Based on policy review, record review, facility document, and interview, the facility failed to submit a five-day investigative summary to the State related to an allegation of neglect for 1 (Resident #1) of 3 sampled residents reviewed for abuse/neglect. Findings included: 1. A review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with an original date of 08/01/2001 and revised date of 2023, revealed, It is the policy of this facility that 'abuse' allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. 2. Medical record review of the Resident Face Sheet revealed the facility admitted Resident #1 on 04/25/2022, with diagnoses that included Conduct Disorder, Cognitive Communication Deficit, Mild Vascular Dementia with Mood Disturbance, and Recurrent Severe Major Depression with Psychotic Symptoms. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2022, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with toilet use and was frequently incontinent of bowel and bladder. Review of an incident report dated 08/22/2022, indicated on 08/20/2022, Resident #1 informed a certified nursing assistant of an allegation of neglect. Per the incident report, the resident stated their incontinence brief had not been changed since 08/19/2022. A review of facility documents revealed no evidence a five-day investigative summary report had been submitted to the state agency. During an interview on 10/13/2023 at 3:18 PM, the Director of Nursing (DON) said the Administrator was responsible for reporting issues to the state agency. During an interview on 10/12/2023 at 4:47 PM, the Administrator stated he reported Resident #1's concerns to Adult Protective Services (APS), the state agency, the local police department, and the Ombudsman. The Administrator stated he had not filed a five-day report with the state because APS investigated and stated there were no issues, and because the allegations were unsubstantiated. In a follow-up interview on 10/13/2023 at 5:29 PM, the Administrator stated he was unaware a five-day report had to be submitted to the state agency.

Based on Centers for Disease Control and Prevention (CDC) guidelines, policy review, Work Summary Report review, Screening Log review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained to ensure all staff who enter the facility completed the screening process for the prevention and potential spread of COVID-19 when 26 of 174 staff members (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, #2, #3, and #4, Respiratory Therapist (RT) #1, Social Worker #1, Maintenance #1, Receptionist #1 and #2, Physical Therapist Assistant (PTA) #1, #2, and #3, Occupational Therapist Assistant (OTA) #1 and #2, Physical Therapist (PT) #1, Certified Nursing Assistant (CNA) #1, #2, #3, #4, and #5, Temporary Nurse Assistant (TNA) #1 and #2, and Dietary Staff #1, #2, and #3) failed to complete the screening log prior to working 4 of 6 days (3/1/2022, 3/4/2022, 3/5/2022, and 3/6/2022) reviewed; and when 1 of 3 nurses (LPN #5) failed to perform hand hygiene for 1 of 4 sampled residents (Resident #32) observed during medication (med) administration. This had the potential to affect the 56 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) guidelines document 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 they can properly manage .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 Staff/Visitor/Vendor Screening Log and the facility's Work Summary Report dated from 3/1/2022-3/6/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 3/1/2022 - TNA #1, OTA #1 and #2, PTA #1, #2, and #3, and Dietary Staff #3. b. 3/4/2022 - LPN #1, #2, and #3, Maintenance #1, CNA #1, PTA #1 and #3, OTA #1, and Dietary Staff #1 and #2. c. 3/5/2022 - LPN #4, CNA #2 and #3, TNA #2, and Receptionist #1. d. 3/6/2022 - Social Worker #1, RT #1, LPN #4, PT #1, PTA #2, CNA #4 and #5, TNA #1, and Receptionist #1 and #2. During an interview on 3/16/2022 at 3:05 PM, the Infection Preventionist was asked about the staff failing to screen prior to entering the facility. The Infection Preventionist stated, .I audit weekly or twice a week .I don't know how I failed to catch those staff that didn't screen .I think it has to do with the time clock . Review of the facility's undated policy titled, Hand Washing and Hand Sanitizer, revealed .Hand hygiene is the primary means to prevent the spread of infection .Wash or sanitize hands after removal of gloves . Review of the facility's policy titled, Administration Procedures for All Medications, dated 1/1/2019, revealed .Cleanse hands .before beginning a med pass, before handling medication, and before contact with a resident . Observation at the 100 Hall Medication Cart on 3/15/2022 at 8:12 AM, revealed LPN #5 failed to perform hand hygiene before she prepared Resident #32's medications. LPN #5 disposed of the medication packages in a trash bag, touching the inside of the trash bag with her bare hands. LPN #5 failed to perform hand hygiene before she removed the cap to Resident #32's eye medication. Observation at the 100 Hall Medication Cart on 3/15/2022 at 11:56 AM, revealed LPN #5 failed to perform hand hygiene, donned gloves and cleaned the blood glucose meter. LPN #5 doffed her gloves and donned clean gloves without performing hand hygiene. LPN #5 went to Resident #32's room, wearing the same gloves, and checked the resident's blood glucose. LPN #5 did not remove her gloves, perform hand hygiene, and don clean gloves prior to checking the resident's blood glucose level. Observation at the 100 Hall Medication Cart on 3/15/2022 at 12:12 PM, revealed LPN #5 failed to perform hand hygiene and prepared insulin. LPN #5 did not perform hand hygiene, donned clean gloves, went to Resident #32's room, and administered the insulin. During an interview on 3/16/2022 at 1:30 PM, the Director of Nursing (DON) confirmed staff should wash their hands prior to administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to store an ice scoop under sanitary conditions for 1 of 2 (200 Hall) ice storage areas and failed to ensure practices were followed to maintain infection control for 1 of 1 (Resident #25) sampled residents observed during perineal care. The findings include: 1. The facility's Safety & [and] Sanitation Best Practice Guidelines policy dated 11/2017 documented .the handle of the scoop must be stored so that it does not touch the ice . 2. Observations in the 200 Hall nourishment room on 4/29/19 at 11:30 AM and at 3:39 PM, revealed the ice scoop was stored inside the portable ice bin on top of the ice. Interview with the Director of Nursing (DON) on 4/30/19 at 11:40 AM. in the 100 Hall, the DON was asked if it was acceptable for the ice scoop to be stored inside the ice bin. The DON stated, No. 3. The facility's undated Perineal Care policy documented, .To provide cleanliness and comfort to the patient .prevent infections .Remove gloves and discard. Wash and dry your hands . 4. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Palliative Care, and Fracture of Left Pubis. Observations in Resident #25's room on 4/29/19 at 11:37 AM, revealed Certified Nursing Assistant (CNA) #2 provided perineal care to Resident #25. CNA #2 did not remove the soiled gloves used during the perineal care. After performing the perineal care, CNA #2 assisted the resident to sit on the bedside, took the resident's hairbrush, and began brushing and touching Resident #25's hair. Interview with the DON on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to perform perineal care and wear the same gloves to brush a resident's hair. The DON stated, No.

Based on policy review, observation, and interview, the facility and failed to ensure meal trays were served under sanitary conditions when 3 of 7 (Certified Nursing Assistant (CNA) # 1, #2, and #3) staff members failed to perform proper hand hygiene during dining. The findings include: The facility's undated Hand Washing and Hand Sanitizer policy documented, .Hand hygiene is the primary means to prevent the spread of infection . Observations in Resident #3's room on 4/29/19 at 11:57 AM, revealed CNA #1 delivered Resident #3's meal tray into her room. CNA #1 repositioned Resident #3. CNA #1 and CNA #2 then pulled Resident #3 up in the bed. CNA #1 opened the meal tray, poured Resident #3's milk, touched items on the tray, opened Resident #3's straw, touched the straw with his bare hands, and inserted it into Resident #3's drink without performing hand hygiene. Observations in Resident #5's room on 4/30/19 at 7:32 AM, revealed CNA #3 delivered Resident #5's meal tray, moved a garbage can, then set up the meal tray, and stirred the food with the utensils, without performing hand hygiene. Observations in Resident #21's room on 4/30/19 at 7:39 AM, revealed CNA #3 delivered Resident #21's meal tray, pulled Resident #21 up in the bed, opened the silverware, opened the juice, and put the straw into the juice, without performing hand hygiene. Observations in Resident #23 and Resident #6's room on 4/30/19 at 8:01 AM, revealed CNA #3 and CNA #2 pulled Resident #23 up in the bed. CNA # 2 then removed her gloves and went to Resident #6 and set up her meal tray, opened her jelly and spread it on her food, opened the juices, opened the straw and put it into Resident #6's drink, without performing hand hygiene. Observations in Resident #303's room on 4/30/19 at 8:05 AM, revealed CNA #3 delivered Resident #303's meal tray, raised the head of the bed, adjusted Resident #303's oxygen on her face, moved a cord on the floor under the bed, moved the over-bed table in front of the resident, opened and sprinkled sweetener over the food, opened the carton of milk, opened the straw and put it into the drink, without performing hand hygiene. Interview with the Director of Nursing (DON) on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to reposition residents, touch articles in the room such as garbage cans and things on the floor, then set up meal trays without performing hand hygiene. The DON stated, They should perform hand hygiene before setting up the tray.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy documented .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . 2. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed 5 unsecured syringes containing 5 milliliters of heparin 100 units/milliliter (an anticoagulant medication). Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the heparin syringes. The DON stated, No. The DON confirmed the medication was not secured.

Based on policy review, observation and interview, the facility failed to ensure the environment was free from accident hazards as evidenced by unsecured and accessible chemicals and needles stored in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's .Storage of Hazardous Chemicals policy documented, Hazardous chemicals are to be stored out of the reach of patients. Examples of hazardous materials are .Acetone . 2. The facility's .EQUIPMENT AND SUPPLIES FOR ADMINISTERING MEDICATIONS policy documented, .The following equipment and supplies are .maintained by the facility for the proper storage, preparation and administration of medication .needles . 3. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed a bottle of nail polish remover (acetone), 4 bottles of shave cream labeled Keep out of Reach of Children, 5 bottles of anti-perspirant deodorant labeled, Keep out of Reach of Children, 3 denture cleanser tablets, (9) 24-gauge needles, and (2) 23-gauge needles, all unsecured. Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the nail polish remover, the items labeled Keep out of reach of children, or the needles. The DON stated, No. The DON confirmed the chemicals and sharps were not secured.