Based on observation, resident interview, family interview, staff interview, and facility documentation review, the facility staff failed to maintain a resident's personal privacy affecting one resident (Resident #110- R110) in a survey sample of 11 residents. The findings included: For R110, the facility staff failed to ensure the resident's privacy was maintained during care, conversations with visitors, and during phone calls, due to the constant monitoring of the resident while in their room, via a video camera with auditory monitoring being observed by a staff member 24 hours a day. On 5/13/24 at 6:15 p.m., upon the survey team's arrival to the unit, it was observed that in the hallway across from the nursing station there were several devices that were on vertical poles, that could be moved around and at the top, there was a camera. On 5/13/24 at 6:30 p.m., R110 was observed to be on the telephone in the room and was not available for an interview. On 5/14/24 at 09:13 AM, observations were conducted in R110's room. It was noted that one of the video cameras on the pole was observed in the room. R110 was asked about the device, and he stated that it keeps an eye on him and will scold him if he tries to get up. When asked how it made him feel to know someone was watching him all the time, R110 said, not good, uncomfortable. R110 was asked if he agreed to it being in the room and R110 said, no, all the rooms have it. The survey team did not observe this device in other resident rooms on the unit. R110 went on to say that if he tries to get up it will tell him to stop and wait for someone to come help him. On 5/14/24 at approximately 9:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON was asked about the device in R110's room. The DON explained that it was a virtual monitor that is a video camera and has the option for audio. A virtual monitor tech is upstairs and can watch and listen to him and can talk to him. The DON asked if the resident consented to such device. The DON explained that they are educated on the device and what it does but no formal consent it obtained. On 05/14/24 at 09:55 a.m., during a clinical record review, a Virtual Sitter Patient Initiation Report Form was noted. The form indicated that for R110 the initiation criteria identified was: falls, medical device interference (pulling of lines), dementia, poor short-term memory, impulsivity, and foley in place. Review of the physician orders revealed no order for the virtual monitor. During the clinical record review, it was noted that on 5/13/24, R110 sustained a fall, which required sutures for a laceration to the head. On 05/14/24 at 10:01 a.m., the DON provided the surveyor with an education document, that he indicated is reviewed with residents and/or families. The DON also assisted the surveyor in reviewing R110's clinical record and on 5/7/24, which was the day of admission, R110's behavior was noted as attempt to get OOB [out of bed], confused and noted, observation status initiated, monitoring type virtual, education provided. There was no evidence of any consent of such device by the resident and/or family. On 05/14/24 at 10:37 a.m., a telephone interview was conducted with the daughter of R110. The daughter was asked about the virtual monitor and stated, I don't like that the machine can hear us when we are there privately, if there was some button that showed it was muted would be great. The family member said that she wasn't aware initially that there was a 2-way microphone and wasn't told that they could listen and communicate through the device. She went on to say that the facility staff just brought it in, there was no discussion as to if they wanted it or it being optional. She said that at one time her father had a roommate, and she didn't know if the roommate was aware that they could watch him as well. During the above conversation with R110's daughter, she said, If he said he didn't want it, it's not his option, it's the nurses, he doesn't like it. it is creepy, that someone can watch and hear all the time. She added, If I were a patient rehabilitating, I would be very offended to have that in my room, as a woman to have body parts exposed, it would be very intrusive, and sometimes it is embarrassing if staff listen to us, because he picks at me. I would want them to ask me. On 05/14/24 at 01:02 p.m., R110 was interviewed again. R110 said, It doesn't feel too good to know they are watching and listening all the time. On 5/14/24 at approximately 2 p.m., the surveyor visited the virtual monitor technician (other staff #1- OS#1), in their office. It was noted that OS #1 was sitting in front of two large screens that had multiple residents with a live video feed of their room. It was noted that one Resident, who was located elsewhere within the hospital and not on the skilled care unit, was being assisted with a bed bath by two staff members, and the resident's body could be seen unclothed. OS #1 adjusted the camera to take the resident's body out of view and indicated she did that because the surveyor was in the room, but normally wouldn't adjust it. OS #1 was observed to talk to residents through the camera device/virtual monitor located in the resident's room and could hear what the resident was saying. OS #1 stated that during care such as baths, nursing staff are to call the virtual monitor tech and ask them to turn the privacy screen on, which was like a screen saver on a computer. OS #1 said, staff rarely remember to call to have this done. When asked if there was a way for nursing staff to turn off the device during care, OS #1 said, no, they have to call us and tell us to put a privacy screen on. OS #1 went on to explain the device cannot be disengaged by the resident, staff, or visitors to stop the monitoring or allow for privacy. On 5/14/24 at 3 p.m., during an end of day meeting, the above concerns were shared with the director of nursing. When asked if consent is obtained prior to the virtual monitor being used, the DON stated that it was part of the consent to treat. On 05/15/24 at 08:37 a.m., the DON reported to the survey team that the virtual monitor for R110 had been discontinued following the end of day meeting. On 05/15/24 at 08:42 a.m., an interview was conducted with RN #2 (registered nurse). RN#2 said the virtual monitor is used if a patient is confused, impulsive and high fall risk. When asked if this is something that the doctor must order and consent be obtained for, RN #2 said, no, and explained that a nurse can initiate it and no physician order is needed. RN #2 said, they [the resident and/or family] are aware, we tell them what it is, that it is a camera it can keep eyes on you and keep you safe, it can speak to you, and you can speak to them. When asked about privacy during care, RN #2 said, If we are going to bathe or toilet a resident we call, and the virtual monitor and they will turn camera off. On 5/15/24, a review of the facility document titled Resident Rights was conducted. This document read in part, As a resident on our skilled nursing unit, we want you to be informed and involved in making decisions about your care. All residents shall have rights, which include, but are not limited to the following: . 9. Each resident may communicate privately with individuals of his/her choice . The document titled, Virtual Sitter: Patient Monitoring Technology was reviewed. It read, Patient safety and privacy are our highest priorities at [facility name redacted]. For this reason, we are using a virtual sitter for your safety. Virtual sitter is a patient monitoring device to assist your care team to maintain your safety and required medical treatment. Examples include fall prevention and keeping lines and devices in place; all of which can lead to a delay in healing and recovery. How the virtual sitter works: never records video or audio, video camera and two-way audio- trained staff member to see and speak to you, . Privacy mode (no video or audio) is used when a doctor or nurse is providing care or dressing, bathing, and using the toilet. When the light goes off, privacy mode is on. No additional information was provided.

Based on observations, staff interviews, and facility document, it was determined that the facility staff failed to prepare and store food in a safe and sanitary manner for one of one unit. The findings included: The facility staff failed to hold the cold food at a safe temperature, to label food items for storage, and to discard food by the used by date. On 5/13/24 at 6:30 p.m. a tour of the facility's kitchen was conducted. During the observation of the refrigerator, there was kidney beans, beets, prunes, celery - which was brown, and cut red onions stored in containers with no labels. Also found were sliced green peppers that had brown spots on them, sliced eggs that had a white milky appearing liquid in the container with them, blueberries that were shriveled and mushy in appearance, opened ranch dressing that was beyond the use by date, sliced red onions that had liquid in the container with them, and unwrapped cheese that had visible mold on one corner. All of these items were still in the refrigerator two days past the used by date and available for use. The freezer section was observed to contain a package of frozen hamburger with a label that had a use by date of 5/9/24. While observing facility staff obtaining temperatures of the food being served, the chicken salad registered at 42.4 degrees Fahrenheit and the cold bacon registered at 43.0 degrees Farhenheit. On 5/13/24/ at 6:45 p.m., an interview was conducted with the nutrition service supervisor. When asked about proper food storage, the nutrition service supervisor verbalized that every item that is placed in the refrigerator or freezer should have a label with a use by date. The nutrition service supervisor verbalized that depending on the item, labels are good for 3-5 days, stating again that all items should be labeled when placed in the refrigerator or freezer. When questioned further, the nutrition service supervisor verbalized that items should be rotated in the refrigerator and freezers daily and that out of date items should be removed. When the package of meat was pointed out, the nutrition service supervisor verbalized that the hamburger's date was too old to still be in the freezer and did not know why it was not removed during the daily rotations of the food. On 5/15/24 at 10:00 a.m., a review of the facility documentation was conducted. The facility policy titled, Nutrition Services Infection Control Policy, read in part, .Any outdated perishables will be discarded. Foods should be refrigerated at 41 degrees or below. If food items are to be directly placed in the refrigerator they are to be lightly covered, labeled, and dated. All refrigerated items are to be used in 72 hours or frozen for future use. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #165 was admitted to the facility on [DATE] with diagnoses that included sepsis related to methicillin resistant staphylococcus aureus (MRSA), congestive heart failure, muscle weakness, cellulitis of the left and right lower limbs, non-pressure chronic ulcers of the left and right lower legs, and type 2 diabetes. The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #165 as moderately impaired for daily decision making with a score of 11 out of 15. On 07/13/2021 during the tour, observed outside of Resident #165's room was an Isolation Contact sign including instructions to wear personal protective equipment (PPE) before entering the room. Observed outside the room were new PPE supplies and hand sanitizer. The unit manager (RN #1) was asked why Resident #165 was on isolation. RN #1 stated the isolation was related to Resident #165 having MRSA and full PPE was required to enter the room. On 07/13/2021 at 2:30 p.m., Resident #165 was interviewed regarding the quality of care since her admission. Resident #165 stated things were going well and she planned to discharge home once she completed her antibiotics. Resident #165 was asked if staff wore PPE each time they entered the room. Resident #165 stated, yes, they do. I understand between this pandemic and me having MRSA they have to protect themselves and all of the patients. Resident #165's clinical record was reviewed on 07/13/2021. The admission assessment dated [DATE] documented .isolation contact. A review of the baseline care plan did not document goals and/or interventions isolation contact and social services/discharge goals. A review of the electronic clinical record and the paper chart did not document evidence that a copy of the baseline care plan had been provided to Resident #165. On 07/14/2021 at 10:00 a.m., Resident #165 was interviewed about care plan participation. Resident #165 was asked if she had received a copy of the baseline care plan and/or medications since being admitted . Resident #165 stated, I remember getting some papers from the hospital when I discharged . No one has had a meeting with me since I've been here about my care or given me any papers. The nurse will tell me what medications they give me each shift, but I don't have a list of medications. Resident #165 was asked if she received a summary of her initial care needs/goals developed at admission. Resident #165 stated, no. On 07/14/2021 at 11:00 a.m., the DON was asked if the isolation precautions and social service/discharge interventions should have been included on the baseline care plan. The DON stated yes. The DON stated the residents were followed by case management services for assistance with discharge plans. 6. Resident #168 was admitted to the facility on [DATE] with diagnoses that included left knee septic arthritis, hypertension, atrial fibrillation, type 2 diabetes, hyperlipidemia and long term use of anticoagulants. The most recent minimum data set (MDS) dated [DATE] was the 5 day admission assessment and assessed Resident #168 as cognitively intact for daily decision making with a score of 14 out of 15. During the initial tour Resident #168 was interviewed regarding the quality of care since his admission. Resident #168 stated, things are fine. This is a wonderful place and they treat me great. Resident #168 was asked about his discharge plans. Resident #168 stated, right now they are focusing on getting me stronger and clearing up the knee infection with the use of antibiotics. My plans are to discharge home as soon as the doctor releases me. Resident #168's clinical record was reviewed on 07/13/2021. Observed on the admission: Medical History and Functional Status form was the following: .Anti-Coagulant Therapy - Yes. A review of the baseline care plan did not document goals and/or interventions for anti-coagulant use and social services/discharge goals. A review of the electronic clinical record and the paper chart did not document evidence that a copy of the baseline care plan had been provided to Resident #168. On 07/14/2021 at 9:15 a.m., Resident #168 was interviewed regarding about care plan participation. Resident #168 was asked if he received a copy of his baseline care plan and/or medication list since his admission. Resident #168 stated, I recall receiving some discharge papers from the hospital., but I haven't received any forms while I've been down here. I'm not aware of having a care plan meeting since I've been down here. The staff come in here daily and ask me about my goals for the day and I just simply tell them I want to get stronger and return home to my wife. Resident #168 was asked if he received a summary of his initial care needs/goals developed at admission. Resident #168 stated, no. On 07/14/2021 at 11:00 a.m., the DON was asked if the anti-coagulant use and social service/discharge interventions should have been included on the baseline care plan. The DON stated yes. The DON stated the residents were followed by case management services for assistance with discharge plans. The above findings were discussed with the DON during a meeting on 07/14/2021 at 12:30 p.m. 7. Resident #169 was admitted to the facility on [DATE] with diagnoses that included right leg BKA (below knee amputation) revision, hypertension, gait disorder, peripheral vascular disease, chronic neuropathic pain, tobacco abuse, and Etoh dependence. The admission assessment assessed Resident #169 as alert and oriented. During the initial tour Resident #169 was interviewed regarding the quality of care since his admission. Resident #169 stated, I'm glad to be here. There were several other locations that I was offered. However, this one was the best with 5 stars. So far things have been going great. I've got this PICC line in my arm they are treating the infection that started after my last surgery. I know I will be here at least until August 3 to complete these antibiotics. I hope to go home and eventually get fitted for my prosthetic leg. Resident #169's clinical record was reviewed 07/13/2021. Observed on the Patient Summary was the following antibiotic medications Ceftriaxone Sodium (Rocephin), Metronidazole (Flagyl), and Vancomycin HCL. A review of the baseline care plan did not document goals and/or interventions for the use of the antibiotics and social service/discharge goals. A review of the electronic clinical record and the paper chart did not document evidence that a copy of the baseline care plan had been provided to Resident #169. On 07/14/2021 at 7:27 a.m., the director of nursing (DON) was interviewed regarding the baseline care plan. The DON stated the baseline care plan was completed at bedside with the resident and/or family usually about 2 hours after admission. The DON was asked if a copy of the baseline care plan was provided to the resident and/or family member. The DON stated no, they are given a copy of their medications. The DON was asked if the resident and/or family member were required to sign anything to document their receipt of the medication list. The DON stated, no. The DON was asked if the medication list was printed and provided to the resident and/or family member then why wasn't the care plan printed and provided as well. The DON stated, we just don't print them [care plan]. It is not part of our practice to give a copy of the baseline care plan. On 07/14/2021 at 9:00 a.m., Resident #169 was interviewed regarding care plan participation. Resident #169 stated, I remember getting some hospital discharge papers, but no one has discussed with me my plan of care over here. The nurses in come in and talk with me and therapy has cut me back to three days because I'm so independent. Resident #169 was asked if he was provided with a summary of his initial care needs and/or medication list. Resident #169 stated, no. On 07/14/2021 at 11:00 a.m., the DON was asked if the antibiotic use and social service/discharge interventions should have been included on the baseline care plan. The DON stated yes. The DON stated the residents were followed by case management services for assistance with discharge plans. The above findings were discussed with the DON during a meeting on 07/14/2021 at 12:30 p.m. A review of the facility's Care Plans policy (revised 6/19) documented the following under Procedure: 1. The admitting nurse will initiate the baseline plan of care by adding appropriate interventions to the work list and baseline care plan based on problems identified on the admission assessment within 8 hours of admission. 2. This includes dietary and activity orders, treatments, and patient preferences. This information is reviewed with the patient/patient representative . Based on resident interview, staff interview, facility policy review and clinical record review, the facility stafffailed to develop baseline care plans to address immediate care needs and failed to provide a written summary of the plan for seven of seven new admission residents in the survey sample. Baseline care plans for Residents #65, #66, #67, #69, #165, #168 and #169 did not include all immediate care needs regarding management of a PICC (peripherally inserted central catheter), pain management, therapy services, medications and/or anticoagulant use. These residents nor their representatives were provided a written summary of the baseline care plan. The findings include: 1. Resident #65 was admitted to the facility on [DATE] with diagnoses that included COPD (chronic obstructive pulmonary disease), prostate cancer, hemorrhagic cystitis, hypoxia, coronary artery disease, hypertension, aortic stenosis and gastroesophageal reflux disease. An admission assessment dated [DATE] assessed Resident #65 as alert, oriented and able to understand instructions. Resident #65's clinical record documented physician orders dated 7/8/21 for occupational and physical therapy evaluations and treatments. The record documented a physician's order dated 7/8/21 for the opioid pain medication oxycodone 5 milligrams (mg) every 4 hours as needed and Tylenol 650 mg every 6 hours as needed for pain management. Resident #65's baseline care plan dated 7/8/21 included no problems, goals and/or interventions regarding pain management or therapy services and included no list of current medications. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. 2. Resident #66 was admitted on [DATE] with diagnoses that included hip fracture, congestive heart failure, history of right hip replacement, left eye blindness, hypothyroidism, glaucoma and history of pulmonary embolism. An admission assessment dated [DATE] listed the resident as confused with visual/hearing impairments. Resident #66's clinical record documented physician orders dated 6/30/21 for a bed/chair alarm and occupational/physical therapy evaluations and treatment. The record documented physician orders dated 6/30/21 for the anticoagulant Eliquis 5 mg twice per day, the opioid medication oxycodone 2.5 mg every 4 hours as needed, oxycodone 5 mg every 4 hours as needed and Tylenol 650 mg every 6 hours as needed for pain management. Resident #66's baseline care plan dated 6/30/21 included no problems, goals and/or interventions regarding pain management or anticoagulant use. The plan listed a speech therapy evaluation but made no mention of occupational or physical therapies. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. 3. Resident #67 was admitted to the facility on [DATE] with diagnoses that included post hip joint replacement, fractured femur, chronic respiratory failure with hypoxia, chronic kidney disease, anxiety, benign prostatic hyperplasia and ischemic heart disease. An admission assessment dated [DATE] as alert, oriented and able to understand instructions. Resident #67's clinical record documented physician orders dated 7/6/21 for the anticoagulant Eliquis 2.5 mg twice per day, Tylenol 500 mg every 6 hours as needed and the opioid medication Tramadol 50 mg every 6 hours as needed for pain. Resident #67's baseline care plan dated 7/6/21 included no problems, goals and/or interventions regarding pain management or daily use of an anticoagulant. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. 4. Resident #69 was admitted to the facility on [DATE] with diagnoses that included right total knee revision, hypoxemia, chronic kidney disease, diabetes, COPD, anemia, atrial fibrillation, history of myocardial infarction and history of COVID-19. An admission assessment dated [DATE] assessed Resident #69 as alert and oriented. Resident #69's clinical record documented physician orders for surgical wound care and occupational/physical therapy evaluation and treatment. The record documented physician orders dated 7/5/21 for the anticoagulant Eliquis 2.5 mg twice per day, Metformin 500 mg each day for diabetic management, Tylenol 1000 mg three times per day for pain management and oxycodone 5 mg every 4 hours as needed for pain. Resident #69's baseline care plan dated 7/5/21 included no problems, goals and/or interventions regarding anticoagulant use, prescribed therapies, diabetes or pain management. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. On 7/13/21 at 2:54 p.m., the director of nursing (DON) was interviewed about baseline care plans and any written summary provided to residents. The DON stated, We don't print it out [baseline plan] and hand it to them. The DON stated the baseline care plan was developed at the bedside with the nurse, resident and/or their family. The DON stated the information from the baseline plan was entered into the health record system by a unit tech and updated daily. The DON stated copies of the baseline plan were not provided to the residents and/or families. On 7/14/21 at 7:27 a.m., the DON was interviewed again about baseline care plans for Residents #65, #66, #67 and #69 that made no mention of anticoagulant use, pain management, medications or therapy services provided. The DON stated baseline care plans were completed usually within two hours of admission. The DON stated the admitting nurse reviewed the care plan goals and resident needs when the baseline care plan was developed. The DON stated again that the residents and families were not provided a written summary or copy of the baseline plan. On 7/14/21 at 7:52 a.m., Resident #65 was interviewed about his baseline care plan. Resident #65 stated he did not recall any information about a care plan and did not receive a copy of a care plan. Resident #65 stated discharge instructions were provided from the hospital but he was not aware of a baseline plan since admission to the skilled unit On 7/14/21 at 7:55 a.m., Resident #66's family member was interviewed about a baseline care plan or written plan summary upon admission. The family member stated they received discharge papers from the hospital but did not get a written care plan summary upon admission to the skilled unit. The family members looked through papers at the bedside and stated the hospital discharge summary was all that had been provided. On 7/14/21 at 9:19 a.m., Resident #67 was interviewed about his baseline care plan or written plan summary. Resident #67 stated he had some papers from the hospital but he had received no copy or summary of a care plan since his admission to the skilled unit. On 7/14/21 at 9:21 a.m., Resident #69 was interviewed about her baseline care plan and any plan summary provided by the facility. Resident #69 stated she did not get a summary or copy of a care plan. Resident #69 stated she thought her medications were the same as when she was hospitalized but she had not received a medication list since admission to the skilled unit. These findings were reviewed with the DON on 7/14/21 at 12:30 p.m.