**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #1 and #2) reviewed for pharmacy services. 1. The facility failed to administer Resident #1's Losartan per the recommended and prescribed blood pressure parameters in July and August of 2025. 2. The facility failed to administer Resident #2's Isosorbide per the recommended and prescribed blood pressure parameters in July and August of 2025. These failures could place residents at risk for complications, as well as jeopardize their health and safety.Findings included: Record review of Resident #1's face sheet, dated 08/26/2025, revealed a [AGE] year-old female with an original admission date of 04/17/2018, and a current admission date of 11/02/2023. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Essential Primary Hypertension (high blood pressure which occurs without an identifiable medical condition causing it). Record review of Resident #1's Quarterly MDS assessment, dated 08/12/2025, revealed a BIMS score of 01, which revealed severely impaired cognition. MDS also revealed an active diagnosis of Hypertension. Record review of Resident #1's care plan, last reviewed 08/23/2025, revealed a care plan for potential for hyper/hypotensive episodes related to Hypertension and antihypertensive medications. Interventions included give medications as ordered, and/or report abnormal blood pressures to doctor. Record review of Resident #1's active physician orders, started 03/29/2025, revealed an order for Losartan Potassium (a medication used to treat high blood pressure) 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Record review of Resident #1's July 2025 MAR revealed Losartan Potassium 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 07/05/2025 7:00 AM B/P 113/65 Administered 07/11/2025 6:00 PM B/P 119/70 Administered07/13/2025 7:00 AM B/P 106/68 Administered07/22/2025 7:00 AM B/P 110/75 Administered07/27/2025 6:00 PM B/P 102/66 Administered07/28/2025 6:00 PM B/P 102/78 Administered Record review of Resident #1's August 2025 MAR revealed Losartan Potassium 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 08/11/2025 7:00 AM B/P 116/60 Administered08/16/2025 7:00 AM B/P 110/60 Administered08/16/2025 6:00 PM B/P 118/62 Administered08/23/2025 7:00 PM B/P 117/66 Administered Record review of Resident #2's face sheet, dated 08/27/2025, revealed an [AGE] year-old male with an original admission date of 04/03/2024. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Essential Primary Hypertension (high blood pressure which occurs without an identifiable medical condition causing it). Record review of Resident #2's Change in Condition MDS assessment, dated 07/27/2025, revealed a BIMS score of 07, which revealed severely impaired cognition. MDS also revealed an active diagnosis of Hypertension. Record review of Resident #2's care plan, last reviewed 08/06/2025, revealed a care plan for medication to treat hypertension. Interventions included give medications as ordered and monitor blood pressures as ordered and notify doctor if results are high or low. Record review of Resident #2's active physician orders, started 03/05/2024, revealed an order for Isosorbide Mononitrate (a medication used to treat high blood pressure) 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Record review of Resident #2's active physician orders, started 09/15/2024, revealed an order for Losartan Potassium 25 MG, give one tablet by mouth twice daily for hypertension; Hold if systolic blood pressure was less than 120. Record review of Resident #2's July 2025 MAR revealed Losartan Potassium 25 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 07/01/2025 7:00 AM B/P 115/64 Administered 07/12/2025 6:00 PM B/P 107/61 Administered Record review of Resident #2's July 2025 MAR revealed Isosorbide Mononitrate 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Dates when Losartan was given outside of parameters included: 07/01/2025 7:00 AM B/P 115/64 Administered 07/12/2025 7:00 AM B/P 107/61 Administered Record review of Resident #2's August 2025 MAR revealed Losartan Potassium 25 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 08/01/2025 7:00 AM B/P 118/81 Administered 08/06/2025 7:00 AM B/P 119/75 Administered08/11/2025 7:00 AM B/P 110/66 Administered08/15/2025 7:00 AM B/P 116/76 Administered08/22/2025 7:00 AM B/P 119/79 Administered Record review of Resident #2's August 2025 MAR revealed Isosorbide Mononitrate 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Dates when Losartan was given outside of parameters included: 08/01/2025 7:00 AM B/P 118/81 Administered 08/04/2025 7:00 AM B/P 119/71 Administered08/06/2025 7:00 AM B/P 119/75 Administered08/11/2025 7:00 AM B/P 110/66 Administered08/15/2025 7:00 AM B/P 116/76 Administered08/22/2025 7:00 AM B/P 119/79 Administered In an interview on 08/27/25 at 12:12 PM, LVN-B stated he thought he got confused and probably messed up while administering blood pressure medication since there were multiple medications with multiple different parameters. He stated he always checked the residents' blood pressures when they got blood pressure medication, and then he always checks parameters for the medication, but he must have gotten confused. LVN-B stated the blood pressure was checked to make sure it was within range, because if they give a medication for hypertension when the blood pressure was already low, it could continue to drop, and the patient could bottom out. If the blood pressure dropped too low it could cause the resident serious harm. LVN-B denied having any residents experience hypotensive crisis or episodes in the past couple of months. He stated he had been educated and in-serviced regarding administering blood pressure medications, as well as taking vital signs. In an interview on 8/27/25 at 1:25 PM, RN-C stated she always checked the parameters in the orders, but thought she just missed some because the blood pressures taken were close to the ordered parameters. She stated she should have been more careful and paid more attention. RN-C stated the blood pressure was assessed to see if it was too high or too low. RN-C stated if antihypertensive medication was given when the blood pressure was already low, it could cause the resident to have a hypotensive crisis. She stated she had not seen any residents have any signs or symptoms of hypotension in the past couple of months. RN-C stated the blood pressure should always be checked and compared to the parameters prior to administering any blood pressure medication so a resident was not harmed. In an interview on 8/27/25 at 1:49 PM, LVN-D stated nurses should always check the parameters in the orders prior to administering a blood pressure medication because if it was given outside of parameters, it could cause harm, or even death, to a resident. He stated he did not remember the last time he was in-serviced regarding blood pressure medications or vital sign parameters, but he thought it was around two years ago. Record review of the facility's Administering Medications policy, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #100), reviewed for care plans. The facility failed to implement and ensure Resident #100 had 2 beveled mats on floor as care planned dated 10/25/24. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings included: Record review of Resident #100's face sheet dated 1/15/25 reflected a [AGE] year-old-male with an original admission date of 3/05/22. Diagnoses included Dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), hypertension (high blood pressure), and unsteadiness on feet. Record review of Resident #100's care plan dated 10/25/24 stated Resident #100 was at risk for falls due to unsteadiness on feet. Interventions included 2 beveled mats. Record review of Resident #100's annual MDS dated [DATE] reflected a BIM score of 2 (severe cognitive impairment), utilized a wheelchair, and required partial/moderate assistance with sitting/standing and chair/bed transfers. During an observation on 01/14/25 at 02:55 PM Resident was asleep in bed with one floor mat noted to right side of the bed. During an observation on 01/15/25 at 01:50 PM Resident was in bed. One floor mat noted to right side of the bed. In an interview on 01/15/25 at 01:52 PM LVN C stated Resident #100 should have had two floor mats at bedside for fall precautions as Resident #100 had a history of sliding himself off the bed. LVN C stated she was not sure why Resident #100 did not have two floor mats but would immediately get another floor mat to have at Resident #100's bedside. LVN C stated Resident #100 needed two floor mats at bedside to prevent possible injury in case of a fall. In an interview on 01/15/25 at 01:54 PM CNA D stated Resident #100 was supposed to have two floor mats for fall precautions. CNA D stated if she saw only one floor mat at Resident #100's bedside, she would have reported it to the nurse immediately. CNA D stated she did not notice there was only one floor mat as that side of the bed is was closer to the wall and she usually assists Resident #100 on the right side of the bed. CNA D stated she was not sure why Resident #100 only had one floor mat but was going to get another one. CNA D stated Resident #100 needed a floor mat at each side of the bed to help prevent possible injury in case of a fall. In an interview on 01/15/25 at 04:35 PM the DON stated Resident #100 should have had two floor mats at bedside due to having a care plan that was person centered and should be followed for the resident's safety. The DON stated by not having two floor mats then Resident #100 could potentially have an injury if he sustained a fall. The DON stated the nursing managers are responsible for making sure care plans are implemented and followed. The DON stated she was going to in-service staff immediately on implementation of care plans. Record review of facility's Care Plans, Comprehensive Person-Centered Policy dated 3/2022 stated: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #67) reviewed for pharmacy services. The facility failed to ensure Resident #67's physician order for Latanoprost Opthalmic Solution (eye drops) were administered at bedtime as ordered. This failure could place residents at risk for non-therapeutic responses to medications. Findings included: Record review of Resident #67's face sheet dated 01/16/25 revealed a [AGE] year-old female with an initial admission date of 04/17/18 and a current admission date of 11/02/23. Pertinent diagnoses included dementia and glaucoma (fluid buildup in the front part of the eye, causing increased pressure and damage to the optic nerve). Record review of Resident #67's Comprehensive MDS assessment section C, cognitive patterns, dated 11/09/24 revealed a BIMS score of 1 (severe impairment). Record review of Resident #67's care plan revised 11/14/24 revealed the focus I have impaired vision r/t diabetes and glaucoma. I wear glasses. I am at risk for injury r/t decreased visual field. DX: Glaucoma. Interventions listed for the focus included: - Administer eye drops as ordered (if ordered); - Encourage independence of ADL's and provide support as needed; - Keep environment free from small objects on floor, very hot liquids, and other hazardous items; - Monitor for eye pain/discomfort & report to MD. Record review of Resident #67's order summary revealed an active order dated 11/03/23 for Latanoprost Ophthalmic Solution 0.005% (Latanoprost). Instill 1 drop in both eyes one time a day for glaucoma. During an observation of medication administration at 7:39 AM on 01/15/25, this state surveyor observed MA A instill 1 drop of Latanoprost Opthalmic Solution 0.005% in both eyes of Resident #67. The pharmacy label on the Latanoprost read as follows: Instill 1 drop into both eyes at bedtime. Wait 3-5 minutes between drops. In an interview with MA A at 7:41 AM on 01/15/25, MA A stated she did not notice that the label on the medication stated to give the eyedrops at bedtime. MA A stated she had given the eyedrops to Resident #67 in the morning for as long as she could remember. MA A stated she compared the name of the resident, the name of the drug and the number of drops on the label to what was written on her computer and those all matched. MA A stated it was important to follow orders as written by the doctor. MA A stated when she saw a label was mismatched with what the computer showed then she would inform her nurse about the discrepancy. In an interview with RN B at 9:23 AM on 01/15/25, RN B stated it was important to follow doctor's orders as prescribed for the safety and health of the resident. RN B stated if the MA saw a discrepancy between the label on the medication and the order in the computer then they should hold the medication and inform the nurse. RN B stated if there was any discrepancy in an order, she would call the doctor to verify what the proper dose, route, and timing of the medication was. RN B stated she would put a change in direction sticker on the pill package to correct the error. In an interview with the DON at 9:43 AM on 01/16/25, the DON stated before any medication was administered, the employee should make sure the label matched what the order showed in the computer. The DON stated if the MA saw a discrepancy from the label to what the computer showed they should notify the nurse. The DON stated the nurse should then look into the resident's chart to see if they could determine which order was correct and notify the physician to clarify. The DON stated the nurse should instruct the MA to put a change in direction sticker on the label of the medication and call the pharmacy to order a new label or new medication. The DON stated medications were prescribed for a reason and for it to be effective it needed to be administered how the physician asked it to be. The DON stated the nurse that received the order copied it into the computer. The DON stated they reviewed new orders every day in their morning meetings. Record review revealed the facility policy titled Administering Medications revised April 2019 stated the following: Medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on record review, observation, and interviews, the facility failed to provide a safe, functional, and comfortable environment to include fire extinguishers throughout the buildings were regularly inspected and maintained for 1 of 4 portable fire extinguishers inspected throughout the facility. One of four portable fire extinguishers that were observed for monthly quick checks were not inspected monthly. This failure could result in undetected impairments of the portable fire extinguishers delaying suppression of fires exposing residents and staff to smoke inhalation and other fire related injuries resulting in more than minimal harm. Findings included: Record review of portable fire extinguisher quick check tags revealed 1 of 4 fire extinguishers were not inspected monthly. Observations on 10/26/2023 at 12:00 PM revealed 1 portable fire extinguisher in the laundry area did not have any indication that monthly quick checks were performed since June 15th, 2023. In an interview on 10/26/2023 at 12:00 PM Housekeeper A said she worked in the laundry and did not know when the fire extinguishers should be inspected. In an interview on 10/26/2023 at 12:25 PM with the Administrator and maintenance worker B they said the fire extinguishers should be checked monthly to ensure proper operation. The Administrator and maintenance worker B observed the fire extinguisher was last inspected June 15th, 2023. No explanation was given why the fire extinguisher had not been inspected since then. Maintenance worker B said the fire extinguishers are inspected by the maintenance department. The Administrator said not having a working fire extinguisher could endanger the lives of the staff and residents. Record review of facility Fire Extinguishers policy dated 2001 and revised April 2008 indicate The facility has placed fire extinguishers strategically throughout the facility and shall keep them operable at all times.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen reviewed for pests. The facility failed to treat gnats in the kitchen This failure could affect all residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings were: An initial tour of the kitchen on 10/23/23 at 10:20 a.m. with the DM revealed gnats in all of the general kitchen areas. Observation of the kitchen on 10/26/23 at 6:40 a.m. revealed a swarm of gnats in the kitchen near the dishwasher machine area, and in all of the general kitchen areas. Interview with DW B on 10/23/23 at 03:42 p.m. stated he had seen gnats in the kitchen, but they came and went-they were not constantly there. An interview with DW C on 10/26/23 at 06:45 a.m. stated she had seen gnats everywhere in the kitchen. She stated she had not told anyone about the gnats because everyone knew about them. An interview with the DM on 10/26/23 at 06:50 a.m. stated she got a shipment of a solution about 3 days ago that took care of the gnats. The DM stated kitchen staff poured the solution into the kitchen drains at night so it could sit, and it did a good job of killing the gnats. The DM stated kitchen staff used the solution for the first time last night since they received the shipment of the solution. The DM did not answer why the kitchen did not use the solution right away or on a regular basis. An interview with the MSA on 10/26/23 at 11:00 a.m. revealed he knew about the gnats in the kitchen. The MSA stated the kitchen staff treated it at night when there was no food around and the water was settled because it goes in the drain. The MSA stated he did not know if the kitchen staff was using the solution to rid the gnats on a regular basis. A phone interview with the MS on 10/26/23 at 2:00 p.m. revealed he had worked at the facility for 6 years and no one ever told him about any gnats. The MS stated the facility had regular pest control. An interview with the ADM on 10/26/23 at 4:00 p.m. revealed she was aware of the gnats in the kitchen and knew the kitchen staff was treating the gnats on an as-needed basis. The ADM was unaware of the potential for gnats to cause cross-contamination and illness. A record review of the only Maintenance logs provided revealed several months from 2016. A record review of the facility pest control logs dated 2023 revealed regular montly pest control, but not for gnats.

Based on Observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: 1. The meat freezer was not sealing properly 2. The ice machine had jagged edges These failures could place residents at risk of foodborne illnesses and injury. Findings included: An initial tour of the kitchen on 10/23/23 beginning at 10:20 a.m. and interview with the DM revealed the outsides of the ice machine were heavily rusted and becoming detached from the machine creating a hazard of sharp rusted metal. The seals on the meat freezer doors had ice on them, breaking the seals away from the freezer and melting. The doors to the meat freezer were not closing properly because of the bad seals. The DM stated it had been that way for a couple of weeks, and she had told maintenance. The DM stated kitchen staff checked the meat freezer often to make sure it was still running and not thawing the items inside. There was no documentation for the extra checks of the meat freezer. The items inside were cold and hard to the touch. An interview with the MSA on 10/26/23 at 11:00 a.m. revealed he did not know about the meat freezer or the ice machine in the kitchen. The MSA stated the kitchen staff or the MS did not inform him of everything that goes on in the kitchen. The MSA stated he did not make regular rounds in the kitchen and only went in there if the MS needed help. A phone interview with the MS on 10/26/23 at 2:00 p.m. stated he had straightened out the seal on the meat freezer yesterday. The MS stated he had the meat freezer repaired not too long ago, that a wire was loose and kept tripping the breaker, and the meat freezer was holding temperature, so we (the repairmen) did not look at it. The MS stated he did not know how long the meat freezer had been that way until this surveyor pointed it out. The MS stated he saw the rusted sides on the ice maker bin but could not give an estimated time for how long it was like that-for a while I guess. The MS stated he was about to get bids for the freezer part(s). The MS stated it was important to maintain kitchen equipment to avoid catastrophes, such as it was not possible to know when the freezer could go out, and all that food would be ruined. The MS stated if the seal in the meat freezer should shift because of melting ice, it would make a big mess and the residents would not get the meats and nutrition they should. The MS stated he did not make regular rounds in the kitchen and only went in there to fix things as needed and when they (the kitchen staff) told him about it. The MS stated the kitchen staff was responsible for overseeing the kitchen. A record review of the only Maintenance logs provided revealed several pages from 2016.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to keep accurate temperature and chemical logs 2. The facility failed to label and date items in the nutrition rooms 3. The facility failed to discard and replace dented pans 4. The facility failed to maintain cleanliness in the ice machine 5. The facility failed to maintain cleanliness of the floor These failures could place residents at risk of foodborne illnesses. Findings include: Initial tour of the kitchen on 10/23/23 beginning at 10:20 a.m. with the DM revealed the high-temp wash log was missing documentation per DW A. DW A stated the kitchen staff sometimes did not document and he had to get on them for it. DW A stated there was no excuse other than that sometimes they (staff) just don't do it. There was a dented metal colander hanging on the pan rack. The ice machine had a black fuzzy substance on the ice chute, identified as mold and removed with a paper towel by the DM. There was a large dark-brown liquid substance on the floor behind the stove. The DM stated she did not know what it was, and that something must have spilled and never got cleaned up. The DM stated they used a cleaning sheet, but they did not always follow it. Interview with DW B on 10/23/23 at 03:42 p.m. stated his co-workers told him to fill in the shifts he worked. He stated he only filled in the shifts he had worked. DW B stated he did not fill in the log every day because he was too busy. DW B stated he did not know why accurate logs were important. DW B would not reveal the co-worker's names, only that they were a boy and a girl. Observation of the nutrition room in the 200 Hall on 10/25/23 at 2:40 p.m. revealed 1 unlabeled, open, and half-eaten dill pickle, 1, 64 oz. of honey thick-it water expired 09/24/23, and 1 unlabeled 6-pack of 5.5 oz. of green Jell-O. Observation of the nutrition room in the 100 Hall on 10/25/23 at 2:44 p.m. revealed 1 unlabeled full quart container of sherbet, 6 unlabeled 3 oz. containers of sherbet, 1 unlabeled and open pint of ice cream, and 3 unlabeled ice cream treats. An interview with the ADON on 10/25/23 at 2:42 p.m. stated that residents who got the expired honey-thickened water could be affected because the thickened water could lose its thickness and they could aspirate it and get pneumonia and depending on the severity, could end up in the hospital and be put on antibiotics. An interview with the RM on 10/25/23 at 2:47 p.m. stated items in the refrigerator and freezer should be labeled because staff needs to know who the food belongs to, so no one gets the wrong thing, like a diabetic might get someone else's sugary treat and get sick. An interview with DW C on 10/26/23 at 06:45 a.m. stated she was trained by two other dishwashers, not the DM. DW C stated she did not know if hot water was used to sanitize the dishes, but the water was super hot. DW C stated she thought the temperature of the water should be 150F. An interview with the DM on 10/26/23 at 08:55 a.m. stated she trained the staff on the dishwasher and chemical testing, and that she should stay on top of it (the logs) to make sure they do it. The DM stated she threw the dented colander away because it needed to be thrown away because bacteria or bits of food could get stuck in the dents and crevasses and come off in the food and make someone sick or break a tooth because it was metal. The DM stated she was responsible for checking and replacing dented pans. The DM stated the dented colander was an oversight and it should have been thrown away sooner. An interview with MSA (maintenance supervisor assistant) on 10/26/23 at 11:00 a.m. revealed not sure what type the washer was but thought it was a high-temperature washer. He did not know what temperature the washer should run at. Record review of the dishwasher logs dated 05/01/23-10/23/23 and interview with the DM on 10/23/23 at 3:12 p.m. revealed all blanks on the washer temperature and chemical strip log had been filled in with black marker-like ink for the following dates: 06/09/23 -06/12/23, 06/27/23-06/30/23, 07/10/23-07/15/23, 07/17/23-07/19/23, 07/26/23, 07/30/23-07/31/23, 08/30/23-08/31/23, 09/19/23, 10/03/23, 10/04/23, 10/09/23, 10/10/23 -10/16/23. Interview with the DM on 10/23/23 at 3:13 PM, she stated she did not know who would have done that. The DM stated DW B had worked some of the days where there was no documentation, and she would tell him when he came to work that day. Record review of the facility policy titled, Dishwashing Machine Use revised 03/2010 revealed Policy Statement: Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. 7. The operator will check the temperature using the machine gauge with each dishwashing machine cycle and will record the results in a facility-approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. A record review of in-services and training for the kitchen staff revealed all had completed a computerized Texas Food Handler Safety; one had expired on 04/01/23. 05/22/23-Diets, snacks, drinks, green sticker program, diet roster. 07/07/23-Food high MSG. 07/14/23-All diets will be liberalized on all diets upon admission, and all NAS (No Added Salt) and NCS (No Concentrated Sweets) will be discontinued. Textures will stay the same. Exceptions will be renal diets. 08/01/23-Renal Diets. 08/24/23 Handwashing; must wash hands for 20 seconds, explained when handwashing is needed, must wash hands when you change your gloves, after bathroom, entering or leaving a room, after eating food, etc. 10/24/23-Temperature logs, Temperatures must be logged in real-time with exact temperature. Review of References: TAC 228.111 (p) Warewashing equipment (three-compartment-sink) determining chemical sanitizer concentration: concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Figure: 25 TAC 228.111(n)(1) Sanitizer Concentration range: 25-49 ppm, when the minimum temperature is 150 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (R #1), reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for R #1, use of anticoagulant medication. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of R #1's Face Sheet revealed a [AGE] year-old female, with an original admission date of 10/11/2016. Diagnosis included, Type 2 diabetes ( insufficient production of insulin in the body), Dysphasia (difficulty swallowing), Alzheimer's Disease (neurodegenerative disease that affects a person's cognitive in daily activities including memory, thought control, and language), Heart Failure, Pulmonary Embolism (blockage of an artery in the lungs), Fracture of Lower Leg, including Ankle, TIA (transient ischemic attack, similar to a stroke), and Cerebral Infarction (type of stroke caused by impaired blood flow to the brain). Record review of R #1's Quarterly Minimum Data Set, dated [DATE] revealed R #2 has a BIMS (Brief Interview Mental Status) of 10 (Moderately Impairment) and requires Extensive Assistance with, bed mobility, transfers, Dressing, Toilet use and Personal Hygiene. Record review of R #1's Care Plan dated 7/14/2023 revealed no care plan for anticoagulants. Had an actual fracture to right tibia and right fibula and fracture to left ankle. Record review of R #1's orders stated; -Plavix Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day for CAD dated 7/12/2023 -Eliquis Oral Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day related to PULMONARY EMBOLISM (I26) dated 8/23/2023 - Monitor for blood in stools or urine, bleeding gums, or excess bleeding with minor injuries, check if any signs or symptoms present, notify MD immediately and document dated 7/12/2023 Interview on 8/24/2023 at 2:57pm DON stated, anticoagulants such as Plavix should be care planned as it was person-centered and direct care staff need to be able to identify any adverse effects of anticoagulants. Interview on 8/24/2023 at 3:15pm MDS Coordinator stated, Plavix should be care planned and must have missed it by mistake. MDS Coordinator stated it is important to care plan anticoagulants so nurses and staff are aware R #1 is on this type of medication so they can be looking for signs and symptoms of bruising, bleeding, or complications, especially since R #1 had fractures. MDS Coordinator stated he would update R #1's care plan immediately. Record review of Care Plan, Comprehensive Person-Centered Policy dated December 2016 stated; A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The care planning process will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; m. aide in preventing or reducing decline in the resident's functional status and/or functional levels; o. Reflect currently recognized standards of practice for problem areas and conditions. 12. The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 1 resident, Resident #1 (#R1) of 5 staff members who were observed for infection control, in that; 1.)CNA in training did not perform hand hygiene for at least 20 seconds. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings include: Record review of R #1's Face Sheet revealed a [AGE] year-old female, with an original admission date of 10/11/2016. Diagnosis included, Type 2 diabetes ( insufficient production of insulin in the body), Dysphasia (difficulty swallowing), Alzheimer's Disease (neurodegenerative disease that affects a person's cognitive in daily activities including memory, thought control, and language), Heart Failure, Pulmonary Embolism (blockage of an artery in the lungs), Fracture of Lower Leg, including Ankle, TIA (transient ischemic attack, similar to a stroke), and Cerebral Infarction (type of stroke caused by impaired blood flow to the brain). Record review of R #1's Quarterly Minimum Data Set, dated [DATE] revealed R #2 has a BIMS (Brief Interview Mental Status) of 10 (Moderately Impairment) and requires Extensive Assistance with, bed mobility, transfers, Dressing, Toilet use and Personal Hygiene. Record review of R #1's Care Plan dated 7/14/2023 revealed R #1 was at risk for infection r/t (related to) Covid-19 due to Advanced age, Immunosuppressed, Heart Disease and Lung Disease. Observation on 8/24/2023 at 2:38pm. R #1 was in need of personal care (brief change and bed sheet change). CNA in training completed brief change for R #1 and removed gloves and washed hands for approximately 10 seconds. CNA in training put on new gloves and assisted with changing soiled bed sheets. Once completed, CNA in training removed gloves, began assisting R #1 with moving personal items such as drinks and bedside table closer to R #1, lowered R #1's bed, and covered R #1 with blankets. CNA in training then proceeded to wash hands for approximately 8 seconds. Interview with CNA in training on 8/24/2023 at 2:50pm stated, she has been working at the facility for approximately 3 months and hands should be washed for at least 20 seconds to prevent cross contamination and possible infections to residents. CNA in training stated she was nervous and thought she washed hands for about 20 seconds but realized she may have rushed her hand washing while she sang Old McDonald song in her head. CNA in training stated she does not know why she sang that song as she was taught to sing the Happy Birthday song twice. CNA in training stated that hand hygiene and infection control in-services are conducted almost weekly. Interview with DON on 8/24/2023 at 3:05pm, stated it is important to perform proper hand hygiene as to prevent the spread of infections to residents and staff/visitors. DON stated, while performing hand hygiene with soap and water, it should be done for at least 20 seconds or greater and routine hand hygiene in-services are conducted frequently. Record Review of Handwashing and Hand Hygiene Policy dated August 2015 stated; Washing Hands Procedure 1.Vigorously lather hands with soap and water and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands.