**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy and procedure review the facility failed to ensure staff performed hand hygiene during medication administration to Resident #40 and Resident #50 to prevent cross contamination of germs and failed to initiate isolation precautions for Resident #20 to prevent the spread of influenza. This affected two out of three residents observed during medication administration and one out of three residents reviewed for isolation precautions. The facility census was 82. Findings include: 1. Medical record review revealed Resident #40 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including rhabdomyolosis ( muscle injury where muscles break down), schizoeffective disorder, hypo-osmoality, alcohol abuse, anemia, osteoarthritis, lupus erythmatosis (body's immune system attacks tissues and organs), heart attack, low magnesium and potassium level, atrial-fibrillation, depression, Raynaud's syndrome, vascular heart disease, retinopathy, cataracts, urinary retention with neuromuscular bladder, angioneurotic edema (unpredictable frequent edematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system), and acute respiratory/kidney failure. Medical record review revealed Resident #50 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including right lower leg pain, acute cough, intervertebral disc degeneration of the lower back, high blood pressure, gastroesophageal reflux disease, chronic kidney disease, scoliosis, group B vitamin deficiency, encephalopathy, and anemia. An observation of Licensed Practical Nurse (LPN) #91 administer 11 medications to Resident #40 on 04/28/25 at 8:59 A.M. revealed a failure to perform hand hygiene to prevent cross contamination of germs. LPN #91 dispensed the following medications in a medication cup: - lactobacillus acidophilus two capsules - colace 100 milligram (mg) tablet - duloxetine 30 mg tablet - potassium chloroide 10 milliequivalents (mEq) tablet - Lasix 20 mg tablet - Thera M multivitamin with minerals supplement 1 tablet - ethylene glycol powder 1 gram (gm) - thiamin 100 mg tablet - sodium chloride 1 gm tablet - sertraline 50 mg tablet - sertraline 25 mg tablet LPN #91 then removed the two lactobacillus acidophilus capsules from the medication cup and opened the capsules with her bare hands to empty the capsules in the medication cup mixed with applesauce. LPN #91 proceeded to administer the above listed medications to Resident #40 and did not perform hand hygiene after administering Resident #40's medications. LPN #91 then proceeded to remove Resident #50's medications from the medication cart and administer the following seven oral medications to Resident #50: - guaifenesin 600 mg tablet - amlodipine 5 mg tablet - colace 100 mg tablet - senna 8.6 mg tablet - metoprolol 37.5 mg tablet - pantoprazole 40 mg tablet - losartan potassium 100 mg tablet After administering the above seven medications LPN #91 failed to perform hand hygiene. An interview with LPN #91 on 04/28/25 at 9:40 A.M. confirmed she opened the lactobacillus using her bare hands, did not perform hand hygiene after administering Resident #40's medications, and did not perform hand hygiene after administering medications to Resident #50. Review of the facility's policy titled Medication Administration - Preparation and General Guidelines revised August 2014 indicated medications were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications were to do so only after they had been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The policy further indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The procedure included: Handwashing and Hand Sanitization: The person administering medications was to adhere to good hand hygiene, which included washing hands thoroughly - before beginning a medication pass, - prior to handling any medication, - after coming into direct contact with a resident, - before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations, and before and after administration of medications - via enteral tubes. - Examination gloves were to be worn when necessary Hand sanitization was to be done with an approved sanitizer - between hand washings, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). - at regular intervals during the medication pass such as after each room, again assuming handwashing was not - Sanitization was not a substitute for proper handwashing, and washing should be done if there is any question. indicated. 2. Medical record review revealed Resident #20 was re-admitted on [DATE] with diagnoses including spastic paraplegia, asthma, diabetes mellitus, anemia, heart failure, kidney disease, atherosclerotic heart disease, morbid obesity, gout, edema, high blood pressure, depression, insomnia, hypothyroidism, deep vein thrombosis of right lower extremity, cognitive impairment, anxiety with restlessness/agitation, osteoarthritis, abnormal liver function, rotator cuff tear of right shoulder, disorder of kidney and ureter, vitamin D deficiency, high potassium level, gastroesophageal reflux disease, embolism of left popliteal vein, respiratory synctial virus (RSV), hearing loss, eye diseases, high cholesterol, dizziness, low blood pressure, low heart rate, urinary retention, hydronephrosis, and pulmonary embolism. Further review of the medical record revealed nursing progress notes dated 03/19/25 which indicated Resident #20 was re-admitted to the facility from the hospital with a diagnosis of influenza A. The nursing progress note revealed Resident #20 had a moist cough, abnormal lung sounds on both sides and was receiving Tamiflu medication to treat the diagnosis of influenza A. Further review of Resident #20's clinical record revealed no documentation that isolation precautions were implemented. A review of Resident #20's physician orders dated 03/01/25 to 03/31/25 revealed no order to implement isolation precautions. The above was confirmed with the Director of Nursing on 04/29/25 at 12:00 P.M. Review of the the facility's undated policy and procedure titled Isolation - Categories of Transmission-Based Precautions revealed the policy statement indicated transmission-based precautions were initiated when a resident developed signs and symptoms of a transmissible infection; arrived for admission with symptoms of an infection; or had a laboratory confirmed infection; and was at risk of transmitting the infection to other residents. The indications for contact precaution isolation included : 1. Contact precautions were to be implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. Contact precautions were also used in situations when a resident was experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that could not be contained and suggested an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified. 3. Contact precautions were to be used for residents infected or colonized with MDROs in the following situations: a. When a resident had wounds, secretions, or excretions that are unable to be covered or contained; and b. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission was occurring. 4. These strategies could differ depending on the prevalence or incidence of the MDRO in the facility and region. For example, additional usage of PPE (enhanced barrier precautions) could be used for residents who did not meet criteria for contact precautions but were infected or colonized with MDROs (or have risk factors for MDRO acquisition). 5. The decision on whether contact precautions were necessary were to be evaluated on a case by case basis. 6. The individual on contact precautions was to be placed in a private room if possible. If a private room was not available, the infection preventionist was to assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). 7. Staff and visitors were to wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff were to change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves were to be removed and hand hygiene performed before leaving the room. c. Staff were to avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 8. Staff and visitors were to wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 9. When transporting individuals with skin lesions, excretions, secretions, or drainage that was difficult to contain, contact precautions were to be taken during resident transport to minimize the risk of transmission. This deficiency represents non-compliance investigated under Complaint Number OH00165067.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure accurate documentation related to medication administration; ensure a clear and accurate reconciliation of controlled substances; ensure controlled medications were not administered without physician orders, and as needed medications were not removed from secured storage areas prior to being requested or needed by the residents. This affected seven (Residents #16, #5, #14, #40, #84, #85 and #79) of seven residents reviewed for medication administration. The facility census was 82. Findings include: 1. Medical record review revealed Resident #16 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including mild intellectual disability, Alzheimer's disease, cerebral infarction (stroke), convulsions, pulmonary/heart disease, peripheral vascular disease, gastritis/colitis with esophageal reflux disease, high blood pressure/cholesterol, end stage kidney disease, diabetes mellitus, psychotic disorder, depression, anxiety, and osteoarthritis. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 received high risk medications including an anticonvulsant medication. Review of a physician order dated 03/18/22 indicated to administer Resident #16 Lacosamide 100 milligrams (mg) orally at bedtime for seizures related to unspecified convulsions. Review of Resident #16's plan of care indicated Resident #16 had a seizure disorder and history of a stroke. Interventions included to administer medications as ordered, observe for effectiveness and side effects, and document the location of seizure activity, type of seizure activity, duration, level of consciousness, and post-ictal state after seizure activity. A review of Resident #16's Controlled Substance Accountability Sheet for the documentation of Lacosamide administration dated 03/18/25 indicated inaccurate documentation of the date and time the medication was dispensed, amount administered, quantity wasted/destroyed and quantity remaining. On 04/23/25 the documentation indicated one tablet of Lacosamide remained in stock. On 04/24/25 at 9:00 A.M. the documentation indicated one tablet was dispensed, one tablet administered and the quantity remaining zero. The quantity remaining should have been one. On 04/24/25 at 4:00 P.M. the documentation indicated no tablets were dispensed and one tablet was administered with one tablet remaining which was incorrect. The remaining amount should have been zero. On 04/28/25 the documentation indicated there was one tablet of Lacosamide remaining, one tablet dispensed, one tablet administered and should have one tablet remaining. The documentation indicated no tablets remained. It was not clear upon reviewing the Controlled Substance Accountability Sheet where the Lacosamide was obtained; sometimes the medication was removed from the medication cart and sometimes the medication was removed from the electronic medication dispensing system. The electronic medication dispensing system was used when the medication was available in Resident #16's stock of medication. An interview with Registered Nurse (RN) #90 on 04/28/25 at 11:30 A.M. verified she had documented Resident #16's Lacosamide removal and administration to Resident #16 on the Controlled Substance Accountability Sheet incorrectly. An interview with Director of Nursing and Administrator on 04/29/25 at 12:00 P.M. verified the above findings and they confirmed the documentation on Resident #16's Controlled Substance Accountability Sheet was incorrect. 2. Medical record review revealed Resident #5 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including morbid obesity, fractured right arm/right clavicle/thoracic vertebra, depression, sleep apnea, dislocation of right acromioclavicular joint, epilepsy, nervous system diseases, chronic kidney disease, peripheral vascular disease, high cholesterol, constipation, vitamin D deficiency, anxiety, and gastroesophageal reflux disease. A review of Resident #5's physician orders dated 03/01/25 to 03/31/25 indicated to administer oxycodone hydrochloride five milligram (mg) tablet orally every six hours as needed for pain. Medical record review revealed Resident #14 was admitted on [DATE] with diagnoses including surgical joint replacement, arthropathies, cataracts, eye disease, cardiac pacemaker/defibrillator, anxiety, depression, atrial-fibrillation, osteoarthritis, dilated cardiamyopathy, gastroesophageal reflux disease, fibromyalgia, heart failure, high cholesterol, high blood pressure, and migraine. A review of Resident #14's physician orders dated 03/01/25 to 03/31/25 indicated to administer Tramadol hydrochloride 50 mg orally every six hours as needed for mild pain. Medical record review revealed Resident #40 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including rhabdomyolosis (muscle injury where muscles break down), schizoeffective disorder, hypo-osmoality, alcohol abuse, anemia, osteoarthritis, lupus erythmatosis (body's immune system attacks tissues and organs), heart attack, low magnesium and potassium level, atrial-fibrillation, depression, Raynaud's syndrome, vascular heart disease, retinopathy, cataracts, urinary retention with neuromuscular bladder, angioneurotic edema (unpredictable frequent edematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system.), and acute respiratory/kidney failure. A review of Resident #40's physician orders dated 03/01/25 to 03/31/25 indicated to administer Ativan 0.5 mg orally every six hours as needed and to administer oxycodone 10 mg every six hours as needed for pain. A review of the Controlled Dispensing documentation for removal of controlled substances from the electronic dispensing system dated 03/31/25 revealed from 7:32 P.M. to 7:33 P.M. one oxycodone five mg tablet and one lorazepam (Ativan) 0.5 mg tablet was removed for Resident #40, one Tramadol 50 mg tablet was removed for Resident #14 and one oxycodone five mg tablet was removed for Resident #5. An interview with Registered Nurse (RN) #92 on 04/29/25 at 9:27 A.M. revealed she had been disciplined for removing Resident #5, Resident #14, and Resident #40's controlled narcotics at the same time from the electronic dispensing system in the facility. RN #92 stated she had difficulty walking and did not want to walk back and forth three times because she knew she would be administering the as needed medications to Resident #5, Resident #14 and Resident #40 some time during her 12 hour shift. A review of the facility documentation of the investigation of RN #92 dated 04/01/25 revealed Resident #5, Resident #14 and Resident #40's controlled narcotic medications were removed from the electronic dispensing system at the same time. The investigation indicated the Director of Nursing (DON) received the daily electronic dispensing system report with controlled narcotics pulled from the night before. After reviewing, the DON noted that narcotics were all pulled around the same time. Due to narcotics being as needed, the DON questioned why they were pulled simultaneously. The DON interviewed the listed residents on the report and all residents confirmed they received their medications. The DON and the Administrator spoke with RN #92 who stated, I pulled them at the same time to save myself a trip. 3. Medical record review revealed Resident #85 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including emphysema, malnutrition, iron deficiency anemia, atherosclerotic heart disease, cardiomyopthy, hypo-osmoality, osteoarthritis, bone density disorder, left pubis pelvic fracture, and post-traumatic headache with acute post-traumatic general pain. Review of Resident #85's physician order dated 03/28/25 indicated to administer oxycodone hydrochloride 2.5 mg every eight hours as needed for pain due to diagnosis of a fracture of left pubis. Review of Resident #85's Medication Administration Record (MAR) dated 04/01/25 to 04/30/25 indicated on 04/02/25 Resident #85 received oxycodone hydrochloride 2.5 mg orally at 1:22 A.M. Review of Resident #85's Controlled Substance Accountability Sheet dated 03/29/25 to 04/10/25 indicated on 04/02/25, Registered Nurse (RN) #92 removed oxycodone five milligram (mg) tablet to administer to Resident #85 at 1:30 and 7:30. There was no documentation to indicate if the medication was administered in the A.M. or P.M. An interview with RN #92 on 04/29/25 at 4:15 P.M. revealed she had administered Resident #85's oxycodone medication two hours early. RN #92 confirmed Resident #85's physician order for oxycodone indicated the oxycodone could be administered for pain every eight hours and she administered the oxycodone medication at 1:30 A.M. and 7:30 A.M. on 04/02/25 which was six hours between doses and should not have been administered until eight hours between doses. An interview on 04/30/25 at 12:45 P.M. with the Administrator verified there was no documentation that Resident #85 was administered the oxycodone 2.5 mg dose at 7:30 A.M. on Resident #85's Medication Administration Record (MAR) or clinical record. The Administrator confirmed the documentation on Resident #85's narcotic control sheet did not indicate if the oxycodone removed from the medication cart was removed during the morning hours, afternoon hours or evening hours at 1:30 and 7:30 on 04/02/25. The Administrator also verified RN #92 had removed Resident #85's oxycontin medication from the medication cart at 7:30 A.M. on 04/02/25 but did not document the administration of the oxycontin medication in Resident #85's clinical record and/or MAR. 4. Medical record review revealed Resident #84 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease, heart failure, hydronephrosis, gastritis, uropathy, high blood pressure, diabetes mellitus, high cholesterol, atherosclerotic heart disease, cerebral infarction (stroke), diaphragmatic hernia, anxiety with adjustment disorder, obstructive sleep apnea, osteoporosis, urinary retention, right tibia/fibula fracture, and neuropathy. Further review of the medical record including Resident #84's physician orders revealed there was no physician order for the administration of liquid Morphine. Review of Resident #84's Medication Administration Record (MAR) dated 09/01/25 to 09/31/25 revealed no documentation Resident #84 was administered liquid Morphine. An interview with Registered Nurse (RN) #90 on 04/28/25 at 11:06 A.M. revealed RN #90 stated she had administered Resident #84 liquid Morphine without an order. RN #90 said she gave the dosage of Morphine to Resident #84 on or about 09/25/24. Resident #84 had complained of pain and RN #90 found a bottle of liquid Morphine in the locked medication drawer of the medication cart and measured five milligrams (mg) of the liquid and administered the Morphine to Resident #84. RN #90 stated she could not explain how a bottle of liquid Morphine was labeled with Resident #84's name without a physician order. A review of RN #90's statement sent to the Ohio Board of Nursing (OBN) dated 01/09/25 revealed that on or about 09/25/24, RN #90 administered Morphine to Resident #84. The statement indicated it had been said that the resident had not had an order for Morphine and also had a listed allergy to Morphine. That particular day RN #90 had shared with a co-worker (unnamed) that Resident #84 did not seem to be doing well and that RN #90 thought she may be starting the process of dying. RN #90 made the co-worker aware that Resident #84 was still lucid and if he wanted to go and say hello and visit it might be a good time. When the co-worker returned, he had stated that Resident #84 had a complaint of pain and requested pain medication. Together RN #90 and the co-worker walked back to the medication cart where RN #90 pulled the narcotic medication record, opened the narcotic drawer where Resident #84's prescribed Morphine was found. RN #90 then drew up the Morphine medication, entered Resident #84's room and made Resident #84 aware of the administration of the requested pain medication of Morphine and that the liquid Morphine would be placed under her tongue, RN #90 then administered the Morphine. After RN #90 was done both staff exited the room. RN #90 returned to the medication cart, documented the medication was given on the paper chart, and then went to the electronic chart and was unable to find the order for the Morphine medication listed. RN #90 notified the primary care Certified Nurse Practitioner (CNP) of the error. The CNP asked if there were any adverse reactions and to please continue to monitor. The resident was in the care of Hospice at that time. Having been an RN Case Manager for a hospice company in the past, RN #90 was aware that hospice treated the symptoms of a dying resident which also meant that if a resident had a said allergy to a medication with no history of anaphylactic reaction the symptoms were treated. Resident #84 had shown no signs or symptoms of adverse reaction. RN #90 reported the medication error her next shift to the Director of Nursing (DON). RN #90 received verbal disciplinary action for the error. Also, being made aware, moving forward, to report any medication error to management immediately. RN #90 indicated had the resident not had a valid written prescription the medication would not have been available or received by the facility from the pharmacy. The medication was clearly labeled with Resident #84's name. A review of the OBN letter dated 01/27/25 revealed the OBN had investigated RN #90 for administering Morphine medication to a resident without a physician order. The Nursing Board recommended RN #90 complete additional training prior to her RN license renewal within 180 days of the date of the investigation on 01/25/25. An interview with the Administrator and DON on 04/29/25 at 12:45 P.M. verified the above findings and confirmed RN #90 had administered the Morphine medication to Resident #84 without a physician order. It could not be confirmed where the Morphine bottle came from and/or if it had Resident #84's name on the label. 5. Medical record review revealed Resident #79 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage, glaucoma, high blood pressure, legal blindness, obesity, peripheral vascular disease, psychosis, mood disorder, pseudobulbar affect, arthopathies, insomnia, and ringing of the ears. A review of Resident #79's nursing progress notes dated 04/27/25 timed 9:07 A.M. revealed Resident #79 was crying loudly and not able to state why he was crying. Resident #79 denied pain and was pulling on his catheter, Redirection and repositioning were ineffective. Ativan was administered with good results noted. Further review of Resident #79's medical record revealed there was no order for the administration of Ativan to Resident #79. An interview with the Director of Nursing (DON) on 04/29/25 at 3:38 P.M. revealed she was informed by Registered Nurse (RN) #92 that she had administered Resident #21 the Ativan medication and had documented the administration of the Ativan in the nursing progress notes in Resident #79's clinical record by accident. The DON verified the documentation of the administration of the Ativan medication in Resident #79's progress note dated 04/27/25 at 9:07 A.M. was inaccurate. Resident #79 did not receive the Ativan medication. Review of the facility's policy titled Medication Administration - Preparation and General Guidelines revised August 2014 indicated medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications would do so only after they had been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The policy further indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The policy indicated the FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, were applied for each medication being administered. A triple check of these Five Rights was recommended at three steps in the process of preparation of a medication for administration: (1) when the medication was selected, (2) when the dose was removed from the container, and finally (3) just after the dose was prepared and the medication put away. a. Check #1: Select the Medication - label, container and contents checked for integrity, and compared against the medication administration record (MAR) by reviewing the Five Rights. b. Check #2: Prepare the dose - the dose was to be removed from the container and verified against the label and the MAR by reviewing the five Rights. When medications were administered from a central location, such as the medication room, medications for the immediate administration time were to be prepared not more than 60 minutes in advance for all residents, or per applicable state law or regulation. In no case should more that one dose time be prepared in advance. Documentation (including electronic) indicated the individual who administered the medication dose recorded the administration on the resident's medication administration record (MAR) directly after the medication was given. At the end of each medication pass, the person administering the medications was to review the MAR to ensure necessary doses were administered and documented. In no case was the individual who administered the medications to report off-duty without first recording the administration of any medications. This deficiency represents non-compliance investigated under Complaint Number OH00165067.

Based on observation, staff interview, review of the facility policy, review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when the county community transmission levels were high. This had the potential to affect 31 residents (#5, #6, #7, #10, #11, #12, #14, #15, #17, #20, #21, #26, #28, #29, #32, #33, #34, #38, #42, #46, #48, #51, #58, #62, #68, #71, #72, #74, #76, #80, and #81) who resided on the 2 East Hall. The facility census was 79. Findings include: Review of the CDC COVID Data Tracker website on 03/07/23 revealed the community transmission levels for the county in which the facility was located was high and in the red. Observation during tour of the facility on 03/07/23 at approximately 8:55 A.M. revealed State Tested Nurse Aide (STNA) #475 passing breakfast trays on the 2 East hall. STNA #475 was not wearing a facemask. Interview with STNA #475 at the time of observation revealed wearing a facemask was optional. Sometimes STNA #475 wore a facemask and other times she did not. Today STNA #475 decided not to wear a facemask. STNA #475 stated information regarding community transmission levels and what PPE staff needed to wear was posted by the time clock. Interview on 03/07/23 at 9:07 A.M. and 10:42 A.M. with the Director of Nursing (DON) revealed based on the information obtained from a website (not the CDC community transmission levels) indicating the county levels were medium and in the yellow the facility was allowing staff to have the option of wearing a facemask. Review of the CDC website with the DON revealed the county transmission level was high and in the red. The DON stated the accurate community transmission level would be posted and staff would be notified of the appropriate PPE to wear. Observation on 03/07/23 at 3:42 P.M. revealed STNA #473 on the 2 East Hall without wearing a facemask. Interview with STNA #473, at the time of the observation, verified she was not wearing a facemask in an area where residents could be encountered. STNA #473 stated facemask were available at the nurses station and also by the time clock. STNA #473 stated notes were left to let staff know what PPE they should be wearing and she did not check to see what PPE was required prior to coming onto the 2 East Hall. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/27/23 revealed, under recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, when SARS-CoV-2 community transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. Source control options for healthcare personnel include A NIOSH-approved particulate respirator with N95 filters or higher; a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators; a barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks; or a well-fitting facemask. Review of facility policy titled COVID-19; SARS-CoV-2, dated 09/28/22 revealed when SARS-CoV-2 community transmission levels were high (red), source control was recommended for everyone in a healthcare setting when in areas that could encounter residents. Source control was defined as the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they were breathing, talking, sneezing, or coughing. This deficiency represents non-compliance investigated under Complaint Number OH00140441.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure incontinence care was provided timely for two residents (Residents #27 and #226) and failed to ensure one resident (Resident #226) was shaved. This affected two residents (Residents #27 and #226) out of three residents reviewed for care for dependent residents. The facility census was 73. Findings include: 1. Review of Resident #226's medical record revealed an admission date of 07/13/22, a re-entry date of 07/21/22, and diagnoses included Wernicke's encephalopathy, schizophrenia, and dementia. Review of Resident #226's admission Minimum Data Set (MDS) 3.0 assessment revealed Resident #226 had severe cognitive impairment. Resident #226 required extensive assistance of one staff member for bed mobility, toilet use and personal hygiene. Resident #226 was always incontinent of urine. Observation on 07/26/22 at 11:39 A.M. of Resident #226 revealed him sitting in his wheelchair near the nurses station. Resident #226 had several days growth of facial hair and was dressed in a hospital gown and socks. Observation on 07/27/22 at 8:30 A.M. of Resident #226 sitting in the hall in his wheelchair wearing a hospital gown and socks, and still had not been shaved showing several days growth of facial hair. Review of Resident #226's care plan dated 07/28/22 included Resident #226 had an Activity of Daily Living (ADL) self-care performance deficit related to diagnoses. Resident #226 would achieve maximum ADL function through next the review. Interventions included Resident #226 required extensive assist of one staff to maximize independence. Resident #226 required extensive to total assist of one staff for toileting. Resident #226 had potential impairment to skin integrity related to fragile skin, including impaired mobility, incontinence of bowel and bladder. Resident #226 would maintain or develop clean and intact skin by the review date. Interventions included to keep skin clean and dry, and keep body parts from excessive moisture. Review of Resident #226's progress notes on 7/29/2022 at 10:14 P.M. written by Licensed Practical Nurse (LPN) #530 included Resident #226's sister had the resident standing behind his wheelchair with his pants down and door open. Resident #226's sister stated her brother never looked like this when she took care of him. Resident #226's sister proceeded to take pictures of Resident #226 on her phone. When asked why she had his pants down Resident #226's sister said his scrotum was never red like this when she took care of him. Resident #226's sister lifted the residents scrotum and started to take pictures with her phone sending them to someone as evidence by Resident #226's sister asking a person on the phone do you see how red he is? Resident #226's sister also continued to take pictures of his buttocks. The Certified Nurse Practitioner (CNP) was notified of Resident #226's excoriation and a treatment for excoriation was started to his scrotum and upper thighs per CNP orders. Review of Resident #226's physician orders dated 07/29/22 revealed dermaseptin (skin barrier ointment) to by applied to his scrotum and perineal area every shift after incontinence care to promote skin integrity. Review of Resident #226's shower sheets dated 07/22/22, 07/26/22, and 08/02/22 did not reveal documentation Resident #226 had his face shaved. Review of Resident #226's shower sheet dated 07/29/22 stated no to the question was face shaved. Observation on 08/03/22 at 9:34 A.M. of State Tested Nursing Assistant (STNA) #547 providing incontinence care for Resident #226 revealed his incontinence brief was wet, but not saturated. STNA #547 stated Resident #226's incontinence brief was dry when she checked it at 7:00 A.M. STNA #547 stated Resident #226 was sleeping at 7:00 A.M. and she did not notice if his gown and draw sheets were wet. Observation did not reveal redness or skin breakdown, but the bottom part of Resident #226's gown was wet and two reusable cloth draw sheets were wet underneath him. STNA #547 stated the night shift aide must have changed his brief but not his gown or the cloth draw sheets. Observation on 08/03/22 at 2:45 P.M. with Registered Nurse (RN) #602 and STNA #547 revealed Resident #226 had beard stubble his on face. Interview on 08/03/22 at 3:46 P.M. with STNA #547 confirmed Resident #226 had stubble on his face. STNA #547 stated she did not have time to shave him this morning, and was planning on it this afternoon but her assignment changed and she was moved to a different nursing unit and was unable to shave Resident #226. Review of the facility policy titled Personal Care/Bathing, revised 10/2017 included shaving was offered to resident daily during the routine bathing process. 2. Review of Resident #27's medical record revealed an admission date of 04/27/22 and diagnoses included dementia with behavioral disturbance and weakness. Review of Resident #27's admission MDS 3.0 assessment dated , 05/04/22 revealed Resident #27 had moderate cognitive impairment and required extensive assistance of one staff member for bed mobility and toilet use. Resident #27 was always incontinent of urine and frequently incontinent of bowel. Review of Resident #27's care plan dated, 07/29/22 included Resident #27 had bowel and bladder incontinence related to activity intolerance, confusion,dementia, impaired mobility, inability to communicate needs, physical limitations and pain. Resident #27 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to provide incontinence care with care rounds every shift. Observation on 08/03/22 at 10:35 A.M. with STNA #547 of incontinence care for Resident #27 revealed her incontinence brief was very wet. STNA #547 stated she did not check her before now because she was busy getting other residents up and serving breakfast. Observation of a dark red area across Resident #27's coccyx approximately 4 inches long with a purple area in the center of the red area was noted. The red area extended across the coccyx and bilateral buttocks. STNA #547 stated the residents on the nursing unit required a lot of assistance from the staff and it was hard to get to the residents in a timely manner. STNA #547 stated she did not care for Resident #27 on 08/02/22 and did not know when she developed the red area on her coccyx. An interview on 08/03/22 at 10:55 A.M. with LPN #521 revealed on 07/31/22 she was assigned to the nursing unit Resident #27 resided on and Resident #27 did not have a red area on her coccyx. LPN #521 stated Resident #27 had been lying in her bed a lot because she had COVID-19 and just came off precautions a couple days ago. LPN #521 confirmed the red area extended across the coccyx and bilateral buttocks and had a purple center. Observation of LPN #521 revealed she pushed on the red and purple areas, the red area blanched within three seconds and the purple area sluggishly blanched. An interview on 08/03/22 at 11:02 A.M. with Registered Nurse/Wound Nurse (RN/WN) #803 confirmed the red and purple areas across Resident #27's coccyx and buttocks. Resident #27 stated the area did not hurt. Review of Resident #27's progress notes dated 08/3/2022 at 11:14 A.M. included Resident #27 had a reddened area to coccyx. Intact linear blanchable reddened area noted across coccyx area. Notified CWOCN (Certified Wound Ostomy Incontinence Nurse), would assess during next rounds day. See new orders for Triad cream every shift and no brief in bed to promote skin integrity. Resident denied pain. Review of Resident #27's medical record including progress notes from 07/27/22 through 08/03/22 did not reveal documentation Resident #27 had a red and purple area across her coccyx and buttocks. This deficiency substantiates complaint number OH00134604.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure one resident's (Resident #51) catheter was evaluated timely due to urine leakage around the catheter insertion site. This affected one resident (Resident #51) out of three residents reviewed for catheters. The facility census was 73. Findings included: Review of Resident #51's medical record revealed an admission date of 09/24/21 and diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of Resident #51's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was cognitively intact, had total dependence of one staff member for toilet use and had an indwelling catheter. Review of physician orders dated 07/08/22 revealed orders to change the foley catheter, size 16 French with a 10 cubic centimeter (CC) balloon, monthly and as needed for obstruction. Review of Resident #51's care plan dated 07/15/22 included Resident #51 had an indwelling catheter, size 18 french with a 10 cubic centimeter (cc) balloon related to obstructive uropathy and urinary retention. Resident #51 would remain free from catheter-related trauma through the review date. Interventions included to position the catheter bag and tubing below the level of the bladder; monitor and document for pain or discomfort due to the catheter. Review of Resident #51's physician orders dated 07/19/22 revealed foley catheter (indwelling) 16 french, 10 cc balloon to continuous drainage for urinary retention due to neurogenic bladder. Observation on 08/01/22 at 12:00 P.M. of State Tested Nursing Assistant (STNA) #539 providing catheter care for Resident #51 revealed Resident #51 stated his catheter leaked every day. Observation revealed Resident #51 had an indwelling catheter, and the disposable chux pad (waterproof bed pad) under Resident #51 was soaking wet with urine, and his gown was very wet on the bottom half with urine. Resident #51's buttock area was reddened with a nickel size abrasion on the bottom of left buttock. STNA #539 confirmed Resident #51 had reddened buttocks and an abrasion on the bottom of his left buttock. STNA #539 applied barrier cream and indicated the area looked better today than it had last time she cared for Resident #51. Resident #51 stated he told multiple nurses his catheter leaked, the nurses did not know why it leaked, and none of them did anything about the leaking catheter. Resident #51 stated he told all his nurses, he told today's nurse and yesterday's nurse and other nurses his catheter leaked. Observation on 08/01/22 at 12:00 P.M. with Licensed Practical Nurse (LPN) #590 of Resident #51's leaking catheter, wet bed pad and gown indicated Resident #51 did not tell her about his leaking catheter. LPN #590 stated Resident #51 probably told the night nurse about his catheter. LPN #590 asked Resident #51 if his catheter was leaking and Resident #51 stated yes, it was leaking tons. LPN #590 stated she would look into his catheter problem. Interview on 08/01/22 at 4:19 P.M. with STNA #524 revealed something was supposed to be done about Resident #51's catheter and the catheter leaked every day she worked. STNA #524 stated Resident #51 kept a towel over the catheter area because it leaked. STNA #524 stated when she provided care for Resident #51, the sheet under him and his gown were soaked with urine and needed to be changed. STNA #524 stated she told the nurses Resident #51's catheter leaked, and the nurses knew all about Resident #51's leaking catheter. Interview on 08/01/22 at 4:40 P.M. with STNA #538 revealed Resident #51's gown and chux were wet sometimes when she provided care. STNA #538 stated she did not know why Resident #51's catheter was leaking and she told the nurse about it. STNA #538 indicated she did not remember which nurse she told. Observation on 08/01/22 at 4:46 P.M. of STNA #538 providing care for Resident #51 revealed he had a towel covering the area where the catheter was. Further observation revealed the towel and chux were wet. STNA #538 confirmed the findings. Interview on 08/01/22 at 4:48 P.M. with Assistant Director of Nursing/RN (ADON/RN) #805 revealed Resident #51 had chronic problems with his catheter. ADON/RN #805 stated when Resident #51's catheter was changed the issue was resolved. ADON/RN #805 indicated leaking was a chronic problem, the foley got displaced and the balloon needed adjusted or changed. ADON/RN #805 stated the nurses should change or fix the problem when they were told about it and there should be a progress note in Resident #51's medical record. Interview on 08/01/22 at 4:52 P.M. with LPN #590 revealed she was told about Resident #51's leaking catheter earlier today but she had been too busy to go in to assess the problem. LPN #590 stated when she had a chance she would go in and fix the problem, or would pass it on to the night shift nurse. Review of Resident #51's progress notes from 07/27/22 through 08/01/22 at 4:52 P.M. did not reveal documentation Resident #51's catheter was leaking or any intervention taken to correct the problem. Review of the facility policy titled Foley Catheter Care, revised 10/2017, included the facility would promote urinary health and management to the resident with a foley catheter to provide the resident with dignity and to prevent the potential for urinary tract infection. Placement of the foley catheter would be checked every shift. The catheter would be replaced as needed, or in accordance with physician's orders. Indications for changing the catheter include obstruction, either by encrustation or mucous, symptomatic infection, or leakage around catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Employee Handbook, the facility failed to ensure activities were provided in a dignified and professional manner for 11 residents (Resident #22, #45, #19, #64, #21, #67, #04, #68, #03, #60, and #224) of 31 residents who resided in the Memory Care Unit. The facility census was 73. Findings include: Observation while in the Memory Care Unit on 07/25/22 at 3:26 P.M. revealed 11 residents, Resident #22, #45, #19, #64, #21, #67, #04, #68, #03, #60, and #224, were sitting at a table in the lounge area of the Memory Care Unit. The lounge area was located directly across from the nurses station. Activities Director #515 was sitting at the head of the table in the lounge area with the 11 residents. Licensed Practical Nurse (LPN) #521 was working at the nurses station. LPN #521 revealed residents were in a group activity. Observation revealed during the activity, Activities Director #515 asked multiple questions including if anyone knew what a blunt was. The Residents appeared confused while looking at Activities Director #515, some grimacing, some smiling, and some just looking at her with no expression. Activities Director #515 then explained different definitions of a blunt including it was marijuana, while making hand gestures of smoking a blunt while laughing. Activities Director #515 explained to the residents she smoked blunts back in the day and you'd know if it was a good blunt if you got the munchies. If it was a bad blunt you did not get the munchies (while continuing to make hand gestures of smoking while laughing). Activities Director #515 went on to ask the residents if any of them knew what a [NAME] was and gave a description of a [NAME] to the Residents. Interview on 07/26/22 at 3:45 P.M. with Activities Director #515 revealed when she was sitting in a group with the 11 residents on 07/25/22 she was doing a Fun in Words activity titled 60's slang. Activities Director #515 explained the resident's were a black culture and blunt and [NAME] were what they knew from their generation being in a black culture. Interview on 07/27/22 at 7:40 A.M. with the DON revealed discussing smoking blunts using hand gestures, and discussing hookers would not be an appropriate activity. Interview on 07/27/22 at 7:55 A.M. with LPN #521 verified she was at the nurses station on 07/25/22 during afternoon activity and verified the activity would not be appropriate for all of the residents who were at that activity. Record review of the Employee Handbook, revised September 2012, revealed a section listed under employee conduct explaining kindness, patience and respect towards residents, visitors and one another were mandatory, and friendly and professional atmosphere should prevail at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Employee Handbook, the facility failed to ensure activities were provided in a dignified and professional manner for 11 residents (Resident #22, #45, #19, #64, #21, #67, #04, #68, #03, #60, and #224) of 31 residents who resided in the Memory Care Unit. The facility census was 73. Findings include: Observation while in the Memory Care Unit on 07/25/22 at 3:26 P.M. revealed 11 residents, Resident #22, #45, #19, #64, #21, #67, #04, #68, #03, #60, and #224, were sitting at a table in the lounge area of the Memory Care Unit. The lounge area was located directly across from the nurses station. Activities Director #515 was sitting at the head of the table in the lounge area with the 11 residents. Licensed Practical Nurse (LPN) #521 was working at the nurses station. LPN #521 revealed residents were in a group activity. Observation revealed during the activity, Activities Director #515 asked multiple questions including if anyone knew what a blunt was. The Residents appeared confused while looking at Activities Director #515, some grimacing, some smiling, and some just looking at her with no expression. Activities Director #515 then explained different definitions of a blunt including it was marijuana, while making hand gestures of smoking a blunt while laughing. Activities Director #515 explained to the residents she smoked blunts back in the day and you'd know if it was a good blunt if you got the munchies. If it was a bad blunt you did not get the munchies (while continuing to make hand gestures of smoking while laughing). Activities Director #515 went on to ask the residents if any of them knew what a [NAME] was and gave a description of a [NAME] to the Residents. Interview on 07/26/22 at 3:45 P.M. with Activities Director #515 revealed when she was sitting in a group with the 11 residents on 07/25/22 she was doing a Fun in Words activity titled 60's slang. Activities Director #515 explained the resident's were a black culture and blunt and [NAME] were what they knew from their generation being in a black culture. Interview on 07/27/22 at 7:40 A.M. with the DON revealed discussing smoking blunts using hand gestures, and discussing hookers would not be an appropriate activity. Interview on 07/27/22 at 7:55 A.M. with LPN #521 verified she was at the nurses station on 07/25/22 during afternoon activity and verified the activity would not be appropriate for all of the residents who were at that activity. Record review of the Employee Handbook, revised September 2012, revealed a section listed under employee conduct explaining kindness, patience and respect towards residents, visitors and one another were mandatory, and friendly and professional atmosphere should prevail at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pureed food was prepared to the appropriate, smooth consistency for residents requiring pureed diets. This affected three residents (Resident's #9, #19, and #30) who had a physician order for pureed diet texture. The facility census was 73. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 10/14/15 and diagnoses included Alzheimer's disease and dysphagia. Resident #9's physician orders on 02/10/21 revealed a diet order for a regular diet with pureed texture and thin liquids consistency. Review of Resident #9's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was unable to complete the cognitive assessment due to rarely or never understood. Resident #9 required total dependence of one staff member for eating. 2. Review of Resident #19's medical record revealed an admission date of 03/14/16 and diagnoses included Alzheimer's disease, esophageal obstruction, and dysphagia. Resident #19's physician orders on 12/18/18 revealed orders for a regular diet, pureed texture and nectar thick liquids consistency. Review of Resident #19's Annual MDS 3.0 assessment dated [DATE] revealed Resident #19 was unable to complete cognitive assessment and Resident #19 required supervision for eating. 3. Review of Resident #30's medical record revealed an admission date of 09/09/19 and diagnoses included dysphagia and dementia. Resident #30's physician orders dated 03/18/22 revealed orders for a regular diet, pureed texture and nectar thick liquids consistency. Review of Resident #30's Quarterly MDS 3.0 assessment dated [DATE] revealed resident had severe cognitive impairment and required limited assistance of one staff member for eating. An observation was conducted on 07/28/22 at 10:35 A.M. of [NAME] #513 preparing pureed food for the resident meal. [NAME] #513 placed approximately six pickle spears into the food processor and turned the food processor on. [NAME] #513 stopped and started the food processor three times then placed the pickle puree in a metal container. Upon taste test of the pickle puree by the surveyor it was revealed the pureed pickle did not have a smooth texture but instead had chunks of pickle skin in it. [NAME] #513 verified the finding and stated she would puree the pickles a fourth time to create a smooth consistency. An observation was conducted on 07/28/22 at 12:03 P.M. with Dietary Manager (DM) #576 and [NAME] #513 who revealed the pureed pickles were not going to be served to the residents for the lunch meal due to the inability to puree the pickles to remove the chunks of skin. [NAME] #513 stated she ran the pickles two more times through the food processor but the chunks of pickle skin were still present. [NAME] #513 informed the surveyor the food processor was on it's last leg and the kitchen staff had to run it several times just to get it to work. [NAME] #513 explained if it ran too long it would just stop working. DM #576 stated the pickle puree was not going to be served to the residents and instead peas had been pureed to use as a substitute for the pureed pickles. The pureed peas were already in a metal, steam table pan to be used for meal service. The taste test by the surveyor of the pureed peas revealed the pea puree had pieces of intact pea skin in it and was not a smooth consistency of puree. DM #576 confirmed the presence of pea skins in the puree and stated the pea puree would not be served to the residents. DM #576 stated the peas were processed three times through the food processor but the skins were still present. Review of the facility policy titled Texture and Consistency-Modified Diets, undated, included the food and nutrition department would be responsible for preparing and serving the diet texture and fluid consistency as ordered by the physician. Care would be taken to serve the foods and fluids as ordered on the consistency-altered diet or fluids.

Based on observation, interview, and review of the facility policy, the facility failed to ensure expired medications and expired medical supplies were removed from the medical supply rooms and the medication cart, after the expiration date. This had the potential to affect all 73 residents residing at the facility. Findings include: Interview on 07/27/22 at 8:03 A.M. with Assistant Director of Nursing/Registered Nurse (ADON/RN) #805 revealed the main medication room, of the five located in the facility, used by all nurses for all residents had an Alixa dispensing machine, intravenous (IV) supplies including IV solutions, IV starter kits, IV tubing, over the counter stock medications, and additional medical supplies. Observation on 07/27/22 at 8:05 A.M. with ADON/RN #805 of the main medication storage room revealed there were two carts next to the Alixa machine filled with IV bags of solution. The room also had multiple cabinets filled with supplies and over the counter medications. Observation revealed two expired IV administration sets (IV tubing). The first set had an expiration date of 09/19/20 and the second set had an expiration date of 02/19/21. In the same room was a container of insyte needles, (needle used to start an IV) in the container was insyte 24 gauge with an expiration date of 12/31/19 and three insyte 20 gauge with an expiration date of 06/30/20. In one cabinet, a partially used isopropyl rubbing alcohol bottle had an expiration date 07/2016, a container of bleach wipes had an expiration date of 2019 (unable to read the month), in addition seven IV kits were located in a different storage area with one expiration date of 09/30/19 and six had expiration dates of 01/07/20. In the cart next to the Alixa machine were multiple bags of IV solution. Two IV bags labeled cipro 400 milligrams (mg) read discard after 01/28/22. ADON/RN #805 verified all findings. Observation on 07/27/22 at 8:20 A.M. with ADON/RN #805 of the East Medication Storage room revealed six individual influenza vaccine syringes, located in the medication storage refrigerator, with an expiration date of 06/30/22. ADON/RN #805 verified all findings. Observation on 07/27/22 at 8:27 A.M. with ADON/RN #805 of the 200 hall medication cart revealed a partially used container of clorox wipes with an expiration date of 06/22 and a container of purell hand sanitizing wipes with an expiration date of 04/22. ADON/RN #805 verified all findings. Interview on 08/03/22 at 8:15 A.M. with the DON revealed there was no specific policy for disposal of medical supplies. The DON verified expired medications and medical supplies should have been removed from the medication rooms and medication carts at the time of expiration. The DON revealed this was the pharmacy technician who would come to the facility two times a month and check the expiration dates of the medications and medical supplies to assure all expired medications and supplies were removed from the supply room and disposed of. Record review of the facility policy titled, Medication Storage in the facility revised August 2014, revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secured closures are immediately removed from inventory, disposed of according to procedures for medication disposal.

Based on observation, interview, and record review the facility failed to ensure cold foods were stored and served at proper temperatures, and failed to ensure the high temperature dish machine was consistently hitting 180 degrees Fahrenheit to properly sanitize the dishes and cookware. This had the potential to affect all residents receiving meals from the kitchen except for one resident (#226) who did not eat by mouth. The census was 73. Findings included: 1. Observation on 07/25/22 at 8:15 A.M. of the kitchen with Dietary Manager (DM) #576 revealed there was a power outage starting on 07/25/22 at 1:30 A.M. and the walk-in cooler and walk-in freezer in the kitchen were not hooked up to the emergency back-up generator leaving that equipment without power to maintain proper cold storage temperatures. DM #576 stated they were opening the cooler and freezer as little as possible to conserve the cool temperatures. DM #576 stated she had been trying to get back-up power to the kitchen for three years but had not been successful. Observation of the tray line revealed [NAME] #513 and Dietary Aides (DA)'s #545 and #592 placing eggs, hot cereal and yogurt into disposable styrofoam containers with disposable utensils to be served to the residents. DM #576 stated they were able to cook eggs and hot cereal because the flat top stove was supplied by natural gas and not electricity. Observation of tray line food temperatures on 07/25/22 at 8:20 A.M. completed by DM #576 revealed the yogurt was 62 degrees Fahrenheit (F) and the yogurt was in a metal container with no ice under the container to keep it cold. DM #576 stated the yogurt should be under 35 F. DM #576 stated they were about half done serving breakfast and she was worried about the food temperatures in the cooler and freezer. DM #576 revealed she arrived at the facility around 8:10 A.M. and did not have a chance to get ice before starting to serve the breakfast tray line so the yogurt had been sitting at room temperature as it was being dished into the disposable styrofoam containers for meal service. Review of the food temperature log on 07/25/22 at 8:20 A.M. with DM #576 revealed there were no temperatures logged for any of the foods being served for the breakfast meal. Interview on 07/25/22 at 8:20 A.M. with [NAME] #815 revealed she took the temperature of the breakfast food before tray line, but did not document it on the food temperature log because she wanted to get started with breakfast. [NAME] #815 was unable to report the temperatures of the food. Observation of the walk-in-coolers on 07/25/22 at 8:25 A.M. with DM #576 revealed there were no thermometers visible through the window of the cooler. DM #576 confirmed there were no thermometers visible inside the cooler and the temperature was unable to be determined. DM #576 stated there was a thermometer in the back of the cooler, but it could not be seen and she did not know the temperature of the food in the cooler because she was trying to limit the number of times the door was opened to the cooler. Interview on 07/25/22 at 8:25 A.M. with [NAME] #513 revealed she noted the temperature of the cooler when she arrived at the facility but did not document it anywhere because she wanted to get started with breakfast. [NAME] #513 stated she arrived around 5:30 A.M. and the cooler temperature was 45 F, but the walk-in-freezer thermometer was hard to read and she did not check the temperature. Interview on 07/25/22 at 9:41 A.M. with Maintenance Supervisor (MS) #555 revealed he received a text at 1:12 A.M. from Licensed Practical Nurse (LPN) #574 regarding the power outage and arrived at the facility between 6:00 A.M. and 6:30 A.M. MS #555 confirmed the kitchen was not on a back-up emergency generator and he did not know why. Interview on 07/25/22 at 9:41 A.M. with DM #576 revealed she was notified at 5:38 A.M. by [NAME] #513 of the power outage. DM #576 stated dietary staff did not work night shift and she did not know about the power outage until [NAME] #513 notified her at 5:38 A.M. so there had been no temperature monitoring of the food inside the coolers or freezer throughout the night. Observation on 07/25/22 at 9:42 A.M. of the walk-in-cooler with DM #576 and MS #555 revealed a thermometer hanging in the cooler revealed the temperature was 50 F. DM #576 brought a digital thermometer with her into the cooler, stating the thermometer had been calibrated that morning. DM #576 checked food temperatures and found lactose-free milk in a cup with a lid had a temperature of 48.7 F, nectar thick consistency juice had a temperature of 50 F, chocolate milk in a single serving carton had a temperature of 42.2 F, two open gallons of milk had temperatures of 45.2 F and 46.9 F, a metal container with chicken salad had a temperature of 46.4 F, turkey lunch meat had a temperature of 43.3 F, a raw egg was 45.2 F, a hard-boiled cooked egg had a temperature of 50.3 F, a pitcher of milk had a temperature of 48.4 F. DM #576 stated she needed to go through the cooler and discard food. Interview on 07/25/22 at 9:50 A.M. with LPN #574 revealed on 07/25/22 at around 1:00 A.M. to 1:30 A.M. she heard a loud boom, a short time later the power went out and after about 10 seconds the generator kicked on and some of the facility power was restored. LPN #574 stated she notified the Director of Nursing (DON), the Administrator, the on-call supervisor and the Maintenance Supervisor #555 of the power outage. LPN #574 stated she was busy making sure the residents were taken care of and extension cords were used for important resident equipment like air mattresses, oxygen, tube feedings, and so LPN #574 did not enter the kitchen all night. LPN #574 stated the other nurses working night shift did not enter the kitchen or check the cooler and freezer. Observation on 07/25/22 at 3:12 P.M. of the walk-in-cooler with DA #589 revealed the chicken salad was still in the cooler and had not been discarded. Review of the menu changes on 07/25/22 at 3:15 P.M. due to the power outage for the lunch meal revealed deli sandwiches, potato chips, pickles and watermelon were served to the residents. Interview on 07/25/22 at 3:21 P.M. with DM #576 confirmed the chicken salad was still in the cooler and had not been discarded. DM #576 stated she was very busy and still needed to go through the cooler. DM #576 stated she used the turkey lunch meat for the lunch meal because it was in sealed, unopened packages and she thought it was alright to use even though the temperature was 43.3 F earlier. DM #576 stated she would not have had anything to serve for the lunch meal if she did not use the turkey. Review of the Food Temperature Log on 07/25/22 at 3:21 P.M. for the lunch meal with DM #576 revealed the deli-sandwiches temperature was 42 F. The food temperature log stated cold foods temperature should be served at 41 F or lower. DM #576 confirmed the sandwiches should have had a temperature of 41 F or lower at the point of service. Interview on 07/25/22 at 3:32 P.M. with Registered Dietician (RD) #627 revealed she was notified regarding the power outage around 6:30 A.M. RD #627 stated temperatures in the walk-in-cooler and walk-in-freezer should be monitored because there was a four hour window after the power outage for safe food storage and the food should not be in the danger zone. RD #627 was not sure how often the food temperatures should be monitored. RD #627 stated a temperature of 62 F for yogurt was in the danger zone. Interview on 07/25/22 at 3:43 P.M. with the Administrator revealed the power was back on in the facility at 10:30 A.M. Interview on 07/25/22 at 4:17 P.M. with the Administrator revealed even though the chicken salad was not removed from the walk-in-cooler there was no chance it could be served to the residents and the kitchen staff were in the kitchen the entire time. The Administrator stated no residents had been sent out for food borne illness in the past month. Interview on 07/25/22 at 3:45 P.M. with DM #576 revealed the food temperatures were checked at 8:15 A.M., 9:41 A.M. and 2:00 P.M. DM #576 stated she did not have the food temperatures documented on a disaster log because she had been so busy today. Review of the facility policy titled Food Safety and Sanitation, undated, included stored food was handled to prevent contamination and growth of pathogenic organisms. Refrigerated foods were stored at or below 41 degrees Fahrenheit. Review of the facility policy titled Food Safety Requirements, undated, included holding temperature (ready for service) should be 135 F or above for hot foods and 41 F or below for cold foods. 2. Observation on 07/25/22 at 10:40 A.M. with Dietary Aide (DA) #545 and Dietary Manager (DM) #576 of the dish machine wash and rinse cycle revealed the wash cycle gauge was not functioning and did not display the wash cycle water temperature. DA #545 confirmed the wash cycle gauge was broken and had been broken for awhile. DM #576 confirmed the gauge was broken and the representative from the service company was called about it two weeks ago. Record review on 07/25/22 at 10:40 A.M. with DM #576 of the Dish Machine Temperature Log revealed on 07/16/22 and 07/17/22 temperatures for the wash and final rinse cycles were not documented for the breakfast and lunch meals, 07/22/22 did not have temperatures for the wash and final rinse cycles documented for the breakfast, lunch and dinner meal, on 07/23/22 there were no temperatures documented for the breakfast and lunch meals, on 07/24/22 there were no temperatures documented for the breakfast, lunch, and dinner meals, and on 07/25/22 there were no temperatures documented for the breakfast meal. DM #576 confirmed the temperatures were not documented. Observation on 07/28/22 at 10:45 A.M. with DA #545 and DM #576 of the dishwashing machine completing washing and rinse cycles revealed the rinse temperature did not reach 180 degrees F. Observation of the dishwashing machine complete five cycles revealed the rinse temperature only reached 176 F. DM #576 stated sometimes the dishwashing machine lost heat as the day progressed and the representative from the dishwashing machine company was called about the issue. DM #576 stated when the temperature did not reach 180 F the dishes were washed two to three times. DM #576 stated the dishwashing temperature was double checked with a paper thermometer as a back-up to ensure dishes were sanitized appropriately. DM #576 revealed the paper thermometers were accurate to 160 F so were not able to measure up to the required 180 F for the final rinse. Review of the Service Detail Report dated 07/28/22 at 2:04 P.M. from the dishwasher company included documentation the dishwasher was not hitting the rinse temperature and the thermostat was turned up a bit to hit 184 F after a few tests. Review of the manufacturer information for the paper thermometers titled Paper Thermometer revealed the paper thermometer was a temperature sensitive tape device that read up to 160 degrees F. Review of the facility policy titled Dish Machine Temperature Log, undated, included staff would record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services would spot check the log to assure temperatures were appropriate and staff was correctly monitoring dish machine temperatures. Review of the facility policy titled Dishwashing, undated, included dishes, pots and pans would be washed using procedures, chemicals and equipment that resulted in clean, sanitized dishes, pans flatware and utensils. Dish machine temperatures were logged at each meal on the Dish Machine Temperature Log and minimum temperatures, as required by the manufacturer were wash 150 to 160 F and Final Rinse 180 to 195.

Based on record review and interview with the Administrator, the facility failed to provide a Facility Assessment identifying what resources would be needed to provide competent care to the residents during both day-to-day operations and emergencies. This had the potential to affect all 73 residents residing in the facility. The facility census was 73. Findings included: Interview on 07/25/22 at 9:12 A.M., during the entrance conference, the Administrator was asked to make the Facility Assessment available to the survey team. Record review was conducted of the facility document titled IFC Self-Assessment Guide for Health Care Organization, dated 01/09/22. and provided by the Administrator to the survey team as the Facility Assessment requested at the entrance conference. The document consisted of 13 pages of self-assessment elements for the facility. The document was completed by the Administrator and the Director of Nursing as indicated on the first page. There were no members of the governing body or other facility staff listed as participants in this assessment. It did not contain both the number of residents and the facility capacity, the care required by the resident population to meet the acuity needs of the residents, the staff competencies necessary to provide the level and types of care needed for the resident population, the physical environment, equipment, services and other physical plant considerations needed to care for the residents, any ethnic, cultural or religious factors for the residents nor did it contain information on the facility resources ( all physical structures, medical and non-medical equipment), medical services, staffing plans including management and non-management positions, information on technology resources and resources needed in case of an emergency. On page three there was a typed line reading see detailed facility assessment. An interview was conducted on 07/28/22 at 3:40 P.M., 08/01/22 at 4:56 P.M. and 08/02/22 at 2:50 P.M. with the Administrator regarding the contents of the ICF Self-Assessment Guide for Health Care Organizations, dated 01/09/22, compared to the federal regulation requirements for content of the Facility Assessment. The Administrator verified the document was provided by him as the current Facility Assessment requested by the survey team and he had provided said document to two of the three surveyors on the survey team. The Administrator provided no additional information to reflect a detailed Facility Assessment had been completed for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement appropriate infection control practices regarding the proper use of personal protective equipment (PPE) by all direct care staff providing care and services to residents on transmission based precautions for COVID-19 and COVID-19 quarantine precautions. This had the potential to affect all 73 residents residing in the facility. The facility also failed to ensure reusable medical equipment (glucometer) was appropriately sanitized in between residents affecting Resident #29, #51 and #324. The facility census was 73. Findings included: 1. Record review revealed Resident #48 had an admission date of 10/13/20. Diagnoses included Alzheimer's disease. An additional diagnosis of COVID-19 was added on 07/18/22. Resident #48 resided in the memory care unit. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had severe cognitive impairment. Resident #48 required limited assistance and supervision with activities of daily living. Record review of the care plan dated 07/18/22 revealed Resident #48 was on droplet isolation precautions due to positive COVID-19. Interventions included to adhere to infection control precautions at all times by all staff, and wear appropriate personal protective equipment per policy. Record review of the physician order dated 07/18/22 revealed an order for droplet precautions due to a diagnosis of COVID 19. Observation on 07/25/22 at 9:26 A.M. revealed Wound Care Consultant Certified Nurse Practitioner (CNP) #906 entered Resident #48's room without putting on an isolation gown. Resident #48 was lying in bed and began sitting up. Wound Care Consultant CNP #906 went over to Resident #48 and began assisting Resident #48. Wound Care Consultant CNP #906 then closed Resident #48's door for privacy. Resident #48 had a sign on the door to please see the nurse before entering and an isolation cart next to the entrance of the door. Wound Care Nurse Registered Nurse (RN) #803 was at the treatment cart next to Resident #48's doorway and verified Resident #48 was diagnosed with COVID-19 requiring isolation. Wound Care Nurse RN #803 opened Resident #48's door and instructed Wound Care Consultant CNP #906 Resident #48 was diagnosed with COVID -19 and she would need to leave his room to put on the appropriate PPE. Interview on 07/25/22 at 9:30 A.M. with Wound Care Consultant CNP #906 revealed she was unaware Resident #48 was on isolation and was not notified by the facility it was in COVID-19 outbreak status. Wound Care Consultant CNP #906 revealed she did not read the sign posted on Resident #48's door and needed to be directed by staff before entering a room if the resident was on isolation. Wound Care Consultant CNP #906 confirmed she did not wear an isolation gown prior to assisting Resident #48 with care. Wound Care Consultant CNP #906 then left the unit without washing her hands, changing her mask or cleaning her goggles. Interview on 07/25/22 at 9:33 A.M. with Wound Care Nurse RN #803 confirmed Wound Care Consultant CNP #906 was in Resident #48's room with the door closed assisting Resident #48 to prepare for wound care. Wound Care Nurse RN #803 confirmed Wound Care Consultant CNP #906 did not have the appropriate PPE on, did not clean her goggles, change her mask, or wash her hands prior to exiting the unit onto another residential area. Observation on 07/25/22 at 9:39 A.M. revealed Hospice STNA #907 entering the memory care unit where three Residents (Resident #48, #27, and #53) were positive for COVID-19. Hospice STNA #907 verified she was not wearing goggles nor a face shield for eye protection. Interview on 07/25/22 at 9:40 A.M. with LPN #521 confirmed Hospice STNA #907 was not wearing goggles nor a face shield when she entered the unit. LPN #521 revealed Hospice STNA #907 was there to assist Hospice Resident #21 who also resided in the memory care unit and staff should be wearing eye protection on the unit. Interview on 07/25/22 at 9:53 A.M. with the DON revealed contract staff such as Hospice staff would be expected to wear appropriate PPE when entering the facility and entering a residents room requiring isolation precautions. The DON revealed she did not know how the contract staff were notified of the facility outbreak status. Observation on 07/25/22 at 3:02 P.M. revealed STNA #550 entered the memory care unit and was not wearing goggles nor a face shield. STNA #550 verified she was not wearing goggles or a face shield when she entered the unit. Observation on 07/27/22 at 1:13 P.M. revealed RN #602 entered Resident #48's room with the bottom strap of the N-95 mask dangling under his chin. After exiting Resident #48's room, RN #602 did not clean his goggles and placed the new N-95 mask on with the bottom strap dangling under his chin. Interview on 07/27/22 at 1:18 P.M. with RN #602 confirmed he entered Resident #48's room with the bottom strap of the N-95 mask dangling under his chin. After exiting Resident #48's room, RN #602 verified he did not clean his goggles and placed the new N-95 mask on with the bottom strap dangling under his chin. 2. Record review for Resident #27 revealed an admission date of 04/27/22. Diagnosis included dementia and muscle weakness. An additional diagnosis of COVID-19 was dated 07/18/22. Record review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #27 had moderately impaired cognition. Resident #27 required extensive assistance for bed mobility, transfers, dressing, grooming, and toilet use. Record review of the care plan dated 07/18/22 revealed Resident #27 was on droplet precautions due to a diagnosis of COVID-19. Interventions included to adhere to infection control precautions at all times by all staff. Record review of the physician order for Resident #27 dated 07/19/22 revealed an order for droplet isolation due to a diagnosis of COVID-19. Observation on 07/25/22 at 12:33 P.M. revealed State Tested Nursing Assistant (STNA) #504 was assisting Resident #27 in her room with setting up the lunch tray sitting in front of Resident #27. STNA #504's isolation gown was not tied at the top or at the waist. The top of the isolation gown was dangling at STNA's elbows as she was setting up the lunch tray. STNA #504 continued assisting Resident # 27 with positioning and the lunch tray. Interview on 07/25/22 at 12:37 P.M. with STNA #504 confirmed the isolation gown was not tied and was dangling at the elbows while providing care for Resident #27. STNA #504 confirmed she did not change her mask, clean her goggles or wash her hands prior to leaving Resident #504's room. Observation on 07/25/27 at 12:38 P.M. revealed STNA #504 then walked up the hall, retrieved a lunch tray for Resident #18 (not on isolation precautions), she did not change her mask, clean her goggles or wash her hands and delivered the lunch tray to Resident #18. Interview on 07/25/27 at 12:41 P.M. with STNA #504 verified she delivered the lunch tray to Resident #18 and did not wash her hands, clean goggles or change her mask after assisting Resident #27 and before assisting Resident #18. Observation on 07/27/22 at 4:09 P.M. revealed Radiology Technician #908 was in Resident #27's room performing a procedure. Radiology Technician #908 was wearing his N-95 mask below his mouth exposing his mouth and nose and was not wearing goggles. Interview on 07/27/22 at 4:17 P.M. with Radiology Technician #908 verified his face mask was below his mouth while in Resident #27's room and he had no goggles on. Radiology Technician #908 left the unit and did not change his mask. 3. Record review for Resident #326 revealed an admission date of 07/07/22. Resident #326 was discharged to the hospital on [DATE] and returned 07/19/22. Diagnosis included acute and subacute infective endocarditis and sepsis. Record review of the MDS dated [DATE] revealed Resident #326 had intact cognition. Resident #326 required limited assistance of one for bed mobility, extensive assistance of one for transfers and limited assistance of one for toilet use and personal hygiene. Record review of the care plan dated 07/25/22 for Resident #326 revealed resident was on droplet isolation precautions related to guidelines for quarantine related to recent hospitalization. Interventions included to adhere to standard infection control precautions at all times by all staff. Record review of the physician order for Resident #326 dated 07/19/22 revealed quarantine for 14 days post admission as COVID precautions. Observation on 07/26/22 at 11:47 A.M. of RN #544 assisting Resident #326 with medication administration revealed RN #544 donned her isolation gown and did not tie the top of the gown. RN #326 did not place a surgical mask over the N-95 mask. The top of the gown fell to RN #544's elbows while providing care to Resident #326. RN #544 exited Resident #544's room then did not change the N-95 mask or clean her goggles. Interview on 07/26/22 at 11:57 A.M. with RN #544 while she was walking up the hall confirmed she did not tie the top of the gown causing it to fall to the top of her elbows while providing care to Resident #326. RN #544 also verified she did not change her mask prior to exiting the room and she did not clean her goggles. Interview on 08/01/22 at 9:31 A.M. with Infection Preventionist Assistant Director of Nursing RN #805 revealed all staff including contract staff were expected to donn and doff appropriate PPE prior to entering rooms positive for COVID-19 or on quarantine including an N-95 mask and goggles or face shield while in the residential areas of the facility. 4. Record review for Resident #29 revealed an admission date of 12/03/20. Diagnosis included type two diabetes mellitus (dm). Record review of the physician orders for Resident #29 revealed an order for novolog flex pen ( an insulin pen) dated 07/06/22. The order was to inject as per sliding scale after checking the resident's blood sugar level. Observation on 07/26/22 at 8:20 A.M. with RN #544 who was assessing Resident #29's blood sugar level using a glucometer. After RN #544 assessed Resident #29's blood sugar, RN #544 then wiped the glucometer off with a hand sanitizer wipe for less than five seconds and sat the glucometer directly on top the medication cart. Interview on 07/26/22 at 8:24 A.M. with RN #544 confirmed she briefly wiped the glucometer off with a hand sanitizer wipe and revealed she would normally use a bleach wipe for 30 seconds but she did not have bleach wipes. RN #544 verified she used the same glucometer for all of her residents who required a blood sugar assessment. 5. Record review for Resident #324 revealed an admission date of 07/09/22. Diagnosis included type two diabetes mellitus. Record review of the physician orders for Resident #324 revealed an order for the insulin lispro dated 07/14/22. The order was to inject as per sliding scale after checking the residents blood sugar level. Observation on 07/26/22 at 08:35 A.M. with RN #544 who was assessing Resident #324's blood sugar using a glucometer. After using the glucometer, RN #544 wiped the glucometer off with a bleach wipe for less than six seconds, then assessed Resident #29's blood sugar. RN #544 then wiped the glucometer off again with a bleach wipe for approximately six seconds after assessing the blood sugar for Resident #29 then sat the glucometer on top the medication cart which RN #544 verified at the time of the finding. 6. Record review for Resident #51 revealed an admission date of 09/25/19. Diagnosis included type two diabetes mellitus. Record review of the physician orders for Resident #51 revealed an order for humalog (insulin)solution dated 07/19/22 inject as per sliding scale after assessing the blood sugar. Observation on 07/26/22 at 8:44 A.M. of RN #544 assessing Resident #51's blood sugar using a glucometer revealed after RN #544 assessed Resident #51's blood sugar, she placed the glucometer in the top drawer of the medication cart without cleaning the glucometer. Interview on 07/26/22 at 8:56 A.M. with RN #544 confirmed she did not clean the glucometer after assessing Resident #51's blood sugar, and she placed the glucometer in the top drawer of the medication cart. RN #544 confirmed she used the same glucometer for Resident #29, #324, and #51. Interview on 07/26/22 at 9:10 A.M. with the DON revealed the medication cart should have had three glucometers on it and each glucometer should have been cleaned a minimum of two minutes before the next use because that is what was indicated in the manufacturer instructions so that is what the nurse should follow to clean the glucometer. The DON provided the manufactures instructions titled, Cleaning and disinfecting the On Call Pro Blood Glucose Monitoring System. Record review of the facility policy titled, Cleaning and Disinfecting of Equipment, dated October 2017, included the manufacturers guidance titled, Cleaning and disinfecting the On Call Pro Blood Glucose Monitoring System. The instructions included a cautionary statement to not disinfect the meter with any product containing bleach. The meter should be disinfected using Super Sani cloth germicidal disposable wipes with a contact time of two minutes. Record review of the Community Risk Level for Cuyahoga County for COVID-19, updated 07/28/22, revealed the community risk level was high. Record review of the policy titled, Covid-19, Coronovirus, revised 06/28/22, revealed after receipt of confirmed COVID 19 test results the resident would remain in droplet precautions per guidelines. Any new admissions would be placed in a 14 day quarantine if not updated. The facility would provide cumulative updates to their residents, their representatives, families and staff at least weekly during an outbreak or by 5:00 P.M. the next calender day following the subsequent occurrence of either: each time a COVID 19 infection was identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. Record review of the facility policy titled, Covid 19 Donning and Doffing, revised 01/05/22, revealed if the facility was in outbreak status for COVID-19 eye protection must be donned by all staff in all zones. Instructions included, while donning the gown, fully cover the torso from neck to knees, arms to end of wrist, and wrap around the back, fasten in back of neck and waist. The donning of the mask instructions indicated staff should secure ties or plastic bands at the middle of head and neck. For residents on a 14 day quarantine, a surgical mask would be worn over the N-95 mask and disposed of after exiting quarantined rooms and before entering another residents room. Wash hands or use alcohol based hand sanitizer immediately after removing all PPE.

Based on observation, interview and record review the facility failed to ensure the high temperature dish machine was in good repair and functioning properly, and failed to ensure the kitchen's food processor used to make pureed foods was in good repair. This had the potential to affect all residents residing in the facility except for one resident (#226) who did not eat by mouth. The facility census was 73. Findings include: 1. Observation on 07/25/22 at 10:40 A.M. with Dietary Aide (DA) #545 and Dietary Manager (DM) #576 of the dish machine wash and rinse cycle revealed the wash cycle gauge was not functioning and did not display the wash cycle water temperature. DA #545 confirmed the wash cycle gauge was broken and had been broken for awhile. DM #576 confirmed the gauge was broken and the representative from the company was called about it two weeks ago. Review of the facility document titled Extra Service Request, dated 07/25/22 and timed 12:07 P.M., from the dish machine company representative included temperature gauges were bad and both the rinse and wash temperature gauges were replaced. Observation on 07/28/22 at 10:45 A.M. with DA #545 and DM #576 of the dish machine completing washing and rinse cycles revealed the rinse temperature did not reach 180 degrees Fahrenheit (F). Observation of the dish machine complete five cycles revealed the rinse temperature only reached 176 F. DM #576 stated sometimes the dish machine lost heat as the day progressed and the representative from the dish machine company was called about the issue. DM #576 stated when the temperature did not reach 180 F the dishes were washed two to three times. DM #576 stated the dishwashing temperature was double checked with thermolabels ( paper thermometers) as a back-up to ensure dishes were sanitized appropriately. DM #576 confirmed the thermolabels were accurate to 160 F (not the required 180 F). Review of the document Service Detail Report, dated 07/28/22 at 2:04 P.M., from the dish machine company included the dishwasher was not hitting the rinse temperature and the thermostat was turned up a bit to hit 184 F after a few tests. Review of the Extra Service Request,, dated 07/29/22 at 1:16 P.M., from the dish machine company representative included the dishwasher was not hitting the rinse temperature so burnt wires and the thermostat were replaced. 2. An observation was conducted on 07/28/22 at 10:35 A.M. of [NAME] #513 preparing pureed food for the resident meal. [NAME] #513 placed approximately six pickle spears into the food processor and turned the food processor on. [NAME] #513 stopped and started the food processor three times then placed the pickle puree in a metal container. Upon taste test of the pickle puree by the surveyor it was revealed the pureed pickle did not have a smooth texture but instead had chunks of pickle skin in it. [NAME] #513 verified the finding and stated she would puree the pickles a fourth time to create a smooth consistency. An observation was conducted on 07/28/22 at 12:03 P.M. with Dietary Manager (DM) #576 and [NAME] #513 who revealed the pureed pickles were not going to be served to the residents for the lunch meal due to the inability to puree the pickles to remove the chunks of skin. [NAME] #513 stated she ran the pickles two more times through the food processor but the chunks of pickle skin were still present. [NAME] #513 informed the surveyor the food processor was on it's last leg and the kitchen staff had to run it several times just to get it to work. [NAME] #513 explained if it ran too long it would just stop working. DM #576 stated peas had been pureed to use as a substitute for the pureed pickles. The pureed peas were already in a metal, steam table pan to be used for meal service. The taste test by the surveyor of the pureed peas revealed the pea puree had pieces of intact pea skin in it and was not a smooth consistency of puree. DM #576 confirmed the presence of pea skins in the puree and stated the pea puree would not be served to the residents. DM #576 stated the peas were processed three times through the food processor but the skins were still present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician orders reflected Resident #58's wishes regarding end-of-life medical treatment. This affected one (Resident #58) of 26 residents (Residents #2, #4, #5, #6, #10, #17, #19, #20, #31, #34, #39, #40, #47, #52, #54, #56, #58, #62, #64, #65, #72, #76, #84, #137, #241, and #287) reviewed. The facility census was 87. Findings include: Review of the record revealed Resident #58 was admitted on [DATE] with diagnoses including dementia and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive deficits. Review of the record revealed she had two hospitalizations during her stay returning to the facility most recently on 05/05/18. Review of DNR (Do Not Resuscitate) Identification Form signed by the physician on 05/05/18 revealed Resident #58 was a DNRCC-Arrest (Do Not Resuscitate Comfort Care-Arrest). DNRCC-Arrest meant the resident was to receive standard medical care until she experienced cardiac or respiratory arrest. Review of the physician order dated 05/06/18 indicated the resident was a full code. Full code meant cardio-pulmonary resuscitation would be initiated if she experienced cardiac or respiratory arrest. During an interview on 06/04/18 at 3:08 P.M., Register Nurse/Unit Manager #220 confirmed Resident #58's wishes as to life-saving measures and the physician order were not in agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report results in Influenza A and B Antigen test. This affected one (Resident #7) of seven residents (Resident #7, #23, #27, #53, #290, #291, and #292) reviewed who had Influenza A and B Antigen tests completed. Findings include: Review of the record revealed Resident #7 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, and anemia. Review of a progress note dated 12/28/17 at 3:47 P.M. indicated the resident had congestion, a non-productive cough, complaints of body aches, chills, and elevated temperature. The resident was given Tylenol. The nurse practitioner was notified and ordered a nasal swab to test for influenza. Review of the Influenza A and B Antigen test done on 12/28/17 revealed the results were reported to the facility on [DATE] at 6:12 P.M. and indicated Resident #7 was positive for Influenza A. Review of the progress notes revealed no evidence the physician or nurse practitioner were notified of the results until January. On 01/03/18, the physician ordered Tamiflu 75 milligrams once daily for the flu until 01/25/18. During an interview on 06/07/18 at 1:49 P.M., the Director of Nursing confirmed Tamiflu was not started until 01/04/18. She indicated she could not find any evidence the physician or nurse practitioner were promptly notified of the results of the Influenza A and B Antigen test. .

Based on observation and interview the facility failed to ensure opened foods were labeled. This affected 86 residents receiving meal trays from the kitchen except Resident #59 who received nothing by mouth. The facility census was 87. Findings include: During the initial tour of the kitchen on 06/04/18 at 8:54 A.M. with Dietary Manger (DM) #201 the following items were found to have been opened and undated in the walk in freezer: garlic bread, philly steak meat, onion rings, pork chops, hot pockets, hamburgers, sausage patties, and confetti pancakes. The walk in cooler contained a frosted sheet cake that was uncovered and destined to be served for dinner that day. These observations were verified with DM #201 on 06/04/18 at 9:00 P.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to maintain an environment to prevent the development and transmission of communicable diseases and infections. This had the potential to affect 87 residents living at the facility. Findings include: 1. Medical record review revealed Resident #6 was admitted on [DATE] with diagnoses of cellulitis, urinary retention and dementia. The quarterly Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a suprapubic catheter and was incontinent of bowel. laboratory results dated [DATE] of an urinalysis revealed Escherichia coli ESBL, bacteria that can become resistant to antibiotics and is hard to treat. The June, 2018 medication administration record (MAR) indicated Augmentin, an antibiotic for urinary infection was started. On 06/04/18 at 8:45 A.M. interview with the Director of Nursing (DON) revealed the facility had no residents on contact isolation precautions (used to prevent the transmission of infections requiring the use of gowns, gloves and mask to be worn before entering the room). Observation on 06/04/18 at 11:05 A.M. and 06/05/18 at 8:24 A.M. of Resident #6's room revealed contact precautions were not in place. Observation on 06/06/18 at 9:43 A.M. revealed contact precautions were in place for Resident #6. Interview with State Tested Nurse Aide (STNA) #230 at 9:46 A.M. revealed contact precaution were put in place for Resident #6 on 06/05/18 about 2:30 P.M. for ESBL in urine. Interview on 06/06/18 at 3:33 P.M. with the Infection Control Preventionist revealed Resident #6 should have been placed on contact precautions on 06/03/18 on receipt of laboratory confirmation of ESBL in urine. Review of a physician order for Resident #6 dated 06/05/18 at 7:00 P.M. revealed staff were to maintain contact isolation precautions. Review of the facility's Progressive Quality Care Isolation Precautions Policy dated 2016 revealed isolation should be established immediately. Individuals placed in isolation, for suspected or confirmed infections, would have isolation procedures implemented only to the degree necessary to prevent the transmission. 2. Review of the facility's Legionella Water Management Plan dated 05/03/17 revealed the facility used control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens. Interview with the Administrator on 06/07/18 at 4:50 P.M. revealed the Legionella control measures listed in their management plan were not monitored to intervene if control measure were not met.