Based on resident and staff interviews, record review, review of facility documents, and review of the facility policy titled, Management of Residents' Personal Funds, the facility failed to provide written quarterly statements within 30 days of the end of the quarter to one of 43 residents (R) (R78) and/or the resident representative to inform them of the residents' balance in their personal funds account. This failure had the potential to cause R78 and/or the resident representative to be uninformed of the balance in their account. Findings include: Review of the facility's undated policy titled, Management of Residents' Personal Funds, revealed, Policy Statement: Our facility manages the personal funds of residents who request the facility do so. Policy Interpretation and Implementation: . 3. Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident . 4. Should our facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds are managed in accordance with established policies and federal/state requirements . Further review of the facility's policy revealed that the policy failed to address the requirement to provide a written quarterly statement to the resident and/or resident representative within 30 days of the end of the quarter. Review of the Trail Balance report dated 3/1/2025 revealed 43 resident names as having active accounts. Review of R78's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/2025, located in the EMR under the MDS tab, revealed R78 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of a facility-provided document titled Resident Statement Landscape documented that R78 had a resident account through the facility, with entries dated 2/26/2025 through 5/6/2025. During an interview on 5/6/2025 at 10:29 am, R78 stated he had not received any statements about his account. During an interview on 5/6/2025 at 3:12 pm, the Business Office Manager (BOM) verified that R78 had an active resident funds account. During an interview on 5/6/2025 at 3:40 pm, the BOM stated no quarterly statements had been sent out since the end of December 2024 due to the transition between resident fund management providers. The BOM further stated that the March 2025 statements should have been provided in April 2025.

Based on staff interviews, record review, and review of the facility policy titled, Admission, Transfer, and Discharge, the facility failed to provide a written notification of transfer to the hospital to the resident and resident representative for one resident (R) (R26) reviewed for hospital transfer. This deficient practice had the potential to affect the resident and their representative by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's undated policy titled Admission, Transfer, and Discharge revealed that the policy did not provide guidance related to providing the written notification of transfer to the resident and the resident representative. Review of R26's Electronic Medical Record (EMR) revealed a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R26 was cognitively intact. Review of R26's EMR located under the Census tab revealed that R26 was discharged to the hospital on 3/20/2025 and returned to the facility on 3/25/2025. There was no record in the EMR of the facility providing a written notice of transfer to the resident or the resident representative. During an interview on 5/8/2025 at 11:53 am, the Director of Nurses (DON) stated the facility called the family and noted in the chart when a resident was transferred. The DON stated the facility did not provide a written transfer notice to the resident or resident representatives. During an interview on 5/8/2025 at 11:55 am, the Social Services Director (SSD) stated that she was unsure about written transfer notices being sent to the family. During an interview on 5/8/2025 at 1:28 pm, the Assistant Director of Nurses (ADON) stated that the facility called the resident's representative and documented in the nurse notes in the EMR for transfers.

Based on observations, staff interviews, and review of the facility policies titled Food Storage Areas and Food from Family Members, the facility failed to ensure food items were labeled, dated, and securely wrapped in the kitchen storage areas and in two of two resident pantries. In addition, the facility failed to ensure that staff food items were stored separately from resident food items. These failures had the potential to place the 89 residents who consumed food from the kitchen at risk of foodborne illness. Findings include: Review of the facility's policy titled, Food Storage Areas, dated 4/20/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in, first out should be followed with Refrigerator Food codes, and internal tools may be used as a reference for proper dating. Review of the facility's policy titled, Food from Family Members, dated 3/20/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in, first out should be followed with Refrigerator Food codes, and internal tools may be used as a reference for proper dating. Storage food from family members will be placed in one of the two units' refrigerators. After resident food is dated, there will be a three-day period to be used. After three days, residents' food will be thrown out. Observations on 5/5/2025 from 10:30 am to 11:15 am, during the initial kitchen inspection with the Dietary Manager (DM), revealed that the main refrigerator contained hamburger patties in an open plastic bag inside a cardboard box, exposed and undated. Hot dogs were observed in an open plastic bag inside a cardboard box, exposed and undated. Breaded chicken tenders were observed inside an open cardboard box, exposed and undated. Observation in the kitchen pantry storage room revealed rice stored in a large open bag with no date, white rice in a large paper bag that was open with no date, and extra-long rice in a large, open paper bag with no date. [NAME] sugar was observed in a large plastic bag that was open, with no date. Observations on 5/5/2025 from 1:30 pm to 2:15 pm, during the inspection of the nutrition pantry on the Unit North, with the DM, revealed that the resident refrigerator contained bean dip in a plastic container inside a shopping bag. Inside the shopping bag was a receipt dated 1/31/2025. Further observation revealed three insulated food bags, which the DM stated belong to staff, pineapple chunks in a plastic container dated 3/31/2025, green grapes in a plastic container with a resident's name and no date, and watermelon in a plastic container with no resident name or date. Observations on 5/5/2025 from 1:30 pm to 2:15 pm, during the inspection of the nutrition pantry on the Unit South, with the DM, revealed the resident refrigerator contained slices of deli meat in a plastic bag with no date or resident name, two insulated food bags, which the DM thought belonged to staff, and iced tea in a plastic container with no resident name or date. During an interview on 5/5/2025 at 2:20 pm, the DM confirmed all identified concerns and stated that food products should be in a closed package and dated by staff when taken out of the main refrigerator. The DM confirmed that the rice products should be in closed containers and dated by staff after being opened. The DM stated that food had not been checked for expiration dates. The DM confirmed that the staff members were using the residents' refrigerators, and that resident food was not being dated or labeled with the residents' names.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to store resident personal care items in a sanitary manner in two bathrooms shared by a total of eight residents on one of two halls. Findings include: Observation on 3/15/22 at 9:15 a.m. revealed that there were four wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms [ROOM NUMBERS]. Observation on 3/15/22 at 9:45 a.m. revealed that there were three wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms [ROOM NUMBERS]. Observation on 3/16/22 at 10:00 a.m. revealed that there were four wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms [ROOM NUMBERS]. Observation on 3/16/22 at 10:15 a.m. revealed that there were three wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms [ROOM NUMBERS]. Observation on 3/17/22 at 9:00 a.m. revealed the same concerns with the unlabeled and unbagged wash basins in the bathroom for rooms [ROOM NUMBERS], and rooms [ROOM NUMBERS]. Observation in the bathroom shared by rooms [ROOM NUMBERS], and rooms [ROOM NUMBERS] revealed that the wash basins remained unlabeled and unbagged. During observation rounds made on 3/17/22 at 8:00 a.m. for rooms 12-13, and rooms 16-17 with Registered Nurse (RN) BB verified the improper storage of resident wash basins. She agreed the wash basins should be labeled with a resident's name and placed in a bag. Interview with RN BB on 3/17/22 at 8:00 a.m. revealed wash basins should be labeled and bagged. She stated the Certified Nursing Assistants (CNAs) are responsible for making sure the wash basins are bagged after each use. RN BB stated the residents receive one shower weekly because of COVID. She stated there is currently no COVID in the building. RN BB also stated residents receives six bed baths and one shower weekly. She stated residents are given baths with the wash basins in the bathroom. RN BB further stated there is no way to know who the wash basins belong to if the basins are not labeled. She stated the CNAs should change the wash basins when they get old and dirty looking. She stated she could not give an exact time frame, but they should change it when it looks dirty probably after a couple of weeks. RN BB stated those wash basins should have been thrown away. RN BB verified the concerns with the sanitary storage of the above wash basins and stated that the wash basins should have been bagged and labeled with the resident's name. Interview with CNA DD on 3/17/22 at 10:30 a.m. revealed there is no set time to change the wash basins. She stated she randomly changes them in a couple of weeks after use. CNA DD stated whoever get the wash basin is responsible for labeling and bagging it. Interview with CNA NN on 3/17/22 at 10:40 a.m. revealed anyone can change out wash basins. She stated if a resident is a new admit whoever admits them can label and bag their wash basin. CNA NN stated if the wash basins are not bagged or labeled it should be thrown away an get new ones. She also stated if the wash basins are not labeled there is no way to tell who it belongs to. Policy on storage of residents' personal care items requested. Interview on 3/17/22 at 11:20 a.m. with Administrator KK revealed there is not a policy on storage of residents' personal care items.

Based on observation, staff interview, and review of the facility policy Food Preparation Safety and Service, the facility failed to ensure expired foods were properly discarded and opened food items were properly dated and labeled in the walk-in cooler, the walk-in freezer, and the dry food pantry. In addition, the facility failed to ensure the oven and food carts were clean. This deficient practice had the potential to affect 83 of 85 residents receiving an oral diet. Findings Include: Review of the facility policy Food Preparation Safety, and Service dated 9/2020 revealed all food sources not in their original packages are covered, dated, and labeled. Further information on this policy includes Part C. Equipment - which indicates all kitchenware and food contact surfaces used to prepare and service food and drink are cleaned and sanitized before use and cleaned after each meal preparation time. Observation of the kitchen on 3/15/22 at 11:00 a.m. with the Dietary Manager revealed there was expired food in the pantry: Cream of Mushroom Soup dated 2019, Golden Cream Style Corn best by date 2021, and Spice Ground Cinnamon dated 9/18/17. The Dietary Manager discarded the food items after the surveyor noted the expiration dates. Observation on 3/16/22 starting at 10:30 a.m. of the walk-in cooler and freezer with the Dietary Manager revealed the following foods with improper labeling: Vanilla wafers open -no date on bag, sliced tomatoes open and in plastic dietary container with no date on bag, bacon open with no date, smoked sausage open with no date, tater tots (x2) open with no date on bags. During an observation and interview on 3/16/22 at 10:40 a.m., Dietary Manager confirmed the stove and carts had debris on them. The Dietary Manager also stated it is the responsibility of the person prepping the food to label and date the item.