Based on observation and interview, it was determined that the facility failed to ensure that equipment was clean and sanitary for 1 of 1 kitchen observed and handling of food for 1 of 2 kitchenettes observed. Findings include: Observation on 7/22/2025 at approximately 8:30 a.m. of the ice machine in the main kitchen with Staff B (Food Service Director) revealed a greenish brown film located in the interior of the ice machine below the ice cube metal grid.Interview on 7/22/25 at approximately 8:30 a.m with Staff B confirmed the above observation.Review on 7/24/25 of the manufacturer's instructions of the facility's ice machine revealed, .General : Clean and sanitize the ice machine every 6 months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test water quality and recommend water treatment .Observation on 7/22/25 at approximately 8:40 a.m. of the first floor satellite kitchenette refrigerator with Staff B revealed 5 supplemental shakes with a hand written date of 7/20/25.Interview on 7/22/25 at approximately 8:40 a.m. with Staff B confirmed the above finding. Staff B stated that the handwritten date on the above supplemental shakes was the use by date which was the 14th day from the thaw date. Review on 7/23/25 of the supplemental shake container revealed the following instructions: .Use thawed product within 14 days. Keep Refrigerated .

Based on interview and record review, it was determined that the facility failed to implement and review, at least annually, the facility's water management program, which had the potential to effect the facility census of 69 residents who resided at the facility.Findings include:Review on 7/24/25 of the facility's Water Management Program revealed that the facility had identified multiple at-risk areas in the facility, including water heaters, expansion tanks in the maintenance office; pipes, valves and fittings in the bathrooms, shower rooms and kitchen; faucets, aerators, faucet flow restrictors in the bathrooms/kitchen; shower heads and hoses in the first/second floor shower rooms; air washer and humidifiers in the second floor resident rooms; eyewash stations in the laundry, shower, chemical rooms, housekeeping closets and shower rooms; ice machines in the kitchen and 1st and 2nd floors; CPAP machines, bubblers for oxygen, nebulizers in the resident rooms; hydrotherapy equipment, heater-cooler units in the therapy office; water filters in the employee lounge and the [brand name omitted] coffee maker. Further review revealed the program did not describe what control measures would be applied and monitored to the at risk areas. Interview on 7/24/25 at 12:05 p.m. with Staff D (Maintenance Director) revealed that the facility identified the above areas where Legionella could grow and spread. Staff D was unable to provide additional documentation for control measures for the identified at-risk areas in the facility. Staff D did not know what nationally-recognized standard was used to developed their facility's water management program. Interview on 7/24/2025 at 12:18 p.m. with Staff F (Infection Preventionist) revealed that Staff D managed the Water Management Program. Staff F confirmed that they did not have documentation that Water Management Plan was discussed at a committee meeting and did not know which nationally-recognized standards the facility used to develop the facility's water management program. Review on 7/24/25 of the facility's policy titled Legionella Policy revealed it was last reviewed/updated on 11/20/2018. Interview on 7/24/2025 at 1:32 p.m. Staff E (Administrator) confirmed that there was no additional documentation to identify how control measures were applied and monitored and confirmed there was no documentation to show the policy had been reviewed since 2018.

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary care to ensure that a resident's ability to communicate was maintained with a communication device for 1 of 1 resident reviewed for communication in a final sample of 19 residents (Resident Identifier is #40). Findings include: Interview on 5/13/24 at approximately 12:10 p.m. with Resident #40's Durable Power of Attorney (DPOA) revealed that Resident #40 has difficulty with communication due to his/her advanced Parkinson's Disease and was admitted in March 2024 with a communication board that he/she used to allow for easier communication. Resident #40's DPOA stated that he/she has not seen the communication board since shortly after admission. Interview on 5/14/24 at approximately 8:30 a.m. with Staff M (Registered Nurse) revealed that he/she did recall Resident #40 being admitted with a communication device that he/she used at home. Staff M confirmed that it could not be located at the time of the interview. Interview on 5/14/24 at approximately 8:35 a.m. with Staff K (Licensed Nursing Assistant (LNA)) and Staff F (LNA) revealed they were unaware of Resident #40 using a communication board. Staff K stated that Resident #40 can answer simple yes or no questions when asked if you give him/her enough time to respond. Interview on 5/14/24 at approximately 8:45 a.m. with Staff M revealed that the communication board was located in a drawer in Resident #40's room. Interview on 5/14/24 at approximately 11:50 a.m. with Resident #40 revealed that communication with the staff has been difficult without his/her communication board.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents receive appropriate treatment to maintain mobility for 1 resident reviewed for limited range of motion in a final sample of 19 (Resident Identifier is #28). Findings include: Review on 5/14/24 of Resident #28's care plan revealed: Interventions for Preventing Pressure Injury, dated 3/19/24, Place face cloth rolled into R [right] hand, change with care and re-apply should resident remove. Observation on 5/13/24 at approximately 10:00 a.m. revealed Resident #28 was asleep in bed with his/her right hand clenched. There was no rolled face cloth in his/her right hand. Observation on 5/13/24 at approximately 12:15 p.m. revealed Resident #28 was up in his/her chair in the dining room. His/Her right hand was clenched. There was no rolled face cloth in his/her right hand. Observation on 5/14/24 at approximately 11:00 a.m. revealed Resident #28 was up in his/her chair in the hallway. His/her right hand was tightly clenched with no rolled face cloth in his/her right hand. Interview on 5/14/24 at approximately 11:30 a.m. with Staff I (Licensed Nursing Assistant) revealed that Staff I did not know that Resident #28 should have a rolled face cloth to hold in his/her right hand. Review on 5/14/2024 or Resident #28's Physical Therapy Discharge Summary, dated 2/20/23, revealed: discharge goal met if Pt [patient] tolerates folded/rolled wash cloth in right hand between palm and thumb >/= [less than or equal to] 8 hours without evidence of skin integrity issues or new/worsening pain.

Based on interview and record review, it was determined that the facility failed to ensure that an ongoing collaboration and communication process was established between the nursing home and the hospice company for 1 out of 1 hospice residents reviewed in a final sample of 19 residents (Resident Identifier is #6). Findings include: Review on 5/13/24 of Resident #6's Medical Record revealed they had been admitted to hospice services as of 4/26/24. Review on 5/14/24 of Resident #6's Hospice Team Care Plan as of 5/3/24 revealed the visit frequency for aide to be 3 x [times] week x [for] 9 weeks. Review on 5/14/24 of Resident #6's Hospice Aide Weekly Visit Record revealed the following: Week of 4/29/24-5/3/24 had one aide visit that was documented on 5/2/24; Week of 5/6/24-5/10/24 had one aide visit that was documented on 5/9/24. Interview on 5/14/24 at approximately 10:00 a.m. with Staff N (Unit Manager) confirmed the above finding. Staff N stated that there was no actual schedule for the facility staff to know when the Hospice Aide is coming in to see Resident #6. Interview on 5/14/24 at approximately 11:30 a.m. with Staff O (Hospice Aide) confirmed that he/she had only documented one visit for each of the above two weeks for Resident #6. Staff O stated he/she came only once the week of 4/29/24-5/3/24, as he/she was new to their case load and that was normal. Staff O stated that they did come three times the week of 5/6/24-5/10/24, but had only documented one visit. Staff O confirmed that there is no schedule for the days or times that they come to see Resident #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to follow facility policy on contact precautions to reduce transmission of communicable diseases in 1 of 1 residents reviewed for Transmission Based Precautions in a final sample of 19 residents. Findings include: Standards: Per Centers for Disease Control (CDC) Follow specific recommendations when treating a patient with confirmed or suspected C. Difficile infection .When entering the room of a patient with C. difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination. (Accessed at https://www.cdc.gov/clean-hands/hcp/clinical-safety/ on 5/16/24). Observation on 5/13/24 at approximately 8:30 a.m. of Staff H (Licensed Practical Nurse (LPN)) revealed them entering a Transmission Based Precaution (TBP) room [ROOM NUMBER]-1 without donning a gown and/or gloves. Further observation revealed that Staff H was administering resident's medications without a gown and gloves. Interview on 5/13/24 at approximately 8:30 a.m. with Staff H revealed that the resident was on contact precautions for Clostridium Difficile (CDiff). Staff H stated when he/she is not providing direct care he/she does not put on PPE. Interview on 5/13/24 at approximately 2:10 p.m. with Staff G (Unit Manager/Infection Preventionist) revealed it is the facility's policy for the staff to wear a gown and gloves before entering a room with transmission based precautions for CDiff. Review on 5/13/24 of Facility Infection Prevention and Control Program, on page 5 revealed: .C-Difficile gastroenteritis, contact precautions .

Based on observation, interview, and record review, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 of 1 residents reviewed for choices in a final survey of sample of 19 residents (Resident identifier #60). Findings include: Observation on 3/30/23 at 11:00 a.m. of Resident #60's overbed table revealed a medicine cup containing 7 medications. Resident #60 was not present in the room. Interview at 11:05 a.m. with Staff B (Registered Nurse) confirmed that the Resident #60 had not been assessed to self-administer medications and that the medications should not have been left at the bedside. Interview at 11:10 a.m. with Staff C (Licensed Practical Nurse) revealed that he/she did leave the medications on the bedside table for Resident #60 to take when he/she gets out of the bathroom. Staff C confirmed that the medications in the cup were Resident #60's a.m. medications. Medications in the medication cup were: Losartan 50 milligrams (mg) Oxybutin Chloride ER (extended release) Vitamin D3 25 micrograms (mcg) Tylenol 325 mg 2 tablets Tramadol 50 mg Lasix 40 mg Valium 2 mg Review on 3/30/23 at 11:20 a.m. of Resident #60's medical record revealed that Resident #60 had no documented evidence of an assessment to self-administer medications. Interview on 3/30/23 at 11:30 a.m. with Staff A (Director of Nursing) confirmed that Resident #60 was not assessed to self-administer medications.