**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 of the resident's wishes involving their advance directives/code status for one of one sampled resident (5).Findings include:1. Record review of the medical record for resident 5 revealed:*She was admitted on [DATE].*Her Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated she had moderate cognitive impairment.*The CPR (cardiopulmonary resuscitation, an emergency procedure to provide chest compression and often rescue breathing to preserve brain function and maintain blood circulation) Statement of Decision indicated the resident wanted CPR.*Her advance directive (a legal document that expresses a person's health care wishes if they become unable to speak for themselves) indicated she did not want CPR, signed on [DATE]. 2. Interview and medical record review on [DATE] at 9:26 a.m. with registered nurse (RN) H about resident 5 revealed:*Resident 5's CPR status in the paper medical record stated I do wish CPR to be initiated, signed by her power of attorney (someone designated on a legal document to act on resident's behalf) and her doctor on [DATE].*RN H stated the form was reviewed quarterly (every three months) at every care conference with the family.*Her CPR status was listed as do not resuscitate (DNR) in the electronic medical record (EMR).*Her doctor ordered her status as DNR in the EMR on [DATE]. 3. Interview and medical record review on [DATE] at 3:45 p.m. with RN CC about resident 5 revealed:*If she needed to verify a resident's CPR status to determine if she was to provide CPR or withhold it, she would look at the resident's paper chart.*She looked at the CPR Statement of Decision form in resident 5's paper chart and indicated the resident would want CPR. She stated she thought that was incorrect, looked at Resident 5's EMR, and stated she was listed as a DNR there. The DNR order was ordered on [DATE] by her doctor.*She verified that resident 5's South Dakota Advance Directive, located in her paper chart and signed by the resident on [DATE], indicated she did not want her life prolonged but to be kept comfortable.*She checked the white dry-erase board in the report room, which listed any resident who wanted CPR. Resident 5 was not listed.*She stated she would notify the social worker, obtain a new form for the resident's family to sign, and then send it to the doctor to be signed.*She stated she would keep the incorrect form in the resident's chart until the new form was completed, unless the social worker directed otherwise.*She stated there were no electronic copies of the CPR Statement of Decision form, and the paper copy was to be kept in her chart. 4. Interview on [DATE] at 3:50 p.m. with the director of nursing (DON) B about resident 5 revealed she expected the resident's code status in the EMR and paper charts to match. 5. Review of the provider's undated Advance Directive Information policy revealed:*The provider is required by Federal Law.It is the policy of [the provider] to respect autonomy [personal choice]. Advance Directives, including the living will and durable power of attorney for healthcare, will be honored. 6. Review of the provider's handout that was untitled about Resident Rights and advance directives stated: The Resident has a right to formulate advance directives. It is the responsibility of the Resident to timely provide the Facility with copies of the Resident's advance directive for reference and incorporation into the Resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and policy review, the provider failed to ensure a resident's right to a sense of dignity and respect was maintained by failing to promptly serve residents' meals for one of two observed meal services.Findings include: 1. Interview on 7/15/25 at 3:17 p.m. with resident 26, the resident council president, revealed: *She felt there was a problem with residents waiting a long time to have their food served. *She stated, “We wait an hour to eat, and that happens a lot.” *She stated that other residents had expressed the same concern. -Residents came to speak with her individually because many of them did not like to speak in front of a large group. -She did not say if she had brought those concerns to the dietary manager or administrator. Review of the resident council minutes from the past three months revealed no comments or notes about excessive wait times at meals. 2. Observation in the main dining room of the 7/15/25 evening meal revealed: *At 5:05 p.m. residents were entering the main dining room for the evening meal scheduled to be served between 5:00 p.m. and 6:30 p.m. -Resident 12 was assisted into the dining room by a staff member and seated at a table. -There were no water glasses or beverages on the table. *At 5:19 p.m. resident 46 entered the dining room assisted by a staff member to sit with resident 12 at her dining table. *There were seven staff members observed in the dining room. *At 5:21 p.m., the staff members began to take resident’s food orders and deliver meal trays. *At 5:58 p.m., residents 12 and 46 were heard conversing, saying, Good [NAME], they haven't eaten either, while they looked around the dining room and remarked, Something needs done around here . -Both residents stated that they had been waiting a long time, .at least 30 minutes. *At 6:02 p.m., resident 12 and resident 46 stood up and started to walk away from the table. *At 6:03 p.m., dietary aide (DA) DD approached residents 12 and 46, asked them to sit back down at their table and stated, I haven't even given you ladies food yet. *At 6:06 p.m., DA DD served residents at another table and stated, I'm sorry it's going so slow. *At 6:07 p.m., DA DD encouraged resident 12 to sit down again and stated, It's been a while, but I'll get you some food.” DA DD then asked residents 12 and 46 what they wanted for their meals. -Resident 46 stated to DA DD I'm not hungry, but DA DD encouraged her to order some food. She chose the hoagie sandwich meal option. *At 6:11 p.m. DA DD served resident 12 a hoagie sandwich and broccoli and she began to eat her meal. -She waited 66 minutes for her meal to be served. *Resident 46, who had not been served her meal, reached towards resident 12's plate of food. -Resident 12 stated to her, It's yours, take it, but resident 46 did not take any food items. *At 6:13 p.m. DA DD served resident 46 a chef salad and a glass of water. -She waited 54 minutes for her meal to be served. *Interview at that time with resident 46 about her meal revealed she stated the meal was good. When asked if she had to wait a while for her meal to be served, she replied Yeah, I know in a disgusted tone. 3. Observation on 7/15/2025 at 5:03 p.m. of the table closest to the serving window in the assisted section of the dining room revealed: *Residents 15 and 22 were seated at the assist table, waiting for their meals to be served. *Resident 15 was seated at the table in front of a white adjustable tray and was served a glass of juice at 5:10 p.m. -She received her meal and remaining drinks at 5:33 p.m. -She waited 30 minutes to receive her meal. *Resident 22 received his meal and drinks at 5:26 p.m. -He waited 23 minutes to receive his meal. 4. Observation on 7/15/25 at 5:03 p.m. of the table closest to the handwashing sink in the assisted section of the dining room revealed: *Residents 4 and 11 were seated at the table. -Resident 4 had been served his meal and drinks and was feeding himself. -Resident 11 was waiting to be served her meal. Her meal and drinks were served at 5:36 p.m. *Resident 47 was assisted to the table and seated in front of a white adjustable tray at 5:14 p.m., and her meal was served at 5:37 p.m. -She waited 23 minutes to receive her meal. -She struggled to pick up the cut pieces of the sandwich. Paid feeding assistant GG assisted resident 47 with eating her yogurt, but did not assist or offer to help her with the sandwich. *Paid feeding assistant GG sat at the table with the residents and provided physical assistance and verbal cueing to residents 4, 11, and 47 until 6:08 p.m., when they finished eating. 5. Observation on 7/15/25 at 5:05 p.m. in the assisted dining section of the dining room revealed: *Resident 35 was seated at a table the assisted dining section at 5:06 p.m. She was not served her meal until 5:24 p.m. *Resident 36 was seated at her table at 5:09 p.m. Her meal was placed in front of her around 5:35, which was 26 minutes after she arrived in the dining room. No one assisted her to eat until 5:44 p.m. Her meal sat in front of her, untouched, for 9 minutes. *Resident 7 was seated at her table at 5:10 p.m. Her meal was placed in front of her at 5:37 p.m., which was 27 minutes after she arrived in the dining room No one assisted her to eat until 5:44 p.m. Her meal sat in front of her, untouched for 7 minutes. Review of resident 7’s and resident 36’s electronic medical record (EMR) revealed that they required full assistance from staff to eat. 6. Interview on 7/17/25 at 11:14 a.m. with DA DD revealed: *There was no order to which resident was served first in the dining room. *He said the dietary aides served whoever came to the dining room first. *The residents with diabetes were a priority to get their food first. *The dietary aides tried to spread out around the dining room with a goal of shortening the wait time for residents to be served their meals. 7. Interview on 7/17/25 at 11:39 a.m. with dietary manager D revealed: *She conducted her own dining observation at supper on 7/16/25 and confirmed that several residents waited “for a long time” for their meal. -She confirmed some residents waited an hour for their meals. *She was unsure of a solution due to the “bottleneck” and slowing down at the service window since there was only one person who plated the meals. 8. Interview on 7/17/25 at 1:54 p.m. with registered dietitian EE revealed: *She indicated that ideally, the residents should be served their meal “as soon as the resident arrives to the dining room.” *She estimated that a reasonable amount of time for residents to wait would be 30 minutes. *With the open dining concept, lunch and supper were difficult meals as all residents would arrive to the dining room in a short period of time. *She described the “bottleneck” slow down at the service window was because they only had one person plating the meals. *She indicated that it was “incredibly unusual” for residents to wait over an hour to be served their meals. 9. Review of the provider’s 2/18/25 The Dining Experience policy revealed: *Policy: “The goals of the dining experience is to enhance the individuals[‘] quality of life through person centered dining: providing person centered care and attention: nourishing, palatable, and attractive meals that meet the individuals[‘] daily nutritional and special dietary needs.” *Procedure: -“1. Staff will work with each person as an individual to meet their personal needs. Everyone will be treated with dignity and respect…” -“…5. Individuals at the same table will be served at the same time to the best of staff availability.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to provide range of motion (measurement of movement around a joint or body part) (ROM) exercises for two of two residents (26 and 36) in an attempt to prevent a decline (worsening in physical status) in ROM.Findings include: 1. Observation and interview on 7/15/25 at 3:40 p.m. with resident 26 revealed she:*Was lying in bed and had some deformity to her fingers. She indicated she had arthritis.*Was alert and capable of making her needs known.*Participated in a restorative program Whenever I can get in and indicated that occurred approximately twice per week.*Wanted to have restorative programming more than she was, because she felt the more she moved around, the less pain she had.*Indicated she does not wear any type of splints or devices to help with stretching, preventing further ROM decline in her hands. 2. Interview on 7/17/25 at 9:56 a.m. with certified nursing assistant (CNA)/restorative aide Z regarding restorative exercises revealed:*She tried to do restorative exercises with resident 26 at least twice a week.*She stated it was hard to get everyone in for restorative exercises more than twice a week because she was the only restorative aide and there were a lot of residents on a restorative program.*Sometimes it was hard to get resident 26 in for exercises when her daughter visited.*Another restorative aide was to start next week to help her.*She stated the goal for resident 26 was to maintain her current ROM function.-Her ROM had improved since she admitted to the facility. 3. Continued interview on 7/17/25 at 10:00 a.m. with CNA/restorative aide Z about resident 36 revealed:*The resident had started to decline, and her passive (movement to the area is provided by someone else) ROM was getting worse.*Her joints had started to contract (muscles, tendons, or skin tighten and shorten, leading to a reduced range of motion).*She had tried to massage the resident in addition to providing passive ROM (PROM) exercises.*CNAs did not provide ROM. She stated, Just restorative does it.-Leadership had been considering having the CNAs start to assist with PROM exercises.*She tried to see the resident at least twice a week or more because her ROM had started to decline and her muscles were getting tighter. *She reported that the resident had shown nonverbal cues of pain during ROM exercises sometimes. 4. Interview on 7/17/25 at 11:05 a.m. and again at 1:41 p.m. with restorative registered nurse (RN) F regarding restorative exercise programming revealed:*CNAs do not perform ROM exercises while working on the floor assisting residents with care needs, but they were looking into having them do it.*Resident 36's right leg ROM has been worsening over the past two months.*Every resident on admission was to be assessed for restorative needs and a restorative plan.*Resident 36 had been independent with transfers on admission.-As of 7/17/25, she was dependent on staff with transfers using a mechanical lift (a mechanical device used to assist with transfers). *Resident 36 was admitted on [DATE], and since then she had:-Lost the ability to walk and transfer herself.-Decreased ROM and limitations to her shoulders, elbows, and knees. *She stated resident 36 currently had stiff joints in both of her knees, shoulders, and elbows. Her right hip had progressed to where it has crossed over the left leg.*Resident 36 had been placed on the restorative program after the resident started to develop contractures.*She stated they talk about residents 36's restorative program at every care conference.*She expected the resident to have had ROM as much as the restorative aide could do it in a week, but at least a few times per week.*She stated another restorative aide was starting next week, so residents could be seen more.*She was unsure how often ROM should have been completed to help prevent contractures.*Resident 36 had been on hospice from 11/16/24 to 4/29/25. She was unsure if hospice provided ROM exercises, in addition to the provider's restorative program, during their visits.*She stated Resident 36's hands were tight, but she did not have any hand devices in place to help with the stretching or prevention of contractures.-She has been able to get her hands to relax during PROM exercises. 5. Interview on 7/17/25 at 2:05 p.m. with restorative nurse F about restorative programing and resident 26 revealed she:*Would have expected the resident to have restorative exercises done a few times per week.-She did not state what she considered a few times a week was.*Stated resident 26 completed exercises in her room on her own in addition to the restorative program.*Reported that resident 26's weakness varies day by day.*Stated that resident 26 did not use any devices to prevent further ROM limitations and contractures.*Stated she completed ROM assessments with each resident's Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs).*Felt the CNA/restorative aide would have notified her if there were any changes to the resident's strength. 6. Observation on 7/17/25 at 2:12 p.m. of resident 36 revealed:*She was lying in bed sleeping, and her hands were clenched into fists without any devices in her hands to assist with preventing a further decline or to promote comfort.*She was tilted to her right side and appeared thin and frail.*She had a mechanical lift in her room. 7. Interview on 7/17/25 at 2:55 p.m. with DON B revealed:*She would have expected the restorative aide to perform ROM exercises up to five days per week as the aide worked five days a week.*Another restorative aide was planned to start next week.*She was not sure how often ROM exercises needed to be completed to help prevent contractures.*She would have expected restorative RN F to follow the facility's policy, and to notify the provider of resident 36's worsening contractures. 8. Review of resident 26's electronic medical record (EMR) and comprehensive care plan revealed:*She was admitted on [DATE].*She had a diagnosis of restless leg syndrome (a disease that causes the urge to move the legs), osteoarthritis (a disease that causes cartilage to break down in the joints), pain in her right knee, left shoulder rotator cuff (a shoulder muscle) injury, weakness, and swelling.*Her Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact.*She had limited physical mobility related to weakness, impaired balance, and limited ROM to her left knee and shoulders.*Her 11/27/23 initiated goal was to maintain upper extremity (UE) strength to assist with dressing and care, and to remain free of complications related to her limited mobility, including new or worsening of existing contractures. That was revised on 5/16/25.*Her restorative care plan indicated she was to receive:-Active ROM program #1: Upper body exercise, up to level 6 resistance (an external force that opposes muscle contraction during physical activity) for fifteen minutes, for up to six times per week, initiated 11/27/23.-Active ROM program #2: Seated lower extremity exercises with a two-pound ankle weight or t-band (a stretchy band that provides resistance) for 2 sets of 15 repetitions (number of times the activity is completed), up to six times per week, initiated on 6/26/23 and revised on 11/27/23.-Active ROM Program #3: Core exercises with a ROM arc (a therapeutic device used to improve upper extremity mobility) or a one-pound dowel (bar) for 2 sets of 20 repetitions, up to six times per week, initiated on 6/26/23.-Active ROM Program #4: Handgrip of five pounds or clothespins for 3 sets of 20 repetitions, up to six times per week, initiated 6/26/23 and revised 11/27/23.-Active ROM Program #5 upper extremity exercises with up to two-pound hand weight or dowel and t-band for 15 repetitions, up to six times per week, initiated on 6/26/23 and revised on 10/04/2024.*She was to be encouraged to participate in restorative therapy to maintain strength and prevent deterioration.*She was evaluated by physical therapy (PT) for strengthening and transfers on 2/18/25. The resident had wanted to increase her left knee ROM.*She was discharged from PT on 3/18/25; PT indicated she had reached her maximum potential and goal for her left knee but had not met her goal for bendability of her left knee. They stated she met her goal for left knee strength.*Her ROM was limited in both of her shoulders, her fingers related to arthritis, her left knee, and a slight limitation to both elbows.*Staff were to monitor/document/report to medical doctor (MD) as needed (PRN) for signs and symptoms or complications related to arthritis: joint pain, joint stiffness, swelling, a decline in mobility, a decline in self-care ability, contracture formation/joint shape changes, crepitus (grating sound with joint movement), and pain after exercise or weight bearing.*A progress note on 7/10/25 indicated the resident had pain in her right elbow. She rated it 10/10 (ten out of 10 pain on a zero to 10 pain scale, with 10 being the worst). Her ROM was assessed and noted to be limited. The resident stated she did not want to go to the emergency room that evening, but she wanted to see a doctor in the clinic the next day, 7/11/25.*A progress note on 7/11/25 indicated the resident had right elbow pain. She rated it at 3/10 (three out of ten). She stated the pain was worse with movement. She was not able to straighten her elbow completely, that was not new for her, and the resident thought it was due to her arthritis. She declined to see a doctor at that time. 9. Review of resident 26's 4/1/25 through 7/13/25 active ROM (AROM, meaning the resident was able to participate) restorative therapy program documentation revealed:*She had not received AROM exercises from 4/1/25 through 4/13/25.*The week of 4/14/25, she received forty-two minutes over zero to one day of AROM.*The week of 4/21/25, she received sixty-eight minutes over one to two days of AROM, and it was noted that the resident had not been available one day that week to participate.*The week of 4/28/25, she received thirty-eight minutes over zero to one day of AROM, and it was noted she refused to participate one day that week.*The week of 5/5/25, she received thirty-three minutes over one day of AROM, and it was noted that the resident had not been available one day that week to participate.*The week of 5/12/25, she received forty-one minutes over one day of AROM.*The week of 5/19/25, she did not receive AROM. There were no refusals or issues with resident availability documented.*The week of 5/26/25, she received ninety-two minutes over one to three days of AROM.*The week of 6/2/25, she did not receive AROM, and she had refused one day that week.* The week of 6/9/25, she received eighty minutes over one to two days of AROM.*The week of 6/16/25, she received seventy-nine minutes over one to two days of AROM.*The week of 6/23/25, she received eighty minutes over one to two days of AROM.*The week of 6/30/25, she received forty-one minutes over one day of AROM.*The week of 7/7/25, she received thirty-six minutes over zero to one day of AROM, and she refused to participate one day that week. 10. Review of resident 36's EMR and comprehensive care plan revealed:*She was admitted on [DATE].*She had a diagnosis of dementia, major depressive disorder, a disorder of bone density and structure, and back pain.*Her BIMS score was 99, which indicated she did not want to, or she was unable to participate in the cognitive assessment.*She received hospice services from 11/16/24 through 4/29/25.*She had been dependent upon staff to meet her activities of daily living (ADL) needs and to develop a plan of care to ensure her ROM and current function did not worsen.*A restorative note on 6/19/25 indicated that the resident's contracture to her right lower extremity had worsened at the knee and hip. Her right leg overlapped her left leg more. It had been more difficult to perform some of her ADLs. They would continue to provide her passive range of motion (PROM) as she tolerated.*A care conference note on 5/14/25 indicated the resident continued a restorative program consisting of UE/LE (upper extremities [arms and hands]/lower extremities [legs and feet]) PROM, she tolerated therapy well, and staff had assisted with PROM routinely. Her ROM was slightly limited in both shoulders, elbows, and knees. Her legs were stiff, and those limitations did not affect her daily functioning, as she was dependent on staff for her care needs.*A note by MDS nurse FF on 5/6/25 indicated the residents' functional limitations were upper extremity (shoulder, elbow, wrist, hand) to have impairments on both sides. And her lower extremity (hip, knee, ankle, foot) had no impairment.*A Restorative Program note on 2/21/25 indicated she continued a restorative program for UE and LE PROM. She tolerated therapy well and participated routinely. Her ROM had been slightly limited in both her shoulders, elbows, and knees. Her joints were stiff. She used a body pillow. She was not able to bend her knees enough to get into the whirlpool tub.*She was dependent on staff for meeting all her ADL needs.*Staff were to encourage her to participate in the restorative program to maintain her strength. That intervention was initiated on 12/06/2020 and revised on 5/31/2024.*Staff were to ensure proper positioning in bed.That intervention was initiated on 11/07/2024 and revised on 06/12/2025.*Due to her inability to fully bend her knees to safely get into and out of the whirlpool tub, she was not able to use the whirlpool.*Her joints were very stiff, and she had slight ROM limitations to bilateral knees, shoulders, and elbows, but that did not affect daily functioning. That intervention was initiated on 12/06/2020 and revised on 09/29/2024.*Her nursing rehab/restorative plan included PROM to her upper extremities, hands, and lower extremities for twenty repetitions, up to six times a week. This intervention was initiated on 08/04/2022 and revised on 02/27/2024.*Staff were to observe and report changes in her usual routine, sleep patterns, decrease in functional abilities, decrease in ROM, withdrawal, or resistance to care. 11. Review of resident 36's restorative therapy minutes dated 4/1/25 through 7/17/25 revealed:*The week of 4/1/25, she received one day of PROM that was for twenty minutes.*The week of 4/14/25, she received sixty-seven minutes over three days of PROM.*The week of 4/21/25, she received one hundred thirty-two minutes over six days of PROM.*The week of 4/28/25, she received eighty-five minutes over four days of PROM.*The week of 5/5/25, she received eighty-seven minutes over four days of PROM.*The week of 5/12/25, she received sixty-six minutes over three days of PROM.*The week of 5/19/25, she received ninety minutes over four days of PROM.*The week of 5/26/25, she received forty-five minutes over two days of PROM.*The week of 6/2/25, she received sixty-seven minutes over three days of PROM.*The week of 6/16/25, she received one hundred ten minutes over five days of PROM.*The week of 6/23/25, she received sixty-seven minutes over three days of PROM.* The week of 6/30/25, she received sixty-eight minutes over three days of PROM.*The week of 7/7/25, she received sixty-eight minutes over three days of PROM. 12. Review of the provider's Restorative Therapy policy dated March 2025 revealed: * A restorative therapy/nursing program and restorative care assists residents to return or maintain the highest practical physical, mental, and psychological functional level and well-being. The program helps the resident prevent decline unless circumstance, such as a progressive deteriorating condition, makes the decline unavoidable.*A restorative therapy aid's primary purpose is to perform restorative nursing procedure that maximizes the resident's existing abilities, emphasizes independence instead of dependence, and minimizes the negative effects of disability with an attitude of realistic optimism under the supervision of the Therapy Coordinator, a licensed therapist, and/or the Director of Nursing. They assist with.assists residents with therapy procedures as assigned by the Therapy Coordinator, ensure resident safety and comfort.*Restorative services provided are established, delegated, taught, and supervised by therapy and nursing.*Restorative procedures are determined/initiated by a licensed nurse in charge of the restorative program. Changes will be made in the plan of care as determined by the nurse, physician, and/or therapist.*.Our facility has an active program of restorative nursing, which is developed and coordinated through the resident's care plan.*The facility's restorative nursing program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence.*.Immobility affects every body system and contributes to the resident's overall health.*The restorative nurse and charge nurses collaborate with restorative aide and CNAs routinely to determine any changes that need to be made to the restorative programs.*The Restorative Nurse/Rehab Nurse is the liaison between formalized therapy and nursing services to assist residents to achieve or maintain their highest level of function, maintain skills learned in therapy, minimize declines in function, and to restore level of function lost through illness, debility, or lack of motivation. They perform rehabilitation/restorative assessments upon all new admission and for existing residents evaluations on admission, quarterly and/or as clinically indicated. Consults with nurses and CNA's [CNAs] in developing a restorative plan of care.Restorative care focuses on a person's ability to participate in ADLs . and joint range of motion.Nursing staff carry out restorative nursing care daily for residents that require such services including, but not limited toa. Maintaining good body alignment and proper positioning;b. Encouraging and assisting bedfast residents to change positions routinely to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities;f.Assisting residents with their routine ROM exercises;*.If any staff notice a decline in a resident's ADL or mobility function, activity tolerance, eating/swallowing function, activity level, emotional or self-esteem level, cognition, etc., the doctor will be notified by Restorative Nurse or Charge Nurse of a need for evaluation by appropriate discipline if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate infection prevention and control measures were effectively implemented and followed for:*One of one sampled resident (26) with an indwelling catheter and who was dependent on staff for transfer assistance, toileting needs, and catheter care received those cares with necessary enhanced barrier precautions (EBP).*Three of three sampled residents (1, 9, and 28) who received medications per nebulizer equipment had their equipment maintained and stored properly when not being used.*One of two clean linen distributing carts lacked a suitable protective cover while transporting items.Findings include: 1. Observation and interview on 7/15/25 at 3:40 p.m. with resident 26 revealed she: *Was lying in her bed with a catheter bag hanging from the bed frame. *Had the catheter for a few months. *Stated that the staff had sometimes worn gowns and gloves when they cared for her. *A sign was hanging on the inside of her door from the Centers for Disease Control and Prevention (CDC) indicating the resident was on EBP (glove and gown use when providing contact care) and everyone must: “clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing”. It also indicated, “Do not to wear the same gown and gloves for the care of more than one person.” Review of resident 26’s electronic medical record (EMR) and comprehensive care plan revealed: *She was admitted on [DATE]. *She had a diagnosis of neuromuscular dysfunction of the bladder (a condition where the bladder’s ability to store and release urine is impaired). *Her Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact. *She was on EBP due to having an indwelling urinary catheter, and the staff had been required to wear a gown and gloves when assisting her with high-contact resident care activities. *She required two staff members to transfer using a mechanical lift. *Staff should have worn gloves and gowns when assisting her with transferring and her catheter care. Interview on 7/16/25 at 3:10 p.m. with CNAs BB and AA regarding resident 26 revealed: *She was dependent upon staff to assist her with transfers, toileting needs, and catheter care. *She had required the use of a mechanical lift (a mechanical lift and sling used to lift a person’s full body) for all transfers. *She was on EBP, so the staff should have worn gloves and gowns when assisting her with toileting and her catheter care. *They stated they did not need to wear gloves and gowns for her transfers, unless they helped her to the commode. *The gowns had been kept in the resident's closet in a tote. *They had used washable gowns, and they could have reused them if they left the room and were coming right back. Otherwise, they disposed of the gowns in a garbage bag and sent them to the laundry. Observation on 7/17/25 at 10:15 a.m. of CNAs J and I with resident 26 in her room revealed: *The surveyor entered the resident's room with her approval. *The resident had just showered, was in the shower chair with a shirt on, no clothes on her bottom half, and her catheter bag was lying on the floor. *Staff were standing next to her with a mechanical lift and had been hooking up the sling when the surveyor came into the room. *CNAs J and I were not wearing gowns or gloves. *Once the surveyor came into the room, CNA I walked over to the resident's closet to get gowns and gloves. There was only 1 gown left, and CNA I put on the gown and a pair of gloves. -CNA J did not wear any personal protective equipment (PPE, such as gowns and gloves) to transfer the resident to her bed. *After the resident was in bed, CNA J left the room while CNA I assisted the resident with dressing her bottom half. *CNA J: -Came back into the room with gowns and restocked the resident's tote. -Had not put on any PPE after she restocked the tote and before assisting CNA I with transferring the resident back into her wheelchair. *Once in her wheelchair, CNA I put the catheter bag on the floor without a barrier between it and the floor. Once they finished getting the resident situated, CNA I placed her catheter bag into a dignity bag and hung the catheter bag on the wheelchair. *Both CNA I and J performed hand hygiene when they left the room. Interview on 7/17/25 at 2:34 p.m. with infection preventionist C regarding the above observations revealed she: *Expected the CNAs to follow the provider's policy to wear PPE during care and transfers of a resident on EBP. *Expected the CNAs not to reuse gowns after being worn, even if they were coming right back. *Expected the CNAs not to place the catheter bag on the floor, and stated it was concerning that they did that. *Stated that all CNAs were educated on PPE use at their recent extravaganza educational event. *Provided the surveyor with copies of the staff education, CDC signs, and a pocket guide for CNAs from the CDC about EBPs. Interview on 7/17/25 at 3:50 p.m. with director of nursing (DON) B revealed she would have expected the staff to follow their EBP policy. Review of the providers' revised February 2024 Enhanced Barrier Precautions policy revealed: *“EBPs are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. -1. EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. -2. EBPs employ targeted gown and glove use during high contact resident care activities when contract precautions do not otherwise apply. --a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). --b. PPE is changed before caring for another resident. --c. Face protection may be used if there is also a risk of splash or spray. -3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include but are not limited too: --a. dressing --b. bathing/showering --c. transferring --d. providing hygiene --e. changing linens --f. changing briefs or assisting with toileting --g. device care or use (… urinary catheter…) --h. wound care -4. EBPs are indicated…. -5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. -6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. -7. The use of EBPs does not impose…. -8. Standard precautions apply to all care of all residents regardless of suspected or confirmed infection or colonization status. -9. Staff are trained prior to caring for residents on EBPs. -10. Signs are posted in the door or wall outside the resident's room indicating the type of precautions and PPE required. -11. PPE is available inside the resident rooms. -12. Residents, families and visitors….” 2. Observation and interview on 7/15/25 at 9:27 a.m. with resident 1 in her room revealed: *She had a nebulizer machine (a device that converts liquid medication into an inhalable mist) on her bedside table next to her recliner chair. *The nebulizer tubing and mask were attached to the nebulizer machine, and liquid was visible in the medication reservoir. *The nebulizer mask was lying directly on the bedside table without a barrier. Review of resident 1’s electronic medical record (EMR) revealed: *The nebulizer mask and parts were to be rinsed after each use and washed after the last treatment of the day. *The nebulizer mask and tubing were to be replaced every Saturday. *Nursing staff were to complete and document lung assessments before and after each treatment. Observation and interview on 7/15/25 at 9:43 a.m. with resident 28 in her room revealed: *She had a nebulizer machine on her nightstand. *The tubing and nebulizer mask were attached to the machine. Liquid was visible in the medication reservoir. *The nebulizer mask was resting uncovered, directly on the nightstand without a barrier. Observation and interview on 7/15/25 at 2:30 p.m. with resident 9 in her room revealed: *She had a nebulizer machine on her nightstand. *The mask and tubing were attached to the nebulizer machine, and there was liquid visible in the medication reservoir. *The nebulizer mask was lying uncovered on the nightstand, with no barrier between the mask and the nightstand. Observation on 7/17/25 at 8:13 a.m. in resident 9’s room revealed that the nebulizer mask and tubing remained attached to the machine and were again lying uncovered on the nightstand without any barrier. Interview on 7/17/25 at 8:40 a.m. with infection preventionist (IP) C revealed that she would expect nebulizers to be rinsed after each use and cleaned daily, as per facility policy. Interview on 7/17/25 at 11:23 a.m. with DON B revealed: *Nebulizer masks and tubing were to be replaced once a week. *Nebulizer masks were not to be left without being placed on a barrier. *Nebulizer masks should have been rinsed and stored properly after the treatment and in accordance with their policy. Review of the provider's May 2025 Policy and Procedure: Administering Medications Through a Nebulizer revealed: *Procedure -When the nebulizer is complete, remove the mask or take the nebulizer unit from the resident. -Wash the nebulizer equipment per nebulizer care and cleaning procedure. Review of the provider's May 2025 Policy and Procedure Cleaning a Nebulizer revealed: *Purpose -To prevent the growth of bacteria on nebulizer equipment.” *“Procedure after each use: -Remove the tubing from the mask or mouthpiece and aerosolize cup. -Rinse with warm tap water between each medication. -Allow to air dry on clean barrier in bowl. *Procedure at end of day: -Remove the tubing from the mask or mouthpiece and aerosolize cup. -Disassemble the pieces and wash them in warm soapy water. -Rinse under a steady stream of warm water. -Allow to air dry on a clean barrier in the bowl, place in the bottom drawer of bathroom or in resident closet. -Mask and/or mouthpiece and tubing will be changed weekly. -Filter will be changed monthly by Care Team Tech (CTT) or designee. 3. Observation and interview on 7/17/25 at 10:21 a.m. with laundry assistant T revealed: *She had worked in the laundry department for about a year and a half. *The linen cart used to deliver clean linen to residents did not have a cover that enclosed the rack. It was open on the ends. *The cover was made of fabric, which was not cleanable. *She stated the cover was supposed to be temporary and that a new cover was supposed to have been ordered for the linen cart. Interview on 7/17/25 at 11:34 a.m. with IP C revealed: *She confirmed the linen cart was not enclosed by the current cover. *She stated she thought the fabric was machine-washable but was unsure if that was being done and that she would follow up with environmental services director/housekeeping S to confirm. Interview on 7/17/25 at 11:47 a.m. with IP C and environmental services director/housekeeping S revealed: *They agreed the linen cart cover “is not ideal.” *They confirmed that it was not being machine washed. *They confirmed it did not enclose the linen cart, and did not cover the linen to prevent cross-contamination. Review of the provider’s 2001 “Laundry and Bedding, Soiled” policy revealed: *Transport -“Linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule.” -“Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.” *Storage -“Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to follow food safety standards by having failed to: *Maintain a sanitary kitchen environment in one of one kitchen.*Discard expired foods (spinach and white icing) in one of one walk-in cooler and one of one dry storage area.*Store perishable foods (sweet cream butter) at the appropriate temperatures.*Practice safe food handling with glove use by one of one dietary aide (R).*Practice appropriate hand hygiene (washing hands or using hand sanitizer) while assisting residents to eat by one of two paid feeding assistants (GG).*Practice appropriate hand hygiene with glove use by one of one cook (HH).Findings include: 1. Observations on 7/15/25 from 8:31 a.m. to 9:35 a.m. during the initial kitchen tour revealed: *The tea dispenser in the beverage preparation area was visibly soiled. -The spout had a buildup of sticky brown residue, the bag of tea concentrate inside the machine was starting to deposit clumps of dried tea on the inside of the bag, and the tubing connecting the tea bag to the spout was visibly soiled on the inside of the clear tube. -There was a layer of dust on top of the machine. -There was a sticker on the inside of the machine that read, “IMPORTANT – PERFORM CLEANING EVERY OTHER DAY. -The bag of tea was not dated to indicate when it had been hooked up to the tea dispenser. *The filter on the side of the water and ice dispenser machine was covered with dust. *The cabinetry was made of wooden particle board. -The cabinet space under the sink had visible signs of water damage. -The boards were warped, had water stains on them, and there were black specks throughout the cabinet space that appeared to have been mold. *In the dish washing room: -The paint was peeling away from the walls. The exposed drywall appeared to have water damage. -The wall-mounted fan had a layer of dust on it. The fan was pointed directly at the clean dish area. -The garbage disposal was disconnected from the sink. In place of the disposal, an old white food bucket (one that may have contained food such as peanut butter, ice cream, coleslaw, etc.) was installed in its place as a makeshift sink basin. That food bucket was in poor condition. *Inside the dishwasher: -The upper wash arm had lint stuck in one of the spray nozzles. -There was a thick layer of wet soap scum and food particles caked to the upper inside of the dishwasher doors. *In the main kitchen, the cabinetry was also made from wooden particle board. -The cabinet spaces under the various sinks were in the same deteriorated and moldy condition as the cabinets in the beverage preparation area. -There was visible water damage in the cabinet that contained the water heater. -Other cabinet spaces were lined with white plastic sheeting. --There was a buildup of a brown sticky substance throughout the cabinet and drawer spaces. --Those cabinets and drawers stored food preparation equipment that included colanders, pots, pans, mixing spoons, spatulas, among other tools. *There was a stainless-steel food prep table to the left of the walk-in cooler. The drawers in that table contained serving scoops. There was an abundance of food crumbs and dust in the drawers. *There were at least four bags of spinach in the walk-in cooler that were visibly wilting and had a collection of brown and white liquid in the bags. -The delivery label indicated those bags of spinach had been delivered on 6/19/25, which was 26 days prior to the survey entrance. *There was an unlabeled and undated container of what appeared to have been butter sitting on the counter at room temperature. -There were two, one-pound bricks of sweet cream butter sitting behind that container. They were soft to the touch as if they had been sitting out at room temperature for a few hours. The manufacturer’s label read, “PERISHABLE KEEP REFRIGERATED.” *The drywall behind the reach-in cooler was deteriorating and crumbling on the floor. *There was a bucket of “White Dipping Icing” in the dry storage area with “6-14” handwritten on the side of the bucket. -There was an unclearly handwritten opened date that read either “Open 7-26-24” or “Open 9-26-24.” -The manufacturer’s sticker on the side of the bucket read, “USE BY 02 [DATE].” 2. Interview on 7/15/25 during the initial kitchen tour at 9:25 a.m. with dietary aide R and cook Y revealed: *One of their coworkers had recently cleaned the walk-in cooler and missed the spoiled spinach. *They could not remember when spinach was last on the menu. -When reviewing the menu, it was discovered that there was supposed to have been a spinach side salad that night for supper. 3. Interview on 7/15/25 during the initial kitchen tour at 9:35 a.m. with dietary manager D revealed that she had started her position as the dietary manager about three weeks ago. 4. Observation on 7/15/25 at 11:13 a.m. of dietary aide R in the dining room revealed:*She was plating and serving meals from the serving window. *She was wearing gloves and used her gloved hands to touch multiple surfaces and utensils, including plates and tongs, and then directly touched ready-to-eat food items (dinner rolls).*At 11:19 a.m., she continued to use the same gloved hands to touch multiple surfaces and then handled ready-to-eat foods (dinner rolls) without changing gloves or performing hand hygiene.*At 11:28 a.m., she was observed to continue that same pattern of touching multiple items with those same gloved hands and then handling ready-to-eat foods.*At 11:36 a.m., she again touched various items with those same gloved hands and handled a ready-to-eat bun.*At 11:42 a.m., she wiped her face with the back of her left gloved hand and then resumed plating meals without changing gloves or washing her hands. Interview on 7/17/25 at 12:12 p.m. with infection preventionist (IP) C revealed the above observations did not meet her expectation of appropriate hand hygiene. 5. Observation on 7/15/25 of the assisted section of the dining room revealed: *At 5:50 p.m., paid feeding assistant GG sat between residents 11 and 47 at assist table #2, helping them eat. -Using her right hand, paid feeding assistant GG started rubbing resident 11’s right shoulder to wake her up so she would eat. -Without performing hand hygiene, paid feeding assistant GG picked up resident 47’s spoon (with her right hand) and fed her a bite of yogurt. *At 5:55 p.m., feeding assistant GG took off the clothing protector from resident 47 and washed her face and hands with a wet washcloth. *Without performing hand hygiene, she returned to resident 11, sat down, picked up her glass, and helped her with a sip of her Ensure protein drink. *At 5:58 p.m., paid feeding assistant GG assisted resident 47 out of the dining room by pushing her wheelchair. *At 6:00 p.m., she returned to the table, did not perform hand hygiene, picked up resident 11’s spoon, and offered her a bite while rubbing the resident’s right shoulder. *At 6:05 p.m., paid feeding assistant GG stood and approached resident 4 at the table, did not perform hand hygiene, and picked up his spoon and fed him a bite. *She returned to resident 11, did not perform hand hygiene, removed her clothing protector, washed the resident’s face and hands, adjusted the resident’s lap blanket, and helped her out of the dining room by pushing her wheelchair. *At 6:08 p.m., paid feeding assistant GG returned to the table, did not perform hand hygiene, removed the resident’s dirty dishes, approached resident 35 at another table, placed her hand on resident 35’s back, picked up her spoon, and gave it to her. *At 6:12 p.m., without performing hand hygiene before, paid feeding assistant GG washed resident 4’s face and hands, removed his clothing protector, and helped him out of the dining room by pushing his wheelchair. *Paid feeding assistant GG did not perform hand hygiene between assisting residents after direct resident contact multiple times during meal assistance. *No glove use was observed during the meal service by paid feeding assistant GG. 6. Interview on 7/16/25 at 2:47 p.m. with dietary manager D revealed that she was aware of the issues that needed to be addressed, such as the deteriorating cabinets, the peeling paint, and crumbling drywall. She said she had discussed the necessary renovations with administrator A to make him aware of the situation. 7. Interview on 7/17/25 at 9:58 a.m. with cook HH revealed: *They deep cleaned the kitchen every two months. *It had been about two months since the kitchen was last cleaned. 8. Interview and observation on 7/17/25 at 10:07 a.m. with dietary aide II revealed: *The dishwasher was to be drained and rinsed every night. *They delimed the dishwasher once per week. *He was not aware of the grime buildup inside the dishwasher doors. 9. Observation and interview on 7/17/25 at 10:23 a.m. with cook HH revealed: *He was using the robot coupe (a type of food blender) to make mechanically altered food. *He was using his key to press in the safety button on the robot coupe. -He explained that the robot coupe had broken some time ago but would still work if the button was manually pressed and held there. 10. Interview on 7/17/25 at 10:26 a.m. with dietary aide R and cook HH revealed: *In the approximately two years dietary aide R had been working there, she had always stored the butter on the counter. -She was not aware that the manufacturer’s label read, “Perishable, Keep Refrigerated.” *Cook HH said that the butter is kept at room temperature on the counter for it to be spreadable. They only used that butter for buttered toast. *He was aware that the manufacturer’s label read, “Perishable, Keep Refrigerated.” 11. Observation on 7/17/25 from 10:53 a.m. to 11:07 a.m. of cook HH serving lunch in the kitchen revealed: *At the beginning of the meal service, he put on a pair of gloves without performing hand hygiene first. *After he dished to-go orders, he changed his gloves and did not perform hand hygiene before putting on a new pair of gloves. *At 11:02 a.m., he took off those gloves to write on a piece of paper, put his pen back in his pants pocket, and without performing hand hygiene, put on a new pair of gloves. 12. Interview on 7/17/25 at 11:24 a.m. with dietary manager D revealed: *She confirmed she was aware of the deteriorating cabinetry, the drywall, and the garbage disposal. *She expected staff to perform hand hygiene before putting on gloves, when switching tasks, and after taking gloves off. *That week was her second or third week as the dietary manager and was aware that there were necessary improvements to make. 13. Review of the provider’s January 2024 Glove Use When Preparing/Serving Food revealed: *Policy: “Bare hand contact with ready to eat food is prohibited.” *“Gloves must be worn when handling ready to eat food directly. Tongs/Utensils may be used instead of gloves when serving/preparing ready to eat foods. *“Gloves may become contaminated and/or soiled and must be changed between tasks.” *“Disposable gloves are single-use items and shall be discarded after each use. *“Hands should be washed (following Bethel hand washing policy), before gloves are put on.” 14. Review of the provider’s January 2024 Food Handling – Preventing Foodborne Illness policy revealed: *Policy: “Food will be stored, prepared, handled and served so that the risk of food borne illness is minimized.” *“Critical factors implicated in food borne illness are: Poor personal hygiene of dietary staff; inadequate cooking and improper holding temperatures; contaminated equipment; and unsafe food sources. *“All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing food borne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. *…“All food service equipment and all utensils will be sanitized according to manufacturer’s recommendations. 15. Review of the provider’s 2/18/25 Food Storage policy revealed: *Policy: “Sufficient storage facilities are provided to keep foods safe and wholesome. Food is stored in an area that is clean, dry and free from contamination. Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination.” *…“All stock is rotated with each new shipment, [old] stock is always used first.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and policy review the provider failed to ensure resident and/or their representative received a written notification with information regarding a transfer to the hospital and was provided a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled resident (42) that was reviewed for facility initiated hospital transfers. Findings include: 1. Review of resident 42's electronic medical record (EMR) revealed: *She was complaining of chest pain in the dining room on 12/6/23. *A standing order for Mylanta 15 mL was given at 12:30 p.m. *She was transported to her room. *Her vital signs were: -Temperature 97.3. -Blood pressure 171/91. -Respirations 26 -Oxygen 93% room air. *She was given an Albuterol nebulizer treatment per physician's order. *After nebulizer treatment she stated, Something is wrong, and I need to go to the hospital now. *Her son was called and agreed resident should go to the emergency room. *She was admitted to the local hospital for further evaluation. *She returned to the facility on [DATE]. Further review of the EMR and paper chart revealed there was no written notification to the resident or her responsible party regarding the Bed Hold policy and no notification to the Ombudsman that resident 42 had been sent and admitted to the hospital. Interview on 1/18/24 at 9:48 a.m. with social service designee (SSD) K revealed: *She reviewed the bed hold policy with residents and their representatives upon admission. *The charge nurse would notify the family and complete the bed hold form when a resident was transferred to the hospital. *She could not find a signed bed hold for resident 42's 12/6/23 hospital transfer. *She was not aware the Ombudsman needed to be notified for hospital transfers when residents were admitted . Interview on 1/18/24 at 10:18 a.m. with director of nursing B revealed: *It was her expectation that the bed hold would be signed for all hospital transfers. *She confirmed a bed hold was not signed when resident 42 went to the hospital. *A verbal notification was given to the family over the phone. Review of the provider's undated Bed Hold Policy and Notification revealed: *It is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization, observation or therapeutic leave of our Bed Hold Policy and Notification. *Each resident/legal representative will be informed by a (provider) staff of the facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization, observation or therapeutic leave.

12. Interview and observation on 1/17/24 at 2:46 p.m. of the nurse's station with LPN/IP C regarding the above observation of RN E revealed: *She had not seen RN with her goggles and N95 mask on. *She found RN E's goggles and N95 mask in a paper bag with her name on it in a cupboard at the nurse's station. *There were other paper bags in that cupboard. *She confirmed that not removing the goggle and the N95 mask at the resident's room and walking down the hallway with those items on was not acceptable practice following entry into a COVID-positive resident's room. 13. Interview on 1/17/24 at 3:15 p.m. with housekeeping manager N regarding the bathtub room revealed: *When asked who cleaned the bathtub room she stated, They [nursing staff] said they were cleaning it, but I should have checked. *She stated that the certified nurse aides (CNAs) cleaned the bathtub, and she cleaned the room. 14. Interview on 1/18/24 at 11:19 a.m. with LPN/IP C about the above observations revealed: *There was no medication cart cleaning policy. *She expected the medication cart to have been cleaned and disinfected every day at the end of the shift. *She confirmed that RN J should have cleaned and sanitized the medication cart after she set the potentially contaminated N95 mask onto the cart. *She agreed there were missed hand hygiene opportunities. *She stated that staff were educated on the donning and doffing of PPE. 15. Interview on 1/18/24 at 1:37 p.m. with LPN/IP C, DON B and administrator A regarding the above observations revealed LPN/IP C would expect: *Staff to take off the gown and gloves inside the resident's room, then exit the room, remove the goggles or face shield and mask, put it in the brown paper bag, close the paper bag, put the paper bag in the second drawer of the dresser. *Hand hygiene should have been performed prior to before putting on PPE and after removing PPE. *Staff should have sanitized their hands before removing protective eyewear and N95 masks and before closing the brown paper bag to avoid contamination. *She agreed that the staff observations confirmed the staff had not followed the expected processes for infection prevention. *She stated staff have been educated on infection control and PPE use, and again in December 2023. 16. Interview on 1/18/24 at 3:05 p.m. with LPN/IP C about her expectations for TBP signage and bathtub room cleanliness revealed: *Signage should have been posted on the resident doors who were on TBP. -The signage should have specifically stated which type of TBP was required (contact, droplet, or airborne). *The facility used a text message/call system to alert all staff and families of TBPs. *Her expectation was that all razors were labeled and stored in the resident's room. *When asked if razors were shared, she stated, they all have their own. -She explained that razors were provided to any resident that did not have one. *Her expectation was that all resident's personal products in the cupboard should have been labeled. 17. Review of resident 2's electronic medical record revealed she was diagnosed with influenza A on 1/12/24. 18. Review of the provider's Policy & Procedure: Isolation - Initiating Transmission - Based Precautions revised December 2018 revealed: *Policy Statement - Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions. Droplet Precautions, or Airborne Precautions. *Policy Interpretation an Implementation- -5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: --a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. --b. Post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. --c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room; Review of the provider's Isolation - Categories of Transmission-Based Precautions policy reviewed on 5/6/20 revealed: *Policy Statement: 1.Transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. *Droplet Precautions -7. Signs- The facility will implement a system to alert staff to the type of precaution resident requires. --a. The facility utilizes the following system for identification of Contact Precautions for staff and visitors: Sign on the door. *Precautions for Coronavirus: -1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. -2. Implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets. -5. Mask with eye protection --a. Put on a mask with eye protection when entering the room. Review of the provider's February 2014 Storage of Resident Personal Care Items policy revealed: *Policy -Resident personal care items are stored in a manner that discourages cross contamination and/loss of items. *Procedure -a. Resident personal care items including, but not limited to, hair combs, brushes, picks, tooth/denture brushes, denture cups, colognes, body sprays, powders shall be labeled with the resident's name or initials using a black permanent marker or a label machine if they are stored in the resident's bathroom. The items do not require labeling if they are stored in the resident's room. -b. Personal care items are stored on the shelved areas of their closets in their room or in a drawer unit in the residence bathroom. Depending on the residence preference. -c. The shelves of the closet are labeled to allow individualizes grouping of oral hygiene, personal care & hair/care items. -d. If a drawer unit in the bathroom is utilized, the appropriate drawers are labeled with the resident's name using the label machine. Review of the provider's November 2018 Policy & Procedure: SHAVER CLEANING revealed: *Procedure: -5. Brush any whiskers into the trash using shaver brush. -6. Release shaver heads from holder. -7. Wash shaver heads with warm soapy water . -15. Replace shaver in the proper place (resident room or utility room). Based on observation, interview, and policy review, the provider failed to ensure the following: *Appropriate use, storage, and disposal of personal protective equipment (PPE) by three of three registered nurses (RNs) (E, I, and J) after entering two of two sampled resident's (2 and 7) rooms who were on transmission-based precautions (TBP) for influenza A and COVID-19. *Signage for the type of isolation precautions required for two of two sampled residents (2 and 7). *Storage and labeling of resident's personal care items in one of one bathtub rooms. *Cleanliness was maintained in one of one bathtub room to prevent the buildup of residue and dust. Findings include: 1. Observation and interview on 1/16/24 at 4:16 p.m. with RN I outside resident 2's room revealed: *She was wearing a gown, mask, and gloves when she exited the room. *There was no signage on the resident's door to indicate she was on TBP. *There was a PPE cart in the hallway to the right of resident 2's room and there were two laundry hampers a few steps away to the left of her room. *There was a blue rectangular sign on the upper right-hand door frame that read wash your hands. *Resident 2 had influenza A. *She stated, The resident would be on droplet precautions, which goes along with contact precautions. *When asked how a visitor might know if the resident was on TBP and what PPE to wear, RN I went back into the resident's room and came back out with a sign. -She indicated that the sign was on the inside of the door. -She proceeded to post the sign on the exterior of the door. *The sign indicated the five steps of donning PPE. The sign did not indicate what type of PPE was required to enter that room. 2. Observation on 1/17/24 at 9:03 a.m. through 9:15 a.m. with RN J revealed: *She was outside of resident 2's room with the medication cart. *There were now two signs on the resident's door. *The signage indicated the five steps of donning PPE and how to hand rub that explained how to appropriately use hand sanitizer. *There was still no signage to indicate what type of PPE was required to enter the resident's room. *She removed a brown paper bag from the medication cart, removed a used N95 mask from the bag, and placed it directly on the medication cart. -She then placed the N95 mask back into the bag. -She had not sanitized the medication cart after placing the potentially contaminated N95 mask directly on the cart. *Without performing hand hygiene, she donned a gown, a surgical mask, and gloves before entering resident 2's room. *She came out of the room with her PPE still on. She had not removed or discarded the contaminated PPE in the resident's room. *With the contaminated gloved hands, she touched the door handle to close the resident's door. *She then removed her gloves, gown, and mask. -She walked to the laundry hampers a short way down the hall to place the soiled PPE inside the hamper. *After performing hand hygiene, she placed the resident medication cards on the potentially contaminated medication cart. *She prepared the resident's medications and donned the PPE without performing hand hygiene. *She knocked on the resident's door, touched the contaminated door handle with her contaminated gloves, and entered the resident's room. 3. Observation of the PPE supply dresser that was located by resident 7's door revealed: *It contained opened N95 masks in paper bags in the second drawer. *The bags were open on the end without folding or closure of any kind. *Some bags had names on them, some had not had names on them. *No cleaning or disinfecting supplies on it or in it. 4. Interview on 1/17/24 09:15 am with the director of nursing (DON) B revealed: *Resident 7 was COVID-19 positive. *Her isolation window was anticipated to end on 1/23/24 or 1/24/24. *Visitors were able to go into her room directly and back out with the proper use of PPE. *All visitor's information was posted at the front entrance to wash hands, not come in if sick, etc. *They did send out a notice to all the families and staff that there was a positive in the building. 5. Interview on 1/17/24 at 9:25 am with licensed practical nurse/infection preventionist (LPN/IP) C regarding PPE for COVID outbreaks revealed: *Resident 7 was positive last week. *They do not require masking for one isolated case, but would if there was more than one positive COVID case, and that was what their policy indicated. *She stated they follow the CDC guidelines so when that changes, they change their policy. 6. Observation and interview on 1/17/24 at 9:57 am with LPN/IP C regarding resident 7's door signage and the PPE supply dresser revealed: *She was not able to state what type of precautions the resident was on. *There was no signage on the door that identified the type of PPE required. *There was a sign on the door the stated BEFORE ENTERING EVERYONE MUST: *gown *gloves *mask *goggles. *She stated that since they had enough supply, staff wore N95s and stored in paper bags. *The paper bags were again noted to have been opened at the end. *LPN/IP C turned one bag top over and shut the drawer. *LPN/IP C stated staff wear the N95 mask during their shift and then would get a new N95 mask and a new paper bag at the beginning of their next scheduled shift. 7. Observation of LPN/IC on 1/17/24 at 10:44 am revealed: *She stated she had previously stated the wrong precaution type, that it [COVID] was a step above, which was airborne. *She then placed an airborne precautions sign on resident 7's door. 8. Observation on 1/17/24 at 1:14 p.m. of the bathtub room across from the chapel revealed the following items were improperly stored and labeled per the provider's policy: *There was an electric razor stored in a three-drawer plastic storage tower with other resident's personal hygiene products such as nail files, nail clippers, and combs. -The electric razor appeared clean on the outside but inside the razor head, there was a significant amount of hair. *There was an opened package of rolled bandages labeled [resident name] leg 3rd in the above-mentioned storage tower. *There were three open cardboard boxes of bar soap labeled with resident information stored on top of the tub. *There were approximately 55 personal care products (assorted shampoos, soaps, lotions, and body sprays) on two shelves in the wooden cabinet. Only 11 out of the approximately 55 containers were labeled with the resident's information. *10 out of the 16 pieces of paper in the tub room were not laminated or in page protectors, that meant those papers were not a cleanable surface. *There was a cloth bag hung on the arm support of the tub seat that was visibly soiled with an unidentifiable white residue. *There was an open white N95 mask hanging from the glove box holder on the back wall. *There was significant dust on top of the tub, on the radio on the windowsill, and on the oxygen concentrator. 9. Interview on 1/17/24 at 1:26 p.m. with housekeeper M about cleaning the bathtub room revealed: *Housekeeping was responsible for cleaning the bathtub room. *She did not know how often the bathtub room should have been cleaned. 10. Observation on 1/17/24 at 2:10 p.m. of the PPE supply cart located near resident 7's room revealed: *One unwrapped N95 mask on top of the PPE dresser and one opened paper bag containing one unwrapped N95 with no name on the bag. *LPN/IP C discarded the N95 on top of the PPE dresser without using gloves or performing hand hygiene. *LPN/IP C discarded the paper bag containing the used N95 without using gloves or performing hand hygiene. 11. Observation on 1/17/24 at 2:16 p.m. of RN E revealed she: *Had walked down the hallway with goggles and an N95 mask on her face and then stopped at the PPE dresser by resident 7's room. *Put on a gown and gloves and then entered resident 7's room with a medication cup in her hand and shut the door. *Opened the door and was noted to have removed and discarded the gloves and gown inside the resident's room. *Exited the resident's room with the same goggles and N95 on her face. *Continued to walk down the hallway with those goggles and N95 on her face. *Then stood at the nurse's station, removed the goggles and the N95, and then placed them in a paper bag.

Based on observation, interview and policy review the provider failed to maintain sanitary conditions in the kitchen and to ensure foods were stored, handled, prepared and served in a safe and sanitary manner for the following: *Appropriate glove use and hand hygiene for one of one cook (D) while preparing and serving food. *Appropriate glove use and hand hygiene for two of two dietary aides (G and H) while handling food. *Appropriate glove use and hand hygiene for one of one cook assistant/dietary aide (L) while serving food. Findings include: 1. Initial kitchen tour on 1/16/24 at 3:41 p.m. revealed: *One container of Orchard Splash prune juice with an expiration date of 10/12/23 was open, and in the refrigerator *Two boxes of food items (hoagie buns and garlic toast) was sitting on the floor of the walk-in freezer. *Cook D put on gloves, placed those gloved hands on a wheeled garbage can and moved it, then begun slicing strawberries with those same gloves on. *Cook D then walked over to the stovetop, stirred a food item in a pot, returned and continued to cut the strawberries, all with those same gloved hands. *Cook D walked about the kitchen, touching several surfaces including counters, papers (hanging on cupboard doors/cork boards/clipboards) and drawers without removing his gloves, washing hands or putting on new gloves and again returned to cutting the strawberries. Observation and interview on 1/16/24 at 5:10 p.m. through 5:24 p.m. with cook D during evening meal prep & service revealed he: *Stated he had been working as a cook for about a year. *Had gloves on both hands, placed an oven mitt over his gloved left hand and checked on a trayed food item in the oven. *Then closed the oven door and removed the oven mitt from his left hand, leaving his gloves in place. *Moved to a two-sectioned sink and filled a large pot with water with those same gloved hands. *Continued to use those oven mitts with the same gloves on while stirring the food item on the stove. *Continued to move throughout the kitchen while he touched multiple surfaces and placed pans in the food warmer with those same gloved hands. *Obtained temperatures of the carrots, chowder, pie filling, pot pies and used the same towel to wipe the temperature probe between each food item that was probed. *Had the same gloves on throughout the entire observation period. 2. Observation on 1/16/24 at 5:19 p.m. through 5:29 p.m. of dietary aide G revealed she: *Went in and out of the kitchen without washing her hands or putting on gloves and removed items from the refrigerator. *Was not wearing a hairnet, but her hair was styled in a single braid. *Walked in and out of the walk-in cooler and delivered food items to the dining room without gloves or washing her hands. 3. Observation on 1/16/24 at 5:20 p.m. through 5:29 p.m. of dietary aide H revealed he: *Entered the kitchen and had not washed his hands or put on gloves. *Entered the walk-in cooler/freezer area and exited with a tub, placed it on the counter and placed jugs of milk in it, then exited the kitchen. *Again entered the kitchen without washing his hands or putting on gloves. *Entered the walk-in cooler/freezer area and delivered a metal tub containing what appeared to have been individual containers of ice cream to a counter behind the food service area and exited the kitchen. 4. Observation on 1/16/24 at 5:33 p.m. through 5:45 p.m. of [NAME] D while plating and serving food revealed he: *Held a slice of bread in his previously gloved left hand, added egg salad on it and placed another slice of bread on top of it to make a sandwich. *Placed the sandwich on a cutting board, cut it, placed it on a plate, filled a soup bowl with chowder and placed the bowl on the plate with the same gloved hands. *Then rested his gloved hand on his apron (right hip area), rested the gloved hand on top of plate and used that plate to assemble another sandwich in the same manner as stated above. *Wiped food off his gloved left hand with the towel that was used to wipe off the food thermometer probe. *Wiped his nose then his face with his right gloved hand and proceeded to plate the resident's food and served it. Interview on 1/16/24 at 5:51 p.m. with cook D regarding food temping process, glove use and hand hygiene revealed he: *At that time removed his gloves, washed his hands and put on a new pair of gloves. *Stated he used the sanitizer, walked to the wall-mounted sanitizer jug, pointed to it (jug is tabled as J-512 ) and stated Now it's just a dirty rag. *Then stated he usually used alcohol pads to clean the thermometer probes but they were out and was not aware where alcohol pads were located. *He stated that he would change his gloves when he was done with a task and moved on to another task. 5. Observation on 1/17/24 from 8:15 a.m. through 8:33 a.m. of cook assistant/dietary aide L while plating and serving resident's food in the kitchen revealed she: *Coughed into her left elbow/arm bend and did not wash her hands or change her gloves. *Continued to plate and serve resident's food. *Then stated her gloves were too big, discarded those gloves and put on a new pair of gloves without washing her hands. *Picked up toast from a tray with those gloved hands, placed toast on a plate and served it. *She continued to use those same gloved hands throughout the remainder of the observed breakfast food service. 6. Observation and interview on 1/17/24 at 8:27 a.m. of the walk-in freezer with dietary manager F revealed: *Four boxes of food items stored on the freezer floor, identified as: doughnuts, cinnamon rolls, hoagie buns, and garlic toast. *She stated that those items should not have been placed on the floor. 7. Observation on 1/17/24 11:30 a.m. of cook assistant/dietary aide L revealed: *While plating resident food items, she turned around and sneezed into her left elbow/arm bend area. *She had not washed her hands or changed her gloves. *She continued to plate and serve resident food, sneezed again without performing hand hygiene or changing her gloves. 8. Interview on 1/18/24 at 8:09 AM with dietary manager F regarding the above observations regarding food storage, food handling, expired foods, glove use, hand hygiene and kitchen sanitization revealed her expectations would have been for the following: *Staff should wash their hands when entering the kitchen. *Gloves and an apron should have been worn by staff when handling food. *Staff should wash their hands and put on a new pair of gloves after coughing or sneezing. *Staff should use alcohol probe wipes between each food item when taking temperatures. *No food items in boxes should have been placed on the floor in the freezer. 9. Review of the provider's January 2024 Glove Use When Preparing/Serving Food policy revealed: *Gloves must be worn when handling ready to eat food directly. Tongs/Utensils may be used instead of gloves when serving/preparing ready to eat foods. *Gloves may become contaminated and/or soiled and must be changed between tasks. *Disposable gloves were single-use items and should be discarded after each use. *Hands should have been washed before glove use. Review of the provider's updated January 2024 Food Preparation and Service policy revealed: *Food preparation staff would adhere to proper hygiene and sanitary practices to prevent the spread of food borne illnesses. *Dietary services staff and other staff that assist with meal service should wash their hands before serving food to residents. Handwashing will also occur after collecting soiled plates and food waste prior to handling food trays. *Bare hand contact with ready to eat food was prohibited. *Staff that entered the kitchen should wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not come in contact with the food. Review of the provider's updated January 2024 Food Handling - Preventing Foodborne Illness policy revealed: *Critical factors implicated in Foodborne illness are: Poor personal hygiene of dietary staff .contaminated equipment. *All employees who handle, prepare or serve food would be trained in the practices of safe food handling and preventing food borne illness. Employees will demonstrate knowledge and competency in those practices prior to working with food or serving food to the residents. *All food service equipment and utensils would be sanitized according to manufacturer's recommendations. Review of the provider's 10/27/2017 Food Storage policy revealed: *Food was stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. *Food should have been stored off of the floor.

Based on observation, interview, record review, and policy review, the provider failed to ensure a dressing change for one of three sampled residents (13) with a pressure ulcer had been: *Completed with appropriate and sanitary technique. *Completed according to the provider's wound care policy: Findings include: 1. Observation on 1/26/23 at 9:35 a.m. of registered nurse (RN)/wound care nurse (WCN) C while completing a dressing change for resident 13's pressure ulcer on her coccyx revealed: *She had completed hand hygiene upon entering the room and went to the closet to obtain the wound care supplies. She realized an item was missing and told the resident, I'll be right back, and left the room to obtain it. *Came back into the room, performed hand hygiene and put on clean gloves. *With those gloved hands she: -Put the packaged supplies on the bedside table without a barrier. -Opened the bottle of Dakin's 0.25 % solution and poured the solution into a four-ounce plastic cup. -Used the bed's remote to raise the resident's bed. -Loosened the resident's incontinent product and repositioned the resident on her left side to complete the wound care to her coccyx. -Held the incontinent product toward the resident's perineum as she was having bladder spasms with urine leakage around her urinary catheter. She said she often had those during repositioning. -Removed the soiled packing from the resident's pressure ulcer area. *Removed the gloves, performed hand hygiene, and put on new gloves. She then: -Obtained a 4 x 4 gauze and a bottle of wound cleanser from the closet and laid both items on the bed, without first placing a barrier. -Without wiping the tip of the nozzle with an alcohol pad, she sprayed the wound cleanser on the resident's wound, and used the 4 x 4 gauze to wipe the wound area. -At that time the resident had begun to have a bowel movement. -Wearing the same gloves, she used cleansing wipes to complete perineal care, removed the soiled incontinent product, and placed a clean incontinent product underneath the resident. *She removed her soiled gloves, performed hand hygiene, and placed a pair of clean gloves on her hands. With those gloved hands she: -Touched the resident's leg to reposition her. -Used an alcohol pad to clean the scissors and cut the Kerlix gauze to the length she needed. -Put the gauze in the cup with the Dakin's solution. -Put the packaged thick absorbent dressing directly on the bed linen, without a protective barrier, and opened the package. -Using the same gloved hands, she took the Dakin's-soaked gauze and packed it loosely into the resident's wound, covered the wound with the thick absorbent dressing, and repositioned the resident on her back. -RN/WCN C then removed her gloves, and without performing hand hygiene, fastened the sides of the resident's brief, and covered her with a blanket. Interview on 1/26/23 at 10:25 a.m. with director of nursing B revealed she agreed RN/WCN C should have used a barrier for all the dressing change supplies and under the resident. She agreed RN/WCN C had missed opportunities for hand hygiene. Review of the provider's undated wound care policy revealed: Preparation: 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc. with alcohol pledget [pad] before opening, as necessary. Equipment and Supplies 1. Dressing material, as indicated, (i.e., gauze, tape, scissors). 2. Disposable cloths, as indicated. 3. Antiseptic (as ordered). 4. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure 1. Use disposable cloth (paper towel is adequate) to set up a clean field on resident's overbed table. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard Wash and dry your hands thoroughly. 6. Put on [clean] gloves. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 14. Remove the disposable cloth next to the resident and discard into the designated container. 15 Remove disposable gloves . Wash and dry your hands thoroughly. 16. Reposition the bed covers. Make the resident comfortable. Use supportive devices [pillows, positioning wedge] as instructed. 20. Wipe reusable supplies with alcohol as indicated (i. e., outsides of containers that were touched by unclean hands, scissor blades, etc.) 22. Wash and dry your hands thoroughly.