**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff implemented appropriate interventions and oversight of restraints for two of eight sampled residents (Resident 38 and Resident 45) when: 1. Resident 38's mitten restraint (soft hand cover used to prevent a person from scratching or removing medical devices) was not properly worn or secured to Resident 38's right hand. 2. Resident 45's restraint was not reassessed monthly as required by the facility's policy and procedures (P&P) for Restraint, Physical Guidelines for Use and Assessment. These failures had the potential to result in unsafe restraint use, decreased resident safety and violation of residents' rights. Findings: 1. A review of resident 38's Face sheet (FS-Document containing resident demographics), indicated, Resident 38 was admitted to the facility on [DATE]. A review of Resident 38's History and Physical (H&P- a document containing demographic information), dated January 9, 2025, indicated, Resident 38 had a history of tracheostomy (trach-a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, spastic quadriplegic cerebral palsy (a condition that makes all four limbs stiff and hard to control), and intractable epilepsy (seizures or a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness) that are very hard to control with medication). During an observation on August 24, 2025, at 2:07 PM, in room [ROOM NUMBER], Resident 38 was observed with right hand mitten restraint completely off, laying on stomach, and was lifting right arm near the trach. No staff or family members were present in the room. During a concurrent observation and interview on August 24, 2025, at 2:11 PM, with Licensed Vocational Nurse (LVN 3), in room [ROOM NUMBER], Resident 38 was observed to have mitten restraint completely off. LVN 3 verified and stated that Resident 38 should have mitten restraint to the right hand. LVN 3 stated it is important for the mitten restraint to be reapplied because Resident 38 tends to grab on things. A review of Resident 38's orders, dated April 11, 2024, indicated, Resident 38 had an order for Mitten to R [Right] Hand. indication for restraints: Pulling at Lines, Tubes, or Dressing. During an interview on August 24, 2025, at 4:54 PM, with Resident 38's father, he stated, the reason that Resident 38 was on restraint's because she puts her hands in her mouth, makes herself gag and pulls on things. During an interview on August 24, 2025, at 5:02 PM, with LVN 3, LVN 3 stated, it was a shared responsibility between Certified Nurse Assistant (CNAs) and LVNs for monitoring residents' restraints. LVN 3 further stated that improper restraint application can lead to pulling and dislodging devices. During a concurrent interview and record review on August 27, 2025, at 12:07 PM, with the Director of Nursing (DON) and the administrator (Admin), the facility's P&P titled, Restraint, Physical Guidelines for Use and Assessment, dated September 2020, was reviewed. The P&P indicated .Padded Hand mittens.to keep the resident's movements from pulling out tubes. tracheostomy tubes.wrap webbing around the resident's wrist and secure webbing with the slider buckle.tighten webbing sufficiently to prevent from removing mittens. The DON stated that the policy was not followed since Resident 38 was able to get out of the restraint. The DON further stated it is important to follow the policy to keep the residents from harming themselves. 2. A review of Resident 45's FS, indicated, Resident 45 was admitted to the facility on [DATE]. A review of Resident 45's H&P, dated May 8, 2025, indicated that Resident 45 had a history of agitation and restlessness with potential to harm self, intracranial hemorrhage (bleed inside the brain), trach dependent, and G-tube dependent. During an observation on August 24, 2025, at 10:15 AM, Resident 45 had a mitten restraint to right arm. During an interview on August 24, 2025, at 10:18 AM, with Charge Nurse (CN 1), CN 1 stated, the facility will reassess the need for restraints every month, the interdisciplinary team (IDT- a group of healthcare professional who work together to plan and coordinate a resident's care) will discontinue the restraint if the resident passes a 72-hour trial without needing the restraint. A concurrent interview and record review on August 24, 2025, at 3:10 PM, with CN 1, Resident 45's physical restraint medical symptom summary sheet, dated from January 1, 2025, through, August 2025, was reviewed. CN 1 confirmed, Resident 45's restraint was last reviewed on June 30, 2025 (55 days from last assessed). CN 1 stated sometimes they are a little late documenting it into the chart. CN 1 verified that the month of July was missing. CN1 stated, the person who updated the form was Minimum Data Set Nurse (MDSN). During a concurrent interview and record review on August 24, 2025, at 3:38 PM, with the MDSN, Resident 45's physical restraint medical symptom summary sheet, dated January 1, 2025, through, August 2025, document, was reviewed. The physical restraint medical symptom summary sheet indicated, Resident 45's restraint was last reviewed on July 31, 2025. The MDSN verified and confirmed that Resident 45's July restraint assessment was updated today, August 24, 2025 (24 days late). The MDSN stated that the document should have been updated sooner since it is important to do the monthly reassessment to ensure whether the resident still needed the restraints. During an interview on August 27, 2025, at 12:04 PM, with CN 2 and the DON, CN 2 stated that restraints are assessed every month. CN 2 stated that based on the physical restraint medical symptom summary sheet nursing staff will report in the IDT meetings. CN 2 further stated that if physical restraint medical symptom summary sheet was missing a month, then it was not reported in the IDT meetings because IDT team based off the physical restraint medical symptom summary sheet. During a concurrent interview and record review on August 27, 2025, at 12:10 PM, with the DON and Admin, the facility's P&P titled, Restraint, Physical Guidelines for Use and Assessment, dated September 2020, was reviewed. The P&P indicated .the duration of use, not to exceed thirty (30) days.monthly reassessments; the interdisciplinary team will reassess the use of the restraint, the effectiveness of the action plan, less restrictive measures and their effectiveness, progress of the restraint reduction plan and further actions to be taken. The DON confirmed that the policy was not followed since the facility was missing the documentation for July. The DON stated it is important to follow the policy to ensure safe and quality care for the residents and to be restraint free as much as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatments and services to promote wound healing and prevent pressure ulcer (PU- a sore that develops on the skin when there is too much pressure on one area for a long time) development for two of 12 sampled residents (Resident 7 and Resident 37) when: 1. For two residents (Resident 7 and Resident 37), who were at risk for PU development, the repositioning was not documented every two hours. 2. For Resident 37, low air mattress was programmed with the incorrect resident weight. These failures may have contributed to the development of pressure ulcers in Resident 7 and Resident 37, potentially exposing them to harm and resulting in prolonged hospitalization. Findings: 1a. A review of Resident 7’s “admission Record (contains medical and resident demographics), undated, indicated, Resident 7 was admitted to the facility on [DATE]. A review of Resident 7’s “History & Physical” (H&P- a document containing demographic information), dated September 8, 2024, indicated, Resident 7 has a history of decubitus ulcer (a sore on the skin from lying in one spot for too long) of coccyx (the small tailbone at the bottom of the spine), tracheostomy (trach- a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G-tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, and anoxic encephalopathy (brain damage caused by lack of oxygen). A review of Resident 7’s “Pressure Ulcer Treatment Care plan,” dated March 14, 2025, through August 23, 2025, indicated “turn and reposition at least q [every] 2 hours.” A review of Resident 7’s “Wound Care Note,” dated May 16, 2023, indicated, Resident 7 had a wound to the “Sacro coccyx [ the lower end of the spine where the sacrum and tailbone meet] .type…partial thickness… Measurements (length/width/depth): 1 X [BY] 1 CM [Centimeter-unit of measurement] …. Right ischial tuberosity [the bones that support your weight when you sit down] …type: …partial thickness… measurements (length/width/depth) 2 x 3 cm…Braden score [BS-a tool used to assess a patient's risk for developing pressure injury. Score of 15-18 at risk, score 13-14 moderate risk, 10-12 high risk, 9 or below indicates very high risk] 10…turn q2h [every 2 hours].” A review of Resident 7’s “Wound Care note,” dated June 24, 2025, indicated Resident 7 had a wound to “Location: Sacro coccyx…type: Reopened Stage 4 [full thickness skin and tissue loss, muscle, tendons, ligaments cartilage or even bone is visible.] Pressure Injury [PI- a sore that develops on the skin when there is too much pressure on one area for a long time]…Measurements (length/width/depth): 1.8 cm X 2.5 cm X 1.2 cm…tunneling…1.8 cm… Location: Right ischial tuberosity…type: stage 3{full-thickness skin loss where subcutaneous fat is visible, but bone, tendon, or muscle is not exposed] pressure injury…measurements (length/width/depth): 1.5 cm x 0.5 cm x 1.7 cm…Braden score: 10… reposition: turn q2h…” A concurrent interview and record review on August 27, 2025, at 12:29 PM, with the Director of Nursing (DON) and Administrator (Admin), Resident 7’s “ADLS [activity of daily living, including turns]”, dated August 1, 2025, through August 26, 2025, was reviewed. The “ADLS” for repositioning was completed as follows: On August 19, 2025, at 10:00 PM: position supine (on the back) On August 19, 2025, at 1:36 AM: position supine (3.5 hours without turn) On August 25, 2025, at 12:40 AM: position “head of the bed elevated” On August 25, 2025, at 10:02 AM: position “head of the bed elevated” (9 hours and 22 minutes without turn) The DON verified and confirmed that the nursing staff did not document repositioning every two hours and should have. The DON further stated that “head of the bed elevated” did not count as a turn. A follow-up concurrent interview and record review on August 27, 2025, at 12:32 AM, with the DON and Admin, the facility’s policy and procedure (P&P) titled, “Skin Care, prevention,” dated February 2024, was reviewed. The P&P indicated, “…Turn and reposition the dependent resident at least every two hours, and as needed…” The DON stated that the expectation for the staff was to turn the residents at least every two hours. The DON further stated that nursing staff did not follow the policy and should have to promote healing and to maintain the quality of life for the residents. 1b. A review of Resident 37’s “admission Record, undated, the “admission Record” indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37’s “History & Physical, dated August 25, 2025, the H&P indicated Resident 37 had diagnoses which included obesity (a chronic condition characterized by excessive body fat accumulation that poses a risk to health), encephalopathy (a broad term for any diffuse brain disease altering brain function), tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an artificial airway) and a gastric feeding tube (a thin, flexible tube inserted into the stomach through the abdominal wall to provide nutrition when a person cannot eat adequately by mouth). During an observation on August 26, 2025, at 5:45 AM, in Resident 37’s room, Resident 37 was lying on a low air loss mattress (a specialized mattress used to help treat and prevent pressure ulcers) and was turned to her left side. A sign titled, “turn clock” (schedule indicating at what times residents are supposed to be turned and in what direction) posted above the head of Resident 37’s bed indicated the resident was supposed to be turned to her left from two to four, and to her right from four to six. During a concurrent observation and interview on August 26, 2025, at 5:54 AM, with Certified Nursing Assistant 3 (CNA 3), in Resident 37’s room, CNA 3 acknowledged Resident 37 was turned to the left side despite the “turn clock” indicating the resident was supposed to be on her right side from four to six. CNA 3 further stated Resident 37 had been turned to her left side since 4:45 AM. CNA 3 stated residents were supposed to be turned every 2 hours. During further interview on August 26, 2025, at 6:04 AM, with CNA 3, CNA 3 stated at 4:45 AM she (CNA 3) had to change Resident 37’s brief and when she was done, she did not turn Resident 37 to the right side (as indicated on the turning schedule) because by the time 6:00 AM would have come around, she would not have had enough time to return back to Resident 37 to turn her because she knew she would have been busy changing all the other residents on the unit before shift change. CNA 3 then stated she wanted Resident 37 to be on the left side so she was turned to the correct side as indicated by the turning schedule at the time shift change occurred at 7:00 AM. During continued observation on August 26, 2025, at 6:50 AM, Resident 37 was still turned to her left side and no staff had turned Resident 37 from the time Resident 37 was initially observed to be turned to the left side at the 5:45 AM observation. During continued observation on August 26, 2025, at 7:13 AM, Resident 37 was still turned to her left side and no staff had turned Resident 37 from the time Resident 37 was initially observed to be turned to the left side at the 5:45 AM observation. During continued observation on August 26, 2025, at 7:48 AM, Resident 37 was still turned to her left side and no staff had turned Resident 37 from the time Resident 37 was initially observed to be turned to the left side at the 5:45 AM observation. During continued observation on August 26, 2025, at 8:15 AM, CNA 4 entered Resident 37’s room and turned Resident 37 from her left to her right side (Three hours and thirty minutes had passed since 4:45 AM). During an interview on August 26, 2025, at 2:09 PM, with Registered Nurse 3 (RN 3), RN 3 stated all residents were supposed to be turned every two hours for the prevention of pressure ulcers. During an interview on August 27, 2025, at 2:20 PM, with the DON, the DON stated residents were supposed to be turned every two hours as indicated on their turning schedule. During a review of Resident 37’s Minimum Data Set Assessment (MDS assessment – a comprehensive assessment of the resident), dated July 24, 2025, the MDS assessment indicated in section M0150 “Risk of Pressure Ulcers/injuries,” that Resident 37 was at risk for development of pressure ulcers/injuries. During a review of Resident 37’s care plan titled, “Pressure Ulcer Risk Care Plan,” dated February 15, 2025, the care plan indicated, “…At risk for further pressure ulcer related to: -history of resolved pressure ulcer; presence of compromised scarred tissue, -Immobility, -incontinent bowel…Interventions…Turn and reposition at least every 2 hours…” During a review of the facility’s P&P titled, “Skin Care, Turning,” dated February 2024, the P&P indicated, “…It is the policy of this facility to turn and re-position all dependent residents a minimum of every two hours routinely, and as needed. It is the policy of this facility to provide skin care to dependent residents every two hours at the time of turning and as needed…” 2. A review of Resident 37’s “admission Record,” undated, the “admission Record” indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37’s H&P, dated August 25, 2025, the H&P indicated Resident 37 had diagnoses which included obesity, tracheostomy, and a gastric feeding tube. During an observation on August 24, 2025, at 12:11 PM, in Resident 37’s room, Resident 37 was lying on a low air loss mattress. The programmable setting of the low air loss mattress was set to 350 – (to) 500 pounds (lbs—unit of weight). During a concurrent observation and interview on August 24, 2025, at 12:23 PM, with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated she was the nurse assigned to Resident 37 and confirmed Resident 37’s low air loss mattress was set to 350 – 500 lbs. LVN 8 stated the weight setting was incorrect. LVN 8 then looked up Resident 37’s weight in the electronic health record and stated Resident 37 weighed 133 lbs. LVN 8 stated she was not aware the low air loss mattress was set for the incorrect weight and stated the programmed weight should have been 100 – 165 lbs. LVN 8 further stated it was important that the low air loss mattress was programmed accurately for the residents weight because it changed the way the air mattress worked and it was most beneficial to the residents if it was programmed to the residents correct weight. During a review of Resident 37’s physician’s orders, dated January 28, 2025, the physician’s orders indicated, “Low air loss overlay…Citadel 200 bed for wound management.” During a review of Resident 37’s care plan titled, “Pressure Ulcer Risk Care Plan,” dated February 15, 2025, the care plan indicated, “…At risk for further pressure ulcer related to: -history of resolved pressure ulcer; presence of compromised scarred tissue, -Immobility, -incontinent bowel…Interventions…Pressure redistribution mattress as needed…” During an interview on August 26, 2025, at 2:09 PM, with RN 3, RN 3 stated the Citadel 200 bed was supposed to be set specifically for the residents’ weight range. RN 3 further stated it was important to ensure the low air loss mattress was set appropriately because depending on the residents’ weight, the bed would adjust its settings. During an interview on August 27, 2025, at 2:20 PM, with the DON, the DON stated the Citadel bed was a low air loss mattress and staff were expected to ensure the bed setting was set to match the residents’ weight. The DON stated the bed used the programmed weight range to change the air flow in the mattress. During a review of the facility’s P&P titled, “Skin Care, Prevention,” dated February 2024, the P&P indicated, “Policy: To maintain skin integrity; to prevent skin and tissue breakdown and the development of pressure sores…8.5 Consistently use pressure reducing devices such as pressure relief mattresses, static air, alternating air, gel, or water type mattresses or overlays as ordered…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 5) received necessary treatment and services to maintain, increase range of motion (ROM- moving the joints to keep them flexible and prevent stiffness) or prevent further decline when nursing staff did not perform ROM as ordered by physician and specified in the care plan (a guide for nurses to follow regarding the plan of care). This failure had the potential to result in decreased mobility and pain and increased the risk of further contractures (muscles and tendons have tightened and shortened).Findings: A review of Resident 5's Face sheet (FS-Document containing resident demographics), indicated, Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's History & Physical (H&P- a document containing demographic information), dated May 6, 2025, indicated, Resident 5 has a history of cerebral palsy (CP-a condition that affects movement, balance, and muscle control), tracheostomy (trach- a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G-tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, severely contracted, and epilepsy (seizures or a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness). A review of Resident 5's Active orders, dated January 19, 2023, indicated Range of motion LTC [long term care] BID [ 2 times a day] provide PROM [Passive range of motion- a health care provider moves resident's joints for them like bending an arm or leg] exercises to BUE [both arms] q [every] AM shift [7:30 AM to 7:00 PM] and BLE [both legs] q night shift [7:30 PM to 7:00 AM] as tolerated. A review of Resident 5's ROM Care Plan, dated April 2025, through October 2025, indicated, PROM exercises to BUE Q AM shift, BLE Q NOC [night] shift as tolerated. A concurrent interview and record review on August 26, 2025, at 1:45 PM, with Certified Nursing Assistant (CNA 1), Resident 5's Restorative Activity Prom, dated from July 31, 2025, through August 26, 2025, was review. The Restorative Activity Prom for repositioning was not completed every shift as follows: July 31, 2025: AM shift: no documentationAugust 1, 2025: AM and PM shift: no documentationAugust 2, 2025: AM and PM shift: no documentationAugust 3, 2025: AM and PM shift: no documentationAugust 11, 2025: AM and PM shift: no documentationAugust 12, 2025: AM and PM shift: no documentationAugust 13, 2025: AM and PM shift: no documentationAugust 14, 2025: PM shift: no documentationAugust 15, 2025: AM and PM shift: no documentationAugust 16, 2025: AM shift: no documentation CNA 1 verified and confirmed the missing ROM. CNA 1 stated, she was unable to provide other documented evidence to show Resident 5 received ROM every shift. CNA 1 stated it was important to complete the ROM as ordered to prevent residents from getting further contracted. CNA 1 stated that the CNAs were responsible for providing the ROM. During a concurrent interview and record review on August 27, 2025, at 11:27 AM, with the Director of Nursing (DON) and Administrator (Admin), the facility's policy and procedure (P&P) titled, Nursing care, restorative & supportive, dated February 2024, was reviewed. The P&P indicated, Restorative and supportive care shall include: .Providing range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited range of motion. The DON stated the policy was not followed, and the nursing staff was expected to follow the physician orders and complete documentation. The DON further stated that it was important to provide ROM as ordered for patient safety.

Based on observation, interview, and record review, the facility failed to ensure the safety and security of medications when Licensed Vocational Nurse 5 (LVN 5) left 12 medications on a computer desk unattended, and unsecured in a resident's room. This failure had the potential to place all 87 residents living on the unit at risk of harm due to increased risk for medication diversion (when a medication is taken for use by someone other than whom it was prescribed.)Findings: During a concurrent observation and interview on August 26, 2025, at 8:46 AM, with LVN 5, in Resident 18's room, LVN 5 placed 12 medications on a portable computer desk located at the bedside of Resident 18. The 12 medications included:-Glycopyrrolate (a medication commonly used to treat stomach ulcers or to inhibit respiratory secretions) 1 milligram (mg - unit of measure) tablet crushed-Vitamin C 500 mg tablet crushed-baclofen (a muscle relaxant) 10 mg tablet crushed-sennosides/docusate/sodium (a combination medication used to treat constipation) 8.6 mg /(per) 50 mg tablet crushed-amlodipine besylate (medication used to treat high blood pressure) 5 mg tablet crushed-vitamin D3 10 micrograms (mcg - unit of measure) 400 international units (iu - unit of measure) tablet crushed-Famotidine (medication used to treat stomach ulcers) 20 mg tablet crushed-carmex ointment (lip moisturizer) 10 mg topical (applied to the skin)-calcium carbonate (an antacid commonly used to treat heartburn or upset stomach) 500 mg tablet crushed-mineral oil USP (commonly used to treat dandruff) 30 milliliters (ml - unit of measure) topical-polyethelene glycol powder (laxative used to treat constipation) 3350 17 grams (gm - unit of measure)-multivitamin w/minerals liquid 15 mls LVN 5, then left Resident 18's room to retrieve a blood pressure cuff and left the 12 medications on the computer table at the bedside of Resident 18 who was lying in bed. LVN 5 returned a few minutes later and stated the unit only had three blood pressure cuffs and she had to go find one. LVN 5 then administered all 12 medications to Resident 18. During an interview on August 26, 2025, at 9:00 AM, with LVN 5, LVN 5 stated she needed to get a blood pressure cuff so she had to leave Resident 18's room. LVN 5 further stated that she should not have left medications unattended, especially with the behavioral health unit (a hospital-based unit or standalone facility that provides intensive, structured care for individuals experiencing a mental health crisis or substance abuse issues) right next door. 5 acknowledged the increased risk of someone coming into the room and consuming or taking the medications when they were not supposed to. During an interview on August 27, 2025, at 2:20 PM, with the Director of Nursing (DON), the DON stated staff should never leave medications unattended if they were not locked in a drawer or locked in a medication cart. During a review of the facility's policy and procedure (P&P) titled, Safe Storage of Medications, dated January 2023, the P&P indicated, Purpose: To outline procedures for safe storage of medications. Policy: Medications will be stored under appropriate conditions to maintain medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing errors.All medications dispensed from the pharmacy and not immediately administered to the patient must be secured in an approved medication storage area, including locked medication carts, treatment carts, medication rooms, medication refrigerators, or automated dispensing machines.2.0 Medication storage areas must be secured at all times so that unauthorized persons cannot obtain access to them. 2.1 Medication carts and treatment carts containing medications must be locked unless under the direct supervision of the nurse or other licensed/registered personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide full visual privacy for two of 28 sampled residents (Resident 59 and Resident 70) when there was no curtain between Resident 59's and Resident 70's bed. This failure had the potential to compromise resident 59's and Resident 70's dignity and right to full visual privacy.Findings: A review of Resident 59's Face sheet (FS-Document containing resident demographics), indicated, resident 59 was admitted to the facility on [DATE]. A review of Resident 59's History & Physical (H&P- a document containing demographic information), dated February 11, 2025, indicated, Resident 59 has a history of cerebral palsy (CP-a condition that affects movement, balance, and muscle control), tracheostomy (trach- a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G-tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, and seizures (a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness.) A review of Resident 70's FS, indicated, Resident 70 was admitted to the facility on [DATE]. A review of Resident 70's H&P, dated June 23, 2025, indicated that Resident 70 has a history of down syndrome (a condition present at birth caused by an extra chromosome, leading to developmental and physical differences), trach dependent, G-tube dependent, and seizures. During an observation on August 24, 2025, at 12:10 PM, in room [ROOM NUMBER], there was no curtain dividing Resident 59 and Resident 70. During an interview on August 24, 2025, at 12:14 PM, with Charge Nurse (CN 1), CN 1 stated that the way the facility staff ensure privacy was having a curtain between residents. During a concurrent observation and interview on August 24, 2025, at 12:16 PM, with CN 1 in room [ROOM NUMBER], the room was observed without a curtain between Resident 59 and Resident 70. CN1 verified and stated she was unsure of how long or the reason of missing the curtain in the room. CN 1 further stated that Environmental Services (EVS) takes care of hanging curtains. CN 1 confirmed there should have been a curtain to provide privacy for both residents. During an interview on August 24, 2025, at 12:31 PM, with EVS Staff (EVSS1), EVSS 1 stated that she was unsure of why there was no curtain or who took off the curtain. During a concurrent interview and record review on August 24, 2025, at 11:39 AM, with the Director of Nursing (DON) and the Administrator (Admin), the facility's policy and procedures (P&P) titled, Resident Privacy and confidentiality, dated February 2024, was reviewed. The P&P indicated, . to assure the resident's right to personal privacy and confidentiality .Nursing staff will use curtain to provide full visual privacy during resident care, toileting, treatments and issues of dignity and other requested times . The DON indicated that the facility's P&P was not followed since there was no curtain in the room. The DON further stated it is important to follow the policy to provide each resident their right to be treated with dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program for 14 of 85 sampled residents (Resident 16, 18, 22, 24, 33, 41, 43, 52, 63, 68, 77, 82 and 83) when: 1. For one resident (Resident 41), there was no date or staff initial on Resident 41's gastro enteral tube (G tube- a feeding tube inserted through abdomen into the stomach to provide nutrition, fluids, and medication directly to the digestive system) and water flush bag (a bag with water administered to residents through G tube). 2. For 10 residents (Resident 83, 82, 63, 77, 52, 68, 22, 60, 24, and 41), suction tubes( a plastic tube used to remove bodily fluids and secretions, or foreign materials from a body cavity or passage by creating vacuum) were not used according to the policy and procedures (P&P) for disposable equipment change associated with artificial airway(a medical device such as a tube or other devices inserted into a patient's respiratory track to maintain and open airway) and mechanical ventilators (a medical procedure where a machine is used to assist or replace a person's breathing ). 3. For four resident (Resident 83, 33, 43 and 18 ), the facility staff did not use appropriate proper personal protective equipment (PPE- equipment used to minimize injuries and illness) during medication administration. 4. For one resident ( Resident 16) the facility staff did not wear appropriate PPE during transfer of a resident from shower. These failures had the potential to place residents at a greater risk for spreading infection from cross-contamination (the transfer of harmful bacteria) causing a preventable infection and negative impact on residents' health and safety.Findings: 1. During a review of Resident 41’s “Record of Admission” (demographic data), undated, the “Record of Admission” indicated, Resident 41 was admitted to the facility on [DATE], with the diagnosis of respiratory failure (a medical condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide father in the body). During a review of Resident 41’s “Orders”, dated August 7, 2025, the “Orders” indicated, Resident 41 was ordered to be on continuous GT feeding with [Formula Name] with the rate to be given at 55 milliliters [ml—unit measurement] per hour. During a concurrent observation and interview on August 24, 2025, at 10:40 AM, with Licensed Vocational Nurse (LVN 4), in Resident 41’s room, Resident 41’s G tube feeding bottle and water flash bag were observed with no date and initials on label. LVN 4 acknowledged that label did not have date and initials. LVN 4 stated that the nursing staff was expected to date and initial on the label for the G tube feeding bottle and water flush. LVN 4 further stated that G tube feeding bottle and water flush were scheduled to be changed every 24 hours, as this label did not have the date and initials it would be hard to say when it was hung. During a concurrent observation and interview on August 24, 2025, at 10:45 AM, with the Infection Preventionist (IP) nurse, Resident 41’s G tube feeding bottle and water flush bag were observed with no date and initials on the label. The IP nurse confirmed that G tube feeding and water flush bag has no date and initials on the label. The IP nurse stated the nursing staff were expected to complete the label with the details including date, time and initials when the G tube feeding was hung. The IP nurse further stated it was an infection control concern when the nursing staff did not know when the G tube feeding was hanged. During a concurrent observation and interview on August 24, 2025, at 11:10 AM, with Registered Nurse 2 (RN 2), Resident 41’s G tube feeding bottle and water flush bag were observed with no date and initials on the label. RN 2 acknowledged that the label has no date and initials. RN2 stated that the nursing staff was expected to complete the label with date and initials to know when the G tube feeding was hung. RN 2 further stated, it was a concern for infection control since the bag should be changed every 24 hours as per policy. During a concurrent interview and record review on August 27, 2025, at 2:50 PM, with the IP, the facility’s policy and procedure (P&P) titled, “Administration of formula via feeding tube, gravity, bolus, pump”, dated March 2024, was reviewed. The P&P indicated, “…. Pump or infusion control method . 17.0 pump bags, syringes and tubing are to be changed every 24 hours and properly labeled with date, time and nurses initials”. The IP stated, the policy was not followed. 2a. During a review of Resident 83’s “Face sheet” (demographic data), undated, the “Face sheet” indicated, Resident 83 was admitted to the facility on [DATE], with the diagnosis of respiratory failure. During a review of Resident 83’s “Order”, dated May 17, 2023, the “Orders” indicated, Resident 83 needed suction twice daily. 2b. During a review of Resident 82’s “Face sheet”, undated, the “Face sheet” indicated, Resident 82 was admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure. During a review of Resident 82’s “Orders”, dated January 18, 2017, the “Orders” indicated, Resident 82 needed to be evaluated for suction at least every two hours and as needed. 2c. During a review of Resident 63’s “Face sheet”, undated, the “Face sheet” indicated, Resident 63 was admitted to the facility on [DATE], with the diagnoses of respiratory failure and cardiac arrest (a condition in which the heart suddenly stops beating effectively). During a review of Resident 63’s “Orders”, dated November 22, 2023, the “Orders” indicated, Resident 63 needed to be evaluated for suction at least every two hours and as needed. 2d. During a review of Resident 77’s “Face sheet”, undated, the “Face sheet” indicated, Resident 77 was admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure. During a review of Resident 77’s “Orders”, dated January 18,2017, the “Orders” indicated, Resident 77 needed to be evaluated for suction at least every two hours and as needed. 2e. During a review of Resident 52’s “Face sheet”, undated, the “Face sheet” indicated, Resident 52 was admitted to the facility on [DATE], with the diagnoses of chronic respiratory failure and anoxic brain (a condition in which brain does not receive enough oxygen even when blood flow is adequate). During a review of Resident 52’s “Orders”, dated July 11, 2025, the “Orders” indicated, Resident 52 needed to be evaluated for suction at least every two hours and as needed. 2f. During a review of Resident 68’s “Face sheet”, undated, the “Face sheet” indicated, Resident 68 was admitted to the facility on [DATE], with diagnosis of respiratory failure. During a review of Resident 68’s “Orders”, dated April 18, 2024, the “Orders” indicated, Resident 68 needed to be evaluated for suction at least every two hours and as needed. 2g. During a review of Resident 22’s “Face sheet”, undated, the “Face sheet” indicated, Resident 22 was admitted to the facility on [DATE], with the diagnoses of bronchial asthma (a condition in which persons airway becomes inflamed narrow and swollen and produce mucus which makes difficulty to breathe), and cerebral palsy (a continental disorder of movement muscle tone and posture). During a review of Resident 22’s “Orders”, dated January 30, 2025, the “Orders” indicated, Resident 22 needed to be evaluated for suction at least every two hours and as needed. 2h. During a review of Resident 60’s “Face sheet”, undated, the “Face sheet” indicated, Resident 60 was admitted to the facility on [DATE], with the diagnosis of respiratory failure. During a review of Resident 60’s “Orders”, dated November 29, 2021, the “Orders” indicated, Resident 60 needed to be evaluated for suction at least every two hours and as needed. 2i. During a review of Resident 24’s “Record of “Face sheet”, undated, the “Face sheet” indicated, Resident 24 was admitted to the facility on [DATE], with a diagnosis of respiratory failure. During a review of Resident 24’s “Orders”, dated May 24, 2023, the “Orders” indicated, Resident 24 needed to be suctioned twice daily. 2j. During a review of Resident 41’s “Face sheet”, undated, the “Face sheet” indicated, Resident 41 was admitted to the facility on [DATE], with the diagnosis of Respiratory Failure. During a review of Resident 41’s “Orders”, dated January 16, 2017, the “Orders” indicated, Resident 41 needed to be evaluated for suction at least every two hours and as needed. During an observation on August 24, 2025, from 10:00 AM through 11:00 AM, Resident’s 83, 82, 63, 77, 52, 68, 22, 60, 24, and 41 was observed to have suction tube (a medical tube that connect to a machine to get rid of patient’s fluid) with no labels connected to suction canister (a container used to store body fluids, such as mucus, blood, secretions using a negative pressure suction) by their bedside. During a concurrent observation and interview on August 24, 2025, at 11:15 AM, with Respiratory Therapist (RT1), the suction tubings with no labels were observed. RT1 acknowledged and confirmed that the suction tubings did not have labels. RT1 stated suction tubings were a shared responsibility between respiratory therapists and nursing staff. RT1 further stated, the section tube should be labeled with date and initials so that staff would know when the tubing must be changed. During a concurrent observation and interview on August 24, 2025, at 11:20 AM, with the IP, the suction tubing with no labels were observed. The IP confirmed that the suction tubing was missing labels. The IP stated staff were expected to place a label with date and initials according to the policy. The IP further stated, it is a concern for infection control as staff would not know when the suction tubing was placed and needed to be changed. During a concurrent interview and record review on August 27, 2025, at 2:55 PM, with the IP nurse, the facility’s P&P titled, “disposable equipment change associated with artificial airway and mechanical ventilators”, dated March 2023, was reviewed. The P&P indicated, “… purpose: to define the frequency at which disposable supplies associated with mechanical ventilation are changed… Procedures: all disposable equipment used in the provision of care to the patient with an artificial airway, including mechanical ventilation and aerosol therapy, is changed according to the frequency identified for each respective device. The Inline suction catheter is changed every 24 hours and as needed.1.4.2 a sticker, indicating the day the unit is to be changed”. The IP stated the policy was not followed. 3a. During an observation on August 26, 2025, at 8:03 AM, in Resident 83’s room, LVN 1 was observed to administer medication to Resident 83 through G tube by wearing gloves. During an interview on August 27, 2025, at 8:40 AM, with LVN 2, LVN 2 stated that it was not necessary to wear gown while passing medications. LVN 2 further stated, some staff preferred to use gown while passing medications to prevent spilling off medications to their scrub. During an interview on August 27, 2025, at 8:48 AM, with Registered Nurse 1 (RN 1), RN 1 stated, staff were expected to wear gown and gloves while passing medications. RN 1 further stated, staff were expected to follow enhanced barrier precautions during the care provided for residents to prevent infections. 3b. A review of Resident 33’s “Record of Admission”, indicated, Resident 33 was admitted to the facility on [DATE]. A review of Resident 33’s “History and Physical (H&P - Contains medical history, diagnoses and assessments), dated April 28, 2025, indicated, Resident 33 has medical history of tracheostomy dependent, gastrostomy dependent, cerebral palsy, and epilepsy (seizures or a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness). During a medication administration observation on August 26, 2025, at 8:15 AM, with LVN 6, LVN 6 did not wear a gown despite having to give medication to Resident 33, through G-tube 3c. A review of Resident’s 43 “Record of admission” indicated, Resident 43 was admitted to the facility on [DATE]. A review of Resident 43’s H&P, dated February 11, 2025, indicated Resident 43 has medical history of Tracheostomy dependent, G-tube dependent, cerebral palsy, epilepsy and shaken baby syndrome (a serious brain injury caused by violently shaking an infant leading to bleeding, swelling or even death.) During a medical administration observation on August 27, 2025, at 8:15 AM, with LVN 7, LVN 7 did not wear a gown despite having to give medications to Resident 43 through G-tube. During an interview on August 27, 2025, at 8:18 AM, with LVN 7, LVN 7 stated, Resident 43 was not on any type of precautions such as droplet (keeping germs from spreading though cough sneezes or talking by using a mask, gown, gloves, and proper hand hygiene), contact precautions ( keeping germs from spreading through touch by wearing a gown, gloves, and proper hand hygiene), or enhanced barrier precautions. LVN 7 stated that she was not wearing an isolation gown because she did not have a chance to grab it prior to administering medication. LVN 7 stated she puts on a gown when administering medications because of personal preference but indicated that the staff did not have to gown up unless they are on contact, droplet, or EBP precautions. 3d. During a review of Resident 18’s “Record of Admission”, undated, the “Record of Admission” indicated, Resident 18 was admitted to the facility on [DATE]. During a review of Resident 18’s H&P, dated July 10, 2025, the H&P indicated Resident 18 was admitted to the facility with diagnoses which included chronic respiratory failure with hypoxia (a long-term condition where the lungs and respiratory system cannot get enough oxygen into the blood, resulting in dangerously low blood oxygen levels (hypoxemia) over time), and anoxic brain injury (a condition where the brain does not receive enough oxygen for an extended period, leading to damage or death of brain cells). During an observation on August 26, 2025, at 8:51 AM, with LVN 5, LVN 5 was preparing to administer medications to Resident 18 who was lying in his bed. Resident 18 had a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an artificial airway) and a gastric feeding tube (a thin, flexible tube inserted into the stomach through the abdominal wall to provide nutrition when a person cannot eat adequately by mouth). Without wearing a PPE gown (protective garment worn in healthcare which provide a physical barrier that covers the torso and arms, helping to prevent the transmission of microorganisms by acting as a barrier between healthcare workers and patients), LVN 5 accessed Resident 18’s gastric feeding tube with a 60 cubic centimeter (cc – unit of measure) syringe, checked gastric residual (volume of stomach contents), and verified correct placement (ensured the feeding tube was positioned in the stomach). LVN 5, while still not wearing a PPE gown, then administered 10 medications to Resident 18 through the residents gastric feeding tube. During an interview on August 26, 2025, at 2:38 PM, with LVN 5, LVN 5 stated when she administered medications to Resident 18, she did not have on a gown because a gown was optional and not required since Resident 18 was not in an isolation room (a room designated specifically with transmission based isolation precautions) because Resident 18’s room did not have an isolation sign posted outside the doorway and therefore it was not a requirement to wear a gown during patient care activities. During an interview on August 27, 2025, at 2:05 PM, with the IP, the IP stated all three of the skilled nursing facility units required EBP during high contact care activities. The IP further stated all residents in the skilled nursing facility were under EBP because they all either had a tracheostomy, required mechanical ventilation (the use of a machine that helps you to breathe or breathes for you), or had gastric feeding tubes and staff were supposed to wear a gown and gloves during the “six moments of care” which included: morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave a room, and cleaning and disinfecting the environment. During an interview on August 27, 2025, at 2:14 PM, with the DON, the DON stated staff were supposed to be following EBP and wear a gown and gloves when administering medications to residents who had a feeding tube. During a review of the facility’s P&P titled, “Enhanced Barrier Precautions,” dated March 2025, the P&P indicated, “The purpose of Enhanced Barrier Precautions (EBP) is to reduce the spread of multidrug-resistant organisms (MDROs) in the nursing homes…EBP Guidelines…1.5 EBP are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized…Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident activities include: -Dressing – Bathing/showering – Transferring – Providing hygiene – Changing linens – Changing briefs or assisting with toileting – Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator – Wound care: any skin opening requiring a dressing…Indwelling medical Devices: include, but are not limited to, central vascular lines (including hemodialysis catheters), indwelling urinary catheters, feeding tubes, and tracheostomy tubes…” 4. During a review of Resident 16’s “Record of Admission”, undated, the “Record of Admission” indicated Resident 16 was admitted on [DATE]. During a review of Resident 16’s H&P, dated May 17, 2025, the H&P indicated Resident 16 was in a vegetative state (a condition in which a person is awake but unaware of their surroundings or themselves) and had diagnoses which included chronic respiratory failure with hypoxia, and anoxic encephalopathy (a condition where the brain experiences a deprivation of oxygen which leads to widespread damage to brain cells), and was status post (previously had surgery for) tracheostomy and gastric feeding tube. During an observation on August 26, 2025, at 2:45 PM, in Resident 16’s room, Certified Nursing Assistant 2 (CNA 2) was returning from the shower with Resident 16. Resident 16 was dripping water, had towels draped over him and was lying in a shower bed (a mobile, water-resistant bed/gurney used to wash people with limited mobility) and had a tracheostomy and a feeding tube. CNA 2 stated the facility’s staff had just showered Resident 16 and were going to transfer him back to bed. CNA 2 was wearing a gown which was tied in the back, the head loop was around her neck, but the arm sleeves were not used and were instead tucked into the front of the gown similarly to how one would wear an apron. CNA 2 then transferred Resident 16 from shower bed to his regular bed while wearing her gown without the use of the sleeves. During an observation on August 26, 2025, at 3:03 PM, with CNA 2, CNA 2 retrieved linen from a linen cart which was outside Resident 16’s room. CNA 2 was still wearing her PPE gown like an apron and was not using the sleeves of the gown. During a concurrent observation and interview on August 26, 2025, at 3:07 PM, with CNA 2, CNA 2 was still wearing her PPE gown like an apron and stated she had just transferred Resident 16 to bed and changed his linens. When asked why she was wearing a PPE gown like an apron without the use of the arm sleeves, CNA 2 stated it was because she often would get too hot when she used the arm sleeves of the gowns so she would not use the sleeves, so she stays cooler. During an interview on August 27, 2025, at 2:05 PM, with the IP, the IP stated EBP were supposed to be used during the “6 moments of care” which included morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave a room, and cleaning and disinfecting the environment. The IP further stated as a part of EBP, staff were supposed to wear a gown and gloves when performing any of the “6 moments of care.” During a follow-up interview on August 27, 2025, at 2:08 PM, with IP, the IP stated, all residents in skilled nursing facility were required to be on EBP since all residents either had a tracheostomy, or a feeding tube. During a follow up interview on August 27, 2025, at 2:12 PM, with the IP, the IP stated, it was not appropriate for any staff member to wear a PPE gown without putting their arms in the sleeves. The IP further stated it was important to wear PPE appropriately to help prevent the spread of infection. During a review of the facility’s P&P titled, “Enhanced Barrier Precautions,” dated March 2025, the P&P indicated, “…1.7 EBP will be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility…Definitions…Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes… High-contact resident activities include: -Dressing – Bathing/showering – Transferring – Providing hygiene – Changing linens – Changing briefs or assisting with toileting – Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator – Wound care: any skin opening requiring a dressing…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's right were followed for one of four sample residents (Resident 81), when Resident 81 was placed on a left soft wrist restraint (device to prevent excessive movement of a body part to which they are attached) without an Informed Consent. This failure resulted in Resident 81 and Resident 81's Representative not being fully informed about the care and treatment provided. Findings: During a review of Resident 81's clinical record, the Record of Admission (contains demographic and medical information), indicated Resident 81 was admitted to the facility on [DATE]. A review of the Resident 81's History and Physical (H&P-contains information of health issues), dated July 28, 2024, indicated, admission diagnoses which include Cerebral Palsy (disorder that permanently affect a person's movement and muscle coordination), Tracheostomy status (an opening through the neck into the windpipe to allow air to fill the lungs and help a person breathe), and Gastrostomy status (a tube inserted through the abdomen to deliver fluids, nutrition, and medications directly to the stomach). During an observation on August 12, 2024, at 3:22 PM, in Resident 81's room, Resident 81 was resting in a bed with a soft wrist restraint on his left wrist, tied to the bed. During a concurrent interview and record review on August 15, 2024, at 2:18 PM, with the Neuro Care Unit Manager (NM), Resident 81's Order Summary Report, dated July 5, 2024, was reviewed. The Order Summary Report indicated, Left wrist restraint to prevent pulling at lines, tubes, and dressings. The NM acknowledged and stated there should have been a consent for the soft wrist restraint but could not find one. During a concurrent interview and record review on August 16, 2024, at 9:16 AM, with the NM, the facility's Policy and Procedure (P&P) titled, Restraints, Physical Guidelines for Use and Assessment, dated September 2001, was reviewed. The P&P indicated, .Complete the consent for use of the ordered physical restraint .the physician will discuss with the resident/representative the risk for injury based on individual resident factors and the potential risks and benefits of all options under consideration including using or not using a restraint. Additionally, the resident/representative will be informed of the right to refuse or revoke consent for the use of restraint. The physician will obtain informed consent from the resident/representative. The NM stated the policy was not followed and further stated the physician should have obtained informed consent prior to the application of the soft wrist restraint because it is our policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the enteral nutrition (liquid nutrition administered via feeding tube) was administered as ordered for one of 88 residents (Resident 60) when the feeding pump (a device used to deliver food to patient via feeding tube) was not stopped as ordered for Resident 60, causing Resident 60 to receive excessive feeding. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise the health of Resident 60. Findings: During a review of Resident 60's clinical record, the Record of Admission (contains demographic and medical information), the Record of Admission indicated, Resident 60 was admitted to the facility on [DATE]. A review of Resident 60's History and Physical (H&P-contain diagnoses information), dated November 26, 2023, indicated, the resident was admitted with diagnoses which included Gastrostomy status (a tube inserted through the abdomen that delivers nutrition and hydration directly to the stomach), Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), and Tracheostomy (an opening in the neck and into the windpipe to help someone breathe). During a review of Resident 60's Order Summary Report, dated August 7, 2024, the Order Summary Report indicated, The resident is to receive [Name of tube feeding] at 52 ml (milliliter- a unit of measurement) per hour or until 1040ml/1560 kcal (kilocalorie - the amount of energy in food) is infused via pump daily; feeding to start at noon (12:00 PM). During a concurrent observation and interview on [DATE], at 10:01 AM, with Licensed Vocational Nurse (LVN 4), in Resident 60's room, Resident 60 was resting in bed with the feeding pump infusing [Name of tube feeding] at a rate of 52 ml per hour. The total amount infused noted on the pump screen indicated 1512ml. LVN 4 confirmed and stated the feeding pump should not be running at this time and should have been stopped when the 1040ml (an excess of 472ml) infusion was completed, per the physician order. During a concurrent interview and record review on August 15, 2024, at 9:33 AM, with the Neuro Care Unit Manager (NM), the facility's Policy and Procedure (P&P) titled Closed System Ready-to-hang Containers of formula Procedure for dated April 1994, was reviewed. The P&P indicated, .to accurately administer the amount of formula ordered by the physician . The NM acknowledged and stated the policy was not followed. The NM further stated it is important to follow the policy because the amount of feeding ordered is calculated by the nutritionist based on the calorie needs for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure secure storage of medications for one of 15 medication carts (a mobile cart used by licensed nurses to store and transport medication to resident rooms) when Medication Cart #1 was left unlocked and unattended by a licensed nurse in North wing. This failure had the potential to cause unsafe access from unauthorized personnel to medications which could potentially cause harms and injuries from misuse of medication. Findings: During an observation on August 15, 2024, at 5:33 AM, Licensed Vocation Nurse (LVN 6) was observed utilizing Medication Cart #1 prior to entering inside room [ROOM NUMBER] and closed the door without locking the cart. Medication Cart #1 was parked in the hallway, by room [ROOM NUMBER] in the North wing, and was left unlocked and unattended by LVN 6. During an interview on August 15, 2024, at 5:40 AM, LVN 6 acknowledged and stated she did not lock the medication cart and should have locked it after she removed the medication. LVN 6 further stated it is important to lock the medication cart to keep the medication safe and to follow facility's policy. During a concurrent interview and record review on August 15, 2024, at 9:22 AM, with the NeuroCare Unit Manager (NM), the facility's Policy and Procedure (P&P) titled Safe Storage of Medication dated June 1974, was reviewed. The P&P indicated, .Medication carts and treatment carts containing medications must be locked unless under the direct supervision of the nurse or other licensed/registered personnel . The NM stated the policy was not followed and the nurse should have locked the medication cart before entering the room. The NCUM further stated it is important to keep all medications locked to make sure the medications are kept safe and only licensed and authorized personnel have access to the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 85's H&P, indicated, Resident 85 was admitted on [DATE], with diagnoses which included respiratory failure with tracheostomy, cerebellar hemorrhage, hypertension, and diabetes mellitus. A review of Resident 85's Order Sheet, dated August 14, 2024, indicated, resident was ordered to be on droplet isolation for ESBL. During a review of Resident 57's H&P, H&P indicated, Resident 57 was admitted to the facility on [DATE], with diagnoses which included anoxic encephalopathy (when your brain loses oxygen supply), cardiac arrest (when the heart suddenly and unexpectedly stops pumping), seizure (a sudden, uncontrolled burst of electrical activity in the brain), chronic hypoxemic respiratory failure and diabetes (a chronic disease that affects how your body turns food into energy). There was no indication that Resident 57 was on any transmission-based precautions. During a concurrent observation and interview on August 16,2024, at 8:15 AM, with the Infection Preventionist (IP) in Resident 85 and 57's shared room, a droplet precaution sign was on the wall outside the room. Residents 85 and 57 were lying in bed with the ceiling suspended curtains, between the two residents, drawn open. The IP stated Resident 57 is not on isolation but Resident 85 was on droplet precautions. During a concurrent interview and record review on August 16, 2024, at 9:17 AM, with the IP, the federal regulations for droplet precautions was reviewed. The federal regulations for droplet precautions indicated, .If it becomes necessary for a resident who requires droplet precaution to share a room with resident who does not have the same infection, the facility should make decisions regarding resident placement on a case-by-case basis after considering infection risks to other resident in the room and available alternatives. Spatial separation and drawing curtain between resident bed is especially important in multi-bedrooms with infections transmitted by the droplet route . The IP acknowledged and stated the federal regulation for droplet precautions were not followed. During a subsequent concurrent interview and record review on August 16, 2024, at 9:20 AM, with the Neuro Care Unit Manager (NM), the federal regulations and the CDC guidelines for droplet precautions were reviewed. The CDC guidelines for droplet precautions indicated, .Spatial separation of greater than or equal to 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bedrooms with infections transmitted by the droplet route . The NM acknowledged the federal regulations, and the CDC guidelines were not followed and further stated that those were important to follow for the protection of the other residents from being exposed. Based on observation, interview, and record review, the facility failed to maintain infection control practices for four (4) of seven (7) sampled residents (Resident 51, Resident 69, Resident 57, and Resident 85) when: 1. Resident 51, who was not on transmission-based precaution (methods that are used to help stop the spread of germs from person to another), was observed less than three (3) feet (unit of measurement) apart from Resident 69 who was on transmission-based precautions. 2. The visitor of Resident 85, who was on droplet isolation (an infection control practice uses to prevent the spread of infection that are transmitted through respiratory droplets), was not educated about the proper use of Personal Protective Equipment (PPE-such as mask, gown and gloves worn to minimize exposure to illnesses) and was seen walking out of the isolation room without taking off the PPE. 3. Resident 57, who was not on transmission-based precautions was observed in the same room with Resident 85, who was on transmission-based precautions, with the ceiling suspended curtains drawn opened between the residents. These failures had the potential to put all residents, visitors, and staff at risk to be exposed to a contagious disease (illness caused by spread of germs) that could compromise residents' health and may lead to actual harm from preventable diseases. Findings: 1. A review of Resident 69's History and Physical (H&P-contains the overall condition of the resident), indicated, Resident 69 was admitted to the facility on [DATE], with diagnoses which included respiratory failure encephalopathy (a condition when lungs cannot get enough oxygen into the blood which cause disturbance of brain function) with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), and subarachnoid hemorrhage (bleeding in the brain and surrounding tissues) from ruptured aneurysm (when a weakened area in a blood vessel wall burst, leading to bleeding). A review of Resident 69's Order Sheet, dated August 19, 2024, indicated, Resident 69 was ordered to be on droplet and contact isolation (a type of transmission-based precaution that is used to prevent the spread of diseases that can be transmitted through direct or indirect contact with an infected person or contaminated surfaces) for Extended-Spectrum Beta-Lactamase (ESBL-a type of infection that is difficult to be treated). A review of Resident 51's H&P, indicated, Resident 51 was admitted on [DATE], with diagnoses which included chronic respiratory failure (long term condition when lungs can't get enough oxygen into the blood) with tracheostomy, and diabetes (disorder characterized by high blood sugar). There was no indication that Resident 51 was on any transmission-based precaution. During a concurrent observation and interview on August 12, 2024, at 10:15 AM, with License Vocational Nurse 1 (LVN1), Resident 51 and Resident 69 were observed in room [ROOM NUMBER]. room [ROOM NUMBER]'s door was open, with a sign taped to it, which stated, stop and report to nurse's station before entering room. The back of the sign stated, Droplet and Contact Precaution Isolation, and indicated that an isolation mask, gown, and gloves were the required PPE that needed to be worn by any person when entering the room. Resident 51 was seen on a geriatric chair (a specialized recliner-like chair designed to provide comfort and support for elderly or disabled individuals who may have limited mobility) and Resident 69, who was seen in his bed. There was no cubicle curtain drawn between Resident 51 and Resident 69. LVN 1 stated that Resident 51 and Resident 69 should be kept at least three (3) feet apart. LVN 1 verified and confirmed Resident 51 and Resident 69 were separated only one and a half (1.5) feet apart. During a concurrent interview, on August 12, 2024, at 10:25 AM, with the Infection Preventionist (IP) and LVN 1, IP stated that the facility's policy and procedure (P&P) indicated, it is feasible, residents with and without transmission-based precaution can be in the same room. IP further explained Resident 51, who was not on transmission-based precaution, could share room with Resident 69, who was on droplet and contact isolation, but they must be at least three (3) feet apart. LVN 1 confirmed and stated, Resident 51 and Resident 69 were seen only 1.5 feet apart. IP responded by saying, Since they are not 3 feet apart, they are not following the policy. A review of facility's P&P titled, Transmission-based precaution, dated May 1997, indicated, . 2.2.1 If a private room is not available and cohorting [divide people into groups] with a like illness is not feasible, the patient shall be separated at all times by at least three feet from other patient .3.2.2 Ensure that patients are physically separated from each other by at least 3 feet. Draw the cubicle curtain closed between beds to minimize opportunity for direct contact . 2. A review of Resident 85's H&P, indicated, Resident 85 was admitted on [DATE], with diagnoses which included respiratory failure (ability to maintain adequate gas exchange in the lung) with tracheostomy, cerebellar hemorrhage (bleeding in the small space in brain), hypertension (high blood pressure), and diabetes mellitus. A review of Resident 85's Order Sheet, dated August 14, 2024, indicated, resident was ordered to be on droplet isolation for ESBL. During a concurrent observation and interview on August 15, 2024, at 1:52 PM, Resident 85 was observed in room [ROOM NUMBER]. room [ROOM NUMBER]'s door was open, with a sign taped to it, which stated, stop and report to nurse's station before entering room. The back of the sign stated, Droplet Precaution Isolation, and indicated that an isolation mask, gown, and gloves were the required PPE that needed to be worn by any person when entering the room. One visitor was seen inside the room, with PPE on. The visitor was observed walking out of the room wearing PPE. The visitor stated he visited Resident 85 and had never been informed by staff that he needed to remove the PPE before leaving the room. During an interview on August 15, 2024, at 1:57 PM, with LVN 2, LVN 2 stated she has not educated Resident 85's visitor to remove PPE before leaving isolation room. During an interview on [NAME] 15, 2024, at 2:09 PM, with Registered Nurse 1 (RN 1), RN 1 stated that she educated family members to wear PPE when entering isolation room but did not educate the family members to remove the PPE before leaving the room. RN 1 further stated, according to the facility's P&P, the family members should remove PPE before leaving the isolation room. During an interview on August 15, 2024, at 2:14 PM, with the Director of Nursing (DON), the DON stated, per policy, staff and resident's family should wear PPE when entering isolation room and should remove PPE when leaving the isolation room. A review of facility policy and procedure (P&P) titled, Transmission-based precaution, dated May 1997, indicated, .The gown will be removed before leaving the room and discarded into the regular trash unless it heavily soiled with blood, body fluids, or other potentially infectious materials .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Centers for Disease Control and Prevention (CDC-a service organization that protects the public's health's) guideline was followed appropriately for two (2) of four sampled residents (Resident 57 and Resident 85) when the Infection Preventionist (IP) did not assess, monitor, and manage the transmission-based precaution (methods that are used to help stop the spread of germs from person to another) appropriately. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to all residents and staff in the facility. Findings: During a review of Resident 85's History and Physical (H&P-contain diagnoses information), indicated, Resident 85 was admitted on [DATE], with diagnoses which included respiratory failure (a condition when lungs cannot get enough oxygen into the blood) with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), cerebellar hemorrhage (bleeding in the small space in the brain), hypertension (high blood pressure), and diabetes mellitus (characterized by high blood sugar). A review of Resident 85's Order Sheet, dated August 14, 2024, indicated, resident was ordered to be on droplet isolation (an infection control practice used to prevent the spread of infection that are transmitted through respiratory droplets), for Extended-Spectrum Beta-Lactamase (ESBL-a type of infection that is difficult to be treated). During a review of Resident 57's H&P, H&P indicated, Resident 57 was admitted to the facility on [DATE], with diagnosis which included anoxic encephalopathy (when the brain loses oxygen supply), cardiac arrest (when the heart suddenly and unexpectedly stops pumping), seizure (a sudden, uncontrolled burst of electrical activity in the brain), chronic hypoxemic respiratory failure (prolong lack of oxygen in the blood)and diabetes (a chronic disease that affects how your body turns food into energy). There was no indication that Resident 57 was on any transmission-based precaution. During a concurrent observation and interview on August 16,2024, at 8:15 AM, with the Infection Preventionist (IP), in Resident 85 and 57's shared room, a droplet precaution sign was on the wall outside the room. Residents 85 and 57 were lying in bed with the ceiling suspended; curtain between the two residents, were drawn open. The IP confirmed and stated Resident 57 is not on isolation (needs to be separated from others), but Resident 85 was on droplet precautions. During a concurrent interview and record review on August 16, 2024, at 9:17 AM, with the IP, the facility's policy and procedure (P&P) titled, Transmission-Based Precautions, dated May 1997, and the federal regulations for cohorting [placing together] isolation and non-isolated patients regarding droplet precautions, were reviewed. The P&P indicated, .If a private room is not available and cohorting with a like illness is not feasible, the patient shall be separated at all times by at least three feet from other patients . The federal regulations for cohorting isolation and non-isolated patients regarding droplet precautions indicated, .if it becomes necessary for a resident who requires droplet precaution to share a room with resident who does not have the same infection, the facility should make decisions regarding resident placement on a case-by-case basis after considering infection risks to other resident in the room and available alternatives. Spatial separation and drawing curtain between resident bed is especially important for residents in multi-bedrooms with infections transmitted by the droplet route . The IP acknowledged and stated the facility's policy was missing the drawing of the curtain between resident beds and further stated it should have been in their policy. The IP further stated, she did not know the curtains should be pulled forward when cohorting with a droplet precaution resident. During a concurrent interview and record review on August 16, 2024, at 9:19 AM, with the Neuro Care Unit Manager (NM), the facility's P&P titled, Transmission-Based Precautions, dated May 1997, was reviewed. The P&P indicated, .If a private room is not available and cohorting with a like illness is not feasible, the patient shall be separated at all times by at least three feet from other patients . During a follow-up interview and record review on August 16, 2024, at 9:20 AM, with the NM, the federal regulations and the CDC guidelines for droplet precautions, were reviewed. The CDC guidelines for droplet precautions indicated, .Spatial separation of greater than or equal to 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bedrooms with infections transmitted by the droplet route . The NM acknowledged the federal regulations and the CDC guidelines for the drawing of the curtains for droplet precautions were not accurately reflected in the facility's policy. The NM stated it is important for the policy to reflect the standard of practices for the protection of residents from being exposed to infections. During a review of the facility's job description titled, Infection Preventionist, dated November 30, 2021, indicated, .responsibilities, Job details 1.1 Responsible for assisting the department to ensure compliance program in sub-acute services, State and CMS regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to complete a restraint monitoring assessment for one of three sample residents (Resident 79). This failure had the potential to result in skin breakdown and physical harm to Resident 79. Findings: During an observation on June 5, 2023, at 9:40 AM, in Resident 79's room, Resident 79 was lying on his back with eyes closed. Gastrostomy (a surgical opening through the stomach) feeding was running and Resident 79 was positioned by pillows and side rails of the bed were padded. Resident 79 was observed to have a white colored mitten restraint (soft, padded protection worn by the patient on one or both hands) on his left hand, and the right hand has contractures (shortening and hardening of muscles, tendons, or other tissue). A review of Resident 79's face sheet (patient demographics) indicated that Resident 79 was admitted to the facility on [DATE], with the diagnosis that indicated hypoxemic respiratory failure (inadequate oxygen in blood). During an interview on June 7, 2023, at 12:31 PM, with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated, the mitten restraint was ordered since April 28, 2023. LVN 6 further stated that the restraints should be evaluated and documented every two hours. During a concurrent interview and record review on June 7, 2023, at 1:29 PM, with Registered Nurse 2 (RN 2), RN 2 stated, restraints should be evaluated every two hours and should be documented in Resident 79's electronic documentation under the section of Restraint Monitoring Non-Violent. RN 2 acknowledged there was no documentation found that staff completed visual observation, skin, circulation, range of motion on June 6th, 2023, from 07:00 AM through 6:00 PM (11 hours). During a review of Resident 79's Active Order Profile Record, dated April 28, 2023, the doctor's order indicated, Pulling at lines, tubes or dressings, Restraints: Mitten to left hand, q2 (every two) hr (hour). Monitor for episodes of pulling out for medical tubing and dressings as well as checking skin integrity during release of restraints q2 hrs. During a record review of the Resident 79's care plan, dated April 28, 2023, the care plan indicated visual checks at least every 2 hours, release and re-position at least every 2 hours. During a concurrent review of the facility's policy and procedure (P&P) titled, Restraints, Physical Guidelines for use and Assessment the P&P indicated, .10. the staff member will apply the restraint in such a manner as not to cause discomfort or harm to the resident. All restraints will be released for repositioning, checked for application, circulation, and pressure a minimum of every two hours. The release and restraint checks will be documented on the designated nursing record or restraint flowsheet.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 32) received assessment and monitoring of pressure ulcers when Resident 32 was found to have a Deep Tissue Injury (DTI - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying tissue from pressure and/or shear) on the right heel but the facility had no documentation of the DTI indicated in Resident 32's skin assessments. This failure had the potential for a delay in the identification and subsequent treatment for Resident 32's DTI. Findings: During an observation on June 7, 2023, at 7:09 AM, in Resident 32's room, Resident 32 was lying in bed on her back, with her eyes open. Resident 32 was non-verbal, the head of the bed was elevated to a 45-degree angle, a tracheostomy it was connected to a ventilator (a surgical incision in the windpipe which, is connected to a machine that helps the person to breathe). Resident 32 had a percutaneous endoscopic gastrotomy (PEG placement of a feeding tube through the skin and the stomach wall) which was connected to a feeding pump (a pump that moves a fluid such as a fuel at a controlled rate). Resident 32 need total assistance from staff with frequent repositioning while on bed. Resident 32 had an indwelling catheter (a rubber tube that is inserted into the bladder to drain the urine). A posted sign on the wall by her bed indicated Resident 32 need to be repositioned every 2 hours. During a review of Resident 32's clinical record, the document titled Order summary Dated May 30, 2023, at 5:33 PM, indicated, . Left Heel Pressure Injury Deep Tissue Injury (PI DTI): Cleanse with wound cleanser, pat dry . During a concurrent interview and record review with the Wound Treatment Nurse 1, (WTN 1) on June 7, 2023, at 8:21 AM, Resident 32's Order Summary for wound care, dated May 30, 2023, at 5:33 PM, indicated Resident 32 pressure deep tissue injury was entered in the clinical record as being on the left heel, the affected site was the right heel, not the left. WTN 1, stated the treatment was provided on the right heel, not on the left heel areas as it was documented in Resident 32's electronic chart. The WTN 1 acknowledged that it was an error in documentation and, information had been documented on the wrong side. During an interview with the Clinical Nurse Manager (CNM 1) on June 8, 2023, at 1:25 PM, CNM 1, stated that during her own internal investigation, she found out that the deep tissue injury on Resident's 32's right heel was found on May 30, 2023, while Certified Nurse Assistant 1 (CNA 1) was providing personal care to Resident 32. The CNM 1, stated CNA 1, noticed a maroon discoloration on the right heel and reported it, to the License Vocational Nurse 1 (LVN 1), then, LVN 1, reported it to the Registered Nurse 1(RN 1.) According to CNM 1, the registered nurse assigned to Resident 32 on May 30, 2023, who was RN 1, failed it to document the injury. During a review of Resident 32's clinical record, the document titled, Braden Score dated May 30, 2023, was reviewed. The document indicated Resident 32 was at high risk for developing a pressure ulcer with a Braden Assessment score of 10. (Braden Scale is used to identified of patients at risk for forming pressure sores less than 12=patient is high risk) During an interview with Registered Nurse 2 (RN 2) on June 8, 2023, at 3:24 PM, RN 2 stated that the RN 1, assigned to Resident 32 on May 30, 2023, failed to document a change of condition, further interview with RN 2, indicated that there was no documentation prior to the development of the right deep tissue injury (DTI) found in their computer system. During a record review of the clinical record for Resident 32, the documents titled Skin wounds Assessments was reviewed for the following dates and indicated: a. For May 29, 2023, no skin assessment of the right heel was found b. For May 28, 2023, no skin assessment of the right heel was found. c. For May 27, 2023, no skin assessment of the right heel was found. d. For May 26, 2023, no skin assessment of the right heel was found. e. For May 25, 2023, no skin assessment of the right heel was found. f. For May 24, 2023, no skin assessment of the right heel was found. g. For May 23, 2023, no skin assessment of the right heel was found. During a review of the clinical record for Resident 32, the document titled Wounds Assessments dated May 30, 2023, indicated Resident 32's, right heel deep pressure injury was discovered on May 30, 2023, at 5:39 PM. During a review of the facility's policy and procedure (P&P) title, Skin Care Prevention,Dated, February 11, 2003, the P&P indicated, 1. The licensed nurse will document the overall condition of the resident's skin every shift in the resident record, utilizing the shift physical assessment or narrative notes. During a review of the facility's P&P titled, Change in Resident Condition / Notification of Changes indicated d. All nursing actions will be documented in the licensed progress notes as soon as possible, including assessment, notifications, actions taken and resident's response. 6. Document resident change of condition and response in Nursing Progress notes, on 24-Hour Report and update resident care plan as indicated .''

Based on observation, interview, and record review, the facility failed to ensure a urinary catheter (a flexible tube used to empty bladder and collect urine in a drainage bag) was changed according to the physician's order for one of two sampled residents (Resident 33). This failure had the potential to cause a urinary infection to Resident 33 whose health condition was already compromised. Findings: During an observation on June 7, 2023, at 12:10 PM, inside Resident 33's room, Resident 33 was observed lying in bed with an indwelling urinary catheter draining amber colored urine. During an interview on June 8, 2023, at 10:40 AM, with the Clinical Nurse Manager 1(CNM 1), CNM 1 stated the catheter was not changed for the month of May 2023, as system did not trigger it. The CNM 1 further stated the indwelling urinary catheter was eventually changed on June 7, 2023. During a concurrent interview and record review on June 7, 2023, at 1:36 PM, with the Registered Nurse 2 (RN 2), the RN 2 showed Resident 33's physician's order dated September 9, 2020, for an indwelling urinary catheter, which must be changed monthly and as required when, clogged, dislodged, or leaking. The RN 2 stated the last time indwelling urinary catheter was changed was on April 23, 2023. RN 2 confirmed that indwelling urinary catheter was not changed for the month of May 2023. During a review of the Active Order Profile (physician's order) for Resident 33, on June 7, 2023, at 12:30 PM, the physician's order indicated, Change Coude [type of urinary catheter that has a curved tip] 16 French [size] with 10 cc [cubic centimeter - unit of measure) water to use for balloon inflation every month and prn [if needed] for plugged, dislodge, or leaking. During a review of Resident 33's care plan (an individualized plan for the medical care of a resident) titled, Indwelling Urinary Catheter Care Plan dated May 12, 2021, the care plan indicated Resident 33 needed an indwelling urinary catheter for wound management of a pressure ulcer (bedsore) in left ischium (hip bone). The care plan further indicated, Urologist [ physician who specializes in diseases of the urinary tract] to change indwelling catheter may change PRN with 2 licensed nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change an intravenous (IV-administered into the vein) tubing for one of three sampled residents (Resident 338). This failure had the potential to result in serious infections and complications for Resident 338. Findings: During an observation on [DATE], at 9:00 AM, in Resident 338's room, the infusion (method of putting fluids, drugs into the blood stream) pole had multiple IV tubing connected to the Resident 338. One of the tubing indicated Change on [DATE]. The medication connected to that tubing was an antibiotic (medicine that inhibits the growth of or destroys microorganisms) Fetroja (cefiderocol) dated [DATE], at 05:00 AM. During an interview on [DATE], at 9:00 AM, with the Registered Nurse 4 (RN4), RN 4 stated, the time and date on the IV tubing did not match with the time and date on the antibiotic medication hung on the pole, which means that the tubing was expired. During a concurrent interview on [DATE], at 9:30 AM, with the Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated the date on the tubing was identified as the date in which the tubing should be changed, so the tubing was supposed to be changed on [DATE]. LVN 6 further stated the nurse hung the new antibiotic medication in an expired tubing. During a review of the resident's electronic Active Order Profile, dated [DATE], the doctor's order indicated, Fetroja (Cefiderocol) 2,000 mg [milligram - unit of measure], Misc [miscellaneous], IV, q8hrs [every eight hours], Indication: Bacteremia . During a review of Resident 79's electronic health record, the Medication Administration Record (MAR), dated [DATE], indicated that RN 3 administrated antibiotic Fetroja on [DATE], at 05:00 AM. During a review of the facility's policy and procedure (P&P) titled Intravenous (IV)infusion therapy, Vascular-Peripheral Access, Maintenance and Discontinuation, dated [DATE], the P&P indicated, Change intermittent (secondary)tubing every 24hours.

Based on observation, interview, and record review, the facility failed to ensure equipment was maintained in safe operating condition when: 1. One of four refrigerators observed, had condensation (water) dripping from the top of the refrigerator. 2. One of one freezer had ice forming on the floor and on the freezer fans. These failures had the potential for spoilage and/or contamination of the food stored inside the refrigerator and freezer which can cause foodborne illnesses to a population of three out of three medically compromised residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Director of Nutrition Service (DNS) on June 5, 2023, at 9:17 AM, One of the four refrigerators observed, had condensation dripping from the top of the refrigerator area. The DNS acknowledged the refrigerator was dripping and stated it needed to be repaired. During an observation and concurrent interview with the Nutrition Assistant 1 (NA 1) on June 7, 2023, at 5:20 AM, NA 1 acknowledged that one of the refrigerators was dripping water from the top area and wall, NA 1 stated that it will need to be repaired. During an interview on June 7, 2023, at 6:13 AM with the Supervisor Services (SS), SS acknowledged the refrigerator was dripping from the top and the wall, SS stated that it should be fixed immediately. During an interview with the Director of Facility 1 (DOF 1) on June 7, 2023, at 8:57 AM, DOF 1 acknowledged the refrigerator was dripping from the top and the wall and stated that it would need to be repaired. During an interview with the Director of Nutrition Services (DNS) on June 7, 2023, at 12:18 PM, DNS acknowledged that the refrigerator equipment was not working properly. DNS stated that the evaporator coil needed to be fixed and that it would be repaired. During a review of the facility's policy and procedure (P&P) titled, EC145: equipment inspection, Maintenance, Repairs and Documentation indicated 5. FNS leadership is responsible for educating staff on tagging and reporting equipment that is not functioning properly. FNS staff should know how to tag out equipment that is not properly functioning, remove equipment from service, and report information to get equipment fixed. 2. During an observation and concurrent interview with the Director Nutrition Services (DNS) on June 6, 2023, at 8:24 AM, one of one freezer was forming ice around the fans and on the floor. DNS stated she would have someone to check it. During an interview with Nutrition Assistant 1, (NA 1) on June 7, 2023, at 5:20 AM, the NA 1, acknowledged that the freezer was forming ice around the fans and on the floor. NA 1 stated that it would need to be repaired. During an interview with the Supervisor Services (SS) on June 7, 2023, at 6:13 AM, in the kitchen the SS acknowledged that the freezer was building up ice around the two-fans and on the floor. SS stated that it should be fixed immediately and that he would have engineering inspect it. During an interview with the Director of Facilities (DOF) on June 7, 2023, at 8:57 AM, DOF acknowledged the freezer had ice forming around the two fans and on the floor and stated that the freezer parts were ordered and will be replaced. During an interview with the DNS on June 7, 2023, at 12:20 PM, DNS stated that ice was forming in the freezer was because the equipment was not working properly but that it would be repaired. During a review of the facility's policy and procedure P&P titled, EC145: Equipment Inspection, Maintenance, Repairs and Documentation Frequency Monthly indicated 5. FNS leadership is responsible for educating staff on tagging and reporting equipment that is not functioning properly. FNS staff should know how to tag out equipment that is not properly functioning, remove equipment from service, and report information to get equipment fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of four residents (Resident 27, 52, and 62) sampled for enteral nutrition (a form of nutrition delivered to the digestive system in the form of a liquid usually through a feeding tube) received nutritional services as was prescribed by their doctor when: 1. The facility did not ensure staff labeled enteral nutrition bottles (bottles which contain the enteral nutrition) and water flush bags (bags filled with water administered with enteral nutrition) in accordance with their policy and procedure for Residents 27, and 52. This failure had the potential for either the enteral nutrition bottle, or the water flush bag and tubing set to exceed the manufacturer's prescribed hang-time (amount of time a feeding is safe to use after opened), and for Resident 27 and 52 to not receive the prescribed amount of nutritional calories resulting in weight loss. 2. The facility did not ensure the enteral (Nutrition delivered into the digestive system as a liquid) feeding tubing was changed within 24 hours for Resident 62 in accordance with the facility's policy and procedure (P&P) and manufacturer's guidelines. This failure resulted in Resident 62 to receive an enteral feeding via tubing that was expired (used against manufacturer's guidelines) which had the potential to result in contamination of the enteral nutrition. 3. The facility did not administer enteral feeding to Resident 52 and 62 as ordered by the physician. In addition, the clinical record intake volume (amount received) of enteral nutrition, inaccurately reflected the amount of feeding the residents 52 and 62 received. These failures resulted in Residents 52 and 62 to not receive the daily calories as was specified in the residents' physician orders and in accordance with their care plans (the individualized plan for the medical care of a resident). In addition, this failure resulted in the medical record for both Residents 52 and 62 to have incorrect information documented for the intake volume each resident received. Findings: 1a. During an observation on [DATE], at 10:23 AM, in Resident 27's room, Resident 27 had an enteral nutrition bottle and water flush bag which was connected to an infusion pump (a pump which administers the enteral feeding nutrition to the resident at a set rate). Neither the enteral nutrition bottle nor the water flush bag had the start time (time at which the enteral nutrition bottle was started) and the enteral nutrition bottle also did not have the nurses' initials. During a concurrent observation and interview, on [DATE], at 11:24 AM, with Licensed Vocational Nurse 2 (LVN 2), in Resident 27's room, LVN 2 stated documentation on the enteral nutrition bottle and water flush bag should include the residents name, room number, date and time, nurse's initials and flow rate. LVN 2 then observed the enteral nutrition bottle and water flush bag at Resident 27's bedside, which was connected to the infusion pump and stated the enteral nutrition bottle and the water flush bag were both missing the start time and the enteral nutrition bottle did not have the nurse's initials. LVN 2 further stated the enteral nutrition bottle and water flush bag were not labeled correctly by the nurse on the previous shift. During an interview on [DATE], at 7:19 AM, with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated documentation on the enteral nutrition bottle and water flush bag should include the residents name, date, time, and flow rate. LVN 3 further stated the importance of labeling the enteral nutrition bottle and water bag was to ensure you know what date and time it was started to ensure the feeding does not run longer than the bags were supposed to be hung for and that it was an indicator of when it (enteral nutrition bottle and water bags) needed to be changed. During a concurrent interview and record review, on [DATE], at 8:16 AM, with the Clinical Director 1 (CD 1), the facility's policy and procedure (P&P) titled, Administration of formula via Feeding tube, Gravity, Bolus, Pump, dated [DATE], was reviewed. The P&P indicated, .3.1.17 Pump bags, syringe, and tubing (open system) [water bags are connected to the tubing] are to be changed every 24 hours and properly labeled with date, time, and nurses initials. 3.1.18 The closed system requires a new spike set with each bottle so date is to be documented on bottle instead of tubing. Tubing to be changed every 48 hours. The CD 1 stated the enteral nutrition bottle and water flush bags were both supposed to be labeled with at a minimum the date, time, and nurse's initials per the facility's policy and procedure. During a review of the facility's P&P titled, Closed System Ready-to-Hang Containers of Formula, Procedure for, dated [DATE], the P&P indicated, Purpose: to accurately administer the amount of formula ordered by the physician .Policy: Ready-to-Hang formula will be used as part of the closed system enteral. Feeding Ready-to-Hang formula may hang for a maximum of 24 hours .Procedure. 4. Fill in information on container label (i.e., resident name, room, date, start time and rate). 5. Label feeding set with start time, date, and nurse's initials . 1b. During an observation on [DATE], at 3:41 PM, in Resident 52's room, Resident 52 had an enteral nutrition bottle and water flush bag which was connected to an infusion pump. The enteral nutrition bottle did not have the time indicated on it, had an incomplete date, 6/ /23 which was blank for the day, and had no nurse's initials. In addition, the water flush bag did not have a start time on it or nurse's initials. During a concurrent observation and interview on [DATE], at 3:46 PM, with Licensed Vocational Nurse 4 (LVN4), in Resident 52's room, LVN 4 stated documentation which was supposed to be included on the enteral nutrition bottles and water bags included the residents name, date, time, and flow rate. LVN 4 further stated she also includes the nurse initials on the water bag but stated she did not think initials were required on the enteral nutrition bottle. LVN 4 then observed the enteral nutrition bottle and water flush bag at Resident 52's bedside and stated the nurse who started the feeding did not include the start date, time or nurse initials. LVN 4 then observed the water flush bag and stated it did not have the start time or nurse initials indicated on it. During an interview on [DATE], at 9:55 AM, with the Clinical Nurse Manager 1 (CNM 1), the CNM 1 stated labeling on the enteral nutrition bottle should include the date, time, and nurse initials. The CNM 1 further stated the labeling on the water flush bag should include the flow rate, date, time, and nurse's initials. The CNM 1 further stated the importance of labeling with the date, and time was for infection control to ensure the enteral nutrition bottle and water bag tubing was not used for longer than the manufacturers recommendations and that they were supposed to be changed every 24 hours. During a review of the facility's P&P titled, Closed System Ready-to-Hang Containers of Formula, Procedure for, dated [DATE], the P&P indicated, Purpose: to accurately administer the amount of formula ordered by the physician . Policy: Ready-to-Hang formula will be used as part of the closed system enteral. Feeding Ready-to-Hang formula may hang for a maximum of 24 hours .procedure. 4. Fill in information on container label (i.e., resident name, room, date, start time and rate). 5. Label feeding set with start time, date, and nurse's initials . 2. During an observation on [DATE], at 10:10 AM, in Resident 62's room, Resident 62 was lying on his back with enteral feeding running at a rate of 35ml (milliliter - unit of measure)/hr (hour). The water flush bag (bags filled with water administered with enteral nutrition) had less than 100 ml of water. The feeding bottle and water flush bag was labeled with date and time as [DATE], at 2200 (10:00 PM) and initialed by the nurse. The feeding bottle contained 200 ml of enteral feeding formula. During a concurrent observation and interview on [DATE], at 10:20 AM, with the Licensed Vocational Nurse 5(LVN 5), in Resident 62's room, the LVN 5 verified, the label on the feeding bottle and the water flush bag was dated as [DATE]rd at 10:00 PM. The LVN 5 stated the tubing should have been changed after 24 hours. The LVN 5 further stated the enteral feeding for Resident 62 is administered for 20 hours according to the doctor's order to meet the calorie requirement and the intake amount. During an interview on [DATE], at 8:51 AM, with the Clinical Director 1 (CD1), the CD1 stated, the feeding tubing should be changed every 24 hours; the feeding bottle and the flush bag should have the date, time, patient information, feeding rate, and initial of the nurse who started the feeding. The CD1 acknowledged that the feeding tube was expired, and the feeding formula was administered to Resident 62 using the expired tubing. During an interview on [DATE], at 10:00 AM, with the Clinical Nurse Manager1 (CNM1), the CNM1 stated the enteral feeding bottle expires on 48 hours after it is opened but the tubing connected to the feeding should be changed every 24 hours. The CNM1 further stated the enteral formula and the water flush bag should be labeled with information which include date, time and initial of the nurse. The nurse's practice was to change both the enteral formula and the tubing together. A review of Resident 62's face sheet (patient demographics) indicated that Resident 62 was admitted on [DATE], with the diagnosis that indicated hypoxemic respiratory failure (inadequate oxygen in blood). During a record review of Resident 62's Active Order Profile (physician's order), dated [DATE], the order indicated tube feeding start date [DATE], type: renal [type of diet], route: PEG [Percutaneous endoscopic gastrostomy -a type of feeding tube], start feeding at noon daily. Give Nepro [feeding brand] @ [a] 35ml/hr [milliliter-unit of measure per hour] or until (700ml/1260kcal) [kilocalories - unit of measure] is infused via pump daily. During a review of the facility's policy and procedure (P&P) titled Administration Of Formula Via Feeding Tube, Gravity, Bolus, Pump, dated September ,2009 indicated, Pump bags, syringes and tubing (open system)are to be changed every 24 hours and properly labeled with date ,time, and nurse's initials. 3a. During a review of Resident 52's clinical record, the Record of Admission, (contains demographic and medical information), indicated Resident 52 was admitted on [DATE]. Review of Resident 52's Electronic Health Record (EHR) indicated the resident was admitted with diagnoses which included chronic respiratory failure, type 2 diabetes mellitus (disease in which the body's ability to regulate blood sugar is impacted), tracheostomy status (a surgically created hole in your windpipe that provides an alternative airway for breathing), and gastrostomy status (a tube inserted through the wall of the abdomen directly into the stomach which can be used to provide liquid enteral nutrition). During a review of Resident 52's care plan (an individualized plan for the medical care of a resident) titled, Enteral Feeding Care Plan, dated [DATE], the care plan indicated, Problems/Needs/Concerns .Altered route of feeding due to: Tracheostomy, dysphagia [difficulty swallowing], has feeding tube-GT [gastrostomy tube] At risk for: weight changes, dehydration .Approaches/Interventions .Provide tube feeding and water flush as ordered .Intake and output [amount of fluids the client ingests (intake) and the amount of fluids that leave the body (output)] every shift. During a review of Resident 52's physician's orders, an order dated [DATE] indicated, tube feedings .[brand name of enteral nutrition] 1.5, G tube [gastrostomy tube], give feeding via [by] G tube at 55 milliliters/hour [milliliters per hour - a specified amount of volume per hour] x [times] 20 hr [hours] until (1100ml/1650kcal) infused daily. During an observation on [DATE], at 7:29 AM, in Resident 52's room, Resident 52 had an enteral nutrition bottle and water flush bag which was connected to an infusion pump. The enteral nutrition bottle was dated [DATE], with a time of 1910 (7:10 PM) indicated. There was a flow rate of 55 ml/hr documented on it. The total volume of the enteral nutrition bottle was 1000ml when full and there was 825 mls left in the container. (175 mls were administered to the resident over a 12 hour period from [DATE], at 7:10 PM, until [DATE], at 7:29 AM) During a review of Resident 52's EHR, the tab titled, Iview/I&O/Graphs under intake and output indicated, GI [gastrointestinal] tubes .intake 55mls was documented for Resident 52's intake for all 12 hours between [DATE], at 7:00 PM, until [DATE], at 7:00 AM, which equaled 660 mls which should have been administered to the resident instead of 175 mls which was actually administered (resident received 485 milliliters less than what was documented in the clinical record). During a concurrent observation and interview on [DATE], at 3:27 PM, with Licensed Vocational Nurse 5 (LVN 5), in Resident 52's room, LVN 5 observed the enteral nutrition bottle and water flush bag at Resident 52's bedside and stated they were both dated [DATE], at 7:10 PM. LVN 5 further stated the resident was supposed to receive 1100 mls of enteral nutrition daily. During a concurrent interview and record review on [DATE], at 9:55 AM, with the Clinical Nurse Manager 1 (CNM 1), Resident 52's EHR was reviewed. The CNM 1 stated Resident 52 record included documentation which indicated Resident 52 received 55 mls/hr for 12 hours between [DATE], at 7:00 PM until [DATE], at 7:00 AM which would equal 660 mls of enteral nutrition that the resident should have received. CNM 1 then reviewed a picture that was taken of the enteral nutrition bottle that was at Resident 52's bedside on [DATE], at 7:29 AM; CNM 1 confirmed the bottle had 825 mls left in it. CNM 1 then stated the bottle should have only had 340 mls left in it since the documentation in the resident's intake and output indicated that the enteral nutrition ran for 12 hours at 55 mls/hr (485 ml discrepancy). The CNM 1 further stated she did not know why Resident 52 did not have the correct amount of enteral nutrition administered. The CNM 1 stated her expectation was that the residents receive enteral nutrition volume daily as ordered by the physician and documentation in the resident's clinical record was supposed to be accurate regarding intake volumes. The CNM 1 stated resident's who do not receive the entire volume of enteral nutrition as ordered by the physician can be at risk for weight loss. During an interview on [DATE], at 10:43 AM, with the CNM 1, the CNM 1 reviewed Resident 52's clinical record and stated there was no documentation or notes regarding why the enteral nutrition was not administered to Resident 52 or why the discrepancy existed. The CNM 1 further stated the nurse was supposed to document why the enteral nutrition was not administered and the intake and output in the resident's clinical record should have reflected that the enteral nutrition was not administered. During a review of the facility's P&P titled, Closed System Ready-to-Hang Containers of Formula, Procedure for, dated [DATE], the policy indicated, Purpose: To accurately administer the amount of formula ordered by the physician .Policy: Ready-to-Hang formula will be used as part of the closed system enteral. Feeding Ready-to-Hang formula may hang for a maximum of 24 hours .Recording: .2. Record amount [of enteral nutrition] given on intake and output record. During a review of the facility's P&P titled, Assessment and Care Planning, dated [DATE], the P&P indicated, Purpose: To identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet resident's individual needs and to assist the resident in reaching the highest level of independence possible .Policy: .Information will be used to develop a comprehensive resident care plan to allow the resident his/her highest practicable level of physical, mental and psychosocial functioning . During a review of the facility's P&P titled, Care Planning, dated [DATE], the policy indicated, Policy: .the facility will initiate a written care plan based on the resident assessment and on the individual needs of the resident .Procedure: .4. Identify the problems or needs. After information has been gathered, the data is analyzed to determine what problems and needs exist .b) A problem is a difficulty or concern experienced by the resident. c) The problems include currently existing difficulties as well as potential problems as identified by the minimum data set: .5) Nutritional status/requirements. During an interview on [DATE], at 8:50 AM, with the Clinical Director 1 (CD 1), the CD 1 stated the facility did not have a P&P regarding following physician's orders. 3b. During an observation on [DATE], at 10:10 AM, in Resident 62's room, Resident 62 was lying on his back with enteral feeding running at a rate of 35 ml/hr (milliliter per hour - unit of measure). The water flush bag (bags filled with water administered with enteral nutrition) had less than 100 ml of water. The feeding bottle and water flush bag was labeled with time and date as [DATE], at 2200 (10:00 PM) and initialed by the nurse. The feeding bottle contained has 200 ml of enteral feeding formula. During a concurrent observation and interview on [DATE], at 10:20 AM, with the Licensed Vocational Nurse 5 (LVN 5), in Resident 62's room, LVN 5 stated the enteral feeding for Resident 62 was supposed to be administered for 20 hours according to the doctor's order to meet the calorie requirement and the intake amount. However, thirty-six (36) hours after the enteral feeding was initially administered on [DATE] at 10:00 PM, the bottle was observed to have 200 ml remaining formula. A review of Resident 62's face sheet (patient demographics) indicated that Resident 62 was admitted on [DATE], with the diagnosis that indicated hypoxemic respiratory failure (inadequate oxygen in blood). During a record review of Resident 62's Active Order Profile (physician's order), dated [DATE], the order indicated Tube feeding start date [DATE], type: renal [type of diet], route: PEG [Percutaneous endoscopic gastrostomy - a type of feeding tube], start feeding at noon daily. Give Nepro [feeding brand] @ [at] 35ml/hr [milliliter-unit of measure per hour] or until (700ml/1260kcal) [kilocalories - unit of measure] is infused via pump daily. During a concurrent interview and record review on [DATE],at 10:00 AM with the Clinical Nurse Manager1(CNM1), the NM stated doctor's orders are followed as recommended. The NM acknowledged that the feeding was not delivered correctly, and the Resident 62 was missing adequate intake and calorie according to the doctor's order. The CNM1 further stated missed feeding could cause weight loss for the resident. During a review of the facility's P&P titled, Closed System Ready To Hung Container of Formula, dated [DATE], indicated Purpose To accurately administer the amount of formula ordered by the physician. Procedure .Replace feeding every 24 hours.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Two Steamtable pans (3.5-gallon containers) Full of fried beans and two steamtable pans (3.5-gallon containers) full of fried rice were found uncovered and unlabeled inside the refrigerator. 2. Beans which were cooling down, were not included on a cooling down log (a log used to ensure food is cooled to an appropriate temperature within a specified timeframe to prevent spoilage of food). 3. An opened box of three (3) pounds of turkey patties was found inside a refrigerator with no open date. 4. An opened box of approximately two (2) pounds of bacon was found inside a refrigerator with no open date. 5. Three (3) fifteen (15) pound boxes of bacon were found open and undated inside a refrigerator. 6. A 40-pound box of turkey breast was found inside a refrigerator with no open date. 7. Two (2) pounds of baby arugula (a leafy vegetable) with an expiration date of May 29, 2023, was found inside a refrigerator. The leaves of the vegetables were wilted. 8. A Three (3) Pound bag of diced celery was found inside the refrigerator and undated. 9. The kitchen's preparation table in the catering area was found to have crumbs on it and was dusty underneath. 10. The ice machine (a machine which creates ice) airgap drain (a type of drain designed to prevent backflow) was found to contain black and brown colored stains and was dusty. 11. The freezer was found to have spilled blueberries on the floor. These failures had the potential to contaminate food and cause foodborne illnesses to a population of three out of three medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on June 5, 2023, at 9:02 AM with the Director of Nutrition Services (DNS), in the facility's kitchen, there were 2 steamtable pans (3.5-gallon containers) full of fried beans and two steamtable pans (3.5-gallon containers) full of fried rice found uncovered and unlabeled inside the refrigerator. DNS stated the trays should be covered. During an interview with the DNS on June 7, 2023, at 12:02 PM, in her office, the DNS stated that the steamtable pans (3.5-gallon containers full of fried beans and two steamtable pans 3.5-gallon containers full of fried rice) were placed in the refrigerator by [NAME] 1, (CK 1) and that he neglected to cover it and log them in the cooling log. During a record review of the cooling log dated June 5, 2023, at 7:30 AM indicated that the white rice was placed inside the refrigerator at 7:30 AM, for the cooling process and was recorded on the cooling log. 2. During an observation and interview on June 5, 2023, at 9:02 AM, beans which were cooling down, were not included on the cooling down log. The DNS acknowledge that the beans were not recorded on the cooling log. According to the DNS after she spoke with the CK 1, she found out that the CK 1, neglected to log the beans in the cooling log. The DNS stated she expected the staff follow the cooling process as indicated in their policy. During a review of the facility's policy and procedure (P&P) titled, PCO39A Cooling Food Dated 2019, the P&P indicated, 3. Appropriate methods used for cooling include . C. Use plastic wrap or foil lay flat and slightly vented to cover to allow heat to escape .4. When food reach 41 degrees F [Fahrenheit] or less, cover the food, date and label, and document cooling procedure on log. 3. During an observation and concurrent interview with the DNS in the kitchen on June 5, 2023, at 9:05 AM, an opened box of three (3) pounds of turkey patties was found inside a refrigerator with no open date. The DNS stated the box of turkey patties should be dated when it was opened. During an interview with the DNS on June 7, 2023, at 12:04 PM in her office, the DNS stated the turkey patties should have been dated when it was opened and used within 3 days. During a review of the facility's P&P titled PCO19: Storage Expiration Dates. Dated, 2019, the P&P indicated, 4. Deli meats use within 4 days . Labels should be audited daily to ensure compliance . 4. During an observation and concurrent interview with the DNS in the kitchen on June 5, 2023, at 9:06 AM, an opened box of approximately two (2) pounds of bacon was found inside a refrigerator with no open date. The DNS stated the box of bacon should have been dated when it was opened. During an interview with the DNS on June 7, 2023, at 12:06 PM, in her office the DNS stated that the bacon should have been dated when it was opened for use. During a review of the facility's P&P title, PCO19: Storage Expiration Dates, dated 2019, the P&P indicated,6 .and bacon use within 7 days .Labels should be audited daily to ensure compliance . 5. During an observation and concurrent interview with the DNS in the kitchen on June 5, 2023, at 9:14 AM, three (3) fifteen (15) pound boxes of bacon were found open and undated inside a refrigerator. The DNS stated the boxes should have been dated when it was opened. During an interview with the DNS on June 7, 2023, at 12:08 PM, the DNS stated that the bacon boxes found to be open should be used within 7 days, but the boxes did not have a label, indicating when they were opened. During a review of the facility's P&P title, PCO19: Storage Expiration Dates dated 2019, the P&P indicated, 6 .and bacon use within 7 days .Labels should be audited daily to ensure compliance. 6. During an observation and concurrent interview, with the DNS, in the kitchen, on June 5, 2023, at 9:14 AM, a 40-pound box of turkey breasts was found inside of a refrigerator with no open date. The DNS stated that the box should have been dated when it was opened. During an interview with the DNS on June 7, 2023, at 12:10 PM, the DNS stated that the 40 pound of turkey breasts should be used within 3 days once the box is opened. During a review of the facility's P&P title,PCO19: Storage Expiration Dates dated 2019, the P&P indicated, 4. Deli meats use within 4 days .Labels should be audited daily to ensure compliance. 7. During an observation and concurrent interview with the Manager Nutritional Services Production (MNSP), in the kitchen, on June 5, 2023, at 9:33 AM, two (2) pounds of baby arugula with an expiration date of May 29, 2023, was found inside a refrigerator. The leaves of the vegetables were wilted. The MNSP stated that the baby arugula should be thrown away. During an interview with the DNS on June 7, 2023, at 12:12 PM, the DNS was informed that a 2 pounds of baby argula leafy vegetable with an expiration date of May 29, 2023, was found inside the produce refrigerator and the leaves of the vegetables were wilted. The DNS stated that it should be discarded. During a review of the facility's P&P titled, PCO19: Storage Expiration Dates dated 2019, the P&P indicated, 3. Raw vegetables . use within two days. Make sure that all employees understand and use the correct expiration date when labeling product. Labels should be audited daily to ensure compliance . 8. During an observation and concurrent interview with the MNSP, in the kitchen, on June 5, 2023, at 9:35 AM, three (3) pounds bag of diced celery was found inside the refrigerator and was undated. The MNSP stated that it should be thrown away. During an interview with the DNS, on June 7, 2023, at 12:14 PM, the DNS stated the bag of 3 pounds of diced celery that was found inside the refrigerator should be labeled and use within 3 days. During a review of the facility's P&P title, PCO19: Storage Expiration Dates dated 2019, the P&P indicated 3. Raw vegetables . use within two days. Make sure that all employees understand and use the correct expiration date when labeling product. Labels should be audited daily to ensure compliance . 9. During an observation and concurrent interview with the DNS, on June 5, 2023, at 9:49 AM, the kitchen's preparation table in the catering area was found to have crumbs on it and was dusty underneath it. The DNS stated that the area should be clean. During an interview with the DNS on June 7, 2023, 12:16 PM, in the DNS office, the DNS stated that the staff was supposed to clean that area every day. During a review of the facility's P&P title, EC140: Cleaning Schedules the P&P indicated, frequency, Daily 4. Leadership is responsible for overseeing cleaning of all areas and equipment. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 10. During an observation and concurrent interview with the DNS, on June 5, 2023, at 10: 22 AM, The ice machine (a machine which creates ice) airgap drain (a type of drain designed to prevent backflow) was found to contain black and brown colored stains and was dusty. The DNS stated that area should be cleaned daily and acknowledged that it looks dirty. During an interview with DNS, on June 5, 2023, at 10:24 AM, in the kitchen the DNS stated the area where the airgap drain was should be cleaned every day. The DNS further stated maintenance performed monthly service on the ice machine and the last maintenance cleaning service was done on May 31, 2023. During a review of the facility's P&P titled, IC134: FNS handling of Ice dated 2019, the P&P indicated, frequency Daily 5. FNS leader responsible for developing maintenance and cleaning schedules for ice machine. Ice machine should be checked for mold, gaskets, etc. Outside and top of ice machine must be clean and free of dirt and dust. 11. During an observation and concurrent interview with the DNS, on June 6, 2023, at 8:24 AM, the freezer was found to have spilled blueberries on the floor. The DNS acknowledged that the floor was dirty and stated she will have someone clean it. During an interview with the DNS on June 7, 2023, at 12:24 PM, The DNS stated, that the freezer should be clean, and the spilled blueberries found on the floor was a recent spill and no one came to clean it up. During a review of the facility's P&P title, EC140: Cleaning Schedules the P&P indicated, frequency Daily 5. Leadership is responsible for overseeing cleaning of all areas and equipment.