Based on the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)15 and RA received the CMS form 10055 for Medicare Part A services. Specifically R15 and RA received CMS form R-131 for Medicare Part B Services for 2 of 2 residents that were discharged from Medicare Part A services and remained in the facility. Findings include: Review of the facility policy titled, Medicare Advance Bebeficiary and Medicare Non-Coverage Notices, states as the Policy Statement, Residents are informed in advance when changes will occur to their bills. Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055). 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service (s), the resident (or representative) is notified in writing whey the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events: a. Initiation - In the situation in which the director of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, a SNF ABN is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary. b. Reduction - In the situation in which the facility proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. c. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. 3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility. The facility admitted R15 and RA with physician orders to receive therapy services. Both residents received the form, CMS 10023, notice of non coverage for Medicare Part A services timely. Both R15 and RA remained in the facility with Medicare Part A days remaining. During SNF Beneficiary Notification Reviews, neither resident R15 nor RA received the correct form, CMS-10055 for an appeal, for the Medicare Part A services ending and whether or not R15 or RA would like to continue the Part A skilled services for Medicare. Both residents, R15 and RA received CMS form R-131 which was for Medicare Part B services and not CMS form 10055 for part A services. During an interview on 03/10/2025 at 01:00 PM with the facility Social Service Director, she provided the forms for R15 and RA and confirmed they were the CMS-R-131 for Medicare Part B services and not the CMS-10055 that both residents should have received.

Based on record reviews and interviews, the facility failed to ensure Resident (R)1 received all medications ordered by the physician. Specifically, R1 did not receive Trelegy Ellipta (a prescription medicine used long term to treat COPD, including chronic bronchitis, emphysema, or both and to treat asthma in adults) or Linzess (a prescription medication used to treat irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in adults) as ordered, for 1 of 1 residents reviewed for medication administration. Findings include: Review of R1's Face Sheet revealed the facility admitted R1 on 11/08/23 with diagnoses including but not limited to: chronic obstructive pulmonary disease, pneumonia, oxygen dependence, nasal congestion and constipation. R1 left the facility against medical advice (AMA) on 11/15/23. Review of R1's medical record revealed Physician Orders for Trelegy Ellipta 100 micrograms (mcgs) - 62.5 mcgs - 25 mcgs powder for inhalation, one puff one time daily. Further review of R1's medical record revealed the ordered medication was not administered on 11/09/23, 11/10/23, 11/11/23 and 11/12/23. Review of R1's Comprehensive Plan of Care indicated the following, Resident is at risk for altered respiratory status related to COPD, (chronic obstructive pulmonary disease), oxygen dependence and nasal congestion. The goal stated, resident will remain free from respiratory distress and have no unrelieved shortness of breath. The interventions included, Assess and monitor respiratory status and signs/symptoms of complications (dyspnea, rate/depth of respirations and cyanosis). Administer medications as ordered . Further review of R1's Comprehensive Plan of Care revealed the following problems, Resident is unable to maintain oxygen saturation. and Resident has potential for chronic pain and pain management related to . irritable bowel syndrome. During an interview on 11/28/23 at 11:15 AM, the Director of Nursing (DON) stated that there was a complaint that R1 has not received any medications since admission. The DON provided a copy of the Medication Administration Record (MAR) and stated R1 has received all medications as ordered except the Trelegy Ellipta and the Linzess. The DON went on to say that the nurses and the Nurse Practitioner (NP) had asked R1's family to bring in these medications. During an interview on 11/28/23 at 1:20 PM, Registered Nurse (RN) stated, the pharmacy did not send those medications because the family was going to bring them in. When the family did not bring the medications the RN stated that she spoke with the NP, but the orders were not changed or clarified. During an interview on 11/28/23 at 1:45 PM, the NP stated that she was not aware that R1 had not received the Trelegy Ellipta and the Linzess as ordered. The NP stated that she had spoken with the family to bring in the medications and was not aware they had not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility document review, the facility failed to treat a resident with dignity and respect for 1 (Resident #2) of 8 residents reviewed for dignity and respect. Specifically, Resident #2 indicated Certified Nursing Assistant (CNA) #1 intimidated them. Findings included: A review of a Face Sheet indicated the facility admitted Resident #2 to the facility on [DATE] with diagnoses that included hypokalemia, fall, hypertension, weakness, and pain. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene, was independent with setup help only for eating, and was totally dependent on staff for bathing. A review of an Initial 2/24-Hour Report, dated 05/26/2023, indicated the Administrator became aware of an allegation of verbal abuse on 05/26/2023 from the previous night (05/25/2023). On 05/25/2023 at 7:30 PM, Resident #2 alleged that CNA #1 was loudly arguing and raised her voice at the resident. Resident #2 also reported that CNA #1 took several clean towels and threw them on the floor of the resident's bathroom. After the Administrator became aware of the allegation, an investigation was initiated. A review of the undated Facility Investigation Summary Report revealed Resident #2 was alert and oriented, both pre and post incident, with a BIMS of 15. The incident occurred in Resident #2's room. CNA #1 reportedly raised her voice at Resident #2 and threw towels around the room. The facility launched a thorough and fact-finding investigation into the allegation made by Resident #2, and as a result of the investigation, the facility substantiated that CNA #1's actions constituted verbal abuse. During a telephone interview on 07/25/2023 at 8:37 PM, Registered Nurse (RN) #3 indicated Resident #2 informed him around 7:30 PM on 05/25/2023 that CNA #1 approached the resident's room and said rudely, I heard you want a shower. Resident #2 said the chalk board indicated that the resident should get a shower because it was Thursday. RN #3 said Resident #2 told him CNA #1 said she could read and was getting loud and argumentative with Resident #2. RN #3 indicated that Resident #2 said he/she did not want CNA #1 back in his/her room. RN #3 indicated he told CNA #1 that she could never raise her voice or argue with a resident. During an interview on 07/26/2023 at 9:17 AM, the Social Worker (SW) indicated the next morning (05/26/2023) CNA #6 said Resident #2 was upset about something that happened the previous night. The SW said she talked to Resident #2. The SW said Resident #2 told her that CNA #1 asked from the doorway of their room if he/she was refusing his/her shower and started throwing towels at the bathroom. The SW indicated Resident #2 directed CNA #1 to the chalk board in the resident's room where it listed shower days as Monday and Thursday. CNA #1 told Resident #1 she could read. Resident #2 reported CNA #1 was shouting at him/her. During a telephone interview on 07/26/2023 at 10:22 AM, Resident #2 indicated CNA #1 said rudely from the room doorway, I hear you want a shower. Resident #2 said he/she pointed to the chalk board in his/her room that indicated the resident's shower days were Monday and Thursday. The resident indicated that when he/she pointed to the chalk board, CNA #1 got louder. Resident #2 told the CNA she did not have to give him/her a shower with all the loud talking and screaming. Resident #2 indicated that CNA #1 had towels in her hand and threw them on the bathroom floor and marched out of the room mumbling something. Resident #2 said she reported the incident to RN #3. Resident #2 said he/she was disappointed. Resident #2 said CNA #1 had given the resident a shower before and there were no problems other than she did not do a good job. During a follow-up telephone interview on 07/26/2023 at 5:36 PM, Resident #2 indicated the resident did not feel that she/he was abused or threatened. Resident #2 said the resident felt intimidated and did not want CNA #1 to take care of him/her after the way the CNA behaved. During an interview on 07/26/2023 at 7:17 PM, the Director of Nursing (DON) indicated that it was her expectation that staff treated residents with respect and dignity. During an interview on 07/26/2023 at 7:36 PM, the Abuse Coordinator revealed that it was his expectation that staff treated residents with respect and dignity. During an interview on 07/26/2023 at 7:45 PM, the Administrator indicated that it was his expectation that staff treated residents with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy and document review, the facility failed to ensure an allegation of verbal abuse was reported to the facility's Abuse Coordinator, Administrator, and the state survey agency within two hours of the allegation being received for 1 (Resident #2) of 8 sampled residents reviewed for abuse. Findings included: A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Reporting Allegations to the Administrator and Authorities section in the policy revealed, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as; a. within two hours of an allegation involving abuse or result in serious bodily injury. A review of a Face Sheet indicated the facility admitted Resident #2 to the facility on [DATE] with diagnoses that included hypokalemia, fall, hypertension, weakness, and pain. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene, was independent with setup help only for eating, and was totally dependent on staff for bathing. A review of an Initial 2/24-Hour Report, dated 05/26/2023, indicated the Administrator became aware of an allegation of verbal abuse on 05/26/2023 from the previous night (05/25/2023). On 05/25/2023 at 7:30 PM, Resident #2 alleged that Certified Nursing Assistant (CNA) #1 was loudly arguing and raised her voice at the resident. Resident #2 also reported that CNA #1 took several clean towels and threw them on the floor of the resident's bathroom. A review of a fax result report revealed the facility did not submit the Initial 2/24-Hour Report to the state survey agency until 05/26/2023 at 11:31 AM, which was approximately 16 hours after the allegation was made. A review of the undated Facility Investigation Summary Report revealed the incident occurred in Resident #2's room. CNA #1 reportedly raised her voice at Resident #2 and threw towels around the room. The report indicated that Registered Nurse (RN) #3 reported the incident timely to their supervisor, but their supervisor (the previous Director of Nursing) did not report the allegation timely to the Abuse Coordinator. A review of an email correspondence from the Human Resources Director to the Abuse Coordinator, dated 05/29/2023, revealed on 05/26/2023 the Abuse Coordinator became aware of an allegation of abuse that the previous Director of Nursing (DON) was notified of but had not reported to him. The email indicated the Human Resources Director and the Abuse Coordinator spoke with the previous DON about the concern of not reporting the allegation to the Abuse Coordinator, and the previous DON said she did not think it was abuse, and if she had, she would have reported it. During an interview on 07/25/2023 at 4:50 PM, the Abuse Coordinator indicated the previous DON never reported the incident to him. The Abuse Coordinator said he heard it from the Social Worker (SW) on 05/26/2023 between 8:30 AM and 9:00 AM. The Abuse Coordinator indicated that it was his expectation that staff reported abuse allegations immediately to the nurse on duty or to the DON, Administrator, or directly to the Abuse Coordinator. He indicated there was information posted throughout the facility indicating who to report abuse to with phone numbers included. During a telephone interview on 07/25/2023 at 8:37 PM, RN #3 indicated Resident #2 informed him around 7:30 PM on 05/25/2023 that CNA #1 approached the resident's room and said rudely, I heard you want a shower. Resident #2 said the chalk board indicated that the resident should get a shower because it was Thursday. RN #3 said Resident #2 told him CNA #1 said she could read and was getting loud and argumentative with Resident #2. RN #3 said he called the previous DON immediately and reported the incident, and the previous DON said she had strep throat and would handle it. During an interview on 07/26/2023 at 9:17 AM, the SW indicated the next morning (05/26/2023) CNA #6 said Resident #2 was upset about something that happened the previous night. The SW said she talked to Resident #2. The SW said Resident #2 told her that CNA #1 asked from the doorway of their room if he/she was refusing his/her shower and started throwing towels at the bathroom. The SW indicated Resident #2 directed CNA #1 to the chalk board in the resident's room where it listed shower days as Monday and Thursday. CNA #1 told Resident #1 she could read. Resident #2 reported CNA #1 was shouting at him/her. The SW said she immediately sent the DON and the Abuse Coordinator a group text notifying them of the allegation. During an interview on 07/26/2023 at 7:17 PM, the current DON indicated that it was her expectation that staff call the DON immediately for any abuse concerns and if nothing happened, to call the Abuse Coordinator. During an interview on 07/26/2023 at 7:36 PM, the Abuse Coordinator revealed that it was his expectation that staff immediately report all abuse allegations to the DON or the Abuse Coordinator and then report the allegation to the state survey agency within the required 2-hour timeframe. During an interview on 07/26/2023 at 7:45 PM, the Administrator indicated that it was his expectation that all abuse allegations be reported immediately to the nurse working on the floor and then to the DON or supervisor to give the person guidance on what to do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and staff interviews, the facility failed to ensure 1 out of 3 Residents, (R)1, was free from abuse related to misappropriation of resident property. Specifically, R1 was involved in a forgery of a financial transaction from a staff employee, Certified Nursing Assistant (CNA)1, resulting in misappropriation of property. Findings include: Review of the facility's revised, April 2021 policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment . 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to . 6. Provide staff orientation and training/ orientation programs . 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Review of an undated Face Sheet on the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with a diagnosis of fracture head of right femur and limitation of activities due to disability. R1 was discharged from the facility on 05/16/22. Review of R1's Minimum Data Set (MDS) obtained from the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/08/22 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R1 is cognitively intact. Review of an Accident/Incident Reporting Form of Bureau of Health Facilities Licensing, 10 Day Report provided by the facility and dated 06/01/22, indicated a neglect or exploitation, suspected or confirmed abuse, took place on 05/16/22 between R1 and CNA1. The 10-day report indicates that, On 05/16/22 resident made allegation that someone had used her personal credit card located in her room to make approximately $1,400 worth of purchases. Facility immediately reported it to Georgetown County Sheriff's office, DHEC, and Ombudsman. Facility submitted follow up report on 05/22/22 to the department stating the facility was unable to substantiate the allegations based on internal investigation but overall investigation was pending outcome from GCSO's investigation. GCSO came to facility today (06/01/22) and reported that their investigation of bank records showed that [name of CNA 1], facility CNA, made the fraudulent charges. GCSO arrested [name of CNA1] on those charges and allegation was officially substantiated. Review of an, Incident Report, provided by the Georgetown County Sheriff's Department on 05/16/22, Case number 22014042, entails that, On May 16, 22 at 11:41 AM, I [Name of Officer] responded to 120 unit 407 Lakes of [NAME] Dr in Pawleys Island Area of Georgetown County in regards to a fraud call. Upon Arrival I met with the male complainant who is the husband and he states that his wife's South State Bank debit card number had been used in several unauthorized transactions within the past several days. The complainant tells me that he was notified by his bank that his wife's debit card had some activity and when he checked her bank account statement, he noticed approx six unauthorized charges. This deputy was informed that the female victim/wife had been in the skilled unit of Lakes of [NAME] since May 02, 22. Review of an undated copy of R1's bank charges that were frauduantly made include: 05/12/22 $126.00 to Southern Finance, 05/12/22 $133.40 to World Finance, 05/12/22 $382.70 to World Finance, pending date $203.98 to Geico, pending date $444.28 to Geico, pending date $239.80 to [NAME] Electric, totaling $1530.22. Review of a facility provided witness statement on 05/16/22 referenced, The following employees verbally stated they have no knowledge of a credit card belonging to resident in room [ROOM NUMBER]. Included the name of CNA1. Review of the employee record of CNA1 disclosed, Abuse & Neglect: How to recognize the Signs/Timely Reporting: Elder Justice Act, [NAME] of Rights for LTC/Resident Rights Confidentiality; HIPPA was completed by CNA 1 on 11/03/2021. Resident Abuse/ Neglect in-service completed and signed by employee, CNA1, 05/04/22. During an interview on 11/08/22 at 11:55 AM, the Administrator indicated that he was informed by R1's husband that there were some charges that were made on R1's account, as he was notified by the bank. R1's husband provided the charges to the facility, and they began an investigation. He explains that they asked all staff to complete a witness statement about using or having seen a credit card that belonged to R1. All staff denied and the facility administrator was not aware of the findings until Georgetown County Sheriff's Department came in to arrest their employee, CNA1. The Administrator states, CNA1 was walked out by the sheriff's department, and she was able to resign on the phone because she knew she was going to be charged. The facility Administrator was unable to provide documentation of a grievance or that the employee, CNA1, was placed on the state nurse aide registry. During a telephone interview on 11/08/22 at 1:12 PM, R1 was asked if she would provide the details on the incident that had taken place in reference to money being taken from her debit card. R1 stated, I think it was about $14.00 and that has been a while ago, we can just drop it, it doesn't matter at this point. R1 did not want to go into further detail about the incident. On 11/08/22 at 1:35 PM and 1:50 PM attempts were made to contact CNA1 via phone number provided in employee record, attempts unsuccessful.

Based on interviews and record review, the facility failed to ensure identified irregularities in the drug regimen for one (Resident (R) 7) of six residents reviewed for unnecessary medications were acted upon. Specifically, the physician did not document the clinical rationale for refusal to implement the recommendations from the pharmacist. This failure placed R7 at risk for use of unnecessary psychotropic medications, which could cause negative side effects such as oversedation, dizziness and loss of balance, uncontrollable involuntary movements, or drug interactions. Findings include: Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/21, revealed the resident did not have any signs of depression or mood symptoms, but displayed other behavioral symptoms not directed toward others on a daily basis R7 scored a zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Review of R7's 07/30/21 Drug Regimen Review by the pharmacist revealed a gradual dose reduction (GDR) was requested of the medications Lexapro and Depakote. A review of the physician's Progress Notes and the response documented on the 07/30/21 Drug Regimen Review showed that the GDR was denied by R7's physician with no reason or rationale documented, and the resident continued with the same doses of the Lexapro and Depakote. During an interview on 12/14/21 at 1:02 PM with LPN3, she stated R7 was diagnosed with late-stage Alzheimer's disease and exhibited some behavioral symptoms related to the dementia. During a phone interview on 12/15/21 at 11:09 AM with the resident's physician, he stated that he did not agree with the GDR recommended by the Pharmacist on 7/30/21 due to not wanting the resident to have increased behaviors, because that has happened in the past. He just forgot to document it specifically in the resident's record. During an interview on 12/14/21 at 3:02 PM with the Director of Nursing, she was shown the blank GDR request from the consultant pharmacist. When asked why the request form blank was, she stated that is normally how they process their paperwork for GDRs and it is understood between staff that a blank sheet of paper means that there are no changes to be made. She then went on to state as a nurse this is how I expect it to be done.

Based on record reviews, interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, the facility failed to implement an effective QAPI program to ensure deficiencies cited during the recertification survey were corrected. (Cross refer F812 and F880) Findings include: A review on 2/9/22 at 11:45 AM of the facility's QAPI committee meeting for 1/26/22 did not include the deficiencies cited (F812 and F880) during the recertification survey, which was part of the facility's plan of correction. As a result, F812 and F880 was cited during the revisit, and the facility remained out of compliance. An interview on 2/9/22 at 11:47 AM with the Director of Nursing confirmed that the deficiencies cited during the recertification survey was not in the monthly meeting minutes as documented on the plan of correction dated 1/13/22. Review on 2/9/22 at 11:55 AM of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, under the Committee Audit Process. 1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. 2. The QAPI Committee shall help various departments, committees, disciplines and individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. 3. The committee shall track the progress of any active plans of correction. 4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented.

Based on observation, interview, and review of facility policy and procedure the failed to ensure staff properly donned personal protective equipment (PPE) while delivering lunch to Resident (R) 59, who was on transmission based precautions. Findings include: Review of facility policy titled Isolation-Categories of Transmission-Based Precautions revised date 10/18 revealed, .5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC (Centers for Disease) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room .Contact Precautions .4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . During an observation during lunch tray delivery on 12/13/21 at 12:06 PM revealed a Certified Nursing Assistant (CNA)1 enter into R59's room without a gown and/or gloves donned while delivering R59's lunch. CNA1 handed R59 her salt, pepper, and butter off of her tray and then exited the room without washing and/or performing hand hygiene. Observation of R59's door revealed a sign Contact Precautions and See nurse prior to entering resident room. Thank you. During an observation on 12/13/21 at 12:49 PM revealed CNA1 re-entered R59's room to re-collect the meal tray without a gown and/or gloves donned. No hand washing and/or hygiene performed post exiting the room. During an interview on 12/13/21 at 1:00 PM CNA1 stated, We only have to put on a gown and gloves when we are delivering some type of care to her. Just delivering her meals, we aren't required to put on the gown and gloves. During an interview on 12/13/21 at 4:05 PM with the Director of Nursing (DON) stated, The staff is only required to don PPE if they are providing care to the resident. Delivering meal trays they do not have to put on the PPE.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy and procedure the facility failed to ensure expired supplies were removed from the patient care areas and the narcotics disposal form contained all pertinent information needed for disposal. Findings include: 1. During an observation of the medication supply room on [DATE] at 11:50 AM revealed four vacuette blood collection tubes expired on [DATE]. During an interview on [DATE] at 11:50 AM with LPN1 stated, The night shift is responsible for checking supplies for the medication room. 2. During an observation on [DATE] at 12:49 PM of the treatment cart revealed the following: forty-four vaseline petrolatum gauze strips expired [DATE], twenty-two steri-strips expired 1/20, sixteen tegaderm films 4 inch x 4 3/4 inch expired 8/21, one hydrofera blue bacteriostatic wound dressing expired 9/20, and thirty povidone-iodine prep pads expired 2/21. During an interview on [DATE] at 12:55 PM with RN stated, Night shift is responsible for checking for expired supplies. It should be checked every night. During an interview on [DATE] at 2:59 PM with the Interim Director of Nursing (DON) stated, There should be no expired supplies on the floor and we do not have an expired supplies policy. 3. Review of facility policy titled Discarding and Destroying Medications revised date 04/19 revealed, .4. Schedule II, III, and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications .11. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. The name and strength of the medication; d. The name of the dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses . During a review of the facility Narcotics Disposal form on [DATE] at 9:55 AM revealed the form failed to include the resident's full name, strength of the medication to be disposed, and method of disposal of the controlled medications. During an observation of the controlled medication file cabinet on [DATE] at 09:55 AM revealed the following controlled scheduled narcotics with the potential for abuse with an acquisition form wrapped around them: Lyrica, Fentayl patches, Oxycodone pills, Morphine sulfate liquid, and Ativan pills. The acquisition sheet was attached to the medications with the initials of the DON by the remaining number in the pill pack or liquid solutions. During an interview on [DATE] at 10:00 AM with the DON stated, The pharmacist and I will complete the disposal sheet together for the meds (medications). The nurses and I will put the information on the removal forms that is located in their books on the carts and we keep those sheets. Pharmacy comes at least quarterly for us to dispose of the meds. I am the only person with a key to the narcotics cabinet and probably the pharmacist. I'm not sure. During an interview on [DATE] at 12:06 PM with the Pharmacist stated, I usually come every three months to waste narcotics. I came right in September during the last DON. I always destroy the meds (medications) with the DON or his/her designee. The process for destroying the narcotics when I arrive is when the person is discharged or deceased , they (the facility) state the information on the sheet and then I sign off on that sheet. That form goes into the records with all of the other sheets. I check accuracy of the meds by double checking the lists and my signature details what I destroy. I do not have access to the file cabinet where the meds are located. During an interview on [DATE] at 1:50 PM with the DON stated, Narcotics that need to be wasted are removed from the cart with the acquisition sheet and initialed with my signature and placed in the file cabinet in the medication room. We do not have any other system or use a form for what is in the cabinet until the pharmacist arrives for us to destroy it. We only use the narcotic disposal form that I provided to you earlier. I am the only one with a key to the cabinet and we have never had an issue with drug diversion in the building. This process has always worked for us.

Based on observation, interviews, and record review the facility failed to ensure proper handling of food storage and holding temperatures in the main kitchen and one of one satellite serving kitchen. This failure had the potential to cause foodborne illness for all six residents of the facility who received food served from the main and/or satellite kitchen. Findings include: On 12/13/21 at 9:21 AM, observation of the dry storage room revealed: an opened jar of cashew butter that expired 09/21/21, an opened jar of roasted peanuts not dated when opened, stir fry sauce not dated when opened, and a foiled, unidentified item that was not dated or labeled. Additionally, these items were opened and were not sealed or covered: yellow cake mix box, large box of dried cranberries, and a large bag of chickpeas. The freezer in the main kitchen also contained several items not dated when opened: thousand island dressing, balsamic vinaigrette, a jar of horseradish, and jar of banana peppers. Additionally, in the freezer, there was not an inside thermometer observed. At this time, the Director of Food Services verified there was no thermometer inside the freezer, and stated the staff always measured the temperature using the built-in thermometer on the outside of the freezer. On 12/14/21 at 11:50 AM, observation of lunch food preparation and service in the serving kitchen showed that food holding temperatures were outside of acceptable ranges. The Dietary Manager (DM) measured the holding temperatures prior to and/or during meal service. The smoked salmon BLT tempted at 60 degrees Fahrenheit, egg salad at 60F, chicken tenders at 80F, and onion rings at 80F. The DM did not take any action to remediate the holding temperatures before serving the foods. On 12/14/21 at 3:30 PM, during an interview, the Director of Food Services said that he expected his staff to know the holding temperatures and what action should be taken to bring food to its proper temperature. He also indicated that staff should know how to properly label, date, and properly seal items when they are opened and remove them when expired. The facility's Food Receiving and Storage and Food Preparation and Service policies addressed proper food storage and food holding temperatures. Food Receiving and Storage: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (used by date). Food Preparation and Service: 6. Previously cooked food must be reheated to an internal temperature of 165 Fahrenheit (F) for at least 15 seconds. 8. Mechanically altered hot foods prepared for modified consistency diet must stay above 135F during preparation or they must be reheated to 165F for at least 15 seconds.