Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 2 of 15 (Certified Nursing Assistant (CNA) A and CNA G) failed to use courtesy titles when addressing residents. The findings include: 1. Review of the facility policy titled, Dignity, dated February 2021, revealed .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .and feelings of self-worth and self-esteem .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling . 2. Observation during dining on the second floor [NAME] Dining Room on 3/24/2025 at 12:23 PM, revealed CNA A placed a plate down on the dining room table in front of Resident #336 and stated, There you go, sweetheart. 3. Observation during dining on the first floor [NAME] Hall on 3/24/2025 at 12:27 PM, revealed CNA G placed a plate down on the Resident's over bed table and stated, Here's your food my darling. Observation during dining on the first floor [NAME] Hall on 3/24/2025 at 12:34 PM, revealed CNA G announced herself as she entered the room of Resident #24 and stated, Hey there darling .enjoy, honey . Observation during dining on the first floor [NAME] Hall on 3/24/2025 at 12:38 PM, revealed CNA G announced herself as she entered the room of Resident #62 and stated, Hey darling . Observation during dining on the first floor [NAME] Hall on 3/24/2025 at 12:41 PM, revealed CNA G set a plate down on the over bed table of Resident #16 and stated, Here, darling . Observation during dining on the first floor [NAME] Hall on 3/24/2025 at 12:46 PM, revealed CNA G set a plate down on the over bed table of Resident #58 and stated, Here, darling .do you need me to raise your head honey . 4. During an interview on 3/26/25 at 12:20 PM, the Director of Nursing (DON) confirmed that residents should be addressed with courtesy titles and should not be referred to with pet names.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin for 1 of 1 (Resident #287) sampled residents reviewed for injury of unknown origin. The findings include: 1. Review of the facility policy titled Unexplained Injuries, dated 11/11/2024, revealed .if the injury is of unknown source, reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures .An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury .An injury of unknown source shall be investigated even if the resident is discharged from the facility as a result of an injury, or an injury of unknown source is identified after discharge (i.e. fractured rib in the emergency room) .Reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. 2. Review of the medical record revealed Resident #287 was admitted to the facility on [DATE], with diagnoses including Anemia, Atrial Fibrillation, Gastroesophageal Reflux Disease, and Malnutrition. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 10, which indicated Resident #287 was moderately cognitively impaired. Resident required moderate assistance with toileting, supervision assistance needed with transfers, and resident was max assistance with bathing. Resident was taking anticoagulants. Review of Nurse's Note dated 9/19/2024, revealed Family requested for resident to be sent to the ER [Emergency Room]. FNP [Family Nurse Practitioner] .notified. New order [to] send resident to ER .Daughter at bedside . Review of (named hospital) admission History and Physical Exam documentation dated 9/20/2025, revealed .Principal problem: Subdural hematoma, Active Problems: Hematuria, Altered Mental Status, Hypocalcemia History of Present illness .Onset 2 days ago. Sudden worsening. Unsure of trauma or inciting event in nursing home .Imaging: CT [Computed Tomography used for imaging the body by means of Xray] Head without Contrast result date 9/19/2024 .Preliminary Report .Acute Subdural Hematoma along the right frontal convexity, maximum thickness of 6mm [millimeter] . During an interview on 3/27/2025 at 7:55 AM, the Administrator confirmed that the facility was made aware of resident's subdural hematoma on 9/20/2024, and confirmed that it should have been reported as an injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the policy review, record review, observations, and interviews the facility failed to provide an environment free of accident hazards for 3 of 4 (Residents #5, #56, and #286) sampled residents when staff left disposable razors out and unattended in the resident's room and the facility failed to care plan resident for anticoagulation therapy. The findings include: 1. Review of the facility policy titled, Hazardous Ares, Devices and Equipment, dated 7/2017, revealed .All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible .A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include .Equipment and devices that are left unattended .Sharp objects that are accessible to vulnerable residents .Resident vulnerability is based on risk factors including .functional status .cognitive abilities .health treatments (e.g., medications) . Review of the facility policy titled, High Risk Medications- Anticoagulants, dated 11/11/2024, revealed .The facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences .The resident's plan of care shall alert staff to monitor for adverse consequences .The resident's plan of care shall include interventions to minimize risk of adverse consequences . Review of the facility policy titled, Comprehensive Care Plans, dated 11/11/2024, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing .needs . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Dementia, Psychosis, Adult Failure to Thrive, Atrial Fibrillation, and Anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed there was no Brief Interview for Mental Status (BIMS) score, which indicated Resident #5 was severely cognitively impaired and required partial/moderate assistance with grooming. Review of the Care Plan dated 2/23/2025, revealed Resident #5 had difficulty communicating with others related to dementia and acute confusion, impaired functional status, and receives anticoagulants. Review of the Physician's Order dated 9/3/2024, revealed, .Eliquis 2.5 [an anticoagulant used to prevent blood clots] mg [milligram] tablet .1 tab [tablet] By Mouth Twice daily . Observations in Resident #5's room on 3/24/2025 at 9:47 AM,11:33 AM, and 12:59 PM, revealed a blue disposable razor on the Resident's bathroom vanity. During an interview on 3/24/2025 at 1:00 PM, Licensed Practical Nurse (LPN) B confirmed that disposable razors should not be left out and unattended in a resident's room. 3. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Atrial Fibrillation, and Cognitive Communication Deficit. Review of the annual MDS assessment dated [DATE], revealed Resident #56 had a BIMS score of 11, which indicated Resident #56 was moderately cognitively impaired. Resident required partial/moderate assistance with grooming, and medications included an anticoagulant. Review of the Physician's Order dated 3/4/2025, revealed, .Eliquis 2.5 mg tablet .1 tablet By Mouth Twice daily . Review of the Care Plan dated 3/18/2025, revealed Resident #56 had impaired functional status, and anticoagulant therapy was not care planned. Observations in Resident #56's room on 3/24/2025 at 10:07 AM, and 12:58 PM, revealed a blue disposable razor on the bathroom vanity. During an interview on 3/24/2025 at 1:01 PM, LPN B confirmed that disposable razors should not be left out and unattended in a resident's room. During an interview on 3/27/2025 at 8:48 AM, the Director of Nursing (DON) confirmed that if a resident is on an anticoagulant medication the care plan should reflect that. 4. Review of the medical record revealed Resident #286 was admitted to the facility on [DATE], with diagnoses including Dementia, Atrial Fibrillation, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 8, which indicated Resident #286 was moderately cognitively impaired. Resident required assistance of staff to perform Activities of Daily Living (ADLs). Resident was taking an antiplatelet. Review of Physician's Order dated 3/10/2025, revealed .Xarelto [used to prevent blood clots] 20mg .1 tablet By Mouth Every evening . Observations in the Resident's room on 3/25/2025 at 10:48 AM, 10:55 AM, and 12:47 PM, the resident was sitting up in wheelchair (wc). There were 3 blue disposable razors on the Resident's bathroom vanity. Observation and interview in the Resident's room on 3/25/2025 at 12:56 PM, LPN E was asked to Resident's room. LPN E was asked if the 3 razors on the resident's bathroom vanity should be left out and unattended. LPN E confirmed that the razors should not be out in the resident's room. During an interview on 3/25/2025 at 1:08 PM, the DON confirmed that disposable razors should not be left out and unattended in a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a comprehensive assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 10 of 33 ( Resident #3, #5, #13, #21, #26, #38, #42, #59, #78 and #286 ) sampled residents reviewed. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.19.1 revised October 2024, pages 2-22 through 2-24, revealed .The admission assessment must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z0500B) must be no later than day 14 . The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD [Assessment Reference Date] . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], and discharged on 1/3/2025 with diagnoses of Polyneuropathies, Hypertension, Diabetes, and Atrial Fibrillation. Review of the admission MDS assessment dated [DATE], revealed item Z0500B was completed on 12/16/2024, and should have been completed by 11/6/2024. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Dementia, Psychosis, Adult Failure to Thrive, and Atherosclerotic Heart Disease. Review of the admission MDS assessment dated [DATE], revealed item Z0500B was completed on 1/1/2025, and should have been completed by 12/3/2024. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Dementia, Diabetes, and Chronic Kidney Disease. Review of the annual MDS assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 1/14/2025. 5. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Parkinson's Disease, Aphasia, and Gastro Esophageal Reflux Disease. Review of the annual MDS assessment dated [DATE], revealed item Z0500B was completed on 8/16/2024, and should have been completed by 8/8/2024. 6. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Vascular Dementia, Anxiety, and Hypertension. Review of the annual MDS assessment dated [DATE], revealed item Z0500B was not completed, and should have been completed by 3/11/2025. 7. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses Nontraumatic Intracranial Hemorrhage, Dementia, and Anxiety. Review of the annual MDS assessment dated [DATE], revealed item Z0500B was completed on 1/6/2025, and should have been completed by 11/21/2024. 8. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Cerebral Infarction, Epilepsy, Peripheral Vascular Disease and Hypertension. Review of the annual MDS assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 2/7/2025. 9. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], and discharged on 12/11/2024, with diagnoses including Fracture of Tarsal Right foot, Fracture of Metatarsal Right foot, Hypertension and Protein-Calorie malnutrition. Review of the admission MDS assessment dated [DATE] revealed item Z0500 was completed on 11/18/2024, and should have been completed by 10/30/2024. 10. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Depression, Urinary Tract Infection, and Asthma. Review of the admission MDS assessment dated [DATE], revealed that item Z0500B was not completed, and should have been completed by 2/23/2025. 11. Review of the medical record revealed Resident #286 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Dementia, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed item Z0500 was not completed, and should have been completed by 2/20/2025. 12. During an interview on 3/26/2025 at 11:57 AM, the MDS Coordinator was asked who signs MDS assessments verifying they are complete. The MDS Coordinator stated, The DON [Director of Nursing]. The MDS Coordinator was asked how the DON is made aware there are assessments that need to be completed. The MDS Coordinator stated, I send her a text or an email. The MDS Coordinator confirmed there was no one working in the MDS position when she started at the end of November and there were incomplete MDS assessments that she had to catch up. The MDS Coordinator confirmed that annual assessments should be completed 14 days after the ARD. During an interview on 3/27/2025 the DON confirmed assessments for Residents #13 and #42 were signed as complete as of today 3/27/3035. The DON confirmed these assessments should have been completed prior to today. The DON was asked why the MDS assessment are not being completed timely. The DON stated, Probably because I was not made aware. The DON was asked do you expect to be notified when assessments are ready to be completed. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 13 of 33 (Resident #2, #5, #11, #13, #21, #23, #26, #30, #33, #41, #42, #55, and #56) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.19.1 October 2024, page 2-35, revealed, .The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD [Assessment Reference Date] . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Hypertension, Hypertension, and Gastro Esophageal Reflux Disease. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was dated 3/14/2025, and should have been completed by 2/8/2025. 3. Review of the medical record revealed Resident #5 was admitted to the facility on with diagnoses including Dementia, Psychosis, Adult Failure to Thrive, and Atherosclerotic Heart Disease. Review of the quarterly MDS dated [DATE] revealed item Z0500B was completed 3/27/2025, and should have been completed by 3/6/2025. 4. Review of the medical record revealed Resident # 11, was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Anxiety, and Functional Quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item Z0500B was completed on 12/18/2024, and should have been completed by 11/14/2025. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item Z0500B was completed on 3/14/2025, and should have been completed by 2/11/2025. 5. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Dementia, Diabetes, and Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 10/27/2024, and should have been completed by 10/16/2024. 6. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Parkinson's Disease, Aphasia, and Gastro Esophageal Reflux Disease. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 12/18/2024, and should have been completed by 11/8/2024. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 2/11/2025, and should have been completed by 1/5/2025. 7. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Hypertension and Osteoporosis. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 10/27/2024, and should have been completed by 10/17/2024. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 1/14/2025. 8. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Vascular Dementia, Anxiety, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 12/18/2024, and should have been completed by 12/11/2024. Review of the quarterly MDS assessment dated [DATE], revealed time Z0500B was completed on 10/26/2024, and should have been completed by 9/14/2024. 9. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Atherosclerotic Heart Disease, Hypertension and Hyperlipidemia. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 2/24/2025. 10. Review of the medical record revealed Resident #33, was admitted to the facility on [DATE], with diagnoses including Failure to thrive, Dementia, Legal Blindness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item 0Z500B was completed on 1/2/2024, and should have been completed by 12/1/2025. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 3/2/2025. 11. Review of the medical record revealed Resident # 41, was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Depression, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item Z0500B was completed on 10/27/2024, and should have been completed by 10/16/2024. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 1/14/2025. 12. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Cerebral Infarction, Epilepsy, Peripheral Vascular Disease and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 6/15/2024, and should have been completed by 5/10/2024. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 8/14/2024, and should have been completed by 8/10/2024. Review of the quarterly MDS assessment dated [DATE], revealed item Z0500B was completed on 1/6/2025, and should have been completed by 11/10/2024. 13. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Diabetes, Atrial Fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed item Z0500B was completed on 3/27/2025, and should have been completed by 1/15/2025. 14. Review of the medical record revealed Resident #56, was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Heart Failure, and Glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed item Z0500B was completed on 3/27/2025, and should have been completed by 3/18/2025. 15. During an interview on 3/26/2025 at 11:57 AM, the MDS Coordinator was asked who signs MDS assessments verifying they are complete. The MDS Coordinator stated, The DON [Director of Nursing]. The MDS Coordinator was asked how the DON is made aware there are assessments that need to be completed. The MDS Coordinator stated, I send her a text or an email. The MDS Coordinator confirmed Residents #2, #11 and #30 had assessment that were completed late. The MDS Coordinator confirmed that quarterly assessments should be completed 14 days after the ARD. During an interview on 3/26/2025 at 2:27 PM, the DON confirmed the MDS coordinator notified her when MDS assessments are ready to be signed for completion and she signs them. The DON confirmed Resident #2's MDS was not signed within 14 days of the ARD and Resident #30's MDS was not signed as being complete. The DON confirmed MDS assessments should be completed within 2 weeks of the ARD. During an interview on 3/27/2025 the DON confirmed assessments for Residents #5, #23, #30, #33, #38, #41, #55 and #56 were signed as complete as of today 3/27/3035. The DON confirmed these assessments should have been completed prior to today. The DON was asked why the MDS assessment are not being completed timely. The DON stated, Probably because I was not made aware. The DON was asked do you expect to be notified when assessments are ready to be completed. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete discharge and death in facility assessments using the centers for Medicare & Medicaid services specified RAI process for 9 of 33 (Resident #3, #12, #15, #18, #31, 59, #60, #61 and #224) sampled residents reviewed. The findings include: 1. Review of the MDS 3.0 RAI manual v 1.19.1 revised October 2024, pages 2-38 through 2-39, revealed .Discharge Assessment .Must be completed when the resident is discharged from the facility . Must be completed .within 14 days after the discharge date . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], and discharged on 1/3/2025, with diagnoses of Polyneuropathies, Hypertension, Diabetes, and Atrial Fibrillation. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was completed on 3/27/2025, and should have been completed by 1/17/2025. 3. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Gout, Osteoarthritis and Chronic Kidney Disease. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was not completed and should have been completed by 1/6/2025. 4. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Repeated Falls and Muscle Weakness. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was completed on 3/27/2025, and should have been completed by 12/25/2024. 5. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], and discharged on 12/13/2024, with diagnoses including Heart Failure, Cognitive Communication Deficit, and Atherosclerotic Heart Disease. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was completed on 3/27/2025, and should have been completed by 12/27/2024. 6. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], and discharged on 12/18/2024, with diagnoses including Fractured Left Humerus, atrial Fibrillation and Osteoarthritis. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was not completed, and should have been completed by 1/1/2025. 7. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], and discharged on 12/11/2024, with diagnoses including Fracture of Tarsal Right foot, Fracture of Metatarsal Right foot, Hypertension and Protein-Calorie malnutrition. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was completed on 3/27/2025, and should have been completed by 12/25/2024. 8. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], and discharged on 1/28/025. with diagnoses including Encephalopathy, Cellulitis, Chronic Obstructive Pulmonary Disease, and Hypertension. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was completed on 3/14/2025., and should have been completed by 2/11/2025. 9. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE], and discharged on 12/18/2024, with diagnoses including Dysphagia, Severe Protein Calorie Malnutrition and Osteoarthritis. Review of the discharge MDS assessment dated [DATE] revealed item Z0500B was completed on 3/27/2025, and should have been completed by 1/1/2025. 10. Review of the medical record revealed Resident #224 was admitted to the facility on [DATE], and discharged on 11/19/2024, with diagnoses including Left Femur Fractur, Pneumonia, and Parkinson's Disease. Review of the discharge MDS assessment revealed the assessment was dated 11/19/2025 and item Z0500 was not completed. The MDS should have been dated 11/19/2024 and item Z0500 should have been completed by 12/2/2024. 11. During an interview on 3/26/2025 at 11:57 AM, the MDS Coordinator was asked who signs MDS assessments verifying they are complete. The MDS Coordinator stated, The DON [Director of Nursing]. The MDS Coordinator was asked how the DON is made aware there are assessments that need to be completed. The MDS Coordinator stated, I send her a text or an email. The MDS Coordinator confirmed Resident #60's assessment that was completed late. The MDS Coordinator confirmed that discharge assessments should be completed 14 days after the ARD. During an interview on 3/26/2025 at 2:27 PM, the DON confirmed the MDS coordinator notified her when MDS assessments are ready to be signed for completion and she signs them. The DON confirmed MDS assessments should be completed within 2 weeks of the ARD. During an interview on 3/27/2025 the DON confirmed assessments for Residents #12, #31 and #224 were not complete and assessments for Residents #3, #15, #18, #59 and #61 were signed as complete as of today 3/27/3035. The DON confirmed these assessments should have been completed prior to today. The DON was asked why the MDS assessment are not being completed timely. The DON stated, Probably because I was not made aware. The DON was asked do you expect to be notified when assessments are ready to be completed. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure a safe and sanitary environment in the kitchen and failed to clean the kitchen ice machine filter. The findings include: 1. The facility policy titled, Sanitation, dated 7/11/2024, revealed .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish All utensils .and equipment shall be kept clean, maintained in good repair .Ice that is used in connection with food or drink shall be from a sanitary source and shall be .dispensed in a sanitary manner .Kitchen wastes that are not disposed of .shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily .Kitchen .surfaces .shall be cleaned frequently enough to prevent accumulation of grime . The facility's undated Resident Rights Notice revealed .right to a safe, clean, comfortable and homelike environment . The facility policy titled Food Storage dated 7/11/2024, revealed .Food services, or other designated staff, will always maintain clean food storage areas .Prepared food stored in the refrigerator .shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid . 2. Observations in the kitchen on 3/24/2025 at 9:15 AM, revealed: a. Large cardboard pieces and boxes scattered on the floor outside of the dry storage room. b. The ice machine filter revealed loose dry tan fuzz hanging out of the vent, over the ice door. c. Wet nesting of water droplets on 4 large, long baking sheets stored under the left sink workstation. d. The top convection oven and bottom convection oven revealed dried burned food particles on the bottom of both ovens with splattered food also on the inside doors of both ovens. e. The refrigerator revealed heavy whipping cream unlabeled, open and undated. f. A large bag of breadcrumbs unlabeled, open and undated in the dry storage room. Observation in the kitchen on 3/25/2025 at 12:50 AM, revealed: a. Large pieces of cardboard boxes scattered on the floor outside of the dry storage room. b. Three (3) square cooking pans and 4 long cooking pans with scattered water wet nesting between the cooking pans sitting under the right sink workstation. c. The top convection oven and bottom convection oven with dried burned food particles on the bottom of both ovens with splattered food also on the inside doors of both ovens, as well as burnt black carbon buildup on the bottom and sides of both ovens. d. One half stick of salted butter wrapped loosely in open plastic wrap, unlabeled, open and undated stored in refrigerator. Observations in the kitchen on 3/26/2025 at 2:30 PM, revealed: a. One quarter of a stick of salted butter, open unlabeled and undated in the refrigerator. b. A pack of frozen chicken breasts in an unlabeled, undated plastic bag. c. The top convection oven and bottom convection oven with dried burned on food particles on the bottom of both ovens with splattered dry food also on the inside doors of both ovens, as well as burnt black carbon buildup on the bottom and sides of both ovens. d. A full garbage can with no lid with trash, food debris and soiled wrappings touching the kitchen sink and workstation while frozen chicken was sitting in the sink thawing with cold water running over it. During an interview on 3/26/2025 at 3:40 PM, the Culinary Director was asked should food be stored unwrapped, open, unlabeled and undated in the dry storage room or in the refrigerator or freezer. The Culinary Director stated, No. The Culinary Director was asked should clean cooking pans and cooking sheets have wet nesting with water between the clean stored pans. The Culinary Director stated, No. The Culinary Director was asked should the ice machine filter have dirt and dust hanging from the vents over the ice machine door. The Culinary Director stated, No. The Culinary Director was asked if a full garbage can with no lid with trash, food debris and soiled wrappings sit beside and touch the sink containing thawing food. The Culinary Director stated, No. The Culinary Director was asked should empty cardboard boxes and debris be scattered on the kitchen floor. The Culinary Director stated, No. The Culinary Director was asked should the convection ovens have scattered dried food and burnt black carbon buildup on the bottom and sides of the ovens. The Culinary Director stated, No. The Culinary Director was asked if the inside convection oven doors have scattered food particles and black carbon residue. The Culinary Director stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 15 staff (Dietary Aide J and CNA l) failed to perform hand hygiene and perform proper handling of dinnerware during dining and when 3 of 3 nurses (Registered Nurse (RN) C, Licensed Practical Nurse (LPN) LPN D and LPN E) failed to perform sanitation of reusable equipment during medication administration. The findings include: 1. Review of the facility policy titled Handwashing/Hand Hygiene, dated 10/2023, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections .Hand Hygiene is indicated: after contact with .contaminated surfaces .after touching a resident .after touching a resident's environment . Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, revealed .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected .Reusable items are cleaned and disinfected or sterilized between residents (e.g. [for example] stethoscopes, durable medical equipment) .Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident . Review of Server Training Guide titled, The Farms at [NAME] Station, revealed . The health department established codes to prevent Residents from contamination and contracting food-related diseases .Always follow these guidelines established to protect the public .Handle glassware by the stem. Do not handle glassware by the top rim or glass lip because of germs from your hands may remain on the rim of the glass where a person's mouth comes in contact .use a tray to transport all food and beverages to and from table . 2. Observation on 3/24/2025, at 12:14 PM in the 2 [NAME] Dining room showed Dietary Aide J carrying out food with both her hands full, and the napkin with silverware in it under her arm for Resident #56. Observed on 3/24/2025, at 12:19 PM in 2 [NAME] Dining room showed Dietary Aide J carrying out a drinking glass with a can of soda in it under her left arm, for Resident #5. Observed on 3/24/2025, at 12:52 PM CNA I bring a tray to Resident #26 in his room and said, I will be back to feed you, CNA I left tray on overbed table, didn't wash her hands after making room for food on overbed table and continued to pass lunches. Observed on 3/24/2025, at 12:53 PM CNA I bring food to Resident #11 in her room, the CNA I set up resident to eat, moving objects around on overbed table. CNA I left the room to get a towel off the clean linen cart outside of room in hallway. CNA I did not wash her hands before leaving room and accessing clean linen cart. During an Interview on 3/25/2025 at 4:25 PM, the Director of Nursing was asked if staff should perform hand hygiene after having contact with the resident's environment and before accessing a clean area? The Director of Nursing stated, .no, staff must wash their hands after having touched the resident or their environment . Random observation from 2 [NAME] Dining room on 3/26/2025 at 7:45 AM showed Dietary Aide J drop several individual coffee creamers on the floor in the kitchenette prep area, pick them up off the floor and proceed to give then to resident in 2 East Dining area. During an interview on 3/26/2025 at 3:30 PM, the Culinary Director was asked should the dietary aides place the resident's clean rolled napkins holding eating utensils and drinking cups under their arms prior to delivering the resident's meal. The Culinary Director stated, .no that is not sanitary, we are working on that . 3. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE], with diagnoses including Enterostomy Malfunction, Malnutrition, Adult Failure to Thrive, and Dysphagia. Observation and interview during medication administration on 3/25/2025 at 4:58 PM, revealed RN C performed administration of medications via (by way of) Percutaneous Gastrostomy (PEG) tube, a tube inserted into the gastrointestinal tract to administer medications or nutritional supplements, for Resident #53. RN C checked placement of resident's peg tube using a stethoscope. RN C returned the stethoscope to the medication cart without cleaning or disinfecting after use. RN C was asked if she should clean her stethoscope. RN C confirmed that the stethoscope should be cleaned. 4. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hypertension, Heart Failure, and Pulmonary Emboli. Observation and interview during medication administration on 3/26/2025 at 7:40 AM, revealed LPN D checked Resident #20's blood pressure using an automatic wrist blood pressure (bp) cuff. LPN D returned the wrist cuff to the medication cart without cleaning or disinfecting the blood pressure cuff. LPN D was asked if the bp cuff should be cleaned after use. LPN D confirmed that the bp cuff should be cleaned after use. 5. Review of the medical record revealed Resident #288 was admitted to the facility on [DATE], with diagnoses including Hypertension, Major Depressive Disorder, and Glaucoma. Observation and interview during medication administration on 3/26/2025 at 9:15 AM, revealed LPN E checked Resident #288's blood pressure and pulse oximetry using an automatic machine. LPN F returned the automatic machine to the 2 East Hall. LPN E and LPN F confirmed that the automatic blood pressure cuff and pulse oximeter machine should be cleaned and disinfected after use. During an interview on 3/26/2025 at 2:32 PM, the Director of Nursing (DON) confirmed that reusable equipment should be cleaned and disinfected before and after use and in between patients.