**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number NAC 175 12-006.12(A) Based on interview and record review the facility failed to provide an indication and rationale for the use a prophylactic antibiotic for one (Resident 17) of three residents. The facility identified a census of 63. Findings are: A record review of the facility's Antibiotic Stewardship Policy dated July 2022 revealed the infection preventionist will monitor individual resident antibiotic regimens including: a. Reviewing clinical documentation supporting antibiotic orders b. Compliance with start/stop dates and/or days of therapy A record review of an admission face sheet for Resident 17 revealed the resident was admitted to the facility on [DATE]. A record review of a Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/13/25 revealed in Section C that Resident 17 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15, indicating the resident was cognitively intact. Section H revealed that Resident 17 had a foley catheter (a thin, flexible tube inserted into the bladder to drain urine). Section N revealed that Resident 17 was on an antibiotic. A record review of Resident 17's diagnosis list revealed the following diagnoses: -Benign prostatic hyperplasia with lower urinary tract symptoms (a condition where the prostate gland, located below the bladder in men, enlarges with age). -Calculus in bladder (a hard, mineral deposit that forms in the urinary bladder). -Personal history of urinary tract infections (an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra). -Obstructive and reflux uropathy (a condition where urine flow is blocked within the urinary tract, causing urine to back up and potentially damage the kidneys). A record review of Resident 17's physician orders dated 2/11/25 revealed an order for: Cephalexin Oral Capsule 500 milligrams (mg) (an antibiotic- medications used to treat bacterial infections); give one capsule by mouth one time a day for prophylactic with a start date of 11/22/24. An interview on 2/11/25 at 10:42 AM with Registered Nurse (RN)-A confirmed that Resident 17 was taking the antibiotic prophylactically but RN-A was unsure why. RN-A revealed that Resident 17 had an artificial bladder and had a history of complications as a result of that, including urinary tract infections. RN-A revealed that the antibiotic was ordered by the urologist (a doctor who specializes in diagnosing and treating conditions of the urinary tract and reproductive system). RN-A confirmed that the order did not have a clear indication, diagnosis, or stop date and was not being reviewed by the pharmacist or physician for a rationale for its continuation. An interview on 2/12/25 at 2:45 PM with Director of Nursing (DON) confirmed that Resident 17's use of a prophylactic antibiotic did not have a duration and was not reviewed with a rationale for its continuation. The DON confirmed that it should have been.

Licensure Refeference Number 175 NAC 12-006.09 Based on observation, interviews and record review, the facility failed to implement measures for a contracture of the left hand for 1 (Resident #26) of 1 sampled resident. The facility census was 63 Finding are: Record review of Resident #26's Electronic Medical Adminstration Record (EMAR a legal record of the medications administered to a patient at a facility by a health care professional) for the month of January 2024 revealed Resident #26's admission date was 10/3/19. Record review of Resident #26's EMAR for the month of January 2024 revealed Resident #26's had a diagnosis of unspecified intracranial injury with loss of consciousness of unspecified duration, sequela. Record review of Resident #26's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 10/26/23 revealed Resident #26 had a Brief Interview for Mental Status (a test used to get a quick snapshop of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) score of 0 which indiciated the resident was severely cognitivley impaired. Resident #26's MDS revealed [gender] required moderate assistance with dressing and maximum assitance with personal hygiene. Record review of Resident #26's Care Plan revealed the resident had an intervention to apply a green hand splint to the left hand as ordered. Record review of Resident #26's EMAR for the month of January 2024 revealed an order to apply a palm pillow to the resident's left hand in the morning and remove it at night. The EMAR also indiciated the palm pillow may be removed during meals. The EMAR revealed the left palm pillow was applied on 1/22/2024-1/24/2024. An observation on 1/22/24 at 2:55 PM revealed, Resident #26 was sitting in [gender] recliner and looking forward. The palm pillow was not in/on Resident #26's left hand. An observation on 1/23/24 at 10:13 AM of Resident #26 revealed the resident did not have the palm pillow in [gender] left hand. An observation on 1/23/24 at 1:30 PM revealed Resident #26 was sitting in the recliner watching TV with no palm pillow in the left hand with their left hand closed tight. An observation on 1/24/24 at 10:00 AM revealed Resident #26 was in the Sensory Room with other residents and staff without the palm pillow in their left hand. An interview on 1/24/24 at 11:04 AM with Nursing Aide (NA)-B confirmed that the palm pillow should be on Resident #26. NA-B confirmed the night shift staff assisted Resident 26 in getting up for the day and NA-B failed to check and/or place Resident 26's left hand palm pillow. An interview with the Director of Nursing at 11:45 AM on 1/24/24 confirmed that resident should have the palm pillow on and the aide should have done this.

Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, interviews, and record review, the facility failed to implement interventions and ensure the resident's environment was free from accident hazards to reduce the risk of falls. This affected 1 (Resident 472) of 3 sampled residents. The facility had identified a census of 63 at the time of the survey. Findings are: A record review of Resident 472's Face Sheet revealed the resident admitted into the facility on 1/8/2024 with diagnoses of: fracture of left ilium, strain of left quadricep muscles, pain in bilateral hips, dementia, depression, and hypertension. A record review of Resident 472's admission Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 1/15/2024 revealed Resident 472 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident 472 had severe cognitive impairment. The MDS also revealed Resident 472 had impairment of his left lower extremities and used a walker and wheelchair. The MDS also revealed Resident 472 required max assistance with oral hygiene, toileting, bathing, dressing, personal hygiene, transfers, and repositioning. The MDS also revealed Resident 472 had a fall history prior to admission and had sustained one fall since admission. The MDS also revealed Resident 472 had a bed and chair alarm in use daily. A record review of Resident 472's Care Plan, dated 1/9/2024, revealed safety interventions due to falls at home that had included keeping the bed in low position, bed and chair alarms, and non-slip footwear. The Care Plan also noted a fall on 1/10/2024 with an intervention to implement anti-lock brakes on the wheelchair. Resident 47'2 Care Plan revealed the resident was on high-risk medication with a possible adverse side effect of dizziness. The Care Plan revealed barriers to Resident 472 being able to discharge as dementia, confusion, weakness, and impaired mobility. An observation on 1/23/2024 at 1:15 PM revealed Resident 472 had on regular white socks and Resident 472's walker and wheelchair were across the room, not within reach. An observation on 1/23/2024 at 2:48 PM revealed Resident 472 had on regular white socks and the walker and wheelchair remained not within reach. An observation on 1/24/2024 at 9:59 AM revealed Resident 472's bedside table containing the call light and water were not within reach. The observation also revealed Resident 472's walker and wheelchair were also not within reach. An observation on 1/24/2024 at 2:43 PM revealed Resident 472's bedside table to be close, but the call light was positioned in the furthest corner away and not within Resident 472's reach. Resident 472's walker and wheelchair were also not within reach. Resident 472 was wearing regular white socks. An interview on 1/24/2024 at 3:03 PM with Nurse Aide (NA) -G revealed that NA-G was aware of where to find resident Care Plans. NA-G confirmed Resident 472 needed to have the bed in low position and supervision to prevent falls, but was unaware of any other interventions in place. An interview on 1/24/2024 at 3:05 PM with Medication Aide (MA)-H revealed MA-H was not aware of Resident 472 having any fall intervention in place but was aware of the interventions being located in the Care Plans. An interview on 1/24/2024 at 3:08 PM with Licensed Practical Nurse (LPN)-I confirmed LPN-I was the nurse responsible for overseeing Resident 472's care. LPN-I revealed the process of rounding on residents to ensure staff were implementing appropriate fall interventions but stated I haven't been over on [specific hall] much today because I have been dealing with another resident on another hall. A record review of the facility's Call Light Policy with a revision date of 11/2021, under section General Guidelines, read When the resident is in bed or confined to a chair be sure the call light is within easy reach. An interview on 1/25/2024 at 8:34 AM with Registered Nurse (RN) -N revealed RN-N conducts spot auditing after breakfast and rounding every two hours to ensure resident's interventions are in place. The interview also revealed RN-N's expectation would be to keep wheelchairs and walkers nearby if not specified otherwise on the care plan.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to implement the required infection prevention and control practices while administering medications to 3 (Residents 25, 28, and 466) of 4 sampled residents. The facility census was 63. The findings are: A. An observation of medication administration on 1/24/24 from 7:23 AM to 7:34 AM revealed Registered Nurse (RN)-J performed hand hygiene (HH) with Alcohol Based Hand Rub (ABHR) at the medication cart, then RN-J took a printed copy of Resident 28's insulin orders and the resident's plastic storage container (which contained supplies for insulin administration) into the resident's room and closed the door. RN-J put on gloves and opened the plastic storage container. RN-J then stated they needed additional supplies, opened the door to the room, obtained a syringe and safety cap from the supply cart in the room next to the resident's room, went back into the resident's room and closed the door with their gloved hand. RN-J then prepared and administered the required doses of insulin to the resident while continuing to wear the same pair of gloves. RN-J then removed their gloves, disposed of trash and syringes in the required receptacles and performed HH via ABHR. A continued observation of medication administration on 1/24/24 from 7:23 AM to 7:34 AM revealed RN-J obtained Resident 466's plastic storage container (which contained supplies for insulin administration) and a printed copy of the resident's insulin order and took them into the resident's room, closing the door behind them. RN-J performed hand hygiene (HH) with Alcohol Based Hand Rub (ABHR) in the resident's room and put gloves on. After reviewing the resident's insulin order and opening the plastic storage container, RN-J stated they needed additional supplies. RN-J opened the door to the resident's room, obtained a syringe from the supply cart in the room next to the resident's room, went back into the resident's room and closed the door with their gloved hand. RN-J then prepared and administered the required dose of insulin to the resident while continuing to wear the same pair gloves. RN-J then removed their gloves, disposed of trash and syringes in the required receptacles and performed HH via ABHR. An interview on 1/24/24 at 2:30 PM with RN-J confirmed RN-J did not remove their gloves prior to opening Resident 28's door and obtaining a syringe and safety cap from the supply cart in the room next to the resident's room and that RN-J continued to wear the same gloves after returning to the resident's room while preparing and administering Resident 28's insulin. RN-J also confirmed RN-J did not remove their gloves prior to opening Resident 466's door and obtaining a syringe from the supply cart in the room next to resident's room and that RN-J continued to wear the same gloves after returning to the resident's room while preparing and administering Resident 466's insulin. A record review of facility policy Standard Precautions Policy and Procedures dated 08/2023, Section 2. revealed Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. B. An observation of medication administration performed by Medication Aide (MA)-K on 1/24/24 from 7:36 AM to 8:00 AM revealed MA-K at the medication cart outside the dining room with Resident 25's Medication Administration Record (MAR) pulled up on the computer screen. MA-K compared each medication label to the MAR and popped each into a plastic medication cup. Once MA-K had all medications for Resident 25 in the medication cup, the medication cart was locked, and the computer screen was cleared. MA-K performed hand hygiene (HH) with Alcohol Based Hand Rub (ABHR), then took the medications to the resident at their table in the dining room. MA-K handed the medication cup to the resident who poured some of the medications into their own hand, placed the cup with the remaining medications on the table and swallowed the medications from their hand with water. The resident then poured more medications into their own hand from the cup and again sat the cup on the table. The resident dropped one of the pills from their hand into the seat of their wheelchair. MA-K picked the pill up with their bare hand and placed the pill into the resident's hand. Resident 25 then put the pill in their mouth and swallowed it with water. MA-K threw away the empty medication cup, performed HH with ABHR, and documented the medications as administered in the resident's MAR. An interview on 1/24/24 at 7:56 AM with MA-K confirmed MA-K did pick up one of Resident 25's pills with their bare hand when the resident dropped the pill onto their wheelchair seat and placed the pill back into the resident's hand.

Licensure Reference Number 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to follow a recipe in a method to preserve nutritive value. This had the potential to affect all residents who consumed these meals. The facility had identified a census of 63 at the time of survey. Findings are: A continuous observation of meal preparation of Smothered Pork Chops on 1/24/2024 at 8:43 AM to 9:20 AM prepared by Dietary Aide (DA)-F revealed the following: - DA-F had seasoned porkchops with an unmeasured amount of black pepper and garlic - DA-F had filled a pot with an unmeasured amount of water then had placed on the stove to bring it to a boil - DA-F had cut an unmeasured amount of onions and then added the onions into the pan with hot water - DA-F had added an unmeasured amount of an opened bag, approximately ¼ remaining of the bag, of Pork Roast Gravy Mix into the boiling water and onions - DA-F had added an entire second bag of Pork Roast Gravy Mix into the boiling water with the first gravy mix and onions - When DA-F had been asked about the measurements, DA-F obtained a measuring cup out of drawer, but did not use it and later put it back into drawer - DA-F had not had a recipe open or available for reference during meal preparation An interview on 1/24/2024 at 8:55 AM with DA-F revealed a measurement of just a little bit of seasoning for the porkchops. An interview on 1/24/2024 at 9:23 AM with the FSS confirmed there was a recipe for the Smothered Porkchops to follow and had provided a copy. A record review of the facility provided recipe for Smothered Pork Chops revealed measurements for 20 servings included ¾ teaspoon of salt, ½ teaspoon of black pepper, 2 ½ tsp of garlic powder, ¾ teaspoon of thyme, ¾ teaspoon of rosemary, and ¾ each of yellow onion. A record review of the label of the Pork Roast Gravy Mix revealed directions to add 11.3 ounces of gravy mix to 4 quarts of water. The label also revealed each bag was 11.3 ounces. An observation of meal preparation of tacos on 1/24/2024 at 9:15 AM by DA-F revealed DA-F had dumped taco seasoning into a 1-cup measuring cup over already cooked ground beef. DA-F had overfilled the measuring cup and had caused the seasoning to overflow onto the ground beef below. A record review of the taco seasoning label read to brown ten pounds of ground then stir in 2 cups of taco seasoning.

Licensure Reference Number 175 NAC 12-006.04D2a Based on an interview and record reviews, the facility failed to have a qualified Dietary Manager. This had the potential to affect all residents. The facility identified a census of 63 at the time of survey. Findings are: A record review of the Hillcrest Nursing Home Facility Assessment Tool with a date of 8/8/2017, under Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies read: Food and nutrition services - Director - 1 (40 hours) support staff - 8 day registered dietician - 2 days/week. A record review of the Hillcrest Nursing Home Job Description for Dietary Director, with a revised date of 12/15, read the qualifying include currently certified as dietary manager or completed a course in dietary management or equivalent or be a registered dietician . An interview on 1/24/2024 at 12:10 PM with the Registered Dietician (RD) confirmed the RD is not full time and the Food Services Supervisor (FSS) is not certified at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC12-006.11E Based on observations, interviews, and record review, the facility kitchen staff failed to store food under sanitary conditions, complete hand hygiene while preparing and serving food, and maintain proper freezer temperatures to keep frozen foods solid. This had the potential to affect all residents. The facility identified a census of 63 at the time of the survey. Findings are: A. An observation during the initial kitchen tour on 1/22/2024 beginning at 12:41 PM of the storage room revealed the following: - 1 bag of Trio cheese sauce mix - the bag had been damaged and was spilling out the light yellow powder contents - 1 Knorr [NAME] sauce mix which had been left open to air and other possible contaminant did not have an opened on date or use by date - 5 bags of Hospitality Mini Marshmallows with a best by date of 12/1/23 - 1 container of Kosher Pickle Chips with a best by date of 8/28/2023 - 4 Karo Syrup containers with best by dates of 12/2/23 - 1 Sahara Burst Pineapple Juice with a best by date of 12/6/23 - Cleaning supplies stored on a shelf within the food storage area An observation during the initial kitchen tour on 1/22/2024 beginning at 12:41 of the reach-in-refrigerator revealed the following: - 1 squeeze bottle of Ranch without a preparation or use by date - 1 squeeze bottle of [NAME] Lynch without a preparation or use by date An observation during the initial kitchen tour on 1/22/2024 beginning at 12:41 of the walk-in refrigerator revealed the following: - 1 opened package of roast beef in a clear Ziploc bag without an opened on or use by date - 1 clear package containing five boiled eggs without an opened or use by date - 1 carton of grape juice with a best by date of 11/25/23 - 1 carton of pineapple juice with a best by date of 1/9/23 - 1 roll of ground beef mix thawing on a shelf above juices and sauce mixes A record review of the Nebraska Food Code 2017, section 3-501.17 (A) revealed Except when packaging food using a reduced oxygen packaging method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . A record review of the undated facility's policy Storage of Food and Supplies included food storage area should be used for food only, cleaning supplies should be store in entirely separate and specific areas, all food will be dated - month, date, and year, and no food will be kept longer than the expiration date on the product. B. An observation on 1/23/2024 at 11:08 AM revealed Dietary Aide (DA)-M had entered the kitchen, prepared the resident drinks while touching the rim of each cup without the benefit of hand hygiene prior to initiating the task. An observation on 1/23/2024 at 11:18 AM revealed DA-M had entered the kitchen and had began to fill dressing bottles without the benefit of hand hygiene prior to initiating the task. A continuous observation on 1/24/2024 beginning at 8:43 AM revealed DA-F had disposed of a bag that had contained juices from raw porkchops then had grabbed an onion from the refrigerator, DA-F then proceeded to cut the onion up without having performed hand hygiene between the food preparation tasks. The continuous observation also revealed two other occurrences of DA-F having completed hand hygiene practices of 14 seconds and 18 seconds during food preparation. An observation on 1/24/2024 at 11:43 AM revealed DA-E had completed washing dishes and then assisted with serving food without the benefit of performing hand hygiene between tasks. A record review of the Nebraska Food Code 2017, section 2-301.14 read Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation. A record review of the Center for Disease Control article Handwashing: A Healthy Habit in the Kitchen, last reviewed on 7/18/2022, listed recommendations to scrub hands for at least 20 seconds for the most effective benefits of hand washing. A record review of the facility's policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices with a revision date of 11/2023 included employees must wash their hands whenever entering or re-entering the kitchen, before coming in contact with any food surfaces, after handing raw meat, and during food preparation to prevent cross contamination when changing tasks. C. An observation on 1/24/2024 at 9:17 AM revealed the freezer temperature was 28 degrees. An interview on 1/24/2024 at 9:23 AM with the Food Services Supervisor (FSS) revealed the freezer had not been working and a maintenance request was placed on 1/15/2024. The FSS revealed Pardes, a refrigeration repair company, had been out on 1/16/2024 and would be out again today. An observation on 1/24/2023 at 9:45 AM revealed food in the freezer, including ice cream and breaded corn dogs were no longer solid. The temperature was 38 degrees in the freezer. An interview on 1/24/2024 at 9:45 AM with the Registered Dietician (RD) confirmed the ice cream was no longer solid. The RD also confirmed the temperature was 38 degrees and stated the temperature was rising quickly to the danger zone. An interview on 1/24/2024 at 9:54 AM with the Administrator revealed the Administrator was aware of the freezer problem and had a plan to move items to downstairs freezer or to another facility if needed. An observation on 1/24/2024 at 12:24 PM revealed the temperature of the freezer was 40 degrees. The observation also revealed no measures to relocate the food in the freezer had been completed. A record review of the undated facility's policy Procedure for Freezer Storage included the freezer should be maintained at a temperature of 0° Fahrenheit (F) to -10° F. A record review of the facility's Refrigerator and Freezer Temperature Record with a date of January 2024 had directions of 2) If temperatures are not within range, recheck within the next 30 minutes. If still not within range notify [NAME] (Person in charge) and follow policy. Document on back of dorm date, time, who you notified, and what was done. The document also revealed had recorded temperatures of: - +7 on 1/12/2024 at 5:30 AM, - +16 on 1/12/2024 at 9:00 PM, - +8 on 1/13/2024 at 5:30 AM, - +16 on 1/13/2024 at 9:00 PM, - +9 on 1/14/2024 at 5:30 AM, - +15 on 1/14/2024 at 8:00 PM, - +20 on 1/15/2024 at 7:30 AM, - +15 on 1/15/2024 at 8:00 PM, - +19 on 1/16/2024 at 5:30 AM, - +15 on 1/16/2024 at 6:00 PM, - +18 on 1/17/2024 at 5:30 AM, - +15 on 1/17/2024 at 8:00 PM, - +20 on 1/18/2024 at 5:30 AM, - +16 on 1/18/2024 at 8:00 PM, - +18 on 1/19/2024 at 5:30 AM, - +15 on 1/19/2024 at 8:00 PM, - +7 on 1/20/2024 at 5:30 AM, - +15 on 1/20/2024 at 8:00 PM, - +8 on 1/21/2024 at 5:30 AM, - +16 on 1/21/2024 at 8:00 PM, - +18 on 1/22/2024 at 5:30 AM, - +20 on 1/22/2024 at 8:00 PM, - +19 on 1/23/2024 at 5:30 AM, - +20 on 1/23/2024, - +20 on 1/24/2024 at 5:30 AM. The document revealed the temperature was 39 at an undetermined time in the PM slot on 1/24/2024. The back of the document revealed no documentation of date, time, who was notified, and what had been done to correct out of range temperatures.

Licensure Reference Number 175 NAC 12-006.17A Based on observation, interview, and record review, the facility failed to provide a sanitary environment by failing to ensure all staff were informed regarding COVID positive residents' quarantine status. This had the ability to affect all residents. Facility census was 43. Record review revealed Resident #22 tested positive for COVID on Friday, 11/25/2022. Record review also revealed Resident #22 was to be in quarantine from Friday, 11/25/2022 through Friday 12/2/2022. On 11/28/2022 an observation revealed Resident #22 was walking down a resident hallway with no mask in place and no staff escort. Resident #22 was stopped in the hallway by NA-C (Nurse Assistant-A) beside the Social Service office. NA-C stated to Resident #22, I'll check to see if you can come out. You just stay right there. Stay right there. I'll go check. Resident #22 was left standing in the hallway by the Social Service office with no PPE (Personal Protective Equipment) in place. Continued observation revealed NA-C returned to where Resident #22 continued standing in the hallway. Resident #22 was escorted back to the resident room by NA-C. On 11/30/22 an interview with NA-C revealed the status of quarantine for Resident #22 had not been communcated to the front line staff to ensure the front line staff were aware of Resident #22's quarantine status. The interview revealed the resident was still in quarantine until Friday 12/2/2022 per the facility COVID policy/procedure/protocol. An interview with the Infection Preventionist confirmed the resident was allowed to stand in the hallway by the Social Service office without a mask in place and while under COVID quarantine. The interview also confirmed quarantine for Resident #22 was to be through Friday 12/2/2022 due to the resident testing positive for COVID on Friday 11/25/2022. The interview also confirmed the status of the quarantine for Resident #22 was unknown due to lack of clear and up to date information delivered to the front line staff in a timely manner. An interview with the Director of Nursing confirmed Resident #22 was allowed to stand in the hallway be the Social Services office without any personal protective equipent in place and while under COVID-19 quarantine. The interview verified the quarantine for Resident #22 was to be through Friday 12/2/2022 due to the resident testing positive for COVID on Friday 11/25/2022. The Director of Nursing verified that the quarantine status for Resident was unclear to front line staff which led to Resident #22 being left standing in the hallway unsupervised while staff verified the residents COVID quarantine status. An interview with the Administrator verified that lack of clear and up to date information regarding the COVID/quarantine status of Resident #22 led to the resident being left in the hallway alone without a mask in place while staff verified the residents COVID/quarantine status.