Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling Foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #3. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 4/9/2025 revealed that Resident ID #3 had a Foley catheter replaced at the facility without a physician's order. Review of Lippincott Nursing Procedures Manual Ninth Edition, last revised in 2023, states in part, .Indwelling Catheter Care and Removal .Indwelling Urinary Catheter Insertion .verify the practitioner's order . Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, obstructive (a structural or functional hindrance of normal urine flow) and reflux (a condition where there is a backflow of urine into the kidney) uropathy and retention of urine. Review of the resident's care plan dated 3/26/2025, revealed a focus area for an indwelling urinary catheter related to his/her diagnosis of obstructive uropathy. Interventions include, but are not limited to, monitor, record, and report signs and symptoms of a urinary tract infection. Review of a physician's order dated 3/26/2025 indicated the use of an 18 French (Fr; refers to the measurement of the outer diameter of the catheter) Foley catheter with a 10 cubic centimeter (cc) (the amount of saline required to inflate the catheter's balloon for stability in the bladder). The order also revealed that the resident had a urology appointment scheduled for April 24, 2025, at 1:30 PM to have the Foley catheter replaced. Review of a progress note dated 4/9/2025, authored by Registered Nurse, Staff A, states in part, Resident observed to be pulling on Foley at times overnight and resistant to redirection to not pull on it. Foley noted to have less than 100 ml (milliliter) urine output at approximately 2am, nurse attempted to flush Foley but unable to get return. Foley removed and new foley 16 fr 5 cc balloon coude tip (a urinary catheter with a curved tip designed to navigate around obstacles in the urethra, such as an enlarged prostate) catheter inserted with immediate return of more than 100 ml urine . This progress note indicates that Staff A replaced the resident's Foley with a Foley that is larger in diameter, has a smaller balloon to anchor it in place, and is a different style Foley than the physician's order. Additionally, the order did not indicate that the resident required a coude catheter. Record review failed to reveal evidence of a physician's order to change the resident's Foley catheter prior to the 4/25/2025 scheduled appointment. Further review of the progress note dated 4/9/2025 revealed, .During foley insertion [genitalia] noted to be slightly enlarged. Nurse provided resident with rolled towel under [genitalia] while in bed. Upon nurse-to-nurse handover [genitalia] and hematuria [blood in the urine] reassessed. [Genitalia] noted to have increased significantly in size while elevated on rolled towel. Hematuria noted to foley bag. Blood noted to urethral opening. Transfer to emergency room for evaluation initiated. During a surveyor interview on 4/17/2025 at approximately 8:30 AM with the Director of Nursing Services, in the presence of the Administrator, she revealed that the resident's diagnosis upon hospital admission was pyelonephritis (inflammation of the kidney usually due to a bacterial infection). She indicated that Staff A should not have changed the resident's Foley catheter, because the resident had an order in place to have it changed at the urologist's office. Additionally, she revealed that she would have expected the nurse to call the physician with her concerns, for further recommendations and orders.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to narcotic medication administration, for 3 of 6 residents reviewed, Resident ID #s 2, 4, and 5. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/9/2025 indicated that two alert and oriented residents reported they did not receive their PRN (as needed) narcotic pain medication overnight after requesting it multiple times and that there appeared to be discrepancies between the narcotic log book and the resident's Medication Administration Records (MAR). According to the Lippincott Nursing Procedures Ninth Edition last revised in 2023 states in part, .Safe Administration Practices .Document all medications administered in the patient's MAR or EMAR [Electronic Medication Administration Record]. Include the medication strength, dose, route of administration, and date and time of administration . A. Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, pain related to lumbar spinal stenosis (a condition in which the spaces in the spine narrow, compressing the spinal cord or nerves) and cognitive communication deficit. Record review revealed a physician's order dated 3/25/2025 for oxycodone (a narcotic medication prescribed to treat pain) 10 milligrams (mg), with instructions to administer 1 tablet every six hours, as needed. Review of the Narcotic Administration Log revealed documentation that the resident was administered one tablet of oxycodone, 10 mg , on 4/9/2025 at 12:30 AM, by Registered Nurse, Staff A. Review of Resident ID #2's April 2025 MAR failed to reveal evidence that the 4/9/2025 dose of oxycodone 10 mg, was documented as being administered to Resident ID #2. B. Record review revealed Resident ID #4 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, spondylolisthesis (a condition that develops when one of the bones in the spine slips out of alignment). Record review revealed the following physician's orders dated 4/6/2025: - oxycodone 5 mg, with instructions to administer one tablet every six hours, as needed for severe pain (for a pain score of 8-10) - oxycodone 5 mg, with instructions to administer ½ tablet (2.5mg) every six hours as needed (for a pain score of 4-7) Review of the Narcotic Administration Log revealed documentation that Staff A administered oxycodone twice on 4/9/2025. Once at 12:05 AM, and then again 6:15 AM. Review of Resident ID #4's April 2025 MAR failed to reveal documentation that the 4/9/2025 doses of oxycodone at 12:05 AM and 6:15 AM were administered to Resident ID #4. C. Record review revealed Resident ID #5 was admitted to the facility in April of 2025 with diagnoses including, but not limited to encephalopathy (a disorder and/or disease of the brain that affects its normal functioning) and multiple cancerous tumors throughout the resident's body. Record review revealed the following physician's orders dated 4/7/2025: - oxycodone 5 mg, with instruction to administer 1 tablet every six hours, as needed for pain (for a pain score of 5 - 8) - oxycodone 5 mg, with instructions to administer 2 tablets, every six hours, as needed for pain (for a pain score of 9 - 10). Review of the Narcotic Administration Log revealed documentation that Resident ID #5 was administered two tablets of oxycodone, 5 mg, on 4/8/2025 at 10:00 PM, by Staff A. Review of Resident ID #5's April 2025 MAR failed to reveal documentation that the 4/8/2025 dose of oxycodone, 10 mg, was administered to Resident ID #5. During a surveyor interview on 4/17/2025 at approximately 9:00 AM, with the Director of Nursing Services, she acknowledged that the documentation in the Narcotic Administration Logs for Resident ID #s 2, 4, and 5, were not documented on the residents' MARs.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms observed and 3 of 4 medication carts observed. Findings are as follows: Review of the facility policy dated 1/2021, titled, Medication Storage states in part, .POLICY: It is the policy of this facility that medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations .14. Outdated, contaminated, discontinued or deteriorated medications .should be immediately removed from stock . 1a. During a surveyor observation on 2/11/2025 at 8:50 AM of the Pond View unit medication cart, in the presence of Registered Nurse (RN), Staff A, the following was revealed: -One Wixela inhaler, opened with a date of 12/12. Review of the manufacturer's instructions indicate to discard the inhaler one month after opening. -One Arnuity inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler one month after opening. -One Treligy Ellipta inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. During a surveyor interview with Staff A, she acknowledged that the Wixela inhaler had a date of 12/12, and that it was outdated. Staff A revealed that the other two inhalers should have been dated when opened. 1b. During a surveyor observation on 2/11/2025 at 9:15 AM of the Tradewinds unit medication cart, in the presence of Licensed Practical Nurse, Staff B the following was revealed: -One Treligy Ellipta inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. During a surveyor interview with Staff B, he acknowledged that the inhaler was opened without a date, and he revealed that the inhaler should have been dated when opened. 1c. During a surveyor observation on 2/11/2025 at approximately 9:30 AM of the Robin's Way unit medication cart, in the presence of RN, Staff C, the following was revealed: -One Anoro Ellipta inhaler, opened with a date of 12/16. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -One Anoro Ellipta inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -Two Treligy Ellipta inhalers, both were opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -One Combivent Respimat inhaler, opened without a date. Review of the manufacturer instructions indicate that once the cartridge is inserted, discard in three months. During a surveyor interview with Staff C, she acknowledged that one of the Anoro inhalers had a date of 12/16. and that it was outdated. Staff C revealed the other inhalers should have been dated when opened. 2. During a surveyor observation on 2/11/2025 at approximately 9:45 AM of the Robin's Way medication room, in the presence of Staff C the following was revealed: -One bottle of Lorazepam intensol, opened without a date. Review of the manufacturer's instructions indicate to discard the Lorazepam 90 days after opening. During a surveyor interview with Staff C, she acknowledged that the Lorazepam intensol should have been dated when opened. During a surveyor interview on 2/11/2025 at 8:50 AM and 4:19 PM with the Director of Nursing Services, she revealed that she would expect that medications are dated when opened and that the outdated inhalers should have been discarded.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that they distribute and serve food in accordance with professional standards for food safety relative to 2 of 4 units observed during the lunch meal service. Findings are as follows: According to the, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last updated in August of 2024, states in part, .'Food Service' means the processes involved in actively serving food to the resident. When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor) . A surveyor observation on 2/11/2025 at approximately 12:00 PM of the Pond View unit, revealed a sheet pan rack (a heavy-duty aluminum rack with uniformly spaced tray slides) being transported from the kitchen to the unit, approximately 300 feet, with desserts that were uncovered. Staff then distributed the desserts to the residents. During surveyor observations on 2/11/2025 at 12:15 PM and 2/12/2025 at 12:18 PM of the Tradewinds unit, revealed a sheet pan rack being transported from the kitchen to the unit, approximately 400 feet, with desserts that were uncovered. Staff then distributed the desserts to the residents. During a surveyor interview on 2/12/2025 at 12:20 PM with Nursing Assistant, Staff D, she acknowledged that the desserts were not covered while being transported from the kitchen. During a surveyor interview on 2/12/2025 at approximately 12:45 PM with the Food Service Director, she acknowledged that the desserts were not covered when being transported to the units. Additionally, she indicated that it has been the facility's practice to not cover desserts, for the last 13 years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 2 of 2 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 indicates that Resident ID #2 was witnessed by staff slapping Resident ID #1 on the back of his/her head at which time, Resident ID #1 then slapped the hand of Resident ID #2. Record review revealed that Resident ID #1 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, Alzheimer's disease, dementia with agitation, cognitive communication deficit, adjustment disorder, anxiety disorder and major depressive disorder. Record review for Resident ID #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] that revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. A surveyor interview with Resident ID #1 was unable to be conducted due to the resident's cognition. Record review revealed that Resident ID #2 was admitted to the facility in December of 2023 with diagnoses including but not limited to vascular dementia with agitation, mechanical complication of a ventricular intracranial shunt, cerebrovascular disease, depression, muscle weakness, adjustment disorder, and convulsions. Record review for Resident ID #2 revealed an MDS assessment dated [DATE] that revealed a BIMS score of 99, indicating that s/he was unable to complete the assessment due to his/her cognition. Record review revealed that Resident ID #2 has a history of behaviors including physical and verbal abuse towards others. A surveyor interview with Resident ID #2 was unable to be conducted due to the resident's cognition. During a surveyor interview with Registered Nurse, Staff A, on 9/20/2024 at 12:57 PM, she revealed that on 7/30/2024 she witnessed Resident ID #2 slap Resident ID #1 on the back of the head followed by Resident ID #1 slapping the hand of Resident ID #2. During a surveyor interview with the Administrator and the Director of Nursing Services on 9/20/2024 at approximately 1:45 PM, the Administrator acknowledged that this incident did happen as it was witnessed by staff and Resident ID #2 did sustain an abrasion on the back of his/her hand as a result of this incident.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 2 residents reviewed for weight gain, Resident ID #11. Findings are as follows: Record review of an undated facility policy and procedure for Weight Loss/Gain Protocol and Heights, provided to the surveyor on 2/28/2024, states in part, .All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain, to assess for underlying causes of weight loss or gain, to intervene accordingly and timely to allow for an optimal level for well-being .PROCEDURE: .For purpose of this policy, a significant weight discrepancy is defined as: .A loss/gain of 5% or greater within one month .When a significant weight loss/gain is noted (as defined above), the following interventions may be considered: 1. Reweigh all residents who are reported to have significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 2 days of the initial weight. 2. If the re-weigh is accurate and there has been a significant weight loss/gain, nursing must notify the; -physician -Dietician -DNS [Director of Nursing Services] .start the weekly weights, if not already on .Document all information in the medical record and update the care plan .If weight loss/gain is desirable, then simply document accordingly and assure plan is current . Record review of the resident revealed s/he was admitted to the facility in July of 2023, with diagnoses to include, but not limited to, cognitive deficit, hyponatremia (sodium levels in the blood are abnormally low), high blood pressure, chronic kidney disease, and atrial fibrillation (irregular and rapid heart rate). Further record review revealed the resident has a care plan for nutritional status dated 8/18/2023 that indicates, I am of nutritional concern r/t [related to] edema [swollen]/diuretic [medication to reduce fluid build up in the body], weight fluctuation . with an intervention including, but not limited to, monitor and record weight per schedule . Record review revealed the following documented weights: 11/8/2023 - 133 pounds (lbs) 1/5/2024 - 138 lbs 2/8/2024 - 146 lbs Further review of the above-mentioned weights revealed a total weight gain of 13 lbs. between 11/8/2023 and 2/8/2024, indicating a 9.77% significant weight gain over 3 months. Additionally, the resident experienced an 8 pound weight gain between 1/5/2024 and 2/8/2024 indicating a 5.8% significant weight gain over one month. Record review failed to reveal evidence that the resident was re-weighed per the facility's policy. Additionally, record review failed to reveal evidence that the physician was notified or that the dietitian was consulted when the resident experienced an unplanned significant weight gain. During a surveyor interview on 2/28/2024 at 10:50 AM, with Registered Nurse, Staff A, she revealed that she was unaware of the above-mentioned weight gain. She revealed that a reweigh should be obtained when a resident experiences a 5 pound weight gain/loss in one month, if the reweigh accurately reflects a significant unplanned weight loss/gain, they whould notify the physician and the dietitian. She further indicated that weekly weights would then be obtained. During a surveyor interview on 2/28/2024 at 11:10 AM, with the DNS, she revealed that she was unaware of the resident's weight gain. Additionally, she was unable to provide evidence that a reweigh had been obtained or that the resident's care plan was revised to reflect the significant weight gain. Additionally, the DNS was also unable to provide evidence that the resident's physician was notified, or that the dietitian was consulted as per the facility policy. During a surveyor interview on 2/28/2024 at 11:12 AM, with the Dietitian, Staff B, she revealed that she was unaware of the above-mentioned weight gain. She further revealed that she would expect staff to inform her when a resident experiences a significant unplanned weight gain and would expect that staff would obtain a reweigh to ensure accuracy.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident observed specific to finger stick blood glucose testing, Resident ID #194. Findings are as follows: Record review of a facility policy titled, Diabetes - Care of equipment SECTION: Infection Control, dated 3/11/2005 states in part, .It is the policy of this facility to develop and support Infection Control practices that are designed to prevent transmission of blood borne pathogens from diabetes-care procedures .4. Dispose of used lancets [used to obtain a blood sample from a finger] at the point of use in approved sharp containers . Record review of a document titled, Competency Validation for Blood Glucose Testing states in part, .discarding the used lancet after use in the sharps container . Record review revealed the resident was admitted to the facility in February of 2024, with a diagnosis including, but not limited to, diabetes (high blood sugar). During a surveyor observation on 2/28/2024 at 12:00 PM, Registered Nurse, Staff C, was observed checking the resident's blood glucose level, she was then observed to remove her used gloves and dispose of them in the resident's waste basket along with the used lancet. During a surveyor interview with Staff C immediately following the above observation, she acknowledged that she disposed of the used lancet in the resident's waste basket, and not in a sharps container per the facility's policy. During a surveyor interview on 2/28/2024 at approximately 12:15 PM, with the Director of Nursing Services, she acknowledged that Staff C should have disposed of the lancet in a sharps container per the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to revise a care plan after each assessment for 1 of 6 residents reviewed relative to safe patient handling (SPH), Resident ID #7. Findings are as follows: Review of a facility policy titled Safe Resident Handling last reviewed on 1/25/2022 states in part, .Conduct a resident handling hazard assessment to identify resident handling tasks .an assessment will be done in order to identify the resident's safest transfer status .Once determined, the resident's transfer status must be added to the care plan and record so that other direct care employees are aware of the resident transfer status . Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to, muscle weakness, muscle wasting and atrophy [loss or thinning of muscle]. Additional record review revealed the resident had impaired decision making and cognitive communication deficit. Record review revealed a Safe Patient Handling assessment dated [DATE] which states in part, .what is the Patients Weight Bearing Capability with the answer marked as None. Further review of the assessment revealed the resident cannot bear weight when transferring. Further record review revealed an annual Minimum Data Set (MDS) Assessment was completed on 10/20/2022. Record review revealed the resident's care plan was revised on 11/4/2022 and failed to specify that the resident cannot bear weight during transfers. During a surveyor interview with Licensed Practical Nurse, Staff A on 12/07/2022 at 9:54 AM, she revealed she was unaware of the 10/4/2022 SPH assessment that indicates the resident cannot bear weight during a transfer. During a surveyor interview with the MDS Coordinator, Staff B on 12/8/2022 at approximately 9:00 AM, she was unable to provide evidence that the resident's care plan was revised relative to the resident's non-weight bearing status as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician, relative to radiology testing for 1 of 4 residents reviewed, Resident ID #7. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to; muscle wasting and atrophy (loss or thinning of muscle). Record review of the resident's bone densitometry test (a test used to measure bone strength) dated 10/12/2022, revealed radiology results indicating s/he had osteopenia (low bone mass). Additional record review failed to reveal evidence that a provider was notified of the bone density results prior to the resident being transferred to the hospital on [DATE]. During a surveyor interview with the Director of Nursing Services on 12/7/2022 at 8:24 AM, she was unable to provide evidence that the provider was aware of the results of the bone density test. During a surveyor interview with the Physician Assistant on 12/7/2022 at 10:06 AM, she acknowledged that she was unaware of the results of the bone density test until 11/29/2022 following the resident's admission to the hospital with a diagnosis of a pathological fracture. During a surveyor interview on 12/7/2022 at 11:40 AM, with the Primary Physician he was unable to provide evidence that the facility notified him of the bone densitometry test results from 10/12/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure a physician reviewed the resident's total program of care, relative to radiology testing for 1 of 4 residents reviewed, Resident ID #7. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to; muscle wasting and atrophy (loss or thinning of muscle). Record review of the resident's bone densitometry test (a test used to measure bone strength) dated 10/12/2022, revealed radiology results indicating s/he had osteopenia (low bone mass). Additional record review failed to reveal evidence that a provider reviewed the bone density results prior to the resident being transferred to the hospital on [DATE]. During a surveyor interview with the Director of Nursing Services on 12/7/2022 at 8:24 AM, she was unable to provide evidence that the provider was aware of the results of the bone density test. During a surveyor interview with the Physician Assistant on 12/7/2022 at 10:06 AM, she acknowledged that she was unaware of the results of the bone density test until 11/29/2022 following the resident's admission to the hospital with a diagnosis of a pathological fracture. During a surveyor interview on 12/7/2022 at 11:40 AM, with the Primary Physician he was unable to provide evidence that the facility notified him of the bone densitometry test results from 10/12/2022.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that staff utilize Personal Protective Equipment according to professional standards to prevent the potential development and transmission of COVID-19 for 1 staff member, Staff A, relative to 2 resident who tested positive for COVID-19, ID #s 6 and 52. Findings are as follows: During the entrance conference on 12/04/2022 with the Director of Nursing Services she indicated that the facility is experiencing a COVID-19 outbreak and there are 17 COVID-19 positive residents in the facility. Record review of a facility policy titled, Care of the Covid-19 Positive Resident last reviewed on 11/18/2022, states in part, .Full PPE [personal protective equipment] for Staff- N95, gowns, gloves, face shields/goggles will be worn during care of the COVID positive resident (on isolation) . 1. Record review revealed Resident ID #6 was admitted to the facility in December of 2021 and was diagnosed as COVID-19 positive on 11/26/2022. During several surveyor observations from 12/4/2022 until 12/6/2022 signage was posted outside of Resident ID #6's room that stated in part, Isolation, Droplet/Contact Precautions. In addition to Standard Precautions Staff and Providers MUST: .Eye protection (goggles or face shield) . During surveyor observations on 12/4/2022 at 9:06 AM, 12/5/2022 at 1:34 PM, and 12/6/2022 at 8:36 AM, LPN (licensed practical nurse) Staff A was observed entering Resident ID #6's room without a face shield or goggles. During a surveyor interview on 12/6/2022 at approximately 8:45 AM with Staff A, she acknowledged entering the residents room without wearing eye protection. 2. Record review revealed Resident ID #52 was admitted to the facility in February of 2022 and was diagnosed as COVID-19 positive on 12/1/2022. During several surveyor observations from 12/4/2022 until 12/8/2022 signage was posted outside of Resident ID #52's room that stated in part, Isolation, Droplet/Contact Precautions. In addition to Standard Precautions Staff and Providers MUST: .Eye protection (goggles or face shield) . During surveyor observations on 12/4/2022 at 11:01 AM and 12/6/2022 at 8:31 AM, Staff A was observed entering Resident ID #52's room without a face shield or goggles. During a surveyor interview with the Infection Control Nurse on 12/6/2022 at 12:47 PM, she revealed that she would expect the staff to follow the signage on the door and wear full PPE in a COVID-19 positive residents room including a face shield or goggles. During a surveyor interview on 12/6/2022 at 10:17 AM, with the Director of Nursing Services, she revealed that all staff entering a COVID-19 positive resident's room are expected to wear full PPE including a face shield or goggles per the facility policy.