Based on observations, interviews, record reviews, and facility policy review, the facility failed to honor a resident's rights to make choices regarding daily routines by not assisting a cognitively impaired resident outdoors for scheduled smoking breaks (Resident #25) and regarding bathing times (Resident Council Attendees: Res #33, #2, #51, #5, #10, #41, #31, #16, #11, and #20) for 11 of 57 residents residing in the facility. Findings included: A review of the facility's policy, Resident's Rights Policy, dated of 3/24 revealed, Every resident in this facility has the right to .22. Use tobacco in accordance with applicable policies, rules, and laws . A review of the facility's policy, Dignity and Respect, dated 7/22 revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. This facility shall protect and promote the rights of the resident. 1. Facility staff shall display respect when .caring for .residents, as constant affirmation of their individuality and dignity as human beings. 2. Each resident of the facility has the right to a dignified existence. 3. All residents should have autonomy of choice .4. Schedules of daily activities allow flexibility for residents to exercise choice about what they will do and when they will do it. Resident's individual preferences regarding such things as . activities, friendships . will be elicited and respected by the facility, and efforts will be made to accommodate these wishes .5. Residents will be .treated in a manner that maintains bodily privacy. A closed door and/or drawn cubicle curtain should be utilized to maximize the privacy of each resident while rendering care . A review of the facility's policy, Bathing dated 01/24 revealed, Purpose To ensure resident comfort and dignity .Processes Inquire with the resident concerning bathing preferences, (e.g., time of day, type of bathing, shower, bed bath, etc.). Offer the resident choice in their bathing routine . Choices (Smoking) A record review of the Care Plan Item/Task Listing Report dated 5/2/25 revealed a total of eighteen (18) residents that smoke, including Resident #25. On 5/5/25 at 12:13 PM, during an observation and interview, Resident #25 was observed up in her wheelchair in her room. She explained that she had been at the facility for a couple of years and typically went out to smoke a couple of times a day. She stated she had smoked for most of her life. Other residents were observed heading out to the designated smoking area, but Resident #25 remained in her room. On 5/5/25 at 12:30 PM, during an observation, Resident #25 remained in her room watching television, while other residents were observed returning from the smoking area. On 5/5/25 at 12:45 PM, during an observation and interview, no residents or staff were observed outdoors at the smoking area. Certified Nurse Aide (CNA) #2 explained that the smoke break had been changed to 12:00 or 12:30 PM and had already occurred. She stated that housekeeping was responsible for taking residents out for the morning and noon breaks. She confirmed that Resident #25 still smoked but would sometimes forget to go, and if the staff remembered, they would take her; otherwise, it was overlooked. She confirmed she did not take Resident #25 out to smoke that day. On 5/6/25 at 12:40 PM, during an observation and interview, Resident #25 was sitting in her room watching television and stated she had not been out to smoke that day and that no one had come to get her or inform her of the smoking times. On 5/6/25 at 1:00 PM, during an interview with CNA #3, she explained that she tries to get Resident #25 for smoke breaks if she is in her room. She reported that the resident had still been in the dining room during the smoke break and confirmed she did not take her out that day. On 5/6/25 at 1:25 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that Resident #25 is very forgetful and does not always remember to go out to smoke. She did not know if the resident had gone out that day. She reported that staff sometimes reminded her and assisted her outdoors but acknowledged this did not happen every day. She explained the facility typically has four smoke breaks per day and that the mid-day break had been changed from 1:00 PM to either 12:00 or 12:30 PM. She stated that housekeeping staff took the residents out, but they did not retrieve them individually; rather, the residents would line up in the hallway after lunch. On 05/08/25 at 09:00 AM, during an interview, Resident #25 reported she has not been outside to smoke today. On 05/08/25 at 10:50 AM, during an interview with Housekeeping/Maintenance #1, he reported he did smoke break this morning for the residents and confirmed that Resident #25 was not at the smoke break this morning. On 5/8/25 at 2:00 PM, during an interview with the Director of Nursing (DON), she confirmed that Resident #25 was a smoker and was not being reminded daily or consistently assisted out for smoke breaks. She stated she expected staff to honor the residents' right and ensure that cognitively impaired residents are informed of and assisted with smoking times. On 5/8/25 at 2:20 PM, during an interview with the Administrator, she confirmed that Resident #25 was a smoker and often forgot about smoke breaks. She stated that the resident's family occasionally came to take her out to smoke but was unaware that staff were not informing or assisting the resident. She confirmed there were no posted smoke break times in the facility and stated she expected staff to assist cognitively impaired residents with smoking if they wished to do so. A record review of the admission Record revealed the facility admitted Resident #25 on 3/10/23 with current diagnoses including Alzheimer's Disease. A record review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/25 revealed she had a Brief Interview for Mental Status (BIMS) score of 6, which indicated her cognition was severely impaired. Choices and Privacy (Bathing) A record review of the Resident Council Minutes dated April 2025 revealed the residents complained about the bath schedules, not knowing when they are scheduled. On 05/05/25 at 3:00 PM, during a meeting with the Resident Council, ten (10) residents were present, each with a Brief Interview for Mental Status (BIMS) score averaging 14, indicating cognitively intact status. The residents expressed multiple concerns regarding shower practices. Several residents reported they were not informed in advance of their scheduled shower days and were frequently awakened as early as 5:00 AM for bathing. While some residents preferred early showers, others stated they would rather bathe in the afternoon but were told that if they did not shower between 5:00 AM and 1:00 PM, they would not receive a shower that day. Residents also raised concerns regarding a lack of privacy in the shower room. They reported being bathed simultaneously with another resident-one in the whirlpool and one in the shower stall-without the privacy curtain being drawn. After their showers, residents stated they were pulled into the middle of the shower room floor to be dried off and dressed, exposing their bodies to the other resident. Additionally, staff were entering and exiting the shower room and conversing with the bathing staff, often leaving the door open and privacy curtain not pulled, resulting in potential exposure to the hallway. On 05/06/25 at 11:43 AM, during an interview with Certified Nursing Assistant (CNA) #1, she stated she serves as the designated shower aide and is scheduled to work Monday through Friday from 5:00 AM to 1:00 PM. She added that she occasionally works on the floor during weekends when the facility is short-staffed. CNA #1 explained that resident showers are routinely provided between 5:00 AM and 1:00 PM, Monday through Saturday, and are not scheduled during the afternoon or evening. She acknowledged that some residents have voiced complaints about receiving showers so early in the morning but stated that all showers are scheduled during that time frame because that is when staff are available. CNA #1 also stated that because the residents were the same sex she didn't think it was a problem for them to take showers at the same time. On 05/06/25 at 12:05 PM, during an interview with Certified Nursing Assistant (CNA) #2, she stated she serves as a shower aide and is scheduled to work Monday through Friday from 5:00 AM to 1:00 PM. CNA #2 explained the resident shower schedule: residents on B Hall and the right side of D Hall receive showers on Monday, Wednesday, and Friday, while residents on C Hall and the left side of D Hall are scheduled for Tuesday, Thursday, and Saturday. She further explained that residents with scheduled physician appointments or dialysis are prioritized to receive showers first, typically between 5:00 AM and 6:00 AM. CNA #2 stated that shower services pause during breakfast and lunch hours so that shower aides can assist with meal service. She confirmed that showers are not provided after 1:00 PM daily and that showering residents of the same sex in the shower room at the same time was not a problem and that the shower room does not have a lot of space. During an interview on 05/08/25 at 3:00 PM, the Administrator stated she had recently returned from leave and had been back at the facility for approximately one (1) month. She explained she was not aware of any resident complaints regarding the shower schedule or process. The Administrator stated she would collaborate with the Director of Nursing (DON) to assess each resident's shower preferences and ensure they are being accommodated.

Based on observation, interview, record review, and facility policy review, the facility failed to honor a resident's food preferences and provide a menu alternative for one (1) of sixteen (16) sampled residents. Resident #30. Findings Included: A review of the facility's policy, Dignity and Respect, dated 7/2022 revealed, A facility must treat each resident with dignity and respect and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality . 4 . Residents' individual preferences regarding such things as menus . will be elicited and respected by the facility, and efforts will be made to accommodate these wishes . A review of the facility's policy, Alternate Food for Food Preferences, dated 5/2018 revealed, Substitutes of similar nutritive value are offered to residents who refuse food served . 7. The nursing assistant, on observing that a resident is refusing a food, offers the alternate food to the resident . On 5/5/25 at 11:04 AM, during an interview and observation, Resident #30 explained that he did not eat chicken, but the facility continued to serve it to him. He reported he had informed Certified Nurse Aides (CNAs), but his food tray continued to include chicken. In an interview and observation on 5/5/25 at 11:54 AM, Resident #30 was observed from the hallway sitting upright in a chair in his room as CNA #1 brought in his tray. The meal consisted of chicken and dumplings, fried okra, and a roll. The resident told CNA #1 that he did not eat chicken however, CNA #1 did not offer an alternate meal and placed the tray on the bedside table before entering the hallway. The State Agency (SA) asked CNA #1 what the resident had for lunch and CNA #1 and SA returned to the resident's room. The resident again stated he did not eat chicken. CNA #1 stated she was unsure what was on the menu as the alternate meal for the day. On 5/6/25 at 1:47 PM, during an interview with the Dietary Manager, she revealed she had been made aware of Resident #30's food preference on 5/2/25 but had forgotten to input the information into the meal ticket system. She explained that residents are typically asked about food preferences upon admission. She reported that the resident's dislike for chicken was now added to his meal ticket and that CNA #1 had notified her of the issue. A record review of the admission Record revealed the facility admitted Resident #30 on 4/10/25 with diagnoses including Fracture of Shaft of Humerus, Left Arm. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/25 revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment by not maintaining appropriate and comfortable water temperatures in resident rooms on three (3) of three (3) resident halls, affecting all 57 residents residing in the facility. Findings included: A review of the facility's policy, Resident Environment, dated 9/15, revealed, It is the policy of this facility to provide a safe, clean, comfortable, and homelike environment . Resident #21 On 5/5/25 at 11:53 AM, during an observation, the hot water in Resident #21's bathroom (room [ROOM NUMBER]) reached a lukewarm temperature after a few minutes but never became hot. On 5/6/25 at 1:00 PM, during an interview with Resident #21, he explained the hot water in his bathroom never gets hot and he must wash his face with cold water every day. He stated he had told everyone about the issue, but nothing had been done. He added that even after running the water for a long time, it would only get warm. A record review of Resident #21's admission Record revealed the facility admitted the resident on 4/10/2024 with current diagnoses including Vascular Dementia. A record review of the 5-Day Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/25 revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Resident #56 On 5/5/25 at 12:00 PM, during an observation, the hot water in the bathroom of Resident #56's room (room [ROOM NUMBER]) only became warm after three (3) minutes and never reached a hot, comfortable temperature. A record review of Resident #56's admission Record revealed the facility admitted the resident on 1/30/25 with the diagnoses including Hemiplegia and Hemiparesis. A record review of Resident #56's admission MDS with an ARD of 2/6/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #12 On 5/5/25 at 12:05 PM, during an observation and interview with Resident #12 she reported the bathroom water has never been hot and only gets lukewarm. The State Agency (SA) observed the hot water running in the bathroom (room [ROOM NUMBER]) for over two (2) minutes, and the water never got hot. A record review of Resident #12's admission Record revealed the facility admitted the resident on 12/6/21 with current diagnoses including Type 2 Diabetes Mellitus. A record review of Resident #12's Comprehensive MDS with an ARD of 3/10/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. On 5/5/25 at 12:13 PM, during an observation of the hall (Rooms 213-224), the hot water in both sinks and showers throughout the hall was lukewarm. Residents #29 and #42 On 5/5/25 at 12:20 PM, during an interview with Residents #29 and #42, both residents reported the water in their rooms had been lukewarm for a long time. They stated they had reported the issue to nursing and maintenance staff, but no action had been taken. A record review of Resident #29's admission Record revealed the facility admitted the resident on 9/5/24 with current diagnoses including Atrial Fibrillation. A record review of Resident #29's Quarterly MDS with an ARD of 4/1/25 revealed a BIMS score of 11, indicating the resident's cognition was moderately impaired. A record review of Resident #42's admission Record revealed the resident was admitted on [DATE] with current diagnoses including Parkinson's Disease. A record review of Resident #42's Quarterly MDS with an ARD of 3/17/25 revealed a BIMS score of 11, which indicated the resident's cognition was moderately impaired. On 5/5/25 at 1:00 PM, during an observation of the visitor bathroom in the center of the building, the hot water did not become hot after running for over two (2) minutes. On 5/5/25 at 3:00 PM, during a Resident Council meeting, council members stated they had complained multiple times about the lack of hot water in their bathrooms and showers to Administration, Activities, and Maintenance, but no corrective actions had been taken. Resident #22 On 5/6/25 at 12:20 PM, during an observation of Rooms 201-209, the SA allowed the hot water to run for one (1) minute in each bathroom sink, and the water remained lukewarm. During an interview with Resident #22 in room [ROOM NUMBER], he confirmed the hot water in the sink only gets warm after one (1) to two (2) minutes but never gets hot. A record review of Resident #22's admission Record revealed the facility admitted the resident on 8/8/17 with current diagnoses including Pulmonary Hypertension. A record review of Resident #22's Quarterly MDS with an ARD of 4/23/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. On 5/6/25 at 12:27 PM, during an observation, room [ROOM NUMBER]'s hot water remained lukewarm after running for one (1) minute. On 5/6/25 at 1:15 PM, during an interview with Certified Nurse Aide (CNA) #4, he confirmed that the hot water in resident rooms had not been hot in several months and that upper management had been notified multiple times without resolution. On 5/6/25 at 1:30 PM, during an interview with Licensed Practical Nurse (LPN) #2, she stated residents across all halls had complained about the hot water in their rooms not getting hot. She confirmed the water in the shower rooms does get hot, but not in the residents' rooms. On 5/6/25 at 2:35 PM, during an interview with CNA #5, she stated she had been at the facility since February 2025 and the water in resident rooms had never gotten hot. She explained that the issue had been reported to the Administrator and other members of management without resolution. She stated that residents had consistently complained and that staff are supposed to wash their hands with warm, soapy water-but the water never gets hot. On 5/7/25 at 3:05 PM, during an interview and observation of water temperature checks with Housekeeping/Maintenance #2, he stated that hot water temperatures are checked once a week, usually on Tuesdays. He confirmed residents had complained for months. He reported that during his last recorded check in December 2024, no improvements had been made. He stated the highest temperature he had observed was around 110 degrees Fahrenheit (F) after letting water run for ten (10) minutes. He provided the following temperature readings: room [ROOM NUMBER] was 70°F and reached 90°F after two (2) minutes; room [ROOM NUMBER] was 90°F and remained there after two (2) and three (3) minutes; room [ROOM NUMBER] was 70°F and reached only 72°F after three (3) minutes; and room [ROOM NUMBER] was 76°F with low pressure and reached 90°F after three (3) minutes. This temperature check encompassed one room on each hall. On 5/8/25 at 3:30 PM, during an interview with the Administrator, she confirmed she was aware of the hot water problems in resident rooms. She explained the facility had consulted several water companies and was told the facility needed a new boiler system or additional tankless hot water heaters. She confirmed that recommendation had been made in December 2024, but no decisions or corrective actions had been implemented.

Based on observation, interviews, record review, and the facility policy review, the facility failed to implement activity care plan approaches for three (3) of 13 sampled residents. Resident #23, Resident #27, Resident #32. Findings include: Review of the facility's policy, Care Plan Process, revised 8/17, revealed, .The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care .Interventions are actions that should promote meeting the established goal . Resident #23 Record review of the Care Plan for Resident #23 with a problem onset date of 09/21/2022 revealed Problem/Need: Resident needs encouragement and assistance to activities . Approaches . One on one activities, music TV .Invite resident to church, bingo, and group discussion . During an observation on 10/30/23 at 4:00 PM, Resident #23 was in her wheelchair being pushed by a therapy staff down the hallway. The staff member asked the resident if she wanted to go to the dayroom for activities. The resident asked what the activities were, and the staff member responded that the residents were watching TV. Resident #23 stated that she could watch television in her room. On 11/01/23 at 3:15 PM, during an observation, Resident #23 was in the dayroom, sitting at a table with a book. The television was on, and other residents were watching the program. There were no structured activities taking place. On 11/01/23 at 03:22 PM, an interview with Resident #23 revealed she was not enjoying the television program that was playing in the dayroom. Resident #23 explained that she enjoyed participating in activities and getting out of her room and it made her feel bad when there was nothing to do at the facility. She stated that once she realized Bingo was canceled, she got her puzzle book to work on. Resident #27 Record review of the Care Plan for Resident #27 with a problem onset date of 09/26/2022 revealed Problem/Need: Resident needs encouragement and assistance to activities .Approaches . One on one activities, music TV .Invite resident to church, bingo, and group discussion . During observations on 10/30/23 at 11:00 AM, Resident #27 was sitting in the dayroom and at 11:10 AM. The activity of Noodle Balloon Ball as noted on the Activity Calendar was not in progress. During an observation on 11/1/23 at 10:00 AM, Resident #27 was sitting in the dayroom. The activity of Team Building Exercise as noted on the Activity Calendar was not in progress. During an observation on 11/1/23 at 12:15 PM, Resident #27 was sitting in the dayroom. The activity of Bean Bag N A Bucket as noted on the Activity Calendar was not in progress. During an observation on 11/1/2023 at 3:10 PM, Resident #27 was sitting in the dayroom and at 3:15 PM, Resident #23 was in the dayroom. The activity of Fun Bingo as noted on the Activity Calendar was not in progress. Resident #32 Record review of the Care Plan for Resident #32 with a problem on set date of 07/07/2022 revealed Problem/Need: Resident needs encouragement and assistance to activities .Approaches One on one activities, music TV .Invite resident to church, bingo, and group discussion . During observations on 10/30/23 at 11:00 AM, Resident #32 was sitting in the dayroom. The activity of Noodle Balloon Ball as noted on the Activity Calendar was not in progress. Record review of the Activity Calendar for October 2023 revealed on 10/30/23, Noodle Balloon Ball was scheduled for 11:00 AM and Team Building Exercise Games were scheduled for 2:00 PM. During an observation on 10/30/23 at 2:10 PM, Resident #32 was wandering the hallways and Resident #27 was sitting in the dayroom. The activity of Team Building Exercise Games as noted on the Activity Calendar was not in progress. Record review of the Activity Calendar for November 2023 revealed on 11/1/23, Team Building Exercise was scheduled for 10:00 AM, Prize Bean Bag N A Bucket was scheduled for 12:00 PM, and Fun Bingo was scheduled for 03:00 PM. On 11/02/23 at 12:15 PM, an interview with Registered Nurse #2/MDS Nurse revealed it is the responsibility of the Activities Director (AD) to assure the Resident's care plan goals and interventions are met. On 11/02/23 at 12:50 PM, in an interview with the AD, he confirmed that resident care plans were not followed consistently regarding the care plan interventions. On 11/02/23 at 12:56 PM, in an interview with the Director of Nursing (DON), she acknowledged the facility did not follow the care plan regarding activities. She stated that she expected the staff to follow the care plan for the residents. On 11/02/23 at 01:02 PM, an interview with the Administrator confirmed the care plan was not followed consistently regarding activities.

Based on observations, staff and resident interviews, record review, and the facility policy review, the facility failed to provide structured activities for three (3) of 13 sampled residents. Resident #23, Resident #27, and Resident #32 Findings Include: Review of the facility's, Activity Programs & Activity Program Scheduling, revised 11/17, revealed, The facility will provide for an ongoing program of age-appropriate activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial needs of each resident .Activity Programs & Activity Programs Scheduling .Activity Programs - Scheduling .Activity programs will be conducted as scheduled. An alternate will be provided upon cancellation of a scheduled program. Procedures .1. Programs are to be held as reflected on the activity calendar, as well as in the daily morning announcements. 2. If, for some reason, the scheduled program cannot be held .activity staff should either conduct that program or conduct an alternative program. 3. Only under rare circumstances should an activity be canceled and not replaced with another activity .4. If, for some reason, a program or alternate program cannot be held, announce the change .notify each Charge Nurse so that they man notify all floor staff, and note the change on the large activity calendar . Resident #23 During an observation on 10/30/23 at 4:00 PM, Resident #23 was in her wheelchair being pushed by therapy staff down the hallway. The staff member asked the resident if she wanted to go to the dayroom for activities. The resident asked what the activities were, and the staff member responded that the residents were watching television (TV). Resident #23 stated that she could watch TV in her room. Record review of the November Activity Calendar for November 2023 revealed Fun Bingo was scheduled for 3:00 PM on 11/1/23. On 11/01/23 at 3:15 PM, during an observation, Resident #23 was in the dayroom, sitting at a table with a book. The television was on, and other residents were watching the program. There were no structured activities taking place. On 11/01/23 at 03:22 PM, an interview with Resident #23 revealed she was not enjoying the television program that was playing in the dayroom. Resident #23 explained that she enjoyed participating in activities and getting out of her room and it made her feel bad when there was nothing to do at the facility. She stated that once she realized Bingo was canceled, she got her puzzle book to work on. A record review of the Face Sheet revealed the facility admitted Resident #23 on 09/21/22 with diagnoses that included Wedge Compression Fracture of the Lumbar. A review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Further review revealed her activity preferences, listed as very important, were reading, listening to music, being around animals, keeping up with the news, favorite activities, going outside for fresh air, and participating in religious services or practices. Resident #27 Record review of the Activity Calendar for October 2023 revealed Noodle Balloon Ball was scheduled for 11:00 AM on 10/30/23. During an observation and interview on 10/30/23 at 11:00 AM, Resident #27 was sitting in the dayroom talking to other residents. There were no structured activities, such as Noodle Balloon Ball, observed in the dayroom. Resident #27 stated that she was bored. Record review of the Activity Calendar for October 2023 revealed Team Building Exercise Games were scheduled for 2:00 PM on 10/30/23. During an observation on 10/30/23 at 2:10 PM, Resident #27 was sitting in the dayroom. There were no structured activities, such as Team Building Exercise Games, observed in the dayroom. There were residents in the day room sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. Record review of the Activity Calendar for November 2023 revealed Team Building Exercise was scheduled for 10:00 AM on 11/1/23. During an observation on 11/1/23 at 10:00 AM, Resident #27 was sitting in the dayroom but there were no structured activities, including no Team Building Exercise observed. There were residents in the dayroom sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. Record review of the Activity Calendar for November 2023 revealed Prize Bean Bag N A Bucket was scheduled for 12:00 PM on 11/1/23. During an observation on 11/1/23 at 12:15 PM, Resident #27 was sitting in the dayroom. There were no structured activities, including Bean Bag N A Bucket observed. There were residents in the dayroom sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. Record review of the Activity Calendar for November 2023 revealed Fun Bingo was scheduled for 3:00 PM on 11/1/23. During an observation on 11/1/2023 at 3:10 PM, Resident #27 was sitting in the dayroom. There were no structured activities observed, including Bingo. There were residents in the dayroom sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. A record Review of the Face Sheet revealed the facility admitted Resident #27 on 09/26/22 with diagnoses including Hypothyroidism, Depression, and Hypertension. A record review of the Annual MDS with an ARD of 9/7/23 revealed Resident #27 had a BIMS score of 7, which indicated her cognition was severely impaired. Further review revealed that it was very important for the resident to do her favorite activities. Resident #32 During an observation on 10/30/23 at 11:10 AM, Resident #32 was sitting in a chair in the dayroom and was not interacting with other residents. The television was on, but there were no structured activities, including Noodle Balloon Ball in progress. During an observation on 10/30/23 at 12:25 PM, Resident #32 was sitting in the dayroom. There were no structured activities taking place and other residents were in the day room watching television. During an observation on 10/30/23 at 01:23 PM, Resident #32 was walking in the hallway while other residents continued to watch television in the dayroom. The next scheduled activities on the activity calendar were scheduled for 2:00 PM Team Building Exercise Game. On 10/30/23 at 2:10 PM, Resident #32 continued to wander the halls. On the activity calendar team building exercise game noted in the day activity day room. During an observation on 10/31/23 at 1:40 PM, Resident #32 was walking in the hallway during the resident's Halloween Party in the dayroom. There was no one-on-one (1:1) activities conducted for Resident #32. No activities were provided for Resident #32 during the survey. Record review of the Face Sheet revealed the facility admitted Resident #32 on 07/07/2022 with diagnoses including Adult Failure to Thrive, Unspecified Dementia without Behavior Disturbances, and Restless and Agitation. Record review of the Annual MDS with an ARD of 6/23/23 revealed it was very important for Resident #32 to go outside when the weather was good and to participate in religious practices. Record review of the Quarterly MDS with an ARD of 09/18/23 revealed Resident #32 required Staff Assessment for Mental Status, which indicated that her cognition was severely impaired. At 1:45 PM on 10/31/23, during an interview with Certified Nursing Assistant (CNA) #5, she explained Resident #32 usually did not participate in activities with the other residents, however she would occasionally go outside, and she enjoyed dancing. CNA #5 confirmed that Resident #32 had not been involved in any activities during the week. During an interview on 10/31/23 at 10:00 AM, with the resident council members, they complained the facility did not provide enough activities and that the scheduled activities were not conducted daily. They stated that there were no activities on weekends, which caused them to be bored with nothing to do. Previously, the facility provided movies, popcorn, and snacks on Sundays and the members expressed they would like to do that again, but there was no one at the facility on weekends to set it up. During an interview on 11/1/23 at 09:30 AM, with Registered Nurse (RN) #1, she confirmed there is no one scheduled to conduct activities on weekends. The nurse said the residents had several coloring books and arts and crafts they can do, or they can watch television. RN #1 also confirmed that the churches that are scheduled to come on Sundays do not always show up, so the staff will ensure the television is turned on to a church service for the residents. During an interview on 11/2/23 at 09:00 AM, with CNA #1, she confirmed the facility did not have staff scheduled to conduct activities with the residents on weekends. CNA #1 confirmed that the churches that are scheduled on Sundays do not always show up to the facility, and she tried to turn the television on to keep the residents occupied when that happened. CNA #1 also confirmed that the residents did not have activities during the week because the Activities Director (AD) was busy performing maintenance work. During an interview on 11/2/23 at 09:10 AM, with CNA #2, she confirmed the facility did not have activities on weekends. She also confirmed that the resident activities are not consistent because the AD wears two (2) hats (maintenance and activities), which is why he is unable to perform activities that are scheduled on the calendar. During an interview on 11/2/23 at 9:25 AM, with CNA #3, she confirmed the activities are not consistent and that the residents become upset sometimes because they are looking forward to certain activities, especially Bingo, and are disappointed when the activity does not occur. CNA #3 also confirmed there was no one scheduled to provide activities on weekends. On 11/02/23 at 9:30 AM, during an interview with the Director of Nursing (DON), she confirmed that Resident #32 should have 1:1 scheduled activities. She explained Resident #32 should be more involved in activities. During an interview on 11/02/23 at 9:54 AM, the DON confirmed that activities were not consistent because the AD was also used as the Maintenance Director and was pulled to do maintenance work while also performing activity duties. The DON also confirmed the facility did not have staff scheduled to conduct weekend activities with the residents. The DON stated the residents were bored and had nothing to do during the week because the activities were not consistent. On 11/02/23 at 10:00 AM, during an interview with the AD, he explained that Resident #32 liked activities that were 1:1 and that she enjoyed dancing. The AD confirmed that Resident #32 had not had any 1:1 activity during the week of survey because he was conducting maintenance for the facility and was not able to complete the activities that were scheduled. During an interview on 11/02/23 at 10:12 AM, with the AD confirmed that he failed to provide consistent activities for the residents. The AD said he also worked doing the maintenance for the facility, and if something broke down, he had to repair it. The AD confirmed he did not follow the activity calendar during the week of the survey because he was called to do maintenance duties several times. He said that he improvised by doing a quick devotion or talk with the residents in the dayroom. The AD confirmed that he did not notify the residents or the Charge Nurse of the changes in the Activity schedule, but going forward they would be notified. He stated that he had made the activities calendar three (3) weeks ago and had not updated the calendar. He acknowledged the activities were not consistent. During an interview on 11/02/23 at 11:29 AM, the Administrator confirmed that the resident activities were not consistent, and that the AD also does maintenance work for the facility. The Administrator said that she was unaware that the resident activities were not being completed because the AD was doing maintenance duties and that she had hired a maintenance person who will begin employment with the facility next week.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide respiratory care consistent with professional standards of practice as evidenced by nebulizer mask and oxygen tubing for a resident (Resident #40) did not have a designated storage bag for two (2) of four (4) observations. Findings include: A review of the facility's policy, Infection Control Oxygen Equipment Cleaning revised 08/21 revealed Use disposable tubing, mask, and cannula's for patients receiving oxygen therapy .10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date . A review of the facility's policy Nebulizer, revised 10/17 revealed . Cleaning Nebulizers . 4 . Store in clean plastic bag . On 10/30/23 at 12:03 PM, during an observation and interview with Resident #40, she explained that she wore oxygen as needed and received breathing (nebulizer) treatments three times a day and once at night. There was an oxygen concentrator in her room in which oxygen tubing with a nasal cannula was stored on top of the oxygen concentrator. There was also a nebulizer machine and mask sitting on the resident's bed, and not in a plastic storage bag. An observation on 10/31/23 at 12:33 PM revealed a nebulizer machine and mask lying on the bed in Resident #40's room. There was also oxygen tubing draped on top of the oxygen concentrator. At 1:50 PM on 10/31/23, during an interview with Certified Nurse Aide (CNA) #5, she explained Resident #40 asked for assistance from the nurses when she needed a nebulizer treatment. CNA #5 said that the resident does not normally use her oxygen. CNA #5 confirmed the nebulizer machine and mask were lying on the resident's bed and the oxygen tubing with the nasal cannula was stored on top of the oxygen concentrator and not in a plastic bag. At 2:00 PM on 10/31/23, during an interview and observation with Licensed Practical Nurse (LPN) #1, she administered a nebulizer treatment for Resident #40. She confirmed the nebulizer mask was on the resident's bed and she used the same mask to administer the treatment. After completing the nebulizer treatment, LPN #1 placed the nebulizer mask and tubing in the top drawer of the nightstand. She did not place it in a storage bag. LPN #1 reported that Resident #40 did not wear oxygen continuously but only as she needed it for shortness of breath. She confirmed the oxygen tubing was stored on top of the concentrator but stated that it is usually in a clear bag. On 10/31/23 at 2:30 PM, during an interview with the Director of Nursing (DON), she explained all respiratory equipment, including oxygen tubing and nebulizer masks, were to be stored in clear bags. The purpose of storing the equipment in the bags was to prevent the equipment from falling on the floor and to prevent contamination. A record review of the Physician Orders for the month of November 2023, revealed Resident #40 had a Physician's Order, dated 9/13/23, for inhaled nebulization four times daily and a Physician's Order, dated 5/30/23, for Oxygen per nasal cannula as needed. A record review of the Face Sheet revealed the facility admitted Resident #40 on 09/30/21 with diagnoses that included Chronic Obstructive Pulmonary Disease. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/23, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.

Based on interview and facility policy review the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place in March 2021. This was for one (1) recited deficiency originally cited in March 2021 on an annual recertification survey. The deficiency was in the area of activities. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee. Findings Include: Review of the facility's, Quality Assurance Performance Improvement Program, revised 11/22, revealed .This facility shall develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The facility shall have in place a system that continuously strive to improve the quality of care and services received by residents in this facility .Objectives .each department shall institute outcome measurements designed to monitor effectiveness of established systems .Procedure .Many sources of information will be used in QAPI activities to include but not be limited to .State, Federal .surveys to prioritize and assign PIP's (Performance Improvement Projects) or corrective action plans as needed .Each department must identify the problem areas, investigate, and determine the probable cause, establish a plan of correction, and evaluate the outcome . F679 Based on observations, staff and resident interviews, record review, and the facility policy review, the facility failed to provide consistent activities for three (3) of 13 sampled residents. This has the potential to affect all residents that reside in the facility. Resident #23, Resident #27, Resident #32 F679 was also previously cited in March 2021 for failing to ensure activities were provided for the residents residing in the facility. An interview on 11/2/23 at 12:35 PM, with the Activity Director (AD), revealed that he did not attend QAPI meetings because he had been working in the Maintenance Department and did not have time. The AD stated that he was unaware the facility had received deficiencies for failing to provide activities during the previous annual survey in March of 2021 and that he had not read the previous survey information. The AD confirmed that he had not submitted activity reports to be reviewed by the Administrator. During an interview on 11/2/23 at 1:00 PM, with the Director of Nursing (DON), she said she became employed by the facility in July of 2023 and was not working at the facility during the previous annual survey in March of 2021. The DON stated that she had not read any information regarding the previous survey and was not aware of the previous citation regarding resident activities or the submitted plan of correction. The DON reported that the QAPI team had not discussed the Activities Program in their QAPI meetings. During an interview on 11/2/23 at 1:30 PM, the Administrator revealed she was not working at the facility during the last annual survey in March of 2021, but she was aware of the previous citation regarding resident activities. The Administrator confirmed that the QAPI team had not discussed the Activity Program or the previous survey deficiencies in the QAPI meetings. She explained that she felt as if the previous deficiency had been corrected and did not realize that the AD was performing maintenance duties. The Administrator stated that resident activities should have been completed before the AD assisted in the Maintenance Department.

Based on interviews, record review, and facility policy review, the facility failed to change a resident's suprapubic catheter as needed for leakage for one (1) of two (2) residents reviewed with indwelling catheters. Resident #1. Findings Include: Record review of the facility policy, Indwelling Catheterization, revised 11/17, revealed, .Catheters should only be inserted by licensed, adequately trained personnel. Supra-pubic catheters may be changed by a physician or a qualified professional nurse . Record review of the Face Sheet revealed the facility admitted Resident #1 on 5/19/22 with a diagnosis of Paraplegia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 8/22/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section H revealed Resident #1 had an indwelling catheter. Record review of Physician Orders for the month of November 2022 revealed, Resident #1 had a Physician's Order with an order date of 10/3/22 to Insert new 18 FR (French) 30 cc (centimeter) indwelling suprapubic catheter every month or as needed for leakage or dislodgment. Record review of Departmental Notes for Resident #1 revealed documentation by the Director of Nursing (DON) on 11/4/2022 at 4:21 PM, for Late entry: 11/3/2022 Resident suprapubic catheter changed by myself . On 11/8/22 at 10:45 AM, during an interview with Resident #1, he stated that his supra pubic catheter had been leaking for a few days and he reported it to Registered Nurse (RN) #1 who is the wound care nurse. RN #1 told him that she was not comfortable changing the suprapubic catheter and would notify the DON that the catheter was leaking and needed to be changed. However, the DON did not change the catheter until the next day when the Ombudsman came into the facility to visit him. He said it made him uncomfortable to have to lay on sheets that were wet with urine and it caused his room to smell bad. On 11/8/22 at 11:04 AM, during an interview with RN #1, she confirmed that Resident #1's supra pubic catheter was leaking on 11/2/22. She informed the DON on 11/2/22, but she (RN #1) did not follow up the same day to ensure that the leaking catheter had been changed. The DON did not change the catheter until 11/03/22. On 11/8/22 at 1:30 PM, during an interview with the Ombudsman, she confirmed that on 11/3/22, she visited Resident #1 and observed that his linens were wet up to his mid back area and there was a strong urine odor in his room. She immediately reported it to the DON and she changed his leaking suprapubic catheter that day (11/3/22). On 11/8/22 at 2:15 PM, during an interview with the DON, she confirmed that on 11/2/22, RN #1 reported that Resident #1's supra-pubic catheter was leaking and needed to be changed. She said the catheter wasn't changed on 11/2/22 due to miscommunication. The DON did not change the leaking catheter until 11/3/22. The DON commented that it is her expectation that the staff immediately change any catheters noted to be leaking.

Based on observation, interviews, record review and facility policy review, the facility failed to honor the resident's rights by not allowing them to smoke for three (3) of five (5) residents reviewed for smoking for Resident #15, Resident #24, and Resident #25. Findings include: Review of the facility's policy, Resident Rights, revised 11/2017, revealed all residents in long term care facility have rights guaranteed to them under Federal and state law. Residents residing in this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights Include: To participate in other activities, including social, religious, and community activities that do not interfere with rights of other residents. To reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Review of the facility's policy, Smoking Policies and Regulations, revised 04/2015, revealed residents are permitted to smoke in designated areas. This policy noted the staff will monitor residents for safety purposes during smoking. Review of the facility's list of smokers in the facility, dated 2/10/21, revealed five (5) residents were on the smoking list. Resident #15 Observation 02/09/21 at 09:59 AM of Resident #15 lying in bed watching television. Resident is alert an oriented, speech is clear, able to make needs known. During an interview on 02/09/21 at 09:59 AM, with Resident #15, revealed the facility has not allowed the residents to leave their rooms because they have two (2) COVID-19 positive residents on the COVID-19 unit. Resident #15 said he was told he could not smoke because all residents are quarantined. Resident #15 also said the nurse told him chew the nicotine gum to help with the sensation. Resident #15 said he refused the gum because he did not like it. Record review of the Comprehensive Care Plan, revised 12/10/20, revealed Resident #15 has a potential for injury related to smoking. Interventions included supervision with smoking and was prescribed nicotine gum. Record review of the Physician's Orders, dated 2/2021 revealed Resident #15 was ordered Nicotine four (4) milligrams (mg) chewing gum by mouth (PO) every (q) four (4) hours as needed (PRN) for nicotine cravings. Record review of Resident #15's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/17/20, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #24 During an interview on 02/09/21 at 09:53 AM with Resident #24, stated the facility refused to let the residents come out of the rooms to smoke. Resident #24 said the facility has two (2) COVID-19 positive residents on the COVID-19 unit. Resident #24 said the facility offered nicotine gum. Resident #24 also said she does not like being in the room all day with nothing to do. Resident #24 stated there is only so much on the television. Resident #24 stated she did not think it was fair. Record review of the Comprehensive Care Plan, revealed Resident #24 has potential for injury related to smoking. Record review of the Physician's Orders for Resident #24, dated 2/2021, revealed an order for Nicorette Chewing Gum, two (2) mg, two (2) pieces of gum PRN q four (4) hours to curb smoking cravings. Record review of Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/21, revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident is cognitively intact. Resident #25 During an interview on 02/09/21 at 09:45 AM with Resident #25, revealed she is tired of staying in her room. Resident #25 stated she tries to stay out of trouble. Resident #25 said she does not like to complain, but she doesn't like that nicotine gum. Resident #25 stated, if you stick your head out the door you are told to go back in your room. Resident #25 also stated the residents are not allowed to smoke because they are quarantined. The facility has two (2) residents that are positive for COVID-19 in the building. Resident #25 said both residents are on the COVID-19 Unit, which is closed. Resident #25 stated she doesn't understand why they could not socially distance and smoke. Record review of Resident #25's Physician's Orders, dated 2/2021, revealed an order for Nicorette chewing gum two (2) mg, two (2) pieces prn q four (4) hours, to curb smoking cravings. Record review of the Comprehensive Care Plan, revised 1/12/21, revealed Resident #25 has a potential for injury related to smoking. Record review of Resident #25's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/20, revealed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. During an interview on 02/11/21 at 11:14 AM, the Administrator confirmed the facility has not allowed the residents out of their rooms because two (2) residents tested positive and were placed on the COVID-19 unit. The Administrator also confirmed the residents were not allowed to smoke because of the positive residents on the COVID-19 unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review the facility failed to provide an ongoing activities program for five (5) of (14) sampled residents, Resident #28, Resident #32, Resident #15, Resident #24, and Resident #25. The facility's, Activity Programs and Activity Program Scheduling policy, revised 11/17, revealed the facility has a policy in place to provide an ongoing program of activities. Purpose: To assure that the activities program occurs within the context of each resident's comprehensive assessment and care plan, and is reflective of each resident's individual needs and interests. Resident #28 Record Review of the Face Sheet revealed Resident #28 was admitted on [DATE]. She has diagnoses to include Anxiety Disorder and Major Depressive Disorder. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/18/20, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Care Plan implemented 3/27/2014, revealed Resident #28 enjoys Bingo and other activities. Review of the activity documentation revealed, since 12/28/20 through 2/9/21, the facility documented one (1) activity on 1/27/21 and the next activity on 2/9/21. There were no other activities documented from 12/28/20 through 2/9/21. On 02/09/21, at 9:31 AM, during an interview, Resident #28 stated she was really tired of the COVID-19 quarantine. Resident #28 stated, We don't do anything but stay in our room. They don't come to our rooms and do any activities. On 2/9/21, at 1:45 PM, Resident #28 stated, We have not done any kind of activities for a while. I am tired of staying in my room. Resident #28 stated, proper name-Activities #1, is the activity director and she brought me a coloring book this past weekend. I enjoy Bingo. Sometimes I get in my bed and cry myself to sleep. I have major depression and it makes me feel depressed. On 2/10/21, at 1:12 PM, in an interview with Licensed Practical Nurse (LPN) #1, revealed Resident #28 usually would sleep until time for the 10:00 AM activity, which she attended. Then LPN #1 confirmed Resident #28 would sleep until time for the 2:00 PM activity and she would also attend that activity. LPN #1 stated Resident #28 is very social and loves Bingo. On 02/11/21, at 8:28 AM, Resident #28 was observed up in her wheelchair rolling herself in the hall. State Agency (SA) said, Good morning, you are out of your room. and Resident #28 replied, Yes, we have been freed. Resident #32 Record review of the Face Sheet revealed Resident #32 was admitted on [DATE], with diagnoses of Alzheimer's Disease, Major Depression, and History of Falls. Review of Resident #32's Annual MDS, with the ARD of 1/12/21, revealed a BIMS score of eight (8) which indicates moderate cognitive impairment. Review of Resident #32's Care Plan, dated 5/11/20, revealed Resident #32 has an identified concern of being at risk for social isolation. The interventions noted Resident #32 are to have an activity calendar in room, have one on one activities to include music, television (TV), conversation, touch therapy, and exercise. Further review of Resident #32's Care Plan identified a problem on 3/17/20 that Resident #32 was at risk for Psychosocial well-being concerns related to medically imposed restrictions related to COVID-19 restrictions. One of the interventions was to provide in room activities of choice. Review of the documentation of activities from 3/1/20 to 2/9/21 revealed there was no documentation of in room activities since 5/12/20. On 2/8/21 at 10:15 AM, Resident #32 was observed in bed under covers. On 2/8/21 12:23 PM, Resident #32 was observed standing in her room. On 2/8/21 at 12:40 PM, Residents #32 was in bed under the covers. On 2/9/21 at 8:00 AM, Resident #32 was observed in her bed with the covers over her head. On 2/9/21 at 12:30 PM, Resident #32 was observed in bed asleep. Review of Activity notes date 12/24/20 through 2/9/21, revealed there was no documentation of any activities for Resident #32. On 2/9/21 at 12:41 PM in an interview with Activities #2, revealed since May, she has been working part time, 3 to 4 days a week, only as a CNA. When she was asked when was the last time she conducted activities she replied, around May and then today. On 02/11/21 at 09:01 AM in an interview with CNA #1 revealed Resident #32 likes to color, visit, talk, and play Bingo. She really has been the same since we have been on lock down. On 02/11/21 at 09:05 AM in an interview with CNA #2 revealed residents likes to color. She stated her behaviors have been the same since we locked down for COVID-19. On 02/11/21 at 09:06 AM an unsampled resident was sitting by the Nurses' Station and stated, I am so glad to be out of my room, aren't you? This resident then sang, God Bless America, in a really loud voice. Resident #15 During an interview on 02/09/21, at 09:59 AM, with Resident #15, she stated the facility has not allowed them to leave their rooms because they have two (2) positive residents on the COVID-19 Unit. Resident #15 said the facility does not allow them to do any type of activities. Resident #15 said he is bored and going stir crazy. Resident #15 said he is tired of TV. Record review of the Comprehensive Care Plan revealed, Resident #15 should have social involvement with independent activities. Interventions are to post activity calendar where the resident can easily view, encourage to attend activities of choice, respect resident's choice in regard to limited/no activity, resident enjoys smoking and interaction with other residents during smoke times. Resident #15 is also care planned to be at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19 restrictions. Record review of Resident #15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/20, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #24 During an interview on 02/09/21, at 09:53 AM, with Resident #24, she confirmed the facility has quarantined the residents to their rooms. Resident #24 said she does not like being in the room all day with nothing to do. Resident #24 also said there is only so much on the television. Record review of the Comprehensive Care Plan, dated 1/4/21, revealed Resident #24 is at risk for social isolation and has the potential for mood state related to the diagnosis of Anxiety. Resident is at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19 restrictions. Resident #24 needs encouragement and assistance to attend activities. Resident #24's interventions are to place activity calendar in room, encourage self-initiated activities, one on one activities, music, TV, conversation, touch therapy, exercise,. provide residents with reading, invite resident to church, bingo, and group discussion. A review of Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/21, revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident is cognitively intact. Resident #25 During an interview on 02/09/21, at 09:45 AM, with Resident #25 revealed she is tired of staying in her room. Resident #25 said she makes every effort not to complain. Resident #25 also said if you stick your head out the door you are told to go back in your room. Resident #25 said both residents that are COVID-19 positive are on the COVID-19 Unit so she does not understand why they could not socially distance and smoke. Resident #25 said she is tired of watching TV. Resident #25 stated the facility has not provided activities since December. Review of the Comprehensive Care Plan revealed the Resident #25 needs encouragement and assistance to attend activities. The interventions are to place an activity calendar in Resident #25's room, encourage her to attend self-initiated activities, one on one activities, music, TV, touch therapy, exercise, provide resident with reading, invite the resident to church, bingo and group discussion and transport resident to activities. This Care Plan noted Resident #25 is at risk for social isolation. Resident #25 has a potential for altered mood state related to the diagnosis of Schizophrenia. Resident is at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19 restrictions. A review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/20, revealed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. On 2/9/21 at 2:00, PM, an interview with the Administrator and LPN #2/Staff Development Nurse revealed when asked to speak to the Activity Director, they stated Activity #1 currently works nights from 7 PM to 7 AM because she is the CNA for the COVID-19 unit and is currently at home asleep. On 2/10/21 at 8:15 AM, in an interview with Activity #1, revealed she has been the Activity Director since the end of September/first of October. She stated I am not a certified Activity Director and because of COVID-19 they have not been able to send me for training. I have been working on the COVID-19 Unit as a Certified Nursing Assistant (CNA) on the COVID-19 Unit and I usually work 7:00 PM to 7:00 AM. When asked who does the activities while you are working on the COVID-19 as the CNA she stated, whoever has time, sometimes the dietary staff. Asked where the activity documentation is kept when they do the activities, she replied they document it on paper or in a notebook and I keep the notebook with me in my car. Asked about Resident #32, she stated she likes to socialize and likes to come and sit in Bingo and watch. She stated Resident #32 also enjoys talking with her roommate and I. Asked a second time where the documentation for Resident #32 activities is because there is no documentation since December 2020 in her chart and she replied it should be in Resident #32's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to follow Standard Infection Control Precautions related to removing gloves and performing hand hygiene prior to applying a dressing to a wound to prevent the possible spread of infection for two (2) of three (3) wound care observations. [Resident #14 and Resident #24] Findings Include: The facility's, Standard Precautions, revised June 2014, General Infection Prevention and Control Nursing Policies revealed it is the policy of this facility that all nursing activities will be performed in a manner to minimize the potential for infection in residents, staff, and visitors. The facility's, Dressing Change Policy and Procedure, dated March 2018, noted for staff to perform hand hygiene, put on disposable gloves, remove dressing, pull gloves over dressing and discard into appropriate plastic waste bag. Perform hand hygiene, put on disposable gloves, cleanse the area as ordered, remove gloves, perform hand hygiene, apply disposable gloves, dress the areas as prescribed, and perform hand hygiene. Resident # 14 On 02/10/21, at 9:22 AM, Registered Nurse (RN) #1 was observed, during Percutaneous Endoscopic Gastrostomy (PEG) tube care, using her soiled gloves to apply a clean dressing. She failed to remove her soiled gloves, perform hand hygiene and don (put on) clean gloves prior to the application of the clean dressing. On 02/10/21, at 1:30 PM, interviewed RN #1 stated she should have washed her hands and applied new gloves after she cleaned the PEG tube site, prior to putting on clean dressing. On 2/11/21 at 9:00 AM in an interview with License Practical Nurse (LPN)/Infectious Preventionist (IP) #2, confirmed RN #1 should have wash hands and changed gloves prior to putting on the clean dressing. LPN/IP #2 revealed by not washing hands and putting on clean gloves could cause contamination of the wound. Record review of the Face Sheet revealed Resident #14 was admitted to the facility on [DATE], with the diagnosis of Epilepsy, Gastrostomy, Dysphasia, Anxiety, Chronic Obstructive Pulmonary Disease, Parkinson Disease, Chronic Kidney Disease, Hypertension, and Gastro-Endo Esophageal Reflux. Record review of the Physician Orders for Resident #14, dated 2/9/21, revealed an order to cleanse the PEG site with saline, place a split gauze under the PEG daily and secure with paper tape. Record review of the Comprehensive Minimum Data Set (MDS) for Resident #14, with an Assessment Reference Date (ARD) of 11/27/20, revealed the MDS was coded in Section K-K0510B2 and was checked for a feeding tube. Record review of the Care Plan for Resident #14 revealed the resident has a feeding tube with interventions to cleanse the PEG site with saline and place a split gauze under the PEG daily and as needed. Resident #24 On 02/10/21, at 9:30 AM, during the Nephrostomy Site Wound Care for Resident #24, Registered Nurse (RN) #1 cleansed the overbed table, let the overbed table dry, and brought supplies in room. RN #1 was observed to provide site care but did not wash or sanitize her soiled hands and did not apply clean gloves between the dirty and clean dressing. RN #1 used the soiled gloves to apply the clean dressing around the Nephrostomy Site Wound. On 02/10/21 at 1:30 PM, during an interview RN #1 stated she should have washed her hands and applied new gloves after she cleaned the Nephrostomy Tube Site, prior to applying the clean dressing. Record review of the Face Sheet revealed Resident #24 was admiited on 1/4/21 with the diagnosis of Acute Pyelonephritis, Abnormal Weight Loss, Cirrhosis of Liver, Cognitive Communication Deficit, Weakness, Anxiety, Hypertension, Type 2 Diabetes Mellitus, Urine Tract Infection (10/23/20), Viral Hepatitis, and Centrilobular Emphysema. Record review of the Physician Orders for Resident #24 dated 1/5/21, revealed an order to cleanse the Nephrostomy Site to the Right Flank Daily with Saline, Cover with split Gauze and secure with paper tape. Record review of the Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 1/11/21, revealed under section H0100c: Appliances, that the ostomy was checked. Record review of the Care Plan for Resident #24 dated 1/4/21, revealed Resident #24 has a Nephrostomy tube with the interventions to cleanse the nephrostomy site on the right flank daily with saline, cover with a split gauze and secure with paper tape. On 02/10/21, at 2:00 PM, during an interview with the DON revealed the wound care nurse should have followed the facility's infection control policy and changed her gloves and washed her hands at least the minimum of three (3) times. The DON revealed this would be an infection control issue that could cause wound infection if a nurse does not apply a clean dressing with clean hands and gloves. On 2/11/21, at 9:00 AM, during an interview LPN/IP #2, she confirmed RN #1 should have wash hands and changed gloves prior to putting on the clean dressing. LPN/IP #1 revealed by not washing soiled hands and putting on clean gloves could cause contamination of the site. Record review of an in-service on Infection Control on 7/20/21, revealed RN #1's signature was on the Infection Control Orientation Checklist.