Nhc Healthcare - Lexington

F-F689. Resident R130 did not have an appointment, making the concern unique. A review of patient appointments was conducted by the DON on March 12, 2025, showing that no other patients had been affected by this practice.

A sign in and out log is implemented as of March 12, 2025, listing date and time out, patient name, responsible person taking the resident, witness of patient leaving, the date and time of return, person returning patent and witness of patient return. This form will be signed by multiple parties to include the nurse or designee during any patient leave of absence to include appointments, family outings, etc. Nursing staff present in facility were educated on this practice on March 12, 2025, and education will continue through March 26, 2025. A review of this practice will be conducted daily by DON or designee for the next thirty days. Then twice weekly for fourteen days, then weekly for fourteen days and ongoing thereafter. Findings will be reported during QA meeting monthly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The facility will monitor this corrective plan monthly during QA until sufficient compliance feels met by the QA committee. Level of Harm - Immediate jeopardy to resident health or March 12, 2025. safety

A QAPI meeting was held on 3/12/2025 with the Administrator, Assistant Administrator, DON, Assistant Residents Affected - Few DON, Nurse Managers, Assistant Regional Nurse, Social Worker Director, HIM Director, Director of Rehab.

The Medical Director communicated with via phone. The alleged events were discussed in detail and reviewed and updated processes that will be implemented to assure resident safety from situations of non-supervision are followed up on appropriately.

48835

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46934 potential for actual harm Based on facility policy review, record review, observation, and interview, the facility failed to ensure Residents Affected - Some respiratory equipment (Bipap, CPAP, and Nebulizer Masks) were functioning, maintained, and stored appropriately for 4 of 4 residents (Resident (R)19, Resident R14, Resident R46 and Resident R59) reviewed for respiratory care out of total sample of 12 residents. The facility's deficient practice increased the resident's risk of respiratory complications.

Findings include:

Review of the facility policy titled, 306 Respiratory- Respiratory Therapy Equipment with a revision date of February 2025 revealed, 3. Respiratory equipment (i.e., nasal cannula, aerosols, etc.) at bedside will be covered with a plastic bag when not in use. Respiratory therapy services are important in preventing and managing health care acquired infections in the health care setting. The center's Respiratory Therapy Department will follow established guidelines for cleaning, disinfecting and refilling humidifiers and H2O reservoirs. Disposable tubing and refillable reservoirs will be replaced according to center schedule, Suctioning equipment will be disinfected according to center procedures.

Review of a document provided by the facility titled Specific Medication Administration Procedures with a revision date of 02/25/25, documented, When equipment is completely dry, store in a plastic bag with resident's name and the date on it.

Review of Resident R19's Face Sheet revealed Resident R19 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: acute recurrent sinusitis, chronic maxillary sinusitis, and mild intermittent asthma.

Review of Resident R19's Physician Orders revealed, Prescription ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/; amt: 1 neb; inhalation

Twice A Day - PRN, PRN 1, PRN 2 Open Ended with a start date of 02/17/25.

Review of Resident R19's Care Plan last revised on 01/13/25, revealed, Complications, at risk for related to disease processes of hypertensive CKD stage 4, iron deficiency anemia, hypothyroidism, primary generalized osteoarthritis, depression, mild intermittent asthma, other chronic pain, GERD, other B12 deficiency anemia, hypokalemia, hypomagnesemia, prurigo nodularis, polyneuropathy, left shoulder pain, chronic sinusitis, insomnia, anxiety disorder, vitamin D deficiency, dysphagia, constipation, hallucinations, difficulty walking, cramp and spasm, localized edema, non-pressure chronic ulcer to left foot, abnormalities of gait and mobility, unspecified lack of coordination, and generalized muscle weakness, [Resident R19] has history of C1 displaced vertebra fracture. Approaches directed staff to, NEBULIZER MASK - CHANGE NEBULIZER TUBING AND MASK EVERY 3 DAYS Edited: 02/02/2024 Nebulizer Care: RINSE MASK AND CHAMBER WITH TAP WATER. LET DRY ON PAPER TOWEL AFTER EACH NEBULIZER TREATMENT Created: 02/02/2024. Observe resident for signs of respiratory distress such as shortness of breath, wheezing, gasping, shallow breathing Created: 08/19/2021.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Review of Resident R19's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/25, revealed Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident R19's cognition was intact. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 03/09/25 at 12:58 PM, of Resident R19's room revealed a Medline Nebulizer machine, near the resident's bedside. The Jet nebulizer cap was empty, the adult mask was hooked up to Residents Affected - Some the Jet Nebulizer chamber. The mask was uncovered. The machine was located beside an artificial plant.

The artificial plan had dust particles. The tubing on the machine was dated 03/06/25. Resident R19 stated she used

the machine as needed. Resident R19 stated she used the machine a few days ago. Resident R19 could not recall the last time staff cleaned the machine or replaced the mask.

An observation on 3/10/2025 at 9:09 AM, at 12:18 PM, and on 03/11/25 at 9:09 AM, revealed the Jet nebulizer cap was empty, the adult mask was hooked up to the Jet Nebulizer chamber. The mask was uncovered. The tubing on the machine was dated 03/06/25.

During an interview on 03/11/25 at 4:16 PM, Registered Nurses (RN)3 and RN4 confirmed Resident R19 uses her nebulizer PRN (as needed) and that Resident R19 had a treatment a few days ago, however, could not recall the exact date. Both nurses confirmed tubing should have been changed, and confirmed the date on the sticker was the date it was changed, and it was supposed to be changed on the 9th or 10th, even if it's not in use. Both nurses stated it's the nurse's responsibility to ensure nebulizers are covered when not in use, and tubing is changed every 3 days per order. Both nurses confirmed Resident R19 did not have her nebulizer covered until a few minutes ago.

48835

Review of Resident R59's Facesheet revealed Resident R59 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to chronic obstructive pulmonary disease and obstructive sleep apnea.

Review of Resident R59's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident R59 was cognitively intact.

Review of Resident R59's Physician Orders revealed an order for CPAP, to use CPAP from home at night, pressure 13, at bedtime 9:00 PM.

Review of Resident R59's Medication Administration Record (MAR) dated March 2025 revealed nurse signatures were signed every night at 9:00 PM for usage.

During an observation and interview on 03/09/25 at 3:30 PM, revealed a CPAP (Continuous Positive Airway Pressure) in Resident R59's room. Resident R59 stated, Something is wrong with it for about 2 weeks. They turned it on last night, it worked for a while then it just cut off. I've been asking about getting it fixed, I need it. No-one has said anything, I'm just waiting.

During a follow up interview on 03/10/25 at 2:51 PM, Resident R59 stated, I used the CPAP last night, it cut off twice. There is supposed to be someone coming to look at it. The CPAP is in the drawer. Observation revealed the CPAP machine in Resident R59's dresser drawer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview on 03/10/25 at 4:55 PM, Licensed Practical Nurse (LPN)1 entered Resident R59's room and retrieved the CPAP machine and turned it on. LPN1 stated, It's set for 13 pressure, when it gets to 4 it stops, Level of Harm - Minimal harm or it runs for 10-15 seconds. LPN1 tried it with the mask on also and confirmed it wasn't working. potential for actual harm

During an interview on 03/10/25 at 5:02 PM, Registered Nurse (RN)1 stated, The charge nurse was aware. Residents Affected - Some He let the niece know and there is a pulmonology appointment April 24th. We asked her niece to come pick it up. RN1 confirmed that Resident R59 was not able to use the machine.

During a phone interview on 03/10/25 at 5:12 PM, Resident R59's niece stated, [Resident R59] has been on the CPAP for years. I thought she was using it at night. I don't recall them telling me that it wasn't working. I've never had it serviced. She was on a CPAP at home. Most of her stuff, the nursing home takes care of. Resident R59's spouse spoke up and stated he was not aware of any problems with the machine.

During an interview on 03/10/25 at 5:15 PM, LPN2 stated he checked it an hour or two ago. It popped on and

it only went to 4. LPN2 confirmed Resident R59's CPAP was not working correctly.

During a follow up interview on 03/10/25 at 5:20 PM, RN1 stated on January 20th, the family was called about the machine needing service. RN2 stated, [Resident R59] has an appointment with Pulmonology April 24th. We asked her niece to come pick up the CPAP.

During an interview on 03/10/25 at 6:08 PM, the Nurse Practitioner (NP) stated she's had more issues than we've been successful with it. The mask was replaced at least 2 times. Resident R59 has obstructive sleep apnea and COPD. Resident R59 had a sleep study, her O2 (oxygen) saturation (oxygen in the blood) was dropping in the 80s.

The NP further stated, The facility should provide medical equipment. They own one CPAP machine in the facility. When it works it's great. The NP concluded, My preference would be that [Resident R59] use oxygen every night. We knew she didn't use the machine all through the night. She was averaging about 4 hours.

During a follow up interview on 03/11/25 at 10:57 AM, LPN2 stated, Aero Care was supposed to call [Resident R59's] family. They called the husband a few months ago, he has advanced Parkinson's. I did not know it [CPAP machine] was broken all this time. There is an appointment for Thursday, I called them first thing this morning. The niece is coming to pick it up and take it to them to fix. I spoke to her yesterday. She said she was not made aware back then. [Resident R59's] husband would not have been able to tell her or remember to tell her with his advanced Parkinson's.

During an interview on 03/11/25 at 5:07 PM, the Director of Nursing (DON) stated, I was made aware of [Resident R59's] CPAP machine yesterday. I should have been made aware if they weren't able to get it resolved. Most residents bring there own. My expectations are for me to be notified.

51857

Review of Resident R46's Face Sheet revealed Resident R46 was admitted to the facility on [DATE REDACTED], with diagnoses including, but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left side, aphasia, obstructive sleep apnea, and morbid obesity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Review of Resident R46's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/24, revealed Resident R46 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating that the Level of Harm - Minimal harm or resident is cognitively intact. potential for actual harm

Review of Resident R46's Progress Note dated from January - March 2025 revealed no progress notes related to OSA Residents Affected - Some or breathing difficulties.

Review of Resident R46's Medication Administration Record (MAR) reviewed for the months of January-March 2025, revealed the following: that continuous positive airway pressure (CPAP) is ordered to be used at bedtime with start date 10/10/22 to 03/10/25. CPAP care daily- once a day, wash c-pap mask daily with soap and water and air dry. CPAP care weekly- once a day on Sunday. Wash tubing and head gear with soap and water on Sunday and air dry on 7a- 7p. CPAP filters- once a day on Friday every two weeks, change disposable filters. CPAP humidifier- once a day. Empty and refill humidifier daily with sterile/distilled water on 7p-7a.

During an observation on 03/09/25 at 11:57 AM, Resident R46's CPAP machine and mask were located at bedside.

The CPAP mask was uncovered laying on the nightstand.

During an observation on 03/10/25 at 1:07 PM, Resident R46's CPAP facemask was uncovered on the nightstand.

Review of Resident (R)14's Face Sheet revealed Resident R14 was admitted to the facility on [DATE REDACTED], with diagnoses including, but not limited to: chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, hypertension, osteoarthritis, and anxiety disorder.

Review of Resident R14's Quarterly MDS with an ARD of 01/07/25, revealed Resident R14 had a BIMS score of 5 of 15, indicating that the resident was severely cognitively impaired.

Review of Resident R46's Medication Administration Record (MAR) for the months of January-March 2025, revealed

the following: Nebulizer care is performed on every shift- rinse mask and chamber with tap water. Let dry on paper towel after each nebulizer treatment. Nebulizer mask change is once a day every three days- change nebulizer tubing and mask every three days 7p-7a shift. Budesonide suspension for nebulization; 0.5mg/2ml; 1 unit dose; inhalation every 12 hours for COPD.

During an observation on 03/09/25 at 12:27 PM, Resident R46's nebulizer mask was uncovered at bedside.

During an observation on 03/10/25 at 10:00 AM, Resident R46's nebulizer mask was uncovered on bedside table.

During an interview on 03/10/25 at 1:45 PM, Licensed Practical Nurse (LPN)4 stated that there is a protocol

in place for CPAP storage. Staff follows the orders in the chart and staff changes the face mask once a week and uses distilled water in the humidifier. LPN4 stated the mask must be washed and cleaned after use and placed on a barrier to allow for drying. LPN4 observed Resident R46's CPAP face mask uncovered at bedside. LPN4 stated that the face mask must be protected from germs when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview on 03/11/25 at 3:31 PM, Registered Nurse (RN)1 stated once the resident is complete with nebulizer or CPAP, the face mask is washed out and laid to dry on a waterproof barrier. RN1 stated Level of Harm - Minimal harm or when the mask is not in use, it is placed in a bag for infection control purposes. The CPAP face mask and potential for actual harm tubing is changed every three months, and the nebulizer is washed in soap and water daily. RN1 stated the tubing is washed weekly, and the filters are changed every two-weeks. RN1 stated the face cushion is Residents Affected - Some changed every month, the mask is placed in a plastic bag after use.

During an interview on 03/11/25 at 7:21 PM, the Director of Nursing (DON), stated that she expects respiratory care is being provided per the physician's orders and face masks are stored in their designated storage bags when not in use. The DON encourages patients to utilize the storage bags as well.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51857 potential for actual harm Based on observation, interview, and review of facility policy, the facility failed to ensure used Personal Residents Affected - Some Protective Equipment (PPE) was disposed of properly in accordance with professional standards. Specifically, used PPE was observed hanging outside of the resident's rooms who were currently on droplet precautions for 6 of 9 rooms observed.

Findings include:

Review of the facility's policy titled, 704 Droplet Precautions, documented, Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or both patients are on Droplet Precautions.

Review of the CDC Infection Control Summary of Recommendations with a revision year of 2007, states, Slide 10. PPE must be removed at the point of exit; do not reuse face masks.

During an observation on 03/09/25 at 10:45 AM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/09/25 at 10:45 AM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/09/25 at 1:15 PM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/09/25 at 1:17 PM, there were used gloves balled up on the handrail outside of room [ROOM NUMBER], a droplet precaution room.

During an observation on 03/09/25 at 2:10 PM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/09/25 at 2:31 PM, there was an used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/09/25 at 2:33 PM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/10/25 at 9:00 AM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/10/25 at 10:08 AM, there were two used uncovered face masks hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

During an observation on 03/10/25 at 10:14 AM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 425333 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425333 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare - Lexington 2993 Sunset Blvd West Columbia, SC 29169

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 03/09/25 at 1:10 PM, the Director of Nursing (DON) stated that she is the infection control nurse, and the facility now has nine Covid positive patients. The outbreak started on 02/17/25 with 22 Level of Harm - Minimal harm or positive residents. The facility is maintaining the same staff on the units and reducing community activities to potential for actual harm prevent residents from being around others to contain the spread of Covid.

Residents Affected - Some During an interview on 03/10/25 at 9:57 AM, the Administrator stated that he would have to get with the nursing department on the mask policy guidelines for masking when Covid is in the building.

During a follow up interview on 03/11/25 at 7:24 PM, the DON stated that she expects her staff to don (put on) and doff (take off) their PPE per wherever the isolation is, and PPE should be stored in the bags that are hanging outside the door that contains clean PPE not used PPE. The DON further expects new PPE to be used every time staff enters in a resident's room that is on precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 425333