**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 39 staff members (Certified Nursing Assistant (CNA) #18, #20, #22, and #24) failed to use courtesy titles to address 4 of 166 sampled residents (Resident #109, #159, #372, #373) reviewed during dining observations. The findings include: Review of the facility's policy titled, PATIENT RIGHTS, revealed .The Guarantee of rights that depends on the actions of PARTNERS (employees) are requirements for personnel: right to respect and dignity are requirements of partners . Review of the facility's policy titled, NONDISCRIMINATORY POLICIES, revealed .It is the policy of this center to use courtesy titles ( .Mr., Mrs., Ms.) when addressing patients in all .communications . Observation in the resident's room on 1/18/2022 at 11:24 AM, revealed CNA #20 removed a tray from the meal cart, entered Resident #372's room and stated, Hello Sweetheart. Observation in the resident's room on 1/19/2022 at 5:24 PM, revealed CNA #22 removed a tray from the meal cart, knocked and entered Resident #109's room and stated, Hey Grandma [NAME] are you ready to eat? Observation in the resident's room on 1/19/2022 at 5:45 PM, revealed CNA #18 removed a tray from the meal cart, walked down the hall as she was passing Resident #373's room, and stated to Resident 373, You ok honey. Observation in the resident's room on 1/19/2022 at 6:00 PM, revealed CNA #24 removed a tray from the meal cart, entered Resident #159's room and stated, Hey, sweetie you ready to eat. During an interview on 1/21/2022 at 4:22 PM, the Infection Control Preventionist confirmed that all residents should be addressed by their preferred names and not pet names.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Geriatric Medication Handbook, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #1) failed to provide a substantial snack or meal within 15 minutes of insulin administration for 1 of 5 sampled residents (Resident #137) observed during medication pass. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the GERIATRIC MEDICATION HANDBOOK, 13TH edition, provided by the American Society of Consultant Pharmacists, page 41 and 43, revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Insulin aspart .Rapid-Acting Insulin Analog .Onset .15 min [minutes] .ADMINISTRATION/COMMENTS .15 minutes prior to meals .NovoLog .Insulin Aspart .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes before meals . The findings include: Review of the medical record, revealed Resident #137 was admitted to the facility on [DATE] with diagnoses of Diabetes with Diabetic Neuropathy. Review of the Physician Orders dated 12/29/2021, revealed .Admelog .Insulin lispro [Humalog] . Observation in the resident's room on 1/18/2022 at 4:50 PM, revealed Licensed Practical Nurse (LPN) #7 administered Lispro 8 units into the Resident #137's left arm after acquiring a glucose reading of 396. Resident #137 received his dinner tray at 5:27 PM, 37 minutes after receiving his insulin. During an interview on 1/18/2022 at 5:30 PM, LPN #7 was asked if Lispro was fast acting or slow acting. LPN #7 stated, .Fast acting. During an interview on 1/18/2022 at 5:45 PM, LPN #8/Unit 1 Coordinator was asked if Lispro was fast acting or slow acting. LPN #8 stated, I have to google it .same thing as Humalog .fast acting. During an Interview on 1/20/2022 at 12:20 PM, the Director Of Nursing (DON) was asked when should a resident receive a meal tray or substantial snack after receiving Lispro insulin. The DON stated, .It should have been given within 30 minutes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Centers for Disease Control and Prevention (CDC) guidelines, policy review, Staff Screening Tool review, Daily Schedule Report review, Timecard Detail review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 2 of 40 staff members (Certified Nursing Assistant (CNA) #15 and #18) failed to don (to put on) Personal Protective Equipment (PPE) when entering a droplet precaution room and failed to properly dispose of a mask, and the facility failed to follow Centers for Disease Control (CDC) Infection Control guidelines to ensure all staff who enter the facility completed the screening process for the prevention and potential spread of COVID 19 when 17 of 269 staff members (Licensed Practical Nurse (LPN) #1, CNA #28, Dietary Staff #1, #2, #3, #4, #5, #6, #7, and #8, Health Information Management (HIM) Staff #1 and #2, Maintenance Staff #1 and #2, Recreation Staff #1 and #2, and the Assistant Director of Nursing (ADON)) failed to complete the screening log prior to working on 3 of 5 days (1/1/2022, 1/2/2022 and 1/5/2022) reviewed. This had the potential to affect the 174 residents residing in the facility. The findings include: Review of the undated Center for Disease Control guidelines titled, HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE), revealed .Mask .remove without touching the front .discard in a waste container . Review of the facility's signage titled DROPLET PRECAUTIONS, revealed .STOP .PPE .Surgical Mask .Eye Protection .Gown .Gloves . Review of the Centers for Disease Control and Prevention (CDC) guidelines titled, Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed .a positive viral test for SARS-CoV-2 .symptoms of COVID-19, or .who meets criteria for quarantine or exclusion from work .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility . Review of the facility's policy manual titled, Infection Control [NAME], dated 1/5/2021, revealed .COVID-19 CORE PRINCIPALS OF COVID-19 INFECTION PREVENTION .Screening of all who enter the center for signs and symptoms of COVID-19 (temperature, checks, questions or observations about signs or symptoms . Observation in the resident's room on 1/18/2022 at 11:38 AM, revealed CNA #18 sanitized her hands, removed a meal tray from the dining cart, knocked and entered Resident #373's room, placed the tray on the over the bed table, exited the room and returned to the meal cart. Resident #373's was in droplet precautions. CNA #18 did not don a gown or gloves prior to entering a Droplet Precaution room. Observation in the resident's room on 1/18/2022 at 11:54 AM, revealed CNA #15 donned gown, gloves, and face covering, removed a meal tray from the dining cart, entered Resident #154's room, exited the room in full PPE, walked over to the dining cart and returned the meal tray to the dining cart. CNA #15 then returned to the room and removed her PPE's inside the room. Resident #154 was in contact isolation precaution. Observation in the resident's room on 1/19/2022 at 5:30 PM, revealed CNA #15 removed her surgical mask and placed the mask on top of the isolation cart outside of Resident #369 and #370's room and put on a N95 (mask used in rooms with confirmed respiratory infections) mask. CNA #15 did not properly store or dispose of the surgical mask. Review of the facility's Staff Screening Tool, Daily Schedule Report, and Timecard Details from 1/1/2022-1/5/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19. a. 1/1/2022- Dietary Staff #1, #3, #4, #5, and #6. b. 1/2/2022 - LPN #1, CNA #28, and Dietary Staff #2, #5, #7 and #8. c. 1/5/2022- Dietary Staff #1, #2, and #3, HIM Staff #1 and #2, Recreation Staff #1 and #2, ADON, Maintenance Staff #1 and #2, and CNA #28. During an interview on 1/21/2022 at 4:22 PM, the Infection Control Preventionist confirmed that all staff should screen upon entering the building before reporting to their work stations. The Infection Control Preventionist confirmed that staff should wear the appropriate listed PPE on the signage outside of the isolation rooms. The Infection Control Preventionist confirmed that all PPE's should be removed before exiting an isolation room. The Infection Control Preventionist confirmed that when staff remove their mask, it should be disposed of in the trash.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide timely assessments and treatments for pressure ulcers for 1 of 4 (Resident #87) sampled residents reviewed for pressure ulcers. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Chronic Kidney Disease Stage 4, Heart Failure, Hemiplegia and Hemiparesis, Dysphagia, and Diabetes Mellitus. The care plan dated 6/4/19 documented, .has alteration in skin r/t [related to] dark and reddened areas to (R) [right] foot . The admission Assessment dated 6/5/19 documented, .bilat [bilateral] red heels and outer rt [right] heel dark purple area (possible SDTI) [suspected deep tissue injury] . Review of the wound assessments revealed no assessments were completed for Resident #87's sDTI from admission until 7/9/19. Review of the Treatment Administration Records dated June and July 2019 revealed there was no documentation of wound care treatment for Resident #87 until 7/2/19. Medical record review revealed the pressure ulcer to the right heel remained an unstageable pressure ulcer and had not worsened. Observations in Resident #87's room on 7/18/18 at 2:05 PM, revealed Resident #87, she had a unstageable pressure injury to the right lateral heel. Interview with the Director of Nursing (DON) on 7/31/19 at 2:38 PM, in the Education Room, the DON was asked if Resident #87 was admitted with any pressure ulcers. The DON stated, .she had a suspected deep tissue injury .outer right heel . The DON was asked if weekly skin assessments and treatments should have been done. The DON stated, Yes. The DON was asked when the wound assessments and treatments began. The DON stated, .we started July 2nd . The facility was unable to provide documentation that wound assessments and treatments were provided for Resident #87's pressure ulcer that was identified on 6/4/19, until 7/2/19.