**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 14 residents (Residents #11 and #96) reviewed for assessments: 1. Resident #11's significant change MDS, dated [DATE], identified the resident had insulin. However, Resident #11 did not have insulin. 2. Resident #96's admission MDS, dated [DATE], identified the resident was always continent for urinary bladder. However, Resident #96 had an indwelling urinary catheter. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: 1. Record review of Resident #11's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with the diagnoses of moderate protein-calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function), type 2 diabetes mellitus (not control blood sugar in the body), muscle weakness, anemia (not have enough red blood cells), and vertigo (dizziness). Record review of Resident #11's significant change MDS, dated [DATE], revealed the resident's BIMS was 15 out of 15, which indicated the resident's cognitive function was intact, and in the Section N (medications), the resident was receiving insulin once a week. Record review of Resident #11's physician orders, dated 03/21/2025, revealed there was no orders of insulin. Further record review of the resident's physician order indicated the resident had the order of Trulicity (Dulaglutide) pen injector 3 mg/0.5 ml one dose, subcutaneous, once a day on Friday at 6:00 am for diabetes. Record review of Drugs.com (https://www.drugs.com/medical-answers/trulicity-form-insulin-3544515), dated 03/20/2025, revealed Trulicity is not a form of insulin. It occurs hormone that stimulates insulin secretion. Interview on 03/20/2025 at 12:15 p.m. with a pharmacist surveyor stated Trulicity was not insulin. Interview on 03/20/2025 at 12:20 p.m. with the MDS nurse stated Resident #11 did not have insulin. The resident had Trulicity shot once a week, and the MDS nurse thought it was insulin. However, it was not insulin. The MDS nurse said that Resident #11's significant change MDS, dated [DATE], should have not coded the resident was receiving insulin and inaccurate MDS assessment potentially caused incorrect care to Resident #11. 2. Record review of Resident #96's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (do not have enough oxygen in the tissues in the body), muscle weakness, neuromuscular dysfunction of bladder (nerves that carry messages back and forth between the bladder and the spinal cord and brain do not work), hear failure (heart not pumping enough blood to the body), and kidney disease state 3 (kidneys have damage and less able to filter waste and fluid). Record review of Resident #96's admission MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated the resident had moderate cognitive impairment, and the resident was always continent for urinary bladder. Record review Resident #96's comprehensive care plan, dated 03/19/2025, revealed Resident requires a suprapubic catheter (medical device that helps drain urine from the bladder. It enters the body through a small incision in abdomen) related to neurogenic bladder. For intervention - Keep catheter system. Observation on 03/20/2025 at 2:13 p.m. revealed Resident #96 had a suprapubic catheter, which was one of indwelling urinary catheter, and LVN-A was providing catheter care to the resident. Interview on 03/20/2025 at 12:06 p.m. with the MDS nurse stated Resident #96 had a suprapubic urinary catheter, so Resident #96's admission MDS, dated [DATE], was inaccurate. The MDS nurse said that she should have coded the resident had indwelling urinary catheter because the suprapubic urinary catheter that Resident #96 had was one of the indwelling urinary catheters. It was mistake, and inaccurate MDS assessment potentially caused incorrect care to Resident #96. Record review of the facility policy, titled Resident assessment, revised 03/2022, revealed . 8. All persons who have completed any portion of the MDS resident assessment from must sign the document attesting to the accuracy of such information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan reflected her oxygen status and included a care plan regarding how to take care of the resident's oxygen. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #7's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of chronic kidney disease state 3 (kidneys have damage and less able to filter waste and fluid), venous insufficiency (veins have problem moving blood back to the heart), hear failure (heart not pumping enough blood to the body), muscle weakness, and hypertension (high blood pressure). Record review Resident #7's significant change MDS, dated [DATE], revealed the resident's BIMS score was 11 out of 15, which indicated the resident had moderate cognitive impairment, and the resident was receiving oxygen therapy. Record review of Resident #7's comprehensive care plan, dated 01/13/2025, revealed there was no care plan related to oxygen therapy. Record review of Resident #7's physician order, dated 02/28/2025, revealed the resident had the order of oxygen at 3 liter per minutes via nasal cannular. Apply oxygen via nasal cannula for less than 92% oxygen saturation levels every 4 hours as needed. Interview on 03/18/2025 at 4:42 p.m. with Resident #7 said the resident received oxygen via nasal cannula and sometimes she had difficulty breathing. Interview on 03/20/2025 at 1:04 p.m. with LVN-A stated Resident #7 received oxygen therapy sometimes when the resident's oxygen saturation was less than 92%. Interview on 03/20/2025 at 1:56 p.m. with the MDS nurse stated the MDS nurse should have developed Resident #7's comprehensive care plan related to oxygen therapy because the resident received it sometimes when her oxygen saturation was less than 92%. Further interview with the MDS nurse said she overlooked it, and it was her mistake. No care plan potentially caused improper care to Resident #7. Record review of the facility policy, titled Care plan, comprehensive person-centered, revised 03/2022, revealed 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident highest practicable physical, [NAME], and psychosocial well-being including: (3) which professional services are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, 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 3 residents (Resident #16 ) reviewed for incontinence care. When CNA-C was providing incontinent care to Resident #16 on 03/19/2025, the CNA-C did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #16's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), hypokalemia (low potassium in the blood), muscle weakness, type 2 diabetes mellitus (not control blood sugar in the body), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive function was intact, and the resident was always incontinent to bladder and bowel. Resident #16 was dependent (helper does all of the effort) to sit-to-stand and not applicable to chair-to-bed and toilet transfer. Record review of Resident #16's comprehensive care plan, dated 03/04/2025, revealed Incontinence of bowel and bladder related to history of stroke. For intervention - incontinent care per rounds and monitor and document for signs and symptoms of urinary tract infection. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side without cleaning the suprapubic area. CNA-C cleaned the resident's buttock area, then put a new and clean brief on the resident. Interview on 03/19/2025 at 2:19 p.m. with CNA-C stated she did not clean Resident #16's suprapubic area, because she was nervous and forgot to clean the area. CNA-C said she should have cleaned the area when providing peri-care to Resident #16 and had peri-care training when she was hired, which was three months ago. Interview on 03/20/2025 at 5:05 p.m. with the DON said CNA-C should have cleaned Resident #16's suprapubic area, when providing peri-care to the resident. The DON stated DON had responsibility for monitoring CNA-C by checking off the CNA's skills, but she did not conduct the skill check-off of on CNA-C yet, and that it was scheduled for May of 2025. However, CNA-C followed senior CNAs for three days before she worked on the floor and showed her skills regarding perineal care. Record review of the facility policy, titled Perineal care, revised 02/2018, revealed Clean the peri area with wipes going front to back/clean to dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #26) of one resident reviewed for enteral nutrition. When RN-E administered a medication via gastrostomy tube to Resident #26, RN-E did not check residual by aspiration of gastric content of the resident. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #26's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of moderate protein-calorie malnutrition (not enough protein and energy to meet nutritional needs), dysphagia (difficulty of swallowing), gastro-esophageal reflux disease (stomach acid repeatedly flows back up), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #26's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 6 out of 15, which indicated the resident had severe cognitive impairment and had gastrostomy tube. Resident #26 was dependent (helper does all of the effort) for eating and substantial/maximal assistance (helper does more than half the effort) chair-to-bed transfer and toilet transfer. Record review of Resident #26's comprehensive care plan, dated 03/04/2025, revealed Dependent on tube feeding for nutrition and hydration with potential for complications and side effects. For intervention - administer tube feeding, medications and water flushes as ordered. See medical doctor orders for current feeding orders and check for gastric content/residual volume per protocol and document. Record review of Resident #26's physician order, dated 01/27/2025, revealed the resident had the order of Tube placement checked by aspiration of gastric content and visual inspection prior to feeding or medication administration. Notify supervisor and/or physician/physician extender of abnormal findings. If aspirate greater than (>) 100 cc, hold formula/water/medication and notify physician/physician extender. Observation on 03/19/2025 at 4:52 p.m. revealed RN-E conducted Resident #26's gastrostomy tube placement by visual inspection prior to medication administration after connecting the syringe to the tube, then RN-E flushed the tube with 30 cc of water before giving med via the tube and administered one medication without checking residual by aspiration of gastric content. Interview on 03/19/2025 at 5:05 p.m. RN-E stated he did not check Resident #26's residual by aspiration of gastric content. RN-E conducted the tube placement with only visual inspection. Further interview with the RN-E said he should have checked the resident's residual by aspiration of gastric content because the physician order indicated If aspirate greater than (>) 100 cc, hold formula/water/medication and notify physician/physician extender. The RN-E said that If he did not check the residual, he did not know if the resident's residual was greater than 100 cc. RN-E was nervous and forgot checking the residual. Interview on 03/19/2025 at 5:25 p.m. with Resident #26's primary care physician stated not checking Resident #26's residual did not cause any harm because the resident did not have any history of high residual. The order was not specific but general for most residents with gastrostomy tube. Interview on 03/19/2025 at 5:29 p.m. the DON said RN-E should have checked Resident #26's residual by aspiration of gastric content prior to medication administration as ordered. Not checking Resident #26's residual prior to medication administration did not cause any harm because RN-E administered only one medication, but potentially the resident might have high residual (greater than 100cc). It was DON's responsibility to oversee and monitor nurses' skills regarding tube feeding. Record review of the facility policy, titled Administering medications through an enteral tube, revised 03/2015, revealed . 18. Confirm placement feeding tube per physician order. By aspirating stomach contents, if no residual is aspirated check for bowel sounds, bloating, vomiting, and pain. If not, changes are noted precede to administer medications/formula.20. Checked gastric residual volume to assess for tolerance of enteral feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 2 of 2 nursing staff (CNA-C and CNA-D) reviewed for competencies. The facility did not perform CNA-C and CNA-D's annual skill check-off. This failure could place the residents at risk for receiving care by staff who do not have the training and competency needed for providing care. The findings included: Record review of CNA-C and CNA-D's employee profiles revealed CNA-C was hired to the facility on [DATE], and CNA-D was hired on 05/25/2023. CNA-C did not have skill check-off for perineal care upon hiring date, and CNA-D did not have skill check-off for perineal care in 2024. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side without cleaning the suprapubic area. CNA-C cleaned the resident's buttock area, then put a new and clean brief on the resident. Interview on 03/19/2025 at 2:19 p.m. with CNA-C stated she did not clean Resident #16's suprapubic area, because she was nervous and forgot to clean the area. CNA-C said she should have cleaned the area when providing peri-care to Resident #16 and had peri-care training when she was hired, which was three months ago. Interview on 03/21/2025 at 2:33 p.m. the DON said she did not conduct CNA-C's perineal skill check off on 01/20/2025 (date of hire) and did not conduct CNA-D's perineal skill check off in 2024. The DON did not know what reason the previous DON did not perform the annual skill check-off because the DON was hired to the facility in August of 2025, and the facility generally performed annual skill check-off every April or May. It was DON's responsibility to oversee CNAs' skill check-off for competency. To ensure CNA-C and D's competency to meet residents' needs, when the facility hired CNA-C and D, the facility provided three days to the CNAs for following senior CNAs for three days, and the CNAs should demonstrate their skills correctly, then the facility allowed the CNAs to work on the floor. Further interview with the DON said she would have plan to do the skill check-off in May of 2025. Record review of the facility policy, titled Staffing, sufficient and competent nursing, revised 08/2022, revealed . 2. All nursing staff must meet the specific competency requirements of their respective licensure and certificate requirement defined by state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved two residents (Residents #10 and #97) of five residents reviewed for medication errors. 1. Medication aide-B administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10 on 03/19/2025, but the physician order indicated Metamucil (psyllium husk) 0.4-gram one capsule for constipation. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders. Findings include: Record review of Resident #10's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of chronic kidney disease stage 3 (kidney does not filter waste and fluid well), sciatica (pain that travels along the path of buttock and down to each leg), constipation, osteoporosis (weakness of bone), heartburn, and irritable bowel syndrome with constipation (stomach and intestines pain, bloating, or constipation). Record review of Resident #10's significant change MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact and required set up assistance (helper sets up or cleans up) for eating, chair-to-bed transfer, and toilet transfer. Record review of Resident #10's physician order, dated 05/01/2023, revealed the resident had the order of Metamucil (psyllium husk) capsule; 0.4 gram; amount one; oral; twice a day at 8 am and 5 pm for constipation. Observation on 03/19/2025 at 4:06 p.m. revealed Medication aide-B administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10, instead of Metamucil (psyllium husk) capsule; 0.4 gram. Interview on 03/20/2025 at 11:24 a.m. with Medication aide-B stated she administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10 on 03/19/2025, instead of Metamucil (psyllium husk) capsule; 0.4 gram because the facility was using not Metamucil (psyllium husk) capsule; 0.4 gram but fiber laxative calcium polycarbophil 625 mg, and she was told it was fine from nurses. Interview on 03/20/2025 at 11:25 a.m. with the DON stated the facility was using not Metamucil (psyllium husk) capsule; 0.4 gram but fiber laxative calcium polycarbophil 625 mg for constipation because physician indicated may use generic fiber capsule. However, if the facility did not have Metamucil (psyllium husk) capsule, the facility nurses should have contacted the physician and received more and additional clarification. The DON said it was medication error. 2. Record review of Resident #97's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (bowel is partly blocked and some faces can still get through), muscle weakness, edema (swelling caused by fluid), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and rheumatoid arthritis (chronic inflammatory disorder usually affecting small joints in the hands and feet). Record review of Resident #97's admission MDS, dated [DATE], revealed it was still in progress and in time because the resident was admitted to the facility on [DATE]. Record review of Resident #97's physician order, dated 03/12/2025, revealed the resident had the order of Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm. Place one drop into both eyes two times a day for increasing tear production. Record review of Resident #97's medication administration record, from 03/01/2025 to 03/31/2025, revealed the resident received Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm into both eyes for increasing tear production. Observation on 03/20/2025 at 8:57 a.m. revealed medication aide-B opened Resident #97's Cyclosporine 0.05% eye drop and placed two drops to the resident's each eye. Interview on 03/20/2025 at 9:15 a.m. with Resident #97 said she did not want to talk to the surveyor. Interview on 03/20/2025 at 8:58 a.m. with medication aide-B said she placed two drops of Cyclosporine 0.05% to Resident #97's both eyes because the resident said she would like to receive two drops to just one time a day, instead of one drop to two times a day. Further interview with medication aide-B stated she notified the charge nurse, and the charge nurse said the nurse would report it to Resident #97's primary care physician. However, the nurse did not say anything to medication aide-B, so the medication aide-B thought placing two drops to Resident #97's both eyes once a day was fine. Medication aide-B said she did not remember the nurse's name because the nurse was an agency nurse and did not work anymore since the medication aide-B reported it to the nurse. Interview on 03/20/2025 at 11:07 a.m. with LVN-A stated the nurse did not know Resident #97 would like to receive her Cyclosporine 0.05% eye drop to two drops to her each eye to just once a day, instead of one drop to each eye twice a day. Nobody reported it to LVN-A, and LVN-A said facility nurses should have contacted Resident #97's primary care physician and asked for their advice regarding the resident's preference about the eye drop. If the doctor changed the order, the nurses should update the order and follow the updated order. Interview on 03/20/2025 at 11:12 a.m. with the DON stated the DON did not know Resident #97's preference regarding the resident's Cyclosporine 0.05% eye drop. The DON had knowledge regarding the resident's preference because of the surveyor. Per the nursing schedule, only one agency nurse worked only one day since the resident was admitted to the facility, and it was 03/15/2025. However, the agency nurse did not work anymore. The DON said that the agency nurse should have notified regarding Resident #97's eye drop to the primary care physician and followed any updated order per the professional standard of nursing practice and facility policy. It was medication error also. Resident #97 might not receive adequate care and medical interventions to maintain her health. Record review of the facility policy, titled Administering Medications, revised 04/2019, revealed . 4. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 14 residents (Resident #5) and 1 nursing carts (C-unit nursing cart) out of 2 nursing carts reviewed for storage. 1. Ketoconazole cream for fungal or yeast infection was found on Resident #5's nightstand in the resident's room on [DATE]. 2. The C-unit nursing cart was left open and unattended by RN -E. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: 1. Record review of Resident #5's face sheet, dated [DATE], revealed the resident was an [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), type 2 diabetes mellitus (not control blood sugar in the body), muscle wasting and atrophy (wasting or thinning of muscle mass), embolism and thrombosis of deep vein of lower extremity (blood clot develops in the deep veins in legs), and hypertension (high blood pressure). Record review of Resident #5's annual MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated he had moderate cognitive impairment and required set up assistance (helper sets up or cleans up) for eating, chair-to-bed transfer, and toilet transfer. Record review of Resident #5's physician orders, dated [DATE], revealed there was no physician order regarding the medication of Ketoconazole cream for fungal or yeast infection. Observation on [DATE] at 10:52 a.m. revealed Resident #5 was sleeping in his wheelchair in his room. Medication, Ketoconazole cream was found on Resident #5's nightstand in his room. Interview on [DATE] at 11:18 a.m. with LVN-A stated she saw one medication (Ketoconazole cream for fungal or yeast infection) expired on Resident #5's nightstand in his room with the surveyor. LVN-A said she worked on [DATE] but did not see it. The nurse did not know what reason this expired medication was on Resident #5's nightstand. Further interview with the LVN-A stated Resident #5's daughter visited on [DATE] and might bring it. However, Resident #5 did not have fungal or yeast infection at this time, and making sure all medications were stored in the locked unit even though family member brought was still nurses' responsibility. Interview on [DATE] at 5:05 p.m. with the DON stated all medications should have been stored in the medication room or carts even though family member brought, and it was nurses' responsibility. Resident #5 might have adverse effects due to the unattended medication. 2. Observation on [DATE] at 4:52 p.m. revealed RN-E entered Resident #26's room without locking the C-unit nursing cart and was administering a medication via the gastrostomy tube. While the RN-E was providing a medication to Resident #26, the C-unit nursing cart was left open and unattended in the hallway. Interview on [DATE] at 5:05 p.m. with RN-E stated he did not lock the C-unit nursing cart because he forgot. RN-E stated he should have locked his cart at all times to prevent possible drug diversions. And it was RN-E's responsibility to make sure locking his cart all the time. Interview on [DATE] at 5:29 p.m. the DON said RN-E should have locked the C-unit nursing cart at all times. If the nurse did not lock the carts, some residents or any visitors might take some medications from the carts. Record review of the facility policy, titled Medication Labeling and Storage, revised 02/2023, revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #13) of 14 residents reviewed, in that: Resident #13's personal refrigerator located in her room observed on 03/18/2025, revealed an unknown food wrapped with papers inside the freezer, with no date and no label. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #13's face sheet, dated 03/21/2025, reflected the resident was an [AGE] year old female and was initially admitted to the facility on [DATE] with diagnoses that included: hyperlipidemia (high level of fat), dementia (loss memory or problem solving and other thinking abilities), muscle wasting and atrophy (loss of muscle tissue and strength), and Alzheimer's disease (destroy memory and other important functions). Record review of Resident #13's quarterly MDS assessment, dated 01/31/2025, reflected the resident's BIMS score was 4 out of 15 which indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching assistance as resident completes activity) eating and needed to have set-up assistance (helper sets up; resident completes activity) for chair-to-bed and toilet transfer. Record review of Resident #13's comprehensive care plan, dated 03/12/2025, revealed the resident had cognitive loss/dementia or alteration on though process related to impaired decision making, short-term and long-term memory loss. For intervention - Provide cues. Observation on 03/18/2025 at 10:07 a.m. revealed Resident #13 was not in her room. There was a personal refrigerator in the room, and inside the freezer there was an unknown old food wrapped with paper, with no date and no label on the paper. Interview on 03/18/2025 at 11:14 a.m. LVN-A stated Resident #13's refrigerator in her room had an unknown old food wrapped with papers, with no date and no label on the paper. The facility night nurses were supposed to check it every day. Interview on 03/21/2025 at 10:31 a.m. the DON stated facility night nurses were responsible for overseeing Resident #13's personal refrigerator and responsible for monitoring it daily by making label and date. The DON stated the resident might eat the food and have food born illness. Record review of the facility policy, titled Foods brought by family/visitors, revised 03/2022, revealed . 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored un a manner that it is clearly distinguishable from facility prepared food - Perishable foods are stored in resealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item, and the use by date. 6. The nursing staff will discard perishable food soon or before the use by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #16) of 5 residents reviewed for infection control practices. When CNA-C was providing perineal care to Resident #16, the CNA-C touched new and clean brief with old and dirty gloves after cleaning the resident's buttock area. This deficient practice placed residents at risk for cross contamination and infections. The findings included: Record review of Resident #16's face sheet, dated 03/21/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), hypokalemia (low potassium in the blood), muscle weakness, type 2 diabetes mellitus (not control blood sugar in the body), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #16's quarterly MDS assessment, dated 12/16/24, revealed the resident's BIMS was 15 out of 15, indicated the resident's cognitive function was intact, and the resident was always incontinent to bladder and bowel. Resident #16 was dependent (helper does all of the effort) to sit-to-stand and not applicable to chair-to-bed and toilet transfer. Record review of Resident #16's comprehensive care plan, dated 03/04/2025, revealed Incontinence of bowel and bladder related to history of stroke. For intervention - incontinent care per rounds and monitor and document for signs and symptoms of urinary tract infection. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side, and CNA-C cleaned the resident's buttock area, then put a new and clean brief with an old and dirty glove. Interview on 03/19/2025 at 2:19 p.m. with CNA-C revealed she touched a new and clean brief with an old and dirty glove after cleaning Resident #16's buttock area. CNA-C said she should have changed her old and dirty gloves after sanitizing her hands and then should have put the new and clean brief to the resident to prevent possible infection. She forgot because she was nervous even though she received infection control training from the facility. Interview on 03/20/2025 at 5:05 p.m. with DON said CNA-C should have changed her old and dirty gloves after sanitizing hands and then should have put the new and clean brief to the resident to prevent possible infection when CNA-C was providing perineal care to Resident #16.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 air filters (B-hall air filter) reviewed for environmental concerns. The air filter located B-hall, observed on 03/19/2025, was very dirty with gray colored thickened dust. It was last changed on 04/02/2024. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 03/18/2025 at 3:16 p.m. revealed there was an air filter on B-hall. The air filter was very dirty with gray colored thickened dust. Further observation revealed the air filter was dated 04/02/2024. Interview on 03/19/2025 at 3:26 p.m., Maintenance stated the air filter located B-hall was observed to be very dirty with gray colored thickened dust, and was last changed on 04/02/2024. Maintenance said he was responsible for changing air filters and was supposed to change them every month. He stated he forgot changing the air filter. Interview on 03/19/2025 at 3:35 p.m. with the DON said Maintenance should have changed the air filter every month. Potentially dirty air filter might cause some respiratory problems. Interview on 03/19/2025 at 4:00 pm with Administrator said Maintenance should have changed the air filter every month per the facility's maintenance checklist. Record review of the facility policy's, titled Maintenance checklist, dated 11/2023, revealed Monthly tasks - . 17. Air filters replace throughout facility.

Based on interview and record review, the facility failed to provide mandatory effective training on communications training for 2 of 20 employees (Housekeeper G and LVN K) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Housekeeper G and LVN K annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the previous 12 months for Housekeeper G, provided by the Administrator revealed no evidence of communication training being provided annually. Record review of the personnel records for LVN K revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for LNV K, provided by the Administrator revealed no evidence of communication training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed communication trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure communication trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their communication trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 1 of 20 employees (RN E) reviewed for training, in that: The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided RN E annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for RN E revealed a hire date of 04/24/2023. Further review of a training log from the previous 12 months for RN E, provided by the Administrator revealed no evidence of Infection control training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual Infection prevention trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual infection control trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual infection control trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual infection control trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective in-service training for nurse aides on dementia for 1 of 5 nurse aides (CNA H) reviewed for training, in that: The facility failed to ensure dementia training was provided CNA H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for CNA H revealed a hire date of 07/13/2023. Further review of a training log from the previous 12 months for CNA H, provided by the Administrator revealed no evidence of Dementia training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned dementia trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual dementia trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual dementia trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual dementia trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 14 residents (Resident #5 and #97) and 1 of 1 medication room reviewed for pharmacy services. 1. There was one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in the resident's room on 03/18/2025. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. 3. In the medication room, a. There was one medication (Hydrocortisone cream for fast itch and rash relief) expired on 02/2025 found inside the medication room on 03/19/2025. b. There were total 14 Intell-Swab covid-19 rapid home test for nasal swap expired on 12/31/2024 found inside the medication room on 03/19/2025. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Record review of Resident #5's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), type 2 diabetes mellitus (not control blood sugar in the body), muscle wasting and atrophy (wasting or thinning of muscle mass), embolism and thrombosis of deep vein of lower extremity (blood clot develops in the deep veins in legs), and hypertension (high blood pressure). Record review of Resident #5's annual MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated he had moderate cognitive impairment and required set up assistance (helper sets up or cleans up) for eating, chair-to-bed transfer, and toilet transfer. Record review of Resident #5's physician orders, dated 03/21/2025, revealed there was no physician order regarding the medication of Ketoconazole cream for fungal or yeast infection. Record review of Resident #5's medical record from 03/20/2024 to 03/20/2025 revealed the resident did not have any fungal or yeast infection to his skin. Observation on 03/18/2025 at 10:52 a.m. revealed Resident #5 was sleeping in his wheelchair in his room. There was one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in his room. Interview on 03/18/2025 at 11:18 a.m. with LVN-A stated she saw one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in his room with the surveyor. LVN-A said she worked on 03/17/2025 but did not see it. The nurse did not know why this expired medication was on Resident #5's nightstand. Further interview with the LVN-A stated Resident #5's family member visited on 03/17/2025 and might've brought it. However, LVN-A said Resident #5 did not have fungal or yeast infection at this time, and making sure all expired medications were removed even though family member brought was still nurses' responsibility. Resident #5 might have allergy or not have therapeutic effects due to the expired medication. Interview on 03/20/2025 at 5:05 p.m. with the DON stated all expired medications should have been removed even though family member brought, and it was nurses' responsibility. Resident #5 might have adverse effects or not have therapeutic effects due to the expired medication. 2. Record review of Resident #97's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (bowel is partly blocked and some faces can still get through), muscle weakness, edema (swelling caused by fluid), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and rheumatoid arthritis (chronic inflammatory disorder usually affecting small joints in the hands and feet). Record review of Resident #97's admission MDS, dated [DATE], revealed it was still in progress and in time because the resident was admitted to the facility on [DATE]. Record review of Resident #97's physician order, dated 03/12/2025, revealed the resident had the order of Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm. Place one drop into both eyes two times a day for increasing tear production. Record review of Resident #97's medication administration record, from 03/01/2025 to 03/31/2025, revealed the resident received Cyclosporine 0.05% one drop, ophthalmic twice a day at 8 am and 4 pm into both eyes for increasing tear production. Observation on 03/20/2025 at 8:57 a.m. revealed medication aide-B opened Resident #97's Cyclosporine 0.05% eye drop and placed two drops to the resident's each eye. Interview on 03/20/2025 at 9:15 a.m. with Resident #97 said she did not want to talk to the surveyor. Interview on 03/20/2025 at 8:58 a.m. with medication aide-B said she placed two drops of Cyclosporine 0.05% to Resident #97's both eyes because the resident said she would like to receive two drops to just one time a day, instead of one drop to two times a day. Further interview with medication aide-B stated she notified the charge nurse, and the charge nurse said the nurse would report it to Resident #97's primary care physician. However, the nurse did not say anything to medication aide-B, so the medication aide-B thought placing two drops to Resident #97's both eyes once a day was fine. Medication aide-B said she did not remember the nurse's name because the nurse was an agency nurse and did not work anymore since the medication aide-B reported it to the nurse. Interview on 03/20/2025 at 11:07 a.m. with LVN-A stated the nurse did not know Resident #97 would like to receive her Cyclosporine 0.05% eye drop to two drops to her each eye to just once a day, instead of one drop to each eye twice a day. Nobody reported it to LVN-A, and LVN-A said facility nurses should have contacted Resident #97's primary care physician and asked for their advice regarding the resident's preference about the eye drop. If the doctor changed the order, the nurses should update the order and follow the updated order. Interview on 03/20/2025 at 11:12 a.m. with the DON stated the DON did not know Resident #97's preference regarding the resident's Cyclosporine 0.05% eye drop. The DON had knowledge regarding the resident's preference because of the surveyor. Per the nursing schedule, only one agency nurse worked only one day since the resident was admitted to the facility, and it was 03/15/2025. However, the agency nurse did not work anymore. The DON said that the agency nurse should have notified regarding Resident #97's eye drop to the primary care physician and followed any updated order per the professional standard of nursing practice and facility policy. It was medication error also. Resident #97 might not receive adequate care and medical interventions to maintain her health. 3. a. Observation on 03/19/2025 at 2:46 p.m. revealed there was one medication (Hydrocortisone cream for fast itch and rash relief) expired on 02/2025 found inside the medication room. b. Observation on 03/19/2025 at 2:48 p.m. revealed there were total 14 Intell-Swab covid-19 rapid home test for nasal swap expired on 12/31/2024 found inside the medication room. Interview on 03/19/2025 at 2:49 p.m. with the DON stated there was one medication (Hydrocortisone cream for fast itch and rash relief) expired on 02/2025 and total 14 Intell-Swab covid-19 rapid home test for nasal swap expired on 12/31/2024 found inside the medication room. The DON said she did not know the reason why these expired medications were stored inside the medication room., The DON said all expired medications should have been removed, and it was the facility nurses' responsibility. The DON said the expired covid-19 test might have false result, and residents might have adverse effects or not have therapeutic effects due to the expired medications. Record review of the facility policy, titled Administering Medications, revised 04/2019, revealed . 4. Medications are administered in accordance with prescriber orders, including any required time frame. Record review of the facility policy, titled medication Labeling and storage, revised 02/2023, revealed . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the reach-in refrigerator were labeled after opened or prepared. The facility failed to ensure that items stored in the chest freezer were labeled after opened. These failures could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination. Findings included: Observation of the facility's reach-in refrigerator on 03/18/2025 at 9:17 AM revealed one 1 gallon of milk opened and unlabeled. Observation of the facility's chest freezer on 03/18/2025 at 9:19 AM revealed one box with a bag of rolls open and undated and one box with a bag of French toast open and undated. Interview with the Dietary Manager on 03/18/2025 at 9:23 AM revealed items being stored in the refrigerator and freezer were to be labeled with date they were opened. The Dietary Manager stated open items being stored in the refrigerator and freezers were to be labeled with date opened and date to be used by. The Dietary Manager stated by not labeling open items the residents would have been put at risk of food born illness. Record review of facility policy Food Receiving and Storage, dated 2022, revealed All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 9 (RN E, Dietary Aide F, Housekeeper G, CNA H, Activity Manager I, LVN J, LVN K, LVN L, DON) of 20 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Dietary Aide F and DON received required trainings upon hire. The facility failed to implement and maintain a training program that ensured required trainings were provided to Housekeeper G, CNA H, Activity Manager I, LVN J, LVN K, and LVN L annually. The facility failed to implement and maintain a training program that ensured required trainings were provided to RN E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of the personnel records for RN E revealed a hire date of 04/24/2023. Further review of a training log from the previous 12 months for RN E, provided by the Administrator revealed no evidence of QAPI training, Infection control training or behavior health training being provided annually. Record review of the personnel records for the Dietary Aide F revealed a hire date of 03/05/2025. Further review of a training log from the previous 12 months for Dietary Aide F, provided by the Administrator revealed no evidence of resident rights training, fall prevention training, restraint training, or emergency preparedness training being provided upon hire. Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the previous 12 months for Housekeeper G, provided by the Administrator revealed no evidence of communication training, QAPI training, ethics training, emergency preparedness training being provided annually. Record review of the personnel records for the CNA H revealed a hire date of 07/13/2023. Further review of a training log from the previous 12 months for CNA H, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for the Activity Manager I revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for Activity Manager, provided by the Administrator revealed no evidence of behavior health training being provided annually. Record review of the personnel records for LVN J revealed a hire date of 11/04/2022. Further review of a training log from the previous 12 months for LVN J, provided by the Administrator revealed no evidence of QAPI training, ethics training being provided annually. Record review of the personnel records for LVN K revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months forLVN K, provided by the Administrator revealed no evidence of communication training, ethics training, or emergency preparedness training being provided annually. Record review of the personnel records for LVN L revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for LVN L, provided by the Administrator revealed no evidence of QAPI training, or behavior health training being provided annually. Record review of the personnel records for DON revealed a hire date of 04/22/2024. Further review of a training log from the previous 12 months for DON, provided by the Administrator revealed no evidence of QAPI training being provided upon hire. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The administrator stated shortly before Dietary Aide F started the company had chosen not to use CEU360 and Dietary Aide F did not receive required trainings prior to working in the kitchen. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated during the time the company was being bought out Dietary Aide F started but the company no longer used the online training system. BOM stated Dietary Aide F started to work in the kitchen while BOM was awaiting guidance on how to train new staff. BOM stated it was the responsibility of the BOM and DON to ensure annual trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 6 (RN E, Housekeeper G, CNA H, LVN J, LVN L and DON) of 20 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to RN E, Housekeeper G, CNA H, LVN J, LVN L annually. The facility failed to ensure required trainings were provided to the DON upon hire. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of the personnel records for RN E revealed a hire date of 04/24/2023. Further review of a training log from the previous 12 months for RN E, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the previous 12 months for Housekeeper G, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for the CNA H revealed a hire date of 07/13/2023. Further review of a training log from the previous 12 months for CNA H, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for LVN J revealed a hire date of 11/04/2022. Further review of a training log from the previous 12 months for LVN J, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for LVN L revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for LVN L, provided by the Administrator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for DON revealed a hire date of 04/22/2024. Further review of a training log from the previous 12 months for DON, provided by the Administrator revealed no evidence of QAPI training being provided upon hire. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective training on ethics training for 3 of 20 employees (Housekeeper G, LVN J, and LVN K) reviewed for training, in that: The facility failed to ensure ethics training was provided to Housekeeper G, LVN J, and LVN K annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the last 12 months for Housekeeper G, provided by the Administrator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN J revealed a hire date of 11/04/2022. Further review of a training log from the last 12 months for LVN J, provided by the Administrator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN K revealed a hire date of 06/01/2022. Further review of a training log from the last 12 months for LVN K, provided by the Administrator revealed no evidence of ethics training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual ethics trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual ethics trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual ethics trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual ethics trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71 for 3 of 20 employees (Activity Manager, RN E, LVN L) reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Activity Manager, RN E, LVN L annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for the Activity Manager revealed a hire date of 06/01/2022. Further review of a training log from the past 12 months for Activity Manager, provided by the Administrator revealed no evidence of behavior health training being provided annually. Record review of personnel records for the RN E revealed a hire date of 04/24/2023. Further review of a training log from the last 12 months for RN E, provided by the Administrator revealed no evidence of behavior health training being provided annually. Record review of personnel records for LVN L revealed a hire date of 06/01/2022. Further review of a training log from the last 12 months for LVN L, provided by the Administrator revealed no evidence of behavior health training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual behavioral health trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned trainings that are due to be completed. The Administrator stated it is the responsibility of the BOM and Administrator to ensure that staff receive new employee training and annual behavioral health trainings. The Administrator stated the lack of training could have affected the resident's quality of life and care. Interview with the BOM, on 03/21/2025 at 4:35 PM revealed new staff received on-boarding prior to working the floor via online training system. BOM stated it was the responsibility of the BOM and DON to ensure annual behavioral health trainings were completed by staff annually. BOM stated it was important for staff to complete trainings to ensure resident were well taken care of. Interview with DON on 03/21/2025 at 4:43 PM revealed it was the responsibility of the BOM to ensure staff received their annual behavioral health trainings. DON stated it was important to train the staff to ensure the residents received good quality care. Record review of facility policy In-Service Training, All Staff dated 2001 revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. {Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 25 days (10/05/2024, 10/06/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/19/2024, 10/20/2024, 10/21/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/01/2024, 12/14/2024, and 12/15/2024) of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 25 days between October 2024 to March 2025. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Review of CMS PBJ staffing reports, from October 2024 to December 2024, reflected the facility triggered for no RN hours for FY 4th Quarter 2024 (October 2024 to December 2024). Review of the facility RN schedule from January 2025 to March 2025 revealed the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day for the following dates: 10/05/2024 no hours recorded. 10/06/2024 no hours recorded. 10/10/2024 no hours recorded. 10/11/2024 no hours recorded. 10/12/2024 no hours recorded. 10/13/2024 no hours recorded. 10/14/2024 no hours recorded. 10/19/2024 no hours recorded. 10/20/2024 no hours recorded. 10/21/2024 no hours recorded. 10/26/2024 no hours recorded. 10/27/2024 no hours recorded. 11/02/2024 no hours recorded. 11/03/2024 no hours recorded. 11/09/2024 no hours recorded. 11/10/2024 no hours recorded. 11/16/2024 no hours recorded. 11/17/2024 no hours recorded. 11/23/2024 no hours recorded. 11/24/2024 no hours recorded. 11/28/2024 no hours recorded. 11/30/2024 no hours recorded. 12/01/2024 no hours recorded. 12/14/2024 no hours recorded. 12/15/2024 no hours recorded. Interview on 03/21/2025 at 2:09 p.m. with the Administrator stated the Administrator could not find RN hours for the 25 days, which meant the facility did not have RN working to those 25 days because they could not find RNs. The facility had RN since 12/15/2024. If RNs did not work at the facility, it might cause improper care to residents. Record review of the facility policy, titled Staffing, sufficient, and Competent Nursing, revised 08/2022, revealed 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. Registered nurses many be scheduled more than eight (8) hours depending on the acuity needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of five residents (Resident #28) reviewed for care plans The facility failed to ensure Resident #28's comprehensive care plan addressed the residents individual need for the use of a CPAP (a non-invasive ventilation therapy used to facilitate breathing). This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a stroke, allergy, aphasia (a comprehension and communication disorder), acute respiratory disease, pneumonia, shortness of breath, wheezing, hemiplegia (paralysis of half the body), COPD, morbid obesity, diabetes, high blood pressure and anxiety. Record review of Resident #28's quarterly MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. He was dependent on assistance for toileting, bathing, and dressing. He required substantial/maximal assistance for personal hygiene, and he required partial/moderate assistance with eating. He had shortness of breath or trouble breathing when sitting at rest and when lying flat. He required oxygen therapy and non-invasive Mechanical Ventilator while a resident of the facility and within the last 14 days. Record review of Resident #28's Physician Order Report dated 12/24/2023 to 01/24/2024 revealed an order start date of 10/31/2023 to Monitor BIPAP/CPAP every 2 hours while in use for function and compliance, once a day; 7:00 PM to 7:00 AM. Change BIPAP/CPAP tubing on the first day every month, once a day; 7:00 PM to 7:00 AM. Further review revealed an order start date of 11/01/2023 for the following: Resident may use CPAP during day, as needed (Dx: Chronic obstructive pulmonary disease) once a day; 7:00 PM to 7:00 AM. Record review of Resident #28's care plan last reviewed/revised on 12/04/2023 revealed the resident's need, and physician orders for the use of the CPAP was not addressed. Observation and interview on 01/24/2024 at 11:45 AM, Resident #28's applied the CPAP onto his nose, adjusted the head gear and lowered the head of the bed. Resident #28 stated he would use the CPAP whenever he is flat in bed so he could breathe easier. In an interview on 01/24/2024 at 2:45 PM, the ADON stated Resident #28 would use the CPAP himself when he wanted to. She stated she did not know if the CPAP was part of the resident's care plan and she did not have anything to do with the care plan. In an interview on 01/25/2024 at 3:05 PM, the Regional Consulting Nurse stated Resident #28 did not have a care conference and that it did not meet regulations. She stated she would double check if there was a paper copy of a care conference. She stated care conferences were usually done 2 weeks after admission and with each MDS, usually every 3 months. She stated the care plan should include use of CPAP and the purpose of the care plan was to provide information on how to care for the resident. She stated it should be resident centered d/t every resident would have different needs . In a telephone interview on 01/25/2024 at 4:20 PM, the Regional MDS Nurse had been the MDS nurse for the facility for the past 2 months. She stated a person-centered care plan involved a meeting with the IDT team to review care with family/RP/Resident to meet the resident's needs and concerns. She stated it was important to make sure the resident was getting needs met for continuity of care when a resident comes from a hospital or from home. She stated if a resident was using Bipap/CPAP this should be included in the care plan so different team members could identify respiratory issues that needed to be addressed. She stated this would help provide an accurate picture of the resident's needs and the team would discuss and make sure it was addressed in the MAR. She stated if there were any current issues, the nurse or CNA would discuss with the DON then the DON would make necessary changes to the plan of care. In an interview on 01/26/2024 at 10:56 AM, the Regional Consulting Nurse stated Resident #28's care plan had not been updated d/t changes in staffing and the absence of the MDS nurse at the time. She stated the Regional MDS had been working on care plans and the facility was doing the best they could. She stated this was the root cause of the problem with the care plans not being updated. She stated there was no evidence of a care conference for Resident #28 and that a care conference was part of the Comprehensive Care Plan. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised on December 2016, read in part: .Policy Interpretation and Implementation - 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; .l. Identify the professional services that are responsible for each element of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #28) reviewed for Quality of Care in that: -Nurse Aide F provided services outside the scope of practice of a NA by administering a topical medication to Resident #28's wound. -the ADON delegated outside the scope of nursing practice by allowing Nurse Aide F to administer a topical medication to Resident #28's wound. This failure could place residents at risk of inappropriate medication administration, infection and decline in health. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. His diagnoses included stroke, need for assistance with personal care, difficulty with speech, acute respiratory disease, Pneumonia (inflammatory condition of the lung), urinary tract infection, shortness of breath (difficulty breathing), COPD, hemiplegia (paralysis to one side of the body), obesity, diabetes, HTN and osteoarthritis (a type of joint disease). Record review of Resident #28's quarterly MDS dated [DATE] revealed he had a BIMS score of 6 out of 15 indicating severe cognitive impairment. He had limited range of motion d/t impairment on both sides of his lower extremities. He was dependent on staff or required substantial assistance with ADLs. He had moisture associated skin damage, required nonsurgical dressings and applications of ointments/medications. Record review of Resident #28'scare plan did not address skin injuries/wounds and interventions. The care plan was last reviewed/revised on 12/04/2023. Record review of Resident #28's Wound Evaluation and Management Summary dated 01/23/2024 by the Wound Physician revealed a non-pressure wound of the right buttock to be an abrasion that was 1.0 x 0.7 x 0.1 cm in size. The wound had light serosanguinous exudate (a type of wound drainage secreted by an open wound). The dressing treatment plan was to use Silver Sulfadiazine cream twice daily and discontinue the use of a gauze dressing. Record review of Resident #28's physician orders for the nurse medication flow sheet revealed a prescription order for silver sulfadiazine cream, 1 %, amount: thick layer; topical, twice a day; 7:00 AM - 7:00 PM, 7:00 PM - 7:00 AM. Start date was 11/14/2023. Observation and interview on 01/24/2024 at 12:45 PM, Resident #28 stated he needed a brief change. Nurse Aide F performed peri care. Resident #28 self-turned to his right side and Nurse Aide F wiped the resident's buttocks with disposable wipes around a small dressing over an area on the right buttocks that was loose. Nurse Aide F removed the dressing. Nurse Aide F stated he needed to get a nurse because of the wound. Nurse Aide F removed his gloves and sanitized his hands just outside of the room. Nurse Aide F returned with gloved hands and white cream in a medicine cup. Nurse Aide F stated the ADON gave it to him to put on the wound for now. Nurse Aide F said it was cream that was typically put on the area. Nurse Aide F did not say what the name of the cream was when asked. Nurse Aide F applied the cream over the open area. Nurse Aide F completed the peri care procedure. In an interview on 01/25/2024 at 10:30 AM the ADON stated she gave the cream to Nurse Aide F to apply over Resident #28's wound. The ADON stated it was Silvadene cream (Silver Sulfadiazine) and that only nurses were allowed to administer. The ADON stated it was wrong to have given it to the NA to administer and it should not have happened. The ADON stated she was trying to do so many things at that time. The ADON stated she would fix it and make sure it did not happen again. In an interview on 01/25/2024 at 10:40 AM, the Regional Consulting Nurse stated it was not ok for an aide to administer the Silvadene cream because it was a medication ordered by the MD and nurse aides cannot assess wounds. She stated nurse aides were taught not to put anything over open areas. She stated if the skin was broken it required an assessment. She stated the cream would not have hurt the resident, but it was out of the scope of practice for a nurse aide, and it was out of the scope of practice for the nurse to delegate the task to a NA. She stated it was a deficient practice. Record review of the facility policy titled Administering Medications, revised December 2012, read in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . Record review of the facility policy titled Administering Topical Medications, revised October 2010 read in part: Purpose - The purpose of this procedure is to provide guidelines for the safe administration of topical medications. Preparation: 1. Verify that there is a physician's medication order for this procedure .General Guidelines: 1. Follow the medication administration guidelines in the policy entitled Administering Medications Steps in the Procedure .15. Assess the area for broken skin, drainage, debris, rashes, allergic reaction, or signs of infection .17. Clean the skin. Remove old medication residue, debris, scales, dried blood, etc. If necessary, saturate a gauze pad with solvent and wipe .to remove paste, cream or ointment from the area . Record review of the facility's undated Job Description for Certified Nursing Assistant read in part: Summary: Provide direct nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality care is maintained at all times . Record review of the facility's undated Job Description for LVN, Licensed Vocational Nurse read in part: Summary: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to day nursing activities of your assigned unit. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations that govern the Long-term care facility as well as our established policies and procedures, and as may be direct by the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care for 1 of 6 residents (Residents #28) reviewed for care consistent with professional standards, in that: The facility failed to clean Resident #28's CPAP (a machine used to keep breathing airway open) mask, nasal pillow and tubing daily. The facility failed to change Resident #28's CPAP tubing monthly. These failures could place residents at risk of respiratory infection, decline in health and hospitalization. Findings include: Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. His diagnoses included stroke, need for assistance with personal care, difficulty with speech, acute respiratory disease, Pneumonia (inflammatory condition of the lung), urinary tract infection, shortness of breath (difficulty breathing), COPD, hemiplegia (paralysis to one side of the body), obesity, diabetes, HTN and osteoarthritis (a type of joint disease-causing pain and stiffness). Record review of Resident #28's quarterly MDS dated [DATE] revealed he had a BIMS score of 6 out of 15 indicating severe cognitive impairment. He had limited range of motion d/t impairment on both sides of his lower extremities. He was dependent on staff or required substantial assistance with ADLs. He had shortness of breath when lying flat and when sitting at rest. He required oxygen therapy and non-invasive mechanical ventilator. Record review of Resident #28's physician order report dated 12/24/2023 to 01/24/2024 revealed an order to change CPAP tubing on the first day every month, order start date 10/31/2023. Monitor CPAP every 2 hours while in use for function and compliance, order start date 10/31/2023. CPAP in place at HS, once a day; 7:00 AM - 7:00 PM. Resident may use CPAP during day as needed. Further review of the general flow sheet section of the physician order report did not include orders on when to change CPAP face mask or to use distilled water only in the humidifier chamber. Record review of Resident #28's general administration history dated 11/01/2023 to 11/30/2023 revealed the CPAP tubing was documented as changed on 11/01/20203. Record review of Resident #28's general administration history dated 12/01/2023 to 12/31/2023 revealed the CPAP tubing was documented as changed on 12/01/20203. Record review of Resident #28's general administration history dated 01/01/2024 to 01/26/2024 revealed the CPAP tubing was documented as changed on 01/01/20204. Observation and interview on 01/24/2024 at 11:45 AM, Resident #28's head gear and tubing for the CPAP was hanging between the mattress and siderail. The head gear was touching the floor. The inside of the tubing had areas of brownish, tan discoloration. The humidifier chamber was dry. The outside of the machine was dusty and dirty. The resident applied the CPAP onto his nose, adjusted the head gear and lowered the head of the bed. Resident #28 stated he would use the CPAP whenever he is flat in bed. He stated he owned the CPAP and the tubing was about 6 months old. He stated no one at the facility had ever changed it out or cleaned it and they would use tap water and not distilled water. The equipment was not dated. Interview on 01/24/2024 at 2:45 PM the ADON stated the tubing for Resident #28's CPAP was dirty, needed to be changed and there was no water in the humidifier chamber. The ADON stated the outside of the machine could use cleaning and the tubing had no date. She stated nurses were responsible to clean the CPAP machine, tubing and mask. The ADON stated they should be cleaned daily and by the night shift. The ADON stated the risk to the resident would be lung infection. The ADON stated it should be stored in a plastic bag, but the resident wanted it kept at his bedside with him. The ADON stated the previous DON was supposed to order the parts and that they should be dated. The ADON stated she did not know when the former DON placed the order and did not know where the invoice would be located. The ADON stated she would place an order for parts. Interview on 01/25/2024 at 12:05 PM, the Regional Nurse Consultant stated Resident #28 should have orders for changing tubing for CPAP monthly and the machine should be wiped down weekly and PRN. She stated the facility had standing orders for CPAP and was unsure who did the ordering for supplies. She stated it did not matter whether the CPAP was owned by the resident or not, the facility was responsible to take care of it. Interview on 01/26/2024 at 10:34 AM, the ADON stated there were no CPAP supplies for Resident #28 since his admission in October 2023. Interview on 01/26/2024 at 12:27 PM the Regional Nurse Consultant stated it was upsetting to her that nurses signed off that the CPAP tubing was changed out monthly when it was not done. She stated she did not know why this happened. She stated she expected the nurse's to have brought it up to management's attention so the supplies could get ordered. She stated she did not recognize the names of the nurses who signed the documentation, and they could have been Agency nurses. She stated moving forward she will be asking the current facility nurses about the tubing and will conduct staff inservices . Record review of the facility policy for CPAP/BiPAP Support, revised March 2015, read in part: Purpose .1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety General Guidelines for Cleaning, 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device 4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber. b. clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. 6. Filter cleaning .7. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. 8. Headgear(strap): Wash with warm water and mild detergent as needed. Allow to air dry Record review of the facility's policy titled Infection Control Guidelines for All Nursing Procedures, revised August 2012 read in part: Purpose - To provide guidelines for general infection control while caring for residents General Guidelines - 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether they contain visible blood, non-intact skin, and /or mucous membranes .6. In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the environment was free of accidents hazards for 4 (Resident #20, Resident #25, Resident #26, Resident #30 ) of 5 residents, reviewed for accidents hazards This failure placed residents at risk of injury for accidents or hazard. Findings included: Record review of Resident #25's orders revealed Resident #25 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic shortness of breath and cough), muscle wasting and atrophy (loss of muscle), cough, unsteadiness on feet, colostomy status (opening for the large intestine in the stomach). Record review of Resident # 25's MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Resident #25 required supervision with eating, oral hygiene, and showering/bathing. Resident #25 was independent with upper body dressing, lower body dressing, personal hygiene, and used a wheelchair and walker for ambulating. Record review of Resident #25's Care Plan dated 7/25/2023 revealed . Resident #25 smokes .I will not suffer from unsafe smoking practices through the next review date .instruct resident about the facility policy on smoking, locations, times and safety concerns .notify charge nurse immediately if it suspected resident has violated facility smoking policy . Record review of Resident #25's Smoking assessment dated [DATE] revealed in part . Smoking materials carries matches/lighter, general awareness and orientation-including ability to understand the facility safe smoking policy-0-No Problem . In an interview on 1/24/2024 at 8:56am with Resident #25 she said she kept her lighters in her room. She said her lighters were in her drawer and pointed at her drawer. Resident #25 said she did not keep her lighters at the nurse's station. Record review of Resident # 30 's orders revealed resident was admitted [DATE] with diagnoses of major depressive disorder (persistent sadness), chronic obstructive pulmonary disease, pressure ulcer of the right buttock stage 3 (wound from pressure), pressure ulcer of the left buttock stage 3, venous insufficiency (blood pooling in the veins), nicotine dependence, cigarettes, with withdrawal, other specified diseases of pancreas, morbid (severe) obesity due to excess calories. Record review of Resident #30's MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating Resident #30 was moderately cognitively impaired. Resident #30's required extensive assistance with toileting and bathing, substantial/maximal assist with lower body dressing, putting on footwear, personal hygiene and set up with eating. Resident required a wheelchair for ambulation. Record review of Resident #30's Care Plan revealed in part . Encourage resident to keep all smoking material at nurses' station after smoke break. Education provided to family and resident . Record Review of Resident #30's Smoking assessment dated [DATE] read in part . Carries Matches/Lighter, inappropriately provides smoking materials to others .severe problem .General awareness and orientation including ability to understand the facility safe smoking policy-0-No Problem . In an interview on 1/24/2024 at 9:00am with Resident #30 he said he kept his own lighter in his room. Resident #30 said he kept the lighters in his bedside table. Observation on 1/24/2024 at 9:00am of Resident #30 bag with lighter revealed resident had a white bag in bed with him. Record review of Resident #26 orders revealed resident was admitted [DATE] with a diagnosis of other lack of coordination, Muscle wasting and atrophy, Difficulty walking, Unspecified atrial fibrillation (abnormal heart rhythm), Nicotine dependence, unspecified, uncomplicated, Adult failure to thrive (decline). Record review of Resident #26 MDS dated [DATE] revealed a BIMS score of 11 out of 15 indication the resident was moderately cognitively impaired. Resident was set up or cleanup for oral hygiene, toileting, showering, putting on taking off footwear, and personal hygiene. Resident was independent with upper and lower body dressing. Resident ambulated with a wheelchair. Record review of Resident #26's Care Plan dated 5/10/2023 revealed . Resident #26 is a smoker .I will not suffer injury from unsafe smoking practices through the next review date .instruct resident about the facility policy on smoking, locations, times, safety concerns .Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Record review of Resident #26's Smoking assessment dated [DATE] revealed in part . Capability to follow facility safe smoking policy-0-No problem . In an interview on 1/24/2024 at 9:05am with Resident #26 he said he had his own lighter. He said the facility did not keep lighters. He said his lighter was in his bedside drawer. Record review of Resident #20 Orders revealed resident was admitted [DATE] with diagnoses of Type 2 diabetes mellitus with diabetic nephropathy (problem with sugar regulation that affects the kidneys), Other secondary hypertension (high blood pressure), Mild intellectual disabilities (limitation to mental ability), Hypertension (high blood pressure), Hyperlipidemia High blood fats). Record review of Resident #20's MDS dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. Resident was Supervision or touching assistance with personal hygiene, putting on/taking off footwear, set up or clean up with oral hygiene, toileting hygiene, showering/bathing, and independent with eating, upper and lower body dressing. Resident was ambulatory. Record review of Resident #20's Care Plan dated 12/12/2023 revealed in part . Resident has hypertension and is an occasional smoker .remind resident that cigarettes and lighter are to be kept at the nurse's station . Record review of Resident #20's Smoking assessment dated [DATE] revealed in part . Clinical Judgement-Resident is not capable of even supervised smoking. Smoking will result in danger to self and others .False. In an interview on 1/24/2024 at 9:10am with Resident #20 he said he gets his lighters from the store. He said his family buys them for him. He said he keeps his lighters in the drawer in the bedside table and pulled out 2 lighters and shoed them to the surveyor. Record review of Resident # 12's Orders dated 12/25/2023-1/25/2023 revealed a [AGE] year old male admitted to the facility 10/14/2022. His diagnoses were Cerebral Infarction (Brain cells do not get enough blood), Acute on chronic diastolic congestive heart failure (Heart cannot pump enough blood to meet the bodies need), Dysphagia (Difficulty speaking), Hemiplegia and hemiparesis following cerebral vascular disease affecting left non-dominant side (Paralysis on left side). Record review of Resident #12's MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating Resident #12 was moderately cognitively impaired. He required total assistance with bathing and partial/moderate assistance with toileting, lower body dressing, putting on footwear and personal hygiene. He required supervision with upper body dressing and eating. Record review of Resident #12's Care Plan dated 4/6/2023 revealed in part Resident #12 is a smoker . I will not suffer injury from unsafe smoking practices .Resident can smoke unsupervised .The resident can light own cigarette. Record review of Resident #12's Smoking assessment dated [DATE] read in part . moderate problem with Careless with smoking materials-Drops cigarette/cigar butts or matches on floor, furniture, self, or others; burns fingertips; smokes near oxygen, Smokes Cigarettes/Cigar Butts from Ash Trays, and with his Capability to Follow Safe Smoking Policy. He had a severe problem begging for and/or stealing smoking materials. On 1/24/2024 at 7:30am Surveyor observed empty smoke box in the medication room. In an interview on 1/23/2024 at 7:30am with Nurse Aid F he said he had worked at the facility since 2017. He said they had an in service on smoking before in the past but could not remember the date. He said the residents were supposed to stay in the smoking area when they smoked. He said the lighters were supposed to be at the nursing station. He said the families brought the lighters in to the residents. He said the residents felt like they could carry their own lighters. He said he had removed some personally and said there were some residents he would leave a lighter with. He said staff were not always with the residents when they smoked. In an interview on 1/23/2024 at 7:46am with CNA R, the activities director, she said she had worked at the facility since November 2023. She said they had no one observing the smokers. She said the residents had their own lighters in their rooms with them. She said they had only one resident that wandered in the building. In an interview on 1/25/2024 at 7:25am with Nurse Aid I she said she had worked at the facility for 2 years and 5 months. She said lighters were supposed to be kept at the nurse's station. She said she did not hand lighters to the residents. She said the residents were keeping their own smoking paraphernalia. She said 6 months ago an aide was supposed to always go out with the residents but that stopped. She said if lighters were kept in rooms residents could get them and they could cause an explosion or catch themselves on fire. In an interview on 1/25/2024 at 7:30am with CMA H she said the residents go outside to the smoking area. She said the residents are mostly independent. She said there was usually someone with them. She said they had a smoke box in the medication room they were supposed to be using for residents to put their lighters in. She said if the residents had lighters in their rooms there could be a tragedy. In an interview on 1/26/2024 at 10:30am with the ADON she said she did a smoking assessment on everyone that came into the building. She said they did a recent smoking assessment for the new smoking policy. She said lighters in resident rooms were a fire hazard. She said another resident could wander into the room who was cognitively impaired and cause a fire and for this reason lighters were not allowed in rooms. She said resident lighters were supposed to be kept at the nurses station in the smoke box and lighters were to be taken up by nursing staff at the end of each smoke break. Record review of facilities policy titled, Smoking Policy-Residents dated October 2022 read in part . Lighters, including matches, are prohibited to be kept in patients' rooms.

Based on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 4 dietary support staff Dietary Aide W, [NAME] S, [NAME] R, and Dietary Aide T reviewed for competencies. The facility failed to ensure [NAME] S, [NAME] R, Dietary Aide T, and Dietary Aide W had a current Food Handling Certificate while working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings included: Record review of Dietary Aide W's personnel file information revealed Dietary Aide W was a part-time aide, with a hire date of 12/23/23. No documentation of a food handler's certificate was found in Dietary Aide W's personnel information provided to surveyor. Observation on 1/23/2023 at 11:30 AM revealed [NAME] S was ladling food onto plates and placing the plates on trays with the assistance of [NAME] R. Dietary Aide T was pouring tea and water into cups for resident's lunch meal revealing they were working in the kitchen handling food and beverages. Review of the staff list and the kitchen staff schedule for January 2024, provided by the Administrator on 1/24/24, revealed [NAME] S was a full-time cook with a hire date of 11/29/2023, [NAME] R was a part-time cook with a hire date of 11/30/23, and Dietary Aide T was a full-time aide with a hire date of 12/12/2023. The personnel files, requested on 1/25/24, were not made available to the surveyor to review prior to exit. During an interview on 1/25/24 at 2:05 PM, the Administrator revealed the previous Dietary Manager's last day of employment was 1/5/24 and a replacement has not been hired. The Dietary Manager would be the person responsible for ensuring kitchen staff had Food Handling Certificates and it was not known if the certifications had been completed. During an interview on 1/26/24 at 9:50 AM with the Administrator, the Regional Nurse Consultant, and the Regional Director of Operations, it was revealed that the kitchen staff did not complete the food handling training and did not have certification. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Record review of the Texas Food Establishment Rules of the Texas Administrative Code, Title 25, Part 1, Chapter 228, Subchapter B, dated August 2021, indicated the Certified Food Protection Manager and Food Handler Requirements: .(d) All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. This requirement does not apply to temporary food establishments. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 13 Residents (Resident #27, #22 and #20) reviewed for environment. The facility failed to properly clean/maintain resident #27, #22 and #20's rooms in a sanitary manner. This failure could place residents at risk of unsanitary conditions, psychosocial decline, spread infections which could result in a decline in health. Findings included: Record review of resident #27's face sheet dated 1/25/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, chronic kidney disease, dementia, Cellulitis (infection involving the skin of the lower limbs) and history of diarrhea. Record review of Resident #27's quarterly MDS dated [DATE] revealed he had a BIMS score of 1 out of 15 indicating severe cognitive impairment. He required partial/moderate assistance with toileting, and he was frequently incontinent of bowel and bladder. Record review of Resident #22's face sheet dated 1/24/2024 revealed a [AGE] year-old female admitted to the facility 06/16/2022. Her diagnoses included pervasive developmental disorder (a group of conditions that affect average development such as social and communication skills), restlessness and agitation, psychotic disorders, and heart failure. Record review of Resident #22's quarterly MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. She required supervision for all ADLs. She was always continent of bowel and bladder. Record review of Resident #20's quarterly MDS dated [DATE] revealed a male whose date of birth was 09/17/1986 and was admitted to the facility on [DATE]. He had a BIMS score of 14 out of 15 indicating intact cognition. He required setup or clean-up assistance with toileting hygiene, and he was always continent of bowel and bladder. He had no functional limitations in range of motion. His active diagnoses included hypertension, diabetes, mild intellectual disabilities, morbid obesity. An observation on 01/23/2024 at 10:05 AM of Resident #20's bathroom revealed dirty walls with brown substance splattered on the walls above the garbage can and below the paper towel dispenser. An observation on 01/23/2024 at 10:20 AM of Resident #27's room revealed the doorknob to the bathroom was smeared with sticky semi dry brown unknown substance. During an interview on 01/23/2024 at 2:35 PM LVN N stated Resident #27 had a history of refusing to get cleaned up and at times there would be feces all over the place. LVN N stated the staff probably missed the brown substance on the doorknob. LVN N stated that housekeeping was responsible to clean the room and that she would get the housekeeper to clean the doorknob. LVN N stated it should be cleaned d/t infection control. LVN N stated it was also the responsibility of all staff to clean up when needed. She stated she would make sure all nursing staff and housekeeping were re-educated. During an interview on 01/23/2024 at 2:40 PM, Housekeeper K stated he cleaned Resident #27's room before lunch and that he cleaned everything including the dresser and the bathroom. He stated he did not clean the bathroom doorknob because he did not see the brown smears. An observation on 01/24/2024 at 10:32 AM of Resident #22's room revealed the trash can next to the resident's bed had no liner, it contained trash and had multiple dried splatters of brown unknown substance on the inside and on the rim of the trash can. During an observation and interview on 01/24/2024 at 11:30 AM the ADON looked at the garbage can next to Resident #22's bed and stated it should not look like that with all those brown spots and that she would not like it if it were her room. The ADON stated the risks would be infection. The ADON stated if it was feces, it could be E-coli (bacterial infection in the intestines) and that would be cross-contamination. The ADON stated the housekeepers were responsible to make sure the trash cans were clean and had liners. Resident #20's bathroom still had dirty walls, splattered with brown substance and the ADON stated it should not be dirty. The ADON stated the housekeepers were responsible to keep these areas clean. During an interview on 01/24/2024 at 11:35 AM, the Maintenance Director stated he was responsible for overseeing Housekeeping and stated Resident #22's trash can should have a liner. He stated the brown splatters could be food that was thrown into the trash can. He stated the housekeepers were responsible to keep the trash can clean and that he would be talking with them about it. He stated he expects the housekeepers to disinfect high touch surfaces including all doorknobs. He stated he heard about the brown substance on the bathroom doorknob in Resident #27's room and did not know why that happened. He stated that there have been occasions when feces were all over the walls, chair, and curtains in Resident #27's room. He stated he will conduct an in-service for housekeeping staff on infection control and make sure they wipe everything down including the bathroom walls in Resident #20's room. During an interview on 1/25/2024 at 11:55 AM, the Regional Consulting Nurse stated housekeeping was responsible for keeping resident rooms clean, trash cans clean and doorknobs clean. She stated there were assigned rounds every morning and if something was obvious and needed attention, she expected the staff to take out the trash, if it was feces on those surfaces, it should be wiped off. She expected high touch surfaces including doorknobs to be wiped clean to prevent viruses. Moving forward she stated staff should be making more frequent rounds on Resident #27 and will put a better plan for Housekeeping to check his room more often. Record review of the facility policy titled Quality of Life - Homelike Environment, revised April 2014 read in part: Policy Statement, residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extend possible. Policy Interpretation and Implementation .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order . Record review of the facility's undated Job Description, LVN, Licensed Vocational Nurse, read in part: .The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to nursing activities of your assigned unit Safety and Sanitation .Ensure that all work services areas on your unit are maintained in a clean and sanitary manner, such as nurses' stations, medicine preparation rooms, etc .Participate in the development, implementation and maintenance of the infection control and universal precautions to assure that a sanitary environment is maintained at all times and that aseptic and isolation techniques are followed by personnel . Record review of the facility's undated Job Description, Certified Nursing Assistant, read in part: Summary: Provide direct nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality care is maintained at all times .Safety and Sanitation .Ensure that all rooms on your assignment are maintained in a clean and sanitary manner .

Based on observation, interview, and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 11/1/2023 to 11/30/2023 for a total of 30 days, 12/1/2023 to 12/31/2023 for a total of 31 days and 1/1/2024 to 1/23/2024 for a total of 23 days, reviewed for RN coverage. The facility had no DON from 7/25/2023 to 9/26/2023 and from 12/26/2023 to 1/26/2024. These failures placed the residents at risk for not having decisions made that would have required and RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff. The findings included: Record review of employee files r evealed employment dates of the two previous DON's as: DON A 8/31/2022 to 7/25/2023 DON B 9/6/2023 to 12/26/2023 Record review of facility time stamps revealed facility had no RN coverage: 11/1/2023 to 11/30/2023. 12/1/2023 to 12/31/2023. 1/1/2024 to 1/23/2024. Record review on 1/26/2024 revealed facility census was 38 . In an interview on 1/26/2024 at 8:30am with the Regional Nurse Consultant she said an RN has a higher level of education than an LVN or a Medication Technician. She said the difficulties at the facility were because it was set in a rural area. When asked if they would increase the pay, she said they only paid a little less than other facilities. When asked if they increased the pay would nurses be willing to drive the 16 miles from the larger town she did not answer. She said state laws mandate registered nurses because of the level of experience and knowledge they have. She said when they did not have registered nurses a resident might not be assessed properly. She said the DON had acted as a charge nurse part of the time but did not the other part of the time. She said she had no proof of what days the DON did charge. She said they did not have a policy on nurse staffing because it was not federally mandated, and they only had policies on federal mandates. On 1/26/2024 at 8:30am policy on nurse staffing was requested and not provided. Record review of facilities job description Registered Nurse, no date said in part . The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities of your assigned unit. Such supervision must be in accordance with current Federal, State and local standards, guidelines and regulations that govern the long term care facility, as well as our established policies and procedures .ensure that the nursing services policies and procedures manual is followed by nursing personnel .interpret the departments policies and procedures to employees, residents, visitors, government agencies, etc. ensure that nursing personnel are following their prospective job descriptions.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure refrigerators maintained a temperature at or below 41 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness. Findings included: 1/23/24 Entered kitchen for initial observation. 8:55 Am Refrigerator #1 had a temperature of 51 degrees. 8:55 AM Refrigerator #2 had no thermometer. 9:02 AM observation of Freezer #2 revealed it contained: 1 cardboard box of food not labeled, sealed, or dated;. 1 plastic bag of bacon not labeled, sealed, or dated;. 1 plastic bag of tomato-based sauce not labeled or dated;. 1 plastic bag of chicken strips not labeled or dated. 9:57 AM observation of Refrigerator #1 revealed it contained: 1 plastic bag of bacon not labeled, sealed, or dated;. 1 plastic package of sausages not labeled, sealed, or dated. 9:59 AM observation of the Dry storage area revealed it contained: 1 brown paper bag of potato slices not sealed or dated;. 1 brown paper bag of sugar not sealed or dated;. 1 carton of sprinkles not sealed;. 3 dented cans of chunk light tuna in water. 1/23/24 at 9:30 AM Interview attempts with kitchen staff were unsuccessful due to non-English speaking staff on duty. Interview on 1/23/24 at 11:39 AM with the Dietary Manager from a sister facility who was in the kitchen to assist the kitchen staff. The Dietary Manager reported she had been at this facility for first time last week. She was asked to help out after the Kitchen Manager quit on 1/5/24; no replacement Kitchen Manager had been hired yet. The Dietary Manager ordered food and had started working on sorting out the dry food storage area, which she reported had been disorganized when she arrived. Reviewed earlier findings with Dietary Manager of temperature of refrigerator #1 and missing thermometer on refrigerator #2. She was unable to provide any information about refrigerator temperatures. Also reviewed items in the refrigerator, freezer, and storage area that were not sealed, dated, or labeled. The Dietary Manager said that all food items should be labeled and dated and opened food items should be sealed. The Dietary Manager said it was kitchen staff responsibility to seal and label food items and she did not know who failed to seal and label to the food items. A record review of the facility's policy titled Food Receiving and Storage H5MAPL0335 dated December 2008 reflected the following: Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 8. Refrigerated foods must be stored at or below 40?F unless otherwise specified by law. 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements.

**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 one of four staff (MA A) and three of ten residents (Resident #13, #38 and #17) reviewed for infection control, in that MA A failed to sanitize a wrist blood pressure cuff between uses on Residents #13, #38 and #17. This failure could place residents at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Resident #13 Record review of the face sheet for Resident #13 reflected she was an [AGE] year old female, who was admitted to the facility on [DATE] with the following diagnoses: essential (Primary) hypertension (high blood pressure), vitamin deficiency, and vitamin B12 deficiency anemia due to intrinsic factor deficiency and age-related osteoporosis without current pathological fracture. Record review of the quarterly MDS for Resident #13 dated 10/13/22 reflected a BIMS score of 15, indicating no cognitive impairment. Record review of the care plan for Resident #13 dated 09/19/22 reflected the following: The resident has hypertension. The resident will remain free of complications related to hypertension through review date. Avoid taking the blood pressure reading after physical activity or emotion distress. Monitor for and document any edema. Notify MD. Monitor/document abnormalities for urinary output. Report significant changes to the MD. Record review of the physician orders for Resident #13 dated 09/19/22 reflected the following: Benicar (Olmesartan) tablet 20 mg once a day for Hypertension Hold if SBP<100 and HR<60. Observation on 11/21/22 at 8:44 AM revealed MA A preparing medications for administration on a medication cart and using the computer keyboard on the cart. MA A left her medication preparation to take blood pressure/pulse rate for Resident #13. MA A attached wrist cuff without cleaning/ wiping it with sanitizer. Resident #38 Record review of the face sheet for Resident #38 reflected 90 -year-old male admitted to the facility on [DATE] with diagnoses of dementia, hypertension (high blood pressure), and anemia ( low blood volume). Record review of the quarterly MDS for Resident #38 dated 08/24/22 reflected a BIMS score of 10, indicating a moderate cognitive impairment. Record review of the care plan for Resident #38 dated 07/29/22 reflected the following: The resident has hypertension (HTN) related to Smoking, use/side effects of medication. The resident will remain free of complications related to hypertension through review date. Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Monitor for and document any edema. Notify MD. Monitor/document/report PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea). Record review of the physician orders for Resident #38 dated 12/01/21 reflected the following: Losartan Potassium tablet 50 mg. Give one tablet by mouth. Hold if SBP<100 and HR<60. Observation on 11/21/22 at 9:13 AM revealed MA A preparing medications for administration on a medication cart and using the computer keyboard on the cart. MA A left of her medication preparation to take blood pressure/pulse rate for Resident #38. MA A attached to a wrist cuff without cleaning/ wiping it w ith sanitizer. Resident #17 Record review of Resident # 17's admission record revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: allergic rhinitis and Alzheimer's disease (memory loss). Record review of the quarterly MDS for Resident #17 dated 10/13/22 reflected a BIMS score of 06, indicating severe cognitive impairment. Observation on 11/21/22 at 9:30 AM revealed MA A preparing medications for administration on a medication cart and using the computer keyboard on the cart. MA A left of her medication preparation to take blood pressure/pulse rate monitor for Resident #17, MA A attached to a wrist cuff without cleaning/ wiping it with sanitizer. During an interview and observation on 11/22/22 at 9:34 AM, MA A stated she was supposed to disinfect the wrist cuff monitor between resident uses. She stated she should have used bleach wipes that should have been on her medication cart. She stated that not sanitizing the wrist cuff monitor or the residents' hands could result in them getting sick with infection. During an interview on 11/22/22 at 2:57 p.m., the DON/IP stated she was responsible for most of the staff training, especially around infection control. She stated she taught, in-serviced, watched, and critiqued her staff regularly. She stated they did specialized teaching all week recently for Infection Control. She stated she monitored for compliance what people do by walking the halls and watching them. She stated she had a monitoring schedule. When asked what the schedule was, she stated it was really all the time. She stated she trained staff to sanitize the blood pressure/heart rate monitors using bleach wipes before and after each resident use, every time. She stated she expected them to let the equipment sit and dry for two full minutes. She stated she had done in-servicing and teaching specifically about that issue. She stated the potential consequences of not sanitizing the machines were cross contamination and exposure to infection. She stated that applied to every piece of equipment they used on residents. She stated she derived her guidance from the facility's infection control policy. She stated she did skills checkoffs with MA A because she was an agency nurse and was pulled off the floor. During an interview on 11/22/22 at 3:29 p.m., the ADM stated his expectation was that staff followed the infection control protocol, which was to sanitize equipment between each resident use. He stated he ensured that happened by ensuring the nurse management did in-servicing and made observations of staff performance. Policy and procedure requested on 11/22/22 from DON and none provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 19%, based on six errors out of 31 opportunities, which involved 3 of 5 residents (Resident's #13, #37, and #17) and 1 of 2 staff (MA A) observed during medication administration reviewed for medication error, in that: -MA A did not to administer Benicar (Olmesartan) one blood pressure medication, Furosemide (medication used to reduce excess fluid in the body) and Cyanocobalamin(vitamin) to Resident 13 as prescribed by the physician. -MA A did not to administer Glimepiride (medication used for blood glucose) medication to Resident #37 as ordered by the physician. -MA A did not administer Fexofenadine (medication used for allergy) and Fluticasone Propionate (medication used for allergy) to Resident #17 as ordered by the physician. These failures could place residents at risk for not receiving adequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: Resident #13 Record review of Resident #13's admission record revealed she was an [AGE] year old female, who was admitted to the facility on [DATE] with the following diagnoses: essential (Primary) hypertension (high blood pressure), vitamin deficiency, and vitamin B12 deficiency anemia due to intrinsic factor deficiency and age-related osteoporosis without current pathological fracture. Record review of Resident #13's Physician order summary report on 11/01/22 had Active Orders As Of: 09/19/2022 revealed the following orders: Benicar (Olmesartan) tablet 20 mg once a day for Hypertension Hold if SBP<100 and HR<60, start date 9/19/2022, Cyanocobalamin- cobamamide tablet sublingual 5,000- 100 mcg once a day for vitamin B12 deficiency anemia due to intrinsic factor deficiency, Order Status Active, and Order Date 08/18/2022 and Start Date 08/18/2022. Active Orders As Of: 06/20/2022 Lasix (Furosemide) tablet 40 mg once a day for hypertension, start date 06/20/22 Observation of MA A on 11/21/22 at 8:44 AM during medication administration, MA A did not administer Benicar (Olmesartan) tablet 20 mg 1 tablet, Cyanocobalamin- cobamamide tablet sublingual 5,000- 100 mcg and administered Lasix ( Furosemide) tablet 20 mg to Resident #13. Record review of Resident #13's MAR on 11/21/22 at 8:00 AM and dates 11/1/2022-11/30/2022 revealed the Benicar (Olmesartan) tablet 20 mg 1 tablet, Cyanocobalamin- cobamamide tablet sublingual 5,000- 100 mcg and Lasix ( Furosemide) tablet 40 mg was scheduled for administration 8:00 AM and had been initialed as being administered daily from 11/1/22 through 11/21/22. Resident #37 Record review of Resident # 37's admission record revealed she was an [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: vitamin deficiency, type 2 diabetes mellitus with hyperglycemia (high glucose in the blood). Record review of Resident #37's Physician's orders and Medication Administration Record dated 11/01/22 reflected an order for Glimepiride 2 mg once daily. This order had a start date of 08/08/22. Observation of MA A on 11/21/22 at 8:50 AM during medication administration, MA A administered Glimepiride 4 mg 1 tablet by mouth to Resident #37, instead of Glimepiride 2 mg as ordered by the doctor. Resident #17 Record review of Resident # 17's admission record revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: allergic rhinitis and Alzheimer's disease (memory loss). Record review of Resident #17's Physician order summary report on 11/01/22 had Active Orders As Of: 07/21/2022 revealed the following orders: Flonase Allergy ( Fluticasone Propionate) spray suspension; once a day, 2 spray in each nostril every day and Allegra Allergy ( Fexofenadine) 60 mg 1 tablet twice a day for allergic rhinitis Order Status Active, and Order Date 07/21/2022 and Start Date 07/21/2022. Record review of Resident #17's Physician's orders and Medication Administration Record dated 11/01/22 reflected an order for Flonase Allergy (Fluticasone Propionate) spray suspension; once a day, 2 spray in each nostril every day and Allegra Allergy ( Fexofenadine) 60 mg 1 tablet twice a day for allergic rhinitis. Observation of MA A on 11/21/22 at 9:00 AM during medication administration, MA A administered Flonase Allergy (Fluticasone Propionate) spray suspension; 1 spray to each nostril and Allegra Allergy (Fexofenadine) 60 mg 1 tablet was not given to Resident #17. During an interview on 11/22/22 at 12:55 PM, MA A said she was working through a nurse agency and 11/21/22 was her first day in the facility. She sorry about the error. She said she was pulled from nurses' aides to pass medication. MA A said she sometime works as nurse. MA A said she was not used to facility medication carts and she was medication aide where works full time. MA A said staff should follow the physician's orders when giving medications and the staff were responsible for checking physician's order before administration. In an interview with the DON on 11/21/22 at 1:44 PM, she said the regular MA called off that morning (11/21/22) and that was why she asked the agency MA to help. The DON said her expectation was for the staff to make sure they administered the medications according to the orders and followed physician orders. The DON stated MA A should be following the 5 rights of medication administration. Interview with the Administrator on 11/22/22 at 2:10 PM, he said he expects the nurses to give medication as ordered by the doctor. Record review of the facility's policy for Administrating Oral Medications (revised date October 2010) revealed in part . Steps in the Procedure . 8. Check the medication dose. Re-check to confirm the proper dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** One Med Room & 2 Med Carts. FACILITY Medication Storage and Labeling Based on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication room and, two of three medication carts ( 1medication room, A, B&C medication carts) reviewed for drug labeling and storage, in that: Medication cart for A Hall had 3 Fluticasone propionate nasal spray USP 50 mcg open with no date and Cetirizine Hydrochloride 5 mg 1 bottle. Medication cart for Hall B and C had 3 Fluticasone propionate nasal spray USP 50 mcg open with no date. Medication room cabinets had 2 bottles of Folic Acid expired, oral anti-diarrheal solution, and 4 Summer's Eve medicated Ph-Balanced expired. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: Observation of the medication room cabinet storage on [DATE] 10:20 AM revealed : 2 bottles of Folic Acid 800 mcg 100 tablets each expired 07/2022, oral anti-diarrheal solution expired 05/2022 and 4 Summer's Eve medicated Ph-Balanced douche expired 06/2022. Observation of the medication cart for Hall A on [DATE] at 10:27 AM revealed, 3 Fluticasone propionate nasal spray USP 50 mcg open with no date and Cetirizine Hydrochloride 5 mg 1 bottle expired 10/2022 Observation of the medication cart for Hall A and C on [DATE] at 10:27 AM revealed, 3 Fluticasone propionate nasal spray USP 50 mcg open with no date Interview with MA B on [DATE] at 10:44 AM, she said she only started working with the facility 10/2022. She said she did not know that Fluticasone propionate nasal spray was supposed to be dated after being open. MA B said Fluticasone propionate nasal sprays were already open before started working for the facility. Interview with the DON on [DATE] at 3:09 PM, she said was responsible for checking the medications for expired medication and she would be checking the medication more. DON said she will be checking the medication room and do a lot of in-services. Record review of the facility's policy titled Storage of Medications (Revised [DATE]) revealed in part .Policy Interpretation and Implementation statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy interpretation and implementation . 4. Facility should ensure that medications and biologicals that: (1) have an expired on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines, or (3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy or supplier .