Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure all drugs were labeled in accordance with professional standards. Observation of the front hall medication room revealed a vial of Tubersol solution (an injectable medication used to test for tuberculosis) was not properly stored in the medication refrigerator. The findings include: Review of the facility policy titled, Storage of Medications, revised 2007, revealed the facility would store all drugs, and biological's in a safe, secure, and orderly manner. Continued review of the policy revealed the facility would not use discontinued, outdated, or deteriorated drugs or biological's. Further review revealed all such drugs were to be returned to the dispensing pharmacy or destroyed. Observation on 03/05/2025 at 9:47 AM, of the front hall medication room refrigerator, revealed one opened vial of Tubersol available for use, with an opened date of 01/30/2025. During interview with Licensed Practical Nurse (LPN) 1, on 03/05/2025 at 9:52 AM, she stated night shift nursing staff checked the medication refrigerators and discarded any expired items. She further stated once opened the vial of Tubersol expired after 30 days and should have been discarded and not used. During interview on 03/06/2025 at 4:39 PM, with the Director of Nursing (DON), she stated the nurses and med-techs (medication technicians) should check the medication refrigerator daily on all shifts and discard any expired medications. She stated the vial of Tubersol might have just gotten overlooked. The DON further stated using the Tubersol after the expiration date of 30 days could result in an inaccurate tuberculosis reading. In interview with the Administrator on 03/06/2025 at 5:28 PM, she stated nursing staff should properly discard any expired medications including Tubersol. She said it was nursing's responsibility to check medications for possible expiration dates prior to administration. The Administrator further stated if the expired Tubersol was given it could produce an inaccurate result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain a proper infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases. Observation during wound care on 03/06/2025 at 9:50 AM, revealed Licensed Practical Nurse (LPN) 3 failed to clean the bedside table or place a barrier device to cover it, prior to placing the residents' clean wound dressing supplies on the table for 2 of 14 sampled residents (Resident (R)3 and R11). The findings include: Review of the facility's policy, Infection Control Policy undated, revealed the facility's objectives for its infection control policy included prevention of infection achieved through proper infection control procedures. Per review, the proper infection control procedures included, but were not limited to, handwashing; use of Personal Protective Equipment (PPE); isolation practices, and cleaning and disinfecting of equipment. Review of the facility's policy, Skin Care Management, revised 07/01/2019, revealed its purpose is to prevent the development of avoidable pressure injuries or ulcers. The policy further stated staff were to follow body substance isolation precautions and policies and procedures for dressing changes in regards to infection control. 1. Review of R3's Face Sheet revealed the facility admitted the resident on 04/08/2016, with diagnoses which included Cellulitis, Peripheral Venous Insufficiency, and Type 2 Diabetes Mellitus. Review of R3's medical record revealed the resident had a wound to the coccyx. Review of R3's Treatment Administration Record (TAR) revealed orders which included to cleanse the coccyx with wound cleanser, pat dry, apply MediHoney Ointment and Xeroform (a type of dressing) then cover with a Border Gauze dressing daily. Observation of R3's coccyx wound care on 03/06/2025 at 9:50 AM, revealed LPN 3 failed to clean the bedside table or cover it with a protective barrier prior to placing R3's wound care supplies on it. In an interview with Licensed Practical Nurse (LPN) 3 on 03/06/2025 at 2:18 PM, she stated there are not many places to put things in a resident's room when you are performing a dressing change. She further stated she should have wiped off the bedside table before she placed anything on it. In an interview with the Director of Nursing (DON) on 03/06/2025 at 4:30 PM, she stated typically the charge nurse is responsible for providing wound care to the resident. She further stated that her expectations would be for the the nurse performing wound care to clean the bedside table and place a barrier down before putting wound care supplies onto the table. In an interview with the Administrator on 03/06/2025 at 5:28 PM, she stated that her expectations are that staff perform wound care correctly, on time, and follow the infection control procedures of the facility. 2. Review of R11's Face Sheet revealed the facility admitted the resident on 07/02/2012, with diagnoses which included [NAME] Insufficiency, Lymphedema, and Type 2 Diabetes. Review of R11's medical record revealed additional diagnoses that included: [NAME] Ulcer to Right Plantar Foot; Unspecified Open Wound, Right Foot, Subsequent Encounter. Review of R11's Physician's orders and Treatment Administration Record (TAR) revealed the resident's wound care orders included: to continue cleaning areas with soap and water, apply Gentlan [NAME] (an antiseptic solution) to toes daily with Opticell ag rope (an antimicrobial wound dressing) and Kerlix (wrap dressing) to right plantar foot. Change twice daily. Observation on 03/06/2025 at 9:00 AM, of R11's right plantar foot and toes wound care revealed after removing the old dressing, LPN 3 failed to place a clean pad or protective barrier under the resident's right foot prior to providing the wound care. Per observation, LPN 3 failed to clean R11's wound bed prior to applying the new dressing. Continued observation revealed LPN 3 was wearing several items of jewelry on her bilateral hands which caused a tear in her gloves; however, the LPN failed to get a new pair of gloves prior to initiating R11's wound care procedure. In interview on 03/06/2025 at 2:18 PM, LPN 3 stated she received Infection Control Training in the facility which was provided at least annually. LPN 3 said she felt there were not many places for to place her stuff in the residents' rooms. She stated she should have wiped off the bedside table before placing the wound supplies on it. The LPN reported she should have gotten new gloves when her's tore, as those gloves didn't fit at all. She further stated it was important to clean surfaces where wound care supplies were to be placed to aid in prevention of the spread of infection. In interview on 03/06/2025 at 4:49 PM, the Director of Nursing (DON) stated she expected her nursing staff to perform residents' wound care orders as ordered by physician while following the facility's Infection Control Policy guidelines. She further stated she expected all staff to perform proper handwashing technique and use proper PPE, including gloves, to prevent the spread of infection between residents. In interview on 03/06/2025 at 5:15 PM, the Administrator stated she expected all staff to follow the facility's Infection Control Policy guidelines during wound care treatment to aid in prevention of spread of infection from one resident to another resident.

Based on interview, record review, and review of the facility staffing schedules, it was determined the facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least 8 consecutive hours a day, 7 days a week as required. Review of the facility's staffing schedules revealed the facility failed to provide eight consecutive hours of RN coverage for 15 days between 07/27/2024 and 09/29/2024. This failure affected all persons residing in the facility during those 15 days. The findings include: Review of the facility's, Facility Assessment Tool: Staffing Plan dated 11/01/2022, revealed the facility should have one Registered Nurse (RN) as the Director of Nursing (DON) full-time days, and at least one RN or Licensed Practical Nurse (LPN) for each shift. Continued review revealed the Facility Assessment Tool further noted if more than one new (resident) admit or readmit occurred on a shift, then the facility should consider bringing in another licensed nurse for at least four hours of a shift to assist. Review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, dated 07/01/2024 through 09/30/2024, revealed there was no RN coverage documented for eight consecutive hours for the following 15 dates: 07/27/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/11/2024, 08/18/2024, 08/24/2024, 08/25/2024, 08/31/2024, 09/01/2024, 09/07/2024, 09/08/2024, 09/15/2024, 09/28/2024, and 09/29/2024. In interview with the Director of Nursing (DON) on 03/06/2025 at 4:30 PM, she stated she came in and worked for the eight hour RN coverage. She said she was not aware of what the facility's PBJ Report noted and would have to find out who was responsible for submitting the information for the report. The DON reported she was aware of the Federal Regulations and to the best of her knowledge the facility had a RN working eight hours a day, seven days a week. She said she did not know why the facility's PBJ Report was not reflecting that. She further stated she worked the past weekend both Saturday (03/01/2025), and Sunday (03/02/2025) for eight hours each day. In interview with the Cooperate Account Specialist (CAS) on 03/06/2025 at 5:02 PM, she stated at that time, she was the person responsible for submitting the facility's PBJ Report data. She stated she obtained the data from the facility's payroll system which kept up with the employee's time. The CAS said the data came across downloaded into a text file, and she did have access to the reports. She explained she would have to go back to the employee timecards and look at those specific dates to verify whether they had RN's working on those days. The CAS reported there might have been something she had missed that should have come over to tell her that information. She stated if the employees were salaried then she had to hand key those hours into the system. The CAS said she was not 100% sure she had any safeguards in place to ensure the correct data was entered for the facility's PBJ Report. She further stated she just took the data she had and entered it in the system. In interview with the Administrator on 03/06/2025 at 5:28 PM, she stated the CAS,who was over all of Human Resources (HR) for the facility's parent company, was responsible for doing the PBJ reporting right now. The Administrator stated she was supposed to learn how to do the PBJ reporting but she had not started training for that yet due to her training the new DON and other new staff at the current moment. She reported she, along with the DON, were salaried employees, and that information was put in manually since they did not clock in or out. The Administrator said when they (Administrator and DON) worked it would not show on the PBJ Report. She further stated they sent her the facility's daily census sheets and the dailies so she could see who was working and where they were working. She additionally stated she expected the facility's PBJ data to be submitted accurately and on time. `

Based on observation, interview, record review, and facility policy review, the facility failed to cover, store and serve food in accordance with professional standards for food service safety which had the potential to affect 36 of the facility's 36 residents who consumed food from the kitchen. Observation of the kitchen revealed food items stored in the refrigerator and freezers that were not covered and exposed to air, and which were outdated and not rotated to ensure older items were used first. Further observation of the dry pantry storage revealed two large bins, one filled with cornmeal and a second filled with flour which were undated to indicate when they were opened or when the items should be discarded. The findings include: Review of the facility policy titled, Food Receiving and Storage, revised 07/2014, revealed foods were to be received and stored in a manner that complied with safe food handling practices. Continued review revealed dry foods in storage bins were to be removed from original packaging, labeled and dated with the use by date, and be rotated using the first in-first out (FIFO) system. Further review revealed all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use by date. Observation of the kitchen, on 03/04/2025 at 11:42 AM, revealed refrigerator 1 had an opened box of cream cheese that was not covered and was exposed to air. Per observation, two unopened bags of broccoli and one opened bag of broccoli with expiration dates of 02/24/2025, and the opened bag of broccoli was unsealed and exposed to air. Continued observation revealed a large package of salad lettuce with an expiration date of 02/24/2025, located behind another package of salad lettuce with a newer used by date which indicated the products had not been rotated. Observation of freezer 1 revealed one box of ground beef patties that were uncovered and exposed to the air. Observation of refrigerator 2 revealed a box of sausage patties not covered and exposed to air. Continued observation of freezer 2 revealed a box of oatmeal raisin frozen cookie dough uncovered and exposed to air. Observation of the dry pantry storage area revealed two large bins, one filled with cornmeal and a second filled with flour, which were both undated. In interview with [NAME] 2 on 03/05/2025 at 11:25 AM, he stated he was aware of how to store foods items. He said new products were dated with a received date and stored; however, if a product was opened then an opened date was to be marked on the product package. [NAME] 2 stated most food items were discarded after three days. He reported if the package had an expiration date that preceded the facility's use by date, then staff used the product expiration date and discarded it. The [NAME] said all food items should be rotated to ensure older food items were used first and should be covered to prevent exposure to air contaminants. He stated it was the responsibility of all staff to ensure those guidelines were being followed as in the facility policy. Additionally, he reported if staff did not follow those guidelines residents could be exposed to E.coli (Escherichia coli) or salmonella (common bacteria that can cause food poisoning). [NAME] 2 further stated if the residents were served food that was contaminated, they could become very sick. In interview with [NAME] 1 on 03/05/2025 at 11:25 AM, she stated food items were to be dated, covered properly, and stored. She stated new food items were marked with the received date. The [NAME] reported when opened foods were to be covered, either in the original container or placed into a sealed container. She said opened food items were to be dated with an opened date for staff to know when to discard those items. [NAME] 1 stated all staff had the responsibility to follow the facility's policy and procedures regarding food safety to ensure residents were not being served contaminated or freezer burned foods that might cause sickness. She further stated she believed the facility should be serving residents good quality food. In interview with the Dietary Manager (DM) on 03/05/2025 at 11:35 AM, she stated her expectations for all dietary staff was for them to ensure they were following policies and procedures regarding food safety. She stated if there were concerns with staff not following those guidelines an in-service would be provided. The DM reported food safety was to include covering food items when stored and ensuring the items were dated. She said food safety also included checking the use by or expiration dates to ensure staff were rotating the old and new food items and discarding those that had expired. The DM explained residents could experience sickness, food poisoning, and it was the facility's responsibility to serve food that was nutritious and palatable. Additionally, she further stated the facility was the resident's home and they should be provided quality care. In interview with the Administrator on 03/06/2025 at 5:20 PM, she stated her expectations for the dietary staff was for them to follow the facility's policies and guidelines related to food safety. She stated she expected staff to ensure food items were being stored per safe food practices. The Administrator said safe food practices included covering and dating opened food items before they were stored in the refrigerator or freezers. She reported she would expect the staff to have knowledge of expiration dates and how to rotate old and new products before opening new products as that was part of their job duties. She further stated she would never want to serve residents foods that were unsafe or unacceptable per safety guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure the comprehensive person-centered care plan was implemented for one (1) of sixteen (16) sampled residents (Resident #24). The facility failed to ensure Residents #24's care plan was being followed related to a chair alarm that was to be in place and functioning. The findings include: Review of facility policy Care Plans, not dated, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. It further states each resident's comprehensive care plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Record review revealed the facility re-admitted Resident #24 to the facility on [DATE] with diagnoses which included Unspecified Dementia with Behavioral Disturbance, Major Depression and Anxiety. Review of Resident #24's admission Minimum Data Set (MDS) Assessment, dated 12/05/18, revealed the facility coded this resident as requiring limited assistance of one staff for transfers and ambulation. Further review of this MDS, revealed the facility assessed this resident's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. However, an attempt to interview Resident #24 on 12/11/18 at 1:32 PM, revealed the resident was confused and unable to provide intelligible conversation. Review of Resident #24's Comprehensive 'At Risk for Falls/ Injury' Care Plan, initiated 12/11/18, revealed an intervention for this resident to have a pressure alarm to his/her wheelchair to alert staff of attempts of unassisted transfers and to check placement and function per physician's orders. However, observation of Resident #24's room on 12/11/18 at 1:31 PM, revealed Resident #24 was sitting in a wheelchair, stood up from wheelchair, and started ambulating in room with a unsteady gait. Further observation revealed a wheelchair alarm was in place to wheelchair; however, the alarm was not sounding. At 1:38 PM, the resident was up in the hallway by his/her room ambulating unassisted with a noted unsteady gait. Interview with Certified Nurse Aide (CNA) #1 on 12/11/18 at 1:58 PM, revealed she was expected to follow the residents' care plans. She stated she went and checked Resident #24's alarm after she was informed the resident had been up ambulating by self, and found the alarm was in fact off. She revealed she must have forgotten to turn the alarm on when she assisted the resident up in the wheelchair that morning. Interview with Director of Nursing (DON) on 12/11/18 at 1:53 PM, revealed she expected all staff to ensure they followed the facility care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents; or the resident environment remains as free of accident hazards as possible for two (2) of sixteen (16) sampled residents (Resident #16 and #24). The facility failed to ensure Residents #16's room was free of trip hazards and Resident #24's chair alarm was turned on while resident was in chair. The findings include: 1. Review of facility policy titled, Accidents and Incidents, not dated, revealed it is the policy of the facility to provide a safe and healthful environment. Record review, revealed the facility re-admitted Resident #24 to the facility on [DATE] with diagnoses which included Unspecified Dementia with Behavioral Disturbance, Major Depression and Anxiety. Review of Resident #24's admission Minimum Data Set (MDS) Assessment, dated 12/05/18, revealed the facility assessed the resident's cogntion as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident required limited assistance of one staff for transfers and ambulation. An attempt to interview Resident #24 on 12/11/18 at 1:32 PM, revealed this resident was confused and unable to provide intelligable conversation. Review of Resident #24's re-admission Physician's Orders, dated 11/28/18, revealed an order for a pressure alarm to chair at all times to alert staff of unassisted transfers and placement and function to be check every shift. Review of Resident #24's Comprehensive 'At Risk for Falls/Injury' Care Plan, initiated 12/11/18, revealed this resident was at risk for falls due to he/she has a history of falls, has confusion, poor safety awareness and does not utilize call light effectively. Further review of this care plan, revealed an intervention for this resident to have a pressure alarm to his/her wheelchair to alert staff of attempts of unassisted transfers and to check placement and function per physician's orders. Observation of Resident #24's room on 12/11/18 at 1:31 PM, revealed Resident #24 was sitting in a wheelchair, stood up from wheelchair, and started ambulating in room with a unsteady gait. Further observation revealed a wheelchair alarm was in place to wheelchair; however, the alarm was not sounding. Observation of Resident #24 on 12/11/18 at 1:38 PM, revealed the resident was up in the hallway by his/her room ambulating unassisted with an unsteady gait. Interview with Certified Nurse Aide (CNA) #1 on 12/11/18 at 01:58 PM, revealed she was taking care of Resident #24 and this resident should not be up by him/herself. She stated she must have forgot to turn the wheelchair alarm on when she had assisted Resident #24 up to the wheelchair earlier. She stated she went and checked Resident #24's alarm after she was informed the resident had been up ambulating by self and found the alarm was in fact off. Interview with Director of Nursing on 12/11/18 at 1:53 PM, revealed she stated Resident #24's alarm had not been turned on and that is why the resident had been up ambulating by self due to the alarm not being on did not warn staff this resident had gotten up unassisted. She further stated this resident is to be assisted with ambulation and transfers. She stated she expects the alarm for Resident #24 to be turned on when this resident is in the wheelchair. 2. Review of a current Resident Wander list, provided by the facility, revealed a total of four (4) residents. Record review revealed the facility admitted Resident #16 on 10/31/17, with diagnoses which included Major Depressive Disorder, Cerebral Palsy, and Hypertension. Review of Resident #16's Annual MDS assessment dated [DATE], revealed the facility assessed the resident's cognition as intact, with a (BIMS) score of fourteen (14), which indicated the resident was interviewable. Observations of Resident #16's room on 12/11/18 at 9:58 AM and 12/12/18 at 8:55 AM, revealed an extension cord lying in the floor between both residents beds. Interview with Maintenance on 12/13/18 at 2:43 PM, revealed the residents should not have extension cords in the floor. He stated the extension cord had been removed from the room because it is considered a fall hazard for other residents, staff, and visitors. Interview with the Director of Nursing (DON) on 12/13/18 at 3:45 PM, revealed she would have expected any fall hazards to be identified by staff and corrected. She further stated the extension cord had been removed from Resident #16's room.

Based on observation, interview and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during medication administration. Observation of a medication administration pass on 12/11/18 revealed staff failed to ensure proper hand hygiene during medication administration. The findings include: Review of facility policy Handwashing, not dated, revealed handwashing and hand antisepsis shall be regarded by the facility as the single most important means of preventing the spread of infections. It further states staff will wash hands before having direct contact with residents and after direct contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. Observation of Licensed Practical Nurse (LPN) #1 on 12/11/18 between 3:08 PM to 3:12 PM, revealed LPN #1 administered medication to two (2) residents. LPN #1 administered medications to the first resident and then went back to the medication cart, and then prepared and administered medication to a second resident without washing or sanitizing hands. Interview with LPN #1 on 12/12/18 at 03:15 PM, revealed she is supposed to perform hand hygiene between residents when passing medications. She stated she is expected to follow facility policy and procedures. Interview with facility Infection Control Preventionist on 12/13/18 at 2:32 PM, revealed she expected all staff who passed medications to wash their hands after administering medications to one resident and before going to administer medications to another resident. She stated staff should do this to ensure there is no chance of spreading infections from one resident to the next resident. She further revealed this was an infection control issue. Interview with Director of Nursing (DON) on 12/12/18 at 3:33 PM, revealed she expected staff to perform hand hygiene in between giving different residents medications. She stated she expected staff to follow the facility policy and procedures.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure food was prepared, distributed and served in accordance with professional standards for food service safety. Observation in the kitchen on 12/11/18, revealed the cook was using a soiled rag to clean the food thermometer prior to checking the temperature of foods and the cook was handling ready to eat foods with his soiled gloved hand. Review of the facility Census and Condition, dated 12/11/18, revealed fifty-two (52) of fifty-three (53) residents received their meals from the kitchen. The findings include: 1. Review of facility policy Food Temperatures, not dated, revealed to take temperatures, a clean, sanitized and air-dried thermometer is needed. Observation of the lunch trayline food temperature checks in the kitchen on 12/11/18 at 11:12 AM, revealed [NAME] #1 was cleaning the thermometer, used for checking food temperatures, with a rag that was visibly soiled with brown material on the rag in between checking the temperature of each food. Interview with [NAME] #1 on 12/11/18 at 11:15 AM, revealed he always used a wet rag to clean the thermometer in between checking the temperatures of each food. 2. Review of facility policy General Food Preparation and Handling, not dated, revealed food items will be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared foods. Observation of trayline on 12/11/18 at 11:25 AM, revealed [NAME] #1 was using his gloved right hand to grab country fried steak patties and dinner roll out of the pans to place on the residents' plates, after [NAME] #1 had handled various other utensils and items in the kitchen. Interview with Dietary Manager on 12/11/18 at 02:30 PM, revealed it was not appropriate to use a rag to clean the thermometer prior to using it and she expected the cooks to use alcohol swabs to clean the thermometer in between checking the temperature of foods. She stated it was not appropriate for the cook to use his hand to dish food out, and she expected all ready to eat foods to be handled with utensils.