**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 dependent residents (R5 and R20) of 4 residents reviewed for availability of call lights. Findings include:R5Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking and generalized anxiety disorder.Review of current activities of daily living Care Plan interventions for R5, initiated 10/1/2023, directed staff to place the resident's call light within reach and encourage the resident to use the call light to request assistance as needed.In an observation and interview on 7/29/2025 at 10:43 AM in R5's room, R5 was in her bed and her call light was under the end of her bed and out of reach. R5 reported she was able to use her call light to request assistance but sometimes the call light was left out of her reach.In an interview on 7/31/2025 at 11:44 AM, Certified Nursing Assistant (CNA) C reported R5 was able to use her call light to call for assistance.R20Review of an admission Record revealed R20 admitted to the facility on [DATE] with pertinent diagnoses which included overactive bladder and anxiety.Review of current activities of daily living Care Plan interventions for R20, initiated 7/27/2023, directed staff to place the resident's call light within reach and encourage the resident to use the call light to request assistance as needed.In an observation and interview on 7/29/2025 at 10:31 AM in R20's room, R20 was in her bed and her call light was hanging off the head of the bed behind the headboard and out of reach of the resident. R20 reported she was normally able to use her call light but could not find it.In an interview on 7/31/2025 at 11:44 AM, Certified Nursing Assistant (CNA) C reported R20 was able to use her call light to call for assistance.Review of facility policy/procedure Call Lights: Accessibility and Timely Response, Revised 12/28/2023, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative of a fall with injury for 1 resident (R2) of 2 residents reviewed for falls.Findings include:Review of an admission Record revealed R2 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and muscle weakness. Further review revealed R2 had two activated medical Power of Attorney's (POA).Review of R2's Un-witnessed Fall report dated 1/11/2025 at 6:45 PM revealed R2 fell in his room and sustained a superficial cut to his right eye and was experiencing wrist pain. Further review revealed nursing staff contacted the on-call nurse and physician but there was no documentation that the medical POA was contacted.In a telephone interview on 7/31/2025 at 10:14 AM, POA of R2 A reported she did not receive notification from the facility on 1/11/2025 when he fell.Review of R2's fall follow up Standards of Care Meeting documentation, dated 1/13/2025 at 2:57 PM, revealed documentation that R2's responsible party was notified of the fall with injury on 1/11/2025. Further review of R2's progress notes revealed no confirmation that the responsible party was notified the evening of 1/11/2025.In an interview on 7/31/2025 at 10:44 AM, the Director of Nursing (DON) reviewed documentation from the electronic medical record and reported she did not have any documentation to verify R2's responsible party was contacted at the time of his fall with injury on 1/11/2025. The DON reported that the responsible party should have been notified at the time of this fall with injury.Review of facility policy/procedure Notification of Changes, revised 8/29/2024, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. circumstances requiring notification include. accidents resulting in injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement care planned fall interventions for 1 resident (R2) of 2 residents reviewed for falls.Findings include:Review of an admission Record revealed R2 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and muscle weakness. Review of a current risk for fall Care Plan intervention for R2, initiated 8/25/2023, revealed R2 was to have grip strips in front of the toilet in his bathroom.In an observation on 7/30/2025 at 3:29 PM in R2's bathroom there were no grip strips in front of the toilet.In an interview on 7/31/2025 at 10:26 AM, the Director of Nursing (DON) reported she was not aware grip strips were not in R2's bathroom. The DON reported the floor might have been waxed and the grip strips not replaced afterwards.Review of facility policy/procedure Comprehensive Care Plans, revised 6/30/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly label an ordered tube feeding for one resident (Resident #69) out of three residents reviewed for tube feeding. Findings: Resident #69 (R69)Review of an admission Record revealed R68 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of acute respiratory failure that required a tracheostomy and tube feed for nutrition and hydration. During an observation on 07/29/25 at 1:09 PM, the tube feed bag for R69 contained the following information on the bag: (a) 07/28/25, and (b) 1600 (4 PM). During an interview on 07/31/25 at 8:20 AM, Unit Manager/Registered Nurse (UM/RN) N indicated that the expectation for labeling tube feed bags included the nurse's initials, the date and time the feed was started, the ordered rate of the feed, the residents name, and the type of formula used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to (a) offer ordered nebulizer treatments and (b) adequately clean nebulizer equipment for one resident (Resident #1) out of two residents reviewed for respiratory care. Findings:Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, last re-admitted to the facility on [DATE] following a hospitalization for a bowel obstruction and pneumonia. During an observation on 07/29/25 at 10:32 AM, R1's nebulizer mouthpiece, with the medicine cup attached, sat in a clear plastic bag on the resident's bedside nightstand. Moisture could be seen inside the bag and on the nebulizer equipment. R1 indicated that she had just received a breathing treatment, and staff had not taken it apart and washed it. Rather, staff placed the whole thing in the bag right after she completed the treatment. During an interview on 07/31/25 at 7:26 AM, R1 stated that she had not received any breathing treatments (nebulizer) yesterday or so far today. R1 stated that staff had not offered her the breathing treatments. I was getting them every four hours and then nothing. R1 stated that a breathing treatment was always helpful as she was still recovering from pneumonia. R1 also stated that she had not refused any breathing treatments. Review of an electronic medication administration record (Emar) dated July 2025, for R1 revealed the resident had not received a breathing treatment (nebulizer) since 6:00 PM on 07/29/25. Documentation provided by nursing as to why the nebulizer treatments had not been given to R1 reflected that the resident had refused the treatments. The order for the nebulizer treatment was for 1 treatment every 6 hours. R1 had not received the last six breathing treatments that were available to her as ordered by the physician. Review of the facility policy Small Volume Nebulizer reflected the following steps for cleaning the nebulizer equipment: (1) twist open the nebulizer cup and dump out any residual remaining from treatment, (2) rinse nebulizer cup and components with water, (3) allow nebulizer cup and components to airdry on a clean absorbent towel, and (4) once dry store the nebulizer cup and mouthpiece in a bag and label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately document narcotic administration for one of three residents (Resident #4) reviewed for pharmacy services. Findings:Review of an admission Record revealed R4 was a [AGE] year-old-female, last re-admitted to the facility on [DATE]. with pertinent diagnoses of pneumonia and chronic pain syndrome. Review of a Controlled Substance Record (CSR) for R4 and for the medication (Norco) hydrocodone-apap 10-325 mg (milligrams) one tab every 4 hours as needed for pain, revealed documentation that one tablet was given to R4 on 07/31/25 at 10:00 AM. The review of the record occurred on 07/31/25 at 8:50 AM. During an interview on 07/31/25 at 8:54 AM R4 stated that she was positive that she received a Norco this morning, around 7:30 AM, with her other morning medications. Further review of the same CSR for R4 and the prescribed Norco showed that the previous dose of Norco was given that morning at 6:00 AM by the night nurse (RN O). During an interview on 07/31/25 at 9:00 AM Registered Nurse (RN) D stated that she had given R4 a dose of Norco this morning around 7:30 AM but wrote in 10:00 AM on the CSR to correct the time interval between the doses. RN D also stated that at shift exchange this morning and while reconciling (counting) narcotics, the night nurse (RN O) had not written in a time that a Norco tablet was given during the night shift, so RN O wrote in a time of 6:00 AM. At this point the surveyor called for the Director of Nursing (DON). It was determined through further interviews with R4 and nursing staff that the resident had in fact received the correct doses of Norco and thus ruled out the possibility of misappropriation of narcotics. During an interview on 07/31/25 at 9:25 AM, the DON indicated that nurses were expected to document the precise time a medication was given, especially a controlled substance. During an interview on 07/31/25 at 10:46 AM, RN I stated that it was very important for nurses to document accurately when narcotics are given because many of the narcotics are given for pain or anxiety and keeping them on schedule helps ensure the resident gets maximum control of the pain or anxiety provided by the medication.

Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings include: On 07/29/2025 at 9:55 AM, during the initial walkthrough of the kitchen it was observed that the drain line for the ice machine did not have an air gap, the drain line was below the flood rim of the drain. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 07/29/2025 at 11:25AM, Dietary [NAME] H was observed using the hand sink to fill water pitchers, pitchers were then observed being placed in refrigerator. On 07/30/2025 at 12:22 PM during interview with Certified Dietary Manager (CDM) K, when asked where pitchers were filled, CDM K indicated the process was to fill pitchers from the prep sink. According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing. (C) An automatic handwashing facility shall be used in accordance with manufacturer's instructions.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and to spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: On 7/29/2025 at 1:32 PM, observation noted at time of walkthrough of the facility with Maintenance Director (MD) F and Maintenance Director (MD) B; in the shower room on B Hall, there were water lines coming out of the wall and not attached to any equipment. MD B indicated that the lines were previously used for a tub, but it had been removed and were unaware of the lines used for other purposes. MD B and MD F were asked at that time if there was a flushing schedule for the facility. MD B stated there was no set flushing schedule for the facility but that the lines for the residents' rooms were flushed when the room had been empty and a resident was going to now occupy the room, and the facility lines were flushed if there was a positive Legionella sample. On 7/29/2025 at 1:50 PM, observed in shower room on D Hall, curtained off area that is plumbed as a shower but was currently in use as storage for a lift and 2 shower chairs. MD F was unaware if this shower was in use and if not in use if the lines were being flushed. On 7/31/2025 Operations Maintenance and Control Limits document, undated, from the water management plan was provided for review, this written document indicates that there is a flushing schedule for facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving tube feedings per facility policy and professional standards of care for 1 of 3 residents (Resident #61) reviewed for the care of tube feedings. Findings: Resident #61 (R61) Review of an admission Record revealed R61 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: adult failure to thrive and dysphagia (difficulty swallowing). Review of R61's Order Summary dated 7/15/24 revealed, Enteral Feed Order every day and night shift Check tube placement prior to administration of medications & tube feeding/flush. During an observation on 08/27/24 at 12:08 PM, Registered Nurse (RN) H had prepared medication to administer to R61 via his peg tube (feeding tube). RN H did not assess R61's gastric residual or peg tube placement. RN H then drew up the medication in a syringe (approximately 60 ml of liquid), connected the syringe to the peg tube port/adapter, and firmly pushed the plunger of the syringe until the medication was administered (less than 15 seconds). RN H did not remove the plunger of the syringe, connect the open syringe to the feeding tube port/adapter, and pour the water into the syringe allowing the water to flow in utilizing gravity. During an interview on 8/27/24 at 7:15 AM, RN S reported that the placement of a feeding tube and gastric residual should be assessed prior to the administration of medications and water boluses. During an interview on 8/28/24 at 8:22 AM, RN K reported that medication administration and water boluses should be administered using gravity and should not be pushed. RN K reported that the placement of a feeding tube is assessed prior to administering medications by using the syringe to inject air into the feeding tube while listening for a gurgling sound with a stethoscope of the peg tube site. During an interview on 8/28/24 at 7:10 AM, RN J reported that the placement of a feeding tube and gastric residual should be assessed prior to the administration of medications and water boluses. RN J reported that medication administration and water boluses should be administered using gravity and should not be pushed. During an interview on 8/28/24 at 2:07 PM, Director of Nursing (DON) reported that the licensed nurses were expected to follow the facility policy and procedures when administering medications via peg tube. DON was notified that the facility policy did not reflect how licensed nurses were to assess peg tube placement. DON reported she would review the policy and provide documentation of the procedure the facility nurses were to follow. DON did not provide clarification to the facility's procedural guidelines/policy verbally or in writing prior to survey exit (8/28/24 at approximately 5:00 PM). During an interview on 08/28/24 at 03:30 PM, Corporate Nurse (CN) R reported that unless otherwise ordered, licensed nurses should allow medications and water boluses to flow by gravity when utilizing the peg tube. CN R reported that she had recently updated the facility policy and procedures regarding the assessment of peg tube placement due to the change in the standards of practice and was waiting on corporate's (upper managements) approval to implement the changes and educate the licensed nurses. Review of the facility policy Feeding Tubes last reviewed/revised 6/30/22 revealed, .10. In accordance with facility protocol, licensed nurses should: a. Monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube) b. Tube Placement will be verified before beginning a feeding and before administering medications . 12. Direction for staff regarding how to manage and monitor the rate of flow will be provided: a. Use of gravity flow. b. Use of a pump . Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, PROCEDURAL GUIDELINES Administering Medications Through an Enteral Tube (Feeding Tube) .10. Before administration of enteral medications, verify placement of feeding tube according to agency policy and determine that tube is placed in the stomach or small intestine correctly .22. Check for gastric residual volume (GRV). Draw up 10 to 30 mL of air into a 60-mL syringe and connect syringe to feeding tube. Flush tube with air and pull back slowly to aspirate gastric contents . 25. Administer dose of first liquid or dissolved medication by pouring into syringe. Allow to flow by gravity. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 651-652). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Historically nurses confirmed placement of feeding tubes by injecting air into the tube while auscultating the stomach for a bubbling or gurgling sound or by asking the patient to speak. Current evidence shows that these methods are ineffective in verifying tube placement. Currently, the most accurate method for verification of tube placement is x-ray film examination. At the bedside, nurses test the pH of secretions withdrawn from the feeding tube to confirm tube location on an ongoing basis .PROCEDURAL STEPS: Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement .CLINICAL JUDGMENT: Listening for insufflated air instilled through tube to check tube tip position is unreliable . [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1198-1199). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the pneumococcal and influenza vaccination to 1 resident (Resident #29) of 5 residents reviewed for immunizations, resulting in the potential for residents to contract and spread preventable diseases. Findings include: Resident 29 Review of an admission Record revealed Resident #29 (R29) admitted to the facility on [DATE] with pertinent diagnoses which included dementia and peripheral vascular disease. Further review revealed R29 had an activated medical Power of Attorney (POA). Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 1, out of a total possible score of 15, which indicated Resident #29 was severely cognitively impaired. Review of R29's immunization record revealed the facility documented he refused the influenza and pneumococcal vaccinations. In an interview on 8/27/2024 at 1:44 PM, the Director of Nursing (DON) reported R29's POA consented to the influenza and pneumococcal vaccinations but could not find documentation that these were administered or refused. Review of R29's Influenza Vaccine Consent Form revealed his POA consented to the influenza vaccine on 11/7/2023. Review of R29's November 2023 Medication Administration Record revealed the influenza vaccine was ordered and scheduled to be given on 11/9/2023 or 11/10/2023 and the boxes were blank, indicating the vaccination was neither given nor refused. In an interview on 8/28/2024 at 10:20 AM, the DON reported she was unable to find documentation that R29 had received or refused the influenza and pneumococcal vaccinations. Review of facility policy/procedure Influenza Vaccination, revised 10/26/2023, revealed .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . Review of facility policy/procedure Pneumococcal Vaccine (Series), revised 10/30/2023, revealed .It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate smoking supervision and monitoring for 5 of 14 residents (Resident #25, #1, #27, #26, and #13) reviewed for accidents and safety. Findings: Review of the facility Acknowledgment of Facility Smoking Policy signed by residents deemed appropriate for smoking revealed, .1) Oxygen use is prohibited in smoking areas for the safety of residents. The facility will have a system for removal of the oxygen container, tubing, etc. while the resident is in a smoking area. These items will be kept at least 5 feet away from any smoking area. 2) Smoking items (Cigarettes, lighters, etc.) will be kept secured in a designated area with limited staff access. Residents shall not keep any smoking materials in resident rooms. 3) A list of smoking times will be given to those residents identified with smoking privileges. Residents will also be allowed to smoke in the designated smoking areas during off-scheduled times with a family member or visitor who is able to appropriately supervise the resident for smoking safety. 4) Only facility provided ashtrays shall be used. 5) The attending Physician and the Director of Nursing Services (DNS) shall have the authority to make the determination as to what restrictions, if any, will need to be placed on the resident's smoking privileges. 6) Any resident with smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period. 7) Residents with smoking privileges will be discouraged from smoking outside during inclement weather including storms and temperature extremes. 8) To promote safety for all residents and staff, residents with smoking privileges agree to allow staff to search the resident and resident room/belongings for smoking materials if the facility reasonable suspects smoking materials may be present in those locations. If smoking materials are located, they shall be secured in the facility designated location for smoking materials . Resident #25 (R25) Review of an admission Record revealed R25 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: left and right above knee amputation, dementia, and nicotine dependence. R25 was his own responsible party/decision maker. Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: polyneuropathy (nerve pain), adjustment disorder with mixed anxiety and depressed mood, and chronic pain syndrome. R1 was his own responsible party/decision maker. Review of R1's Care Plan revealed, Keep oxygen away from smoking materials. Ensure removal prior to resident smoking .Date Initiated: 09/26/2023. Review of R1's Nursing Quarterly/Significant Change Evaluation dated 7/30/24 revealed, .Safe Smoking Evaluation- 1. Does the resident currently smoke, use e-cigarettes, or tobacco products? No . Resident #27 (R27) Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: legal blindness, difficulty in walking, intellectual disabilities, convulsions, and muscle weakness. Review of R27's Nursing Quarterly/Significant Change Evaluation dated 6/14/24 revealed, .Safe Smoking Evaluation- 1. Does the resident currently smoke, use e-cigarettes, or tobacco products? No . Review of R27's Electronic Health Record revealed R27 had a court appointed guardian. There was no documentation reflecting that the guardian consented to R27 smoking cigarettes or that they consented to R27 leaving the facility to smoke cigarettes unsupervised. During an observation on 08/27/24 at 11:08 AM, R25 exited the facility through the front entrance in his motorized wheelchair and lit up a cigarette approximately 25 feet away in the center of the driveway. There were no staff, family, or visitors with him. During the observation a compact SUV drove down the driveway causing R25 to move to the sidewalk within 30 feet from the front door next to the D Wing. At 11:10 AM, R1 exited the facility through the front doors on his motorized wheelchair with an oxygen tank attached to the back and lit up a cigarette in the garden area of the circular driveway. There were no staff, family, or visitors with him. At 11:14 AM, R25 finished his cigarette and flicked the white cigarette filter on the woodchips outside of a resident window on the D Wing directly next to the building. There were greater than 10 white cigarette filters observed directly where R25 discarded his cigarette filter. R1 was observed nodding off (appearing sleepy, head dropped down towards his chest, and jerked awake) and then proceeded to ash his cigarette onto the woodchips in the garden area of the circular driveway. When R1 finished his cigarette, he flicked the cigarette until the ember of the cigarette fell to the pavement and unintentionally dropped the cigarette butt on the ground. R1 then stood out of his motorized wheelchair, bent over to pick up the cigarette butt causing him to stumble. R1 did not fall, obtained the butt and placed it in his cigarette container. At 11:24 AM, R1 reentered the facility. There were no staff, family, or visitors with him while he was outside smoking a cigarette. R1 did not utilize the smoking pavilion. At 11:32 AM, R25 reentered the facility. There were no staff, family, or visitors with him while he was outside smoking a cigarette. R25 did not utilize the smoking pavilion. At that time (11:32 AM), R27 exited the facility to smoke a cigarette utilizing the smoking pavilion. The pavilion did not contain a fire extinguisher or other fire suppression tools (fire blanket, fire alarm, etc). At 11:44 AM, R27 reentered the facility. There were no staff, family, or visitors present while he was outside smoking a cigarette. This writer followed R27 back into the facility. At 11:46 AM, a conversation between the front office staff and the Hospitality Aide (HA) F was heard. A front office staff member asked HA F if the smokers (R25, R1, and R27) had signed out of the book (leave of absence book/sign out sheet reflecting a residents location and the time they signed out and back in). HA F reported to the front office staff members that she was not aware that residents were required to sign out if they were not leaving the facility property and were going out to smoke. The Leave of Absence (LOA) logbook was reviewed for R25, R1, and R27 and did not reflect the date, time, and reason for exiting the building/location during the smoking observation period. HA F exited the front office and opened the LOA logbook to R27's record and confirmed that R27 did not sign himself out before exiting the building to smoke a cigarette. HA F reported that if a resident forgets/refuses to sign themselves out to smoke, then a staff member should document the date, time, and reason for leaving for the resident. At 11:54 AM, Scheduler (S) Q and Corporate Nurse (CN) R reported that staff were to keep residents smoking paraphernalia (cigarettes and lighters) locked up in the smoking cart and reported that residents that go out to smoke alone were to sign out of the LOA logbook. Resident #26 (R26) Review of an admission Record revealed R26 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol abuse, neuropathy, and need for assistance with personal care. R26 was his own responsible party/decision maker. Review of R26's Nursing Quarterly/Significant Change Evaluation dated 6/17/24 revealed, .Safe Smoking Evaluation- 1. Does the resident currently smoke, use e-cigarettes, or tobacco products? No . Review of R26's Care Plan revealed, .Resident will often refuse to return cigarettes to staff once done smoking. Staff to only given resident one cigarette at time, instead of entire pack Date Initiated: 08/26/2024. During an observation on 08/26/24 at 10:31 AM, R26 was in his room sitting on the side of his bed. There was a pack of cigarettes in the front pocket of his t-shirt. During an observation on 8/28/24 at 7:50 AM, R26 was exiting the facility to smoke a cigarette. R26 did not sign out of the LOA book. At 9:09 R26 was observed in his wheelchair in the hallway. Review of the LOA logbook on 8/28/24 at 9:15 AM revealed R26 was not signed out at the time he exited the facility to smoke or the time he returned related to above observation. Resident #13 (R13) Review of an admission Record revealed R13 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke affect the left side and epilepsy. R13 was her own responsible party/decision maker. During an observation on 8/28/24 at 07:50 AM, R13 exited the facility to smoke a cigarette. During an observation on 8/28/24 at 8:25 AM, R13 had returned to her room and was receiving her morning insulin. Review of the LOA logbook on 8/28/24 at 9:15 AM revealed R13 was not signed out at the time she exited the facility to smoke or the time she returned related to above observation. During an interview on 8/28/24 at 8:11 AM, Registered Nurse (RN) J reported that resident cigarettes were to be locked up in the smoking cart and residents were to sign themselves out of the LOA logbook if they were going out to smoke independently. During an interview on 08/28/24 at 02:02 PM, NHA confirmed that R1, R26, and R27's Safe Smoking Evaluations were not completed per the facility policy due to incorrect documentation (documented that they were non-smokers). NHA reported that the Director of Nursing would update the Safe Smoking Evaluations for R1, R26, and R27 by the end of the day. During an interview via email on 08/28/24 at 01:42 PM, Nursing Home Administrator (NHA) stated, (R27's) guardian (name omitted) is aware that he smokes and that he goes out alone. In the past she has not had any concerns related to this. My Social Worker (name omitted) called the office today to reconfirm that it's still okay that he does this. There remain no concerns. Confirming there was no documented consent to smoke by R27's guardian. Review of R27's Physician Progress Note dated 8/28/24 revealed, This author contacted (guardian name omitted) voluntary guardian and reconfirmed that (R27) can leave the facility independently if or shopping, banking and independent smoking. Review of the facility policy Smoking Safety last revised 11/28/17 (provided in the resident smoking binder on 8/27/24) revealed, . 1. The facility will have a designated smoking area for residents in accordance with Federal, State and other entities having jurisdiction laws. This area must be one that does not infringe upon the rights of the non-smoker. 2. Designated smoking areas will be equipped with a fire extinguisher which will be mounted in an area to allow free access by staff. 3. Smoking areas will have ashtrays made of noncombustible material and safe design as well as metal containers with self-closing covers into which ashtrays will be emptied at the conclusion of smoking sessions . 4. Oxygen use is prohibited in smoking areas for the safety of residents. The facility will have a system for removal of the oxygen container, tubing, etc. while the resident is in a smoking area. These items will be kept at least 5 feet away from any smoking area. 5. Smoking items (cigarettes, lighters, etc.) will be kept secured in a designated area with limited staff access. 6. All residents will be screened as part of the admission evaluation for smoking practices . 8. Each resident who chooses to smoke will be assessed to determine smoking safety. This may include, but not be limited to: *Cognitive patterns and safety awareness *Communication/hearing/vision *Physical abilities/deficits *Observations of the resident's physical and cognitive abilities 9. The smoking assessment will be completed upon admission, quarterly, with a significant change in status related to smoking, or anytime the facility determines it is warranted . 11. A comprehensive plan of care will be developed in conjunction with the Resident Assessment Instrument process . 13. Residents who smoke will have their specific interventions identified on the resident [NAME] for staff review . Review of the facility policy Smoking Policy Smoking Campus-Residents dated July 2017 (provided in the resident smoking binder on 8/27/24) revealed, .5. Any resident with smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period . 1. Smoking privileges shall be reviewed at least quarterly by the Director of Nursing Services, the Attending Physician, and/or the Care Planning Team. 2. A list of smoking times will be given to those residents identified with smoking privileges. 3. Residents will be allowed to smoke, in the designated smoking area, during off-scheduled times with a family member or visitor. The family member/visitor must agree to stay with the resident during the entire smoking period . 1. This facility shall have the authority to make periodic checks to determine if residents have any smoking articles that are in violation of our smoking regulations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) were in place and followed for 3 residents (Resident #64, #217, and #21) of 4 residents reviewed for Precautions, resulting in the increased potential for cross-contamination, bacterial harborage and spread of infection throughout the facility. Findings include: Resident #64 Review of an admission Record revealed Resident #64 (R64) admitted to the facility on [DATE] with pertinent diagnoses which included nontraumatic intracranial hemorrhage, hemiplegia (paralysis on one side of the body), and dysphagia (difficulty swallowing). Review of R64's Physician's Orders, started 7/26/2024, revealed she received enteral feeding (intake of food via the gastrointestinal tract) through a gastric tube. In an observation on 8/26/2024 at 11:10 AM, Certified Nursing Assistant (CNA) A and CNA B entered R64's room, transferred R64 from her geriatric chair to her bed, changed her brief, and transferred her back into her geriatric chair without donning a gown. There was no signage on R64's door to notify staff that she required EBP's. In an interview on 8/27/2024 at 2:12 PM, Registered Nurse (RN) Unit Manager D reported R64 required EBP because of her gastric tube and should have signage on her door to notify staff of required Personal Protective Equipment (PPE). In an observation and interview on 8/28/2024 at 9:07 AM, R64's room door had EBP signage directing staff to use a gown and gloves with high contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, and changing briefs. CNA B reported the EBP signage was new and placed the day before as R64 required this because of her gastric tube. Review of R64's Electronic Health Record (EHR) on 8/28/2024 at 9:10 AM revealed no active Physician's Order for EBP's. In an interview on 8/28/2024 at 9:19 AM, RN Unit Manager D reviewed R64's EHR and reported there was no Physician's Order or Care Plan intervention for EBP's. RN Unit Manager D reported R64 should have a Physician's Order and a corresponding Care Plan intervention for EBP's. Review of facility policy/procedure Enhance Barrier Precautions, revised 3/26/2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . employs targeted gown and gloves use during high-contact resident care activities . enhanced barrier precautions will be obtained for residents with any of the following . wounds . indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes) . Resident #217 Review of an admission Record revealed Resident #217 (R217) admitted to the facility on [DATE] with pertinent diagnoses which included right femur fracture and enterocolitis due to clostridium difficile (C-diff). Review of a current C-diff Care Plan intervention for R217, initiated 8/23/2024, directed staff to use contact isolation precautions. Review of R217's Physician's Orders, active 8/26/2024, revealed she was in contact precautions related to C-diff infection. In an observation on 8/27/2024 at 11:16 AM, 2 CNA's removed a gown and gloves after providing care to R217 in her room and performed hand hygiene using hand sanitizer. They did not wash their hands with soap and water after providing care. In an interview on 8/27/2024 at 1:44 PM, the Director of Nursing (DON) reported staff were required to wash hands with soap and water instead of using hand sanitizer when caring for residents in contact isolation for C-diff. The DON reported she would educate staff regarding this. In an observation on 8/28/2024 at 9:00 AM, R217's room door had signage that read .wash hands on way in with soap and water. Wash hands on way out with soap and water . In a telephone interview on 8/28/2024 at 10:10 AM, CNA C reported she was working with Resident #217 the morning of 8/27/2024. CNA C reported she was educated on 8/28/2024 that she was required to wash hands with soap and water instead of using hand sanitizer when caring for residents with C-diff. CNA C stated, I was not doing this right before. Review of facility policy/procedure Transmission-Based (Isolation) Precautions, revised 12/27/2023, revealed .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission . An order for transmission-based precautions/isolation will be obtained . Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room . Type and Duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions . Clostridioides difficile, formerly known as Clostridium difficile . precaution . contact . duration . duration of illness . comments . hand hygiene with soap and water . In an interview on 8/28/2024 at 11:20 AM, the DON reported Resident #21 was tested early that morning for C-diff. The DON reported he should be in contact isolation until test results returned negative. The DON reported she had not yet placed signage on Resident #21's door regarding the need for staff to wash hands with soap and water instead of using hand sanitizer. In an interview on 8/28/2024 at 11:38 AM, Housekeeping Supervisor P reported he typically found out about residents in isolation at the morning team meetings. Housekeeping Supervisor P reported he was not aware Resident #21 was being tested for C-diff until the DON notified him just a few minutes ago. Per the Centers for Disease Control and Prevention (CDC), .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html (Article dated 4/3/24). Per the Centers for Disease Control and Prevention (CDC), .C. diff sheds in feces. Any surface, device or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores. Examples include: *Commodes *Bathtubs . C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. *Isolate patients with possible C. diff immediately, even if you only suspect CDI (clostridium difficle infection) . https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html (Article dated 3/5/24). Resident #21 (R21) Review of an admission Record revealed R21 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: acute osteomyelitis of the right ankle and foot (requiring the long-term use of intravenous antibiotics). Review of R21's Nurses' Note dated 8/19/24 revealed, Resident tested positive for COVID 19 . During an observation on 08/26/24 at 10:44 AM, the door to R21's room was closed with a sign posted. The sign contained the following: TRANSMISSION BASED PRECAUTIONS-What you should be wearing before entering room: N95 Mask .Gown .Gloves .Face Sheild. The sign did not indicate the type of Transmission Based Precaution (TBP) R21 was in (contact, droplet, and/or airborne). Review of R21's Provider Note dated 8/28/24 revealed, Notified by nursing that patient has watery brown stools, c/o (complaints of) generalized abd (abdominal) pain. No fever, + chills x once. Meds reviewed, patient is on IV antibiotic. Orders given to obtain stool for c-diff (Clostridium difficile) . Review of R21's Nurses' Note dated 8/28/24 at 1:07 AM revealed, Provider notified resident is having increased abdominal pain and watery brown stools since Sunday (8/25/24). Resident was diaphoretic [NAME] asleep .Orders received for stool for c diff . Per the CDC, R21 should have been placed in contact isolation at this time. Review of R21's Pertinent Charting-Infections/Signs Symptoms note dated 8/28/24 at 5:31 AM revealed, Site of originally identified infection: right foot wound .lab work and c diff stool sample being sent. Review of R21's Order Summary dated 8/28/24 at 01:51 AM revealed, stool for diff (Clostridium difficile) x 1 one time only for water stool . Review of R21's Medication/Treatment Administration Record revealed the c-diff stool sample was obtained on 8/28/24 at 4:13 AM. During an observation on 08/28/24 at 10:30 AM, the door to R21's room was closed with a sign posted. The sign contained the following: TRANSMISSION BASED PRECAUTIONS-What you should be wearing before entering room: N95 Mask .Gown .Gloves .Face Sheild. The signage did not reflect that contact precautions were to be implemented (contact precautions required for c. diff.) During an interview on 08/28/24 at 11:35 AM, Director of Nursing (DON) was notified that R21's door signage did not reflect contact precautions. DON reported she would ensure signage that reflected R21's presumptive positive c. diff infection. During an observation on 08/28/24 at 2:45 PM, the door to R21's room was closed with the same sign observed at 10:30 AM along with an additional printout posted reading wash hands with soap and water going into room and leaving room. There was no signage indicating R21 was in contact precautions in order for staff to ensure proper infection control practices were followed. During an interview on 8/28/24 at 10:34 AM, Laundry Staff (LS) M reported R21 was in isolation for COVID-19. During an interview on 8/28/24 at 10:40 AM, Certified Nursing Assistant (CNA) I reported R21 was in isolation for COVID-19 only. During an interview on 8/28/24 at 10:44 AM, Unit Manager (UM) N reported R21 was in isolation for COVID-19 and would be taken out of isolation on 8/29/24. UM N did not indicate that he was placed in contact isolation at the time c. diff was suspected. R21's Order Summary Report was reviewed on 8/28/24 at 2:45 PM and revealed an order for Enhanced Barrier Precautions (EBP) related to acute osteomyelitis and transmission-based precautions related to positive or suspected COVID-19 status. There was no order for contact precautions related to the presumptive positive c. diff infection. Resident #36 (R36) Review of an admission Record revealed R36 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: a stroke and the use of a gastrostomy tube (feeding tube). R36 was ordered to be in EBP due to his feeding tube and his tracheostomy. Review of R36's Order Summary dated 2/29/24 revealed, every 4 hours .Flush (gastrostomy) tube with (335) ML's H20 (water) . Water bolus/flush to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM (6 times a day). During an observation on 08/28/24 at 11:20 AM it was identified that R21 and R36 had a shared bathroom. There was no signage on the door to the bathroom from R36's room indicating that R21 was in contact precautions for a c. diff infection. At 11:22 AM an attempt was made to open R36's bathroom door. The door was unlocked but R21 was sitting on the toilet having a bowel movement at that time. During an interview on 08/28/24 at 11:33 AM, RN K reported that the facility practice was for nurses to fill a graduated cylinder with tap water from R36 and R21's shared bathroom sink to administer the every 4 hour ordered flushes. RN K reported R21 was in isolation for COVID-19 and had not been notified of any other type of isolation precautions for R21. During an observation on 08/28/24 at 12:33 PM, RN K donned PPE per R36's ordered EBP and entered his room. RN K brought R36's graduated cylinder to R36 and R21's shared bathroom sink and filled it with tap water. There was a smear of feces noted on the bathroom floor near the toilet and the toilet contained fecal waste and used toilet paper. RN K connected a syringe (with no plunger) to the feeding tube port/adapter and poured the tap water from the graduated cylinder into the open syringe, administering the ordered amount of the water bolus/flush. RN K then capped off the feeding tube port/adapter and set the graduated cylinder back down in R36's room. Review of R36's Medication Administration Record revealed that on 8/28/24 R36 was administered a water bolus/flush at 4:00 AM, 8:00 AM, and 12:00 PM (R21's order for stool testing for c. diff was documented on 8/28/24 at 1:07 AM and contact precautions were not implemented). Indicating 3 times that R36 was exposed to c. diff spores from the nurse touching the contaminated surfaces in the bathroom, holding the graduated cylinder and syringe, and connecting the syringe directly to the feeding tube port. During an interview on 8/28/24 at 2:47 PM, R21 was not in his room. Housekeeping Staff (HS) L was in R21's room and reported that he was informed about an hour and a half ago that R21 was being tested for c. diff and was directed by management to clean R21's room and bathroom following the most severe protocol (terminal cleaning per the CDC guidelines to kill c. diff spores). During an interview via email on 08/28/24 at 1:30 PM, Nursing Home Administrator (NHA) stated, It (stool sample) was sent to (laboratory name omitted) this morning. They sent it out for processing and stated at the earliest it would be this afternoon or evening; tomorrow if not today. As of 08/28/24 at 4:45 PM the Clostridium difficile stool sample had not been resulted by the laboratory. R21's Clostridium difficile status was unknown and therefore presumed positive per the CDC. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Antibiotic use alters the normal flora in the GI tract. A common causative agent of diarrhea is Clostridium difficile (C. difficile), which produces symptoms ranging from mild diarrhea to severe colitis. The Infectious Diseases Society of America (IDSA) identified C. difficile as the most common health care-related infection in America. Patients acquire C. difficile infection in one of two ways: by antibiotic therapy that causes an overgrowth of C. difficile and by contact with the C. difficile organism. Patients are exposed to the organism from a health care worker's hands or direct contact with environmental surfaces contaminated with it. Only hand hygiene with soap and water is effective to physically remove C. difficile spores from the hands. Older adult patients are especially vulnerable to C. difficile infection when exposed to antibiotics, and higher mortality and morbidity are observed in this age-group .To decrease the spread of infection, patients with C. difficile are placed on contact/enteric isolation precautions. A private room with a dedicated toilet is preferred to help prevent transmission to other patients. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 1278-1279). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #13 (R13) Review of a Face Sheet for R13 revealed she was originally admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness), bilateral above the knee amputations, and diabetes. During an observation and an interview on 8/24/23 at 9:02 AM, R13 was sitting in her recliner slumped over to her right side with her eyes closed. This surveyor called her name twice when she opened her eyes and stated she was fine when asked but appeared very drowsy. The breakfast trays just came to the hall. R13 stated she did receive her insulin already this morning and has not eaten breakfast yet or had any snacks. During an observation and an interview on 8/24/23 at 9:10 AM, Registered Nurse (RN) C reported she did give R13 her insulin this morning as documented in the MAR. When queried about the exact time 75 units of Novolog was administered, RN C was able to show in the Electronic Medical Record (EMR) that it was given at 7:12 AM, which was approximately 2 hours before she received her breakfast tray. RN C reported she was not worried about giving R13 her insulin so early because she is a good eater and has a high A1C (a diagnostic lab for diabetics) and she had pudding this morning. This surveyor went back to R13s room, and she denied having any pudding that morning. Review of the August Medication Administration Record (MAR) for R13 revealed she was given 75 units of Novolog at the preset time of 8:00 AM and her blood sugars were 122 (normal is 60-100). The actual administration was documented given at 7:12 AM. Review of a Task List document for R13 revealed she did not receive a snack the morning of 8/24/23. Review of Physician Orders for R13 revealed an order dated 7/5/23 for and injection of 75 units of Novolog subcutaneously with meals related to diabetes and to hold if below 120. Review of Insulin Aspart (Fiasp, NovoLOG) | [NAME]'s Drug Guide. (n.d.). Www.drugguide.com. Retrieved August 30, 2023, from https://www.drugguide.com/ddo/view/[NAME]-Drug-Guide/51867/all/insulin_aspart?q=novolog revealed Novolog is a high alert medication that bears a heightened [NAME] of causing significant patient harm when it is used in error. It is a rapid acting insulin that lowers blood glucose levels with an onset of 15 minutes and peaks within 1-2 hours. Review of a policy titled Medication-Insulin last reviewed/revised 1/1/22 revealed It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. 1. All insulin will be administered in accordance with physician's orders. 4. Insulin administration will be coordinated with mealtimes and bedtime snacks unless otherwise specified in the physician order. In an interview on 8/25/23 at 9:10 AM, the Director of Nursing (DON) reported she can only state how she gives insulin to residents and stated she prefers residents to have their food trays in front of them. Said she would expect the resident to have a snack, a meal, or something of substance before administering short acting insulin. Based on observation, interview, and record review, the facility failed to ensure the Doctor's Orders were followed for the administration of medication for two Residents (Resident #7 and Resident #13), resulting in medication administered outside parameters and/or the potential for an adverse outcome Resident #7 (R7) Review of the Electronic Medical Record (EMR) reflected R7 originally admitted to the facility 1/21/22 with pertinent diagnosis that included: Essential Hypertension, Atrial Fibrillation, and Syncope and Collapse. Review of the Doctor's Orders (DO) for R7 revealed three medications were ordered to not be given if the Resident's heart rate was below 65 beats per minute (bpm). These included: Clonidine 0.1 milligrams (mg) ordered to be administered three times a day, Metoprolol 25 mg 1 tablet twice daily, and Amiodarone 200 mg in the morning. The Medication Administration Record (MAR) for R7 for August 2023 from August 1 until August 23 was reviewed. In the section of the MAR that listed the medication, the dose, and times of administration also included the direction to hold if .pulse or heart rate (HR) less than 65 (bpm). The review revealed that the vital signs for R7 were documented on the MAR. The MAR revealed that these medications had been administered 47 times when the heart rate was below 65 bpm and once without a documented pulse. The review also revealed that these same medications had been documented as held 15 times when the pulse was below 65 bpm. This indicated that some staff were cognizant of the ordered heart rate parameter evident on the MAR. Review of the EMR Progress Notes did not reveal documentation that the physician had been contacted regarding frequent administration of medications outside the ordered parameters. On 8/24/23 at 12:26 PM the Director of Nursing (DON) was alerted to the frequent administration of medication to R7 outside of the Doctor ordered parameter. In a follow up interview conducted at 1:40 PM on 8/24/23 the DON acknowledged the administration of medication outside of the parameter. The DON reported that the EMR system had been set to prompt a notification to the administering nurse when a heart rate was entered below 50 bpm and not 65 bpm. The DON did not indicate why nurses did not follow the documented Doctor's order or why a system-generated alert was needed to do so. On 8/24/23 at 1:34 PM a telephone interview was conducted with Physician A who reported that he expects nurses to follow the Doctor's Orders. Physician A reported that I hope that they don't make decisions on their own. The July 2023 MAR for R7 was reviewed for only the Metoprolol 25 mg and only for the dose scheduled for 8:00 AM. This limited review revealed that the medication was administered 18 times when the heart rate was below 65 bpm. That this continued in August 2023 indicated an ongoing lack of supervisory oversite to ensure quality of care by licensed staff. The policy provided by the facility titled Medication Administration last Reviewed/Revised: 1/1/22 was reviewed. The facility policy reflected Policy: Medications are administered by licensed nurses ., as ordered by the physician and in accordance with professional standards of practice . And Policy Explanation and Compliance Guidelines ., 8. Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review, the facility failed to maintain kitchen plumbing and properly cool potentially hazardous food, resulting in the potential for contamination of the physical facility and biological contamination of food products. These deficient practices affect all residents that consume food from the kitchen. Findings include: On 8/22/23 at 10:19 AM, water was observed to be leaking from under the dish machine onto the floor in two locations, the drain trough on the dish machine drain board, and the check valve on the water line underneath the right side of the dish machine drain board. At this time, Certified Dietary Manager (CDM) U was queried if the issue was reported to maintenance and stated, No. According to the 2017 FDA Food Code Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. On 8/22/23 at 10:25 AM, a plastic container of cream of wheat, and a container of sausage gravy were observed to be cooling in the reach-in cooler. The two products were fully covered and condensation was observed accumulating on the clear plastic wrap. At 10:30 AM, CDM U stated that breakfast is done and food is removed from the steam table between 8:30AM and 9:00AM. On 8/22/23 at 11:47 AM, the cream of wheat and sausage gravy temperatures were measured by the surveyor using a digital probe thermometer and found to be 112 degrees F and 82 degrees F, respectively. At this time, CDM U was queried on what they would do if cooling items aren't reaching temperature requirements in the allotted time and stated that they will reheat the food items back up to 165 degrees or discard the cooling food product. CDM U stated they have cooling logs but the cream of wheat and sausage gravy were not on the log. According to the 2017 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); P and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. P (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. P (C) Except as specified under (D) of this section, a TIME/TEMPERATURE CONTROL FOR SAFETY FOOD received in compliance with LAWS allowing a temperature above 5oC (41oF) during shipment from the supplier as specified in 3-202.11(B), shall be cooled within 4 hours to 5oC (41oF) or less. P (D) Raw EGGS shall be received as specified under 3-202.11(C) and immediately placed in refrigerated EQUIPMENT that maintains an ambient air temperature of 7oC (45oF) or less. P According to the 2017 FDA Food Code Section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3)Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; Pf (5) Using containers that facilitate heat transfer; Pf (6) Adding ice as an ingredient; Pf or (7) Other effective methods. Pf (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a fall by not following a resident's care plan for toileting assistance for 1 of 3 residents (R3), resulting in R3 falling and sustaining two skin tears and the potential for serious injury. Findings include: A review of R3's admission Record, dated 2/8/23, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed multiple diagnoses that included generalized muscle weakness and difficulty walking. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/18/22, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R3 was cognitively intact. In addition, R3's MDS revealed she required extensive assistance (resident involved in activity with staff providing weight-bearing support) of two or more staff members for transfers (moving from one surface to another- e.g. from the bed to the wheelchair) and extensive assistance of two staff members for toileting (e.g. transferring on/off commode, cleansing self after elimination, adjusting clothing after toilet use). A review of R3's Nurses' Notes, dated 1/30/23, revealed, Resident was requesting to use the bedside commode. CNA (certified nursing assistant) answered the light and proceeded to assist the resident. Staff assisted the resident x 1 (one person). CNA stated she started to slip so she lowered her to the floor. Medical treatment given. Left hand with oval shaped skin tear just above the thumb approx. 1.5 cm x 1 cm (1.5 centimeters long by 1 centimeter wide). Area cleansed and dressed. Right forearm with small skin tear (pea sized). No head or neck involvement. Per resident she slid down to the floor. Resident denies c/o (complaints of) pain. No other injuries found after full assessment. Intervention of staff education. A review of R3's SOC- Fall (Standard of Care- Fall) form, dated 1/31/23, revealed R3 was lowered to the floor when a CNA was assisting her in the bathroom. The CNA was only using one assist and R3 was a two assist with a sit-to-stand machine. R3 sustained a skin tear to the left thumb measuring 1.5 inches in circumference and a pea sized skin tear to the right forearm. Staff was educated on resident transfer status. A review of R3's activities of daily living care plan, dated 9/14/22, revealed R3 needed two-person assistance with toileting (revised 11/1/22) and two-person assistance using a sit-to-stand machine for transferring from one surface to another (revised on 12/28/22). A review of CNA C's typed statement, dated 1/30/3, revealed, I was transferring resident assist of one and resident started to slide, I then lowered her to the floor. A review of CNA C's One on One Education, dated and signed 1/30/23, revealed CNA C did not follow R3's activities of daily living care plan when she transferred R3 to the bedside commode. R3 needed two-person assistance and CNA C transferred R3 by herself. CNA C's response to the education was she did not know R3's transfer status before she got R3 up and R3 told her that she usually only needs one person to transfer to the commode. During an interview on 2/8/23 at 11:15 AM, R3 stated she always needs two-person assistance using the sit-to-stand machine for transferring for her wheelchair to the commode or to a chair. She denied she had ever told anyone that she needed the assistance of only one person. She further stated that the only time the sit-to-stand machine was not used to transfer her from the bed to the wheelchair or the wheelchair to the toilet was when therapy personnel were working with her. She stated when she was working with therapy personnel, they still always used two people to transfer her. During an interview on 2/8/23 at 2:35 PM, CNA R stated if she answers a call light for a resident that she is not familiar with and they ask her to help them get up or go to the bathroom, then she will go into the hallway and check their electronic [NAME]. She stated that the [NAME] has all the information on it that says what level of assistance that the resident needs for transfers, dressing, bathing, toileting, ambulation, etc. CNA R stated if a resident needs a particular device, like a sit-to-stand, it will be on the [NAME]. CNA R also stated that if she answers a call light and the resident appears to be with it, she will ask them how they transfer and she will take their word for it if what they are saying does not seem suspicious or fishy. She stated this was especially true if they can give her detailed instructions on how they are transferred. CNA R stated if what the resident is telling them seems fishy or suspicious based on what she is seeing or what she has heard about them, then she will check the [NAME] before getting them up or transferring them. During an interview on 2/8/23 at 3:00 PM, the Director of Nursing (DON) stated she would have to now educate all of her staff when she was told that a staff member (besides CNA C) stated they would take a resident's word for how they transfer if the resident seemed with it. During the conversation the DON stated after R3's fall, she had only provided one-on-one education to CNA C as the fall intervention since CNA C was the one who did not follow R3's care plan for transfers and toileting.