Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 treatment carts (Hall 4 cart) reviewed for medication storage. The facility failed to ensure the nurses' treatment cart was not left unlocked and unsupervised for 10 minutes on hall 4. This failure could place residents at risk of loss, diversion or accidental ingestion of medications. The findings include: During an observation on 11/20/24 at 09:10 AM till 09:20 AM revealed RN A left the nurse's treatment cart unlocked and unattended for approximately 10 minutes while she entered a resident's room to attend to them. The cart contained several ointments, nail clippers, dressings and several other normal saline bottles. The cart was facing the hall. During an interview on 11/20/24 at 11:05 AM, RN A said she was not aware she left the treatment cart unlocked. RN A said she always was very good about locking her cart when walking away from it, but she had just plain missed it today. RN A said if the cart was left unlocked then someone could get into the cart and into the supplies used for wound care and medication administration. During an interview on 11/21/24 at 03:30 PM the DON said it was expected for nursing staff to lock their medication carts when not using them. The DON said the nurse had probably forgotten to lock the cart when she went back into the resident's room to perform the resident care. The DON said if the cart were left opened then other unauthorized people or residents could have access of the cart. During an interview on 11/21/24 at 04:22 PM, the Administrator said it was expected for nursing staff to lock their medication carts when not using them. The Administrator said if the cart was left unattended and unlocked it could lead to drug diversions and other people having access to the items in the cart. The Administrator said the failure probably occurred because the staff had gotten nervous due to being observed by the state surveyor. Record review of the facility's policy titled Medication Carts, dated 2003, indicated: The carts are to be locked when not in use or under the direct supervision of the designated nurse. Record review of the facility's policy titled Medication Administration Procedures, dated 2003, indicated : After the medication administration process is completed, the medication cart must be completely locked or otherwise secured.

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 in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure chicken was thawed under running water or in the refrigerator. 2. The facility failed to ensure staff appropriately cleaned and sanitized the thermometer prior testing food temperatures. 3. The facility failed to ensure sick staff wore an appropriate face mask. 4. The facility failed to ensure staff wore effective hair restraints. 5. The facility failed to ensure food was stored in a manner that was not opened to the air. These failures could place residents at risk for food borne illness and cross contamination. Findings include: Observation and interview on 11/19/24 at 9:53 a.m. revealed: A bag of chicken thawing on the counter of the industrial sink, it was not in running water. There was a bag of chicken thawing in running water immediately next to it. Upon moving the thawing bag of chicken, a puddle of pink chicken juices the size of the bag (5 gallons) was observed. [NAME] B stated she took the bag of chicken out at 6 a.m. that morning and left it by the sink. [NAME] B was observed wearing a face mask on. The face mask covered her mouth but not her nose. [NAME] B started coughing she covered her mouth with her arm, [NAME] B stated she did not know what was wrong. [NAME] B was actively prepping food. Observation of the freezer during initial tour revealed a box of chicken with a bag of exposed chicken. Observation of the dry storage during initial tour area revealed a 50-pound bag of dry milk on the floor. Observation and interview on 11/21/24 at 11:08 a.m. revealed some spices on the spice shelf that were open to the air. The DM said they were used the night before and were not closed or wiped off because the other cooks were not paying attention. The DM stated they should be wiped and covered after food preparation. [NAME] C's hair net slid up and left half her hair hanging out, approximately an inch and a half of hair out of net. Observation on 11/21/24 at 11:20 a.m. revealed the DM gave [NAME] C a paper towel with the instructions that if there were large particles of food on the thermometer to wipe off the food prior to cleaning off the thermometer with the alcohol pad [NAME] C had on the counter in front of her. [NAME] C cleaned the thermometer with the paper towel between eight separate dishes. In an interview on 11/21/24 at 11:25 a.m., [NAME] C stated she used the paper towel because she was really a nurse and the DM gave it to her but she normally uses an alcohol wipe. [NAME] C stated the paper towel did not adequately clean the thermometer and it caused cross contamination between dishes. The DM who was also present stated we all make mistakes. Observation at 12:45 p.m. an unidentified dietary staff came in through the dirty dish area with no hair net on while the lunch serving task was still being completed. The staff was holding a hair net and did not put it on until she reached the other side of the kitchen. In an interview on 11/21/24 at 4:07 p.m., the DM stated she did not feel the kitchen did not go well this year because there were a lot of mistakes. The DM stated the mistakes included the raw chicken on the counter and temperature thing with the paper towel. The DM stated she did not think [NAME] B was really sick on 12/19/24 because there was no coughing on 11/20/24 or 11/21/24. The DM stated she was in the process of putting the dry milk up when the State Surveyors came into the kitchen which was why it was on the floor. The DM said she had it on the rack of cans and got it down so she could pour it into the appropriate container. The DM stated the consequence to the thawing chicken improperly was the growth of bacteria and it would do the same thing with the thermometer and the cross contamination. The DM stated she did not say anything to [NAME] C at the time because she did not want [NAME] C to feel like she was being scolded. The DM said hair restraints were supposed to be put on immediately upon entering the kitchen and they weren't supposed to take it off until they left the kitchen. The DM said if the hair net was half on it was not effective because there was hair hanging out and it could fall into the food. In an interview on 11/21/24 at 4:26 p.m the Administrator was informed of all of the kitchen findings. He stated he had no rebuttal to the findings. Record review of the facility's policy and procedure dated 2012, on Thawing Foods revealed: All foods will be thawed in a safe and sanitary manner. Procedure: Foods may be thawed in the following manner: under potable running water of a temperature of 70 degrees or below, with sufficient velocity to agitate and float off loose food particles into the overflow, in a sealed package. All raw meats will be thawed separately from each other, and separately from any other foods. Record review of the facility's, undated, policy and procedure on Dry Storage and Supplies, revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: Storerooms are to be well lighted, ventilated, and temperature controlled. b. All food and supplies are to be store six (6) inches above the floor on surfaces which facilitate thorough cleaning. Record review of the facility's policy and procedure dated 2012, on Infection Control, revealed: We will ensure that all employees practice infection control in the Dietary Service Department, and maintain sanitary food preparation. All dietary service employees will follow Infection Control Policies as established and approved by the Infection Control committee. Procedure. b. Clean hair is required. It is to be totally covered with an effective hair restraint. Food preparation: A, Frozen items are thawed in refrigeration or under cold running water in a draining sink.

**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 provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #2 and #5) reviewed for infection control. 1. RN A failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #5. 2. RN A failed to wash her hands or use hand sanitizer between glove changes during medication administration and PEG tube dressing change for Resident #2. These failures could place resident's risk for cross contamination and the spread of infection. Finding include: 1. Record review of Resident #2's admission record, dated 11/20/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included gastrostomy status (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and cerebral palsy ( A disorder that affect a person's ability to move, maintain balance, and posture). Record review of Resident #2's Order Summary Report dated 11/20/2024, indicated in part: Sucralfate Oral Suspension 1 GM/10ML (Sucralfate) Give 10 ml via PEG-Tube four times a day for ulcer of esophagus. Enteral Feed Order one time a day Cleanse peg tube site with normal saline and gauze, pat dry, apply barrier ointment around stoma, cover with T drain sponge. Order date 08/22/2024. Record review of Resident #2's quarterly MDS, dated [DATE], indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Nutritional Approaches Check all of the following nutritional approaches that apply - Feeding tube. Record review of Resident #2's care plan dated 08/23/24 indicated in part: Focus: The resident requires tube feeding related to difficulty swallowing. GOAL: The resident will remain free of side effects or complications related to tube feeding through the review date. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 80 ml aspirate. Clean insertion site daily as ordered, monitoring for symptoms of infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to doctor if symptoms arise. During an observation on 11/20/24 at 08:55 AM, RN A administered Resident #2's medications via PEG tube and also changed her PEG tube site dressing. RN A prepared the resident's medication on her treatment cart then entered the resident's room. Without first sanitizing or washing her hands she put on a pair of gloves and proceeded to administer the medication via Resident #2's PEG tube. RN A removed her gloves and went to the supply room to obtain a towel and also obtained a dressing from her treatment cart. RN A returned to Resident #2's room and put on a pair of clean gloves without first washing or sanitizing her hands. RN A then removed the old PEG tube dressing, cleaned the PEG site area and while still wearing the same gloves applied the new dressing to the resident. RN A then removed her gloves and stated she was done and proceeded to move to her next assignment without washing or sanitizing her hands. During an interview on 11/20/24 at 11:05 AM, RN A said during Resident #2's medication administration she had not sanitized or washed her hands in between glove changes because she stayed in the same room and provided care for the same resident care. RN A was made aware of the times she went back to the medication cart and the supply closet to obtain items and when she put on clean gloves again, she was not noted to have washed or sanitized her hands. RN A said she was sorry she had not washed or sanitized her hands when she changed her gloves. RN A said if she did not sanitize or wash her hands she could possibly spread germs or infections. During an interview on 11/21/24 at 03:24 PM, the DON said it was expected for nursing staff to wash or sanitize their hands before putting gloves on and after taking them off. The DON said RN A should have sanitized or washed her hands during Resident #2's patient care. The DON said if staff did not wash or sanitize their hands, that could lead to the spread of infections. The DON said she monitored the staff by conducting rounds and in-services regarding hand washing and glove use. During an interview on 11/21/24 at 04:18 PM, the Administrator said it was expected for nursing staff to wash or sanitize their hands before putting gloves on and after taking them off. The Administrator said it could lead to infections if the staff did not wash or sanitize their hands. The Administrator said the failure probably occurred because the nurse got nervous due to the state surveyor observing them. 2. Record review of Resident #5's admission Record, dated 11/21/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included local infections of the skin and subcutaneous tissue (under the skin); debility (weakness); and dementia (A disorder in which a person can lose the ability to think, remember, and reason to the point that it interferes with their daily life). Record review of Resident #5's Quarterly MDS Assessment, dated 10/25/24, revealed: She had long and short-term memory impairment with severely impaired decision-making abilities. At the time of the assessment, there were no skin tears identified. Record review of Resident #5's care plan, revised on 11/11/24, revealed Resident #5 had the potential for impaired skin integrity related to incontinence, impaired mobility, dementia, and fragile skin with decreased safety awareness. The identified goal was the resident would maintain or develop clean, intact skin by the review date. The identified interventions included: follow facility protocols for treatment of injury. Record review of Resident #5's Order Summary, dated 11/21/24, revealed orders: Start date 11/12/24: Skin tear to right calf, cleanse with wound cleanser apply steri-strips. Cover with soft dressing daily. May leave open to air if no drainage present. Record review of Resident #5's Weekly Skin Assessment, dated 11/18/24, revealed: Resident has a healing skin tear to right calf. During an observation on 11/19/24 at 2:23 PM revealed Resident #5 was in bed asleep on a low bed. Resident #5 had a fall mat in place and there were wound care supplies (gloves, gauze, tape, tape) on the fall mat with no barrier in place. During an observation on 11/19/24 at 2:29 PM revealed RN A brought in a linen (porous) towel and placed it on the fall mat. RN A placed the wound care supplies from the fall mat onto the towel. Without any hand-hygiene practices, RN A donned gloves. RN A hooked her left arm under Resident #5's knee and pulled off the dirty dressing. RN A took off the right glove, but not the left. Resident #5 had an approximately 2-inch skin tear to the back of her right shin held together with steri-strips. With no hand hygiene, RN A placed another glove on her right hand and cleaned Resident #5's skin tear. RN A removed the right glove only. With no hand hygiene, RN A donned the right glove, patted Resident #5's skin tear dry. RN A took off her right glove. With no hand hygiene, RN A donned a glove to her right hand and applied antiseptic wound cleanser with an applicator. RN A took off her right glove. Without hand hygiene RN A place a non-adherent dressing on a dressing retention tape and placed on Resident #5's skin tear. RN A then gathered the piled of used gloves/dirty wound care supplies and the towel. RN A threw the gloves/dirty wound care supplies in the trash of the treatment cart, put the towel in the dirty linen barrel and then sanitized her hands with alcohol gel. During an interview on 11/20/24 at 10:46 AM, RN A stated she remembered she removed the old dressing, put it in the glove and took off the glove. RN A said she donned a new glove, cleaned the wound with normal saline, held the wet gauze in the glove and took the glove off. RN A said she put on a new glove, dried the wound, held the gauze and took off the old glove. The RN stated she put on a new glove and applied the antiseptic gel, broke the applicator and took off the glove while holding the applicator. RN A stated then she put the non-stick pad on the tape and applied it. RN A said she threw out the pile of used gloves, put the towel in the dirty linen and sanitized her hands with alcohol gel RN A said she set the wound care supplies up outside the room, so nothing came into the room. RN A said she put the towel on the ground and then placed the wound care supplies on the towel. RN A said the towel was a porous surface so there was not an effective barrier. RN A stated all the supplies were not touching the towel so they were still clean. The State Surveyor reminded her the wound care supplies were on the floor and RN A stated she forgot that part of it and said none of the supplies touched the fall mat before being placed on the towel. RN A said with the supplies laid out on the floor it was not a clean technique. RN A stated she did not remember when she did hand-hygiene prior to doing wound care but she usually did before she entered a room but added she probably did not do it when she left for the towel. RN A said there was no alcohol based hand rub (ABHR) in the room for her to use in between glove changes. RN A thought for a second and then pulled a bottle of ABHR out of her pocket. RN A said she never did hand hygiene between glove changes on the same residents because she was told changing gloves was enough. RN A stated on 11/20/24 when she did wound care Resident #5 was on her side and it was much easier to do. During an interview on 11/20/24 at 1:06 PM, the DON and the Regional RN Consultant stated the expectation was hands were washed prior to starting and gel between dirty to clean. The DON stated the facility expected a non-porous barrier like wax paper or incontinent pad with the plastic backing. The Regional RN stated the corporation's expectation was for the staff to perform hand hygiene, gather their supplies on a tray or wax paper or use a clean bed side table. The Regional RN stated nothing should go into the room unless it could be cleaned, like scissors. The Regional RN said the nurse should put the dry gauze, wet gauze, any medications, date and initial the dressing, put any medication in a cup and get the applicators, gloves, and a bottle of hand sanitizer. The Regional RN stated the staff should bring in a separate trash bag for the dirty supplies. The Regional RN said the corporation expectation was for the staff to apply gloves, take off the dirty dressing, dispose of the dressing, take off gloves, clean hands, don new gloves, clean the wound, pat dry, apply any medications, take off the gloves, gel, don new gloves apply a clean dressing, take off the gloves, sanitize hands, and then get rid of the dirty supplies and clean the resident's area. During an interview on 11/20/24 at 1:35 PM, the Administrator was informed of the 11/19/24 wound care observation. When informed of the supplies on the floor, the Administrator said, you're kidding me? The Administrator stated they saw the issue with infection control. Interview on 11/20/24 at 1:42 PM, the DON stated there were no recent in-services on wound care or infection control. Record review of the facility's policy titled Infection Control Plan, dated 2019, indicated in part: Infection control - the facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection control program - the facility will establish an infection control program under which it - investigates controls and prevents infections in the facility . The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Implement hand hygiene (Hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination. Record review of the facility's policy titled Fundamentals of infection control precautions, dated 3/2023, indicated in part: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care, before and after changing a dressing, upon and after coming in contact with a resident's intact skin, after handling soiled or used dressings, after removing gloves.Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use and hands can become contaminated during removal of gloves, failure to change gloves between resident contacts is an infection control hazard.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one medication cart (carts A and C) of four medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure treatment cart A was locked when unattended. The facility failed to ensure medication cart C was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on 09/20/2023 from 8:30 AM to 09:00 AM, revealed treatment cart A and medication cart C were found unlocked and unattended in front of the nurses station with no staff in sight. The Surveyor waited by the carts until the ADON came around the corner, from the dining room and stated that she had only walked away for a little bit. The ADON stated that she knew that she shouldn't have left the cart unattended while unlocked. During an observation and interview on 09/20/2023 from 10:30 AM to 10:40 AM, revealed medication cart C was found unlocked and unattended in front of the nurses station. RN D was on the other side of desk, on the computer, not paying attention as the Surveyor opened the drawers to the medication cart. The Regional Compliance Nurse and the DON were called over to observe. The Regional Compliance Nurse stated that the nurse was in-serviced about unlocked carts 09/19/23 and should know better. The DON stated that she would in-service all staff immediately regarding locking medication carts and how it can lead to possible harm or drug diversions. During an observation and interview on 09/21/2023 from 11:30 AM to 11:37 AM, revealed medication cart C was found unlocked and unattended in front of the nurses station, no staff in sight. RN D came by and stated it was her cart. RN D stated that it is dangerous to leave carts unlocked when unattended. Anybody could get in the cart which contained over-the-counter medications, zofran, anti-anxiety medications, and blood pressure medications. RN D stated that there were residents who wander around the facility and could hurt themselves by ingesting thee medications. RN D stated that she knew better than to leave the carts unlocked when unattended and that the DON just did an in-service with her yesterday. Review of the facility's policy, titled Medication Carts, dated 2003, reflected (in part): Policy Interpretation and Implementation: 1. Medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse. 3. Carts not in use are to be stored in a designated area not blocking egress in the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 (Resident #19) residents reviewed for indwelling catheters. The facility failed to ensure Resident #19's indwelling catheter was secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Record review of Resident #19's admission record dated 07/21/2022, indicated he was admitted to the facility on [DATE] with diagnosis of neuromuscular dysfunction of the bladder (neuromuscular dysfunction of the bladder is a condition that occurs when either nerves or the brain cannot communicate effectively with the muscles in the bladder). He was [AGE] years of age. Record review of Resident #19's MDS dated [DATE] indicated in part: Brief Interview Mental Status was a 15 indicating the resident was cognitively intact. His urinary incontinence was not rated and the resident had a catheter. Record review of Resident #19's care plan dated 03/18/2022 indicated in part: Focus: At risk for complications related to Indwelling Urinary Catheter. Goal: The resident would have no complications from use of his indwelling catheter such as pain, infection, obstruction. Interventions: Check catheter tubing for proper drainage and positioning. Record review of Resident #19's physician's order report dated 07/21/2022 indicated in part: Catheter leg strap in place, every shift for urine retention. Start date 11/15/2021. During an observation and an interview on 07/21/22 at 09:55 AM revealed Resident #19 was in his bed, awake and alert. The resident's urinary catheter tubing was noted to be unsecured to his leg. The resident said the staff would at times secure it and at other times they would not. Resident #19 said he had a condition which caused him to have several bouts of loose stools and sometimes the catheter strap would get soiled, and the staff would remove it and not replace it. The resident said sometimes when he did not have it secured it would tug on his urethra and make it sore but not always. The resident said he would prefer for it to be secured if possible . During an interview on 07/21/22 at 02:12 PM CNA A said she had just placed a urinary catheter leg strap on Resident # 19's leg. She said she was not aware the resident did not have one and he was supposed to have one to prevent the catheter tubing from tugging. CNA A said if she noticed the resident did not have a leg strap, she would notify the nurse to get a strap for the resident . During an interview on 07/21/22 at 02:28 PM LVN B said it was all of the nursing staff's responsibility to make sure the residents that required a leg strap had one to prevent tugging of their urethras. LVN B said they would see that Resident #19 had a leg strap to secure his catheter. During an interview on 07/21/22 at 03:30 PM the DON said residents that required a leg strap to secure their catheter tubing were supposed to have one. The DON said if the residents did not have the leg strap it could lead to the catheter being dislodged. The DON said Resident #19 did not have a leg strap because it probably got soiled and the aides forgot to apply a clean one. The DON said it was the CNAs responsibility to report to the nurse if the resident was missing the strap and the nurse was supposed to check it every shift. During an interview on 07/21/22 at 03:36 PM the Administrator was made aware of the observation of Resident #19 without a catheter leg strap. The Administrator said it was the nursing staff's responsibility to make sure the residents had their catheters secured if they required one. The Administrator said it just got missed and they would see that the residents had one if they allowed them to place it on them as some would refuse to wear one or they would take it off. Record review of the facility's undated document titled urinary elimination provided by the DON indicated in part: Secure indwelling catheter with catheter strap or other securement device. Leave enough slack to allow leg movement. Attach securement device at tubing just above catheter bifurcation. Securing catheter reduces risk if urethral erosion, CAUTI (Catheter-Associated Urinary Tract Infections) or accidental catheter removal.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 of 11 employee files (AD G, LVN C, LPN D, DON) reviewed for abuse and neglect, in that The facility did not complete employee misconduct registry (EMR) nurse aide registries (NAR) checks upon hire date or annually for (AD G, LVN C, LPN D, DON). These deficient practices could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Review of the facility's Abuse Prevention Program Policy, updated January 2019, revealed To Prohibit and prevent abuse, neglect, exploitation, misappropriation of a resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. 2. Screening, each center will follow any and all state specific requirements: 2. Appropriate licensing board or registry checks 4. Criminal Background check pursuant to company policy or state law 5. OIG exclusion background check The center will not retain any team member with a history of abuse or neglect if that information is known to the center. The center must not employ or otherwise engage individuals who have had a disciplinary action taken against a professional license by a state licensure body or had a finding entered into the state NA Registry concerning or as a result of abuse, neglect, or mistreatment of residents or a finding of misappropriation of property. 1. Record review of the staff roster, dated 07/19/22, revealed AD G's hire date was on 07/31/17. Record review of AD G's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of AD G's EMR/NAR, dated 07/19/22, revealed no results found. 2. Record review of the staff roster, dated 07/19/22, revealed LVN C's hire date was on 2/24/17. Record review of LVN C's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of LVN C's EMR/NAR, dated 07/20/22, revealed no results found. 3. Record review of the staff roster, dated 07/19/22, revealed LPN D's, hire date was on 07/1/15. Record review of LPN D's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of LPN D's EMR/NAR, dated 07/19/22, revealed no results found. 4. Record review of the staff roster, dated 07/19/22, revealed the DON's hire date was on 02/14/03. Record review of the DON's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of the DON's EMR/NAR, dated 11/17/21, revealed no results found. During an interview on 07/20/22 at 4:55 p.m., BOM H confirmed she had done the EMR/NAR searches for listed staff, AD G, LVN C, LPN D, DON prior to 07/19/22, which was after the state surveyor's initial inquiry for those specific staff members. BOM H stated she was unaware of the EMR/NAR. She stated she came from home health and she did not have to run EMR/NAR checks. BOM H stated she had no clue what the EMR/NAR was until it was asked for during the survey. BOM H stated she was unaware the EMR/NAR had to be done upon hire and yearly thereafter. BOM H stated the facility went months without having a BOM, and she was never trained on the EMR/NAR, employed since 6/28/21 as the BOM. Bom H stated the Regional HR performs all the criminal check and license checks which I had observed for the license staff. BOM H stated she was already working on a spread sheet to keep track of hire dates and EMR/NARs that would need to be done after the surveyor asked her for the EMR/NAR. BOM H stated the risk of not running an EMR/NAR check could put the residents at risk due to an employee being hired that could hurt the resident; they would not know if they were unemployable. During an interview on 07/21/22 at 2:46 p.m., the Administrator stated he thought the EMR/NAR checks had already been completed for all staff and was unaware the checks were not previously done for AD G, LVN C, LPN D, DON. The Administrator stated BOM H, and Regional HR was responsible for making sure the checks were done for all staff. The Administrator stated he should know that, but he didn't.