Based on interview and record review, it was determined that the facility failed to report an injury of unknown source timely to the State Survey Agency (SSA) for 1 of 2 residents reviewed for accidents in a final sample of 24 residents (Resident identifier is #7). Findings include: Review on 5/30/25 of Resident #7's medical records revealed a nurses note, dated 5/25/25, that stated Resident #7 had been sent to the emergency room for evaluation due to complaints of right wrist pain. Further review of Resident #7's medical record revealed a nurses note, dated 5/26/25, .brace for right wrist fx (fracture) .can be worn as long as needed for comfort and support. No other acute findings . Interview on 5/30/25 at approximately 9:00 a.m. with Staff A (Administrator) revealed that they were told about Resident #7's injury on 5/26/25. Staff A revealed that the source of the injury is unknown. Staff A confirmed that it was not reported to the SSA. Review on 5/3/25 of facility policy titled Abuse Prohibition, dated 1/24/22, revealed: 6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected . 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will perform the following. 7.3 Report allegations the the appropriate stated and local authority(s) involving .exploitation or mistreatment (including injuries of unknown source) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6 Review on 5/30/25 of Resident #6's care plan meeting notes revealed that Resident #6 had care plan meetings on 11/29/24 and 1/10/25. There was no evidence of a quarterly care plan meeting documented after 1/10/25. Resident #22 Interview on 5/28/25 with Resident #22 at approximately 11:30 a.m. revealed that Resident #22 reported that he/she had was not invited or participated in a care plan meeting for about 6 months. Review on 5/30/25 of Resident #22's care plan meeting notes revealed that Resident #22 had a care plan meeting on 11/27/24. Interview on 5/30/25 at approximately 10:50 a.m. with Staff D (Regional Nurse) confirmed that there is no evidence of quarterly care plan meetings being completed after 11/27/24. Resident #23 Review on 5/30/25 of Resident 23's care plan meeting notes revealed that Resident #23 had a care plan meeting on 9/7/24 and 5/1/25. Further review revealed that there was no evidence of a quarterly care plan meeting documented in December of 2024 or March of 2024. Resident #29 Review on 5/30/25 of Resident #29's medical record revealed that Resident #29 was admitted to the facility on 9/22. Further review revealed that the last documented care plan meeting was on 3/15/24. Resident #57 Review on 5/30/25 of Resident #57's medical record revealed revealed that Resident #57 was admitted in date December of 2024. There was no evidence of care plan meetings being held. Resident #73 Review on 5/30/25 of Resident #73's medical record revealed that Resident #73 was admitted to the facility on [DATE]. Further review of Resident #73's medical record revealed that the last documented care plan meeting was 12/16/24. Resident #80 Review on 5/30/25 of Resident #80's care plan meeting notes revealed that Resident #80 had a care plan meeting on 11/8/24 and 5/8/25. Further review revealed that there is no evidence of a quarterly care plan meeting documented after 11/24 and before 5/25. Resident #86 Review on 5/30/25 of Resident #86's medical record revealed that Resident #86 was admitted to the facility on [DATE]. Further review of Resident #86's medical record revealed no documentation of a care plan meeting. Resident #94 Review on 5/30/25 of Resident #94's medical record revealed Resident #94 was admitted to the facility in January 2024. There was a care plan meeting note dated 4/23/25. Further review revealed that there was no documentation of a care plan meeting for Resident #94 between January 2024 and 4/23/25. Interview on 5/30/25 at approximately 1:00 p.m. with Staff H (Unit Manager) confirmed the above findings and that there was no documentation of a care plan meeting for Resident #94 prior to 4/23/25. Resident #105 Review on 5/30/25 of Resident #105's was admitted on [DATE] and has not had a care plan meeting. Interview on 5/30/25 at approximately 1:30 p.m. with Staff A (Administrator) confirmed that there was no evidence documented of care plan meetings being held after a comprehensive assessment for Resident #6, #22, #23, #29, #57, #73, #80, #85, #86, #94, and #105. Review on 5/30/25 of the facility's Policy OPS416: Person- Centered Care Plan revealed the following . The care plan will be reviewed and revised by the interdisciplinary team after each assessment 10. Care plan meetings will be documented by use of the Care Plan Meeting note. Based on record review and interview, it was determined that the facility failed to hold routine interdisciplinary care plan meetings and revised care plans for 11 of 24 residents reviewed for care planning in a final sample of 24 residents. (Resident identifiers are #6, #22, #23, #29, #57, #73, #80, #85, #86, #94, and #105.) Findings include: Resident #85 Interview on 5/30/25 at approximately 11:30 a.m. with Staff G (Registered Nurse) revealed Resident #85 eats everything given to him/her, will eat clothing and they are unable to give him/her anything or Resident #85 will put it in his/her mouth. In the past they tried foam blocks and Resident #85 tore at them and tried to eat those. Interview further revealed Resident #85 had past surgery to remove a bottle cap he/she had eaten prior to admission. He/she gets one on one throughout the day by all staff and has a private room due to his pica (Pica is a mental health condition where a person compulsively swallows non-food items.) Review on 5/30/25 of Resident #85's care plans revealed no interventions to address Resident #85's pica. Review on 5/30/25 of Resident #85's care plan meetings revealed evidence of only one care plan meeting held on 12/23/24, since admission.

Based on record review, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 3 out of 7 residents reviewed for controlled drugs (Resident Identifiers are #2, #6, and #7). Findings Include: Resident #7 Review on 10/1/24 of the controlled drug record for the Opechee Cart #1 for Resident #7's Diazepam 10 milligram (mg) tablets revealed that there were 22 tablets remaining on 9/30/24 at 8:20 a.m. Observation on 10/1/24 at approximately 9:20 a.m. with Staff A (Registered Nurse (RN)) of Resident #7's Diazepam 10 mg medication card revealed that there were 21 tablets remaining in the medication card. Interview on 10/1/24 at approximately 9:21 a.m. with Staff A confirmed the above findings. Resident #6 Review on 10/1/24 of the controlled drug record for Winnisquam D Cart for Resident #6's Clonazepam 0.5 mg tablets revealed that there were 58 tablets remaining on 10/30/24 at 10 p.m. Observation on 10/1/24 at approximately 9:30 a.m. with Staff C (Licensed Practice Nurse (LPN)) of Resident #6's Clonazepam 0.5 mg medication card revealed that there were 57 tablets remaining in the medication card. Interview on 10/1/24 approximately 9:31 a.m. with Staff C confirmed the above findings. Staff C stated that he/she gave Resident #6 his/her Clonazepan 0.5 mg around 8:00 a.m. and he/she didn't document the information on the controlled drug record sheet when he/she administered the medication. Resident #2 Review on 10/1/24 of Resident #2's controlled drug record for Oxycodone 5 mg revealed that there were 50 tablets remaining on 9/25/24. An entry revealed on on 9/26/24, one tablet was administered with 59 tablets left, not 49. The administration entries continued to decrease with each dose from the count of 59 and not 49 and there were 10 entries with the incorrect count and staff did not identify that the count was incorrect. Interview on 10/1/24 at 12:40 p.m. with Staff B (Director of Nursing) confirmed the above finding. Review on 10/01/24 of the facility policy titled, Controlled Drugs: Management of, revision date of 7/17/24, revealed: .Ongoing inventory: A complete count of all scheduled II-IV controlled substances is required at change of shift .The count must be performed by two licensed nurses and/or authorized nursing personnel .Destruction: Two licensed professionals are required to destroy and document destruction of controlled substances .

Based on observation, policy review, and interview, it was determined that the facility failed to maintain locked storage of medications and biologicals in 1 of 3 medication carts. Findings include: Observation on 10/1/24 at 12:30 p.m. of Staff A (Registered Nurse) revealed they were at the Opechee Unit medication cart and walked into the medication room, leaving the medication cart unlocked in the hallway and out of sight until 12:33 p.m. with no other staff in the area of the medication cart. One resident was in the hallway in the area of the medication cart. Interview on 10/1/24 at 12:35 p.m. with Staff A confirmed the above findings. Review on 10/2/24 of the facility's policy, Storage and Expiration Dating of Medication, Biologicals, revised 8/7/23, revealed: .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that activities were provided to support residents based on the resident's choices and care plan for 1 out of 1 residents reviewed for activities in a final sample of 23 residents (Resident Identifier is #106). Findings include: Resident #106 Observation on 5/29/24 at 9:48 a.m. in Resident #106's room revealed that Resident #106 was awake in her wheelchair with the television off. Resident #106 was staring into the hallway. Interview on 5/29/24 at 11:49 a.m. with Resident #106's family member revealed that he/she was concerned of the lack of music or television when he/she comes to visit Resident #106. Resident #106's family stated that Resident #106 may not be able to participate in activities, however Resident #5 can still listen, especially to activities like live music. He/She stated that Resident #106 was a singer and loved music, especially classical. Observation on 5/29/24 at 1:53 p.m. of the dining room revealed that there was a musician playing music for residents. Observation on 5/29/24 at 1:55 p.m. in Resident #106's room revealed that Resident #106 was awake in her wheelchair watching television. Observation on 5/30/24 at 9:00 a.m. in Resident #106's room revealed that Resident #106 was awake in bed with the television off and no music playing. Interview on 5/30/24 at 12:09 p.m. with Resident #106's family revealed that when he/she arrived, Resident #106 was resting in bed. He/she stated that they noticed there was a music activity going on in the dining room yesterday and they said no one came into the room and asked if Resident #106 wanted to go. He/She stated that he/she would like Resident #106 to be asked, and the resident would decide if they felt up to going or not. Review on 5/30/24 of Resident #106's medical diagnoses revealed that Resident #106 had a diagnosis of advanced Parkinson's disease with Dementia. Review on 5/30/24 of Resident #106's Recreation Comprehensive Assessment, dated 1/19/24, and completed by Resident #106's family revealed the following: -Very important to listen to music; -Interested in pet visits; -Very important to do things with groups of people, likes to socialize or just be present during group activities; -Very important to watch or listen to television. Review on 5/30/24 of Resident #106's current activity care plan revealed that Resident #106 enjoyed listening to classical music, watching television, to participate in music performances, and to go outside when the weather was nice. Review on 5/30/24 of Resident #106's March, April, and May's activity participation record revealed no documented activity participation. Interview on 5/30/24 at 12:30 p.m. with Staff F (Director of Activities) confirmed the above findings. Staff F stated he/she was not sure what Resident #106 preferences because he/she did not do his/her recreation assessment. Interview further revealed that if a resident declined an activity when asked to go, it would be documented on the resident's activity participation record. Interview on 5/30/24 at 12:30 p.m. with Staff G (Activity Aid) revealed that Resident #106 was not asked to go to the live music activity the day prior by Staff G. Staff G stated that he/she started working at the facility in the beginning of May and was unaware of what Resident #106 liked to do for activities. Interview on 5/30/24 at 1:00 p.m. with Staff H (Licensed Nursing Assistant) revealed that Resident #106 liked to watch television. Interview further revealed that Resident #106 was not asked to go to group activities. Review on 5/30/24 of the facility's policy titled, Program Design, revision dated 4/1/18, revealed: .2. The Recreation Department will create a program environment that supports a person's wellbeing and wellness. 3. Group, individual, and independent programs are reflective of the resident's/patient's comprehensive assessments and care plans and the preferences of each resident/patient and will be adapted to ensure participation Review on 5/30/24 of the facility's policy titled, Resident's/Patient's Choice, revision dated 4/1/18, revealed: .2. Residents/Patients will be invited to attend activities and will be provided the opportunity to participate in structured and individual programs. 3.1 Preferences for individuals who have dementia will be determined through communication with the resident/patient, family, friends, and caregivers. 3.2 Assistance will be provided for residents/patients who wish to participate but are not able to get to activities on their own. 4. Resident/Patients who prefer not to participate in structured activities will be offered alternatives and necessary support/resources for meaningful individual pursuit of leisure interests .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to maintain infection control practices in regards to cleaning equipment during wound care in 1 out of 1 observations of pressure ulcer care observed in a final sample of 23 residents (Resident Identifier is #27). Findings include: Review on 5/31/24 of Resident #27's Skin and Wound Evaluation, dated 5/28/24, revealed that Resident #27 had a Deep Tissue Pressure Injury to the right dorsum hallux of the foot, measuring 0.1 by 0.4 by 0.5 centimeters. Review on 5/31/24 of Resident #27's May 2024 Treatment Administration Record revealed the following treatment orders: Cleanse pressure injury to right foot base of great toe with [wound cleanser], pat dry. Cover with oil emulsion to wound bed only, cover with non adherent foam and .wrap with a gauze bandaged roll every 3 days with a start date of 4/26/24. Cleanse [NAME] injuries to right calf with wound cleanser, pat dry, skin repair cream to dry periwound, apply oil emulsion if open area exist, cover with [foam dressing] . wrap with a gauze bandaged roll every 3 days with a start date of 4/19/24. Observation on 5/31/24 at 1:30 p.m. of Staff B (Licensed Practical Nurse) provided wound care to Resident #27's right lower leg/foot area and revealed that there was a bandaged roll, dated 5/28/24, that wrapped the resident's right calf and foot. Staff B cut the bandaged roll with clean scissors and removed the dirty dressings, revealing three different wounds; one to the right hallux (big toe joint) area, and two areas on the lower leg/calf. It was observed that there was serosanguineous drainage to the right hallux dripping down the foot. Staff B placed the dirty scissors on the clean field, removed his/her gloves and washed their hands. Further observation of the wound care revealed that Staff B used the dirty scissors to cut an oil emulsion dressing to the wound bed size, and placed it directly to the right hallux area wound bed. Staff B then used the same scissors to cut a non border foam dressing and bandage roll to cover the oil emulsion dressing. Further observation revealed Staff B also used the same dirty scissors to cut the oil emulsion dressing to the wound bed size to the 2 wounds on the calf. Interview on 5/31/24 at 2:00 p.m. with Staff B confirmed that he/she did not disinfect the scissors between the dirty and the clean dressing change. Staff B stated that he/she would have cleaned the scissors if they had touched the wound bed. Interview on 5/31/24 at 2:30 p.m. with Staff D (Director of Nursing) confirmed that he/she would expect that the scissors would be cleaned between the dirty and clean dressing change. Review on 6/3/24 of the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, retrieved on 6/3/24 from https://www.cdc.gov/infection-control/hcp/core-practices/index.html, revealed: .Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . The practices outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care . The core practices in this document should be implemented in all settings where healthcare is delivered. These venues include both inpatient settings (e.g., acute, long-term care) . 5f. Reprocessing of Reusable Medical Equipment References and resources . Maintain separation between clean and soiled equipment to prevent cross contamination .

Based on interview and record review, it was determined that the facility failed to ensure residents with pressure ulcers had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcers for 2 out of 5 residents reviewed for pressure ulcers (Resident Identifiers are #2 and #3). Resident #2 Review on 8/23/23 of Resident #2's weekly wound evaluations of their facility acquired Stage 3 pressure ulcer on their coccyx revealed the following: 8/23/23 Coccyx Stage 3 measurements 1.06 cm (centimeters) x (by) 1.52 cm; 8/10/23 Coccyx Stage 3 measurements 4.44 cm x 0.81 cm, progress stalled; 7/17/23 Coccyx Stage 3 measurements 2.9 cm x 0.5 cm, progress stalled; 6/28/23 Coccyx Stage 3 measurements 3.41 cm x 0.74 cm, progress stable; 6/9/23 Coccyx Stage 3 measurements 2.31 cm x 1.05 cm, progress stable; 5/24/23 Coccyx Stage 3 measurements 0.61 cm x 0.58 cm, progress improving. Interview on 8/23/23 at approximately 1:45 p.m. with Staff B (Director of Nursing) confirmed that Resident #2 was missing a total of 8 of the last 13 weeks. Resident #3 Review on 8/23/23 of Resident #3's weekly wound evaluations of their facility acquired Stage 3 pressure ulcer to their right heel revealed the following: 8/22/23 Right heel Stage 3 measurements 0.73 cm x 1.11 c.m.; 8/15/23 Right heel Stage 3 measurements 0.48 cm x 0.24 cm, progress improving; 8/8/23 Right heel Stage 3 measurements 0.86 cm x 0.8 cm, progress improving; 8/1/23 Right heel Stage 3 measurements 0.6 cm x 0.37 cm, progress improving; 7/21/23 Right heel Stage 3 measurements 1.04 cm x 0.59 cm, progress stable; 7/12/23 Right heel Stage 3 measurements 0.66 cm x 1.01 cm, progress improving; 7/7/23 Right heel Stage 3 measurements 1.03 cm x 1.06 cm, progress improving; 6/23/23 Right heel Stage 3 measurements 1.2 cm x 1.13 cm, progress stalled; 6/17/23 Right heel Stage 3 measurements 0.44 cm x 0.41 cm, progress stable; 6/9/23 Right heel Stage 3 measurements 0.66 cm x 0.57 cm, progress improving; 6/1/23 Right heel Stage 3 measurements 0.62 cm x 0.73 cm, progress improving. Interview on 8/23/23 at approximately 2:15 p.m. with Staff B confirmed that Resident #3's weekly wound documentation was missing a total of 2 of the last 13-weeks. Review on 8/23/23 of facility policy titled Skin Integrity and Wound Management, revised on 2/1/23, revealed .6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds .

Based on record review, interview, and policy review it was determined that the facility failed to prevent a significant medication error for 1 of 5 residents reviewed for medication errors (Resident Identifier #1). Findings Include: Review on 8/23/23 at 8:30 a.m. of Resident #1's progress note dated 7/3/23 by Staff C (Nurse Practitioner) revealed that Resident #1 had an order for Torsmemide (diuretic) 20 milligram (mg) two times a day that had been discontinued by Staff A (Registered Nurse) on 5/24/23 as he/she thought it was a duplicate order. Review on 8/23/23 of Resident #1's Medication Administration Record (MAR) from 5/23/23 to 7/31/23 revealed that there was no order for Tormedmide from 5/24/23 to 7/3/23 and restarted 7/4/23. Resident #1 had not received the medication during that time period. Further review of the MAR revealed that the resident was taking Tormedmide for edema/congestive heart failure. Interview on 8/23/23 at 2:00 with Staff A (Registered Nurse) confirmed that they had discontinued the order without a physician's order as he/she thought it was a duplicate order.

Based on observation, interview, and record review, it was determined that the facility failed to assess a residents' ability to self-administer medications for 1 of 9 residents reviewed for choices in a final sample of 35 residents.(Resident identifier is #21). Findings include: Observation on 5/9/23 at 10:58 a.m. of Resident #21's over-bed table revealed an inhaler laying on top of the table. Interview on 5/9/23 at 10:58 a.m. with Resident #21 revealed that he/she used the inhaler when needed and had last used it on 5/8/23. Review on 5/10/23 of Resident #21's medical record revealed that there was no physician's order for an inhaler and that there was a physician's order dated 2/4/23 that Resident #21 may not administer own medications. Further review of the medical record revealed that Resident #21 had not been assessed to self administer any medications. Observation on 5/10/23 at 2:10 p.m. of Resident #21's over-bed table revealed the inhaler on top of the table. Interview on 5/10/23 at 2:10 p.m. with Staff L (Licensed Practical Nurse) confirmed that Resident #21 did not have a physician's order for the inhaler and had a physician's order to not self-administer medications. Staff L confirmed that the medication was on the resident's over-bed table. Review on 5/10/23 of the facility's policy Medications: Self-Administration revised 3/1/22, revealed, .Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer . A physician . order is required . Self-administration and medication self-storage must be careplanned .

Based on observation, interview, and record review, it was determined that the facility failed to identify the cause of a fall in an effort to prevent avoidable accidents in the future for 1 of 3 residents reviewed for accidents (Resident identifier is #55). Findings include: Review on 5/11/23 of Resident #55's falls from 3/1/23 through present revealed the following: 5/8/23- ambulating in room without walker and fell; 4/22/23- ambulating in day room without walker and fell; 4/19/23- fall with skin tear, no identified cause; 4/3/23- fell off chair trying to reach a spoon that fell to floor; 3/31/23- found on floor, said they tried to fall onto bed, no identified cause; 3/30/23- walking without walker and fell; 3/26/23- while being assisted lost footing and fell; 3/25/23- fall, continues to be unsteady with ambulation and walker; 3/24/23- tried to clean up a spill on floor independently and fell forward; 3/23/23- fell out of chair with no identified cause; 3/17/23- ambulating independently on another unit with walker and fell backwards; 3/7/23- found on floor with no identified cause. Interview on 5/11/23 at approximately 1:00 p.m. with Staff D (Director of Nursing) confirmed that an identified cause was not obtained for all the above falls for Resident #55. Staff D stated that Resident #55 is not compliant with asking for help. Review on 5/11/23 of facility policy titled Falls care delivery process, revised 7/25/16, revealed .Response to a patient fall .1. Evaluate and monitor patient for 72 hours after the fall .complete change of condition note and enter the fall as a new event into the Risk Management System (RMS). Review patient's medical record and assessments to identify any causes that may have contributed to the fall .3. Implement immediate interventions after the fall . Review on 5/11/23 of faciltiy policy titled Accidents/Incidents, revised on 10/24/22, revealed .Followup/Investigation: .4.4.5 Document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure effective pain management for 1 out 1 resident reviewed for pain in a final sample of 35 residents (Resident Identifier is #112). Findings include: Interview on 5/9/23 at approximately 9:00 a.m. with Resident #112 revealed that he/she did not feel that their pain was being controlled since his/her admission on [DATE]. Review on 5/9/23 of Resident #112's April and May 2023's Medication Administration Record (MAR) revealed the following orders: April 2023 (April 12 thru April 30) -Acetaminophen Tablet 325 milligrams (mg), Give 2 tablets by mouth every 4 hours as needed for mild pain, . Administered 22 doses -Oxycodone Hydrochloric Acid (HCL) 5 mg, Give 1 tablet by mouth every 6 hours as need for severe pain, . Administered 30 doses May 2023 (May 1 thru May 10) -Acetaminophen Tablet 325 mg, Give 2 tablets by mouth every 4 hours as needed for mild pain, . Administered 18 doses -Oxycodone HCL 5 mg, Give 1 tablet by mouth every 6 hours as need for severe pain, . Administered 23 doses Interview on 5/11/23 at approximately 1:15 p.m. with Staff C (Nurse Practitioner) revealed that he/she was unaware of the amount of as needed medications that Resident #112 was being administered, I would expect to be notified of this and I would then scheduled a pain medication. Review on 5/11/23 of Resident #112's care plan for pain revealed that there had been no new interventions added since his/her admission date of 4/12/23. Review on 5/11/23 of the facility pain policy titled, NSG227 Pain Management, Revision Date 10/24/22 revealed: .2. The nurse will notify the physician/advanced practice provider (APP) as appropriate and obtain treatment orders as indicated. .9.3 Ineffectiveness of routine or PRN (as needed) medications including interventions, follow up, and physician/APP notification; .

Based on observation, interview, and record review, it was determined that the facility failed to maintain ice machines in a sanitary condition for 2 of 2 ice machines in accordance with maintenace guidelines for food service safety. Findings include: Main Kitchen Observation on 5/9/23 at 8:40 a.m. of the Main Kitchen ice machine revealed a plastic wall mounted holder for the ice scoop. Further observation of the holder revealed visible dust and dirt inside the holder where the scoop was resting. Interview on 5/9/23 at 8:40 a.m. with Staff I (Cook) confirmed that the above finding. Staff I stated that the scoop was cleaned by the dietary department; however, did not clean the holder. Staff I was not sure who was responsible for cleaning the holder. Interview on 5/9/23 at 8:40 a.m. with Staff J (Maintenance) revealed he/she does not clean the wall mounted holder. Transitional Care Unit (TCU) Observation on 5/9/23 at 9:10 a.m. of the TCU ice machine revealed a stringy mucus like substance that formed in a drip-like manner on the ice shoot. Further observation revealed that when ice comes through the shoot, water drips down this substance and into the cup. Interview on 5/9/23 at 9:10 a.m. with Staff I, Staff A (Unit Manager) and Staff J all confirmed the above findings. They did not know who was responsible for cleaning of the ice machine or when it had last been cleaned. Review on 5/10/23 of the facility's Work History Report for the ice machines revealed that the ice machine had last been serviced and cleaned on 3/15/23. Review on 5/11/23 of the facility's policy titled Pantry/Nourishment Room Sanitation revised 6/15/18 revealed, .1. Food and Nutrition Services staff monitors the cleanliness of the pantry/nourishment rooms including refrigerator/freezers, cabinets, equipment, and surfaces. 2. Food storage and service equipment and surfaces are routinely cleaned by designated staff . Review on 5/11/23 of the facility's policy titled Cleaning Schedule revised on 6/15/18 revealed, .To maintain a clean and sanitary Food and Nutrition Services Department and prevent the growth of bacteria . 1. The Director of Dining Services/Director of Culinary Services uses the Master Cleaning Schedule to establish a Department Cleaning Schedule . 2. The Department Cleaning Schedule includes all of the equipment and areas in the department, frequency of cleaning, and position assigned . 4. Employees clean the assigned equipment/area as scheduled following the established cleaning procedures . 6. Completed schedules are maintained for 30 days . Master Cleaning Schedule . Ice Machine . monthly . Review on 5/11/23 of the maintenance guidelines of the TCU ice machine, provided by the facility, revealed .The maintenance schedule below is a guidelines. More frequent maintenance may be required depending on water quality, the appliance's environment . Maintenance Schedule . Monthly Appliance Exterior . Wipe down with a clean, soft cloth. Use a damp cloth containing a neutral cleaner to wipe off oil or dirt build up .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to maintain patient equipment (oxygen filter and tubing) in a clean and sanitary condition for the use of oxygen for 2 out of 2 residents reviewed for respiratory care in a final survey sample of 35 (Resident identifiers are #71 and #98) Findings include: Resident #71 Observation on 5/9/23 of Resident #71 at 11:10 a.m. revealed Resident #71 was sleeping soundly in bed with a nasal cannula in place. Further observation revealed Resident #71's oxygen filter on the back of the concentrator was covered in lint and dust. Observation on 5/10/23 of Resident #71 at 8:10 a.m. revealed Resident #71 was sitting up in bed, eating breakfast with a nasal cannula in place. Further observation revealed Resident #71's oxygen filter on the back of the concentrator was covered in lint and dust. Interview on 5/10/23 with Resident #71 at 8:10 a.m. revealed that Resident #71 used oxygen continuously. Interview on 5/10/23 with Staff M (Licensed Nursing Assistant) at 8:15 a.m. confirmed Resident #71's oxygen filter was covered in lint and dust. Review on 5/11/23 of Resident #71's medical record revealed a diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Further review revealed a physician's order for oxygen at 0-2 liters/min via nasal cannula to keep saturation above 92 percent (%). Review on 5/11/23 of the manufacturer's instructions for the Invacare [NAME] V Oxygen Concentrator copy right date 2016 revealed .7.3 Cleaning the Cabinet Filter . 1. Remove the filter and clean as needed . Environmental conditions that may require more frequent inspection and cleaning of the back of the filter include, but are not limited to: high dust . Resident #98 Observation on 5/9/23 of Resident #98 at 11:10 a.m. revealed Resident #98 was lying in bed wearing his/her nasal cannula. Observation of Resident #98's tubing revealed the tubing was resting on the floor, there was a visible film on the inside of the tubing and the tubing was dated 4/20. Observation on 5/9/23 of Resident #98 at 12:15 p.m. revealed Resident #98 was sitting in a wheelchair wearing his/her nasal cannula. Observation of Resident #98's oxygen tubing revealed the tubing was resting on the floor, there was a visible film attached to the inside of the tubing and the tubing was dated 4/20. Interview on 5/9/23 with Staff M at 12:20 p.m. revealed that the date on the tubing was the date it was changed. Staff M confirmed the condition of the tubing and that the date documented on Residents #98's oxygen tubing was 4/20. Review on 5/11/23 of Resident #98's medical record revealed a diagnosis of Chronic Diastolic (Congestive) Heart Failure and Acute Respiratory Failure with Hypoxia. Further review revealed a physician's order for oxygen at 0-4 liters/min via nasal cannula continuously to maintain minimum saturation above 92%. Further review revealed a physician's order for oxygen tubing change weekly with 14 foot nasal cannula. Label each component with date and initials. Review on 5/11/23 of facility policy titled Respiratory Equipment/Supply Cleaning/Disinfecting revised on 7/15/21, revealed .5. Schedule for supply changes . Item: Suction connecting tubing .Frequency: Every 7 day .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician's orders for 4 out of a final sample of 35 residents. (Resident identifiers are #112, #56, #94 and #10). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #112 Interview on 5/9/23 at approximately 9:00 a.m. with Resident #112 revealed that he/she did not feel that their pain was being controlled. Review on 5/9/23 of Resident #112's medical record revealed that Resident #112 was admitted to the facility on [DATE]. Review on 5/9/23 of Resident #112's April and May 2023's Medication Administration Record (MAR) revealed an order for Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth every 4 hours as needed for mild pain. Further review revealed that Resident #112 was administered the following as needed doses with the following pain levels: pain level of 6: 4/16, 4/19, 4/24, 4/27 (2 doses), 5/2, 5/4, 5/8 (2 doses) pain level of 7: 4/13, 4/14, 4/20 (2 doses), 4/21, 4/28, 5/6, 5/10 pain level of 8: 5/2 and 5/4 Interview on 5/11/23 at approximately 1:15 p.m. with Staff C (Nurse Practitioner) revealed that he/she would expect for mild pain the numeric value would be 1-3. Resident #94 Review on 5/9/23 of Resident #94's May 2023 MAR revealed the following physician's order: IV [intravenous]: Implanted Port Non-Valved Flush when NOT accessed 20 ml [milliliters] Normal Saline followed by 5 ml Heparin 10 U [Unit]/ml every day shift every 30 day(s) for implanted port. Further review of the mentioned IV flush order revealed that it was scheduled to be done on 5/3/23. Interview on 5/9/23 at approximately 10:15 a.m. with Staff D (Director of Nurses) confirmed that Resident #94's port was not being utilized, and it was not flushed on 5/3/23. Resident #56 Review of [NAME] A. [NAME] and [NAME], Fundamentals of Nursing, 7th Edition, (St. Louis, Missouri, Mosby, Inc., 2009), pg. 708, reveals Give all routinely ordered medications within 60 minutes of the times ordered (30 minutes before or 30 minutes after the prescribed time). Interview on 5/9/23 at approximately 9:30 a.m. with Resident #56 revealed that he/she goes to Dialysis 3 times a week (Monday, Wednesday and Friday). Resident #56 leaves the facility at approximately 6:00 a.m. and returns to the facility between 10:30 a.m. to 11:00 a.m. Review on 5/9/23 of Resident #56's April and May 2023 MARs revealed a physician's order for Hydralazine Hydrochloric Acid (HCL) 25 mg tablet, give 2 tablets 3 times a day, that was scheduled to be administered at 10:00 a.m., 2:00 p.m. and 8:00 p.m. Further review of the Resident #56's April and May 2023 MAR revealed that Hydralazine 25 mg was administered on the following times: 4/28/23 10:00 a.m. dose was administered at 11:43 a.m. 4/29/23 10:00 a.m. dose was administered at 11:31 a.m. 4/30/23 10:00 a.m. dose was administered at 12:07 p.m. 5/1/23 10:00 a.m. dose was administered at 12:07 a.m. 5/2/23 10:00 a.m. dose was administered at 11:35 a.m. 5/7/23 10:00 a.m. dose was administered at 11:24 a.m. Interview on 5/11/23 at approximately 11:15 a.m. with Staff D revealed that the physician should have been notified to change the times on dialysis days. Interview on 5/11/23 at approximately 11:45 a.m. with Staff C revealed that he/she would have expected to be notified of the above findings. Review on 5/11/23 of the facility policy titled, 6.2 Medication Administration Times, Revision Date 1/1/22 revealed: .2. Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) minutes after the designated times of administration . Resident #10 Review on 5/11/23 of Resident #10's medical record revealed they were admitted on [DATE]. Further review of Resident #10's medical record revealed an active physician's order, initiated on 4/18/23, to obtain a weight every Thursday on night shift for 4 weeks, then once a month. Review on 5/11/23 of Resident #10's weights revealed a weight on 4/21/23 recorded. Further review of Resident #10's medical record revealed no other weights had been documented since admission on [DATE]. Interview on 5/11/23 at approximately 2:00 p.m. with Staff A (Unit Manager) confirmed that the weekly weights for Resident #10 had not been obtained as ordered. Review on 5/11/23 of facility policy titled Weights and Heights, revised on 6/15/22, revealed .Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter .

Resident #44 Review on 5/10/23 of Resident #44's medical record revealed an admission date of 11/29/22. Further review of Resident #44's medical record revealed the following provider visits: 11/29/22 MD; 12/5/22 NP; 12/7/23 NP; 12/14/22 NP; 12/19/22 NP; 1/10/23 NP; 1/28/23 MD; 2/22/23 NP; 2/27/23 NP; 4/9/23 NP. Resident #110 Review on 5/10/23 of Resident #110's medical record revealed an admission date of 12/13/22. Further review of Resident #110's medical record revealed the following provider visits: 12/14/22 NP; 12/15/22 MD; 12/19/22 NP; 12/27/22 NP; 1/2/23 NP; 1/8/23 NP; 1/10/23 NP; 1/14/23 NP; 1/31/23 NP; 2/8/23 NP; 2/13/23 NP; 3/1/23 NP; 3/3/23 NP; 3/6/23 NP; 3/20/23 NP; 4/3/23 NP; 4/5/23 NP; 4/7/23 NP; 4/15/23 NP; 5/9/23 MD. Interview on 5/11/23 at approximately 9:15 a.m. with Staff D confirmed the above information. Interview on 5/11/23 at approximately 11:30 a.m. with Staff K (Administrator) revealed that the facility was not tracking physician visits for compliance. Review on 3/11/23 of the facility's policy titled Physician Services revised 8/31/20 revealed, . Centers will ensure that the medical care of each patient is supervised by a physician . 1. The Administrator will establish a process for tracking licensed practitioner visits . 2. The CED (Center Executive Director) will identify designee(s) to track and manage practitioner visits utilizing the PointClickCare Managing Physician visits Reference Guide. 2.1 Designee(s) will enter practitioner visits into PCC at a minimum of weekly. 3. The Administrator will review the Physician Visits Report from PCC weekly to identify any passed due visits. 3.1 If passed due visits are identified, the Administrator will establish a plan to address the overdue visits . Standards and Procedures for all Licensed Independent Practitioners . Visits . a. The attending physician will make required, routine visit to the patient 30, 60, and 90 days after admission. Following the 90-day visit . [Company Name] expects visits to be made at least every thirty (30) days, and the attending physician may alternate every other visit . The attending physician must see the patient at least once every 60 days . Based on interview and record review, it was determined that the facility failed to ensure that the resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, alternating with the nurse practitioner for 5 of 6 residents reviewed for physician visits in a final sample of 35 residents (Resident identifiers are #38, #44, #85, #95, and #110). Findings include: Resident #95 Interview on 5/9/23 at 2:14 p.m. with Resident #95 revealed that Resident #95 stated that he/she sees the nurse practitioner, but does not see the physician. Review on 5/11/23 of Resident #95's medical record revealed an admission date of 2/24/22. Further review of the medical record revealed the following provider visits: -On 2/25/22 was the initial visit by the Medical Doctor (MD). -Nurse Practitioner (NP) saw the resident on 5/4/22, 6/15/22, 6/16/22, 6/21/22, 7/14/22, 7/19/22, 7/25/22, 8/8/22, 8/17/22, 8/31/22, 9/26/22, 10/20/22, 11/14/22, 12/21/22, 1/24/23. -MD saw the resident on 2/14/23 (this is 354 days from the initial visit on 2/25/22). -NP saw the resident on 2/27/23, 3/15/23, 3/24/23, 3/28/23, 4/11/23, 4/19/23, 4/24/23. Interview on 5/11/23 at 11:11 a.m. with Staff D (Director of Nursing) confirmed the above visits. Interview on 5/11/23 at 12:23 p.m. with Staff C (Nurse Practitioner) confirmed that Staff E (Medical Doctor) did not alternate visits for Resident #95 and resident had not been seen by the physician in almost 1 year. Resident #85 Interview on 5/9/23 at 11:05 a.m. with Resident #85 revealed that he/she stated that he/she had not seen the physician since he/she has been at the facility. Review on 5/10/23 of Resident #85's medical record revealed an admission date of 9/7/22. Further review of the medical record revealed the following provider visits: -MD saw the resident on 9/12/22, 10/14/22 and 12/13/22 (this is 60 days from the last visit). -NP saw the resident 1/31/23 and 2/8/23. There were no additional MD or NP visits after 2/8/23 as of 5/11/23 (this is 92 days from the last visit). Interview on 5/11/23 at 9:09 a.m. with Staff D confirmed that Resident #85's visits did not alternate between the NP and MD and it had been more that 60 days since the last visit of 2/8/23. Staff D confirmed that Resident #85 should have had a MD or NP visit in November 2022 based on the admission date. Resident #38 Interview on 5/9/23 at 1:47 p.m. with Resident #38 revealed he/she had concerns about not seeing the physician. Review on 5/10/23 of Resident #38's medical record revealed an admission dated of 9/12/22. Further review of the medical record revealed the following provider visits: -MD initial History and Physical was done on 9/16/22. -NP saw the resident on 9/23/22, 9/26/22 and 11/30/22. -MD saw the resident on 2/14/23 (this is 76 days from last visit). -NP saw the resident on 2/28/23 and 4/14/23. Interview on 5/11/23 at 11:07 a.m. with Staff D confirmed the above and that the NP and MD visits did not alternate. Staff D confirmed that Resident #38 was not seen every 30 days for 90 days from admission by the NP or MD.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were labeled with an open date or use by date and expired medications were removed from use for 3 of 3 medication carts observed (Resident identifiers are #14, #16, #26, #43, #52, #60, #70, #89, #98, #106, #108 and #109.) Findings include: Lakeport Unit Medication Cart Observation on 5/9/23 at approximately 8:35 a.m. of the medication cart with Staff F (Licensed Practical Nurse) revealed the following: A clear medication cup containing 13 capsules unlabeled in the right hand second drawer; Resident #89's Ondansetron (antiemetic) 4 milligram (mg) tablets with an expiration date of 7/31/22; Resident #89's Fludrocortisone Acetate (glucocorticoid) 0.1 mg with an expiration date of 12/31/22; Resident #43's two medication cards for Gabapentin (anticonvulsants or nerve pain medication) 100 mg with expiration dates of 12/31/22 and 2/28/23; Resident #43's open Glargine (insulin) pen with no open or use by date, a do not use 28 days after opening sticker and a pharmacy delivery date of 4/6/23; Resident #109's open Basaglar (insulin) pen with no open or use by date and a pharmacy sticker that stated do not use 28 days after opening; Resident #108's open Aspart (insulin) pen with an open date of 3/23/23 and a do not use after date of 4/20/23 written on the sticker; Resident #108's open Glargine (insulin) pen with a sticker that read do not use after 4/18/23; Resident #108's open Lispro (insulin) vial that was labeled with a use by date of 5/3/23; Resident #14's opened Humalog (insulin) with an open date of 4/4/23 and a do not use 28 days (5/2/23) after opening sticker; Resident #16's open Lantus (insulin) vial with no open or use by date, a do not use 28 days after opening sticker and a pharmacy delivery date of 1/22/23; Resident #106's open Aspart (insulin) with no open or use by dates, a do not use after 28 days after opening sticker and a pharmacy delivery date of 4/10/23. Review on 5/9/23 of Resident #89's medical record revealed the following: Ondansetron 4 mg had been discontinued on 5/7/22; Fludrocortisone Acetate 0.1 mg had been discontinued on 9/23/22. Interview on 5/9/23 at approximately 8:30 a.m. with Staff F confirmed the above findings. Staff F confirmed that all resident medications identified, other than Resident #89's, were currently ordered and in use. Opechee Unit Medication Cart Observation on 5/9/23 at approximately 8:55 a.m. of medication cart 1 with Staff G (Registered Nurse) revealed Resident #60's Hyoscyamine Sulfate (antispasmodic) 0.125 mg tablets with an expiration date of 6/29/22. Review on 5/9/23 of Resident #60's medical record revealed that Hyoscyamine Sulfate 0.125 mg was discontinued on 11/25/22. Interview on 5/9/23 at approximately 9:00 a.m. with Staff G confirmed the above information. Winnisquam Unit Medication Cart Observation on 5/9/23 at approximately 9:20 a.m. of medication cart C side with Staff H (Registered Nurse) revealed the following: Resident #26's open Novolog (insulin) pen with an open date of 3/31/23 and a do not use after 4/28/23 label; Resident #70's Amlodipine Besylate (Antihypertensive) 5 mg tablets with an expiration date of 3/31/23; Resident #52's Amlodipine Besylate (Antihypertensive) 5 mg tablets with an expiration date of 3/31/23; Resident #98's Diltiazem (Antihypertensive) 120 mg tablets with an expiration date of 12/31/22. Review on 5/9/23 of Resident #98's medical record revealed that Diltiazem 120 mg was discontinued on 11/14/22. Interview on 5/9/23 at approximately 9:30 a.m. with Staff H confirmed the above information. confirmed that all resident medications identified, other than Resident #98's, were currently ordered and in use. Review on 5/10/23 of facility policy titled insulin pens, revised on 2/28/21, revealed .follow manufacturer's instruction for product expiration . Review on 5/10/23 of Humalog/Lispro insulin pen and vials manufacturer's instructions revealed .unopened Humalog should be stored in a refrigerator and can be used until the expiration date on the label, if kept in the refrigerator .Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin . Review on 5/10/23 of Novolog/Aspart insulin Pen and Vials manufacturer's instructions revealed .Store unused Novolog pens, Prefill cartridges and vials at room temperature up to 86 degrees Fahrenheit for up to 28 days .dispose after 28 days even if there is insulin left in the pen or vial . Review on 5/10/23 of Lantus/Glargine insulin Pen and Vials manufacturer's instructions revealed .Store unused Lantus vials in the refrigerator between 36-46 degrees Fahrenheit .The Lantus vials you are using should be thrown away after 28 days, even if it still has insulin left in it . Review on 5/10/23 of Basaglar insulin pen manufacturer's instructions revealed .Unused pens may be used until expiration date printed on the Label, if the Pen has been kept in the refrigerator . Store the pen you are currently using at room temperature [up to 86 degrees Fahrenheit] and away from heat and light. Throw away the pen you are using after 28 days, even if it still has insulin left in it .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) during a facility COVID-19 outbreak and used proper hand hygiene practices according to professional standards and the facility's written policies to prevent spread of infections on 4 out of 6 units observed (Winnisquam Unit, Lakeport Unit, TCU (Transitional Care Unit room [ROOM NUMBER]-124), and Opeechee Unit). Findings include: Standard: Review on 3/17/23 of the CDC website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, update date of 9/27/22, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Review on 3/17/23 of the CDC's website titled, Hand Hygiene Guidance, review date of 1/30/20, retrieved from: https://www.cdc.gov/handhygiene/providers/guideline.html, revealed .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal . Interview on 3/17/23 at approximately 9:45 a.m. with Staff B (Director of Nurses) revealed that it was the facility's policy for staff to wear N95 mask and eye protection in resident care units/areas. Winnisquam Unit Interview on 3/17/23 at approximately 10:25 a.m. with Staff C (Infection Preventionist) revealed that the facility was currently in COVID-19 status outbreak with positive COVID-19 residents on each unit. Staff C stated that they had their first cases of COVID-19 (residents and staff) the week of February 20, 2023. Staff C also stated that all staff should be wearing an N95 mask and eye protection on resident care units/areas and full droplet precaution PPE (additional gown and gloves) when entering resident room with COVID-19 positive residents. Observation on 3/17/23 at approximately 10:30 a.m. with Staff C at the Winnisquam Unit resident room [ROOM NUMBER] had a droplet precaution sign posted at resident room [ROOM NUMBER]'s door. Interview with Staff C during observation revealed that the resident in the window bed was positive for COVID-19. Further observation in resident room [ROOM NUMBER] with Staff C revealed that Staff D (Housekeeper) was in resident room [ROOM NUMBER] with gown, gloves, N95 mask, and no eye protection, sweeping the floor. Staff D was observed going out of the resident room without doffing gown and gloves. Staff D was then observed doffing gown and glove outside the hallway. Staff D did not perform hand hygiene (hand washing and/or Alcohol-Based Hand Rub (ABHR)) after doffing PPE. Interview on 3/17/23 at approximately 10:30 a.m. with Staff C confirmed the above findings on Staff D. Staff C stated that Staff D should have eye protection while in resident room [ROOM NUMBER] and doffed PPE inside resident room [ROOM NUMBER] before exiting the room. Review on 3/20/23 of the facility's policy titled, Droplet Precaution, review date of 11/15/22, revealed .Before exiting room, remove and bag PPE and wash hands . Review on 3/20/23 of the facility's policy titled, Hand Hygiene, review date of 11/15/22, revealed .Perform hand hygiene: .After contact with patient's environment . Review on 3/20/23 of the facility's policy titled, Personal Protective Equipment (PPE) Guide for Healthcare Personnel, date of 12/19/22, revealed .Implement Universal Use of Personal Protective Equipment for HCP [Healthcare Personnel] .When a center is experiencing an outbreak, a well-fitting- mask must be used by everyone in the facility .Eye protection .are highly recommended for all patient care encounters . Lakeport Unit Observation on 3/17/23 at approximately 10:45 a.m. with Staff C at the Lakeport Unit revealed that Staff F (Medication Nursing Assistant) was walking out of a resident room with no eye protection and only an N95 mask. The Lakeport Unit had 2 residents who were positive for COVID-19. Interview on 3/17/23 at approximately 10:45 a.m. with Staff C and Staff F confirmed the above observation on Staff F. Staff F stated that he/she should have had eye protection while in resident room and resident care units/areas. Transitional Care Unit (TCU) Rooms 120-124 Observation on 3/17/23 at approximately 11:00 a.m. at the TCU near Lakeport Unit revealed that resident room [ROOM NUMBER] had a droplet precaution sign posted at the door. Interview with Staff C during observation revealed that the resident in the first bed near the door was positive for COVID-19. Further observation in resident room [ROOM NUMBER] revealed that Staff G (Licensed Nursing Assistant) had no gloves while handling and double bagging a trash filled with used PPE. Staff G did not perform hand hygiene before exiting resident room [ROOM NUMBER]'s room. Staff G proceeded to the soiled utility room with the double bagged trash that was filled with used PPE then Staff G exited the soiled utility room after dropping of the double bagged trash without performing hand hygiene. Staff G then went to the supply room then headed to a resident room in Opeechee Unit with a pack of wipes. Interview on 3/17/23 at approximately 11:00 a.m. with Staff C confirmed the above findings of Staff G. Opeechee Unit Observation on 3/17/23 at approximately 11:05 a.m. with Staff C revealed that Staff I (Housekeeper) was at the hallway with no eye protection. Further observation revealed that resident room [ROOM NUMBER] had a droplet precaution sign posted at the door. Interview on 3/17/23 at approximately 11:05 a.m. with Staff I with the electronic translator revealed that Staff I was at resident room [ROOM NUMBER]'s bathroom as he/she was told to clean the bathroom. Staff I stated that he/she did not have eye protection on when he/she was in resident room [ROOM NUMBER]. Interview on 3/17/23 at approximately 11:05 a.m. with Staff C revealed that there was a resident that was COVID-19 positive in resident room [ROOM NUMBER]. Staff C stated that Staff I should have worn eye protection in resident care areas and resident rooms with COVID-19 positive residents.