Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, to include anticoagulant (blood thinner) use, for 1 (Resident #3) of 5 residents reviewed for unnecessary medications, resulting in an incomplete reflection of the resident's medication status and the potential for unmet care needs. Findings include: Resident #3 Review of an admission Record revealed Resident #3 was a female, with pertinent diagnoses which included: unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of a physician's order for Resident #3 revealed, Eliquis Tablet 5 MG (milligrams) (Apixaban) Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION (I48.91) Pharmacy Active 12/7/2022 A review of Resident #3's current Care Plan on 2/11/25 at 10:49 AM, revealed no care planned focus, goals, or interventions related to her Eliquis (an anticoagulant) use. In an interview on 2/11/25 at 2:09 PM, Director of Nursing (DON) B reported she had just recently taken over the position of DON and had previously been the MDS (Minimum Data Set) Coordinator. DON B reported a care plan should be developed and implemented for high-risk medications and gave the example of anticoagulants, antibiotics, and diuretics. DON B reported the MDS Coordinator was responsible for developing the care plan for some of the high-risk medications including Eliquis, because it was an anticoagulant. DON B reviewed Resident #3's care plan with this surveyor and reported there was no care plan in place for her anticoagulant use but that there should have been. DON B reported it was important to care plan anticoagulant use because of the high risk of bleeding while on this type of medication.

Based on observation, interview, and record review, the facility failed to: 1.) maintain safe infection control practices in regards to hand hygiene (glove use) during direct care for 1 resident (Resident #4) and 2.) ensure that all staff consistently don proper PPE (personal protective equipment) prior to conducting high contact activities with a resident where Enhanced Barrier Precautions (EBP) were in place for 1 resident (Resident #12) of 11 residents reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of bacteria. Findings include: Resident #4 Review of Resident #4's Care Plan revealed, .(Resident #4) is on Enhanced Barrier Precautions r/t (related to) history of extended-spectrum-beta-lactamase (this is a type of enzyme or chemical produced by some bacteria, that can make some antibiotics ineffective in treating bacterial infections) in urine, J-tube (indwelling medical device used to deliver nutrition directly into the small intestine), and foley catheter (indwelling medical device used to drain urine from the bladder). Date initiated: 1/13/25. Interventions: Alcohol based handrub or wash with soap and water if visibly soiled before entering and after leaving the room. Staff must wear gown and gloves for all high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with catheter, assisting with J-tube, and wound care. Date initiated: 1/13/25 . During an observation on 02/11/25 at 10:53 AM in Resident #4's room, Certified Nursing Assistant (CNA) F and CNA P were preparing to provide a bed bath and incontinence care for the resident. Resident #4's room was posted with signage indicating that EBP were in place. Resident #4 was observed lying in bed, with tube feeding running via J tube, and a foley catheter. The CNA's donned gowns and gloves and began preparing the wash basin and repositioning Resident #4 in her bed. CNA P was delegated to perform the washing and CNA F was assisting. CNA P used a wash cloth to clean Resident #4's face and lips, and then provided the resident a drink of water. Then with the same gloves on, CNA P obtained wash clothes and water basins out of the residents dresser. At 10:59 AM Licensed Practical Nurse (LPN) R was in the room to turn off the resident's tube feeding. CNA P then began washing Resident #4's upper body, then applied deodorant to the resident's armpits. CNA P removed the positioning wedge that was under the resident's legs and feet. The CNA's positioned the resident onto her side to wash her back. The resident was unable to tolerate and needed to be repositioned and rest for a minute. CNA F then left the room and CNA I came in to help with care. With the same gloves on, CNA P continued with Resident #4's care. CNA P used a wash cloth and cleaned Resident #4's anal area, where there was feces observed on the wash cloth, and a bandage covering her coccyx (tailbone area). CNA P handled Resident #4's tube feeding J tube and reported that it appeared to be leaking. CNA P finished cares, repositioned Resident #4, handled the bedding, moved the table, used the bed controls to raise the head of bed. CNA P did not change her gloves, or perform hand hygiene when moving from dirty to clean, or at any point during Resident #4's care. CNA P exited the room and used hand sanitizer that was in the hallway. In an interview on 02/11/25 at 01:14 PM, Infection Preventionist (IP) M reported that an audit of hand hygiene had been performed recently and they had discovered the need for further education. IP M reported that therapy staff should be donning PPE when performing therapy services in a resident's room when EBP orders were in place. Resident #12 Review of an admission Record revealed Resident #12 was a female, with pertinent diagnoses which included: neuromuscular dysfunction of bladder, unspecified. In an observation on 2/10/25 at 11:26 AM, it was noted that there was a sign on Resident #12's door indicating she was on Enhanced Barrier Precautions. There was a cart with PPE (personal protective equipment) outside of Resident #12's room in the hallway. Review of Resident #12's physician's order revealed, Straight cath (catheterize) via suprapubic using 14 fr (French - size of catheter) catheter every 6 hours and PRN (as needed). Flush at end of cath with 100mL (milliliters) or (sic) normal saline or sterile water four times a day AND as needed Other Active 1/11/2024 Review of Resident #12's current Care Plan revealed, (Resident #12) requires enhanced barrier precautions r/t (related to) intermittent catheterization, hx (history) of recurrent UTIs (urinary tract infections) and urosepsis Date Initiated: 04/23/2024 In an observation/interview on 2/10/25 beginning at 1:29 PM, Resident #12 was seated in her room in her wheelchair. There was a staff member (Occupational Therapy Assistant (OTA) S) present in the room with Resident #12. It was noted that OTA S was not wearing any PPE and was assisting the resident, hands-on, with what appeared to be arm exercises. As OTA S exited Resident #12's room, this surveyor queried OTA S what she had been assisting Resident #12 with while she had been in her room. OTA S reported she had been adjusting Resident #12's splint and was working on upper extremity (arm) range of motion exercises to decrease pain. When queried as to whether PPE should have been worn while working with Resident #12, OTA S reported it was not necessary for staff to wear PPE while working with Resident #12 unless they were touching her catheter in any way. OTA S reported she did not need to wear PPE, including gloves, when touching the resident to do range of motion exercises. According to the the Centers for Disease Control Frequently Asked Questions (FAQ's) about Enhanced Barrier Precautions in Nursing Homes (June 28, 2024) revealed, . 26. Is Physical or Occupational Therapy considered a high-contact resident care activity? Yes. Therapists should use gowns and gloves when working with residents on Enhanced Barrier Precautions in the therapy gym or in the resident ' s room if they anticipate close physical contact while assisting with transfers, mobility, or any high contact activity. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During a tour of the kitchen, at 11:00 AM on 2/10/25, an interview with Certified Dietary Manager (CDM) K, found that the stand up mixer does not get used very often. Upon taking the plastic cover off the mixer, it was observed to have white and yellow dried crusted debris on the inside of the shield / grate of the unit. When asked if she could see the accumulation, CDM K nodded. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . During an interview with CDM K, at 11:18 AM on 2/10/25, it was found that staff cool food and keep a log of their process. A review of the Rapid Cooling Monitoring Chart, dated July 2024 to January 2025, found that logged cooling for stuffed pepper soup, minestrone soup, and turkey, were all logged that they did not reach 70F within two hours of cooling. The bottom of the log states Cool foods from 135F to 70F within 2 hours, and then from 70F to 41F in 4 hours, for a total cooling time of 6 hours maximum. A review of the logged cooling for stuffed pepper soup, not dated, was found to have been 140F at 1:00 PM, 133F at 2:00 PM, and 72F at 4:00 PM. A review of the logged cooling for minestrone soup, not dated, was found to have been 150F at 5:30 PM, 100F at 7:00 PM, 81F at 8:00 PM, and 30F the next morning at 6:30 AM. A review of the logged cooling for turkey, dated on the log for 11/29/24, was found to have been 135F at 2:00 PM, 90F at 4:00 PM, and 39F at 7:00 PM. When asked if this item was served to residents, CDM K stated it was. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less . During a tour of the [NAME] kitchen, at 11:50 AM on 2/10/25, it was observed that pre cooked bacon was found open and exposed in the freezer. CDM K stated that it should be covered or wrapped. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: . (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings . During a tour of the [NAME] kitchen, at 11:52 AM on 2/10/25, it was observed that three buckets of solution were found on the kitchen counter. A green bucket for soapy water, red bucket for sanitizer, and white bucket labeled with disinfectant. When asked what the disinfectant is used for, CDM K stated that staff only use it for tables and surfaces in the dining room, and that usually the disinfectant is not stored on the counter in the kitchen. At this time, the disinfectant was tested with the facilities QT-40 Hydrion quaternary ammonium test kit, and found to be well over the 500 parts per million maximum on the strip. According to the 2022 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. During a tour of the Hillside kitchen, at 12:01 PM on 2/11/25, it was observed that an expired blueberry yogurt was found in the refrigeration unit with a best by date of Feb52025. During a tour of the [NAME] kitchen, at 12:10 PM on 2/11/25, it was found that six yogurts were found passed their best by dates. Two blueberry yogurts dated best by Feb52025 and four strawberry yogurts dates best by Feb42025. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .

Based on observation, interview, and record review the facility failed to develop a baseline care plan for 1 of 12 residents (Resident #232) reviewed for baseline care plans, resulting in the potential for unmet care needs. Findings include: Review of an admission Record revealed Resident #232 had pertinent diagnoses which included: hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominate side and weakness. During an observation on 4/16/24 at 12:29 PM., Resident #232 was seated in his wheelchair, leaning to his left side, at a table in the dining room with his food on the table in front of him and made no attempt to initiate eating. During an observation on 4/16/24 at 12:35 PM., Certified Nurse Assistant (CNA) EE was sitting at the table in the dining room with Resident #232. CNA EE was assisting Resident #232 to eat his lunch. In an interview on 4/16/24 at 12:45 PM., CNA EE reported that Resident #232 was new to the facility, and she was not sure what assistance he required. Review of Resident #232's electronic medical record revealed no noted baseline care plan. In an interview on 4/17/24 at 12:54 PM., Registered Nurse/Nurse Educator (RN/NE) O reported that baseline care plans should be started at admission. RN/NE O reported that a baseline care plan was a resident's basic needs for care and should include things like ADLs (activities of daily living) and transfer status. In an interview on 4/17/24 at 1:04 PM., Director on Nursing (DON) B reported that a paper copy of a baseline care plan was placed into the resident's closet. DON B reported that if an admission occurred on a weekend, the baseline care plan was completed on the following Monday. During an observation on 4/17/24 at 1:10 PM., observed taped to the inside the closet door in Resident #232's room was a paper titled . Care Guide. This paper was observed to have two different types of transfer status information for Resident #232 which included CGA (contact guard assist) x 1 (one person) with a 2 wheeled walker plus a gait belt and a mechanical lift. During an observation on 4/17/24 at 1:29 PM., CNA F transferred Resident #232 from wheelchair into bed with a gait belt and a front wheeled walker. In an interview on 4/17/24 at 1:50 PM., CNA F confirmed that the Care Guide on the inside of Resident #232's closet door did indicate two different types of transfers. When asked how CNA F knew the transfer status of Resident #232, CNA F reported the blue card pined to the cork board next to the resident's bed that revealed a number 1 was her indication that Resident #232 was a one-person transfer. In an interview on 4/18/24 at 10:29 AM., Minimum Data Set/Registered Nurse MDS/RN R reported that the admission nurse should start a baseline care plan. MDS/RN R reported she was responsible for baseline care plans. MDS/RN R reported she was absent from work for two days following Resident #232's admission and did not complete his baseline care plan within 24-48 hours of admission. MDS/RN R reported that the paper care guide taped to the inside of Resident #232's closet door was not his baseline care plan. In an interview on 4/18/24 at 10:56 AM., DON B was asked who was responsible for baseline care plans when MDS/RN R was absent from work and DON B responded RN/NE O was able to complete care plans and so can I . In an interview on 4/18/24 at 11:17 AM., RN/NE O reported that Resident #232's baseline care plan was not completed because MDS/RN R was absent from work. RN/NE O reported that the paper care guide in Resident #232's closet was not a baseline care plan. RN/NE O reported that care plans were now a part of her responsibilities. RN/NE O stated .I didn't know it was up to me to complete baseline care plans. Review of facility policy Baseline Care Plan with an implementation date of 9/2023 reviewed by DON B and Nursing Home Administrator (NHA) A revealed .the baseline care plan will be developed within 48 hours of a resident's admission .a supervising nurse shall verify within 48 hours that a baseline care plan has been developed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 Review of an admission Record revealed Resident #11 had pertinent diagnoses which included: Schizoaffective disorder bipolar type (mental health disorder that can include hallucinations and delusions along with mood swings), restlessness and agitation and post-traumatic stress disorder (PTSD), chronic (a mental health disorder that is triggered by an event and symptoms can include flashbacks, nightmares, anxiety, and/or uncontrollable thoughts about the event). Review of a Minimum Data Set (MDS) assessment for Resident # 11, with a reference date of 3/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #11 was cognitively intact. Review of Resident #11's medical record revealed a diagnosis of post traumatic stress disorder. In an interview on 4/16/24 at 12:57 PM., Resident #11 reported she had symptoms of PTSD. Resident #11 stated there is a lady who lives here that is a trigger for me, and staff is aware . Review of Care Plan for Resident #11 revealed no noted care plan for PTSD or any triggers. Review of Social Work Note for Resident #11 dated 4/12/24 revealed .continues to acknowledge becoming triggered by another resident's personality that she perceives as negative . In an interview on 4/16/24 at 1:04 PM., Certified Nurse Assistant (CNA) F reported that Resident #11 and another resident had to be kept separated due to not getting along. In an interview on 4/17/24 at 2:30 PM., Social Worker (SW) V reported that she was responsible for care plans related to mood and behaviors. SW V reported that a resident with a diagnosis of PTSD, that does have triggers should have a care plan with the triggers listed. In an interview on 4/18/24 at 9:10 AM., Registered Nurse (RN) T reported that Resident #11 did have another resident that was a direct trigger for her. In an interview on 4/18/24 at 11:24 AM., Registered Nurse/Nurse Educator (RN/NE) O reported that Resident #11 was fixated on another resident and has had verbal altercations with this same resident. RN/NE O reported that this same resident was a trigger for Resident #11. In an interview on 4/18/24 at 11:28 AM., SW V reported that Resident #11 and another resident that she disliked have argued but this was not considered a trigger for Resident #11 and was not listed on Resident #11's care plan. SW V reported that Resident #11 did not have a specific care plan in place related to a PTSD diagnosis and any triggers. In an interview on 4/18/24 at 11:53 PM., Nursing Home Administrator (NHA) A reported that Resident #11 had become obsessed with a peer, did have a fixation on the same peer, and Resident #11 does have many different triggers. NHA A reported that there was no care plan for PTSD and triggers for Resident #11. Based on observation, interview, and record review, the facility failed to develop and implement person centered comprehensive care plans for 2 of 12 residents (R9 and R11) reviewed for care planning, resulting in the potential of a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: R9 According to the Minimum Data Set (MDS) dated [DATE], R9 scored 14/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), had no impairments in his arms but did have impairment in his legs, and was independent in rolling left and right. Section M: Skin Conditions indicated R9 was at risk for pressure ulcers, had 1 or more unhealed pressure ulcers with 1 unstageable suspected deep tissue injury in evolution. During an observation and interview on 4/16/24 at 10:42 AM, R9 reported he was able to reposition the top portion of his body from his waist and hips side to side. Resident demonstrated moving side to side without lifting his bottom off the mattress. Certified Nursing Assistant (CNA) I stated, He (referring to R9) is red on his bottom. R9 reported he thought he had a sore on his bottom. During an observation of R9 and interview on 4/16/24 at 10:55 AM, Registered Nurse (RN) S measured a wound on right buttock at 5.5 cm x 2 cm while describing it as shearing. The skin was clear of any barrier cream. The RN stated, (R9) does not use a pad underneath his bottom because of the shearing. He scoots his bottom around. Staff monitor it and put barrier cream on it. I will chart the shearing in a skin assessment, tell the DON (Director of Nursing), and put a note in the doctor book so the PA (Physician's Assistant) will see it tomorrow. Observed the RN applying barrier cream to the shearing. The resident was not wearing underwear under a hospital gown and was lying on wrinkled sheets. During an observation on 4/17/24 at 10:34 AM, R9 was sitting in bed at 45 degrees with his knees bent while wearing a hospital gown and no underwear. His sheets were wrinkled under his bottom. He was on an air mattress set at a comfort level of 4 and alternating pressure. Review of R9's Braden (Scale for Predicting Pressure Sore Risk) dated 4/11/24 at 2:21 PM, indicated the resident was AT RISK with a score of 16.0 with slightly limited sensory perception, skin occasionally moist, chairfast, makes frequent though slight changes in body or extremity position independently, FRICTION & SHEAR as a potential problem during a move the skin probably slides to some extent against sheets .AT RISK 15-18. Review of R9's Order Summary, dated 2/6/24, revealed, Apply Desitin (barrier cream) to bilateral buttocks each shift. Every shift for skin protectant. Review of R9's Order Summary dated 4/16/24 at 11:05 AM indicated staff were to monitor sheering to left buttock and apply Desitin as needed every shift. Review of R9's Care Plan on 4/17/24 and 4/18/24 01:38 PM revealed there was no person-centered treatment plan for shearing to the resident's right buttock. It was noted there was a Care Plan for the resident with foci for malnutrition related to left hell pressure sore (4/9/24), chronic pain related to pressure injuries to buttock (11/3/23), deep tissue injury to bilateral buttocks .stage 2 pressure injury to his coccyx which occurred during stay at facility .deep tissue injury to left heel which occurred at facility . (11/3/23). Review of R9's [NAME] (care guide to direct Certified Nursing Assistant (CNA) person-centered care) did not indicate a treatment guide under Wound Dressing or Monitoring for the shearing on buttock area. Review of R9's Progress Note, dated 4/16/2024 at 11:00 AM, revealed, Health Status Note, Note Text: Shearing noted to left buttock. 5.5 cm (centimeter) x 2 cm. (Director of Nursing (DON) B) notified .order placed in TAR to monitor area. Skin assessment completed. Review of R9's Progress Note, dated 4/17/2024 at 2:27 PM, revealed, Health Status Note, Note Text: Special visit with (name of Medical Doctor) . Skin to buttocks examined. Very small areas of shearing to right buttock. Continue with Desitin application. Resident remains on air mattress. Skin to feet and heels also assessed. Skin intact, heels boggy to touch slowly bleachable . During an interview and record review on 4/18/24 at 11:50 AM, DON B stated, Care Plans are done by (MDS R) who does most of them, probably 95%. She attends the daily Huddles where skin integrity concerns would be discussed and then she puts the concerns in a Care Plan. She is to go to HUDDLE, take the information from them and do care plans. (MDS R) would be responsible for doing the care plan for (R9's) skin shearing. I do not know if she attended the HUDDLE when (R9's) skin was talked about. The facility does not have staff nurses get into or do care plans because they get wonky with them. They do not know the program. I guess I could train the nurses on how to do care plans in the system. If a nurse finds an issue with skin integrity, they write a progress note and tell me. The doctor and I looked at (R9's) shearing yesterday (4/17/24). It was shearing and did not look too exciting to me. During an interview and record review on 4/18/24 at 12:40 PM, RN/MDS Coordinator R stated, I attend HUDDLE up to twice a day, depending if a new nurse comes on at the afternoon shift. I was not at the facility on Monday (4/15/24) or Tuesday (4/16/24). I did not do a care plan for (R9's) skin shearing when I came back to work on Wednesday (4/17/24). I saw the wound today and did change the order from his left buttock to his right buttock. The area has just a little bit of shearing. (R9) has a history of pressure wounds. He came to the facility with one on his buttock (3/30/23) and developed another wound on his heel that has healed. Is the facility supposed to do a care plan for every little bruise and bump? Nurses do not develop Care Plans. That is left to me. If I am gone for an extended time the two other leadership nurses, (DON B and Nurse Educator) I guess could do Care Plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of facility policy, Routine and Transmission Based Cleaning and Disinfecting, with a reference date of 3/2023, revealed a statement This facility will ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .to prevent the development of and transmission of infections .consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas. During an observation on 04/18/24 at 10:18 am, Resident #26 sat with Activity Assistant (AA) DD at a dining table in the memory care unit common area and colored a picture using colored pencils. Approximately 50 colored pencils were available in a plastic storage container. AA DD reported the pencils were for community use. AA DD reported during the pandemic, resident's had their own coloring supplies in effort to avoid cross contamination. During an observation on 4/18/24 at 10:19am, Resident #26 dropped a maroon-colored pencil on the floor. The floor under the table was soiled with food particles from breakfast. AA DD retrieved the pencil from the floor and handed it back to Resident #26 without cleaning it. Resident #26 continuing coloring, then selected a new colored pencil a few minutes later and the maroon pencil was returned to the shared box of supplies. In an interview on 04/18/24 at 10:22 AM, (AA) DD reported there was no set schedule for cleaning activity supplies, and items were just cleaned as needed. AA DD added unless someone is sick, we clean on demand. In an interview on 4/18/24 at 9:41am, Infection Preventionist/Director of Nursing (DON) B reported the Activity Director (AD) C had a schedule for cleaning of shared activity supplies, including the sensory supplies that were available for all residents in the day room and other common areas. In an interview 04/18/24 01:40 PM, AD C reported the activity supplies in the common areas should be cleaned by the responsible staff after each use. AD C reported the supplies were easily accessible by all residents and could be touched by several residents. When told the activity supplies in the day room appeared soiled, AD C stated I'm not surprised. I should work on a cleaning schedule to make sure items are cleaned. AD C reported he developed policies for cleaning of bingo supplies, the supplies used for balloon toss, and for personal fidget items, but had not developed a schedule for cleaning activity supplies that were available to all residents in the common areas of the facility. AD C reported the facility also did not have a cleaning procedure for a companion robot cat and he planned to determine the best method for cleaning it. AD C reported the device had been in use for several weeks, had not been cleaned, and was kept in the common area where multiple residents could access it. During an observation on 4/18/24 at 10:17am, a companion robotic cat (an interactive sensory stimulation tool designed to encourage residents to touch and hold it as they would a cat) sat on the dining table in the common area of the memory care unit. The robotic cat was covered with faux fur. During an observation on 04/18/24 at 12:13 PM, sensory stimulation items including a tackle box with simulated fishing supplies, and a toggle switch board were stored on an open shelf in the day room. The shelf was easily accessible and stood approximately 3' high. The sensory toggle switch board was soiled with 3 spots of dried brown liquid on the top of the device, adjacent to the toggle switches. The outside of the tackle box was soiled with a 3 area of dried brown liquid. The inside of the lid was soiled with more than 30 white flakes that appeared to be dried skin. A dried white substance was also present on the lid. The upper tray of the box was soiled with dried brown liquid, and sticky residue was present on the handle of a plastic clamp in the bottom of the box. In an interview on 04/18/24 at 12:39 PM Housekeeper BB reported she cleaned the resident day room, including the activity supplies in the room (wiped them down) on this date, and the expectation was that any staff member that distributed the activity supplies would clean them after use. During an observation on 4/18/24 at 1:31pm a handheld toggle switch board that sat on the open shelf in the day room, was noted to be soiled with 3 spots of dried brown liquid. The spots were near the toggle switches and along the edge where a user would place their hand to hold the device. During an observation on 04/18/24 at 01:33 PM the soiled tackle box was opened and sat on the table in the day room, the dried brown liquid remained on end of box, dusty debris remained on the inside of the lid, along with the white dried liquid also on the inside of the box. In an interview on 4/18/24 at 1:54pm, DON B confirmed the toggle switch board and tackle box were soiled and should have been cleaned after each use in order to maintain sanitary conditions and reduce the potential for cross-contamination. Based on observation and interview the facility failed to properly store clean and sanitary items, maintain laundry equipment, and clean resident shared equipment. These conditions resulted in the increased risk of clean and sanitary items and equipment to become contaminated before use, increasing the risk of negative outcomes for the resident population. Findings include: During a tour of the facility, with Maintenance Director FF, starting at 9:27 AM on 4/17/24, the following observations were made: The Hillcrest North linen closet found an accumulation of dust and debris located underneath the bottom open wire racks, leaving clean linens open and exposed to possible contamination from cleaning. The clean utility room in [NAME] was found with a cardboard covering on shelves containing clean and sanitary personal hygiene products. An observation of the private bathroom in room [ROOM NUMBER] found a cloth chair stored between the shower and the commode. The Hillcrest South spa was found with cleaning products and personal hygiene products stored commingled in the floor cabinet. The Hillcrest South linen closet was found with an accumulation of dust and debris under the bottom rack and no bottom barrier to protect clean linens from contamination due to cleaning. The Oxygen supply room was found with a dozen packs of oxygen tubing stored underneath the wastewater line of the sink. An observation of the beauty shop found hygiene products and hair care items stored underneath the wastewater line of the sink. Observation of the laundry room found three linen carts used to process and store linens, When asked if these carts would be used for clean linen, Laundry Aide GG, stated yes. The carts were found to be ripped, tattered, and torn with numerous openings in each cart. One of the carts false bottom had been replaced with a piece of plywood that is not smooth and easily cleanable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a dignified dining experience for 3 of 3 residents (Residents #3, #8, #14) reviewed for eating assistance, from a total sample of 12, resulting in a potential for feelings of frustration and decreased sense of self worth. Findings include: Resident #3 A review of a Face Sheet dated 9/29/21 revealed Resident #3 was admitted to the facility with pertinent diagnoses that included vascular dementia, psychotic disorder with delusions, major depressive disorder with psychotic symptoms and weakness. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 required extensive assistance for eating. Resident #8 A review of a Face Sheet dated 6/16/20 revealed Resident #8 was admitted to the facility with pertinent diagnoses that included frontotemporal dementia, chronic pain syndrome, and psychotic disorder with delusions. A review of a Minimum Data Set(MDS) assessment dated [DATE] revealed Resident #8 required total assistance with eating. Resident #14 A review of a Face Sheet dated 6/2/21 revealed Resident #14 was admitted to the facility with pertinent diagnoses that included dementia, cognitive communication deficit, muscle weakness. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 required extensive assistance with eating. During an observation on 2/21/23 at 12:23pm, Resident Assistant (RA) N was observed standing next to Resident #14 in the dining room, loading a spoon with food from the Resident's plate and then bringing the food to the Resident's mouth. RA N then sanitized her hands, walked to Resident #3's side, stood next to the Resident, loaded a spoon with food from that Resident's plate and brought the food to Resident #3's mouth. 4 Residents who needed assistance with eating were present at this time. RA N was the only staff member assisting the residents with eating. During an observation on 2/22/23 at 9:09 am, Resident Assistant (RA) N was observed standing next to Resident #8, loading the Resident's spoon with food and bringing the spoon to Resident #8's mouth. 5 residents who needed assistance were present at this time. RA N was the only staff member assisting the residents with eating. In an interview on 2/22/23 at 9:11am, Resident Assistant (RA) N reported she learned in feeding assistant training that the proper technique for assisting residents with eating was to sit next to them rather than stand. RA N indicated she was the only staff member assisting the residents with eating which made it difficult to follow the proper technique. Residents were observed waiting, at times staring at their plates, unable to attempt to feed themselves as RA N assisted other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury among residents who reside in the South and East 100 Halls. Findings Include: During a tour of the facility, at 3:27 PM on 2/21/23, observation of empty resident room [ROOM NUMBER], found that the bathroom sink temperature reached 124°F while using a rapid read thermometer. At this time, the surveyor went to empty rooms 158 (across the hall) and 163 (down the hall) and ran the hot water for 5 minutes without reaching the 120°F. At 3:38 PM on 2/21/23, the temperature of the 100 hall spa sink was found to be 125.3°F At 3:39 PM on 2/21/23, the temperature of resident room [ROOM NUMBER]'s bathroom sink was found to be 126.5°F At 3:41 PM on 2/21/23, the temperature of resident room [ROOM NUMBER]'s bathroom sink was found to be 122.5°F At 3:47 PM on 2/21/23, the surveyor went to the end of the 100 East hall, room [ROOM NUMBER]. The bathroom sink to empty resident room [ROOM NUMBER] was found to be 122.5°F. At 3:51 PM on 2/21/23, the surveyor informed NHA A that there were concerns regarding excessive hot water at some domestic resident fixtures. NHA A stated that there had been a vendor working on the system and they may still be onsite. At 3:54 PM on 2/21/23, the surveyor and NHA A went to the boiler room. Upon reaching the boiler room it was found the vendor had left the building and NHA A left to report the issue. At this time, the surveyor observed the storage tank labeled Domestic 112°F-118°F and found the outgoing thermometer showed domestic hot water leaving the boiler room at 125°F. At 4:12 PM on 2/21/23, an interview with NHA A found that the vendor had been contacted and was working on the issue remotely, but has concerns about the water temperatures dropping too low during peak demand. The NHA stated that when temperatures were taken this afternoon, it was during low demand when the system heats up the most. At 4:18 PM on 2/21/23, a temperature of the 100 hall spa sink was found to be 121°F. At 4:20 PM on 2/21/23, a temperature of resident room [ROOM NUMBER] was found to be 122°F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain proper storage temperatures in 2 of 2 medication refrigerators in the main medication room, resulting in the potential for decreased potency and efficacy of medications and the exacerbation of resident medical conditions. Findings include: In an observation on 2/22/2023 at 9:45 AM, the Med room [ROOM NUMBER] Refrigerator/Freezer Temperature Check Sheet documented the temperature in the resident medication refrigerator to be 35 degrees Fahrenheit on 2/3/2023, 35 on 2/4/2023, 35 on 2/5/2023, 34 on 2/6/2023, 33 on 2/15/2023, 34 on 2/17/2023, 34 on 2/18/2023, 34 on 2/19/2023, 34 on 2/20/2023, and 33 on 2/21/2023. The Med room [ROOM NUMBER] Refrigerator/Freezer Temperature Check Sheet documented the temperature in the resident vaccine refrigerator to be 34 degrees Fahrenheit on 2/4/2023, 34 on 2/5/2023, 34 on 2/6/2023, 34 on 2/7/2023, 34 on 2/8/2023, 35 on 2/9/2023, 33 on 2/10/2023, 33 on 2/10/2023, 35 on 2/13/2023, 35 on 2/14/2023, 33 on 2/16/2023, 35 on 2/17/2023, and 32 on 2/21/2023. In an interview on 2/22/2023 at 9:45 AM, LPN (Licensed Practical Nurse) J reported that she was not certain what temperature range the medication and vaccine refrigerators are required to be kept at. LPN J reported that she believed the required temperature range was between 36 and 42 degrees Fahrenheit. In an interview on 2/22/2023 at 9:45 AM, DON (Director of Nursing) B reported that nursing staff are required to adjust the refrigerators if the temperature is out the required range. DON B reported that these adjustments are not documented. In an email correspondence received on 2/22/2023 at 3:23 PM, NHA (Nursing Home Administrator) A reported that the facility follows their pharmacy's guidelines regarding the storage of pharmaceuticals. In an email correspondence received on 2/22/2023 at 3:34 PM, NHA (Nursing Home Administrator) A reported that adjustments made to refrigerator temperatures are not documented. Review of facility policy/procedure Medication Cart/Medication Room, revised 11/2021, revealed .Medications that require refrigeration or freezing are kept in the refrigerator or freezer in the locked medication room. Daily checks of temperatures are recorded to ensure proper temperatures . Review of the facility pharmacy's Medication Storage Guidance, dated 2022, revealed that refrigerated medications and vaccines were required to be stored between 36 and 46 degrees Fahrenheit.