Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect during dining when 2 of 28 staff members (Certified Nursing Assistant (CNA) #1 and Activities Assistant) stood to assist residents (Resident #65 and #37) with their meal. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/1/2021, revealed .the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life . Observation in the A Hall on 4/7/2021 at 1:01 PM, revealed CNA #1 was standing over Resident #65 to assist with the meal. Observation in the A Hall on 4/7/2021 at 1:02 PM, revealed the Activities Assistant was standing over Resident #37 to assist with the meal. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .staff should sit down to assist residents with meals .should not stand .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure abuse policies were implemented and followed when facility staff to report allegations of abuse to the Administrator immediately for 1 of 5 sampled residents (Resident #85) reviewed for alleged abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 7/28/2020, documented .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: Immediately . Review of the medical record, revealed Resident #85 was admitted to the facility on [DATE] with diagnoses of Cardiomegaly, Psychosis, Anxiety Disorder, Major Depressive Disorder, and Mood Affective Disorder. Review of the admission Minimum Data Set Assessment (MDS) dated [DATE], revealed Resident #85 scored a 00 on the Brief Interview of Mental Status (BIMS), which indicated severely impaired cognition. Review of the Nurses' Progress Note dated 6/7/2021, revealed an allegation of resident to resident contact on 6/6/2021. Resident #85 was sitting at the desk with his head down and the other resident came by and hit him on the back. Observation in the resident's room on 6/7/2021 at 9:39 AM, revealed Resident #85 alert with confusion. He would answer questions by nodding his head. During an interview on 6/7/2021 at 5:04 PM, the Administrator stated, .we have another resident to resident abuse to report .the Assistant Director of Nursing (ADON) was reviewing the resident's medical record [Resident #13] and found a note that she had slapped a resident on the shoulder yesterday [6/6/2021] when she was leaving the Dining Room . During an interview on 6/10/2021 at 5:39 PM, the Administrator confirmed she should have been notified immediately about the incident of the alleged abuse that occurred on 6/6/2021 and that she was not aware of the incident until 6/7/2021 at approximately 4:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Geriatric Medication Handbook, policy review, medical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #2) failed to administer insulin within the proper time frame related to meals for Resident #61. The failure to provide a substantial meal or snack within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the Geriatric Medication Handbook, eleventh edition, page 41 revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Rapid-Acting Insulin Analog .ONSET .15 min [minutes] .5-[to]10 minutes .before meals . Review of the facility policy titled, Medication-Insulin, revised 10/30/2020, revealed .to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on resident's condition .insulin administration will be coordinated with meal times . Review of medical record, revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Diabetes, Seizures, Abnormal Weight Loss, and Peripheral Vascular Disease. Review of the Physician's Orders dated 7/8/2019 revealed, Novolog Insulin inject 9 units for blood glucose reading of 221-290 before meals. Observations in the resident's room on 6/8/2021 at 12:14 PM, revealed LPN #2 administered 9 units of Novolog insulin subcutaneously to Resident #61. Observations in the Dining Room on 6/8/2021 at 12:53 PM, revealed Resident #61 took their first bite of food, this was 39 minutes after Resident #61 received the insulin. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .should provide a meal or snack within 15-30 minutes of administering insulin .

Based on policy review, observation, and interview, 1 of 28 staff members (Certified Nursing Assistant (CNA) #2) failed to distribute and serve food in a sanitary manner during dining when the staff touched food with their bare hands. The findings include: Review of the facility's policy titled, .Hand hygiene ., revised 5/7/2021, revealed .all staff will perform proper hygiene procedures to prevent the spread of infection to other personnel, residents and visitors .all staff working in all locations within the facility with the exception of food prep [preparation]areas .employees may not contact exposed, ready-to-eat foods with their bare hands and shall use suitable .gloves are not a substitute for hand washing or hand hygiene .if your tasks requires direct contact with ready-to-eat food, wash your hands and exposed portions .prior to donning gloves and before touching food .wash hands immediately after removing gloves . Observations in the resident's room on 6/7/2021 at 12:45 PM, revealed CNA #2 picked up a hot dog with her bare hands and served it to Resident #259. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .staff should not touch residents food with their bare hands .

Based on policy review, observation, and interview, the facility failed to ensure appropriate infection control measures were followed during medication administration when 2 of 4 nurses (Licensed Practical Nurse (LPN) #1 and 2) touched medication with their bare hands and failed to rinse a disposable piston syringe after medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) (a tube placed in the stomach for nutrition). The findings include: Review of the facility's policy titled, Flushing a Feeding Tube, revised 3/10/2021, revealed .Upon completion of the administration, remove plunger from barrel and wash all reusable equipment with warm water. Dry the equipment thoroughly, store in a bag or container for next use . Observation on 6/8/2021 at 7:53 AM, LPN #1 touched Resident #6's Exelon capsule with bare her hands. Observation in front of the resident's room on 6/8/2021 beginning at 8:40 AM, revealed LPN #2 touched Resident #63's gabapentin capsule with her bare hands. Observations in the resident's room on 6/8/2021 at 8:54 AM, revealed LPN #2 completed PEG medication administration using a piston syringe for Resident #63. The piston syringe was placed in a plastic bag at the bedside. LPN #2 did not rinse the piston syringe with water after use. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .nurses should not touch medications with their bare hands .piston syringe should be rinsed with warm water after use .

Based on policy review, observation, and interview, the facility failed follow infection control procedures to prevent the potential spread of infection when 1 of 20 (Certified Nursing Assistant (CNA) #1) staff members failed to perform appropriate hand hygiene and placed a dirty plate lid cover on a clean meal cart. The findings include: The facility's Handwashing/Hand Hygiene policy dated 2/18 documented, .Employees must wash their hands .Before and after direct contact with residents . Observations in Resident #96's room on 4/8/19 at 12:20 PM, revealed CNA #1 touched the bottom of Resident #96's sock, performed tray set up, then removed a piece of cornbread out of the wrapper with her bare hands and placed it on the resident's plate without performing hand hygiene. CNA#1 left the room and placed Resident #96's plate cover lid on the food cart with meal trays. that had not been served. Interview with the Director of Nursing (DON) on 4/11/19 at 10:18 AM, in the DON office, the DON was asked if staff should touch the bottom of a resident's sock, perform meal tray set up, take a piece of cornbread out of a wrapper with her bare hands, and place it on the resident's plate. The DON stated, No . The DON was asked should a plate cover lid be taken out of a resident's room and be placed on the food tray cart with meal trays that have not been served. The DON stated, No.