Based on record review and interview, the facility failed to develop and implement a plan of care to address a resident's UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTIs in the sample of three.Findings include:The facility's Person-Centered Comprehensive Care Plan policy dated 12/2016 documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team will review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. R1's Urine Culture Final Report dated 9/13/25 documents, Final Report: greater than100,000 cfu/ml (colony-forming units/milliliter) Escherichia Coli.)R1's Physician's Order dated 9/13/25 documents, Ceftin 500 mg (milligrams) BID (twice daily) for seven days.R1's current Care Plan does not include a plan of care to address R1's current UTI.On 9/21/25 at 2:45 PM V1 (Administrator) verified R1 does not have a plan of care to address R1's UTI. V1 stated, (V2/Director of Nursing) is responsible for the development of (R1's) UTI Care Plan.

Based on record review and interview the facility failed to implement a surveillance plan for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks among residents and staff. These failures have the potential to affect all 27 residents residing within the facility.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Surveillance for Infections policy dated 09/2027 documents, The facility will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. a. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: Identifying information. Diagnoses. admission date, date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test); Infection site. Pathogens; Invasive procedures or risk factors. Pertinent remarks (additional relevant information). Also, record if the resident is admitted to the hospital, or expires; and Treatment measures and precautions (interventions and steps taken that may reduce risk. 1. For targeted surveillance using facility-created tools, follow these guidelines: a. Record detailed information about the resident and infection on an individual infection report form (Infection Treatment/Tracking Report, Infection Report Form, or similar form). B. Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (Line Listing of Infections by Resident or similar form). C. Summarize monthly data for each nursing unit by site and by pathogen (Facility-Wide Monthly Infection Report by Site, Facility-Wide Monthly Infection Report by Pathogen, or similar form). D. Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. (See Facility-Wide 12-Month Pathogen Trends or Facility-Wide 12-Month Infection Site Trends or similar tool.) E. Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period. On 9/19/25 at 1:00 PM V2 (Director of Nursing/DON) provided an Order Listing Report dated 8/2025 and 9/2025 that V2 used as the facility's infection surveillance plan and the facility's Infection Control Surveillance Binder. The Order Listing Report documents antibiotics prescribed with the diagnoses the antibiotics were prescribed for to treat for residents during this timeframe. These Order Listing Reports do not include the residents' identifying information, admission date, date of infection onset, or pathogens. The facility's Infection Control Surveillance Binder does not include line listings and infection control tracking logs for each nursing unit that include the residents' identifying information, admission date, date of infection onset, site of infection, pathogen, whether the infection was facility-acquired, sites of infection among residents in the facility or in particular units, or trends and patterns. This same Binder does not include evidence of employee infection control tracking. On 9/19/25 at 2:00 PM V2 stated, I was the interim Director of Nursing starting in July (2025) after (V13/Prior DON) resigned. I signed as the actual Director of Nursing in September (2025). V2 verified the Infection Control Surveillance Logs for residents and staff have not been completed since July 2025.

Based on record review and interview the facility failed to designate a qualified infection preventionist to implement the facility's infection prevention and control programs. This failure has the potential to affect all 27 residents residing within the facility.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Infection Preventionist Job Description dated 10/12/20 documents, The Infection Preventionist is responsible for the effective direction, management, and operation of the infection prevention program. Position Qualifications and Credentials: Specific training in Infection Prevention and Control through accredited continuing education program.The facility's Facility assessment dated 2025 does not include an Infection Preventionist as part of the facility's staffing plan based on their current census and needs.On 9/19/25 at 10:45 AM V1 (Administrator) stated, (V2/Director of Nursing) is the facility's infection preventionist and is responsible for the facility's infection control program. (V4/Regional Nurse) and V5 (Regional Infection Preventionist) oversee the facility's infection control program and are on-site maybe once or twice a month. V1 verified V2 has not completed infection preventionist education.On 9/19/25 at 2:00 PM V2 stated, I have enrolled in infection preventionist class. I have not taken the classes yet.

Based on observation, interview, and record review, the facility failed to ensure showers in the resident's bathrooms were free of a brown/black furry textured substance, water was available in one shower room, faucets were in good working order, cracked tile in the shower rooms was repaired, unconnected piping wasn't exposed, and functioning ventilation fans in resident rooms. This failure has the potential to affect all 26 residents who reside in the facility. Findings Include:The Facility's current resident census sheet dated 7/16/2025, documents 26 residents reside in the facility.The Facility's Safety and Supervision of Residents policy dated 11/14/2024 documents, Policy Statement, our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety, 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.The Facility's Homelike Environment policy (not dated) documents, Policy Statement, residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary, and orderly environment.On 7/16/2025 at 10:30 AM, on the main North Hall there are two shower rooms labeled one and two. Shower room one had no working water and previous bathtub was out of room leaving piping and broken tile. Next to shower area was broken tile on the right side of the wall. In shower room two there was broken tile in shower area on the floor next to the drain, and broken tile around water faucet floor base in the left and right corners.On 7/16/2025 at 10:45 AM, on East Hall rooms one through eight all had brown/black furry textured substance in the showers, ventilation fans were not turning on in all rooms, and rooms two, three, four, and six shower faucets were leaking.On 7/16/2025 at 11:00 AM, V7 (Administrator in Training) stated he was overlooking maintenance while their head of maintenance was out this week. V7 toured shower rooms and resident rooms and confirmed that he was aware of the issues and had only called one person to do the repairs and has been waiting a month maybe. V7 confirmed he has not tried to call any other contractors to help with resident bathrooms and shower rooms.

Based on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 26 residents who reside in the facility.Findings Include:The Facility's current resident census sheet dated 7/16/2025, documents 26 residents reside in the facility.The Facility's Staffing policy (not dated) documents, Policy Statement, our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.The Facility's staffing sheets dated 6/16/2025-7/16/2025 document all days with no Registered Nurse for eight consecutive hours, 6/28, 6/29,7/3, 7/3, 7/5, 7/6, 7/10, 7/12, 7/16.On 7/16/2025 at 1:00 PM V6 (Director of Nursing) stated I am the only Registered Nurse on staff, I am also responsible as Director of Nursing, MDS (minimum data set) Coordinator. V6 states she will work the floor, and she is also the only nurse manager to cover if a nurse or certified nurse aid calls in. V6 stated I am aware we do not have the staff to have a registered nurse for eight hours every day since I am the only one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to use a gait belt, or a two person assist for a transfer for one resident (R3) of two residents reviewed for falls in the sample of 20. Findings include: The Fall Policy dated 7/2014 document To ensure that the resident's environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistive devices to prevent accidents. The Gait belt Policy dated 3/16/2020 documents Purpose: To give guidance as to the proper use of a gait belt to reduce injury to staff and resident. Policy: Staff will utilize gait belt at all times while transferring or ambulating a resident as outlined in this policy. Procedure: 1. The gait belt is part of the C.N.A (Certified Nursing Assistant) uniform and is the responsibility of the C.N.A to have on their person at all times. R3's admission Record documents that R3 was admitted on [DATE] with diagnoses which included Parkinsonism, Unspecified Convulsions, Type 2 Diabetes Mellitus, and Alzheimer's Disease. R3's Minimum Data Set/MDS assessment dated [DATE] documents that R3 has a BIMs/Brief Interview of Mental Status of 6 (severe impairment). R3 has upper and lower extremity impairment on both sides, is dependent on staff for activities of daily living, and requires substantial assistance for transfers. R3's current Care Plan documents that R3 has an activity of daily living self-care performance deficit related to weakness (dated 10/10/2017). I require max assist of two with wheeled walker, and gait belt to move between surfaces safely and as necessary (dated 4/26/2024). Sometimes I have moments of weakness and difficulty transferring. I may use mechanical lift sit to stand with two assists. I have potential for falls as evidenced by history of falls in Morse Falls score related to seizure disorder, use of anti-seizure medication, antidepressants, history of falls and balance impairment. Morse Fall Risk Score is high. Staff education provided that resident is a two assist for care plan to help reduce falls (dated 5/17/2020). R3's Post Fall Investigation Report dated 8/2/24 documents that R3 was lowered to the floor with no injury during a transfer. The Root Cause was identified as R3 was transferred with an assist of one. R3 is to be transferred with an assist of two and a gait belt. R3's Nursing Note dated 8/2/2024 at 10:17 PM, documents CNA (V8) called out for assistance. (V8) stated he had to lower (R3) to the floor. No injuries noted at this time. R3's Witnessed Fall Report dated 8/2/24 at 6:25 PM documents (R3) became weak suddenly and was lowered to the floor, (R3) is 2 (two) assist with gait belt for transfers, (R3) has history of seizure activity and bilateral lower weakness, nursing staff to assess (R3) before transfers and if too weak to transfer with 2 assist reattempt at a later time or use a third person to help with transfers to help prevent falls. On 12/11/24 at 11:25 AM, V3/Director of Nursing stated that R3 is an assist of two and R3 had a fall when a CNA transferred R3 without assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R19's Progress Note, dated 4/4/2023 and signed by V5/LPN (Licensed Practical Nurse), documents (V5/LPN) called to (R19's) room. Upon assessment recurring stage two pressure ulcer to right buttock. R19's current Physician Orders documents an order to cleanse bilateral buttock, skin prep and apply a (foam dressing) every evening shift, Monday, Thursday, Saturday and as needed. On 12/9/24 at 10:52 AM V5/LPN stated that R19 has a pressure sore on (R19's) right and left buttock. On 12/9/24 at 10:55 AM no EBP sign was observed on R19's door and no PPE was observed inside or outside of R19's room. On 12/9/24 at 2:40 PM V5/LPN and V7/CNA prepared to provide treatment to R19's left and right buttock. V7/CNA had gloves on and rolled R19 onto R19's right side. R19's left, and right buttock were observed and had an open small pea sized area on each buttock. During R19's treatment V5/LPN nor V7/CNA wore a gown, only gloves. On 12/9/24 at 2:50 PM V5/LPN and V7/CNA both verified they were not wearing gowns during V19's wound treatment. V5/LPN and V7/CNA both stated they were unsure what EBP is. On 12/11/2 at 11:05 PM V3/Director of Nursing/Infection Preventionist stated she was unaware of what EBP's were, and it has not been implemented. V3 verified R19 has a pressure wound and R24 has a urinary catheter. Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two residents (R19 and R24) of two residents reviewed for EBP in the sample of 20. Findings include: The Enhanced Barrier Precautions policy (not dated) documents Purpose: Reduce the spread of Infection. Procedure Providers and staff must clean hands before entering and leaving the room, wear gloves and gown for the following high-contract resident care activities - dressing, bathing/showering, and transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with devices such as a central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. 1. R24's admission Record documents that R24 was admitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Essential (Primary) Hypertension. R24's Minimum Data Set/MDS assessment dated [DATE] documents that R24 has a BIMs/Brief Interview of Mental Status of 4 (severe impairment). R24 has an indwelling urinary catheter. R24's current Care Plan documents I have an indwelling catheter which increases my risk for UTI/Urinary Tract Infection. I have a catheter for: urinary retention. On 12/9/24 at 10:03 AM no EBP sign was observed on R24's door and no PPE was observed inside or outside of R24's room. On 12/10/24 at 10:12 AM, V4/Certified Nursing Assistant provided catheter care for R24. V4 did not wear Personal Protective Equipment/PPE while doing catheter care. V4 stated that he was never told that PPE should be worn when providing catheter care for R24.

Based on observation, interview and record review the Facility failed to store and label open food items in the Facility refrigerator and freezer. This failure has the potential to affect all 28 Residents residing in the Facility. Findings include: Facility Cold Food Storage Policy, revised 9/15/22, documents: cold food storage is maintained to prevent foods from becoming hazardous with growth of microorganisms and reduce cross contamination and food borne illness; all cold food will be refrigerated, and temperatures will be monitored to assure proper temperature is maintained; all foods will be labeled with date prepared and time; and discard all potentially hazardous foods. The Facility Resident List Report, dated 1/2/24, documents 28 Residents residing in the Facility. On 1/2/24 at 10:10 am, the Facility Refrigerator contained an open and undated bag of shredded cheddar cheese, half of an onion, half of a tomato, container of lettuce and a block of cheese. The Facility freezer contained an open, unsealed, and undated bag of meatballs, chicken patties and hamburger patties. On 1/2/24 at 10:18 am, V4 (Dietary Manager) stated, These food items should all be dated and completely sealed. I am not sure how long the container of salad has been in there, but I think it looks like it has been in there for too long. On 1/3/24 at 1:45 pm, V2 (Administrator) stated, I think some of the food gets opened or thrown in the refrigerator, and then not stored correctly, especially over the weekend or at night, when we get food out for the Residents, sometimes it does not get dated and placed back into the refrigerator the way it should. It should be dated and labeled if it has been opened.