**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #10) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #10's face sheet dated 11/08/23, revealed an 82- year- old female admitted to the facility on [DATE] with diagnoses including personal history of Covid-19, cutaneous abscess of perineum, constipation, reduced mobility, and Alzheimer's disease. Review of Resident #10's MDS assessment dated [DATE] revealed Resident #10 required substantial/maximal assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #10 was always incontinent of bowel and bladder. Review of Resident #10's Care Plan dated 03/26/23 revealed Resident #10 is incontinent of bowel and bladder related to loss of control/muscle tone, impaired mobility. Observation of incontinence care for Resident #10 on 11/06/24 at 2:30 p.m. revealed CNA A did not wash her hands prior to donning gloves. She retrieved the resident's clean brief and placed it near the soiled brief. Resident #10's brief was soiled with fecal matter. CNA A wiped the resident from front to back. She made 5 strokes of clean with the same soiled wipes. CNA A did not change her gloves and continued to clean Resident #10. She used the same soiled gloves to apply skin protector on Resident #10. CNA A's gloves were visibly soiled with fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before putting Resident #10's clean brief and placing it underneath the resident. She removed the soiled gloves and fastened the clean brief on Resident #10. CNA A retrieved the trash and walked out of Resident #10's room without washing her hands. In an interview on 11/06/24 at 2:41 p.m. with CNA A, she said she should have washed her hands before starting care and changed her gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #10. CNA A stated she has been in the facility since August 2024 and had infection control training last month. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. CNA A added she did not follow standard precautions and good infection practice because she was nervous. During an interview with the DON on 11/08/24 at 10:17 a.m., she stated she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility's protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. The DON explained she was the infection preventionist responsible for training staff and monitoring infection control practices. She stated she monitors the staff by conducting in-services. The DON added the staff receive infection control training annually and in-services at least once a month. Review of the facility's Hand hygiene policy revised 02/11/22 reflected: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. C. the dishwasher sanitizer did not meet required level for proper sanitization. D. food was open to air and not sealed. E. food was not dated when opened. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings included: In an observation on 11/5/24 at 8:50 AM, during the initial tour of kitchen, revealed the following: 1. Dry storage area had an opened bottle of vanilla that was not dated and covered in dried vanilla down the bottle, there were open cracker packets in a bin with bags of fruit punch mix, sugar and creamer packets lying on the shelves and floor. Observation of dirt, food crumbs, cans of soda and trash underneath the shelves and along the walls. 2. Refrigerator #1, crumbs and unknown dried brown substance was noted on bottom shelf. One container of leftover food noted with a cracked lid and another with premade sandwiches had plastic wrap partially covering food. 3. Beverage station had dried red substance and food crumbs. 4. Refrigerator #2 (small juice fridge) there was a container with 2 baggies that contained shredded cheese and sour cream undated. 5. Main kitchen/Serving Area on the prep station there was a used Styrofoam cup with no lid, the station was dirty with food crumbs near clean dishes/utensils, an open bottle of lemon juice undated, and the storage under the prep area has a black greasy substance where the clean pots and lids were kept. 6. Warmer #1 had trays inside with a dried leftover substance, and under the warmer was a piece of chicken. Behind the stove was a drinking cup, a fryer basket, food container, some plastic wrap and a bottle of lemon juice with no date covered in a greasy substance. In an observation and interview on 11/5/24 at 9:28 AM Dietary Aide A was washing and removing dishes from dish machine then putting them up in the clean part of the kitchen storage. He stated that he or his coworkers check the dish machine several times a day and document on the log . He was unable to voice what proper chlorine sanitization level should read when using test strips. In an observation and interview on 11/5/24 at 9:31 AM Dietary Manager tested the chlorine sanitizer level in the low temperature dish machine which read at a level of 25 parts per million. The Dietary Manger stated this level was not the correct level and should read between 50-100 parts per million when tested. She further stated that lack of proper chlorine sanitization level could lead to sickness. She also stated that she and her staff would review the dishes that were washed at this level and re-wash them. In an interview on 11/7/24 at 7:18pm the Dietary Manager stated the following regarding kitchen cleanliness and sanitation, We have already started cleaning. I told them(kitchen staff) we need a schedule and have put one in place for housekeeping to do the floors once a month. We do have a cleaning schedule, but they are so new that they just do at it if you know what I mean. I told my Assistant Dietary Manager that we must hold them accountable. She stated that an adverse outcome of unclean kitchen could cause bugs or sickness.Facility policies and procedures for food storage and cleaning schedules were requested on 11/7/24 at 7:18 PM from Dietary Manager, but not provided. Record review of the policy Equipment Cleaning Procedures revised 1/2013 revealed the following [in-part]: Policy: It is the policy of this facility that all dietary equipment and environment are cleaned and sanitized in a manner that meets local(if applicable), state, and federal regulations. Fundamental Information: Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning is the practice of removing soil and dirt with an approved cleaning agent . Cleaning Frequency: Daily: Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily. Record review of the policy Ware Washing revised 5/2012 revealed the following [in-part]: Policy: The purpose of ware washing is to clean and sanitize utensils and equipment used during the preparation and service of food from the dietary department. Proper ware washing is an essential component m the prevention of food borne illnesses. Procedure: The following temperature and sanitizer strength will be followed: 2. Low temperature Dish Machines b. chemical: Chlorine sanitizer= 50ppm (parts per million) Quat sanitizer= 200ppm (or according to manufacturer's instructions)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1(Resident #1) of 2 residents reviewed for infection control practice, in that: 1) CNA C and CNA D failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. 2) LVN A failed to perform hand hygiene and change gloves while providing wound care. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 02/13/24, revealed the resident was an 82- year- old female admitted to the facility on [DATE] with diagnoses of personal history of Covid-19, acute candidiasis of vulva and vagina (Fungal infection), and Alzheimer's disease. Review of Resident #1's MDS assessment, dated 11/27/22, revealed Resident #1 required total assistance with most activity of daily living (ADLs) and two-person assist. Resident #1 was frequently incontinent of bowel and always of bladder. Review of Resident #1's care plan, dated 10/30/22, revealed the resident was care planned for being incontinent of bladder and bowel related to impaired cognition and mobility. Observation of incontinence care for Resident #1 on 02/12/24 at 10:32 a.m. revealed CNA C and CNA D was about to transfer the resident from wheelchair to bed when the surveyor entered the room. Both used proper transfer technique to move the resident. Both CNA C and CNA D did change gloves after transferring Resident #1. CNA C removed the resident's soiled brief. She wiped from front to back. Resident #1's brief was soiled with urine and fecal matter. Both repositioned Resident #1. CNA C continued to clean the resident bottom area. CNA C gloves were visibly soiled with urine. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. CNA C applied skin protector on the resident perineal area with same soiled gloves. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves for transferring and repositioning the resident including touching the perineal area and fastened the clean brief to the resident. CNA C and CNA D did not wash their hands before exiting Resident #1's room. In an interview on 02/12/24 at 10:48a.m with CNA C she stated she had been employed at the facility for 2 years and received infection control in-services 4 months ago. CNA C stated cross contamination meant mixing clean with dirty. CNA C stated she should have washed hands and changed gloves before retrieving the resident clean brief. She noted Resident #1 could get an infection for not using good infection control practice. Interview with CNA D on 02/12/24 at 10:52a.m revealed she had been employed at the facility since May 2023 and received infection control training on orientation. She stated cross contamination was transferring germs from one place to another. CNA D stated she should have changed her gloves and washed her hands before fastening Resident #1clean brief. She noted Resident #1 could get sick for not washing hands or changing gloves. Review of physician orders for February 2024 reflected, Sacrum-Apply hydrocolloid dressing FOR MASD (moisture-associated skin damage), every day shift every Monday, Wednesday, Friday. Observation of pressure ulcer on Resident #1 on 02/12/24 at 11:04 a.m. revealed LVN A did not wash his hands but donned gloves before the start of care. He prepared a clean field on a paper spreader. LVN A removed old dressing revealing a thin clear dry wound on the coccyx with granulation (healing) around the wound bed. LVN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean dressing and placing on Resident #1's wound. LVN A picked it up the trash and walked out of the room without washing hands. In an interview on 02/12/24 at 11:12 a.m. with LVN A, he revealed he should have washed his hands before starting care and changed his gloves during care. LVN A also revealed she should have changed his gloves before retrieving a clean dressing and placing on Resident #1's wound. LVN explained he had been employed in the facility since August 2023 and received infection control training during orientation. He said the resident could acquire an infection when he did not follow good infection control practices including washing hands before commencing care. During an interview with the DON 02/12/24 at 11:20a.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the staffs were expected to wash hands don gloves before starting care. Review of the facility Hand hygiene policy implemented 11/12/17 reflected, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection t other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1) Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2) Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice. 3) Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. a) Hands are visibly dirty. b) Hands are visibly soiled with blood or other body fluids. c) Before and after eating . d) Between resident' contacts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the health status for 1 of 8 residents (Resident #2) whose MDS assessments were reviewed, in that: 1. Resident #2 had broken natural teeth This failure placed residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings included: Resident #2 Review of Resident #2's admission Record, dated 09/15/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] diagnoses included: dementia (loss of memory and other thinking abilities), chronic obstructive pulmonary disease (a lung disease that blocks air flow and makes it difficult to breath); muscle weakness; and diabetes (a disease that results in too much sugar in the blood. Review of Resident #2's admission MDS Assessment, dated 07/07 /2023, revealed she had a BIMS score of 14 (cognitively intact) and had no natural teeth or tooth fragments. During an observation and interview on 09/14/23 at 10:30 AM with the surveyor and MDS nurse B present, Resident #2 was noted to have broken and missing teeth on her upper gums. She stated she had not asked to see a dentist, but she would like to. She stated she had a partial for the top gums, but they did not fit properly. She stated they did not hurt and she was able to eat, but somethings were harder to chew. In an interview on 09/14/2023 at 10:40 AM, the LVN MDS Coordinator B stated she did not have a facility policy for completing MDS assessments. She agreed that the admission MDS on Resident #2 was not accurately descriptive of her dental status. She stated a part time MDS nurse had completed the assessment She stated she followed the guidelines of the RAI Manual to complete assessments. She stated failure to not complete the MDS accurately could result in the resident not receiving needed care and services. Review of the RAI Manual section L oral dental status, dated10/2019 revealed in Part: This section is intended to record any dental problems present in the 7 days what look back period. Poor oral health has a negative impact on quality of life, overall health, and nutritional status. Assessment can identify gum disease that can contribute to or cause systemic diseases and conditions, endocarditis, and poor control of diabetes. Assessing dental status can help identify residents who may be at risk for aspiration malnutrition, pneumonia, endocarditis, and poor control of diabetes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of four residents (Resident #142) reviewed for Comprehensive Care Plans. The facility failed to develop and implement a comprehensive person-centered care plan to meet care areas triggered (cognitive loss, Visual function, adl assistance, urinary incontinence, falls, nutritional status, pressure area risk, psychotropic drug use and code status). This failure could place residents at risk of not receiving care that is relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings include: Record review of Resident #142's face sheet dated 09/14/23 revealed resident was a 48 -year-old female with an admission date of 07/04/2023. Diagnoses included: diabetes (a medical condition in which there is too much sugar in the blood); hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles); pain disorder; cardiomegaly (enlarged heart); dysphagia (difficulty swallowing); abnormal gait, and lack of coordination. Record review of Resident #142's admission MDS, dated [DATE] documented Resident #142 had a BIMS score of 11 (moderately cognitively impaired). Resident #142 was able to understand others and make her needs understood. The MDS documented Resident #142 utilized a wheelchair, required extensive assistance with one person assist for personal hygiene and two-person assistance with transfers and bed mobility, she was always incontinent of bowel and bladder, she experienced pain during the 5 day look back period and was on a scheduled pain management regimen, was at risk for pressure ulcers, took an antidepressant and a diuretic, and was a full code. The MDS was signed as completed on 07/07/2023. The CAA was (and care plan decisions) were dated as complete on 07/07/2023. Record review of Resident #142's Care plan revealed that the following care areas which were triggered in the CAA were not addressed in the care plan until: Cognitive Loss - 7/27/23 Visual Function - 7/27/23 ADL Assistance - 09/09/2023 Urinary Incontinence - 09/09/2023 Falls - 06/06/23 Nutritional Status - 08/21/23 Pressure Ulcer Risk - 09/09/2023 Psychotropic Drug Use - 09/09/2023 Code Status - 07/27/2023 In an interview on 09/14/2023 at 10:22 AM, MDS Coordinator A and B said the care plan should have been completed within 7 days of the completion of the comprehensive assessment and within 21 days of admission. They stated they should looked at the CAT (care area triggers) when the MDS was completed and ensure those area were on the resident's care plan They stated it was an oversight that this care plan was not done in a timely manner. They stated this failure could place the resident at risk for staff not recognizing the resident's care needs. In an interview on 09/14/2023 at 1:30 PM, the DON said that it was the responsibility of the MDS Coordinator, social worker, and the nurses to ensure the resident's care needs were documented in the care plan in a timely manner when captured in the comprehensive assessment. Record review of the Facility policy titled Care Plans and CAAS dated 05/16/2016, revealed the following [in part]: The purpose of this guide is to ensure that an interdisciplinary care plan is used in addressing the CAT'S (care area triggers) generated by the MDS assessment in order to thoroughly address the care area assessments and ultimately achieve a comprehensive care plan for each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include resident or the resident's representative in the IDT (Interdisciplinary team) in the comprehensive care planning within 7 days after completion of the comprehensive assessment for 1 of 3 residents (Resident #7) reviewed for care plan timing/revision. The facility failed to ensure Resident #7's care plan was reviewed by the IDT (Interdisciplinary team), which failed to include the resident or the resident's representative after the Comprehensive MDS assessment. This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life. The findings included: Review of Resident #7's face sheet, dated 09/15/2023, revealed a [AGE] year-old female, with an admission date of 10/03/2005 and a re-admission date of 08/13/2023. Diagnoses included: Metabolic encephalopathy (brain dysfunction is disturbed due to disease in the body), Type 2 Diabetes Mellitus (chronic condition the affects the way the body produces blood sugar), and hypotension (low blood pressure). Review Resident #7's MDS assessment history revealed an annual assessment dated [DATE]. Section C revealed a BIMS score of 15, which means the resident is cognitively intact. Review of Resident #7's comprehensive care plan revealed it was last Reviewed/Revised on 04/27/2023 by the MDS Coordinator. There was no documented evidence that a care plan meeting was conducted for this care plan. Record review of Resident #7's progress notes revealed there was not a care plan meeting completed in April or May 2023. The care plan meeting was completed quarterly with the following dates of: 09/26/2023, 06/27/2023, 03/28/2023. Interview with Resident #7 on 09/12/2023 at 10:40 AM revealed the following: She revaled she had not been invited to careplan meetings and would like to dicuss some of the issues she is having with her needs. She revealed if she was invited, she would attend. She revealed that she makes decisions for her care. Interview with the RN MDS Coordinator on 09/14/2023 at 2:00 PM revealed the following: She revealed that they do not go off of the MDS schedule, they do them Quarterly. She revealed that the Social Worker completed the care planning process by contacting the family for the comprehensive care plan meeting. Interview with the Social Worker on 09/14/2023 at 3:23 PM, revealed that every 3 months they have a care plan meeting, this includes annual assessments. She said she does not know what type of assessment it is; she just does one every 3 months; she does not go off of the MDS schedule. She revealed there was not an IDT completed in April 2023 or May 2023, that coincides with the Annual MDS assessment. She revealed since there was not a comprehensive care plan meeting, they did not include the resident or the resident's representative, she revealed this failure places residents at risk of not having family involved in their care planning process. Review of the facility's policy and procedure for Care Plans and CAAS, (05/16/2016), revealed the following [in part]: Care Plan Updates: * The IDT will review the care plans Annually, Quarterly and as needed to ensure all goals and approaches are appropriate. * The IDT will sign their designated sections of the care plan thereby signifying that they have reviewed their section of each care plan. Care Plan Meetings: * The Social Worker will use the facilities designated form for documentation by IDT of meeting. Form will be filed out in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3(Resident #45) residents reviewed for safe transfers. The facility failed to ensure Resident #45 was transferred with a gait belt. This failure could place residents dependent on staff for assistance with transfers at risk for falls and/or injury. Evidence includes: Record review of Resident 45's face sheet revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of history of unsteady gait, muscle wasting and weakness, psychosis (a mental disorder characterized by disconnection with reality) and lack of coordination. Record review of Resident 45's significant change MDS dated [DATE] revealed she required extensive assistance of 2 with transfer, bed mobility and hygiene. Record Review of the video taken on 09/09/23 by the electronic monitoring camera in resident #45's room revealed during the transfer or resident #45 completed by CNA's E and F (without a gait belt) the 2 aides hooked their arm underneath the resident's armpits with the resident facing in the direction of the bed that she was transferred to. The recliner she was transferred from was approximately 5 feet from the bed. The CNA's fell with the resident itno the bed during the transfer. The resident appeared frightened with the manner with which she was transferred. The resident was not injure. Interview with the DON on 9/14/2023 at 10:00 AM revealed she had viewed the video of the transfer (by CNA E and CNA F) with Resident 45's daughter and she agreed that the family member had a reason to be upset. She stated it was her expectation for the staff to use a gait belt with all transfers and transferring a resident using the technique displayed by CNA E and CNA F in the video was not acceptable and could result in injury to the resident and the aides. She stated it was the charge nurses responsibility to monitor the aides on their shift to see that they were doing safe transfers. She stated she was in-servicing the staff on proper transfer techniques and doing proficiency checks. She stated she had suspended the aides pending the investigation of the complaint by Resident #45's family member. She called the aides that did the improper transfer on the video into her office, and they had received training and a disciplinary action. Observation and interview on 09/13/2023 with CNA C and CNA D, CNA C stated Resident #45's care plan had been updated and she was now transferred with a Hoyer lift. She stated a Hoyer lift was always done with 2 people. The CNA's were observed transferring Resident #45 with the Hoyer lift and their technique was correct and safe. Interview on 09/13/2023 at 2:47 pm, Administrator stated it was expected for CNAs to use a gait belt at all times when transferring a resident. The Administrator stated failure to do so could result in a fall. Record review of policy Transfers of Residents, dated 05/2012, revealed in part: Use a gait belt around the resident to protect both the resident and you. Position the chair so that the 2 transfer surfaces are at a 45-degree angle.

Based on observation, interview and record review, the facility failed to ensure the accurate administration of medications for 1 of 4 residents observed for medication administration. (Resident #7) Treatment Nurse left a medication at Resident #7's bedside, unattended. This failure could place residents who received medications administered by the treatment nurse at risk of not receiving the intended therapeutic benefit of their medications and a possible medication error to another resident. Findings included: During an observation and interview on 09/12/2023 at 10:42 AM., Resident #7 was lying in her bed. There was a medication cup with cream next to her bed. She revealed that the medication cup was left there the prior day by the treatment nurse. She revealed that she was supposed to administer the fungal ointment herself but that she had not gotten around to it. SH revealed it was not a medication he could self-administer. The Electronic Treatment Record for Resident #7 dated 09/12/2023 revealed a physician's order for treatment on the left breast fold; by applying the antifungal cream Q-day and PRN for prevention every shift for excoriation/redness. The medication was last administered on 09/11/2023 from 6AM to 6PM. During an interview on 09/12/2023 at 11:00AM., LVN B revealed the following: She said that she had not given the treatments for Resident #7 yet that day. She said that she left the antifungal cream at her bedside yesterday and forgot about it. She revealed that she normally does not leave meds at bedside. She looked at the medication cup and said the antifungal treatment had not even been used. She stated this failure could result in the resident putting it on the wrong part or someone else getting it. Policy and Procedures titled Medications- Treatment dated 02/02/2014 revealed the following: 4.Adminsiter the medication according to the physician's orders. 5. Document initials and/or signature for medications and treatments administered on the MAR and TAR immediately following administration. 7. Circle initials for those medications or treatments that were not administered and document the reason for the non-administration on the MAR and TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program, designed to provide a safe, sanitary, and comfortable environment, and help prevent the development and transition of communicable disease and infection for 8 Staff for COVID-19 (CNA A, CNA B, CNA K, AD C, HR D, HA E, LVN J and [NAME] F). The facility failed to ensure staff (CNA A, CNA B, CNA K, AD C, HR D, HA E, LVN J and [NAME] F) to wear face mask, face shield, and perform hand hygiene per facility policy. The Facility failed to ensure Resident #8 stayed in her isolation (warm zone) room. Resident #8 was found playing bingo in the dining room not wearing any PPE and not social distancing from Resident #2. This failure placed residents at risk for contracting an infection/COVID-19. Findings include: According to the CDC: You were exposed if: you were in close contact with someone that was less than 6 feet away from someone with COVID 19 for a total of 15 minutes or more over a 24-hours period. https://www.cdc.gov/coronavirus/2019-ncov/downloads/your-health/qi-guidance-quarantine.pdf Accessed 1/20/2023. Record review of facility's COVID 19 positive logs from 1/2/2023 to 1/10/2023 indicated 26 positive residents and 8 positive staff. Review of Resident #8's face sheet revealed Resident #8 was a [AGE] year-old female, admitted to the facility 2/2/2022. Major diagnosis includes dementia, communication deficit, pulmonary disease, and muscle wasting. Review of Resident #8's Minimum Data Sheet, dated 1/3/2023, revealed BIMS of 5 which indicated severe cognitive impairment. During an observation on 1/9/23 at 1:45 PM, Resident #8 was not in her room. Resident #8 was on isolation due to covid exposure by roommate (Resident #6 who tested positive for covid on 1/9/2023). Resident #8 was found, by investigator, in dining room with 13 other residents, none of the residents were wearing a mask. Social distancing was not being performed between Resident #8 and Resident #2 who were both sitting at the same table playing bingo. During an interview on 1/12/23 at 9:45 AM, DON stated that Resident #2, who was exposed to COVID 19 by Resident #8 during bingo, was tested yesterday 1/11/2023 and resulted negative. She stated that Resident #8 should be remaining in her room (warm zone), with no roommate for a minimum of 7 days because Resident #8's roommate tested positive for COVID 19. She stated the facility did not set up a warm zone and hot zone. She stated the facility set up an entire hall as a hot zone but all residents that are individually isolated (warm zones) are to remain isolated in their rooms by themselves until, they either test positive and are moved to the hot zone or remain symptom free and test negative for 7 days. Record review of COVID 19 testing log, dated 1/11/2023 indicated that Resident #2 and Resident #8 both tested negatives. During an observation on 1/9/23 at 3:35 PM, HA E entered Resident #8's isolation room, (warm zone) to help resident up out of bed and onto side of bed. HA E exited Resident #8's room and went into Resident #5 (cold zone) to hand resident her TV remote off the floor. No hand hygiene was completed before or after exiting either room and no PPE was donned or doffed going into or out of isolation room. During an interview on 1/9/23 at 3:45 PM, HA E stated she did not think much of what she was doing, just going into Resident #8's room very quickly to help the resident and as she left, she saw Resident #5 in the next room trying to pick up his remote. She stated she just reacted to help and did not think about coming out of a quarantine room or hand sanitizing. She stated she knew she is to put on PPE for the resident's protection. Review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old male, admitted to the facility 7/25/2017. Major diagnosis includes major depressive disorder, edema (swelling caused by too much fluid trapped in the body's tissues), rash, and constipation. Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS of 15 which indicated no cognitive impairment. During an interview on 1/10/23 at 9:45 AM, Resident #1 stated he felt PPE is not being used properly. He stated there have been multiple times that he has seen employees/aides go in and out of resident's room without PPE on or coming out of a quarantine room (warm zone) with PPE on but did not doff PPE before going to another resident's room. He stated 3 days ago in the evening, he was out in the hallway and watched an employee come out of the hot zone over to the night pantry, get some ice/snacks for a resident and go back into the hot zone. He stated there is just a lot of observations he has made where PPE is not being worn properly. He stated he could not remember the exact names of any employees. Review of Resident #2's face sheet revealed Resident #2 was a [AGE] year-old female, admitted to the facility 1/16/2013, major diagnosis includes sepsis, pneumonia, chronic respiratory failure, muscle wasting and atrophy. Review of Resident #2's Quarterly MDS 10/5/2022 revealed BIMS of 15 which indicated no cognitive impairment. During an interview on 1/10/23 at 1:45 PM Resident #2 stated she is very concerned about the COVID 19 in the building. She stated she has not been vaccinated and needs to be protected. She stated it is very important that the facility does everything they can to protect her from being exposed. She stated she has seen some employees with their mask pulled down or go into quarantine (warm zone) rooms with no PPE on. She stated, I know they are trying very hard but some of them just don't use the PPE they should. Review of Resident #5's face sheet revealed Resident #5 was a [AGE] year-old female, admitted to the facility 6/18/2016, major diagnosis includes difficulty walking, osteoarthritis, weakness, and muscle wasting. Review of Resident #5's MDS 12/31/2022 revealed BIMS of 13 which indicated no cognitive impairment. During an observation on 1/9/23 at 1:15 pm, 4 employees (CNA A, AD C, HR D, and [NAME] F) were in the hot zone with only N95 mask on. Employees were not wearing gowns, face shields, or gloves. Each employee went back to their offices, not on the hot zone, no hand hygiene was done by any employee leaving the hot zone. During an interview on 1/10/23 at 2:45 PM, HR D stated the proper PPE to be worn in the hot zone was face shield, mask, gown, gloves. She stated she did not have any of the PPE because she was only in the hot zone to help hang signage on the residents' doors. She stated she should have put the proper PPE on while in the hot zone. During an interview on 1/10/23 at 3:05 PM, AD C stated the proper PPE to be worn in the hot zone was face shield, N95 mask, gown, gloves. She stated she did not have any of the PPE because she was only in the hot zone to help hang signage on the residents' doors. During an interview on 1/10/23 at 3:15 AM, [NAME] F stated the proper PPE to be worn in the hot zone was face shield, mask, gown, gloves. She stated she did not have any of the PPE because she was only in the hot zone to help hang signage on the residents' doors. During an observation on 1/9/23 at 10:15 PM, a group of 3 employees (CNA B, LVN J, and CNA K) were standing at nurses' desk not wearing mask or had them pull down below their chins. Employees were talking and hanging out. None of the employees were practicing social distancing. During an interview on 1/9/23 at 10:25 PM, CNA B stated he was the CNA for the hot zone. He stated that his shift is from 6:00 AM to 6:00 PM. He stated he is supposed to stay on the hot zone for his entire shift. He stated he only recently stepped out of the hot zone to help the other hallway. He stated he should not have left the hot zone. He stated on the hot zone, the PPE that is to be worn at all times is face shield, mask, gown and gloves. During an interview on 1/9/2023 at 10:45 PM, RN I stated that the PPE to be worn on the hot unit is N95 mask, gown, gloves, and face shield. She stated she always works the hot zone for the night shift. She stated that any employee that was to work the hot zone is to work the hot zone their entire shift and not to leave it. She stated CNA B does work the 6:00 PM to 6:00 AM shift and should always stay on the unit with her She stated that CNA B does go and talk with the other employees at times during the shift, outside of the hot zone. During an observation on 1/10/2023 at 2:15 PM, CNA A went into Resident #6's room to assist resident out of bed and then exited Resident #6 room. CNA A went directly from Resident #6 room into Resident #7's room and helped Resident #7 get call light off the floor and handed it to Resident #7. CNA A had no PPE on except N95 mask, no donning or doffing of PPE was done and no hand hygiene completed. Both Resident #6 and Resident #7 were located on the hot zone. Review of Resident #6's face sheet revealed Resident #6 was a [AGE] year-old female, admitted to the facility 4/27/2022, major diagnosis includes hypokalemia, hyperlipidemia, constipation, lack of coordination, COVID 19 and muscle wasting. Review of Resident #6's Annual MDS 11/14/2022 revealed BIMS of 14 which indicated no cognitive impairment. Review of Resident #7's face sheet revealed Resident #7 was a [AGE] year-old female, admitted to the facility 10/28/2022, major diagnosis includes dementia, weakness, repeated falls, COVID 19 and impulse disorder. Review of Resident #7's Quarterly MDS revealed no BIMS had been completed. During an interview on 1/10/23 at 9:45 AM CNA A stated she was told by DON that while she was in the hot zone, she only had to wear her N95 mask. She stated she was to don PPE on outside the room, help the resident and then doff PPE inside the room. She stated because she was on the hot zone, she did not realize she did not have PPE on and went into the Resident #7's room to help her. She stated she should have donned and doffed PPE before going into both resident's room. During an interview on 1/10/2023 at 2:45 PM, DON stated that the expected PPE to be worn on the hot zone was gown, gloves, goggles/shield, and N95 mask. She stated her expectation for the hot zone would be that all PPE must be always on and donned on and doffed off when entering and exiting a resident's room. She stated she did expect employees to put on goggles or a face shield when entering a resident's room, but she feels if an employee is in the hot zone with regular reading glasses on that is okay if they don't go into the resident's room without having a proper eye coverage. She stated that once an employee comes onto their shift for the day, they are to remain on the hot zone their entire shift and not leave the hot zone for any reason. She stated that all employees should have known what PPE to wear and that it should be on the entire time they are in the hot zone. She stated all staff should know this because she just did an in-service on PPE to be worn on which zone. She stated that the employees that are on that unit, should always stay on that unit and once they come into work they clock in and go to the hot zone unit, they are not to leave unless going home for the day. She stated her employees that were helping on the hot zone should have been in full PPE because it puts other residents at risk. During an interview on 1/10/23 at 11:45 PM, ADMIN H stated that her expectation of the hot zone was that once an employee comes into work, no matter what shift, they are to remain on the hot zone the entire shift and not leave for any reason. She stated her expectation of PPE to be worn while working on the hot zone is face shield, N95 mask, gown, and gloves. During an interview on 1/12/23 at 3:35 AM, DON stated that she felt that mass testing once a week and contact tracing, in between, was enough to slow down the spread of covid19 in the facility. She stated that she started mass testing and overnight on 1/2/23, she had 8 positive residents. She stated by doing the spot checking, 7 more residents tested positive from 1/3/23 to 1/5/23. She stated the next mass test was on 1/9/23 and 11 more residents were positive. Record review of in-service dated 1/9/23, titled COVID 19 Policy and Surveillance, presented by the DON G which covered: Hand hygiene, proper PPE to be worn in cold, warm, and hot zones. Checking residents and employees for any signs or symptoms of COVID 19. How to DON and DOFF PPE properly. All staff were included in the training. Record review of facility Coronavirus Testing policy, dated 10/24/22, section titled: Personal Protective Equipment: 1. Staff who enter the room of a patient with suspected or confirmed COVID 19 infection should adhere to standard precaution and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. (i.e., goggles o a face shield that covers the front and sides of the face).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who needs resporatory care is provided care consistent with standards of practice and the care plan for two of two residents (Resident #118 and #65) reviewed for respiratory care, in that: Resident #118's nebulizer and T piece (plastic portion of the nebulizer kit shaped like a T used for delivering inhaled medications) was laying on top of Resident #1's dresser exposed (without being secured in a bag to prevent contamination) with medication in the medication delivery nebulizer. Resident #65's nebulizer and mask were laying on top of Resident #65's dresser without being secured or in a bag to prevent contamination with medication in the medication delivery nebulizer. This failure could place residents who use small volume nebulizer at risk for exposure to communicable diseases and infections. The findings include: Review of Resident #118's undated Face Sheet revealed he was a [AGE] year-old male admitted on [DATE] with the following diagnoses: acute respiratory failure (the inability to process oxygen and carbon dioxide), hypoxic encephalopathy (lack of oxygen to the brain), myocardial infarction (failure of the heart to circulate blood), atrial fibrillation (ineffective pumping of the heart) and laryngectomy stoma (an opening created by a surgical process to remover or bypass a person's vocal cords). Review of Resident #118's admission MDS assessment, dated 06/28/22 revealed he had a BIMS score of 15 out of 15, indicating he was cognitively intact and able to make his needs known. Review of Resident #118's care plan, dated 6/28/22 revealed: -Stoma to Throat - Resident has a surgical wound and is at risk for infection, pain, and decrease in fictional abilities. -Goal: Resident 's wound will be free from the signs and symptoms of infection . -The care plan did not include the process of changing nebulizer cups or sanitary storage. Review of physician orders dated 06/28/22 revealed the following: Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% every six hours as needed . During an observation and interview on 07/19/22 at 2:53 PM, Resident #118 was resting in bed awake and alert and visiting with his sister. A dirty towel was noted on top of his dresser with medication nebulizer and tail piece extending from the nebulizer cup was uncovered with a slight amount of medication remaining in the medication cup, loose oxygen tubing laying inside of the drawer and attached to the power unit that pumps air to the nebulizer creating a mist of medication. During an interview on 07/19/22 at 3:15 PM, with an unidentified nurse identifying herself as the charge nurse for floor Resident #118 resided in, confirmed the nebulizer was not covered and not dated and should have been dated and, in a bag, to protect the device from being contaminated. Review of Resident #65's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses of sepsis, unspecified organism, pneumonia, chronic respiratory failure with hypoxia (inability to oxygenate tissues of the body) and pneumonitis due to inhalation of food and vomit. Resident #65 did not have a s care plan. This surveyor requested but was not provided prior to exit. Review of physician's orders dated 07/08/22 revealed: DuoNeb (ipratropium bromide and albuterol sulfate) every 6 hours as needed for shortness of breath. During an observation and interview on 07/19/22 at 3:15 PM, Resident #1 was resting in bed awake and alert. A nebulizer cup attached to a mask was noted on top of her dresser with medication nebulizer and mask was uncovered with a slight amount of medication remaining in the medication cup, loose oxygen tubing attached to the power unit that pumps air to the nebulizer creating a mist of medication During an interview on 07/19/22 at 3:15 PM, CNA A confirmed that the nebulizer was not covered and not dated and should have been dated and in a bag, to protect the device from being contaminated. Review of facility's policy and procedure title, Respiratory: Nebulizer Mist Therapy dated 4/16/2014 revealed the following [in part]: .20. Store nebulizer, t-piece, and mouthpiece in separate, labeled plastic bag (change all disposable parts once a week and label with date and initials). Review of website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086084 on 07/22/22 revealed the following: Problem: Although many improvements in patient safety have been made in the nation's health care system, medication errors and health care-associated infections (HAIs) still top the list of problems .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen observed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of roaches in the kitchen. The facility's failure placed the residents at risk for foodborne illness and/or disease spread by pests. The findings include: During an observation and interview on 7/22/22 at 10:17 AM, live roaches were observed in the dishwashing machine area and in the food preparation/cooking areas on the floor and wall behind the storage and cooking equipment. Further observation showed utensils and trash were found under equipment and in corners. The Dietary Manager said she was aware of the problem and had been working with the Pest Control Vendor. Review of the dietary department cleaning records, provided by the Dietary Manager on 7/22/22, revealed staff had not been cleaning behind and under the kitchen equipment. The Daily Cleaning Schedule was last initialed and dated on 7/03/22 by the 1 PM to 8:30 PM shift staff. Review of the facility's contract with the pest control company, undated, revealed the contracted pest control company would provide bi-monthly service. Review of the facility's pest control service manual, used to organize the service invoices, revealed there was nothing mentioned or documented regarding any problems in the kitchen. Review of the contracted pest control service invoices revealed the following: - 7/12/22 - Treatment for General Pest, Scorpions and Mice/Rat bait stations. Treatment area- Common Areas, Entry Ways, Hallways. The Technician Comments did not mention pests/roaches in the kitchen. - 6/27/22 - General pest. Treatment area- Common Areas, Entry Ways, Hallways. The Technician comments documented met with DM (Director of Maintenance), he had no issues, spoke with kitchen staff, had no issues. - 6/13/22 - Treatment for General Pests, target areas - Bathrooms, Breakroom, Common Areas, Entry Ways, Hallways. Technician comments: DM had no issues, Kitchen no issues. In a telephone interview on 7/22/22 at 11:13 AM, the pest control service personnel stated she was unaware of any problems in the facility's kitchen and the service technician's records showed he had not been treating areas in the kitchen. In an interview on 7/22/22 at 2:01 PM, the Maintenance Director stated the pest control service technician told him what was done and/or found during the service visit. He stated he was unaware of any problems in the dietary department until today. Review of the facility's Pest Control Policy, undated, revealed the following [in part]: .this facility will maintain an on-going Pest Control program to ensure that the building is kept free of insects and rodents .