**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a person-centered care plan for post-traumatic stress disorder (PTSD). This affected two residents (Residents #10 and #24) out of 15 residents reviewed for care planning. The facility census was 35. Finding include: 1. Review of the medical record for Resident #10 revealed and admittance date of 10/04/24 with diagnoses including chronic obstructive pulmonary disease (COPD), venous insufficiency, post-traumatic stress disorder (PTSD), depression, dementia, type II diabetes, and chronic kidney disease. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and had moderate depression. The resident required supervision with activities of daily living. No behaviors were noted. The resident was recorded as having received antidepressant medications. Review of Resident #10's care plan dated 12/27/24 revealed the resident had potential for psychosocial well-being problems and was at risk for changes in mood related to nursing home placement. On 12/19/24, the resident was agreeable to a psychological consult at the facility and continued to see psychiatry in the community for PTSD. Interventions included psychology consult as needed and to review preferences quarterly and as needed. The plan did not identify trigger-specific interventions and ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Interview on 01/15/25 at 12:30 P.M. with Registered Nurse (RN) #850 verified she did not develop a specific care plan for PTSD for Resident #10 or Resident #24 that identified triggers or interventions to minimize or eliminate triggers. RN #850 stated that PSTD was referenced in Resident #10 nutritional, activities of daily living, and skin integrity plan. 2. Review of Resident #24's medical record revealed an admission date of 05/09/24 with diagnoses including osteoarthritis, PTSD, traumatic brain injury, type II diabetes, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required substantial to maximum assistance with activities of daily living. No behaviors were noted. The resident was recorded as having received antidepressant medications. Review of Resident #24's care plan dated 12/04/24 revealed the resident was at risk for psychosocial wellbeing decline and changes in mood related to diagnosis including depression, anxiety, parkinsonism, hydrocephalus, transient ischemic attack (TIA) a brief stroke, traumatic brain injury and PTSD. Intervention included to identify factors that influence resident psycho-social wellbeing/mood. No factors were identified. The plan did not identify trigger-specific interventions or ways to decrease the resident's exposure to triggers which could re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of the facility policy, the facility failed to ensure showers were completed for Resident #4. This affected one resident (Resident #4) of two residents reviewed for activities of daily living. The facility census was 35. Findings include: Review of Resident #4's medical record revealed an admission date of 06/14/22 diagnoses including type II diabetes, heart disease, depression and dementia. Review of Resident #4's care plan dated 10/15/22 revealed she required assistance with bathing and dressing. Review of Resident #4's progress notes revealed a note dated 04/21/23 at 11:18 A.M. which stated the resident requested one shower per week. The resident agreed to receive a shower on Monday mornings. Review of Resident 4's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required substantial to maximal assistance with showers. Review of Resident #4's shower documentation for December 2024 revealed the resident received a shower on 12/02/24, 12/09/24, 12/16/24 and 12/30/24. There was 13 days without a shower from 12/16/25 to 12/30/25. Interview on 01/12/25 at 3:36 P.M. with Resident #4 stated she received a shower every other week. Interview with the Director of Nursing on 01/13/25 at 2:49 P.M. verified the resident received a shower on 12/16/24 and on 12/30/24, and confirmed the resident went 13 day without receiving a shower. Review of the facility policy titled Shower and bathing schedules, revised April 2023 revealed the resident bathing schedule is set-up that each resident is given at least whirlpool tub bath or shower once a week according to their preference.

Based on observation, staff interview, and policy review, the facility failed ensure food was labeled and dated in a manner to prevent food contamination and spoilage, failed to ensure expired food was disposed of timely, and failed to ensure food was served to residents in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 35. Findings include: 1. Tour of the facility's main kitchen and kitchenette on 01/12/24 between 8:00 A.M. and 8:33 A.M. with Dietary Manager (DM) #759 revealed the following that was observed and verified at the time of discovery: a. An open plastic container of sour cream with an expiration date of 01/06/25. b. Five packages of raisins with an expiration date of 11/13/24. c. An open package of liquid butter with no date. d. An open package of baking soda with no date. e. An open package of sprinkles with no date. f. An open package of marshmallows with no date. g. Four packages of orange juice thickener with a best-by date of 11/15/24. h. A peanut butter container in both the main kitchen area and kitchenette with expiration dates of 11/24/24. i. The ceiling lights directly above the kitchenette serving area had numerous dead bugs. 2. Observation of the dinner time meal service on 01/12/24 between 5:00 P.M. and 5:30 P.M. revealed the meal was being served by Dietary Aide (DA) #761. During the entire observation, DA #761 was noted to not be wearing a hair net while actively engaged in the serving of the dinner time meal. An interview on 01/12/24 at 5:33 P.M. with the Director of Nursing (DON) verified that DA #761 was not wearing a hair net as required. Review of the policy entitled Food Safety/Sanitary Conditions dated 11/01/19 revealed hair restraints must be worn to prevent hair from contacting exposed food.

Based on record review and staff interview the facility failed to ensure the service of a Registered Nurse (RN) for at least eight hours a day seven days a week as required. This had the potential to affect all residents. The facility census was 30. Findings Include: Review of facility staffing schedules revealed on 04/02/22, 04/03/22, 04/16/22, 04/17/22, 04/30/22, 05/01/22, 05/14/22, 05/28/22, 05/29/22, 06/12/22, and 06/25/22 the facility did not have the services of an RN for eight consecutive hours as required. Interview with the Administrator on 03/07/23 at 5:00 P.M. verified the lack of RN hours on the dates listed above.

Based on observation and staff interview the facility failed to ensure food was labeled and dated properly and the walk in freezer was maintained in good working condition. This had the potential to affect all residents. The facility census was 30. Findings Include: Observation during tour of the kitchen on 03/06/23 between 7:15 A.M. and 7:33 A.M. revealed the following. 1. The walk in in freezer had significant ice build up. Multiple chunks of ice more then six inches in diameter with ice crystals formed were stuck to the freezer shelves. One of the chunks of ice had engulfed a box of tater tots and the box of tater tots was stuck to the ice block and immovable. Hanging from the top of freezer were over ten, six inch long icicles. In addition, there was an undated and opened bag chicken patties, an undated and opened bag of chicken tenders, an undated unlabeled and opened bag of cheese omelettes, an undated and opened box of pork egg rolls, and two undated and opened packages of ham. 2. In the dry storage area there was a dented can of sweet peas, an undated and opened bag of elbow macaroni, an undated and opened bag of rainbow rotini, an undated and opened bag of rigatoni, and an undated and open container of liquid butter. Interview with Dietary Manager (DM) #800 at the time of the discovery, on 03/06/23 between 7:15 A.M. and 7:33 A.M., confirmed the observations.

Based on record review and interview the facility failed to implement and maintain a comprehensive Quality Assurance Performance and Improvement (QAPI) plan. This had the potential to affect all 30 residents residing at the facility. Findings Include: Review of the QAPI program documentation revealed no evidence the plan addressed the full range of care and services provided by the facility which was comprehensive, data driven and ongoing. There were no indicators focusing on outcomes of care, quality of life or resident rights. Interview with Director of Nursing (DON) on 03/09/23 at 2:10 P.M. revealed the facility did not have a plan to provide the survey team. The last QAPI plan was completed on 03/16/21. Interview with the Administrator on 03/09/23 at 2:15 P.M. verified the facility was not participating in any data driven ongoing QAPI programs. Several weeks ago she started considering programs for participation. Review of the facility's policy titled Quality Assurance Program, undated revealed the facility would have a program in effect, in order to continue to identify, monitor, evaluate and promote the maintenance and enhancement of every resident's quality of life and quality of care.

Based on record review and interview the facility failed to implement and monitor measures to prevent the potential spread of Legionella. This had the potential to affect all 30 residents residing at the facility. Findings include: Review of the facility's policy titled Legionella Prevention Program dated November 2017, revealed control measures including physical control measures, water temperature management, disinfectant level controls, visual inspections, environmental testing for pathogens and specific testing protocols with acceptable ranges for control measures. Parameters included: • Hot water to be maintained above a temperature of 122 degrees Fahrenheit (F). • Cold water temperatures to be maintained below 77 degrees F. • Maintain chlorine residual levels at Center of Diseases Control and Prevention (CDC) recommended levels. • Maintain chlorine residual logs to ensure safe levels. Review of the Legionella water testing log from 03/01/22 through 03/01/23 revealed one entry indicating on 05/12/22 the water from the faucet at the eye wash station located in the kitchen was tested and negative for Legionella. There was no documented evidence the other control measures listed in the facility's legionella prevention program were implemented/monitored. Interview with the Administrator on 03/09/23 at 11:00 A.M. revealed the facility had no additional documentation to support the facility's legionella prevention program was implemented/monitored. Review of CMS Survey and Certification letter 17-30-All, dated 06/02/17, revealed facilities were to implement a water management program that considered the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Center of Disease Control and Prevention (CDC) toolkit, and included control measures such as physical controls, temperature management, disinfection level control, visual inspections, and environmental testing for pathogens.

Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was properly stored. This affected 47 out 47 residents residing in the facility who received meals from the dietary department. Findings include: A tour of the kitchen was conducted on 01/21/10 with the Registered Nurse #100 from 8:04 A.M. through 8:15 A.M. Dietary Manager (DM) #101 was not yet at the facility. Observation of the kitchen revealed a black cart had food particles on both shelves, dried cake batter on the mixer which was covered by a plastic bag and considered clean, two bags of noodles and black eyed peas were not labeled or dated in the dry storeroom, there was ice was build-up along the back of the walk-in freezer that created ice on top of a box of dinner rolls and two pizza crusts were not labeled or dated. A follow-up visit was conducted on 01/22/20 at 9:14 A.M. and revealed food splatter and white icing were on the ceiling. DM #101 and Registered Dietitian (RD) #102 verified the findings at time of observation. Review of the policy titled, Food Safety/Sanitary Conditions, dated 11/2019, revealed that food sanitary conditions must be present in healthcare food service settings.