Inspection·December 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to timely identify and treat new skin impairment. This affected one (Resident #72) of one resident reviewed for potential skin impairment. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record revealed Resident #72 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, chronic obstructive pulmonary disease, dysphagia, gastrostomy status, anxiety disorder, delusional disorders, essential primary hypertension, hyperlipidemia, and hypokalemia. Review of the Minimum Data Set (MDS) assessment, dated 10/06/23, revealed the resident was severely cognitively impaired, incontinent, and was dependent for oral and personal hygiene, toileting, showering/bathing, and putting on/taking off footwear. Resident #72 had one venous/arterial ulcer. Review of care plan, dated 10/02/23 and revised on 10/25/23, revealed Resident #72 had potential for pressure ulcer development due to decreased mobility, chronic obstructive pulmonary disease (COPD), vascular dementia, and right-side hemiplegia. Noted areas of skin impairment on resident's body included atrial right foot fourth toe and abrasion right foot toe. Review of wound assessments, dated October and November 2023, revealed Resident #72's right foot second toe was healed in October and the right fourth toe was healed in November. Observation on 12/06/23 at 9:19 A.M., 10:53 A.M., approximately 2:00 P.M. and 4:15 P.M., revealed numerous streaks of unknown reddish colored substance on Resident #72's wall near the middle to end of the bed which was against the wall. Observation on 12/07/23 at 7:50 A.M. revealed the numerous streaks of an unknown reddish colored substance on Resident #72's wall remained present. Interview on 12/07/23 at 7:53 A.M., with State Tested Nursing Assistant (STNA) #119 verified the numerous streaks of reddish color substance on the wall. STNA #119 stated it was likely blood from Resident #72's toes and drew attention to two of Resident #72's toes near the knuckle dark red with apparent dried blood. Interview on 12/07/23 at 7:56 A.M., with Licensed Practical Nurse (LPN) #175 verified being the nurse for Resident #72 and stated she had not been in the resident's room yet today. LPN #175 verified she was not informed of Resident #72 having an abrasion/wound on the toes. Interview on 12/07/23 at 8:00 A.M., with Assistant Director of Nursing (ADON) #155 verified the wounds to Resident #72's toes had not been identified or treated. ADON #155 verified the dried blood on the resident's toes and wall. ADON #155 stated Resident #72 was admitted with wounds to the toes and the wounds had been healed. Review of policy titled, Wound Management Program, dated November 2021, verified the wound management program identifies staff participation and accountability to include expectations of all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0684 caregivers to observe resident skin integrity during the daily provision of the resident's personal care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure care and treatment was provided to a resident with closed urinary drainage system to maintain the closed system to prevent potential infections. This affected one (#53) of one residents reviewed for catheter care. The facility identified four current residents with catheters. The facility census was 81. Findings included: Review of the medical record for Resident #53 revealed an admission date of 02/07/23. Diagnoses included encephalopathy, cerebral infarct, vascular dementia, diabetes, urine retention and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 53 was cognitively impaired and was rarely if ever understood and required partial to moderate assistance for bed mobility, transfers, and toileting. Review of the care plan dated 11/16/23 revealed the resident had an indwelling catheter with interventions to ensure it was placed below the residents and not in the way of the door. Observation on 12/04/23 at 9:45 A.M., with Resident #53 wheeling himself down the hallway with catheter tubing dragging behind him outside of the catheter bag. State Tested Nurses Assistant (STNA) #106 was observed to stop the resident and moved the catheter tubing that was near the wheels to a more centered position on the floor. Observation and interview on 12/04/23 at 9:47 A.M., with Licensed Practical Nurse (LPN) #171 revealed Resident #53's catheter continued to drag on the floor with urine coming out of the tubing in snaking pattern behind him as he wheeled down the hall. LPN #171 confirmed the catheter tubing was outside of the catheter bag and was dragging on the floor leaving a trail of urine behind it. Observation on 12/04/23 at 9:50 A.M., of STNA #106 revealed she picked up the catheter tubing off the floor and put it back in the bag. LPN #171 observed this and informed STNA that the tubing should be sanitized prior to being placed bag in the bag. Continued observation revealed upon removing the tube to sanitize, the catheter bag torn, and a full bag or urine was poured on the floor in the middle of the hallway. Review of the policy titled, Insertion, Removal and Care of an Indwelling Foley Catheter dated April 2021, revealed the catheter tubing and bag shall maintain sterile continuously closed drainage system. If the catheter tubing must be disconnected the tubing should be sterilized. Facilities shall take care not to contaminate the drainage port by touching collection materials to the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's nutritional status was being routinely being assessed by a registered dietician; accurately assess and obtain weights; and timely notify the physician and dietician of significant weight changes. This affected two (#7 and #51) of three residents reviewed for nutrition. The facility census was 81. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #7 revealed a re-admission date of 05/07/23. Diagnoses included epileptic seizures, intellectual disabilities, schizophrenia, chronic obstructive pulmonary disease, dysphagia, anxiety disorder, and adjustment disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and required supervision assistance with transfers and mobility. Review of the plan of care dated 10/12/23 revealed Resident #7 revealed resident had potential for a nutritional problem related to severe hand tremors and required an altered mechanical diet with large portions with interventions to provide diet as ordered and monitor, record and report signs and symptoms of malnutrition including weight loss (over 3 lbs. in one week, over 5% in one month, over 7.5% in three months and over 10% in 6 months) and registered dietician to evaluate and make recommendations as needed. Review of weights revealed on 08/08/23, Resident #7 weighed 157.0 pounds (lbs.). On 09/12/23, resident weighed 166.5 lbs. with weight gain of 6.1%. On 10/03/23, the resident weighed 149.5 lbs. with weight loss of 10.2%. On 11/07/23, residents weighed 156.0 lbs. with weight gain of 4.35%. Review of the Quarterly Nutrition assessments from the diet tech revealed Quarterly assessments were completed on 09/02/23 (prior to the significant weight loss) and 12/02/23 (after several significant weight changes). Review of physician orders revealed on 10/18/23, large meal portions were ordered. Review of dietician notification of change in condition revealed the weight obtained on 10/03/23 was reported to the dietician on 11/05/23 and the physician was notified on 11/17/23. Review of progress note dated 11/05/23 revealed the resident had a weight loss of for one month with weight at 149 lbs. Dietician revealed the resident received a diuretic which may have accounted for the weight loss. The progress note dated 11/15/23 revealed the residents had a weight increase of 4.6% in one month. The dietician revealed residents received large portions and mechanical soft diet with oral intake of 75%-100%. Review of dietician notification of change in condition revealed the weight obtained on 11/07/23 was reported to the dietician on 11/15/23 and the physician was notified on 11/17/23. Interview on 12/05/23 at 4:37 P.M., with Dietician #210 revealed she meets each week with facility staff and review weights and discuss interventions. Dietician #210 stated she was not aware of the significant weight losses and gains for Resident #7. Dietician #210 stated she had requested a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reweigh at some point but was unable to provide a timeframe or month that the reweigh was requested and confirmed no reweigh was completed for any of the significant weight changes. 2. Review of the medical record for Resident #51 revealed an admission date of 02/07/23. Diagnoses included diagnosis metabolic encephalopathy, cerebral infarct, vascular dementia with behavioral disturbance, diabetes type two, kidney disease, bipolar disease, other seizures, urine retentions, neuromuscular dysfunction of the bladder, and cognitive communication deficit. Review of weights revealed on 09/06/23, Resident #51 weighed 179.8 lbs. On 10/01/23, the resident weighed 156.0 lbs. with weight loss of 8.7%. On 10/03/23, resident had re-weighed at 159.5 lbs. with weight loss of 6.6%. On 11/07/23, residents weighed 178.6lbs with weight gain of 14.5%. On 11/29/23, residents weighed 179.2 lbs. with weight gain of 14.9% (from 10/01/23). Review of the Quarterly Nutrition assessments from the diet tech revealed a quarterly assessment was completed on 09/24/23. No assessments have been completed since the significant weight changes were identified. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively impaired. Review of the plan of care dated 10/06/23 revealed Resident #51 revealed resident had potential for a nutritional problem with risk of significant weight loss interventions to provide diet as ordered and monitor, record and report signs and symptoms of malnutrition including weight loss (over 3 lbs. in one week, over 5% in one month, over 7.5% in three months and over 10% in 6 months) and registered dietician to evaluate and make recommendations as needed. Review of physician orders dated 10/18/23 revealed large meal portions were ordered and included use of a divided plate. The physician order dated 10/29/23, revealed a boost was ordered for low protein. Review of the progress notes dated 10/29/23 revealed the physician reviewed laboratory work and ordered a boost supplement for increased protein. Interview on 12/05/23 at 4:37 P.M., with Dietician #210 revealed she meets each week with facility staff and review weights and discuss interventions. Dietician #210 revealed she was unaware of the weight changes until November 2023 and revealed she requested a reweight after the 11/07/23 weight. Dietician #210 confirmed this was not obtained until 11/29/23. Dietician #210 confirmed she had no evidence of documentation or interventions for weight significant weight changes for Resident #51. Interview on 12/07/23 at 9:32 A.M., with the Director of Nursing (DON) revealed his expectation was for staff to complete weights as ordered and if a significant weight loss was identified the dietician and physician should be notified in a timely manner. DON verified facility notification was not completed timely for Resident #7 and #51 and reweights had not occurred timely. Review of the policy titled, Weights, dated May 2021, revealed the facility would obtain weights in a timely manner, document and respond in an appropriate manner. The policy revealed if a weight was 5% or more change from the previous weight a reweigh should occur in a timely manner and be reviewed by the dietician, diet tech and clinical team each month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of policy, the facility failed to ensure proper storage of medications and failed to ensure the medication refrigerator in the medication room was used only for medication storage. This had the potential to affect nine (#7, #17, #19, #35, #48, #51, #53, #62, and #67) of nine residents the facility identified as cognitively impaired and independently mobile an undetermined number of residents who could receive the tuberculin solution. The facility census was 81. Findings include: Observation on 12/04/23 from 2:05 P.M. to 2:33 P.M., revealed a sealed large brown plastic bag on the top of nurse's station top desk left unattended. On the outside of the plastic bag was an itemized inventory sheet of the contents inside the sealed large brown plastic bag that revealed the large brown plastic bag contained resident prescription medications. Further observation revealed the following staff and residents walked by the unattended large brown bag: four unknown State Tested Nursing Assistant (STNA), 10 unknown residents, two Licensed Practical Nurse (LPN) #104 (Unit Manager) and #155 (Assistant Director of Nursing) (ADON), and Maintenance Supervisor (MS) #158. Interview on 12/04/23 at 2:33 P.M., with LPN #155 verified the contents of the large brown plastic bag was resident prescription medications that was delivered by the pharmacy. LPN #155 further stated the pharmacy and facility does not require a signature when medications are dropped off at the facility. Interview on 12/04/23 at 2:44 P.M., with the Administrator stated medications dropped off by the pharmacy are required to have to be signed for as acknowledgment of receiving the prescription medications. Interview on 12/04/23 at 2:50 P.M., with the Administrator identified the following residents (Resident #7, #17, #19, #35, #48, #51, #53, #62, #67) as being cognitively impaired and independently mobile that reside on the unit. Interview on 12/05/23 at 2:27 P.M., with Registered Nurse (RN) #125 stated prescription medications delivered to facility requires signature on the paperwork and on the delivery driver's phone. RN #125 stated a copy of the inventory sheet is left at the facility to verify medications delivered and the inventory sheets are kept in a binder on the specific units. RN #125 stated the prescription medications are then either locked up in the medication cart or the medication room. Review of the itemized inventory sheet for the large brown bag containing prescription medication for the residents revealed the sheet was signed by LPN #171, indicating acceptance and responsibility of the prescription medication. Observation on 12/06/23 at 7:46 A.M., of the medication storage room on A hall revealed a bucket of chicken from Kentucky Fried Chicken in medication refrigerator and an opened, undated vial of tuberculin solution. At the time of the observation RN #125 verified the refrigerator in the medication room is dedicated for medications. RN #125 also verified a bucket of chicken in the medication refrigerator and an opened, undated vial of tuberculin solution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the undated policy titled Receipt of Routine Deliveries, revealed the facility nurse or other facility representative signs the delivery manifest and/or the electronic signature pad, notes time of arrival, and take responsibility for receipt. Review of the undated policy titled Medication Storage, revealed medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with the Ohio Department of Health Guidelines. Employee or resident food should not be stored in the medication refrigerator. Event ID: Facility ID: 365747 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure drinking cups were adequately cleaned. This affected 28 (#2, #3, #4, #6, #13, #15, #20, #24, #25, #29, #30, #34, #38, #39, #40, #42, #43, #46, #47, #49, #56, #66, #68, #73, #75, #79, #80 and #81) of 29 residents in the A hall. The facility identified one resident (#72) to receive no food by mouth. The facility census was 81. Findings include: Observation on 12/06/23 at 12:20 P.M., of the lunch meal service revealed a tray of empty drinking cups to be served to the residents on the A hall for lunch. The empty cups appeared dirty with speckles of pink remnants. Interview on 12/06/23 at 12:18 P.M., with State Tested Nursing Assistant (STNA) #119 and STNA #187 verified the drinking cups brought by the dietary staff appeared to be dirty. STNA #119 and STNA #187 stated the glasses are always dirty. Subsequent observation revealed the STNAs made no effort to have the cups returned to the kitchen to be cleaned and waited for the lunch meal to arrive. Interview on 12/06/23 at 12:23 P.M., with Dietary Corporate Staff #400 upon the returning of the tray of empty drinking glasses to the kitchen verified the drinking glasses appeared dirty and would be rewashed. Review of policy titled, General Cleaning of Dishware, dated 10/01/21, verified if using a three-compartment sink; wash, rinse, and sanitize all parts in addition to verifying sanitizer concentration for each meal period. If using a dish machine; rinse, scrape, or soak all items before washing in addition to using correct rack and do not overload the racks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 potential for actual harm Based on observations, staff interview, training record review and policy review, the facility failed to ensure staff wore proper personal protective equipment (PPE) when entering a COVID positive environment. This had the potential to affect the remaining COVID negative residents on the second floor 21 (#9, #10, #12, #16, #17, #18, #19, #21, #28, #31, #35, #44, #48, #50, #53, #54, #57, #62, #63, #65, #76) of 21 residents the on the second floor. The facility census was 81. Residents Affected - Some Findings included. Observation on 12/04/23 at 5:20 P.M. revealed staff were passing meal trays for dinner. Residents #51 and #67 were roommates and were both COVID positive and had been walking around in the hallway without PPE on. Residents were instructed to go to their rooms for the meal tray to be delivered and residents followed the instructions. After waiting residents became restless and began to argue about who would get their food and why one resident was standing in the doorway waiting for food. Residents were over 5 feet apart and were not gesturing toward each other State Tested Nurse Assistant (STNA) #106 and STNA #141 were observed to enter the room to pass trays and deescalate the residents and requested Licensed Practical Nurse (LPN) #171 to come to assist as needed. STNA #106 and LPN #171 were wearing surgical masks and placed N95 respirators over the surgical mask and then entered the room of two residents that had tested COVID positive. STNA #141 was also present and had placed a N95 over a KN95 mask prior to entering the room with two COVID positive residents. Interview on 12/04/23 at 5:23 P.M., with STNA #106 and STNA #141 confirmed they were wearing masks under the N95 and confirmed they should have taken off the mask and placed to N95 securely prior to entering a COVID positive room. STNA #106 and #141 confirmed they were just going quick when placing the masks on and STNA reported at time staff will just wear a surgical mask when entering a COVID positive room. LPN #171 declined to confirm improper mask usage in a COVID positive room. Interview on 12/04/23 at 6:00 P.M., with Administrator revealed staff should not be wearing an N95 with a mask beneath it when entering a COVID positive room. She revealed an STNA had been sent home for the remainder of the shift due to exposure risk, Administrator was unaware all three staff had inaccurately adorned PPE. Review of the COVID negative residents listed on the second floor included 21 (#9, #10, #12, #16, #17, #18, #19, #21, #28, #31, #35, #44, #48, #50, #53, #54, #57, #62, #63, #65, #76). Review of Quality Improvement Project training information revealed facility completed training in October 2023 related to proper personal protective equipment use and included guides of how to wear PPE correctly. The training flyer stated the N95 needs to be placed to ensure a proper seal. Review of the policy titled, Infection Control Isolation, dated March 2023, revealed the facility would prevent the spread of infection within the facility through the use of isolation precautions. The transmission-based precautions are used in addition to standard precautions and includes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 If continuation sheet Page 10 of 10