Detemir) Inject 18 unit subcutaneously one time a day for hyperglycemia. During preparation of the [Name Brand] long-acting insulin pen, RN A failed to cleanse the pen hub with alcohol prior to insertion of the insulin pen needle into the hub and failed to prime the pen prior to administration of 18 units of insulin to R47 via the insulin pen. Review of the facility Insulin policy, dated 11/11/2019, revealed the following, in part: Insulin Pens: 1. Swab the cartridge (cleanse hub with alcohol pad) and attach the pen needle. Remove cover. 2. Prime the needle until with 2 units, visualize the drop of insulin at the tip of the needle and then dial the correct dose. Prime the pen in a vertical position with the needle pointed upward . Review of the [Name Brand] long-acting insulin Instructions for Use, dated 7/2022, revealed the following, in part: .Routine Use: .Pull off pen cap . Wipe the rubber stopper with an alcohol swab . Prepare the Pen: Hold pen with needle pointing up. Tap cartridge gently with your finger a few times to bring any air bubbles to the top of the cartridge. Keep needle pointing up and press dose button until 0 mg lines up with pointer. Repeat . up to 6 times, until a drop of test medium appears at the needle tip. 2. Non-administration of [Name Brand] Fluticasone Propionate Suspension 50 MCG/ACT (50 micrograms per actuation) nasal spray. During R47's medication administration observation on 11/16/22 at 8:44 a.m., RN A looked in the medication cart and the medication room refrigerator for the [Name Brand] nasal spray. RN A said the medication was not available, and the medication would not be administered that day as prescribed, and therefore was deemed a medication error. Review of R47's Physician Order Summary, for November 2022, revealed the following order: Fluticasone Propionate Suspension 50 MCG/ACT, 2 spray (sic) in both nostrils one time a day for nasal congestion. Start Date: 11/16/2022 0900 (9:00 a.m.). Review of R47's Medication Administration Record (MAR) confirmed the [Name Brand] nasal spray was documented with a number 9 by RN A on the 11/16/22 observed 9:00 a.m. administration with this Surveyor. The number 9 Chart Code indicated Other/See Progress Notes. During an interview on 11/16/22 at 9:10 a.m., When asked if R47's insulin pen hub had been sanitized prior to application of the insulin administration needle, and if the insulin pen had been primed prior to insulin administration, RN A acknowledged neither step in preparation of the insulin pen for medication injection had been performed. When asked about the lack of the [Name Brand] nasal spray to administer to Resident #47, RN A confirmed the MAR had been documented as not administered because the medication was not available in the medication cart or in the medication refrigerator in the nurse's office, and therefore unavailable to administer. During an interview on 11/16/22 at 12:14 p.m., the Director of Nursing (DON) was asked to provide the [Name Brand] long-acting insulin pen Instructions for Use, and the facility policy regarding insulin administration. During an interview on 11/16/22 at 3:17 p.m., the DON confirmed the insulin pen hub should have been cleansed with an alcohol pad prior to application of the insulin administration needle and acknowledged the insulin pen should have been primed prior to insulin administration. The DON was unaware R47's [Name Brand] nasal spray was not available in inventory to administered on 11/16/22, as instructed per physician orders. Review of the facility Administration and Documentation of Medications/Treatments policy, dated 2022, revealed the following, in part: . Medications will be administered in accordance with order of the attending physician/NP (nurse practitioner)/PA (physician assistant) . Medication maybe administered one hour prior or after the prescribed time unless specific time(s) have been indicated for administration, such as before or after a meal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 11/15/22 at 9:00 a.m., during the entrance to the facility the DON and Nursing Home Administrator (NHA) stated there were four Residents ( #9, #46, #74, & #6) who had been identified as positive for influenza on two separate households (A & B). On 11/15/22 at 2:15 p.m., during an interview, IP E stated staff were required to sanitize in and out of a room that is positive for influenza and must sanitize their face shield. IP E then stated staff were allowed to keep the same mask on when entering and exiting a droplet precaution isolation room. When asked what Personal Protective Equipment (PPE) staff were to use when entering a droplet isolation room, IP E stated, a pair of gloves, a gown, a mask, and a face shield were required for entry to a droplet isolation room. On 11/16/22 at 9:05 a.m., during a follow-up interview, IP E stated an additional case of influenza was identified that morning within household A. On 11/16/22 at 1:48 p.m., the infection prevention and control program (IPCP) was reviewed with IP E. During the review, IP E was asked to provide details regarding an outbreak of influenza at the facility which was ongoing during the survey time period. There were five Residents (#6, #9, #44, #46, & #74) who were identified as positive for Influenza at the time of this interview. The IP stated they resided on units A and B, all residents on unit A were screened and COVID-19 tested. IP E then stated residents with two or more symptoms consistent with influenza developed, residents are then tested for influenza. IP E was then asked to provide an outbreak summary for influenza. A review of the Influenza outbreak summary revealed the following: Resident #9 and Resident #46 tested positive for influenza 11/12/22 and resided on household A. Resident #74 then tested positive on the following day 11/13/22 who also resided on household A. Resident #6 tested positive for influenza on 11/14/22 who resided on household B. Resident #44 tested positive for influenza on 11/16/22 and resided on household A, where the first cases were identified. On 11/17/22 at 10:25 a.m., during an interview, IP E was asked how staff were to handle coming on and off the main outbreak area of household A. IP E stated she instructed the staff to limit the traffic on household A. When asked if activities were supposed to be conducted on the main outbreak household A, IP E stated, I hope not. On 11/17/22 at 11:10 a.m., during a follow-up interview, IP E was asked to confirm when the facility recognized the influenza outbreak on household A. IP E stated the influenza outbreak for household A had been officially identified on 11/13/22, when a third resident tested positive for influenza. When asked about signage for the outbreak, IP E acknowledged the signage for the outbreak should have been posted as of 11/13/22 and was not posted until the morning of 11/16/22. Based on the outbreak status of household A as of 11/13/22, IP E also confirmed group activities should not have been occurring on the unit. IP E then stated some of the residents were getting upset about the activity being canceled, so the activities staff went ahead with the activity. IP E confirmed the activities department did visit all of the units on 11/15/22 for a nerf gun hunting activity. When asked to confirm PPE requirements for 'Droplet Precaution' rooms, IP E stated staff were able to enter resident rooms who were influenza positive with a face shield covering their mask and exit only having to doff gown and gloves and sanitize the shield. IP E stated staff were not required to change their mask after leaving a Droplet Precaution' room. On 11/17/22 at 12:21 p.m., during an interview, Activities Director (AD) H stated there was no discussion in the morning meeting on 11/15/22 and acknowledged activities staff proceeded with group activities on 11/15/22 for a nerf gun hunting activity. AD H stated staff started on household B, moved to household A, and then in the afternoon went to household C. AD H stated activities being conducted in household A were restricted to one-to-one at the time of this interview and acknowledged small group activities should not have been held on 11/15/22 for household A. AD H stated no group activities would be held moving forward until the outbreak was over. There were concerns with staff not following CDC guidance with regard to PPE when entering and exiting 'Droplet Precaution' rooms for residents with confirmed influenza as stated below. On 11/17/22 at 1:09 p.m., CNA J was observed entering and exiting Resident #44's room who was currently positive for Influenza A as of 11/16/22. During the interaction, CNA J asked Resident #44 how his lunch meal was and Resident #44 responded. CNA J was observed within 3 feet of Resident #44 during this interaction and proceeded to remove the meal tray from Resident #44's room. CNA J was observed donning and doffing PPE properly except he failed to remove, discard, and replace his facemask before proceeding to non-outbreak areas. CNA J was then observed exiting the unit and traveled through the facility into the employee break room with the same mask worn in the isolation room. It was unknown if there were additional employees in the break room at that time. There was also no PPE station on the unit near the entrance to household A for donning and doffing the mask the facility required to enter the unit. Anyone exiting household A did not have ready access to change their mask upon exiting and at a minimum had to travel to the entrance of the facility approximately 50 feet away in order to change their mask to access the rest of the facility. A review of the facility policy, Standard Precautions, including donning and doffing PPE procedures, dated 10/2/20, read in part: . a. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, bodily fluids, or potentially infectious material is likely . Component Hand Hygiene . Practices After touching blood, bodily fluids, secretions, excretions, contaminated items; before and after removing PPE; between resident contacts . (CDC- [Document #CS250672-E]) HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1 . . 4. MASK OR RESPIRATOR - Front of the mask/respirator is contaminated - DO NOT TOUCH - If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol -based hand sanitizer - Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front - Discard in a waste container . Example 2 . 3. MASK OR RESPIRATOR . - Discard in a waste container . A review of the facility policy, Outbreak of the Flu Activity Department, dated 7/8/20, read in part: .Will provide small group activities on units where flu is at a minimum . A review of the facility policy, Influenza and Viral Respiratory Outbreak Policy, with a revised date of 11/14/22, read in part: Purpose: To prevent, recognize, and manage viral respiratory or influenza outbreaks in the Facility. I. Definitions of a Respiratory Virus Outbreak in (Facility Name): 1. More than two residents in a household (unit) develop a respiratory illness within 72 hours of each other or 2. Laboratory-confirmed positive case (e.g. influenza, respiratory syncytial virus, parainfluenza, adenovirus) or 3. A sudden increase over the normal background rate of acute respiratory illness cases, with or without documented fever II. Infection Control Procedures: 1. Institute standard and droplet precautions as appropriate, use of face masks if direct contact within 3 feet of residents . . 4. The Facility will implement by household: . . g. Post visitor signs alerting them to the outbreak/illness . A review of the facility policy Isolation Precautions, with a revised date of 11/15/22, read in part: . 5> Droplet Precautions: In addition to Standard Precautions, Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets [Larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, . a) Examples of infections requiring Droplet Precautions include, but are not limited to: . 5. Influenza . . c) Masks 1. In addition to Standard Precautions, wear a standard mask when working within 3 feet of the resident . A review of the facility policy Mask, with a revised date of 11/10/22, under Facility Outbreak and b. Resident Driven revealed no guidance to the staff on when to discard and replace a facemask after interaction with a droplet precaution resident. The policy only stated PPE requirements were .N95 mask, gown, gloves, and face shield or goggles . A review of the CDC website at, https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm, web page last reviewed 5/13/21, read in part: Prevention Strategies for Seasonal Influenza in Healthcare Settings . .Fundamental Elements to Prevent Influenza Transmission Preventing transmission of influenza virus and other infectious agents within healthcare settings requires a multi-faceted approach. Spread of influenza virus can occur among patients, HCP (health care personnel), and visitors; in addition, HCP may acquire influenza from persons in their household or community. The core prevention strategies include: .adherence to infection control precautions for all patient-care activities . .Successful implementation of many, if not all, of these strategies is dependent on the presence of clear administrative policies and organizational leadership that promote and facilitate adherence to these recommendations among the various people within the healthcare setting, including patients, visitors, and HCP . 4. Adhere to Standard Precautions .During the care of any patient, all HCP in every healthcare setting should adhere to standard precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. Standard precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. Elements of standard precautions that apply to patients with respiratory infections, including those caused by the influenza virus, are summarized below . .5. Adhere to Droplet Precautions Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility . .HCP should don a facemask when entering the room of a patient with suspected or confirmed influenza. Remove the facemask when leaving the patient ' s room, dispose of the facemask in a waste container, and perform hand hygiene . Resident #74 During an observation of the medication administration task on 11/15/22 at 12:25 p.m., Registered Nurse (RN) C prepared a 0.5 mg (milligram) tablet of lorazepam for R74 and mixed it in pudding in a small plastic 30 cc (cubic centimeter) medication cup. R74 was in droplet precautions for testing positive for influenza. RN C donned appropriate PPE (isolation gown, gloves, and the face mask and face shield she was already wearing during medication administration for all residents on the house). R74 refused the medication in the pudding and requested an individual pill. RN C threw the medication cup with pudding and the lorazepam in R74's bathroom garbage and exited the room after doffing (removing) the isolation gown and gloves at the resident's doorway. RN C sanitized her hands, and the same mask and face shield remained in place as she exited R74's room. RN C touched the front of the face shield with bare hands and placed the face shield on top of her head. Contact between the front of the face shield, and her bare hands was observed, with no hand sanitation performed before preparation of a second lorazepam tablet was retrieved from the medication cart for R74. RN C returned to R74's room and donned another gown and gloves, with no hand sanitation observed. RN C used both dirty, gloved hands to handle the face shield bows in her hair and pulled the potentially contaminated face shield down back over her face. No hand sanitation was performed as RN C entered R74's room with her dirty gloves in contact with the wooden gate blocking the door entrance. R74 refused the second lorazepam tablet, and RN C retrieved the medication cup filled with pudding and the first lorazepam tablet from the Residents bathroom garbage prior to exit from the room. RN C removed the isolation gown and gloves but did not change her mask or sanitize her face shield following either exit from R74's influenza isolation room. Review of R74's MDS assessment, dated 9/2/22, revealed R74 was admitted to the facility on [DATE], with diagnoses that included: hypertension, renal failure, hyperlipidemia, non-Alzheimer's dementia, dementia with behavioral disturbance, impulsiveness, restlessness, agitation, and adult failure to thrive. R74 required extensive, two-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and was totally dependent upon one-person assistance for bathing. R74 scored 5 of 15 on the BIMS reflective of severe cognitive impairment. During an interview on 11/16/22 at 3:23 p.m., the Director of Nursing (DON) was asked about the expectation for doffing and/or sanitation of face shields after use in isolation rooms. The DON stated, The policy says that I need to sanitize my face shield. When again asked what the DON's expectation for staff would be about face shields being doffed, and the performance of hand hygiene when staff exited influenza isolation rooms, the DON stated, She needed to sanitize her hands between being in and out of the room. The DON confirmed there was a potential for environmental contamination and the transmission of infectious organisms. Based on observation, interview and record review, the facility failed to implement proper infection control measures during an outbreak of influenza on one household (Unit A). This deficient practice resulted in the potential for continued spread of influenza to the other residents residing within the household. Findings Include: Resident #9 Review of Resident #9's Electronic Medical Record (EMR) revealed an admission date to the facility on 9/22/22 with diagnoses including: congestive heart failure (CHF), kidney disease stage 3, and failure to thrive. Resident #9's 9/30/22 Minimum Data Set (MDS) assessment revealed she required extensive one person assist for transfers, dressing and personal hygiene. Resident #9 scored a 3/15 on the Brief Interview for Mental Status (BIMS) score indicating she was severely cognitively impaired. Further review of Resident #9's EMR revealed she tested positive for influenza B on 11/12/22 and was placed in Transmission Based Precautions on that day. Upon entering Unit A household on 11/15/22 at approximately 11:30 a.m., there was no signage on the outside of the household doors to indicate there were positive influenza cases. On 11/15/22 at approximately 12:15 p.m., Resident #9 was observed lying in her bed watching television. Resident #9's door had posted signs indicating that it was a transmission-based precaution room with personal protective equipment (PPE) placed on the outside of the door. During this observation, Certified Nurse Aide (CNA) F was observed entering Resident #9's room wearing PPE which included a gown, gloves, face shield and N95. CNA F came out of Resident #9's room with a plastic cup and lid stating that Resident #9 did not want anything to eat or drink. CNA F was observed to sanitize her hands before grabbing the cup, walking it through the main common area, dump the contents of the cup into the sink, and then placed the cup in a used bin. There were no staff members that sanitized the handrail. On 11/17/22 at approximately 9:30 a.m., upon entering the Unit A household, a sign was observed on the outside of the doors to indicate positive influenza cases. An interview was conducted with Medical Director G on 11/17/22 at 12:05 p.m. Medical Director G stated he was informed of the positive influenza cases on 11/14/22 when there was already three residents who had tested positive. When asked what he advised to stop the spread of influenza throughout the household, Medical Director G indicated that the positive residents should remain in their rooms and staff were to wear the proper PPE which included: masks, gowns, gloves, face shield and N95's. Medical Director G confirmed that staff should be removing all of the PPE and placing a new face mask on before providing care to other residents.