**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, record review, observations, and interview, the facility failed to ensure each resident's environment was safe when 1 of 64 resident rooms on the 100 Hall was a vacant and being renovated. The unlocked and unattended 100 Hall room contained hazardous chemicals and materials including paint, an uncovered bucket with a mixture of paint and water liquid used to clean paint rollers, caulking, nails, screws, and sheetrock mud, and was accessible by residents. The findings include: 1. Review of the undated facility policy titled NHC Storage of Hazardous Chemicals, revealed Hazardous chemicals are to be stored out of the reach of patients . 2. Review of the Administrator's job description signed and dated 12/8/2022, revealed .The Administrator has complete administrative and managerial responsibilities within the health care center .Ability to interpret and implement regulations (state and federal) .Promote safety awareness .Assures compliance with State and Federal Regulations and NHC Corporate and Center policies . Review of the Maintenance Supervisor's job description signed and dated 10/18/2024, revealed .The position organizes, directs and supervises the maintenance and repair program involving buildings and grounds. Also coordinates maintenance and repair activities with functions of other departments .When an outside contractor performs a service, it is to be supervised by this position .Responsible for the care and use of supplies and maintenance equipment used in performance of duties . Review of the Maintenance Assistant's job description signed and dated 11/11/2024, revealed .Responsible for the care and use of supplies and maintenance equipment used in performance of duties . 3. Random observation on 12/16/2024 at 10:25 AM, revealed an unlocked vacant room on the 100 Hall, being renovated, containing the following hazardous supplies and materials that were unsecure and unattended: a. 1 five-gallon bucket containing a white liquid substance and a paint roller that was open and without a lid. b. 3 closed boxes of nails on the wall storage unit counter. c. 1 opened plastic container of screws and nails, and 1 unopened plastic container of screws on the floor in front of the wall storage unit. d. 4 five gallon closed buckets of paint and one of the buckets had dried paint around the top rim of the bucket. e. 1 opened box of approximately 10 tubes of caulking near the entrance door. 4. Review of the facility's list of cognitively impaired residents assessed as having wandering behaviors revealed 4 of 8 (Residents #9, #10, #11, and #12) of the residents were mobile. a. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Diabetes, and Moderate Intellectual Disabilities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was not performed due to Resident #9 was severely cognitively impaired. Resident #9 was ambulatory and independent with bed mobility and transfers. b. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Malnutrition, Anxiety, and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #10 was cognitively intact. Resident #10 was ambulatory and independent with transfer and bed mobility. c. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Schizoaffective Disorders, and Moderate Intellectual Disabilities. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not conducted due to Resident #11 was severely cognitively impaired. Resident #11 was ambulatory with supervision and independent with the use of a wheelchair. Resident #11 was assessed for wandering behaviors. d. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Heart Failure, Anxiety, and Alzheimer's Disease. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10 which indicated Resident #12 was moderately cognitively impaired. Resident #12 was ambulatory and was independent with bed mobility. Resident required staff supervision with transfers. Resident was assessed for wandering behaviors. 5. During an interview on 12/16/2024 at 2:14 PM, the Maintenance Assistant confirmed that the following items in the vacant room on the 100 Hall was paint, a bucket with a white mixture of paint and water liquid used to clean paint rollers, nails, screws, caulking, and sheetrock mud. The Maintenance Assistant confirmed that the paint and screws could be hazardous to residents. During an interview on 12/16/2024 at 5:31 PM, the Administrator was asked if hazardous materials or chemicals should be stored in an unlocked room that is accessible by residents. The Administrator stated, if they are hazardous, then no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility services agreement, medical record review, and interviews, the facility failed to provide timely radiology services for 2 of 2 (Resident #1 and #2) sampled residents reviewed with radiology services. The findings include: 1. Review of the facility's policy Lab and X-Ray Services dated 2/2023, revealed .The center maintains agreements/contracts for clinical, laboratory and radiological services . Review of the facility's [Named company] Portable Services Agreement, dated 3/1/2019, revealed .On-Call Emergency Provider Services. Provider shall be available 24 hours a day, seven days a week for STAT requests. STAT [emergency] services is provided for critical situations requiring rapid results .Facility shall use its best efforts to limit STAT orders to urgent situations where the absence of such an order could reasonably be believed to place the patient's health in serious jeopardy or result in serious bodily impairment or dysfunction . Review of the facility's [Named company] Placing An Order, undated, revealed .Click on Orders in blue on the top right .Click on Priority and select [Normal=same day] or [Stat= 2-4 hours] . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Osteopenia, Osteomyelitis Vertebra, Sacral, and Left Hip, Stage 4 Pressure Ulcer Left Hip present on admission, Heart Failure, Osteoarthritis Left Hip, Cerebral Infarction with Left Sided Hemiplegia/paresis, Epilepsy, Gastrostomy Tube, Methicillin Resistant Staphylococcus Aureus of the wound, Severe Calorie Malnutrition and Vitamin D Deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #1 was moderately impaired cognitively for daily decision making. Review of Resident #1's progress note dated 8/29/2022 at 5:02 PM, revealed .pt [patient] was turned to right side and a pop was heard towards hip and upper left leg region. Pt reports of some increased pain. NP [Nurse Practitioner] immediately notified and STAT left knee, femur and lt [left] hip x-ray ordered . Review of [Named Radiology Services] Radiology Report dated 8/30/2022 at 9:17 AM, revealed .Conclusion: Acute fracture left hip .Report was provided to the facility at the time of the dictation . During an interview on 7/5/2023 at 3:16 PM, Registered Nurse (RN) Wound Care Nurse confirmed the 8/29/2022 5:02 PM progress note. He stated .I immediately notified [named Radiology Services] for a stat x-ray . During an interview on 7/5/2023 at 3:31 PM, Assistant Director of Nursing (ADON) was asked what the expectation for timeliness of a stat x-ray is. He stated .When an x-ray is ordered stat, they [named company Radiology Services] are to be onsite in 2-4 hours as stated on the company order form of what stat is . The ADON confirmed 16 hours from the length of time order sent to the radiology company and the radiology report time. He stated .Yes, that is to long . During an interview on 7/5/2023 at 4:55 PM, LPN #1 stated .We call the [named company Radiology Services] and log in to place order when a stat x-ray is ordered .we are at the mercy of the x-ray people when they come .we put the order in but them coming in two to four hours doesn't happen every time and many times they don't call and let us know they can't come stat . 3. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Osteopenia, Chronic Obstructive Pulmonary Disease, Heart Failure, History of Falling, Osteoarthritis, Dementia with Behaviors, Anxiety and Chronic Pain. Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was assessed to have a BIMS score of 3, which indicated Resident #3 was severely impaired cognitively for daily decision making. Medical record review revealed Resident #2 fell on 5/30/2022 at 7:06 PM and stat x-ray ordered. Review of Resident #2's Nurse's note dated 5/31/2022 at 2:14 AM, revealed .Patient has been complaining of left hip pain from fall this shift. Scheduled Tylenol given not effective. STAT x-ray ordered but company [now] states unable to obtain x-ray until the AM. NP ordered send to ER [emergency room] for eval left hip . Review of Resident #2's Emergency Department Patient Summary dated 5/31/2022 at 3:28 AM, revealed .Arrival time 5/31/2022 3:28:31 .apparent ground level fall has a comminuted left hip fracture . During an interview on 7/5/2023 at 3:31 PM, the ADON confirmed Resident #2 waited over 7 hours from the length of time the x-ray order was sent to the radiology services until notification by the radiology services unable to come to the facility until the AM. He stated, .Yes, we notified them of the stat x-ray around 7 PM and it wasn't until after 2 AM we found out they were not going to be able to come to the facility until later on in the morning .we expect 2-4 hours for stat .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a resident's indwelling urinary catheter bag did not touch the floor for 1 of 2 sampled residents (Resident #13) reviewed with indwelling urinary catheters. The findings include: Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Epilepsy, Chronic Respiratory Failure, Neuromuscular Dysfunction of Bladder, Anoxic Brain Damage, Tracheostomy, and Gastrostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #13 had an indwelling urinary catheter. Review of the Physician Order dated 5/18/2021, revealed .Indwelling Catheter . Observation in Resident #13's room on 6/28/2021 at 10:56 AM and 4:45 PM, revealed that the indwelling urinary catheter bag was lying on the floor. During an interview on 6/30/2021 at 12:34 PM, the Director of Nursing (DON) confirmed that the indwelling urinary catheter bag should not be in the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Partner Handbook and Social Work Services Manual, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 18 staff members (Certified Nursing Assistant (CNA) #1, #5, #6, and #7) failed to knock before entering a resident's room and did not use courtesy titles to address residents. The findings include: Review of the facility's undated handbook titled, [Named company] Partner Handbook, revealed .CARING IN A BETTER WAY DAY BY DAY .combines the best clinical care with the best customer satisfaction for patients .Respect your privacy, dignity . Review of the facility's Social Work Services Manual, revised 6/2006, revealed .The Guarantee of rights that depends on the actions of PARTNERS are requirements for personnel .The right to respect and dignity are requirements for the partners . Observation in Resident #44's room during dining on 6/28/21 at 11:41 AM, revealed CNA #1 stated, .she is a feeder, within hearing distance of the resident. Observation in Resident #100's room during dining on 6/28/2021 at 11:48 AM, revealed CNA #6 entered the resident's room without knocking on the door, set up the meal tray, exited the room, went to the meal cart in the hallway, returned to the resident's room and entered the room again, without knocking on the door prior to entering. Observation in Resident #104's room during dining on 6/28/21 at 12:09 PM, revealed CNA #6 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation in Resident #95's room during dining on 6/28/2021 at 5:43 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on her door prior to entering. Observation in Resident #73's room during dining on 6/28/2021 at 5:45 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation in Resident #100's room during dining on 6/28/2021 at 5:50 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation in Resident #91's room during dining on 6/28/2021 at 5:55 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation outside of room [ROOM NUMBER] on 6/28/2021 at 11:51 AM, revealed CNA #7 referred to residents who were dependent diners as, our feeders, while speaking to another CNA, within hearing distance of Resident #86. Observation outside of room [ROOM NUMBER] on 6/28/2021 at 11:58 AM, revealed CNA #7 was speaking to CNA #8, and stated, .there's one feeder ., referring to a resident who was a dependent diner. She said this in a loud voice, within hearing distance of Resident #6. Observation in Resident #75's room on 6/28/2021 at 12:05 PM, revealed CNA #5 stated loudly, She's a feeder . within hearing distance of the resident. During an interview on 6/28/2021 at 12:52 PM, CNA #8 confirmed she heard CNA #7 refer to residents who were dependent diners as feeders and stated residents should not be referred to as feeders, because they are dependent diners. During an interview on 6/28/2021 at 12:55 PM, CNA #6 was asked if she knocked on the residents' doors prior to entering their rooms. CNA #6 stated, Probably not. During an interview on 6/30/2021 at 12:27 PM, the Director of Nursing (DON) confirmed staff should always knock on the resident's door or verbally announce their presence prior to entering the resident's room. The DON confirmed that residents should not be called feeders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Disease Control (CDC) and Prevention guidance, policy review, observation, and interview, the facility failed to food was served under sanitary conditions when 6 of 18 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #5, #6, and #7) failed to don appropriate personal protective equipment (PPE) when entering a contact isolation room, failed to perform hand hygiene after touching potentially contaminated objects before serving residents meals, used their bare hands to handle a resident's food, failed to perform hand hygiene before and after glove use, failed to perform hand hygiene between serving residents, and used long acrylic nails to open a carton of milk. The findings include: Review of the facility's specialized CNA training titled, 000 Training revised 2/11/2013, revealed .MEAL DELIVERY - DINING ROOM .HANDS SHOULD BE WASHED ANYTIME YOU COME IN CONTACT WITH PATIENT OR EQUIPMENT . Review of the facility's policy titled, .TRANSMISSION-BASED PROCEDURES .HANDWASHING, revised 10/1/2008, revealed .Wash hands before and after contact with each patient .before and after removal of gloves . Review of the facility's policy titled, .GLOVE TECHNIQUE (CLEAN), dated 5/2021, revealed .Gloves are used to prevent contamination of healthcare personnel [personnel's] hands when .having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route .or .handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces . Review of the CDC and Prevention guidance titled, .Guideline for Isolation Precautions ., dated 2007, revealed, .Contact precautions .Use of personal protective equipment .wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient .Don gloves upon entry into the room .Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room .Remove gown and observe hand hygiene before leaving the patient-care environment . Review of the medical record, revealed Resident #209 was admitted to the facility on [DATE] with diagnoses of Urinary Tract Infection and Extended Spectrum Beta-Lactamase (ESBL) (a drug resistant bacteria) in the Urine. Review of a Physician's Order dated 6/25/2021, revealed Resident #209 was placed in contact isolation. Review of a Skilled Nursing Note dated 6/28/2021, revealed, .Isolation continued r/t [related to] ESBL urine . Observation in the 200 Hall on 6/28/2021 beginning at 11:14 AM, revealed CNA #7 carried a lunch tray into Resident 209's isolation room and placed it on his overbed table that was beside his bed. CNA #7 failed to don gloves or a gown before she entered the isolation room. CNA #7 touched the foot of Resident 209's bed and adjusted the overbed table. CNA #7 did not perform hand hygiene and donned clean gloves. She then set up the lunch tray for Resident #209, unfolded the silverware from the napkin, and used the silverware to cut up the food. Observation in the 100 Hall on 6/28/2021 at 11:19 AM, revealed CNA #2 assisted a resident down the hallway in her wheelchair to the nursing station, touched her head, and failed to perform hand hygiene. CNA #2 removed a tray from the lunch tray cart and entered Resident #3's room. Resident #3 refused the tray, and CNA #2 placed the tray back onto the clean cart. She then entered Resident #3's room, removed a housecoat from the resident's drawer, donned gloves, and assisted the resident with her housecoat. CNA #2 removed her gloves, failed to perform hand hygiene, and went back to dining cart and continued to serve trays. Observation in the resident's room on 6/28/2021 beginning at 11:26 AM, revealed CNA #1 entered Resident #35's room, placed the lunch tray on the overbed table, and exited the room. CNA #1 failed to perform hand hygiene and pushed the tray cart down the 100 hall. CNA #1 then entered Resident #80's room, failed to perform hand hygiene, and set up the lunch tray, touching all the items on the tray. CNA #1 returned to the cart and obtained another lunch tray, took it into Resident #88's room, failed to perform hand hygiene, and set the lunch tray up, touching all the items on the lunch tray. Observation in the resident's room on 6/28/2021 at 11:32 AM, revealed CNA #1 entered Resident #45's room, placed the lunch tray on the overbed table, dropped her badge on the floor, and picked her badge up off the floor. CNA #1 failed to perform hand hygiene and set up the lunch tray, touching all of the items on the tray. Observation in the resident's room on 6/28/2021 at 11:34 AM, revealed CNA #1 entered Resident #10's room, placed the tray on the overbed table, and moved the resident's wheelchair to the side. CNA #1 failed to perform hand hygiene and set up the lunch tray, touching all the items on the tray. CNA #1 then obtained another lunch tray, took it into Resident #30's room, failed to perform hand hygiene, and set up the lunch tray, touching all the items on the tray. Observation in the 100 Hall on 6/28/2021 beginning at 11:41 AM, showed CNA #7 knocked on Resident #15's door, and set a lunch tray on the overbed table. CNA #7 touched the table, reached down and touched the bottom of the table, near the wheel to adjust the table. CNA #7 failed to perform hand hygiene, touched the water pitcher, and then began to set up the lunch tray. She touched the napkin and removed the silverware, touched the straw and placed it in the iced tea, and used the silverware to cut up the chicken. CNA #7 failed to perform hand hygiene and began to assist the roommate, Resident #10. She picked up Resident #10's spoon and gave her a bite of food. Observation in the resident's room on 6/28/2021 at 11:48 AM, revealed CNA #6 entered Resident #100's room and placed the meal tray on the overbed table, donned gloves, propelled the resident in her wheelchair to the overbed table using the handles, reached down and manually turned the left front wheel of the chair with her left, gloved hand, and continued to set up the resident's meal tray, without removing the gloves and performing hand hygiene. CNA #6 exited the resident's room wearing the same pair of gloves, went to the meal cart, retrieved artificial sweetener from a plastic tray on top of the cart, and returned to the resident's room still wearing the same pair of gloves. CNA #6 removed her left glove and stirred the artificial sweetener into the resident's tea with her left hand, without performing hand hygiene. CNA #6 removed her right glove, exited the resident's room, returned to the meal cart, and opened the door of the cart, without performing hand hygiene. Observation in the 100 Hall on 6/28/2021 at 11:53 AM, showed CNA #7 took a lunch tray in Resident #86's room and placed the tray on the overbed table. CNA #7 then touched Resident #86's gown, touched her blanket, attached the call light button to Resident #86's gown, and failed to perform hand hygiene. CNA #7 then began to set up the lunch tray. She opened the milk, unfolded the napkin and silverware, touched the tip of the straw, and used the silverware to cut up the chicken. Observation in the resident's room on 6/28/2021 at 12:00 PM, revealed CNA #6 entered Resident #99's room, placed the meal tray on his overbed table, raised the head of his bed, moved the overbed table to his bedside, donned gloves, set up the resident's meal tray, removed the lids from the cups and bowls, cut up the resident's meat, added artificial sweetener to his cup of tea, and stirred it with the straw, without performing hand hygiene before donning the gloves. Observation in the resident's room on 6/28/2021 at 12:09 PM, revealed CNA #6 entered Resident #104's room, donned gloves, retrieved house slippers from a drawer in the chest, placed the slippers on the resident's feet, retrieved the resident's walker from across the room and placed it in front of the resident. CNA #6 then set up the resident's meal tray, and cut up food, without performing hand hygiene after touching the potentially contaminated surfaces in the room. Observation in the resident's room on 6/28/2021 at 5:14 PM, revealed CNA #3 unwrapped Resident #10's sandwich with her bare hands, placed her hand on top of the sandwich and cut the sandwich in half. CNA #3 opened the resident's crackers with her bare hands and placed them on the side of the resident's plate. Observation in the resident's room on 6/28/21 at 5:26 PM, revealed CNA #3 placed Resident #86's supper tray on the overbed table, pulled the cord to turn on the light, positioned the resident in bed with the draw sheet with her bare hands, and then failed to perform hand hygiene. CNA #3 set up the supper tray, touching all the items on the tray. Observation in the resident's room on 6/28/2021 at 5:40 PM, revealed CNA #5 opened Resident #312's milk carton by placing her long, acrylic fingernail inside the carton to open the spout. During an interview on 6/30/2021 at 12:27 PM, the Director of Nursing (DON) was asked if staff should don PPE for contact isolation before entering contact isolation rooms during dining. She confirmed PPE should be worn before entering a contact isolation room at any time. The DON confirmed that after touching any equipment or surfaces in the resident's room, staff should always perform hand hygiene before they set up a resident's meal tray. The DON confirmed that staff should not touch the resident's food with their bare hands. The DON was asked how often staff should perform hand hygiene when passing trays. The DON stated, After each patient. The DON confirmed once a tray is taken into a resident's room it should not be placed back on the clean tray cart. The DON was asked if staff should touch the tip of the residents' straws. The DON stated, Not without hand sanitizing. She confirmed staff should not use their fingernails to open a resident's milk carton.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 (Resident #84) abuse incidents reviewed. The findings include: The facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy revised 12/11/17 documented, .INTERNAL INVESTIGATION POLICY .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident .The investigation is conducted immediately under the following circumstances .When it is identified that an alleged incident may have occurred .When there is a question as to whether to conduct an investigation, it is best to do so . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Diabetes, Overactive Bladder, Osteoarthritis, and Anxiety Disorder. Interview with Resident #84 on 7/29/19 at 9:05 AM, in her room, Resident #84 stated, .I was left wet all night. They [staff] didn't do anything. She [Certified Nursing Assistant (CNA)] said I shouldn't be lying about her. The next night they [staff] got on to her [CNA]. The third night she [CNA] kissed me in the mouth and said she [CNA] loved me. Resident #84 was asked if she knew the CNA's name. Resident #84 stated, [Named CNA #1]. She works midnights . Review of an untitled facility timeline presented by the Assistant Director of Nursing (ADON) on 7/29/19 regarding an incident with Resident #84 documented, .7/18/19 .[Named Resident #84] reported the CNA from 11p [pm]-7am shift had not change her [Resident #84] properly. Patient [Resident #84] states that at approximately 2-3 am she [Resident #84] put her call light on because she [Resident #84] was wet and needed to be changed. Patient [Resident #84] stated [Named CNA #1] answered her call light. Only changed her [Resident #84] under pad and brief but did not change her wet bottom sheet .7/22/19---I [ADON] received a call from [Named Resident #84's daughter] .She [Named Resident #84's daughter] stated that her mother [Resident #84] had told her [Named Resident #84's daughter] about the incident of being wet and stated that .when [Named CNA #1] made her first round on 11-7 shift that she [CNA #1] asked [Resident #84] why she [Resident #84] lied on her [Resident #84] and said she [CNA #1] did not change her [Resident #84] appropriately .I [ADON] spoke with [Named Resident #84] who did state all of the above documented that occurred. She [Resident #84] also reported, that [Named CNA #1] cared for her [Resident #84] last night .stated when she [CNA #1] came in to check her [Resident #84], she [CNA #1] leaned over and kissed her [Resident #84] on the lips and stated 'I [CNA #1] still love you [Resident # 84]'. [Named Resident #84] stated that made her feel uncomfortable .and 'I [Resident #84] don't know why this has happened .I [Resident #84] did not lie on her [CNA #1]' .7/23/19 .[Named CNA #1] states she did change [Named Resident #84] properly. When I [ADON] questioned about her [CNA #1] accusing [Named Resident #84] of lying, she [CNA #1] stated, 'Yes, I did ask her why she [Resident #84] lied on me [CNA #1]' .Also questioned [CNA #1] about the kissing [Named Resident #84] on the lips. [Named CNA #1] stated, 'I [CNA #1] would never kiss my patients on the lips, but I do hug and kiss them on the cheek every night I work . The ADON confirmed that she had written this timeline and signed the document. Interview with Resident #84 on 7/31/19 at 8:32 AM, in her room, Resident #84 was asked if CNA #1 often kissed her on the cheek. Resident #84 stated, She kissed me on the mouth. Resident #84 was asked again if CNA #1 sometimes kissed her on the cheek. Resident #84 stated, No. Interview with CNA #1 on 7/30/19 at 7:35 AM, in the Conference Room, CNA #1 was asked what happened with Resident #84. CNA #1 stated, I went in the room and asked the patient, I'm trying to think what I said .asked patient why she [Resident #84] said I didn't change her and .why she [Resident #84] said I didn't change the bottom sheet. CNA #1 was asked if she kissed Resident #84. CNA #1 stated, On the cheek. CNA #1 was asked if she asked Resident #84 if she lied on her. CNA #1 stated, I don't recollect. Interview with the ADON on 7/30/19 at 1:46 PM, in the Conference Room, the ADON was asked about the incident with CNA #1 and Resident #84. The ADON stated, [Named Resident #84] said she [CNA #1] leaned down and hugged her [Resident #84] and kissed her on the lips and she [Resident #84] did not feel comfortable with that .Tuesday morning I came in and talked to her [CNA #1] about her [CNA #1 stating Resident #84] lying on her. She [CNA #1] admitted that she had said that .I then talked about the kiss .[CNA #1] said she .hug them and kiss them [residents] on the cheek . The ADON was asked when she typed up the untitled timeline. The ADON stated, .I completed it yesterday when you asked for it . The ADON was asked if any other residents were asked about CNA #1. The ADON stated, I did not. The ADON was asked if any staff were questioned about CNA #1. The ADON stated, I did not question any staff. The ADON was asked if Resident #84 had ever accused staff falsely. The ADON stated, Not that I'm aware of . The ADON was asked according to their policy, what should be done when there is an allegation of neglect or abuse. The ADON stated, An investigation should be conducted immediately. Interview with the Director of Nursing (DON) on 7/30/19 at 2:59 PM, in the Conference Room, the DON was asked if an investigation had been done about the incidents with Resident #84. The DON confirmed there was no investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Infection Control Manual review, medical record review, observation, and interview, the facility failed to maintain infection control practices for 1 of 2 (Resident #60) sampled residents reviewed for urinary catheters and failed to provide effective dialysis communication for 1 of 2 (Resident #340) sampled residents reviewed for isolation. The findings include: 1. The facility's undated USE OF FOLEY CATHETER policy documented, .Follow the Physician Order for use of the foley catheter .decrease risk of infection related to retention of urine in the bladder . 2. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dementia, Chronic Kidney Disease, Diabetes, Depression, Neuromuscular Dysfunction of Bladder, Retention of Urine, and Benign Prostatic Hyperplasia. A physician's order dated 6/4/19 documented, .Indwelling Catheter change every month due to Neurogenic Bladder/Urinary Retention . 3. Observations in Resident #60's room on 7/29/19 at 8:12 AM, 1:41 PM, and 5:26 PM, revealed Resident #60 was lying in the bed and his indwelling, urinary catheter bag was lying on the floor. Interview with the Director of Nursing (DON) on 7/31/19 at 2:33 PM, the DON was asked should the urinary catheter bag be lying on the floor. The DON stated, No, Ma'am. 4. The facility's Infection Control manual with a revision date of 10/1/08 documented, .It is the right of every patient in the center to receive a standard of care which includes a safe environment which prevents the transmission of infectious disease .The goals of the Infection Control Program .decrease the risk of infection to patients, partners and visitors . The facility's Nursing Home/Dialysis agreement documented .The nursing home will inform [named clinic] of all relevant medical .information . 5. Medical record review revealed Resident #340 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, and Methicillin Resistant Staphylococcus Aureus Infection (MRSA). The physician's orders dated 7/26/17 documented, .Contact Precautions .RELATED TO MRSA BLOOD AND WOUND .Dialysis every Tuesday, Thursday .and Saturday . Interview with Licensed Practical Nurse (LPN) #1 on 7/30/19 at 3:24 PM, in the South Nurse's Station, LPN #1 was asked what type of communication goes with Resident #340 to dialysis. LPN #1 stated, We [staff] fill out a form called the Dialysis Communication Worksheet. LPN #1 was asked did Resident #340 have MRSA which required contact isolation. LPN #1 stated, Yes. LPN #1 was asked if the information concerning the MRSA was included on the Dialysis Communication Worksheet. LPN #1 stated No, but I guess it [MRSA information] should be . LPN #1 was asked if that information was given today in verbal report to dialysis. LPN #1 stated, No . Interview with the DON on 7/31/19 at 2:48 PM, in the Conference Room, the DON was asked if isolation status should be included on the Dialysis Communication Form. The DON stated, Just because it [isolation status] is not on the form doesn't mean they [dialysis staff] don't know. The DON was asked how can isolation status be communicated and not overlooked. The DON stated, I will have to add it [isolation status] to this form. Interview with LPN #2 on 8/1/19 at 9:50 AM, in the Conference Room, LPN #2 was asked if she was over Infection Control. LPN #2 stated, Yes. LPN #2 was asked should the Dialysis Communication Worksheet reflect that the patient is in Isolation. LPN #2 stated, Yes .