Based on 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 for 1 of 120 days (8/24/24) of RN schedules reviewed for RN nurse coverage. The facility failed to ensure there were at least 8 hours of RN coverage on August 24, 2024. This failure could place residents at risk of receiving improper care in the event of an emergency and a diminished quality of life. Findings include: A record review of RN coverage for August, September, October, and November 2024, indicated on 8/24/24 there was no RN in the facility for a 24-hour period. An interview with the DON and ADM on 12/11/2024 at 11:50 AM, revealed there had not been an RN in the building on August 24, 2024. The ADM stated the facility did not have policy and procedures in place regarding RN coverage, other than the state and federal regulations. The DON stated the negative outcome of not having an RN in the facility for at least 8 consecutive hours, 7 days a week was residents who needed advanced care beyond the scope of an LVN, would not be cared for in a proper manner. In the event of an emergency, the LVN might not be equipped to handle resident needs and residents could have a decreased quality of life, due to their needs being outside the scope of practice for an LVN.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 3 (Sunset House ) medication carts observed for . The facility failed to dispose of Bisacodyl Suppositories that expired on 11-2024 in the medication cart located at the Sunset House. This failure could place residents receiving medications at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or receiving expired medications. Findings included: During an observation and interview on 12-11-2024 at 7:09 AM, of the Sunset House medication cart with LVN A, observation of middle drawer holding Bisacodyl Suppositories 10mg, expiration date 11/2024. LVN A stated she must have missed taking out the medication. LVN A took the medication out of the cart to be destroyed. During an interview on 12-11-2024 at 10:13 AM, LVN A stated that she was responsible for ensuring medication were checked and expired medications were taken out of the medication cart. LVN A stated that a possible negative outcome for having expired medications in the medication cart could cause negative symptoms for a resident. During an interview on 12-11-2024 at 10:39 AM, LVN B stated that all nurses were responsible for ensuring expired medications were disposed of and taken out of the medication cart. LVN B stated that expired medications were not effective, and it could possibly hurt the resident. During an interview on 12-11-2024 at 11:00 AM, MA C stated that all nurses were responsible for ensuring expired medications were disposed of and taken out of the medication cart. MA C stated that a possible negative outcome for giving a resident expired medication could be the medication would not be effective . During record review of facility's policy, 'Storage of Medications' (no date) revealed in part, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintain medication storage and preparation areas in a a clean, safe, and sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all foods served to residents were labeled and dated as to when they were received and/or opened. The facility failed to ensure food packaging was properly closed and not open to air. This failure could place residents at risk of food-borne illness. Findings included: An initial tour of the kitchen was conducted on 12/10/2024 at 10:22AM and the following was noted: (1) 4-pound bag dry of cheesecake filling mix-no date received. (1) 10-pound bag of tri-colored rotini-no date received. (1) partial 2-gallon zip closure bag of spaghetti noodles-no date received. (1) partial 10-pound box of cracker crumbs-no date received. (1) 36-ounce box of wild rice blend-no date received. (13) individual packages of Oreo cookies-no date received. (2) 2-pound and (1) partial 2-pound bags of fresh grapes-no date received, and no date opened. (1) whole Smokehouse Pit ham-no date received. (1) 5-oound bag of shredded cheddar cheese-no date received, and no date opened. (22) individual cups of fat free chocolate ice cream-no date received. (1) partial 10-pound bag of frozen pancakes-no date received and open to air. (1) partial 5-pound box of frozen tart pastry shells-no date received and open to air. (1) quart and (1) partial quart of heavy whipping cream-no date received, and no date opened. (1) 8-ounce container of whipped topping-no date received. (1) 16-ounce bottle of lite Italian salad dressing-no date received. (1) 9-ounce package of turkey lunch meat-no date received. (1) partial 5-ounce bag of pepperoni-no date received, and no date opened. (2) 46-ounce cans of pineapple juice-no date received. (3) 50-ounce pump containers of Coffee Mate creamer-no date received, and no date opened. Instructions on containers to discard after 30-days. An interview with the Dietary Manager on 12/10/2024 at 1:38PM revealed the negative outcome of serving foods which had not been dated or were open to air was residents could become sick if they consumed expired foods and foods could lose their nutritional value if left open to air. An interview with the Administrator on 12/11/2024 at 11:50AM revealed the facility had no policy and procedures for food handling and food safety other than the Texas Food Establishment Rules (TFER).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #13) of 12 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #13 was admitted to hospice. This failure to ensure comprehensive and accurate assessments are completed could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition. Finding include: Record review of Resident #13's face sheet dated 11-14-2023 revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements to include tremors), dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified psychosis (a mental disorder characterized by a disconnection from reality), major depression(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety(a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). Record review of Resident #13's last MDS was a quarterly completed 7-25-2023 listing her with a BIMS that was not evaluated due to memory problems and she had a functionality of requiring one to two-person assistance with all her activities. Record review of Resident #13's MDS Tracking List revealed she had an Annual MDS completed on 4-24-2023 and a Quarterly MDS completed on 7-25-2023. No other MDS's were completed between these two dates. Record review of Resident #13's 4-24-2023 annual MDS revealed the following: Section O-Special Treatment, Procedures, and Programs: Other-K. Hospice-Resident #13 is not marked for having Hospice. Record review of Resident #13's 7-25-2023 Quarterly MDS revealed the following: Section O-Special Treatment, Procedures, and Programs: Other-K. Hospice-Resident #13 is marked for having Hospice while a resident. Record review of Resident #13's Order Summary Report printed 11-16-2023 with Active Orders as of 11-16-2023 revealed the following order: Admit to Hospice-Order Date: 5-18-2023. During an interview by phone (because all MDS assessments are completed offsite by a contract company) on 11-16-2023 at 09:16 AM the MDS Coordinator reviewed Resident #13's chart and verified that a significant change of condition was not completed when hospice was ordered, that a significant change of condition should have been completed within 14 days of adding hospice when it was ordered, and that the individual responsible for completing that significant change of condition MDS no longer worked for their company so the MDS Coordinator did not know why the significant change of condition MDS was not completed. The MDS Coordinator reported that not completing the significant change of condition MDS for this resident could result in the facility not being able to track the resident's condition and care. The MDS Coordinator reported that the policy used for the required significant change of condition MDS would have been the RAI manual. During an interview on 11-16-2023 at 09:43 AM the DON with the ADON present reported that if a residents MDS is not done correctly then there will not be continuity of care. The DON reported that the ADON is currently being trained so that they will no longer need an offsite agency due to the repeated issues with MDS's not being completed correctly. During an interview on 11-16-2023 at 09:50 AM the Administrator when advised that Resident #13 did not have a significant change of condition completed 5-2023 when Resident #13 was put on hospice stated, We will get that corrected immediately. Record review of the RAI Manual October 2023 revealed the following instructions: Comprehensive Assessments: 03. Significant Change in Status Assessment (SCSA) o The ARD (Assessment Reference Date) must be less than or equal to 14 days after the IDT's (Interdisciplinary Team) determination that the criteria for an SCSA are met (determination date + 14 calendar days).

Based on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances for 9 of 12 anonymous residents reviewed for resident rights. The facility did not make prompt efforts to follow through on grievances made for staff being on the phone or proper food temperatures when served. This failure could place residents at risk of weight loss, emotional distress, and decreased quality of life. Findings Included: An observation on 11/14/23 at 10:50 AM showed [NAME] D observed in Bldg E talking to someone on the phone via a pink headset that staff was wearing on head. Residents were present after a Resident Council meeting ended in the dining room. An observation on 11/14/23 at 10:55 AM showed [NAME] D returned to kitchen in Bldg E, spoke in Spanish, tapped the left side of the pink headset. After she pressed the left side of the headset, AD provided an alternate meal order for an anonymous resident. An observation on 11/14/23 at 11:16 AM showed [NAME] F sitting at kitchen opening in Bldg G, on a stool, looking at cell phone and eating orange slices while direct care staff was redirecting a resident in the dining room. An observation on 11/15/23 at 12:25 PM, a test tray from Bldg G kitchen was served at a temperature of less than 132.8 degrees Fahrenheit. An observation on 11/15/23 at 12:32 PM, a test tray from Bldg H kitchen was served at a temperature of 141.7 degrees Fahrenheit. An observation on 11/15/23 at 12:50 PM, a test tray from Bldg E kitchen was served at a temperature of 100.9 degrees Fahrenheit. An observation on 11/16/23 at 8:35 AM showed MA B with cell phone propped up on the medication cart while passing out medications in the dining room. An observation on 11/16/23 at 1:18 PM showed [NAME] L with light blue earbuds in while working in the kitchen in Bldg H. An interview on 11/15/23 at 10:32 AM with Resident Council in Bldg E, 4 anonymous residents stated that the food could be hotter and there was too much of the same type of food. An interview on 11/15/23 at 10:32 AM with Resident Council in Bldg G, 8 anonymous residents revealed the food was terrible and some was not edible. Residents indicated that the food needed to be hotter and that there is too much rice. An interview on 11/16/23 at 10:38 AM with [NAME] I with CNA J translating. [NAME] I reported that cell phones cannot be used in front of residents and they must be used behind the facility out on the back patio. She reported that she had to sign a consent/policy for the use of her cell phone and that it had been a while and she did not remember if it was for this facility of the old facility that she used to work at. She reported that if she uses a cell phone if front of residents or at the incorrect time then she will get into trouble. She could not think of any other consequences of misusing cell phones. An interview on 11/16/23 at 10:44 AM with [NAME] K who reported that she is only to use her cell phone on break, that she has received no training on the use of cell phones at this facility, that she did sign a consent/policy when at her old facility, and that she received verbal training from DD. She reported that there would be no negative outcomes for using her cell phone during working hours or in front of a resident. An interview with DD on 11/16/23 was requested on 11/16/23 with [NAME] I and [NAME] K. Interview with DD was not obtained. Record review of Resident Council Minutes dated 9/11/23, 10/2/23, and 11/6/23 revealed that food was not being served hot. Record review of Resident Council Minutes dated 9/11/23, 10/2/23, and 11/6/23 revealed that cooks and CNA's were on their phones a lot. Record review of policy Cell Phone Usage by Employees, not dated, stated: POLICY: Employees of the facility shall not have on their person, nor shall they use personal cell phones in resident areas. PERSONNEL: This policy pertains to all facility employees. Policy stated that while on duty, employees shall keep their cell phones in their vehicle, in the employee break room, in their office or in their locker. Employees may use their personal cell phones while on break in these areas. Record review of Checking Temperatures of Food Received from the Main Kitchen, not dated, stated 1: the temperature of hazardous food prepared in the main kitchen for households will be checked and the temperature recorded. 3: any hot food found to be below 140 degrees Fahrenheit will be reheated for 165 degrees Fahrenheit for 15 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete a MDS assessment every 92 day or within a timely manner for 3 (Residents #12, #18, and #37) of 12 residents reviewed for MDS assessments The facility failed to initiate a MDS assessment or complete an MDS assessment within 14 days after the ARD date for Residents #12, #18 and #37. This failure can place residents at risk of proper needs not being met, quality of care, assistive devices, and accuracy of assistance needed with activities of daily living. Findings included: Record review of Resident #12's face sheet, dated 11/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Polyosteoarthritis (multi joint disease), hyperkalemia (high potassium levels in the blood), major depressive disorder, and chronic kidney disease. Review of Resident #12's MDS assessment, dated 5/15/23, showed a completion date of 5/31/23 (more than 14 days) and a MDS assessment dated [DATE] showed a completion date of 8/21/23. Record review of Resident #12's care plan, dated 11/8/23 shows a MDS assessment was not completed for the assessment. Record review of Resident #18's face sheet, dated 11/14/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, and weakness. Record review of Resident #18's MDS assessment, dated 7/10/23, revealed a completion date of 7/26/23 (more than 14 days). Record review of Resident #37's face sheet, not dated, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #37's admitting diagnoses is congestive heart failure. Record review of Resident #37's MDS assessment, dated 10/1/23, revealed a completed date of 10/25/23 (more than 14 days). In an interview on 11/5/23 at 2:19 PM, ADON indicated MDSN oversees MDS assessments and ADON and DON oversee care plans. In an interview on 11/15/23 at 2:22 PM with MDCN revealed she oversees MDS assessments. MDCN stated that she goes through each resident individually to set a schedule. MDCN stated she has 14 days to complete the care plan and it is completed when a RN signs it. Confirmed Resident #37's MDS assessment was late. MDCN indicated that a negative outcome is not having the proper things care planned. In an interview on 11/15/23 at 2:33 PM, ADON confirmed Resident #37's MDS assessment, dated 10/2/23 with a completed date of 10/25/23, was more than 14 days. ADON stated that a negative outcome was it could affect the resident's care. Record review of the RAI dated 10/1/23, under Chapter 2: Assessments for the RAI, pg 2-17, RAI OBRA-required Assessment Summary chart shows an admission assessment is to be completed on the 14th calendar day of a resident's admission. Pg 2-18 revealed a quarterly assessment must be completed ARD +14 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on , interviews, and record reviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 7 (Residents #1, #3, #11, #12, #18, #25, and #37) of 12 residents reviewed for care plans. Residents #1, #3, #11, #12, #18, #25, and #37 did not have a comprehensive care plan completed 7 days after a comprehensive assessment. This failure places residents at risk for substandard quality of care, accuracy of needs, and assistance with activities of daily living. Findings included: Record review of Resident #1's face sheet, dated 11/16/23, revealed an [AGE] year-old female who was admitted to the facility originally on 2/17/2020 and readmitted [DATE]. Diagnoses included Dementia, major depressive disorder, type 2 diabetes, and epilepsy. Record review of Resident #1's MDS assessments revealed completion dates of 3/9/23, 6/4/23, and 8/27/23. MDS assessment dated [DATE] corresponded with a care plan completed on 3/20/23. MDS assessment dated [DATE] corresponded with a care plan completed on 6/20/23. MDS assessment dated [DATE] corresponded with a care plan completed on 9/14/23. Record review of Resident #3's face sheet, dated 11/16/23, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Diagnoses include Alzheimer's Disease, hypertension, and chronic heart failure. Record review of Resident #3's MDS assessment, completed 4/11/23, revealed a corresponding care plan dated 5/3/23. This revealed the care plans were completed more than 7 days after the comprehensive assessments. Record review of Resident #11's face sheet, dated 11/14/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Dementia, psychophysiological insomnia, delusional disorders, and post-traumatic stress disorder. Record review of Resident #11's MDS assessments and care plans revealed completion dates of 2/26/23, 6/4/23, and 8/23/23. MDS assessment on 2/26/23 had a corresponding care plan with a completed date of 3/20/23. MDS assessment on 6/4/23 had a corresponding care plan with a completed date of 6/20/23. MDS assessment dated [DATE] had a corresponding care plan with a completed date of 9/22/23. This revealed the care plans were completed more than 7 days after the comprehensive assessments. Record review of Resident #12's face sheet, dated 11/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Polyosteoarthritis (multi joint disease), hyperkalemia (high potassium in the blood), major depressive disorder, and chronic kidney disease. Review of Resident #12's MDS assessments and care plans revealed completion dates of 5/31/23 and 8/21/23. MDS assessment completed on 5/31/23 revealed a corresponding care plan dated 5/3/23 indicating the care plan was completed before the comprehensive assessment. MDS assessment completed on 8/21/23 revealed a corresponding care plan completed on 7/31/23 indicating the care plan was completed before the comprehensive assessment. Record review of Resident #18's face sheet, dated 11/14/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, and weakness. Record review of Resident #18's MDS assessments and care plans revealed completion dates of 1/20/23, 4/23/23, and 7/26/23. MDS assessment completed on 1/20/23 revealed a corresponding care plan dated 2/22/23. MDS assessment completed 4/23/23 revealed a corresponding care plan dated 5/22/23. MDS assessment completed on 7/26/23 revealed a corresponding care plan dated 8/23/23. This revealed the care plans were completed more than 7 days after the comprehensive assessments. Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted to facility on 5/20/21. Diagnoses include Combined systolic and diastolic heart failure, depression, and atrial fibrillation. Record review of Resident #25's MDS assessments revealed completed assessments on 12/9/22, 3/9/23, 6/12/23, and 9/7/23. MDS assessment completed on 12/9/22 revealed a corresponding care plan dated 12/7/22. MDS assessment completed 3/9/23 revealed a care plan dated 3/20/23. MDS assessment completed 6/12/23 revealed a corresponding care plan dated 6/20/23. MDS assessment completed 9/27/23 revealed a corresponding care plan dated 9/22/23. This revealed that care plans were completed prior to the completion of the comprehensive assessment or more than 7 days after the comprehensive assessment was completed. Record review of Resident #37's face sheet, not dated, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #37's admitting diagnoses is congestive heart failure. Record review of Resident #37's MDS assessment and care plan revealed the MDS assessment completed on 10/25/23 revealed a corresponding care plan dated 10/1/23 indicating the care plan was completed prior to the comprehensive assessment. In an interview on 11/15/23 at 2:19 PM, ADON indicated MDSN oversees MDS assessments and ADON and DON oversee care plans. In an interview on 11/15/23 at 2:33 PM with ADON and DON indicated the care plan is completed within 48 hours. ADON stated she believes the care plan is done 72 hours after assessment. DON stated that the care plan must be completed by 7 days via policy. ADON confirmed it was a completed date of 10/1/23 for Resident #37. ADON indicated the MDS was completed 10/25/23. DON looked at policy and stated the care plan goals are pulled from but not limited to MDS, prior assessments, etc. DON stated care plan is pull from a thorough assessment including the MDS. ADON confirmed the care plan was dated prior to MDS assessment completion. ADON confirmed dates of care plans for Resident #25 and stated the dates were not 7 days after the comprehensive assessments. ADON stated a negative outcome is it can affect the resident's care. DON stated it can affect the resident's care. Record review of facility policy titled Care Plans- Comprehensive, not dated, states: 2. The comprehensive care plan is based on a thorough assessment that includes but is not limited to, the MDS. 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 4 (Prairie House medication room, Cottonwood House medication room, Cottonwood House medication cart, and Sunset House medication room) of 6 medication storage areas reviewed for medication storage. The Prairie House Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Sunset Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication cart contained 3 insulin pens that had no medication labels. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: Record review of the Prairie House Household Medication room refrigerator log for November 2023 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 11-6-2023-32 degrees Fahrenheit 11-7-2023-30 degrees Fahrenheit 11-11-2023-26 degrees Fahrenheit 11-12-2023-26 degrees Fahrenheit 11-14-2023-26 degrees Fahrenheit During an observation on 11-15-2023 at 08:31 AM of Prairie House Household Medication room refrigerator with LVN A present were the following: 2-Lantus Insulin bottles (manufacturer recommended storage between 36-46 degrees). 1-Humalog Insulin bottle (manufacturer recommended storage between 36-46 degrees). 1-Acetaminophen suppository box (with instructions to store between 68-77 degrees). 1-Bisacodyl suppository box unopened (with instructions to store between 68-77 degrees) During an interview on 11-15-2023 at 08:34 AM LVN A verified the current temperature in the Prairie House Household medication storage refrigerator was 42-43 degrees, that night shift is responsible for monitoring the refrigerator temperatures, and that several temperatures this month had been documented below freezing. LVN A reported that the medications in the Prairie House Household Medication room refrigerator such as Acetaminophen and Bisacodyl needed to be stored at room temperature, that if any of the medications currently present in the refrigerator were to freeze, they would not be affective, and they could affect resident treatment and condition. Record review of the Cottonwood Household Medication room refrigerator log for November 2023 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 11-1-2023-26 degrees Fahrenheit. 11-3-2023-32 degrees Fahrenheit. 11-4-2023-32 degrees Fahrenheit. 11-11-2023-28 degrees Fahrenheit. 11-14-2023-26 degrees Fahrenheit. During an observation on 11-15-2023 at 08:46 AM of the Cottonwood Household Medication room refrigerator the following were observed: 1-Tuberculin diluted apiol (with instruction to store between 36-46 degrees) 2-Lantus insulins (with instructions to store between 36-46 degrees) 1-NovoLog flex pen (with instructions to store between 36-46 degrees) 1-Flu vaccine syringe (with instructions to store between 36-46 degrees) 1-Bisacodyl suppository box (with instructions to store between 68-77 degrees) 1-Promethazine suppository (with instruction to store in refrigerator. Do not freeze) 1-Enbrel (with instructions to store between 36-46 degrees) 4-Basaglar Insulin pens (with instructions to store between 36-46 degrees) 2-NovoLog pens (with instructions to store between 36-46 degrees) During an interview on 11-15-2023 at 09:33 AM MA B verified that the medications that were stored in the Cottonwood Household Medication room refrigerator were documented below freezing by the night shift and MA B reported that if a medication was frozen it would reduce the strength of the medication and it would not be as effective, MA B said that it could and would affect the residents care and the residents would not receive the right dose, or it would be less effective. Record review of the Sunset Household Medication room refrigerator log for November 2023 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 11-4-2023-28 degrees Fahrenheit 11-14-2023-32 degrees Fahrenheit During an observation on 11-15-2023 at 08:46 AM of the Sunset Household Medication room refrigerator the following was observed: 1-Acetaminophen suppository box (with instructions to store between 68-77 degrees). During an interview on 11-15-2023 at 09:33 AM LVN C verified that the medication that was stored in the Sunset Household Medication room refrigerator was documented at below freezing by the night shift and reported that if a medication were to be frozen or stored below the temperature it was listed to be stored at then that medication would not be as effective. LVN C reported that freezing the Acetaminophen medication in the refrigerator would not give residents their needed benefit, that the Acetaminophen would not be effective. During an observation on 11-15-2023 at 11:07 AM of the Cottonwood Household Medication Cart with LVN A noted were 1-Novolog N insulin pen, 1-Novolog R inulin pen, and 1-Basaglar Insulin pen. Upon review it was noted that there was no medication label information on any of the three insulin pens. Noted was the last name handwritten in marker of the resident on the Basaglar Insulin pen. None of the three insulin pens contained the prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration. During an interview on 11-15-2023 at 11:11 AM LVN C verified that there was no resident information on the three insulin pens that were on the Cottonwood Household Medication Cart. LVN C said that if a new nurse or an agency nurse was to administer the insulin, they could have difficulty telling who the insulin is for, and that she (LVN C) was aware of who the insulin was for because she had worked with the residents for awhile. LVN C stated, I see where someone new could give the wrong insulin. During an interview on 11-16-2023 at 09:39 AM the DON reported that the recommended storage temperature in the medication room storage refrigerator is 36-46 degrees. The DON said that if the temperature is out of that range, then it needs to be reported immediately The DON said that if a medication is stored outside the ranges that that medication is listed for then that medication would need to be discarded. The DON reported that if a medication is stored outside of the recommended ranges, then that could affect the medications potency, and the residents may or may not get the appropriate mediation. The DON verified that this could affect resident care. The DON reported that all current refrigerator medication thermometers have been replaced and all the medications that were stored had been discarded. The DON reported that if a medication is not labeled correctly then a medication error could result and there could be potential harm to a resident. Record review of the facility provided polity titled, Storage of Medication undated, revealed the following: Policy Statement- The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation- 3. Drugs container that have missing, incomplete, improper, or incorrect label shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secure location. Record review of the facility provided polity titled, Labeling of Medication Containers undated, revealed the following: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulation. Policy and Interpretation: 2. All medication packaging or container that are inadequately or improperly labeled shall be returned to the issuing pharmacy 3. Labels for individual drug containers shall include all necessary information, sch as: a. The Resident name b. The prescribing physician name c. The name, address, and telephone number of the issuing pharmacy d. The name, strength, and quantity of the drug e. The prescription number f. The date the medication was dispensed. g, Appropriate accessory, and cautionary statements

Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 4 kitchens observed. Staff members failed to practice hand hygiene between plates during lunch service and wear hairnets while in the kitchen. This failure can place residents at risk for infection and cross contamination. Findings included: The following actions were observed in Bldg H: Observation on 11/14/23 at 12:03 PM: CNA D who completed hand hygiene touched scrubs, hair, and face, then delivered plates to residents in the dining room. Observation on 11/14/23 at 12:08 PM DON and CNA D delivered plates with no ABHR or hand washing. Observation on 11/14/23 at 12:09 PM DON delivered another plate, no ABHR; CNA D touched resident chair and clothing. Did not use ABHR prior to delivering food. LVN C touched chair and delivered plate without using ABHR. Observation on 11/14/23 at 12:09 PM CNA D delivered plate to resident. CNA D touching glasses and face then delivered food to resident without practicing ABHR. Observation on 11/14/23 at 12:13 PM CNA D did not use ABHR and delivered food to resident. LVN C touched plate of other resident with chair; delivered to food to resident. No hand hygiene practiced. Observation on 11/14/23 at 12:14 PM CNA D grabbed chair, no ABHR and proceeded to help resident with lunch. Observation on 11/14/23 at 12:15 PM: LVN C grabbed chair from the other dining room then delivered plate to resident. LVN C touched clothing and chair then assisted with meal. No hand hygiene practiced Observation on 11/14/23 at 12:19 PM revealed no hand sanitizer located in either dining room. Observed on 11/15/23 at 10:29 AM, CNA F an individual walk out of the kitchen with no hair net in place. An interview on 11/15/23 at 11:37 AM with DM indicated staff CNA F brought chili to the facility but did not enter kitchen. Observation on 11/15/23 at 3:37 PM, ADM picked up test tray from common room and delivered it to the kitchen. ADM was not wearing a hair net. Observation on 11/16/23 at 1:28 PM, CNA F entered the kitchen area of Bldg H without a hairnet. An interview on 11/16/23 at 1:31 PM with LVN C revealed that hand hygiene should be done between each plate. LVN C indicated staff receives training on it once a year. LVN C stated a negative outcome is things can transfer from resident to resident. An interview on 11/16/23 at 1:34 PM with CNA F revealed that she should wear a hairnet in the kitchen. CNA F was unable to say when her last training was. CNA G stated that Admin or dietary oversees training. CNA F stated a negative outcome could be it would have her hair or germs on the food. An interview on 11/16/23 at 1:39 PM with CNA J revealed the needs to use ABHR between every plate. CNA J indicated she did not receive training at the facility but when she worked at the hospital as a cook. Stated a negative outcome could be contamination. Record review of Employee Sanitary Practices, dated 2013, states the policy is for all kitchen employees with practice standard sanitary procedures. Record review of policy Food Safety and Sanitation, dated 2013, states: 2. b. All staff are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes. o Hair restraints are required and should cover all the hair on the head. Record review of policy titled Hand Hygiene, not dated, states: 2. Alcohol based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water are not indicated per #1 above). According to the World Health Organization, hand hygiene is to be performed: o A- Prior to caring for a resident. o E- after contact with the resident environment. 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: o D- Before and after assisting a resident with meals.