**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to clarify and update the medical records to reflect the desired advance directive for 1 of 1 resident (Resident #64) reviewed for code status. The findings included: Resident #64 was admitted to the facility on [DATE]. A review of Resident #64's paper chart at the nurses' station revealed a paper copy of Resident #64's Medical Orders for Scope of Treatment (MOST) form dated 1/30/24 which indicated to attempt resuscitation with full scope of treatment. The MOST form was signed by Resident #64 and the Nurse Practitioner on 1/30/24. A review of Resident #64's electronic medical record indicated a physician's order dated 3/27/24 for Do Not Attempt Resuscitation (DNAR)/limited scope of treatment. A progress note in Resident #64's medical record dated 3/27/24 by the Medical Director (MD) indicated Resident #64's family wanted to keep her at facility for now and not to send to hospital. (The family) noted that they were aware of decline. (The MD) discussed with multiple family members in room and they wished to have her be Do Not Resuscitate/Do Not Intubate. Resident #64 had a poor long term prognosis. An interview with Nurse #1 on 7/16/24 at 12:20 PM revealed she would refer to Resident #64's paper chart at the nurses' station for her code status. Nurse #1 reviewed the MOST form and stated that Resident #64 was a full code so she would attempt cardiopulmonary resuscitation. After Nurse #1 was prompted to check Resident #64's electronic medical record, she noted that Resident #64's most recent code status order was DNAR. Nurse #1 stated that she was not sure why there was a discrepancy in Resident #64's code status, and said that she would want them to match. Nurse #1 added that if she received a new order from the doctor, she would notify the Unit Coordinator who would give the new code status to the office secretary to get scanned into the electronic medical record and placed in the paper chart. An interview with Unit Coordinator #1 on 7/16/24 at 12:29 PM revealed he didn't know why Resident #64 had conflicting advance directive in her electronic medical record and paper chart. Unit Coordinator #1 stated Resident #64's family might have requested for her code status to be changed. Unit Coordinator #1 shared that the facility's process when there was a change to a resident's advance directive was when they receive an order, the nurse should have a new MOST form signed by the family and the doctor, and then it should be placed in the office secretary's box so it could be filed. Unit Coordinator #1 stated that the advance directives in Resident #64's electronic medical record and paper chart should match. An interview with Unit Coordinator #2 on 7/16/24 at 12:47 PM revealed she remembered when Resident #64 was first admitted to the facility, her family wanted her to be a full code. Unit Coordinator #2 stated that the MD did not fill out a new MOST form when he changed Resident #64's code status to DNAR on 3/27/24. Unit Coordinator #2 confirmed that she acknowledged the 3/27/24 order, but the MD did not tell her about it, and she did not pay much attention to it because it wasn't about her medications. Unit Coordinator #2 stated that she acknowledged a lot of orders each day. Unit Coordinator #2 stated that she thought the MD might have initiated a new MOST form for Resident #64, and she was not aware that he did not. A follow-up interview with UC #1 on 7/16/24 at 12:55 PM revealed he had noticed that some orders got put in the electronic medical records without the nurses knowing about them. He stated that the facility probably needed to have a better process with changing code status especially without the resident going out and coming back from the hospital. An interview with the Director of Nursing (DON) on 7/18/24 at 2:59 PM revealed she found out that the MD spoke with Resident #64's family and they wanted to change her code status, so he put in the order but did not say anything to nursing that he was changing her code status. The DON stated the MD should have went ahead and filled out a new MOST form when he changed Resident #64's code status. The DON further stated that the code status in Resident #64's electronic medical record and paper chart should be the same.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff, and Nurse Practitioner interview the facility failed to follow physician's order to provide and apply a left resting hand splint to prevent further contracture for 1 of 3 resident reviewed for limited range of motion. (Resident #30) The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis of left side and muscle weakness. A quarterly Minimum Data Set for Resident #30 dated 6/25/24 revealed the resident was cognitively intact with no refusals or rejection of care and no orthotic use documented. The care plan for Resident #30 updated on 6/25/24 revealed, Resident #30 had an Activities of Daily Living deficit related to physical functioning with weakness status post hemiplegia following a stroke. A review of the nurse practitioner order dated 4/29/24 revealed occupational therapy to evaluate and treat Resident #30 for left hand contracture, current left-hand splint provided would not fit fingers properly. A review of the occupational therapist evaluation note dated 5/06/24 revealed Resident #30 required a left-hand splint to address his contracture. OT evaluated and would place order for new left-hand splint and when received would provide OT services for Resident #30. An observation and interview on 7/15/24 at 10:52 AM revealed Resident #30 sitting up in his wheelchair dressed. The resident's left hand appeared contracted, and he was not wearing a splint. This surveyor asked Resident #30 if he wore a splint on his left hand and he stated no that therapy supposedly ordered a splint for him to wear but it had not come in yet. An observation on 7/16/24 at 3:55 PM revealed Resident #30 was sitting up in his wheelchair dressed in his room. Resident #30 was not wearing his splint. An interview with the Occupational Therapist (OT) on 7/17/24 at 2:30 PM revealed Resident # 30 suffered from a left-hand contracture and did require a splint for his left hand. She stated she placed an order for Resident #30 left-handed splint with the business manager she believed in March 2024 and still had not received the splint. She revealed equipment orders can sometimes take longer depending on the medical equipment company but never more than a month and she should have checked on the equipment prior to now. The OT stated once Resident #30 received his left-handed splint they would begin services to address his range of motion while using his splint. An interview with the business office manager on 7/17/24 at 2:40 PM revealed she received a request from OT on 5/08/24 to order a left side hand splint for Resident #30. She stated she had completed the order at 2:20 PM on 5/08/24 and received confirmation of the order. She revealed therapy had not notified her of the missing equipment and she was not aware the splint had not been received. An interview with the Nurse Practitioner (NP) on 7/18/24 at 1:44 PM revealed she had seen Resident #30 this morning and realized he did not have his left-handed splint and asked for a temporary splint or washcloth for his contraction until his splint come in. She stated although she did not believe Resident #30 to have no actual change since she had ordered the left-handed splint in April, she had expected that he would have the splint and OT would be working with him by now. She revealed Resident #30 should have his left-handed splint and receive treatment for his contracture to assist with keeping it from contracting more. An interview with the Director of Nursing and the Administrator on 7/18/24 at 3:44 PM revealed they were not aware that Resident #30 did not have a left-hand splint as ordered and there should have been follow-up to assure Resident #30 had the correct left-hand splint as ordered and was wearing it as tolerated.

Based on observation, record reviews, and staff interviews, the facility failed to implement their infection control policy for hand hygiene/handwashing, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure when she doffed her gloves after preparing her dressing for the wound and did not sanitize her hands before donning clean gloves to remove the old dressing from the wound for a resident (Resident #4). This occurred for 1 of 1 resident observed for wound care. The findings included: The facility's policy entitled Hand Hygiene last revised on 08/21/23 read in part: The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens is strongly suspected or proven, and after using the restroom. An alcohol-based hand rub is appropriate for decontaminating the hands: Before direct patient contact, putting on gloves, or inserting an invasive device After contact with inanimate objects in the patient's environment After removing gloves Hand sanitizing: Apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all the product has dried. A wound treatment observation was made on 07/17/24 at 2:15 PM on Resident #4 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on the overbed table which she had covered with a clean garbage bag. The Treatment Nurse washed her hands with soap and water, dried them and donned clean gloves. She proceeded to pull up a chair to the bedside of the resident with her gloved hands and sat down in the chair and applied her isolation gown (Resident #4 was on Enhanced Barrier Precautions) after sitting down in the chair. With the same gloves on, the Treatment Nurse began preparing her dressing and applied antimicrobial skin and wound gel to her gauze and cut her bordered gauze dressing to fit the wound. She doffed her gloves and without sanitizing her hands, donned a clean pair of gloves and removed the old dressing from Resident #4's wound. The Treatment Nurse then doffed her gloves, sanitized her hands, donned clean gloves and proceeded to clean the wound with wound cleanser. She doffed her gloves after cleansing the wound, sanitized her hands, and donned clean gloves and applied the wound gel gauze dressing and covered the wound with the bordered gauze dressing. The Treatment Nurse bagged her trash, doffed her gloves, washed her hands with soap and water and discarded her trash and carried her supplies out of the room. An interview on 07/18/24 at 10:38 AM with the Treatment Nurse revealed she thought it was ok to change gloves without sanitizing her hands because she had not yet touched the resident. She stated she remembered sanitizing her hands during the process of the dressing change but said she should sanitize her hands with every change of her gloves. An interview on 07/18/24 at 11:14 AM with the Infection Preventionist (IP) revealed she did handwashing audits on all staff as part of the infection control program. The IP explained that she would have expected the Treatment Nurse to have sanitized her hands after doffing gloves and before donning clean gloves as outlined in their handwashing policy. She stated in addition, someone from corporate comes in twice a month and does random audits on staff for handwashing. The IP further stated she had not watched the Treatment Nurse or audited her during dressing changes and to her knowledge that corporate had not audited her either but said they could add her to their audit to watch her during dressing changes. An interview on 07/18/24 at 3:01 PM with the Director of Nursing (DON) revealed it was her expectation for all staff to follow the handwashing policy and procedure and sanitize their hands with alcohol-based hand rub or wash their hands with soap and water any time they removed their gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, facility activity calendars, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 8 residents reviewed for activities. (Residents #58, #8, #53, #20, #63, and #16). The residents expressed not being able to leave the facility for almost 2 years made them feel more dependent, sad, depressed, and they missed getting out with the group to shop and socialize with other people. The findings included: A review of the activity calendars for January 2024 through July 2024 revealed activities for inside of the facility or grounds during the week and some activities on the weekends. There were no activities scheduled for outside of the facility and grounds. Review of the Resident Council Meeting minutes for April 2023 through June 2024 revealed the residents requested in July 2023 and August 2023 to go on outings outside the facility. Observation on 07/17/24 at 12:30 PM revealed the facility was located within driving distance to several local and commercial shops, grocery stores, local and commercial coffee shops, fast food and sit-down restaurants. a. Resident #58 was admitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #58 felt it was very important to have activities that that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #58 was cognitively intact. An interview was conducted with Resident #58 on 07/17/24 at 10:38 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told it was not possible to go on outings outside the facility because they did not have a van that could transport a group on outings outside the facility. She stated she felt it was important for residents to get outside in the world and socialize with people other than those at the facility because it allowed them some independence and socialization with other people. Resident #58 further stated she would love to go out to eat with a group and go shopping and be able to touch things and be able to pick out her own belongings. She revealed personally being able to do her own shopping and socializing with other people outside of the facility was very important to her and would make her feel more normal and like she still had some independence. Resident #58 further revealed not getting outside the walls of the facility had made her sad and dependent on others for her needs. b. Resident #8 was admitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #8 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #8 was cognitively intact. An interview was conducted with Resident #8 on 07/17/24 at 10:36 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told it was not possible to go on outings outside the facility because they did not have a van that could transport a group on outings outside the facility. She stated she felt it was important for residents to get outside the walls of the facility because it allowed them some freedom and independence to socialize with other people outside the facility. Resident #8 stated not being able to go on outings had made her feel depressed and sad because she would like to be able to go out to eat and go shopping and pick out her own belongings. c. Resident #53 was admitted to the facility on 0805/22 and readmitted on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #53 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #53 was cognitively intact. An interview was conducted with Resident #53 on 07/17/24 at 10:40 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told it was not possible to go on outings outside the facility because they did not have a van that could transport a group on outings outside the facility. He stated he felt it was very important for residents to get outside the walls of the facility and be able to socialize with one another and other people outside the facility because it made them feel more normal. Resident #53 stated he had been requesting to go to a particular restaurant for some time but had been told it was not possible because there was no transportation to take residents outside the facility. He revealed he did not care about going shopping but knew that was important to some of the residents but said it was important to him to be able to go out to eat with a group and socialize and not being able to do so made him sad. d. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #20 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #20 was cognitively intact. An interview was conducted with Resident #20 on 07/17/24 at 10:32 AM during resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told by administrative staff they did not have a van to transport residents in for 'fun outings just medical appointments. She agreed with other residents they had been told by the administrator that it was impossible to go on outings outside the facility because there was not a van available for transport of the residents. She agreed with other residents that it was important to go on group outings outside the facility because it allowed the residents some independence, socialization with the group and with people outside of the facility and made them feel more like a normal person and not just a resident stuck in a facility. e. Resident #63 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #63 was cognitively intact. An interview was conducted with Resident #63 on 07/17/24 at 10:30 AM during resident council meeting which revealed there had not been a scheduled group activity outside the facility since her admission and the resident council had requested one during their monthly meetings and were told by administrative staff, they did not have a van to transport residents in for 'fun outings just medical appointments. She agreed she felt group activities outside of the facility were important to residents that were able to go and participate because it allowed them to exercise some independence, socialization with the group and outside world and made them feel more like a normal person. Resident #63 agreed with other residents not being able to leave the facility with residents and participate in group activities outside the facility had sometimes made her feel as though she had lost some of her independence and was having to rely on someone else to do her personal shopping instead of doing it herself. f. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #20 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #20 was cognitively intact. An interview was conducted with Resident #20 on 07/17/24 at 10:32 AM during resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told by administrative staff they did not have a van to transport residents in for 'fun outings just medical appointments. She agreed with other residents they had been told by the administrator that it was impossible to go on outings outside the facility because there was not a van available for transport of the residents. She agreed with other residents it was important to go on group outings outside the facility because it allowed the residents able to go some independence, socialization with the group and with people outside of the facility and made them feel more like a normal person and not just a resident stuck in a facility. g. Resident #16 was admitted to the facility on [DATE]. An admission MDS assessment dated [DATE] indicated Resident #16 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #16 was cognitively intact. An interview was conducted with Resident #16 on 07/17/24 at 10:34 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility since her admission and the resident council had requested one during their monthly meetings and were told it was impossible because there was not a van that could transport the residents on outings outside of the facility. She stated she thought that had a great activities program at the facility and was pleased with the activities staff and the programs they offered She agreed with other residents it was important to go on group outings outside the facility because it allowed the residents some independence and socialization with outside people and made them feel more like a normal person. Resident #16 further stated she would love to go on outings to restaurants to eat and go shopping but wanted the internal activities to continue as well. An interview was conducted with the Activities Director (AD) on 07/18/24 at 10:49 AM which revealed she was aware the residents wanted to go on group outings and said they brought it up all the time during resident council meetings. She stated she had been told with the van they currently have there is only room for two to three residents at a time, so they were not able to go on group outings. The AD further stated there was only one van driver and when they had taken the residents to the local fair two years ago it had been a long process for the van driver to take two to three at a time and then get everyone back and forth so last year they had brought the residents food from the fair and set up an inhouse carnival with games for them to play. She explained they had popcorn, snow cones, fried Oreos and funnel cakes provided for the residents. The AD further explained residents had requested to go grocery shopping, shopping at Walmart, Dollar General, and requested to go out to eat at one of the local restaurants. She stated she would love to take the residents on outings because she knew it was important to them, but was told they did not have a van to accommodate outings for fun. An interview was conducted with the Administrator on 07/18/24 at 3:22 PM which revealed she was aware the residents wanted to go on group outings and she wanted them to be able to go out on group outings but said the barrier to group outings was their van only being able to accommodate a couple of residents at a time, only having one van driver, and having the staff to send with the residents on outings. She stated that currently their van was only used for transporting residents to medical appointments. The Administrator further stated they had started a Make a Wish program in which residents wanting to do special things would be accommodated but said they had just started it and it would be a single resident wish and not a group event. She explained they had taken residents who needed to bank appointments and attorney appointments but had not done any group outings or fun activities in the van. The Administrator further explained the social workers were available to do shopping for the residents monthly and were able to get what they needed at stores but said she knew it was not the same as the residents being able to go and pick out their own belongings.

Based on observation and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the facility's 6/10/21 recertification survey. The failure related to two deficiencies that were originally cited during the 6/10/21 recertification survey and was cited on the current recertification and complaint survey of 3/20/23. The recited deficiencies were in the areas of infection prevention and control and food safety requirements and store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program. The Findings included: This tag is cross referenced to: F-880 Based on observations, record review and staff interviews the facility failed to implement their policy for Infection Prevention when 1 of 1 staff (Nurse Aide #1) failed to put on gloves and a gown before entering a resident's room for 1 of 2 residents on contact precautions (Resident #6). During the recertification survey of 6/10/21 the facility was cited for F-880. The facility failed to implement the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 1 of 3 staff members (Staff #1) failed to discard her N95 mask and disinfect her goggles after leaving a quarantine room and before going to a non-quarantine room, 1 of 3 staff members (Staff #2) had no eye protection while in the quarantine room, and 1 of 3 staff members (Staff #3) wore a surgical mask and had no eye protection while in a quarantine room. These practices affected 4 of 4 residents reviewed for infection control. These failures occurred during a COVID-19 pandemic. F-812 Based on observations and staff interviews the facility failed to ensure food preparation knives ready for use were clean. This practice had the potential to affect food served to residents. During the recertification survey of 6/10/21 the facility was cited for F-812. The facility failed to dispose of expired perishable food items in 1 of 1 cooler. Staff drinks were observed to be stored alongside resident food items in the kitchen freezer. The facility also failed to dispose of expired foods and date individual cartons of juice and bottled drinks in 1 of 2 resident nourishment rooms. On 3/23/23 at 2:32 PM the Administrator was interviewed and explained the incidents were isolated. The infection control incident broke down because the staff was not paying attention. The facility had been focused on infection control for 3 years and had improved infection control procedures with lots of training and staff education. The kitchen knives were overlooked and should have been cleaned. Quality assurance committee met monthly, and the goal was to be and remain in compliance with CMS regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to implement their policy for Infection Prevention when 1 of 1 staff (Nurse Aide #1) failed to put on gloves and a gown before entering a resident's room for 1 of 2 residents on contact precautions (Resident #6). The findings included: The facility's policy entitled, Infection Prevention .Contact, Contact Enteric . read in part, Isolation precautions will be used .when standard precautions alone are not adequate to eliminate or minimize occupational exposure to communicable disease .contact precautions are indicated for patients who are known or suspected to be infected with microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces .personal protective equipment (PPE) including gloves and gown are worn to enter a patient's room. Perform hand hygiene with soap and water when leaving room. Resident #6 was admitted to the facility on [DATE] with current diagnoses of Clostridioides diffcile (C-diff), a bacterium that causes an infection of the large intestines, and Methicillin-resistant Staphylococcus Aureus (MRSA), a bacteria that can cause serious infections that can lead to sepsis or death. An observation of the 300-hall on 3/20/23 at 12:20pm revealed Resident #6 was on contact precautions and the signage on the door instructed staff to clean their hands before entering the room, put on gloves before entering the room and put on a gown before entering the room. A continuous observation from 12:20pm to 12:22pm revealed NA #1 went into room [ROOM NUMBER] to deliver the lunch tray. NA #1 did not put on gloves or a gown before taking the meal tray into the resident. NA #1 adjusted the bedside table and pulled the curtain while in the resident's room. NA #1 exited the room, cleaned her hands with hand sanitizer and continued down the hall towards the meal cart. An interview on 3/20/23 at 12:22pm with NA #1 revealed she was aware that Resident #6 was on contact precautions. She stated that since she was not handling the resident's urine, she did not need to put on gloves and a gown. She then stated she should have put on gloves and a gown to enter the resident's room when delivering the meal tray. An interview on 3/20/23 at 4:53pm with the Infection Preventionist (IP) revealed that when a resident was on contact precautions, gloves and a gown should be worn when entering the room, regardless of the reason for going into the room. NA #1 should have put on gloves and a gown before entering the resident's room regardless of the reason for going into the room. The IP stated there were plenty of personal protective equipment (PPE) supplies available and the PPE was provided outside the door of room [ROOM NUMBER]. An interview on 3/21/23 at 3:45pm with the Director of Nursing (DON) revealed NA#1 should have put on gloves and a gown before entering room [ROOM NUMBER]. The DON stated there were plenty of PPE supplies available and were provided outside the door of room [ROOM NUMBER]. She further stated staff should don PPE before entering a room with contact precautions regardless of the reason for going into the room. An interview on 3/23/23 at 2:04pm with the Administrator revealed staff have been educated many times about using PPE when entering a room on contact precautions. The Administrator further stated that regardless of the reason, NA#1 should have donned gloves and a gown before she entered room [ROOM NUMBER].

Based on observations and staff interviews the facility failed to ensure food preparation knives ready for use were clean. This practice had the potential to affect food served to residents. Findings included: On 3/22/23 at 11:55 AM an observation of the kitchen revealed two food preparation knives ready for use in the knife storage rack contained visible dried debris on the sides of the blades. The cook was present when the observation was made. On 3/22/23 at 12:54 PM the Dietary Manager (DM) stated the knives were assigned to be cleaned by the cook after use and were placed in the knife rack by the cook. The DM said the knives should have been cleaned and stored without dried debris on them and were overlooked before storing them. The cook was interviewed on 3/22/23 at 1:13 PM and stated the cooks were responsible to wash, clean and sanitize the knives after use. He said the knives were checked for cleanliness before placing them into the storage rack for use. The cook said he believed the 2 knives were overlooked when they were cleaned. The Administrator stated on 3/23/23 at 2:14 PM that the knives should have been cleaned prior to storing them in the knife rack.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #43 was admitted to the facility on [DATE] with multiple diagnoses which included major depressive disorder and hyperlipidemia. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #43 required extensive assistance with activities of daily living (ADL) and was not coded for active diagnoses of major depressive disorder and hyperlipidemia. A joint interview was conducted with the MDS Nurse and MDS Corporate Consultant on 06/10/21 at 11:50 AM. Review of Resident #43's electronic medical record revealed the resident had an active diagnosis for Major Depressive Disorder dated 01/25/21. The interview further revealed the MDS Cooperate Consultant expected for depression to be coded on Resident #43's MDS. An interview conducted with the MDS Corporate Consultant on 6/10/21 at 2:30 PM revealed Resident #43 had an active diagnosis for Hyperlipidemia dated 10/23/20. It was further revealed the MDS Cooperate Consultant expected for Hyperlipidemia to be coded on Resident #43's MDS. An interview conducted with the Director of Nursing (DON) on 06/10/21 at 4:20 PM revealed Resident #43's MDS should be accurately coded for active diagnoses. An interview conducted with the Administrator on 06/10/21 at 4:45 PM revealed there were errors on Resident #43's MDS and the resident's active diagnoses were expected to be coded correctly on the MDS. 3. Resident #80 was re-admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #80 required extensive assistance with activities of daily living (ADL) and was coded for Hospice care under special treatments, procedures, and programs. A Hospice progress note dated 01/23/21 revealed Resident #80 was discharged from Hospice care in need of no further services. A Physician order dated 02/09/21 revealed Resident #80 was ordered to be discharged from hospice care on 01/23/21. A joint interview conducted with the MDS Nurse and MDS Corporate Consultant on 06/10/21 at 11:50 AM revealed after review of Resident #80's electronic medical record the resident should have not been coded for Hospice due to being discharged before the last MDS review. An interview conducted with the Director of Nursing (DON) on 06/10/21 at 4:20 PM revealed Resident #80's MDS should have been accurate and should not have been coded with current Hospice care. An interview conducted with the Administrator on 06/10/21 at 4:45 PM revealed Resident #80 should not have been coded for Hospice care due to being discharged before the most current MDS review. 4. Resident # 60 was admitted to the facility on [DATE] with diagnoses of progressive neurological condition, dementia, and Parkinson's. Resident # 60's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident # 60 required extensive assistance of one person for bed mobility, dressing, and personal hygiene. Resident # 60 required extensive assistance of two persons for transfers. The MDS indicated Resident # 60 required use of limb and trunk restraints. A review of Resident # 60's medical record revealed no orders or care plans for restraints. Observations of Resident # 60 on 6/6/2021 at 3:36 PM revealed she had a yellow nameplate outside her door (indicating she was a high fall risk). Resident # 60 was sitting upright with a half lap-tray on the right side of her wheelchair. Her right arm was resting on the tray. Resident # 60 was alert but did not respond appropriately to questions. The resident was observed on 6/9/2021 at 3:28 PM lying on her back in a low bed with a scoop mattress. On 6/10/2021 at 10:30 AM Resident # 60 was sitting upright in her wheelchair using her feet to mobilize in the hallway. The resident was observed to grab the wall and attempt to stand. She was observed to stand almost upright before a staff member redirected her. An interview with Nurse Aide # 1 (NA) on 6/10/2021 at 9:23 AM revealed Resident # 60 was a high fall risk. Interventions to prevent falls included a low bed, a scoop mattress, gripper socks, room close to the nurse's station, and frequent checks. NA # 1 stated she was not aware of the use of any restraints in the facility. An interview with the MDS Nurse # 1 on 6/10/2021 at 11:54 AM revealed Resident # 60 did not utilize restraints. The Nurse stated she clicked on restraints by accident when completing the 4/27/2021 MDS. She stated she made the correction earlier today. An interview with the Safety Nurse (Nurse # 12) on 6/10/2021 at 2:50 PM revealed the facility was restraint-free. She stated residents who were a high falls risk were provided numerous interventions to prevent falls up to, but not including restraints. Interventions included yellow nameplates on resident doors, low beds, gripper socks, wheel locks for wheelchairs, call bells, personal items, sensory items and mobility aids (wheelchairs / walkers) all within reach and traffic paths clear of clutter. The Safety Nurse indicated Resident # 60 had a half lap-tray in place for support due to recent fracture of her right arm. As Resident # 60 can still get up, the lap-tray was not a restraint. The Safety Nurse also informed a neurologist had ordered an abdominal binder for hypotensive episodes, but the binder was only placed around the resident's abdomen and was not used to secure her to the wheelchair. An interview with the Director of Nursing on 6/10/2021 at 4:30 PM revealed the facility did not utilize restraints for any resident. She stated the MDS entry for restraints must have been completed in error. She stated her expectation of the MDS was for it to be coded correctly. An interview with the Facility Administrator on 6/10/2021 at 4:55 PM revealed the facility was restraint-free. She stated the MDS was most likely coded in error. Her expectation of the MDS was that it be coded accurately. Based on observations, resident and staff interviews and record review the facility failed to ensure the Minimum Data Set (MDS) was accurate for 2 of 3 residents reviewed for diagnosis and medication ( Resident #6, Resident #43), 1 of 1 residents reviewed for Hospice (Resident #80) and one of one residents reviewed for Restraints (Resident #60). 1.Resident #6 was admitted to the facility on [DATE] with multiple diagnosis which included chronic pain and chronic neuropathy. Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 required limited assistance with activities of daily living (ADL) and was not coded for active diagnosis of depression. Resident #6 was coded as receiving 0 antidepressant medications during the assessment period. A nursing progress note dated 03/08/21 revealed Resident #6 had stated to a staff member that he felt like killing himself at times. He was referred to the Psych Physician for a consultation. A Physician order dated 03/10/21 revealed an order for Sertraline (antidepressant) 25 milligrams (mg) to be taken one by mouth daily due to a diagnosis of depression with anxiety with a discontinue date of 06/21/21. A Physician order dated 05/22/21 revealed an order for Sertraline 50 mg 1 daily by mouth with a discontinue date of 09/02/21 for a diagnosis of depression with anxiety. A joint interview was conducted with the MDS Nurse on 06/10/21 at 11:43 AM. Resident #6's electronic medical record revealed Resident #6 was taking an antidepressant medication during the assessment period for an active diagnosis of depression which had not been coded on the MDS. The MDS nurse stated she had just missed coding the active diagnosis and antidepressant medication by accident. An interview conducted with the MDS Corporate Consultant on 6/10/21 at 11:50 AM revealed Resident #6 was taking an antidepressant medication for an active diagnosis of depression. She stated she expected for depression to be coded on Resident #6's MDS. An interview conducted with the Director of Nursing (DON) on 06/10/21 at 4:20 PM revealed Resident #6's MDS should be accurately coded for active diagnosis. An interview conducted with the Administrator on 06/10/21 at 4:45 PM revealed there were errors on Resident #6's MDS and the resident's active diagnoses were expected to be coded correctly on the MDS. The interview revealed the facility had no recent in-servicing on MDS coding.

Based on observation and staff interviews, the facility failed to dispose of expired perishable food items in 1 of 1 cooler. Staff drinks were observed to be stored alongside resident food items in the kitchen freezer. The facility also failed to dispose of expired foods and date individual cartons of juice and bottled drinks in 1 of 2 resident nourishment rooms. The findings included: a. An observation of the cooler was made on June 7, 2021 at 10:50 AM with the Dietary Manager (DM). The observation revealed the following: A container of tuna salad three-fourths full, with an expiration date of June 4, 2021 written on the container A container of chicken salad, full, with expiration date of May 31, 2021 written on the container b. An observation of a freezer was made on June 7, 2021 at 11:15 AM. The DM was present. The observation revealed the following: Two staff members' drinks were stored alongside food items in a freezer reserved for food for resident consumption. c. An observation of the nourishment room on the 200 hall was completed on June 9, 2021 at 11:25 AM. A staff nurse was present. The observation revealed the following: An intact box of thickened apple juice with use by March 26, 2021 stamped on the box inside the cabinet. A bin of prune juice containers in the refrigerator with no expiration dates on the containers in the refrigerator. 3 bottled drinks with no expiration dates on the bottles in the refrigerator (Available for any resident consumption) 4 containers of vanilla pudding with expiration dates of May 2021. An interview was conducted with the DM on June 7, 2021 at 11:15 AM. The DM stated the expired items in the cooler should have been disposed of at the end of the shift on the day of expiration. He stated opened items should have had the open date written on the package. The DM stated staff thermoses should not be stored alongside items for resident consumption. An interview with the Director of Nursing on June 9, 2021 at 11:55 AM revealed the nourishment rooms were checked daily by dietary staff. She stated the check included review of expiration dates. She indicated the items must have simply been missed. She stated, all we can do now, is do better. An interview with the Administrator on June 10, 2021 at 4:50 PM revealed the food items in the kitchen cooler should have been discarded on the expiration date, the opened items should have been labeled with an opened date, and the nourishment room items should have been checked more closely and disposed of accordingly. She could not explain why personal mugs were stored in the dedicated resident freezer. She stated the DM was still very new to long-term care and would make sure corrections were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 1 of 3 staff members (Staff #1) failed to discard her N95 mask and disinfect her goggles after leaving a quarantine room and before going to a non-quarantine room, 1 of 3 staff members (Staff #2) had no eye protection while in the quarantine room, and 1 of 3 staff members (Staff #3) wore a surgical mask and had no eye protection while in a quarantine room. These practices affected 4 of 4 residents (Resident #235, Resident #338, Resident #285 and Resident #322) reviewed for infection control. These failures occurred during a COVID-19 pandemic. The findings included: The Centers for Disease Control and Prevention (CDC) guideline entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/23/21 indicated, in part: *The Personal Protective Equipment (PPE) recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: 1. Respirator - Put on an N95 respirator (or equivalent or higher-level respirator) before entry into the patient room or care area, if not already wearing one as part of extended use strategies to optimize PPE supply. Disposable respirators should be removed and discarded after exiting the patient's room or care area and closing the door unless implementing extended use or re-use. Perform hand hygiene after removing the respirator or facemask. 2. Eye Protection - Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Remove eye protection after leaving the patient room or care area, unless implementing extended use. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or re-use. A review of the facility's COVID-19 policy entitled, COVID-19 Resident/Teammate Management - COVID Outbreak Response, revised on 3/2021 indicated the following statements under PPE Enhancement: 1. Respiratory protection should be worn at all times when not eating or drinking in the facility. Eye protection for all patient care. 2. For hallways/neighborhoods with two or more cases, teammates shall wear N95 or equivalent respirator for all resident care for the duration of the outbreak. 3. If the outbreak extends beyond a single hallway/neighborhood, routine N95 use will be expanded as appropriate. The facility did not have a policy regarding PPE use and management for staff members when working in the quarantine hall designated for new admissions and re-admissions. 1. A continuous observation was made of Staff #1 on 6/9/21 from 8:14 AM to 9:08 AM during medication administration. During the observation, a sign for special droplet/contact precautions was on Resident #235's room door. While preparing Resident #235's medications in the hallway, Staff #1 was observed wearing a surgical mask and goggles. As she got ready to enter Resident #235's room, Staff #1 discarded the surgical mask, used hand sanitizer and put on an N95 mask on her face. She proceeded to put on a gown and gloves and entered Resident #235's room to administer her medications. Before leaving the room, Staff #1 removed her gown and gloves and washed her hands in the room sink. Staff #1 exited Resident #235's room and did not discard her N95 mask or disinfect her goggles. At 8:26 AM, Staff #1 entered Resident #338's room who was not on special droplet/contact precautions and asked Resident #338 what she wanted to drink. Staff #1 then proceeded to walk from the 400 hallway and passed through 100 hall to the nourishment room that was located on the 200 hall. After obtaining some juices out of the refrigerator, Staff #1 went back to Resident #338's room to give her medications. At 9:08 AM, Staff #1 entered Resident #285's room who was not on special droplet/contact precautions and asked Resident #285 what he wanted to drink with his medications. An interview conducted with Staff #1 on 6/9/21 at 9:09 AM revealed she forgot and should have discarded her N95 mask when she left Resident #235's room who was on special droplet/contact precautions. Staff #1 confirmed that Resident #235 was currently the only newly admitted resident on the hall who was on special droplet/contact precautions. Staff #1 stated that she had been told to leave her goggles on the whole time she was working and to only clean it between shifts unless it was visibly soiled. An interview with the facility's Infection Preventionist on 6/9/21 at 4:28 PM with the Administrator present revealed Staff #1 should have discarded her N95 mask and sanitized her goggles when she exited Resident #235's room. An interview with the organization's Infection Preventionist (IP) on 6/10/21 at 11:15 AM revealed the facility had been practicing extended use for N95 mask and eye protection. The staff members had been trained not to remove their N95 mask and goggles once they put them on, treat both PPE as part of their face and not to touch their face. The organization's IP stated they felt there was a higher chance of contamination with constantly touching their masks to remove them. She explained that the facility was following the organization's infection control policies and procedures. An interview was conducted on 6/10/21 at 4:26 PM with the Director of Nursing (DON) who stated she did not expect Staff #1 to discard her N95 mask and disinfect her goggles after exiting a room on special droplet/contact precautions because that was not what they were trained to do. The DON stated the facility was following the organization's infection control policies and procedures which included to discard their masks and disinfect their goggles at the end of the day. An interview with the Administrator on 6/10/21 at 4:51 PM revealed she expected Staff #1 to have done what she was trained to do related to PPE use. She added that it was hard to keep up with the CDC guidelines because they kept on changing all the time. 2. An observation was made on 06/09/21 of Staff #2 entering Resident #235's room who was on enhanced droplet contact precautions according to the sign on the resident's door. He entered Resident #235's room at 12:40 PM with an N95 mask on but no goggles or face shield. Resident #235 was admitted to the facility on [DATE], and according to her discharge summary from the hospital, was not vaccinated for COVID-19 and had refused vaccines while hospitalized so the resident was placed on enhanced droplet/contact precautions for 14 days. Staff #2 was observed approximately 2 feet from the resident while obtaining her history and exited the room at 1:21 PM. An interview was conducted on 06/09/21 at 2:59 PM with Staff #2. He revealed he had been involved from the beginning through their Quality Assurance and Process Improvement program with COVID-19. He stated he and the Nurse Practitioner (NP) work closely together in managing the residents at the facility. He further stated they were following the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) guidance for nursing homes in caring for the residents at the facility. He mentioned the hospital organization the facility belonged to had also provided education and guidance to the facility staff on COVID-19. Staff #2 indicated he and the staff at the facility were following the protocols and were wearing all the appropriate Personal Protective Equipment (PPE) when caring for the residents. An interview with the facility's Infection Preventionist (IP) on 06/09/21 at 4:28 PM with the Administrator present, revealed Staff #2 was expected to wear goggles when in resident rooms who were on enhanced contact/droplet precautions. An interview with the organization's IP on 6/10/21 at 11:15 AM revealed the facility was following the organization's infection control policies and procedures. The organization's IP stated Staff #2 was expected to wear goggles while in resident rooms who were on enhanced contact/droplet precautions. 3. Resident #236 was admitted to the facility on [DATE], and according to her discharge summary from the hospital, was not vaccinated for COVID-19 and had refused vaccines while hospitalized so the resident was placed on enhanced droplet/contact precautions for 14 days. On 06/09/21 at 1:29 PM Staff #3 was observed entering Resident #236's room with gown, gloves and surgical mask on but no N95 mask and no goggles or face shield on to deliver the resident a pitcher of water. Staff #3 was observed exiting the room, doffing her gown and gloves. An interview on 06/09/21 at 1:35 PM with Staff #3 revealed she had not paid attention to the sign on the resident's door for enhanced droplet/contact precautions and the need for an N95 when going into the room. She stated she was concentrated on getting the resident some water to drink and had not read the sign before entering the room. Staff #3 stated she had received training regarding wearing the appropriate Personal Protective Equipment (PPE) into the room of a resident on enhanced contact precautions but stated she had failed to put on an N95 mask and goggles prior to going into Resident #236's room. An interview with the facility's Infection Preventionist on 6/9/21 at 4:28 PM with the Administrator present revealed Staff #3 should have donned an N95 mask and goggles prior to going in Resident #236's room and should have discarded the N95 when leaving the room and donned a surgical mask for source control. An interview with the organization's Infection Preventionist (IP) on 6/10/21 at 11:15 AM revealed the facility was following the organization's infection control policies and procedures. The organization's IP stated the staff were expected to wear an N95 and goggles while in resident rooms who were on enhanced contact/droplet precautions. The organization's IP further stated they had been practicing extended use for N95 mask and eye protection.