**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right to be free from Misappropriation of Resident Property for 6 of 18 residents (Resident #'s 1,2,3,4,5, and 6). 1.The facility failed to prevent the misappropriation of bottle of megace (Resident #1) and (Resident #4), card of Zofran (Resident #5) and (Resident #3), card of Pantoprazole (Resident #6), card of montelukast (no legible name), Nystatin, Xyzal (no legible name), card of Flexeril (no legible name), (CMA H) removed the medication from the nurses' cart, without authorization, for personal gain. 2. The facility failed to ensure that Resident #2 was not subject to financial misappropriation or exploitation from Housekeeper A from the time period 2/11/2025 to 2/17/2025. Housekeeper A accepted cash in the amount of $60 from Resident #2. The noncompliance was identified as PNC. The past noncompliance began on 2/11/25 and ended on 4/4/25. The facility had corrected the noncompliance before the investigation began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident funds and drug diversion. Findings Included: 1. Record review of Resident #1's Face Sheet dated 3-21-25 revealed a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of Alzheimer's (progressive disease that destroys memory and other important mental functions), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), type 2 diabetes mellitus with diabetic polyneuropathy (complication of diabetes mellitus (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers) and essential hypertension (high blood pressure). Record review of Resident # 1's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 0 indicating Resident #1 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #1 was unable to voice any pain concerns. Record review of Resident #1's Care Plan dated 10-24-24 indicated Resident #1 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain: Location, Severity, on a scale of 1-10, type and frequency; discuss with resident factors that precipitate pain and what may reduce it; administer pain medications as ordered; discuss with resident the need to request pain medications before pain becomes severe; discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record Review orders dated 11/23/2024 indicated Resident #1 was prescribed Megace for weight loss. Record review of Resident #3's Face Sheet dated 3-21-25 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), cognitive communication deficit (the inability to think of the correct word), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), hypothyroidism (thyroid gland doesn't make enough thyroid hormone), GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure). Record review of Resident # 3's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 9 indicating Resident #3's cognition was moderately impaired. The pain assessment frequency indicated resident was occasionally in pain. Record review of Resident #3's Care Plan dated 10-24-24 indicated Resident #1 had potential for pain and was at risk for Injury from Decrease in ADLs. The care plan interventions included discuss with resident factors that precipitate pain and what may reduce it; Administer pain medications as ordered; Discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain; Monitor for potential side effects of pain medication and discuss with resident the need to request pain medications before pain becomes severe. Record Review orders dated 11/22/24 indicated Resident #3 was prescribed Zofran for nausea and vomiting. Record review of Resident #4's Face Sheet dated 3-21-25 revealed a 81-yer-old male who admitted to the facility on [DATE] with a primary diagnosis of hypotension (low blood pressure), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) and cognitive communication deficit (the inability to think of the correct word). Record review of Resident # 4's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 5 indicating Resident #1 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #4 did not have any pain concerns. Record review of Resident #4's Care Plan dated 3-12-25 indicated Resident #4 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain; Discuss with resident factors that precipitate pain and what may reduce it; Administer pain medications as ordered; Discuss with resident the need to request pain medications before pain becomes severe; Discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record Review orders dated 2/19/25 indicated Resident #4 was prescribed Megace for weight loss. Record Review orders dated 7/18/24 indicated was Resident #6 prescribed Pantoprazole for morning indigestion. Record review of Resident #5's Face Sheet dated 3-21-25 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to cognitive communication deficit (the inability to think of the correct word), GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure). Record review of Resident # 5's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 5 indicating Resident #5 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #5 was did not indicate any pain concerns. Record review of Resident #5's Care Plan dated 6-21-24 indicated Resident #5 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain: Location, Severity, on a scale of 1-10, type and frequency; discuss with resident factors that precipitate pain and what may reduce it; administer pain medications as ordered; discuss with resident the need to request pain medications before pain becomes severe; discuss with physician that for maximum pain relief pain medication are best given. around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record Review orders dated 8/1/24 indicated Resident #5 was prescribed Zofran for nausea and vomiting. Record review of Resident #6's Face Sheet dated 3-21-25 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar and essential hypertension (high blood pressure). Record review of Resident # 6's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 0 indicating Resident #6 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #6 was having pain frequently. Record review of Resident #6's Care Plan dated 9-9-24 indicated Resident #6 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain; discuss with resident factors that precipitate pain and what may reduce it; administer pain medications as ordered; discuss with resident the need to request pain medications before pain becomes severe; discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record review of facility's in-service training dated 3/28/25 revealed 35 employees (12 LVN's, 20 CNA's, 8 RN's, 4 CMA's, 1 Administrator) were trained by the abuse coordinator on drug storage: all discontinued medication or medications to be destroyed. Record Review of intake investigation worksheet dated 3/28/25 at 10:00 a.m., Narrative of The Incident: Received phone call from investigator for confidential District Attorney's office. He said he was at CMA H's house and wanted to know if we were missing any meds because he had multiple drugs they had found there while searching the home. He named off multiple prescription drugs that were found. He named off the identified names that were former residents here with what drug their name was on. (He also had names that were not residents here). Actions and Notifications: CMA H's was suspended pending investigation. Dr was notified. Police Officer said he would get a police report number for us. All residents listed were deceased and no meds were narcotics that are counted. Resident #1-megace; Resident#4-Megace; Resident #5-Zofran; Resident#6-pantoprazole; Resident #3-Zofran. -Ombudsman notified. Record Review of typed note located inside the Provider investigation packet dated 3/28/25 at unknown time indicated, on 3/28/25 the Administrator received a phone call from investigator with confidential District Attorneys' office. He told me that he was at CMA H's house and wanted to know If she worked for us. I told him that she did work for us as a medication aide, and he asked if we had any medications missing. I told him that I was not aware of any medications that were missing. He said that he had found numerous cards and bottles of medications and wondered if she was getting them here. He told me that he had the following: 1. Bottle of megace with Resident #1's name, 2. Bottle of megace with Resident #4's name, 3. Card of Zofran with Resident #5's name, 4.Card of Zofran with Resident #3's name, 5. Card of Pantoprazole with Resident #6's name, 6. Card of montelukast with no legible name, 7. Nystatin with no legible name, 8. Xyzal with no name, 9. Card of Flexeril with no legible name, 10. Multiple OTCs, 11. One med with patient name someone else outside of the facility, 12. One med with patient name someone else's name. The Administrator wrote, I informed him that Resident #1, Resident #4, Resident #5, Resident #3 and Resident #6 were all previous patients here and all had passed away here. I told him that the medications would not be meds that we would count shift to shift as they were not narcotics, but that I could not recall any of these meds being an issue with not having with these patients and that I suspected that the meds were probably taken after they passed away. CMA H was arrested on 3/28/25 and therefore, suspended, pending outcome of this investigation. Medical Director was notified by DON. The pharmacist was notified by the DON. Results of the investigation indicated CMA H's was terminated for theft of medications. Ombudsman was notified by myself; Human Resources was notified of the allegation and previous disciplinary actions for attendance. The med carts were checked to ensure all current residents had their medications and there were no concerns found with meds being missing. A Narcotic count was done to ensure that all narcotic counts were correct and there were no concerns found. A list of current residents on the above meds was made and reviewed for any indications that they are not receiving their meds as ordered. There were no concerns noted by the DON. An in-service was conducted on clear bag policy and not having any personal bags in the med room. An additional in service was conducted on process to follow when drugs are discontinued or a resident pass away. Further investigation will be completed by DON in my absence. On 4/4/25 the investigation was completed, and CMA H was terminated. Record Review of the police incident report dated 3/28/25 at 11:11 am indicated, CMA H was facing multiple charges including 1. Possession of Controlled Substance, 2. Possession of Controlled Substance, 3. Forgery Financial Instrument, 4. Possession of Dangerous Drug and 5. Possession of Marijuana Record Review of in-services was reviewed on 5/20/25 at 10:22 a.m.; Ex Employee CMA H's was last in-service on abuse and neglect on 9/20/24. Record Review of the grievance log was reviewed on 5/20/25 at 10:35 a.m. and found no issues from December 2024 to May 2025. Record Review of the Drug and medication carts audits conducted by the Administrator and DON on 3/28/25 at 3:15 p.m., revealed all medications were accounted for. During an interview on 5/20/25 at 12:16 p.m., CMA B stated she had been employed since 2023. CMA B stated she had been in-service on misappropriation recently but did not know when her last in-service on misappropriation was last completed. CMA B stated it had not been too long ago since her last most recent in-service on misappropriation. CMA B stated she had never taken money from a resident. CMA B stated the abuse coordinator was the Administrator. CMA B stated if the medication was narcotics that she would let the DON take the medication off the cart. CMA B stated if the medication was not a narcotic then it's in a locked cabinet in the med room that the medication would be discarded in. CMA B stated the DON would discard the medication in the lock box. CMA B stated she had never logged or documented medication disposal. CMA B stated she was not sure if the DON documented medication disposal. CMA B stated the DON was responsible for removing and securing mediations that were no longer in use. CMA B stated the facility did not return medication to the pharmacy instead the medications would be disposed of at the facility. CMA B stated the designated area for disposing of medication would be the medication room. During an interview on 5/20/25 at 12:26 p.m., LVN C stated when a resident passed away or was discharged that medication was pulled from the cart. LVN C stated the nurses would pull the mediation from the carts. LVN C stated if the medication was a narcotic that she would get the DON who would be the one to remove the mediation off the carts. LVN C stated she would look at the count sheet, the nurses would make sure the count sheet was corrected and the DON would take the medication along with the count sheet and locked her office in her closet that was triple locked. LVN C stated if she found medication that were not labeled or appeared to be expired that she would put the medication in a destruction box located in the medication room. LVN C stated the designated area for medication disposal was the medication room. During an interview on 5/20/25 at 12:44 p.m., CNA E stated she had been employed at the facility for 5 or 6 years. CNA E stated she did not quite remember when her last in-service on abuse and neglect, but it might had been last month. CNA E stated she had so many in-services each month. CNA E stated she did not handle drug destruction or administering medication. During an interview on 5/20/25 at 12:48 p.m., CNA F stated she had been employed at the facility for 2 years. CNA F stated she was in serviced on misappropriation this month (May 2025). CNA F stated the Administrator was the abuse coordinator. CNA F stated the process for handling the medication that was not a narcotic was first she would put the medication inside a lock box in the medication room and let the DON know the medication was discarded in the locked cabinet. CNA F stated if the medication was a narcotic medication that she would count down the medication and write the number of pills left on the count sheet and let the DON know and the DON would remove the narcotic from off the carts. CNA F stated she did not return anything to the pharmacy instead the DON would dispose of the mediation at the facility. CNA F stated if she found medication that was not labeled or expired that she would let the DON know and have the DON to take the medication off the cart. CNA F stated the designated area for drug destruction was the medication room. During an interview on 5/20/25 at 1:03 p.m., LVN G stated she had been employed at the facility for 8 years. LVN G stated in-services on misappropriation was completed recently about a month ago. LVN G stated the abuse coordinator was the Administrator. LVN G stated she normal did not handle drug destruction. LVN G stated if a mediation had not been opened and needed to be returned to the pharmacy, then the pharmacy may pick up the medication. LVN G stated if the medication had been opened and was no longer needed by the resident that the medication would be destroyed by the DON. LVN G stated the DON destroyed medication at the facility. LVN G stated if she found mediation that were not labeled or expired that she gave medications to the DON. LVN G stated the medication room was the dedicated room for mediation disposal. LVN G stated the DON would be responsible for securing medication especially if it was a narcotic medication. During an observation and interview in the medication room on 5/21/25 at 11:30 a.m., with RN K the following were observed: Narcotics were locked in lock box located in the refrigerator; there was no observation of personal bags; there was a locked cabinet with a small hole at the top for placing non-narcotic medications inside for destruction. During an interview with RN K, RN K stated all expired or discontinued medication were to be given to the DON. RN K stated the med aide were to let the DON know that they had expired/discontinued medication and place the expired or discontinued medication inside the locked cabinet to be discarded by the DON. RN K stated the DON was the only person with the keys to the lock box for the narcotics. RN K stated there had never been a time when non-narcotic medication was placed on the countertop and not inside the locked cabinet. RN K stated in-services was last completed a few months ago on drug diversion. RN K stated the DON, and the charge nurses were the only one with the keys to non-narcotic locked cabinet locked in the medication room. During an interview on 5/21/25 at 12:00 p.m., the DON stated if the medication was not a narcotic then medication would go inside the lock cabinet under the counter. The DON stated once the medication was there then she would send the medication back for a possible refund and or to destroy the medication. The DON stated if the medication was a narcotic then she would get the medication off the cart. The DON stated when she received the medication, she verified the medication on the count sheet and lock up the medication in her file closet located in her room. The DON stated her file closet was triple locked. The DON stated herself and the charge nurses were responsible for removing and securing medications that are no longer in use. The DON stated she secured the drugs for resident that passed away or have been sent to the hospital by taking the medication out of the cart and putting the medication in the lock cabinet in the medication room. The DON stated she monitored the non-narcotic drug by conducting cart audit weekly. The DON stated during morning meeting if someone had passed away or was discharge, that she would go to the carts and pull the medications off the cart. The DON stated this process was the same for discontinued medications as well. The DON stated she kept a logbook for pharmacy for medication that were able to be returned to the pharmacy. The DON stated if there was medication that was not labeled or expired then the medication would go into the disposal lockbox. The DON stated she had not ever witnessed staff bringing bags into the medication room. The DON stated prior to this incident staff had been putting expired drugs on to the countertop and not inside the locked cabinet. The DON stated the process now was any drug that was not narcotic were to go inside the locked cabinet. The DON stated her and the ADON would follow up to make sure the medication was removed from the cart and placed in the locked cabinet. The DON stated the med aide, ADON, nurses and herself had a key to the medication room. The DON stated she had no clue regarding the medication found in CMA H's home was missing from the facility. The DON stated she check the medication room in the morning before the meeting and after the meeting she checked the carts to make sure everything was off and once a week she conducted audits. The DON stated it was important to ensure the medication was properly disposed of because the medication belonged to that resident, and it was important for safety. During an interview on 5/21/25 at 12:24 p.m., The Administrator stated the process for handling narcotics was that the narcotics stayed on the cart until the medication could be passed directly to the DON. The Administrator stated the process for handling non narcotics was the non-narcotics were to be placed in the locked cabinet for the DON to destroy. The Administrator stated the DON was responsible for removing and securing medications that were no longer in use. The Administrator stated she monitored the drugs at the facility by monitoring the drug destruction logs every month. The Administrator stated the facility was in the process of putting a camera inside the medication room. The Administrator stated in the past staff were not putting the expired or discontinued medication in the locked cabinet. The Administrator stated since the in-services on misappropriation that staff have gotten better with properly discarding the medications and no medications were found to be left on top of the countertop. The Administrator stated the drugs found in CMA H home were drugs that was on CMA H medication cart. The Administrator stated that she believed CMA H removed the medications from her medication cart and took the medications that she wanted and then put the medications that she did not want in the locked cabinet in the medication room. The Administrator stated the nursing staff had the keys to the medication room. The Administrator stated the DON had the keys to the locked cabinet in the medication room. The Administrator stated she conducted random checks on the medication carts. The Administrator stated she checked the narcotic medication quite a bit. The Administrator stated during her checks she made sure the residents were getting their medication and the medications were still at the facility. The Administrator stated to prevent this from happening again she conducted in services on drug destruction process, the facility will install a camera in the medication room, and she checked the medication room daily. The Administrator stated it was important for the medication to be disposed of properly so that no one who did not need them got ahold of the medications that they were not prescribed. The Administrator stated if staff found medication that was not labeled or was expired that the non-narcotic medication was to be discarded in the locked cabinet. The Administrator stated if the medication was a narcotic, it was to stay on the cart and was counted shift to shift until the medication could be personally handed off the DON. During an attempted phone call on 5/22/25 at 7:53 a.m., CMA H was unavailable for an interview; voicemail left for a return phone call. During a return phone call interview on 5/22/25 at 9:49 a.m., CMA H stated she was to dispose of medication that was expired or no longer in use in the locked cabinet in the medication room. CMA H stated if she did not have any money for her blood pressure medication and the resident was expired then she took the medication home that was to be discarded and take it home for herself. CMA H stated she was not allowed to take narcotics from the facility. CMA H stated the facility was not going to do anything but throw the medication away. CMA H stated every medication that was taken and found in her home was not a narcotic medication. CMA H stated she was in-service on misappropriation at another facility. CMA H stated the medication she took from the facility was just set on the countertop and she took the mediation off the top of the countertop and place in her personal bag. CMA H stated the medication was never in the lockbox. CMA H stated she had a personal clear bag in the medication room. CMA H stated multiple staff were bringing in personal bags and lunch bags inside the medication room. CMA H stated every employee took bags in the medication room. CMA H stated she had nothing else to add to this intake. 2. Record review of Resident #2's face sheet dated 05/20/2025 revealed the resident was a [AGE] year-old female admitted on [DATE]. The resident's diagnoses included: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), cognitive communication deficit (the inability to think of the correct word), dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining).) and essential hypertension (high blood pressure). Record review of Resident #2s admission MDS dated [DATE] revealed a BIMS score of 11, indicating the resident was moderately cognitively impaired. Record review of Resident #2's comprehensive care plan, accessed on 11/07/2024, revealed the Resident has impaired cognitive function or impaired thought processes; Res has cognitive loss (loss of memory, time sense and requires assistance with decision making) Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression Dementia. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness; Cue, reorient and supervise as needed; Discuss concerns about confusion, disease process, NH placement with resident/family/caregivers) and Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Record Review of intake investigation worksheet dated 2/11/25 at 3: 45 p.m., indicated, Narrative of The Incident: Met with, RP of Resident #2, who said that Resident #2 said she had given a staff member some money to get her a vape to keep in her room but did not get the vape. I followed up & met with Resident #2 who said that she had given Housekeeper A in housekeeping some money to get her a vape and some other things, but that Housekeeper A is no longer here because of car trouble and I just chalk that one up to being stupid for giving her money. She could not recall how much money; however, the of Resident#2 report she told her $60; Actions and Notifications: Housekeeper A no longer works here. Self-terminated 1/14/25. Family and MD have been notified. $60 replaced. Pending report to confidential Police Department (waiting for them to come out and take report). Ombudsman notified. Record Review of the Provider investigation Report dated 2/11/25 at 4:36 p.m., indicated, of resident #2, met with admin on 2/11/25 and said that Resident #2 told her (Administrator) that she (Resident #2) gave some money to a staff member who is no longer here to get her some items but that she no longer works here and never got the items. Resident #2 said that she thought it was $60 but could not recall exactly or when it happened. Met with Resident #2 who told me (Administrator) that she had given money to Housekeeping A in housekeeping but said that something was wrong with her car and changed Jobs and has not been back. She (Resident #2) could not recall how much money she had given her (Housekeeper A). I (Administrator) told her that I (Administrator) was going to replace the money and she (Resident #2) said that she did not need it replaced but instead chalked it up as not trusting anyone to give money to for things. I (Administrator) told her that she (Resident #2) could give money to myself or to the activity director, but that I (Administrator) really preferred she not give it to anyone else to get items. She (Resident #2) agreed. Had her (Resident #2) sign that she (Resident #2) received $60, and it was given to her to keep. Life Satisfaction rounds were conducted with no further issues noted. Housekeeper A self-terminated on 1/14/25. She (Housekeeper A) had started work on 11/21/24. Have been unsuccessful in attempts to reach Housekeeper A for her statement. Record Review of written note by the Administrator dated from the Provider investigation report dated on 4/15/25 at unknown time indicated the Administrator received call from Housekeeper A, Saying that the police contacted Housekeeper A and she could be spending 2 years in jail. Housekeeper A said that she took the money-which she said was $40 and bought Resident #2 socks and laundry detergent and that she did bring them to her. Housekeeper A asked if she could bring $60 to us and it be taken care of that way. I told her that was between her and the police. Housekeeper A said she would contact them and then if okay, she would have her r bring us the money because she was now out of state. Record Review of in-services was reviewed on 5/20/25 at 10:22 a.m.; Ex Employee Housekeeping A was last in-service on abuse and neglect on 11/21/24. Record Review of the abuse and neglect policy was reviewed on 5/20/25 at 10:30 a.m. Record Review of the grievance log was reviewed on 5/20/25 at 10:35 a.m. and found no issues from December 2024 to May 2025. Record Review of personnel file for Ex-employee Housekeeper A reviewed on 5/20/25 at 10:44 a.m., revealed Housekeeper A self-terminated on 1/14/25. Record Review of the police Report dated, 2/14/25 at 2:00 p.m., the police report indicated on February 14, 2025, the Administrator came to the Police Department to make a report of a theft. This theft occurred the Nursing Facility, The Administrator informed the offer that Housekeeping A, a former employee at the nursing home received $60 from Resident #2, a resident. Housekeeping A was asked to pick up certain items for Resident #2 with the money she was given. Housekeeping A then left the employ of the nursing home and neither returned the money given nor brought Resident #2 the items requested. During an attempted phone interview with Resident #2 RP on 5/20/25 at 10:53 a.m., of resident #2 RP was unavailable to be reached by phone; voice message left for a return phone call. During an interview on 5/20/25 at 11:00 am Resident #2 stated she did not remember

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 2 residents (Resident #13) reviewed for accident hazards. The facility failed to ensure the cigarettes for Resident #13 were properly secured in the designated locked box behind the nurse's station. The facility failed to ensure Resident #13 was smoking with supervision when she was found outside in the smoking area on 12/04/24 smoking alone. These failures could place residents at risk for injuries. Findings included: Record review of Resident #13's face sheet dated 12/4/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses hemiplegia following a cerebral infarction (a stroke that causes one sided weakness or paralysis), diabetes mellitus (disease in which the body has difficulty controlling the blood sugar), depression, high blood pressure, and lack of coordination. Record review of Resident #13's admission MDS assessment dated [DATE] indicated she was able to make herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact, and she was a current tobacco user. Record review of Resident #13's care plan dated 11/11/2024 indicated she was a smoker and she would have supervised smoking privileges to minimize safety risks with interventions for Resident #13 to keep all lighters/matches with facility staff for safety and she would participate in supervised smoke breaks. Record review of Resident #13's safe smoking assessment dated [DATE] indicated she should be supervised as per facility policy and all smoking equipment would be left at the nursing station in a box. During an observation on 12/4/24 at 09:18 AM Resident #13 was found by surveyor outside in the designated smoking area alone smoking with a lit cigarette in her hand. Resident #13 said the staff were supposed to keep the cigarettes and lighters in a box at the nurse's station. She refused to tell surveyor who gave her the cigarette she had in her hand, nor would she tell who lit the cigarette. She said usually the staff would stay out there in the smoking area with the residents when they would smoke but she guessed the staff did not stay because she was smoking at a different time. During an interview on 12/04/24 at 04:20 PM The DON said when she went outside with Resident #13, Resident #13 had her cigarettes in her pocket. She said the resident handed her the cigarettes and refused to tell her who gave her the cigarettes. The DON said all the staff were responsible for ensuring the resident did not have smoking items on them and did not smoke at undesignated time, or unsupervised. She said the failure placed Resident #13 at risk of burns, safety risks, or respiratory problems. The DON said she had her sign a sheet saying she did not abide by the policy since this was her first time violating the rules. During an interview on 12/04/24 at 05:08 PM The Administrator said Resident #13 went out on pass with friends and family and she could not be 100% sure that she wouldn't have cigarettes. She said her expectation was for all smoking items to be in a locked box at the nursing station and she expected all the residents to turn the cigarettes and lighters in to be placed in the lock box when they would get them from outside of the facility. The Administrator said the failure placed a risk of Resident #13 not following the smoking policy. Record review of the undated facility policy Smoking Policy indicated: It is the policy of this community to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. 1. Smoking by residents is allowed outside in a designated, marked smoking areas .6. Residents will not be allowed to possess any lighters, cigarettes or other smoking material. 7. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 19 residents reviewed for medication storage. (Resident #14). The facility failed to ensure Resident #14's vagisil maximum strength cream (used for vaginal itching), preparation H hemorrhoidal ointment (used for relief of swelling, burning, or pain from hemorrhoids), Asper creme lidocaine roll on (used for pain), fluticasone 50mcg nasal spray (used for allergies), and 2 bottles of Systane eye drops were stored and locked in an area not accessible to unauthorized staff, residents, or visitors. These failures could place residents at risk of injury. Findings included: Record review of Resident #14's face sheet dated 12/04/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses high blood pressure, arthritis, seasonal allergies, and abnormal posture. Record review of Resident #14's admission MDS assessment dated [DATE] indicated she was able to make herself understood and able to understand others. The MDS also indicated she had a BIMS score of 14 which meant she was cognitively intact. Record review of Resident #14's care plan dated 09/26/24 indicated her discharge had been determined to not be feasible based on resident and family request and need for ADL assistance and assistance with medication administration. The care plan also indicated Resident had impaired visual functioning and was at risk for a decrease in ADLs and injuries and she wears glasses with interventions for the staff to administer Systane eye drops at night. Record review of Resident #14's electronic medical record did not indicate Resident #14 had a self-administration assessment. Record review of Resident #14's order summary report dated 12/04/24 indicated she had orders for: 1. Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol (Ophth)) Instill 1 drop in both eyes at bedtime for Burning &irritation with a start date of 08/31/2024. The order summary did not indicate Resident #14 had an order for vagisil maximum strength cream, preparation H hemorrhoidal ointment, fluticasone nasal spray, nor asper creme lidocaine pain roll on. During an observation on 12/02/24 at 11:50 AM Resident #14 was sitting in her room in her wheelchair and had a bottle of fluticasone 50mcg allergy relief nose spray on her bedside table. Resident #14 said her family member brought it to her today. During an observation on 12/02/24 at 03:42 PM Resident #14 had a caddy sitting in her bathroom that had a container of vagisil maximum strength cream, preparation H hemorrhoidal ointment, and an asper creme lidocaine roll on container. During an observation on 12/03/24 at 08:51 AM Resident #14 continued to have the Vagisil maximum strength cream, preparation H hemorrhoidal ointment, and an asper creme lidocaine roll on container in her caddy in her bathroom. During an observation and interview on 12/04/24 at 10:23 AM CNA D walked in Resident #14's bathroom with surveyor and the vagisil maximum strength cream, preparation H hemorrhoidal ointment, and an asper creme lidocaine roll on container continued to be in Resident #14's caddy in her bathroom. CNA D said Resident #14 should not have the medications in her room, but resident was independent with her ADLs most of the time, so the CNAs do not always come into her bathroom. CNA D removed the medications from Resident #14's bathroom. CNA D said the failure placed Resident #14 at risk of self-medicating as well as wandering residents getting a hold of the medication. CNA D also found the bottle of fluticasone 50mcg allergy relief nose spray and 2 bottles of systane eye drops in Resident #14's dresser drawer. CNA D said all staff were responsible for ensuring no resident had medications in their rooms. During an interview on 12/04/24 at 04:56 PM the DON said her expectation was for all residents' medications to be locked in the proper location. She said they had sent letters out to the families to inform them of things that should not be brought into the facility and left with the residents. The DON said during rounds the staff should have found the medications being left out in Resident #14's room and bathroom. The DON said the failure placed Resident #14 at risk of self-treating and not fixing the problems she had. She said the failure could have also caused harm or injury for Resident #14 or any wandering residents that could get into the medications. During an interview on 12/04/24 at 05:04 PM The Administrator said she had sent out letters to the families of residents in the facility about hazardous items not to be left with residents, including medications. The Administrator said her expectation was for the medication to be stored in medication carts and medication rooms. She said all staff were responsible for ensuring that the medications were not in the residents' rooms. The Administrator said the failure placed staff at risk of not knowing what Resident #14 was taking and they could have possibly medicated her with medications that she could have had adverse reactions with. Record review of the facility policy Storage of Medications revised on 08-2024 indicated: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. I. General guidelines .2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications .

**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 1 of 3 residents (Residents #17). 1.CNA A and CNA B failed to use enhanced barrier precautions by donning a gown when performing foley care on Resident #17 on 12/03/2024. 2.CNA A and CNA B failed to change their gloves after performing foley care on Resident #17 and touched the resident and clean surfaces on 12/03/2024. These failures could place residents at risk of exposure to communicable diseases, cross-contamination and infections. Findings included: Record review of the face sheet, dated 12/04/2024, revealed Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), type 2 diabetes (a long term condition where the body had trouble controlling blood sugar and using it for energy), hyperlipidemia (a condition where there are high levels of fat particles in the blood), and obstructive and reflux uropathy (a condition where urine flow is blocked with the urinary tract causing urine to back flow upward into the kidneys). Record review of the comprehensive MDS assessment, dated 10/28/2024, revealed Resident #17 had clear speech and was sometimes understood by staff. The MDS revealed Resident #17 was usually able to understand others. The MDS revealed Resident #17 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS revealed Resident #17 was dependent on staff assistance for toilet hygiene and transfers. The MDS revealed Resident #17 had a foley catheter. Record review of Resident #17's orders summary dated 10/10/2024 indicated cleanse foley catheter insertion site with Thera Worx (hygiene protective barrier) to prevent urinary tract infections and provide foley care every shift. Record review of the comprehensive care plan, revised on 12/02/2024, revealed Resident #17 was on enhanced barrier precautions for indwelling catheter with the intervention of staff will gown and glove during high contact resident care. Record review of Resident #17's comprehensive care plan, revised on 10/10/2024, revealed resident had indwelling catheter and at risk for increased urinary tract infections with the intervention of monitor for signs and symptoms of infection. There was a sign posted regarding use of enhanced barrier protection and personal protection equipment was located in Resident #17's room. During an observation on 12/03/2024 at 4:09 PM, CNA A and CNA B entered Resident #17's room and donned gloves after washing their hands. CNA A and CNA B did not wear a gown for enhanced barrier protection. CNA B performed foley care for Resident #17. CNA A assisted CNA B. CNA A placed the foley catheter bag and tubing on the bed next to Resident #17's leg. CNA A unclamped the tubing from the leg stabilization device and held the tubing while CNA B performed foley care and placed the foley catheter bag below the bladder. CNA A and CNA B did not change their gloves. CNA A and CNA B touched Resident #17's clean brief, blanket and bed side table with the same gloves. After covering Resident #17 and adjusting the bed side table, CNA A and CNA B took off their gloves and washed her hands. During an interview on 12/04/2024 at 01:38 PM, CNA A said she should have used enhanced barrier precautions because Resident #17 had a foley. CNA A said she forgot to grab a gown when providing foley care for Resident #17 to prevent cross contaminations. CNA A said it was important to take dirty gloves off before touching anything clean to prevent spreading germs. She said staff had to take off their dirty gloves, wash their hands and re-glove, if needed. She said it was an infection control issue to touch items or residents with dirty gloves. She said she was trained and educated on enhanced barrier precautions and to remove her dirty gloves before touching anything clean and washing her hands to prevent infection. During an interview on 12/04/2024 at 04:22 PM, CNA B said she should have changed her gloves after the foley care when her gloves were dirty and before touching the resident's brief, blanket and bed side table. She said she was trained to change her gloves and clean her hands after foley care, and she did not because she was nervous. She said what she did was an infection control issue and could spread infection. CNA B said she failed to use enhanced barrier precautions by not utilizing a gown during foley care. CNA B said she is a new CNA and worked at the facility a short time (hire date of 11/21/2024). CNA B said she was assigned to work with a seasoned nurse until orientation completed. CNA B said she was not familiar with the residents on hall 2 and was nervous and realized afterwards the procedure was not done correctly. CNA B said she was aware and had been educated on all residents with foley care required enhanced barrier precautions to prevent the spread of germs and infections. During an interview on 12/04/2024 at 04:35 PM, the ADON said she was the Infection Preventionist. The ADON said it was her job to train, educate and complete skills check evaluations on the CNAs for foley care and enhanced barrier precautions to prevent the spread of infections in the facility. The ADON said it is her responsibility to monitor the staff through random checks, observations, and education to ensure infection control practices are being followed by staff. The ADON said she had started the position about 2 months ago and she had not completed any skill evaluations yet for any staff. The ADON said she was learning her position and would resume the evaluations in January 2025. The ADON said touching clean surfaces with dirty gloves could cause cross contamination of the clean area especially if someone else touched the dirty area with clean gloves or hands. She said the danger to the resident was infection, weight loss and an infection could require the resident to be on antibiotics. The ADON said enhanced barrier precautions should be used for all residents with a foley. The ADON said there were signs in the Resident's rooms to alert staff and the necessary supplies required for enhanced barrier protection such as gowns. During an interview on 12/04/2024 at 4:45 PM, the DON said she expected the staff to follow the procedures for foley care which included enhanced barrier precautions which required wearing the gown during foley care. The DON said infection control was vital for all staff to adhere to and prevent cross contamination. The DON said staff should never touch the residents or resident's items such as linens or reposition the residents with dirty gloves. She said to do that was cross-contamination which could spread infection or cause infection. She said she expected staff to go by their training and change their gloves after a dirty procedure and perform hand hygiene. She said dirty gloves should be changed and hand hygiene performed before going to a clean area. The DON stated she had performed skill evaluations for the staff while the ADON was training. The DON said CNA B was hired approximately three weeks ago and had not completed skills evaluation at this time. During an interview 12/04/2024 at 05:50 PM, the Administrator said she expected staff to follow best practices learned when obtaining their licensure. The Administrator said enhanced barrier precautions were important to protect the residents as well as the staff from infections and should be utilized with residents that had a foley. She said if a staff had dirty gloves on and touched a clean area it was cross-contamination and could possibly cause infection. The Administrator said she felt that CNA A and CNA B were nervous when the surveyor observed the care provided. Record review of a skills check off entitled CNA Skills Fair 2024 - Incontinent Care - Peri/Incontinent Care with Catheter - Male, dated 10/25/2024, indicated CNA A was competent in foley care. Record review of a skills check off entitled CNA Skills Fair 2024 indicated CNA B had not completed the skills check for foley care. Record review of the facility policy titled Enhanced Barrier Precautions, dated 04/01/2024, indicated: Enhanced Barrier Precautions are a CDC guidance to reduce the transmission of multi-drug resistant organisms in health care setting, including nursing homes .requires team members to wear a gown and gloves while performing high contact care who have open wounds or indwelling catheters. Record review of the facility's policy titled Catheters-Insertion and Care, dated 04/2021, indicated: It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications 3. wash hand, put on gloves 17. remove gloves and wash hands. 18. Leave resident in a comfortable position with call light within reach.

**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 1 of 19 residents (Resident #14) reviewed for physical environment. The facility failed to ensure Resident #14's bathroom toilet was functioning properly. The facility failed to ensure Resident #14's bathroom toilet was not briskly running or leaking water for her to use safely. This failure could place residents at-risk of falls and further injuries due to an unsafe environment. The findings were: Record review of Resident #14's face sheet dated 12/04/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses high blood pressure, arthritis, seasonal allergies, and abnormal posture. Record review of Resident #14's admission MDS assessment dated [DATE] indicated she was able to make herself understood and able to understand others. The MDS also indicated she had a BIMS score of 14 which meant she was cognitively intact. The MDS also indicated Resident #14 was always continent of bowel and bladder. Record review of Resident #14's care plan dated 09/26/24 indicated her discharge had been determined to not be feasible based on resident and family request and need for ADL assistance and assistance with medication administration. The care plan also indicated Resident had impaired visual functioning and was at risk for a decrease in ADLs and injuries and she wears glasses. Record review of the facility maintenance request book on 12/02/24 at 03:58 PM indicated there were no maintenance requests noted in the book for Resident #14 for September 2024, October 2024, nor November 2024. During an observation and interview on 12/02/24 at 03:42 PM Resident #14 was sitting in her room and she said she forgot to tell the surveyor about her toilet running and leaking since she admitted to the facility on [DATE]. Resident #14 said her toilet had been having problems since she admitted on [DATE] and she had told staff. The toilet in her room was briskly running water but there was no observation of water on the floor. During an interview on 12/02/24 at 04:03 PM the Maintenance Director said he was aware of the problem with Resident #14's toilet about 3 weeks prior to 12/02/24. The Maintenance Director said he did not have the problem in his maintenance book because he found the problem with Resident #14's toilet running water while he was making rounds to check water temperatures. The Maintenance Director said Resident #14's toilet flapper was not functioning, and he fixed it by replacing it at that time. The Maintenance Director said he would have normally documented in his book, but he did not on that occasion. He said he was not aware the toilet was not operating properly. During an observation on 12/04/24 at 10:35 AM Resident #14's toilet water was leaking on the floor from her toilet to her room. She had left the room, but someone had attempted to use paper towels to try to dry the water up and left paper towels on the floor in the leaking water. During an interview on 12/04/24 at 10:39 AM Community Cleanliness Provider E said he had never noticed the toilet leaking or running but he was not always scheduled to work on Resident #14's hallway. During an observation and interview on 12/04/24 at 10:44 AM Maintenance Director said he came back down to the room on the afternoon of 12/2/24 and checked Resident #14's toilet after he rebuilt (he removed the toilet and put it back together) the toilet and there were no problems with it running or leaking. He said he was responsible for ensuring the toilets in the facility were functioning properly, but he did not know it was leaking. The Maintenance Director said the leaking toilet placed Resident #14 at risk for slipping and falling. During an interview on 12/04/24 at 04:53 PM the DON said her expectation was for the toilet in Resident #14's room to be functional and not leaking. She said the Maintenance Director was responsible for ensuring that the toilet was fixed but all staff were responsible for ensuring all residents' toilets were functioning and reporting in the maintenance book when the toilets were not functioning. The DON said the failure placed Resident #14 at risk for falls. During an interview on 12/04/24 at 05:02 PM the Administrator said her expectation was for the residents' toilets functioning and running properly but she felt the leaking toilet was a different problem that was newly found. The Administrator said the Maintenance Director was responsible for all the maintenance and toilets in the facility. She said the failure placed Resident #14 at risk of injury. Record review of the facility policy Quality of Life-Homelike Environment revised May 2017 indicated: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, and in that: 1) The facility failed to date all food items. 2) Dietary staff failed to dispose of expired foods items 3)The facility failed to ensure proper infection control measures when a resident self-served ice from the ice chest cooler located on Hall 2 on 12/2/2024, 12/03/2024 and 12/04/2024. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observation in the kitchen Refrigerator 1 of 3 on 12/2/24 at 9:56 a.m., the following was observed: -(1) gallon of 2 percent milk unopened expired on 11/28/24. During observation in the kitchen Refrigerator 2 of 3 on 12/2/24 at 10:03 a.m., the following was observed: -(1) serving of hot sauce prep date of 10/31/24. (expired) During observation in the kitchen on 12/2/24 at 10:17 a.m., the following were observed: -(1) 6-ounce container of pumpkin spice seasoning received on 1-19-20 had a use by date of 1-19-24. -(1) 6-ounce container of ground ginger had an open date of 3-21-23 and a use by date of 10-28-24 -(1) container of frosted flakes had a prep date of 11-14-24 and no use by date. -(1) container of Raisin Bran Cereal had a prep date of 11-14-24 and no use by date. -(1) container of cheerios cereal had a prep date of 9-10-24 and no use by date. -(1) container of fruit loop cereal had a prep date of 11-14-24 and no use by date. During an interview and observation of the kitchen on 12/2/24 at 10:03 a.m., the Dietary Manager stated the hot sauce was good for a few months once prepped and the hot sauce should have been discarded from the refrigerator. The Dietary Manager stated the cereal should have had a use by date on the label. During an interview on 12/04/24 at 1:30 p.m., the dietary manager stated he had been the Dietary Manager for a year. The Dietary Manager stated the Administrator oversaw him. The Dietary Manager stated, Yes all food items in the kitchen were to be labeled, dated with receive date, open date and expiration date. The Dietary Manager stated the last in-service on expired foods was last completed a month ago. The Dietary Manager stated he conducted a walk thru in the kitchen daily. The Dietary Manager stated he was aware of the hot sauce and missing use by dates on the cereal. The Dietary Manager stated he was not aware of the expired milk found in the refrigerator. The Dietary Manager stated once food was prepared that the food item was good for a week or two. The Dietary Manager stated it was important to ensure staff were discarding expired foods so that the residents did not get sick. During an interview on 12/04/24 at 1:39 p.m., the Administrator stated she had been employed at the facility for 10 years. The Administrator stated she oversaw the Dietary Manager. The Administrator stated all food items in the kitchen were to be labeled, dated with receive date, open date, and expiration date. The Administrator stated she did not know when the last in-service on discarding expired food items was last completed. The Administrator stated walk throughs were conducted by her weekly in the kitchen. The Administrator stated she was not aware of the surveyor's findings in the kitchen prior to Survey. The Administrator stated it was important to ensure the dietary staff were discarding expired refrigerated foods so that the expired foods were not a hazard to the residents. Record Review of the Food Safety: Food storage policy revised on 4/11/22 indicated, all food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness; (6) Food removed from its original packaging will be labeled with the following: a. Receive Date, b. Open Date c. Contents in the Package; (9) Opened package or leftover food is to be tightly wrapped or covered in airtight, clean. containers. It should be labeled, dated with the opened or use by date. Do not keep leftovers in the refrigerator for more than 7 days. Record Review of FDA Food code dated 2022 indicated, 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Commercially processed food Open and hold cold (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 FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 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; (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. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 3. During an observation on 12/02/2024 at 10:32 AM, a resident was self-serving ice into two personal cups from the ice chest cooler located on Hall 2. During an observation on 12/03/2024 at 10:45 AM, a resident was self-serving ice into two personal cups from the ice chest cooler located on Hall 2. During an observation on 12/04/2024 at 10:42 AM, a resident was self-servicing ice into two personal cups from the ice chest cooler located on Hall 2. During an interview on 12/04/2024 at 4:32 PM, RN C said the residents are given ice by the staff from the ice chest coolers located on Hall 2 and Hall 5. RN C said she had noticed residents self - serving ice from the ice chest coolers but had never thought of it as being cross-contamination until the surveyor interview. RN C said, they would not know if the resident had washed their hands so that could cause some infection control issues. During an interview on 12/04/2024 at 04:35 PM, the ADON said she was not aware of any residents self-serving ice from the ice chest coolers. The ADON said the staff provided the ice and water to the residents every shift. The ADON said it was an infection control issue and could cause cross contamination for the residents to self-serve ice. The ADON said she was the infection control preventionist and responsible for ensuring the facility is following procedures to prevent the spread of infections. During an interview on 12/04/2024 at 4:45 PM, the DON said she was not aware of residents getting their own ice for the coolers in the hallways. The DON said residents should not be allowed to self-serve ice from the hallway coolers because of the risk of cross contamination. During an interview 04/20/2021 at 05:50 PM, the Administrator said she expected infection control policies to be followed by all the staff and all staff was responsible to ensure cross contamination was not occurring in the facility. The Administrator said the staff were responsible to ensure fresh ice was served to the residents. The Administrator said to decrease the chance of cross contamination residents should not self-service ice from the hallway coolers. Record review of the facility's policy titled Infection Control dated 04/20/21, indicated, the facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 3 (Resident # 1) residents reviewed for misappropriation of resident property. The facility failed to prevent a drug diversion (misappropriation) of Resident #1's-controlled medications on [DATE], Hydrocodone-Acetaminophen 7.5-325MG (narcotic pain reliever), Hydrocodone-Acetaminophen10-325MG, and Lorazepam (controlled anti-anxiety medication) 0.5 MG, after she expired on [DATE]. The medications were not found. The non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] diagnoses of dysphagia (difficulty swallowing), myalgia (muscle pain), muscle wasting, lack of coordination, major depressive order (persistent feeling of sadness or loss of interest that can lead to an arrange of behavioral and physical symptoms), anxiety (mental disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), hypertension (high blood pressure), arthropathy (on going swelling and pain of joints). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. The MDS indicated Resident #1 had a BIMS score of 09 which indicated a moderate cognitive impairment. The MDS indicated Resident #1 required maximal assistance with toilet use, bathing, bed mobility, transfer, and dressing, and extensive assistance for personal hygiene. The MDS indicated Resident #1 received setup/supervision assistance for eating. The MDS indicated Resident #1 received scheduled pain medication regimen and received 7 days of opioid (powerful pain-reducing medications) during the assessment period. The MDS assessment indicated Resident #1 received anti-anxiety medication. Record review of Resident #1's care plan dated [DATE] indicated Resident #1 was at risk for alteration of discomfort of musculoskeletal status limited range of motion (happens when swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age). Resident #1's care plan indicated she was at risk for anxiety (mental disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) related to cognitive deficit with the intervention to administer Lorazepam (medication used to relieve anxiety) as ordered. Record review of Resident #1's consolidated physician orders active as of [DATE] indicated the following orders: *Hydrocodone-Acetaminophen 7.5-325 MG give one tablet by mouth every 4 hours as needed for pain with an order start date of [DATE]. *Hydrocodone-Acetaminophen 10-325 MG give one tablet by mouth every 4 hours for pain with an order start date of [DATE]. *Lorazepam Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety, with a start date of [DATE]. Record review of Resident #1's MAR dated [DATE] - [DATE], indicated between this time Resident #1 received a total of: o 28 tablets of Hydrocodone-Acetaminophen 7.5mg-325mg, o 39 tablets of Hydrocodone-Acetaminophen 10/325mg, o 20 tablets of Lorazepam 0.5mg. Record review of the Provider Investigation Report dated [DATE] indicated .incident date unknown. telephone call reporting drug diversion .alleged perpetrator .RN A stealing narcotics from the facility .denied .reporter stated received information from a reliable source .suspension of RN A pending investigation .reviewed all residents that RN A had given narcotic pain medications to from [DATE] to [DATE] .interviewed for any change in pain of residents and unexplained change in pain noted .during investigation the DON noted Resident #1's medications missing after compared to pharmacy manifest .reported to police interviews on all staff who had access to the medication carts associated with Resident 1's missing medications no one admitted to taking drugs or knew what happened to the missing medication .interview with RN A .offered drug screen positive for opiates .no confirmed perpetrator .RN A remained suspended until drug screen confirmed . investigation findings. Record review of staff schedules dated [DATE] - [DATE] indicated RN A had access to the two medication carts with Resident #1's routine and as needed Lorazepam and hydrocodone-acetaminophens. Record review of a progress note dated [DATE] at 12:36 AM indicated LVN D attempted to give Resident #1 pain medication (Resident was not swallowing, refused to open mouth and take medicine. Medication wasted with second nurse. Record review of the facility's pharmacy manifest (tracks the waste to final disposal) dated [DATE] indicated Resident #1 received: o 115 pills of Hydrocodone-Acetaminophen 10-325 MG- dispensed on [DATE], o 90 pills of Hydrocodone-Acetaminophen 7.5-325 MG- dispensed on [DATE], o 60 Lorazepam Tablet 0.5 MG dispensed on [DATE]. Record review of the local police department report dated [DATE] at 12:38 PM, indicated .RN A took a drug test and awaiting results, test showed positive for opiates but sent off for specifics. Resident #1 passed on (died) 07-06-2024 and Hydrocodone 10's, Hydrocodone 7.5's and Lorazepam came up missing. RN A was suspended on [DATE] . During an interview on [DATE] at 4:00 PM, the informant from the local police department, stated he could not reveal his reliable source of information regarding RN A stealing narcotics from the nursing facility. The informant from the local police department said he felt obligated to let the facility know this information because he would not want any resident to be in pain and go without medication. During an attempted phone interview on [DATE] at 4:30 PM, RN A did not answer the phone. During an attempted phone interview on [DATE] at 9:14 AM, RN A did not answer the phone. During an interview on [DATE] at 9:15 AM, LVN C said she had worked the night shift on [DATE], and she recalled the Hydrocodone 10/325 mg being on the cart. LVN C said she did not notice when the medication was no longer on the cart. LVN C said she had no discrepancies with the narcotic counts at the beginning or the end of her shifts. LVN C said routine procedure was to leave any discontinued medications on the medication cart and continue to count the medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and Controlled Drug Administration Record were taken to the DON and verified by the DON and the nurse or MA. The nurses arrived for their shift at 6 am and 10 pm but the MA's shift started at 8 am. LVN C said she had not had any issues with her narcotic counts matching. LVN C said the facility started counting and recording all the cards in the narcotic box at the beginning and end of the shift during the summer. During an attempted phone interview on [DATE] at 12.32 PM, RN A did not answer the phone. A voice message was left to return call and phone number given. During an attempted phone interview on [DATE] at 2:15 PM, RN A did not answer the phone. A voice message was left to return call and phone number given. During an interview on [DATE] at 3:32 PM, RN F said she had worked approximately 6 months at the facility as the 2 PM to 10 PM charge nurse. RN F said she had been educated on the abuse policy on several occasions. RN F denied any abuse within the facility. RN F said the routine procedure was to leave discontinued medications on the medication cart and continue to count the controlled medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and narcotic sign out sheets were taken to the DON and verified by the DON and nurse or MA. RN F said when she arrived for her shift, she ensured the narcotic count was correct by counting and recording all the cards in the narcotic box at the beginning and end of the shift and had been doing this for a few months now. RN F stated the oncoming nurse counts the medications while the off going shift nurse or MA verified totals on the Controlled Drug Administration Record. RN F said the nurse arrived at 6 am and 10 pm but the MAs arrived at 8 am. RN F said she had not had any issues with her narcotic counts matching. During an interview on [DATE] at 12:39 PM, MA B said she had been working at the facility for 1 and a half years and worked all the halls at some point and took over the routine medication cart. She said when she received the medication cart, the Controlled Drug Administration Record was correct, and she had not experienced any discrepancies. She said she could not recall when she last saw the medications for Resident #1 on the medication cart. MA B said over the last few months a new procedure was implemented and the facility started counting and recording the total amount of medication cards in stock in the narcotic locked box. MA B said she would leave any discontinued medications on the cart and continue to count the medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and the Controlled Drug Administration Record were taken to the DON and verified by the DON and the nurse or MA. She said the keys and medication cart passed through a lot of hands because the nurse arrived at 6 am and 10 pm but the MAs arrived at 8 am. She said the morning LVN passed off to the morning MA then the morning MA passed off to the night LVN, then the night LVN passed off to the morning LVN. MA B said she had not had any issues when she worked with her narcotic counts matching. She said when she arrived for her shift, the narcotic count was correct. During an interview on [DATE] at 1:48 PM, the ADON said she was assigned to halls 4,5, and 6 as the charge nurse on [DATE] for the 6AM to 2PM shift. The ADON said she did not experience any drug discrepancies during this time but could not recall if Resident #1's medications were still on the cart that morning or not during the narcotic count down. The ADON said now the facility counted the total amount of cards in the locked narcotic box prior to doing the narcotic count down where the oncoming nurse counts the medications back to the going off shift nurse. The ADON said the routine procedure was to leave any discontinued medications on the cart and continue to count the medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and narcotic sign out sheets were taken to the DON and verified by the DON and the nurse or MA. The ADON said she had been educated on abuse, neglect and misappropriation on several occasions at the facility. During an interview on [DATE] at 2:33 PM, the DON said she had been employed by the facility for approximately 2 years. During the investigation regarding the allegation of misappropriation with RN A, the DON said she reconciliated the pharmacy manifest to the Controlled Drug Administration Record and found the discrepancy between Resident #1's medications because there was no Controlled Drug Administration Record to match the received medications. The DON said the facility implemented adding and subtracting the amount of blister packs of medications added or removed from the narcotic locked boxes. The DON said the pharmacy reconciliation was done monthly now also. The DON said she was too new and was not aware to reconcile the narcotic sheets against the pharmacy manifest until the incident. The DON said the staff had been educated on abuse-misappropriation and reporting, the new implemented narcotic count down per shift counting the card and adding or subtracting. Staff surveys were completed regarding concerns of any residents not getting pain medications, and legal obligation to report those concerns. The DON said resident surveys were completed regarding pain/comfort levels. The DON and Administrator performed chart audits on residents receiving opioids given by RN A and the pain assessment notes were reviewed. The DON said it was important to ensure there was not misappropriation of medications, so the residents received medications appropriately and did not experience pain and or discomfort. During an interview on [DATE] at 2:45 PM, the Administrator said the facility could not find the missing medications, so the facility did have a drug diversion. She said if the drug was not available in the facility's emergency medication kit, then there was a potential for the resident to miss a dose and experience pain. The Administrator said the staff had been educated on abuse-misappropriation and reporting, they had now implemented narcotic count down per shift (counting the card and adding or subtracting) staff surveys were completed regarding concerns of any residents not getting pain medication, and legal obligation to report those concerns. The Administrator said resident surveys were completed regarding pain/comfort levels. The DON and Administrator performed chart audits on residents receiving opioids given by RN A and the pain assessment notes were reviewed. The Administrator said the medications belonged to the residents. The administrator said RN A had denied the allegations of taking narcotics from the facility. The DON said RN A volunteered to take a drug test when confronted with the allegations by the Administrator. The Administrator said the initial drug screen was positive for opioids. The Administrator said RN A stated, I eat lots of poppy seeds and take tons of Benadryl which would cause the positive drug screen result. The DON stated RN A remained suspended from [DATE] - [DATE] while the facility awaited the results of the sent-out drug screen. On [DATE], RN A was allowed to return to work when the final drug screen results were returned negative. Record review of a facility's Abuse, dated [DATE] indicated . the purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, .misappropriation of resident property . The facility had corrected the noncompliance on [DATE] by the following: Suspension of RN A who the allegations involved for misappropriation. All staff educated by in-service on abuse and neglect/misappropriation and legal obligation of reporting of any suspicions per facility policy. Life Surveys completed on staff: (RN G, RN H, CNA K, CNA L). All staff educated by in-service on abuse, neglect, misappropriation and examples and legal obligation to report and suspicion of activity. Self-Report completed to Health and Human Services and the local police department. Audits completed on narcotic locked boxes on all medication carts (inspected cards and verified counts). Residents prescribed with opioids reviewed for unexplained pain concerns. Life Surveys completed on residents to measure of pain and comfort levels (Resident #4 and Resident #5) Audit Report for computer system for as needed medications reviewed for trends administrated by RN A for [DATE] - [DATE]. Reconciliation of Controlled Drug Administration Record to the Pharmacy Manifest completed monthly from [DATE] to present - reviewed. Record Review and interviews of sampled residents (Resident #2, Resident #3, and Resident #4) indicated no misappropriation of property occurred. Record Review of sign in sheet dated [DATE] of all staff educated on abuse, neglect, misappropriation and examples and legal obligation to report and suspicion of activity. Record Review of sign in sheet dated [DATE] of all licensed staff educated utilizing the new narcotic count sheets to be filled out at each shift count. Parts include (addition, subtracting, when and who) to be completed on the new sheet. All medications should match the controlled narcotic sheets prior to any staff leaving the building, no blank spaces on the narcotic sheets, and the electronic computer system MAR should reflect when a medication was given and match the controlled narcotic sheets. All licensed staff interviewed (MA B, LVN C, LVN D, LVN E, RN F) verbalized any allegation of abuse/misappropriation should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours and removing the alleged perpetrator from the victim or any potential victims immediately. They verbalized the implementation of the card counting of the blister packs of the medications added to the narcotic count at the beginning and ending of each shift by utilizing the new narcotic count sheet each shift, no staff can leave prior to a count not being correct. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #25 and Resident #159) reviewed for resident rights. 1. The facility did not ensure CNA B knocked, introduced herself, and explained the procedure prior to entering Resident #25's room and providing care. 2. The facility did not ensure CNA B knocked prior to entering Resident #159's room. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema (complication of high blood sugar where blood vessels in the eye are damaged causing swelling), legal blindness (unable to see), unsteadiness of feet, difficulty in walking, ataxia (loss of coordination of voluntary muscle movements), and muscle wasting and atrophy (loss of muscle and muscle mass leading to its shrinking and weakening). Record review of the quarterly MDS assessment, dated 09/22/2023, revealed Resident #25 had clear speech and was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #25 required an extensive, one-person assistance with personal hygiene, which included washing face. Record review of the comprehensive care plan, revised on 10/05/2023, revealed Resident #25 had an ADL self-care performance deficit related to his disease processes. The interventions included: .requires extensive assistance by 1 staff with personal hygiene and oral care. During an observation and interview on 10/30/2023 beginning at 10:20 AM, Resident #25 was sitting up in his recliner listening to books on tape. Resident #25 stated he was unable to see and was legally blind. CNA B walked into Resident #25's room through the open door. CNA B did not knock or introduce herself. CNA B started making Resident #25's bed, moving the bed away from the wall and back to the wall. CNA B did not explain to Resident #25 what she was doing. CNA B took Resident #25's water pitcher, opened the bathroom door and dumped out his water. CNA B walked out of the bathroom holding Resident #25's water pitcher, flipped the lights out and walked out of his room. During an observation on 10/30/2023 beginning at 10:27 AM, CNA B returned to Resident #25's room. CNA B did not knock or introduce herself. CNA B placed his water pitcher with ice water on his bedside table, then went into his bathroom and wet a washcloth with water. CNA B walked over to Resident #25 and then started wiping his face. CNA B then placed lotion on his head and face. CNA B did not explain to Resident #25 what she was doing. During an interview on 10/30/2023 beginning at 11:00 AM, CNA B stated she should have knocked prior to entering Resident #25's room. CNA B stated, I wasn't paying attention. CNA B stated it was important to knock prior to entering so the resident would know she was coming in. During an interview on 11/01/2023 beginning at 11:03 AM, Resident #25 stated staff normally knocked on his door and started talking. Resident #25 stated he was able to identify the staff by their voice. Resident #25 stated he knew a staff member was in his room because he heard them moving around. During an interview on 11/01/2023 beginning at 2:13 PM, CNA B stated she should have introduced herself and explained what she was doing while in Resident #25's room. CNA B stated she normally knocked, introduced herself, and explained the procedure but she was busy and probably just did not think about it. CNA B stated it was important to knock, introduce yourself, and explain the procedure to a visually impaired resident to ensure they did not become scared and knew she was in the room. CNA B stated it was important to maintain respect and dignity. During an interview on 11/02/2023 beginning at 10:41 AM, the DON stated she expected staff to knock, explain, and interact with residents while providing care. The DON stated it was monitored by random observations during morning rounds. The DON stated it was important to ensure staff knocked, explained, and interacted with residents while providing care to maintain respect of the resident and prevent an invasion of privacy. During an interview on 11/02/2023 beginning at 11:39 AM, the Administrator stated she expected staff to ensure they knocked prior to entering a resident's room and explained what they were doing while providing care. The Administrator stated she was responsible for monitoring to ensure staff knocked, introduced themselves and explained the procedure to residents. The Administrator stated it was important to ensure staff knocked, introduced themselves, and explained the procedure to the residents to maintain their privacy. 2. During an observation on 10/30/2023 at 10:54 a.m., CNA B entered Resident #159 room without knocking. During an interview on 10/30/2023 at 10:57 a.m., Resident #159 stated usually the staff knocked prior to entering. During an interview on 10/30/2023 at 11:00 a.m., CNA B stated she should have knocked prior to entering Resident #159 room. CNA B stated, I wasn't paying attention. CNA B stated it was important to knock prior to entering so the resident would know she was coming in. During an interview on 11/02/2023 at 9:11 a.m., the DON stated she expected staff to knock prior to entering rooms. The DON stated the department heads which included the Administration, Activity Director, Social Worker, ADON, BOM, MDS Coordinator and herself were responsible for making partner rounds. The DON stated during resident council there was a complaint by a resident that staff was not knocking on doors prior to entering. The DON stated an in-service was done and since then there were no further complaints, that she was aware of. The DON stated it was important to knock prior to entering for the resident's privacy and residents right. The DON stated the risk associated with not knocking prior to enring was the resident's privacy had been invaded. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she expected staff to knock prior to entering resident's room. The Administrator stated she monitored by doing random hall rounds and in servicing staff when an issue was noted. The Administrator stated she had not noticed any issues related to not knocking prior to entering. The Administrator stated it was important to knocked prior to entering to protect the resident's privacy. Record review of the facility's policy titled Quality of Life-Dignity revised on 08/2009, indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . 1. Residents shall be treated with dignity and respect at all times . 6. Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering residents' rooms 8. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 residents (Resident #10) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #10's call light was within reach. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 11/01/23, revealed Resident #10 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, heart failure (progressive heart disease that affects pumping action of the heart muscles), cerebrovascular disease (umbrella term for conditions that impact the blood vessels in your brain), and chronic kidney disease, stage 3 (kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant; Kidney disease often cannot be cured in Stage 3, and damage to your kidneys normally is not reversible). Record review of the quarterly MDS assessment, dated 07/27/23, revealed Resident #10 had clear speech and was usually understood by staff. The MDS revealed Resident #10 was usually able to understand others. The MDS assessment revealed Resident #10 had a BIMS of 11, which indicated moderately impaired cognition. The MDS assessment revealed Resident #10 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 07/15/23, revealed Resident #10 was at risk for falls and fractures related to cognitive impairment. The interventions included: ensure call light is in reach and answer promptly. During an observation on 10/30/23 beginning at 9:36 AM, Resident #10 was sitting up on the side of her bed. Resident #10's call light was curled up on the ground, out of arms reach, near the dresser that was located beside her bed. During an observation on 10/31/23 beginning at 9:33 AM, Resident #10 was sitting up on the side of her bed. Resident #10's call light was curled up on the ground, out of arms reach, near the dresser that was located beside her bed. During an observation and interview on 11/01/23 beginning at 10:52 AM, Resident #10 was sitting up on the side of her bed. Resident #10's call light was curled up on the ground, out of arms reach, near the dresser that was located beside her bed. Resident #10 stated she did not normally use her call light. Resident #10 stated her roommate called for her or she would catch staff as they entered her room to get what she needed. During an interview on 11/01/23 beginning at 4:30 PM, CNA B stated she was responsible for ensuring call lights were within reach for the residents. CNA B stated Resident #10 did not use her call light frequently and was pretty independent. CNA B stated she did not think about making sure her call light was in reach. CNA B stated it was important to ensure call lights were left in reach for the residents in case they needed anything or any help. CNA B stated call lights were important if there was an emergency. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to ensure call light were left within reach. The DON stated call light placement was monitored during rounds. The DON stated call light placement was important to ensure residents were able to call for help or ask for assistance. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected staff to ensure every resident had a call light that was within reach. The Administrator stated everyone was responsible for ensuring call lights were left in reach. The Administrator stated it was important to ensure call lights were left within reach, so they were able to call for assistance, if it was needed. Record review of the Quality of Life - Accommodation of Needs policy, revised August 2009, did not address call light placement or use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 20 residents (Resident #28) reviewed for environment. The facility failed to ensure Resident #28's door was properly functioning. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of a face sheet dated 11/02/2023 indicated Resident #28 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of the right side of the body following a stroke), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus (high blood sugars). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #28 was able to make herself understood and understood others. The MDS assessment indicated Resident #28 had a BIMs score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #28 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation and interview on 10/30/2023 at 10:18 AM, the surveyor opened Resident #28's door, but the door would not stay open. Resident #28 instructed surveyor to place a trashcan in front of the door to hold it open. Resident #28 said the only way the door stayed open was if something held it open. During an observation and interview on 11/01/2023 at 8:51 AM, room [ROOM NUMBER]'s door was not staying open on its own. Resident #28 said she had told the Director of Plant Operations that the door needed to be fixed because it would not stay open by itself, but he had still not fixed it. Resident #28 said she could not remember how long ago she had told him. During an interview on 11/02/2023 at 9:39 AM, the Director of Plant Operations said he was responsible for fixing the rooms. The Director of Plant Operations said he had tried fixing Resident #28's door but he was not able to fix it completely. The Director of Plant Operations said he had not reached out to anybody to get assistance in fixing Resident #28's door. The Director of Plant Operations said he was sure it could be fixed, but he did not know how. The Director of Plant Operations said it was important for the door to be fixed because in case of an emergency it would be hard for the resident to get out of their room. During an interview on 11/02/2023 at 12:07 PM, the DON said the Director of Plant Operations was responsible for fixing the doors. The DON said if the residents' rooms needed repaired it should be put on the Maintenance Repairs log. The DON said she had known for a little while that Resident #28's door was not staying open on its own. The DON said she did not notify the Director of Plant Operations because she did not think it was an issue. The DON said it was important for the door to be fixed for safety and because it could make it difficult for the resident to get out of the room. During an interview on 11/02/2023 at 1:31 PM, the Administrator said she had not noticed the door to room [ROOM NUMBER] was not staying open on its own. The Administrator said the Director of Plant Operations was responsible for repairs. The Administrator said if a resident reported a door needing to be fixed to the Director of Plant Operations, she expected him to fix it. The Administrator said it was important for the rooms to be in good repairs because it was the resident's home. Record review was performed of the Maintenance logs with Maintenance Repairs needed dated 9/4/23 to 10/31/23, and there were no entries regarding Resident #28's door. Record review of the facility's policy titled, Quality of Life- Homelike Environment, revised May 2017, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure an accurate MDS was completed for 1 of 20 residents (Resident's #14) reviewed for MDS assessment accuracy. 1. The facility did not ensure Resident #14's most recent MDS assessment reflected his hospice services during the 14-day look-back period. This failure could place residents at risk for not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #14 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), alcoholic liver disease (spectrum of alcohol-induced liver dysfunction ranging from mild, reversible fatty liver to irreversible liver fibrosis and cirrhosis), and type 2 diabetes mellitus without complications (high blood sugar). Record review of the MDS assessment, dated 09/15/2023, revealed Resident #14 had clear speech and was understood by staff. The MDS revealed Resident #14 was able to understand others. The MDS revealed Resident #14 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #14 had a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS revealed Resident #14 did not receive hospice services during the 14-day look-back period. Record review of the comprehensive care plan, revised 08/13/23, revealed Resident #14 had a terminal prognosis related to liver failure. The interventions included: hospice services initiated on 08/13/23. Record review of the order summary report, dated 10/30/23, revealed Resident #14 had an order that started on 06/06/23, for hospice services. During an interview on 11/02/23 beginning at 9:08 AM, the Clinical Reimbursement Coordinator stated she was responsible for ensuring the MDS was accurately filled out. The Clinical Reimbursement Coordinator stated Resident #14 was receiving hospice services. She stated she was unsure why his hospice services were not reflected on the MDS. The Clinical Reimbursement Coordinator stated it was important to ensure the MDS was accurately filled out to represent an accurate picture of the resident to the state agency. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she was responsible for signing the MDS assessment as completed but did not check the MDS for accuracy. The DON stated the Clinical Reimbursement Coordinator was responsible for ensuring the MDS was completed accurately. The MDS accuracy policy was requested. The DON stated corporate staff stated they did not have a facility policy for MDS accuracy, they used the RAI manual. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected the MDS assessment to have been completed accurately. The Administrator stated the Clinical Reimbursement Coordinator was responsible for ensuring the MDS was completed accurately. The Administrator stated it was important to ensure the MDS was completed accurately because it was the base for the plan of care. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2019, revealed Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 20 residents reviewed for care plans. (Resident #5 and Resident #13) 1. The facility did not implement Resident #5's care plan or accurately reflect her diet preferences. 2. The facility failed to develop and implement a care plan for Resident #13's Hospice care services. These failures could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #5 was a [AGE] year-old female who admitted initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (happens when another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and cognitive communication deficit (difficulty with communication that is caused by a problem with cognition). Record review of the MDS assessment, dated 09/08/2023, revealed Resident #5 had clear speech and was understood by staff. The MDS revealed Resident #5 was usually able to understand others. The MDS revealed Resident #5 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #5 had no behaviors or refusal of care. The MDS revealed Resident #5 was independent with eating. The MDS revealed Resident #5 was on a mechanically altered diet. Record review of the comprehensive care plan, initiated on 10/09/2023, revealed Resident #5 was on a mechanical soft diet. The interventions included: dietary manager to monitor/discuss food preferences .diet per orders . The care plan did not address Resident #5's preference to get potato chips with her sandwiches. Record review of the order summary report, dated 10/30/2023, revealed Resident #5 had an order, which started on 09/21/2023, for mechanical soft diet. During an observation and interview on 10/30/2023 beginning at 12:35 PM, Resident #5 had a meal ticket on her meal tray that read mechanical soft. Resident #5 had ruffle potato chips on her plate with approximately 25% missing. Resident #5 stated she did not have any molar teeth in her mouth, which made chewing difficult at times. Resident #5 stated potato chips were soft enough that she was able chew without difficulty. Resident #5 stated she liked potato chips and preferred to have them with her sandwich. During an interview on 11/01/2023 beginning at 4:30 PM, CNA B stated meal trays should have matched the dietary tickets. CNA B stated she did not normally pass meal trays on the hall, so was unsure what diet Resident #5 received. CNA B stated she did not really look at the care plan or [NAME] (electronic system that CNAs are able to access that pulls information from the care plan). CNA B stated if she needed to know information about a resident, she asked the nurses or the management nurse staff. CNA B stated it was important to ensure preferences were included on the care plan, so the facility staff knew what was going on with the resident and to provide better care to the residents. During an interview on 11/02/2023 beginning at 9:08 AM, the Clinical Reimbursement Coordinator stated the IDT was supposed to have been responsible for ensuring care plans were completed accurately and implemented. The Clinical Reimbursement Coordinator stated resident's dietary preferences should have been included on the care plan. The Clinical Reimbursement Coordinator stated the care plan was a map of the resident's care and should have been followed by the facility staff. The Clinical Reimbursement Coordinator stated the CNAs have access to the care plan through the [NAME] which was information that pulled over from the care plan. The Clinical Reimbursement Coordinator stated CNAs were provided training on the care plan during ADL training. The Clinical Reimbursement Coordinator stated it was important to ensure care plans included resident's preferences, so the staff understood how to take of the residents. During an interview on 11/02/2023 beginning at 10:41 AM, the DON stated the Clinical Reimbursement Coordinator was responsible for ensuring dietary preferences were included in the care plan. The DON stated the care plan should have been implemented by the facility staff. The DON stated it was important to ensure dietary preferences were included on the care plan and the care plan was implemented to cover the facility with regulation and so the facility staff knew what was going on with the residents. The policy for comprehensive care plan was requested and not provided upon exit of the facility. During an interview on 11/02/2023 beginning at 11:39 AM, the Administrator stated she did not believe every single resident preference should have been included on the care plan. The Administrator stated Resident #5 was on a mechanical soft diet because of her personal preference and choice. The Administrator stated it was her right to have chips if she wanted them, even if the care plan and physician orders did not specify it. The Administrator stated she did not know where the information should have been documented, she guessed it should have been included on the care plan. 2. Record review of Resident #13's face sheet, dated 11/01/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS assessment dated [DATE] indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. Record review of the care plan last revised on 07/07/2023 indicated Resident #13 had no care plan for hospice services. Record review of Resident #13's order summary report with a date range of 11/01/2023 to 02/27/2023 indicated admit to Hospice as of 09/28/2023. During an interview on 11/02/2023 at 9:35 AM, the MDS Coordinator stated the IDT team was responsible for the care plan, but she ensured that it was complete. The MDS Coordinator stated she was aware that Resident #13 had hospice services. The MDS Coordinator stated Resident #13 should have had interventions in her care plan to hospice services. The MDS Coordinator stated she made a mistake and did not care plan it. The MDS Coordinator stated it was important for Resident #13 to have hospice services on the care plans to ensure appropriate person-centered care. During an interview on 11/02/2023 at 01:00 PM, the DON stated the MDS Coordinator was responsible for ensuring everything for the resident's care was included in the care plans. The DON stated Resident #13 should have had a care plan for hospice services. The DON stated she did not know why it was not in the care plan. The DON stated it was important for Resident #13's hospice services to be included in her care plan because it is the map of providing care of the resident and resulted in continuity of care. During an interview on 11/02/2023 at 01:30 PM, the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include in the care plan hospice services and anything unusual or special for the resident's care. The Administrator stated it was important for Resident #13's hospice services to be included in the care plan so the staff could ensure the resident was receiving appropriate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 2 of 5 residents reviewed for ADLs. (Resident #41 and Resident #210) 1. The facility did not ensure Resident #41 received nail care. 2. The facility failed to ensure Resident #210 received his shower as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #41 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute on chronic congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), essential hypertension (high blood pressure), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with numbness in hands and feet). Record review of the MDS assessment, dated 09/29/2023, revealed Resident #41 had clear speech and was understood by staff. The MDS revealed Resident #41 was able to understand others. The MDS revealed Resident #41 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #41 had no behaviors or rejection of care. The MDS revealed Resident #41 required a limited one-person assistance with personal hygiene. Record review of the comprehensive care plan, revised on 05/20/2023, revealed Resident #41 had an ADL self-care performance deficit related to disease processes. The interventions included: .check nail length and trim and clean on bath days and as necessary During an observation and interview on 10/30/2023 beginning at 9:25 AM, Resident #41 was sitting up in his wheelchair watching television. Resident #41's fingernails were long, broken, and jagged on the thumb, pointer finger, and middle finger on his right hand. Resident #41 stated the facility staff did not frequently cut his fingernails and knew they were broken. Resident #41 asked the surveyor to pull the nail off where it was broken and hanging off. During an observation on 10/31/2023 beginning at 3:01 PM, Resident #41's fingernails were long, broken, and jagged on the thumb, pointer finger, and middle finger on his right hand. During an observation and interview on 11/01/2023 beginning at 11:37 AM, Resident #41 stated he just returned from his shower. Resident #41's fingernails were long, broken, and jagged on the thumb and middle finger on his right hand. Resident #41 stated the facility staff had not trimmed his fingernails but pulled the fingernail off he asked the surveyor to do. Resident #41 stated the staff had not addressed the other fingernails. During an interview on 11/01/2023 beginning at 4:30 PM, CNA B stated the nurses were responsible for ensuring fingernails were cut and trimmed. During an interview on 11/02/2023 beginning at 10:39 AM, LVN E stated CNAs were responsible for ensuring fingernails were cut and trimmed, unless they had diabetes. LVN E stated the nurses were responsible for trimming Resident #41's nails. LVN E stated broken nails could have caused injury and could have caused problems with the fingers. During an interview on 11/02/2023 beginning at 10:41 AM, the DON stated nail care should have been performed by the CNAs on shower days. The DON stated nail care was performed by the nurses if the resident was diabetic. The DON stated nail care was monitored by performing rounds. The DON stated performing nail care was important for skin, hygiene, dignity, and infection control. During an interview on 11/02/2023 beginning at 11:39 AM, the Administrator stated she expected nursing staff to ensure nail care was completed. The Administrator stated everyone was responsible for monitoring to ensure nail care was completed. The Administrator stated nail care was important because of resident rights. 2. Record review of a face sheet dated 11/02/2023, indicated Resident #210 was an [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), type 2 diabetes mellitus with diabetic chronic kidney disease (chronic condition that affects the way the body processes blood sugar with kidney disease caused by the diabetes), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #210's electronic health record on 11/02/2023 indicated Resident #210's admission MDS assessment was in progress. Record review of Resident #210's care plan last revised 10/26/2023 indicated he had an ADL self-care performance deficit and required extensive assistance by 2 staff members with showering 3 times a week and as necessary. Record review of the Bath Shower Sheets since Resident #210's admission on [DATE] indicated one shower sheet for 10/26/2023. There was no shower sheet for 10/30/2023 and 11/01/2023. During an observation and interview on 10/30/2023 at 3:40 PM, Resident #210 was in his bed and his hair was unkempt, oily, and stuck together. Resident #210 said he had a sponge bath a couple days ago. During an observation and interview on 11/02/2023 at 8:55 AM, Resident #210 said he did not have a bath or shower yesterday and he could not remember when his last one was. Resident #210's hair was oily and stuck together and unkempt. During an interview on 11/02/2023 at 9:08 AM, CNA L said today Resident #210's showers were changed to Tuesday, Thursday, Saturday because he went to dialysis on Monday, Wednesday, Friday. CNA L said prior to today he was supposed to receive his showers on Monday, Wednesday, Friday. CNA L said she worked yesterday (Wednesday, 11/01/2023) on the 200 hall and gave showers. CNA L said she was supposed to give Resident #210 a shower, but she had not given him a shower because he was gone to dialysis. CNA L said he returned from dialysis around noon, and she was busy with lunch. CNA L said she had not informed the following shift she had not had time to give him a shower so they could do it. CNA L said it was important for the residents to receive their baths/showers for them to not smell bad and for their skin. During an interview on 11/02/2023 at 9:25 AM, CNA M said she worked the 200 hall on Monday 11/01/2023. CNA M said she did not know if she was supposed to give Resident #210 a shower. CNA M said she did not pay attention to when Resident #210 was supposed to receive his shower. CNA M said she was supposed to check to see who received a shower on Monday. CNA M said she did not give Resident #210 a shower because he was gone to dialysis, and she did not notify the following shift that he needed a shower. CNA M said it was important for the residents to get their showers, so they did not get germs, or an infection, and to prevent skin break down. During an interview on 11/02/2023 11:14 AM, LVN E said the CNAs were responsible for giving the showers. LVN E said she knew Resident #210 had a shower Friday (10/27/2023), but she was not sure if he had received one Monday (10/30/2023) or Wednesday (11/01/2023). LVN E said if the CNAs are not able to get to a shower when it was scheduled, they should let the following shift know for them to complete it. LVN E said the CNAs brought the bath sheets to the nurse for the nurse to sign it. LVN E said she did not realize Resident #210 had not received a shower. LVN E said it was important for the residents to receive their baths/showers for their skin and for their health. During an interview on 11/02/2023 at 12:10 PM, the DON said all the staff were supposed to be making sure the baths/showers were done. The DON said the CNAs were supposed to do what was on the schedule and the nurses were supposed to follow up and ensure the baths/showers were completed. The DON said she was responsible for monitoring that the showers were completed. The DON said she depended on their staff to complete their assignments. The DON said she made rounds every day to make sure people looked clean and well groomed. The DON said she had noticed issues with shower and was trying to address them. The DON said it was important for the residents to get their showers/baths for their hygiene, skin integrity, dignity, and to prevent infections. The DON said she was not aware Resident #210 had not received his showers as scheduled. The DON said if the CNAs were not able to do his shower because he was at dialysis, they should have let the next shift know so they could do it. During an interview on 11/02/2023 at 1:32 PM, the Administrator said the charge nurses were responsible for ensuring the showers were done. The Administrator said she expected for the residents to receive their showers as scheduled. The Administrator said it was important for the residents to receive their showers for them to maintain good hygiene. Record review of the facility's policy titled, Quality of Life- Resident Self Determination and Participation, revised December 2016, indicated, . Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including: a. Daily routine . and bathing schedules; b. Personal care needs, such as bathing methods, grooming styles and dress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 20 residents (Residents #28) reviewed for pharmacy services. The facility failed to ensure Resident #28 received insulin as prescribed. The facility failed to ensure Resident #28's blood sugar was rechecked in an hour. These failures could place residents at risk for hospitalizations, not receiving services to meet their needs, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/02/2023 indicated Resident #28 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of the right side of the body following a stroke), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus (high blood sugars). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #28 was able to make herself understood and understood others. The MDS assessment indicated Resident #28 had a BIMs score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #28 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of Resident #28's Order Summary Report dated 10/31/2023, indicated orders for Fingerstick blood sugars 3 times a day before meals Humulin R Solution (Insulin Regular Human medication used to lower blood sugar) inject per sliding scale: if blood sugar 0 - 70 give 25 ml of orange juice; blood sugar 151 - 200 give 3 units; blood sugar 201 - 250 give 5 units; blood sugar 251 - 300 give 7 units; blood sugar 301 - 400 give 11 units; blood sugar more than 401 give 11 units recheck in 2 hours, if over 400, call the medical director or nurse practitioner, subcutaneously (injection under the skin) every 8 hours as needed for diabetes mellitus with a start date of 02/25/21 Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine medication used to lower blood sugar) Inject 60 units subcutaneously two times a day for diabetes with a start date of 05/31/23. Record review of Resident #28's MAR for October 2023 indicated: 10/27/2023 at 4:30 PM LVN N documented a blood sugar of 422 no Humulin R was administered. 10/29/2023 at 5:00 AM LVN K documented a blood sugar of 449 and administered 11 units of Humulin R as ordered. Record review of Resident #28's progress notes indicated: 10/27/2023 at 8:23 PM LVN N documented the Medical Director was notified of elevated blood sugar 422 at 2:00 PM. Blood sugar reassessed and indicated to have improved blood sugar 391. 10/29/2023 at 5:31 AM LVN K documented medical director noted, recheck in 1 hour. Regarding the blood sugar of 449. The progress notes for 10/29/2023 did not indicate Resident #28's blood sugar was rechecked in 1 hour. Record review of Resident #28's care plan with a target date of 11/11/2023 indicated to perform blood sugar checks as ordered, administer Humulin R per the sliding scale and Lantus as ordered by the doctor. During an interview on 11/01/2023 at 4:17 PM, LVN K said on 10/29/2023 Resident #28's blood sugar was 449 at 5:31 AM. LVN K said he notified the Medical Director, and the Medical Director instructed him to administer the Humulin R per the sliding scale and recheck Resident #28's blood sugar in 1 hour. LVN K said he did not recheck the blood sugar in an hour because he went home. LVN K said he worked from 10 PM to 6 AM, and an hour later was after his shift ended. LVN K said he forgot to tell the nurse that relieved him to recheck Resident #28's blood sugar. LVN K said it was important to follow the doctor's orders and recheck the blood sugar to make sure the blood sugar was coming down, and it was at a safe level. LVN K said high blood sugars could lead to a diabetic coma. During an interview on 11/02/2023 at 12:15 PM, LVN N said Resident #28's blood sugar was elevated on 10/27/2023, and she notified the Medical Director. LVN N said the Medical Director never responded to her text message. LVN N said this was her way to communicate with the Medical Director and he usually responded. LVN N said she did not try to call the Medical Director again because Resident #28 was due to receive her Lantus 2.5 hours after she checked Resident #28's blood sugar. LVN N said she had not administered the Humulin R as ordered because the computer system was telling her it was too early to administer it. LVN N said she did not notify the DON or attempt to call her to receive advise regarding this. LVN said it was her mistake. LVN N said it was important to administer insulin as prescribed because if the insulin was not administered the residents blood sugar could keep getting higher and it could get pretty bad. During an interview on 11/02/2023 at 12:48 PM, the DON said she was not aware LVN N had not administered insulin as prescribed and had not received a response from the Medical Director when she notified him of Resident #28's high blood sugar on 10/27/2023. The DON said she was not aware LVN K had not rechecked or notified the nurse that relieved him that Resident #28's blood sugar needed to be rechecked on 10/29/2023. The DON said if the Medical Director did not respond to a text message the nurses should call him, and if he still did not answer they should administer the insulin per the orders, notify her, and check the residents blood sugar more frequently. The DON said LVN N should have notified her she was receiving an error message in the computer system and administered the insulin per the orders. The DON said LVN K should have passed on in report that Resident #28's blood sugar needed to be rechecked, so the following nurse could follow up on it. The DON said she was responsible for ensuring the nurses were administering medications as prescribed and following the doctors' orders. The DON said she monitored the nurses by randomly checking the nurse's documentation, the MARs, and completing skills check offs. The DON said they had a standards of care weekly meeting and they went through the residents' blood sugars to see whose blood sugars were high and what interventions were done. The DON said it was important to administer insulin and follow up on high blood sugars to manage the residents' diabetes appropriately and to ensure the insulin was effective. The DON said high blood sugars could result in the residents being hospitalized . The DON said it was important to follow the physician's orders because they were in place for a reason to give the residents the best care possible. During an interview on 11/02/2023 at 1:37 PM, the Administrator said the charge nurses were responsible for following the physician orders and administering medications as prescribed. The Administrator said she expected for the charge nurses to do this. The Administrator said she did not know the outcome of not following the physician orders and not administering medications as prescribed because she was not clinical. Record review of the facility's policy titled, General Guidelines for Medication Administration, last revised 08/2020, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 3 of 20 residents (Residents #4, #16 and #24) reviewed for advanced directives. 1. The facility did not ensure Resident #4's OOH-DNR included the physician signature and physician date the document was signed. 2. The facility did not ensure Resident #16's OOH-DNR included the witness 2 signature, physician license number, and physician date the document was signed. 3. The facility did not ensure Resident #24's OOH-DNR included the witness 1 signature. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 05/24/2021. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #4 usually understood others and usually made herself understood. The assessment indicated Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Record review of the Resident #4's care plan, revised on 06/27/2022, indicated Resident #4 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #4's OOH-DNR form dated 10/10/2016 revealed a missing signature and date by the physician. 2. Record review of Resident #16's face sheet, dated 11/02/2023, indicated Resident #16 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Record review of Resident #16's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 09/24/2021. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #16 understood others and made himself understood. The assessment indicated Resident #16 had a BIMS score of 11, which indicated his cognition was moderately impaired. Record review of the Resident #16's care plan, revised on 10/15/2021, indicated Resident #16 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #16's OOH-DNR form dated 09/22/2021 revealed a missing witness 2 signature, physician license number, and physician date. 3. Record review of Resident #24's face sheet, dated 11/02/2023, indicated Resident #24 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. Record review of Resident #24's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 08/01/2023. Record review of the significant change in status MDS assessment dated [DATE], indicated Resident #24 understood others and made herself understood. The assessment indicated Resident #24 had a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of the Resident #24's care plan, revised on 08/13/2023, indicated Resident #24 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #24's OOH-DNR form dated 07/31/2023 revealed a missing witness 1 signature. During an interview and record review on 11/01/2023 at 1:25 p.m., the Director of Resident Support Services stated she was responsible for completing DNRs. After reviewing Resident #4's electronic medical record, the Director of Resident Support Services stated Resident #4 OOH-DNR was missing a signature and date by the physician. After Resident #16's electronic medical record, the Director of Resident Support Services stated Resident #16 OOH-DNR was missing witness 2 signature, physician license number, and physician date. After Resident #24's electronic medical record, the Director of Resident Support Services stated Resident #24 OOH-DNR was missing witness 1 signature. The Director of Resident Support Services stated she was responsible for overseeing and monitoring by weekly audits. The Director of Resident Support Services stated her last audit was on 10/07/2023. The Director of Resident Support Services stated during the audit she checked the resident code status, care plan, and door label to ensure it was updated in PCC. The Director of Resident Support Services stated during her audits she did not look at the physical documents to ensure it was completely filled out. The Director of Resident Support Services stated it was important to ensure DNRs were completed to respect their wishes. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she expected DNR's to be completely filled out, including signatures, dates, and physician license number. The Administrator stated the Director of Resident Support Services was responsible for overseeing and monitoring the DNR. The Administrator stated it was important to ensure the DNR's were completed because, legally the form stated it must have signatures, dates, and physician license number . Record review of the facility's policy titled; Advanced Directives, effective 04/2020 did not address advance directive completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 6 of 20 residents (Resident #8, Resident #13, Resident #19, Resident #25, Resident #47, and Resident #52) reviewed for accidents and supervision. The facility did not ensure Resident #52 smoked in the designated smoking area while being supervised during the smoke break. The facility did not ensure PTA F used the gait belt appropriately while ambulating Resident #25. The facility failed to ensure the safety of Resident #13 by not moving the Resident to another location/bed prior to removing/working on the bed. The facility failed to properly store aerosol can with a labeled Lavender Scent Deodorizer Spray leaving them on Resident #47's dresser. The facility failed to properly store 3 air freshener sprays and 1 container of disinfectant wipes leaving them on the bottom shelf of a stand at the foot of the bed in Resident #8's room. The facility failed to properly store razors leaving them on top of Resident #19's dresser. These failures could place residents at an increased risk for injury. Findings included: 1. Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of sepsis, unspecified organism (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 currently used tobacco. Record review of the comprehensive care plan, initiated on 05/18/23, revealed Resident #52 smoked. The goals included: Resident will have supervised smoking privileges to minimize safety risks. The interventions included: Resident will smoke only in designated smoking area with access to appropriate smoking receptacles. Record review of Resident #52's Safe Smoking Assessment, dated 07/30/23, revealed The resident requires direct supervision while smoking. Record review of the list of designated smoking times and staff responsible for supervising the smoke break, undated, revealed housekeeping staff, dietary staff, and the Social Worker were responsible for supervising the designated smoking breaks. During an observation on 10/31/23 beginning at 3:01 PM, multiple residents were outside in the designated smoking area. The Social Worker was supervising the smoke break and was sitting in a metal chair in the designated smoking area. Resident #52 was sitting up in her wheelchair, outside the designated smoking area on the sidewalk near a grassy area and was approximately 20 feet from a large propane tank. Resident #52 was observed smoking a red-tipped cigarette and flicking her ashes on the ground. The propane tank was in the grass with a metal chain-link fence around it. There was a large sign that read PROPANE: No Smoking; No Open Flames. There were approximately 11 red-tipped cigarette butts in the grass where Resident #52 was sitting. During an observation and interview on 10/31/23 at 3:38 PM, the Administrator accompanied the surveyor into the smoking area. There were approximately 11 red-tipped cigarette butts in the grass approximately 20 feet away from the propane tank. The Administrator stated Resident #52 should not have been smoking outside the designated smoking area. The Administrator stated cigarette butts should not have been thrown on the ground or in the grass. The Administrator stated she would provide in-service education to the facility staff. During an interview on 10/31/23 beginning at 4:06 PM, Food Service Manager C stated she supervised smoke breaks some of the scheduled times. Food Service Manager C stated the residents stayed inside the black gate during smoking breaks, which indicated the designated smoking area. Food Service Manager C stated during the smoke breaks she supervised; no residents had smoked outside the designated smoking area near the propane tank. Food Service Manager C stated she stayed outside with the residents until they were finished smoking. During an interview on 10/31/23 beginning at 4:08 PM, Resident #52 stated she normally sat in the designated smoking area. Resident #52 stated she had been sitting outside the smoking area during the last few days because it was cold, and she wanted to sit in the sun. Resident #52 stated no staff members had attempted to encourage her to sit in the designated smoking area. During an interview on 10/31/23 beginning at 4:13 PM, Community Cleanliness Provider A stated she normally assisted residents to smoke during the 8:30 AM, 10:30 AM, and 1:15 PM smoke breaks. Community Cleanliness Provider A stated the residents normally sit under the covered patio with the black fence around it. Community Cleanliness Provider A stated she had not observed any residents or staff smoking outside the designated smoking area near the propane tank. During an interview on 10/31/23 beginning at 4:23 PM, the Social Worker stated she was responsible for supervising residents during the 3:00 PM smoke break. The Social Worker stated Resident #52 usually sat outside the designated smoking area because she wanted to sit in the sun, but she stated Resident #52 did not normally smoke. The Social Worker stated she had not noticed Resident #52 smoking outside the designated area during the 3:00 PM smoke break. The Social Worker stated an explosion or fire could have happened if residents smoked outside the designated smoking area and threw their cigarette butts on the ground. Record review of the Smoking policy, undated, revealed Smoking by residents is allowed outside in designated, marked smoking areas . The policy further revealed IDT will develop an individualized plan for .required supervision for residents who smoke. 2. Record review of the face sheet, dated 11/01/23, revealed Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema (complication of high blood sugar where blood vessels in the eye are damaged causing swelling), legal blindness (unable to see), unsteadiness of feet, difficulty in walking, ataxia (loss of coordination of voluntary muscle movements), and muscle wasting and atrophy (loss of muscle and muscle mass leading to its shrinking and weakening). Record review of the MDS assessment, dated 09/22/23, revealed Resident #25 had clear speech and was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #25 required an extensive, one-person assistance with transfers, walking, and dressing. The MDS revealed Resident #25 was not steady and only able to stabilize with staff assistance for walking, turning around, and moving from a seated to standing position. Record review of the comprehensive care plan, revised on 10/05/23, revealed Resident #25 had an ADL self-care performance deficit related to his disease processes. The interventions did not address walking. The interventions for transfers included: .requires extensive assistance by 2 staff to move between surfaces as necessary. During an observation on 10/30/23 beginning at 10:06 AM, PTA F assisted Resident #25 with walking down the hallway using his walker. Resident #25 had a gait belt around his upper body. The gait belt was loose, hanging low, and twisted in the middle of his back. PTA F was holding Resident #25's shorts to guide him. PTA F was not holding onto the gait belt. During an interview on 11/02/23 beginning at 8:56 AM, PTA D stated PTA F was not scheduled to work until 11/03/23. PTA D was unable to provide PTA F's phone number at the time of the interview. PTA D stated gait belts should have been placed below the ribs or above the breasts under the armpits depending on the person. PTA D stated the gait belt should have been snug but not too tight. PTA D stated Resident #25 was in between independent and contact guard assistance. PTA D stated Resident #25 required hands on assistance sometimes. PTA D stated staff should not hold onto residents' pants during transfers unless they were falling. PTA D stated if the clothing was loose then he would have held both the pants and the gait belt while walking the resident. PTA D stated the gait belt should not have been twisted when placed on the resident. PTA D stated it was important to ensure the gait belt was placed appropriately to prevent skin injury and potential falls. During an interview on 11/02/23 beginning at 9:28 AM, the Director of Rehab stated the gait belt should be applied around the waist snuggly. The Director of Rehab stated the gait belt should be snug but comfortable for the resident. The Director of Rehab stated the gait belt should not have been twisted, but flat against the residents clothing. The Director of Rehab stated staff should have been holding the gait belt while walking with a resident. The Director of Rehab stated she had only been in the director role for approximately six months and gait belt training had not been performed by the therapy department. The Director of Rehab stated it was important to ensure the gait belt was appropriately placed to prevent an injury to the resident. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to ensure the gait belt was used appropriately. The DON stated the gait belt should not have been twisted or applied loosely. The DON stated the staff should have held the gait belt while ambulating Resident #25. The DON stated gait belt training was provided at least annually and staff would have been retrained if issues were observed. The DON stated it was important to ensure staff was using gait belts appropriately for resident safety. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected therapy staff to follow their practices and procedures for appropriately applying the gait belt. The Administrator stated the therapy manager was responsible for monitoring to ensure gait belts were used appropriately. The Administrator stated it was important to ensure gait belts were used appropriately for resident safety. Record review of an e-mail, accessed on 11/06/23, revealed a statement from PTA D sent by the Administrator as additional evidence. The statement from PTA D revealed In reference to the tag . received for the gait training I performed with the resident in room [ROOM NUMBER]: I was holding onto the patient's shorts elastic waist band because his shorts are loose and the resident requested that I hold them up otherwise they (his shorts) would fall to the ground while ambulating which would impose a safety concern on its own as well as degrade the patient's inherent right to dignity as he would be exposed to the other residents in the hallway. Furthermore, on this topic, this resident is legally blind and requires the use of tactile cues for navigation in a dynamic environment, such as a hallway, and I am unable to provide the most optimum tactile cues by only holding onto the gait belt. Also, this resident typically does not require the constant use of Contact Guard Assistance (holding onto the gait belt) for gait training which would further explain why I was not directly holding onto the gait belt. The gait belt was merely placed on the resident because it is best practice for safety. Rarely, if ever, does this resident require the use of holding onto the gait belt for balance corrections. During a telephone interview on 11/06/23 beginning at 9:57 AM, PTA D stated Resident #25 did not normally use a gait belt. PTA D stated the gait belt was only applied for safety reasons. PTA D stated on 10/30/23 Resident #25 requested him to hold onto his shorts so they did not fall. PTA D stated Resident #25 did not request his shorts to be changed. PTA D stated the gait belt should have been applied snuggly but Resident #25 requested the gait belt not be tight. PTA D stated the gait belt should not have been twisted. PTA D stated it was important to ensure the gait belt was applied properly to prevent injury to the resident in case it needed to be used. Record review of the Safe Lifting and Movement of Residents policy, revised July 2017, revealed .this facility uses appropriate techniques and devices to lift and move residents. The policy did not address the proper use of a gait belt when assisting residents with ambulation. 3. Record review of Resident #13's face sheet, dated 11/01/2023, indicated an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS Resident Assessment and Care Screen indicated 09/18/2023 indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. During an observation on 10/31/2023 at 10:32 AM, the Maintenance Supervisor was lying on the floor with the front portion of his body under Resident #13's left side of bed. The Maintenance Supervisor had a tool in hand and working on the bed. Resident #13's bed was in high position. During an observation on 11/01/2023 at 4:32 PM, the right-side rail had been removed from Resident #13's bed. During an interview on 11/02/23 at 12:07 PM, the DON said usually we take the residents out of the bed to remove the assist rails. The DON said Resident #13 no longer used the rails for bed mobility since she has declined. The DON said the facility had recently gone through and did assessments to make sure the resident's qualified to have the assistance rails and more than likely that's what the maintenance supervisor was doing at that time. The DON said the Resident should not have been in the bed while the work was being done with the bed in high position and the maintenance supervisor under it. The DON said it was not safe for resident or the maintenance supervisor. During an interview on 11/02/2023 at 12:32 PM, the Maintenance Supervisor said he was tightening the rail on resident #13's bed. He said Resident #13 was left in the bed while he made the repairs because he was not disturbing her, and it was not a safety issue. The Maintenance Supervisor said it was the only way to do the repairs to his knowledge because the resident cannot get out of the bed as she is in the dying process. During an interview on 11/02/2023 at 01:30, the Administrator said they would not have move Resident #13 out of bed for the bedrail repairs because she is in the dying process and would not want to cause discomfort and pain. 4. Record review of Resident #47's face sheet, dated 11/01/2023, indicated a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Prostate (abnormal growth where cells divide uncontrollably and destroy bodily tissue), Secondary Malignant Neoplasm of other Parts of Nervous System, Acquired Absence of other Genital Organ (missing one or several genitals due to injury or operation), Paraplegia (paralysis of the lower body), other cord compression, essential Hypertension (high blood pressure), Neuromuscular Dysfunction of Bladder (lack of bladder control related the muscles and nerves do not work well together). Record review of the MDS Resident Assessment and Care Screen indicated 08/30/2023 indicated Resident #47 was able to make self-understood and understood others. The MDS assessment indicated Resident #47 had a BIMS score of 14, which indicated cognitively intact. The MDS assessment Indicated Resident #47 required limited assistance for bed mobility, dressing, and personal hygiene and extensive assistance for transfers and toilet use. During an observation and interview on 10/30/2023 at 1:08 PM, an aerosol can with a labeled Lavender Scent Deodorizer Spray was sitting on the dresser in Resident #47's room. Resident #47 said he had won the aerosol spray during a Bingo game. During an observation on 10/31/2023 at 09:10 AM, an aerosol can with a labeled Lavender Scent Deodorizer Spray was sitting on the dresser in Resident #47's room. 5. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, moderate, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (pain that lasts a long time and affects your mood, sleep, and daily living), and acute kidney failure (sudden and serious condition that affects your kidneys' ability to filter waste and fluid from your blood). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #8 had a BIMS score of 7, which indicated her cognition was severely impaired. During an observation on 10/30/2023 at 4:32 PM, Resident #8 had 3 air freshener sprays and 1 container of disinfectant wipes on the bottom shelf of the stand at the foot of her bed. All items were labeled keep out of reach of children. During an observation on 11/01/2023 at 9:18 AM, Resident #8 had 3 air freshener sprays and 1 container of disinfectant wipes on the bottom shelf of the stand at the foot of her bed. 6. Record review of Resident #19's Order Summary Report indicated he was [AGE] years old and admitted on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia (carbon dioxide level is abnormally high in the blood causing respiratory failure), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus with foot ulcer (high blood sugar levels in the blood with a foot wound). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #19 was able to make himself understood and understood others. The MDS assessment indicated Resident #19 had a BIMs score of 12, which indicated his cognition was moderately impaired. During an observation on 10/30/2023 at 10:37 AM, Resident #19 had razors on his bedside table. Resident #19 said his family member had provided them for him and the CNAs used them to shave him. During an observation on 11/01/2023 at 09:55 AM, Resident #19 had razors on his bedside table. During an interview on 11/01/2023 at 10:01 AM, LVN E said Resident #8 should not have air freshener sprays and disinfectant wipes in her room. LVN E said Resident #8's family must have [NAME] the items into Resident #8's rooms, and she had not noticed them in there. LVN E said all the staff were responsible for ensuring the residents rooms did not have room sprays and disinfectant wipes in them. LVN E said the residents were not supposed to have razors on the dresser. LVN E said she had not seen Resident #19 had razors on his dresser. LVN E said the CNAs should ensure they were not left in the room accessible to the residents. LVN E said it was important for the residents to not keep room sprays because they could be flammable, and it was a danger to the residents. LVN E said the residents should not have disinfectant wipes in their rooms because the residents could confuse them with wet wipes and use the wrong wipe and cause harm to themselves. LVN E said wandering and confused residents could go in the resident's room and harm themselves. LVN E said it was important for the razors to not be left on the resident's dresser because another resident could pick one up and cut themselves and for safety. LVN E said Resident #19 could shave himself without the staff knowing and cut himself and bleed for an extended period before the staff found out. During an interview on 11/01/2023 at 10:33 AM, the ADON said air freshener sprays and disinfectant wipes should not be in the residents' rooms. The ADON said razors were not allowed at the bedside. The ADON said she checked Resident #8's and Resident #19's rooms daily as part of her rounds and she had not noticed the room sprays, disinfectant wipes or razors. The ADON said it was important for the residents to not keep room sprays in their rooms so they would not get something in their eyes or drink something they were not supposed to for their safety. The ADON said it was important for the disinfectant wipes to not be in the residents' rooms because they have chemicals that could harm the residents. The ADON said it was important to not keep razors at the bedside because the residents could be on blood thinners and injure themselves and other residents that did need their hands on the razors could get a hold of them. During an interview on 11/02/2023 at 12:32 PM, the DON said she encouraged the residents to not have room sprays and disinfectant wipes in their rooms. The DON said if they did have them in their rooms these items should be stored somewhere safe and out of reach of other residents. The DON said Resident #8 should not have had room sprays and disinfectant wipes in her room. The DON said it was important for the room sprays and disinfectant wipes to be stored properly and out of reach of other residents for the resident's safety. The DON said she did not want a confused resident to get a hold of these items and hurt themselves. The DON said razors should not be left on top of the dresser. The DON said it was important for razors to be out of the reach of the residents because they could hurt themselves or others. The DON said it was all the staff's responsibility to keep room sprays, disinfectant wipes, and razors out of the residents reach for their safety. During an interview on 11/02/2023 at 1:33 PM, the Administrator said room sprays and disinfectant wipes were allowed in the rooms because it was the residents choice to keep them in their rooms. The Administrator said it was important for room sprays and disinfectant wipes to be out of reach of other residents because if they should not have it, they would not get it. The Administrator said residents were allowed to keep razors at the bedside if they were capable of keeping them. The Administrator said the razors at the bedside could pose a risk to other residents, but there were so many hazards that could be dangerous in the residents' rooms. The Administrator said all the staff were responsible for ensuring the residents environment was safe for them. During an interview on 11/02/2023 at 1:10 PM, the DON said she could not find a policy regarding accidents and hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 3 of 20 residents (Residents #4, #9 and #24) reviewed for medical records. 1. The facility did not ensure Resident #4's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #4's side effects were adequately monitored regarding her antianxiety, antidepressant and antipsychotic medications. 2. The facility did not ensure Resident #9's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #9's side effects were adequately monitored regarding her antianxiety and antidepressant medications. 3. The facility did not ensure Resident #24's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #24's side effects were adequately monitored regarding her antianxiety medication. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included anxiety/major depressive disorder, and schizophrenia (mental condition involving a breakdown in the relation between though, emotion, and behavior). Record review of Resident #4's physician order summary report, dated 11/02/2023, indicated an active physician's order for: *Buspirone 5 mg 1 tablet three times a day for anxiety with a start date of 10/29/2021 *Duloxetine 20 mg 1 tablet daily for depression with a start date of 06/10/2022 *Risperidone 0.5 mg 1 tablet at bedtime for schizophrenia with a start date of 06/07/2023 Record review of the quarterly MDS dated [DATE], indicated Resident #4 usually understood others and usually made herself understood. The assessment indicated Resident #4 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #4 received antianxiety, antidepressants and antipsychotic medications during the 7 day look back period. Record review of the Resident #4's care plan, revised on 06/27/2022, indicated Resident #4 had a behavior related to schizophrenia and used an antianxiety and antidepressant medication. The care plan interventions included, administer Duloxetine as ordered by physician, monitor/document side effects/effectiveness every shift, administer antianxiety medication as ordered by physician, monitor for side effects/effectiveness every shift, and monitor behavior episodes and attempt to determine underlying cause. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. 2. Record review of Resident #9's face sheet, dated 11/02/2023, indicated Resident #9 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included major depressive and anxiety disorder. Record review of Resident #9's physician order summary report, dated 11/02/2023, indicated an active physician's order for: *Buspirone 10 mg 1 tablet by mouth two times a day for anxiety with a start date of 12/01/2021 * Citalopram Hydrobromide 10 mg 1 tablet by mouth daily for depression with a start date of 06/07/2022 *Trazadone 100 mg 1 tablet at bedtime for depression with a start date of 01/11/2022 Record review of Resident #9's annual MDS, dated [DATE], indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 had a BIMS score of 13, which indicated her cognition was intact. The assessment indicated Resident #9 received antianxiety and antidepressant medications during the 7 day look back period. Record review of Resident #9's care plan, revised on 06/17/2022 indicated Resident #9 used an antianxiety and antidepressant medication. The care plan interventions included, administer antidepressant and antianxiety medications as ordered by physician, and monitor/document side effects/effectiveness every shift. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. 3. Record review of Resident #24's face sheet, dated 11/02/2023, indicated Resident #24 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. The face sheet did not address the anxiety diagnosis. Record review of Resident #24's physician order summary report, dated 11/02/2023, indicated an active physician's order for: * Alprazolam 0.25 mg 1 tablet by mouth two times a day for anxiety with a start date of 08/03/2023 * Alprazolam 0.25 mg 1 tablet by mouth every 6 hours as needed for anxiety with a start date of 10/26/2023 Record review of the significant change in status MDS dated [DATE], indicated Resident #24 understood others and made herself understood. The assessment indicated Resident #24 had a BIMS score of 10, which indicated her cognition was moderately impaired. The assessment indicated Resident #9 received antianxiety medication during the 7 day look back period. Record review of the Resident #24's care plan, revised on 08/15/2023, indicated Resident #24 used an antianxiety medication. The care plan interventions included, administer antianxiety medication as ordered by physician, and monitor/document side effects/effectiveness every shift. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. During an interview on 11/01/2023 at 1:44 p.m., LVN E stated the charge nurses were responsible for monitoring/documenting behaviors and side effects in PCC (electronic medical record). LVN E stated psychotropic medications required to be monitored to ensure the medication was effective and to show whether or not the medication was required. LVN E stated if the resident was not having any behaviors, 0 should be documented or if the resident was exhibiting s/sx, 1, 2 or 3 should be documented. LVN E stated it was not appropriate to document NA to indicate if the resident was exhibiting side effects or behaviors. LVN E stated it was important to ensure there was not an error in documentation to prevent the medication from getting discontinued and putting the residents at risk for increased depression, anxiety, and psychotic episodes. LVN E stated the risk associated with error in documentation was extended problems such as tardive dyskinesia, N/V, rash and swelling. During an interview on 11/02/2023 at 9:11 a.m., the DON stated she expected the nurses to monitor for side effects and behaviors by properly documenting in the resident's chart. The DON stated the nurses should assessed the residents for side effects and behaviors for psychotic medications and chart if the resident was exhibiting side effects or behaviors such as panic attacks, yelling, screaming, or cursing. The DON stated if the resident was not exhibiting any s/sx the charge nurses were to document 0 which indicated no side effects/behaviors. The DON stated the monitoring should be 0,1, 2 or 3 and not NA to indicate side effects/behaviors. The DON stated she expected every shift to monitor and document for any side effects or behaviors. The DON stated there was not a consistent procedure for monitoring to ensure follow up for complete documentation. The DON stated it was important to monitor for side effects/behaviors to properly treat the resident and to ensure medication was effective. The DON stated the risk associated with error in documentation was residents not properly being treated for the psychotic medication. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she was referring to the DON regarding psychotropic medications documentation because she was responsible for monitoring that system. During an interview on 11/02/2023 at 11:57 a.m., the Regional MDS nurse stated there was not a policy and procedure regarding behavior monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 9 residents reviewed for insulin administration. (Resident #52) The facility did not ensure LVN P and RN Q administered Resident #52's Humalog (insulin lispro) KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 was taking insulin and an indication was noted. The MDS revealed Resident #52 received an insulin injection 3 out of 7 days during the look-back period. Record review of the comprehensive care plan, initiated on 04/27/23, revealed Resident #52 was at risk for complication related to diagnosis of type 2 diabetes mellitus. The interventions included: Diabetes medication as ordered by doctor. Record review of the order summary report, dated 10/31/23, revealed Resident #52 had the following orders: Insulin lispro injection - inject 5 units subcutaneously before meals and at bedtime for diabetes, which started on 10/08/23. Humalog KwikPen 100 units/ML - inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; notify MD if greater than 400 for orders, subcutaneously before meals and at bedtime for diabetes, which started on 10/11/23. Record review of the MAR, dated October 2023 and November 2023, revealed Resident #52 received insulin injections daily. Record review of the manufacturer's instructions titled Instruction for Use - Humalog KwikPen (insulin lispro) ., accessed on 11/01/23 at 3:09 PM, revealed Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. During an observation and interview on 10/31/23 beginning at 4:00 PM, LVN P was standing at her medication cart. LVN P stated she was going to perform a finger stick blood sugar check and administer insulin to Resident #52. LVN P prepared the finger stick blood sugar check and went into Resident #52's room. LVN P stuck Resident #52's finger and obtained a small amount of blood for the test. The result was 295. LVN P returned to the cart to prepare the insulin for Resident #52. LVN P took a Humalog KwikPen with Resident #52's name on it out of the medication cart. LVN P took the lid off the pen and opened the needle tip to apply to the pen. LVN P applied the needle and rotated the dial to 5 units. LVN P did not prime the pen (push through 2 units of insulin to remove air from the needle). LVN P administered 5 units of insulin to Resident #52's left lower quadrant of her abdomen. LVN P returned to the medication cart and realized she administered the incorrect amount of insulin. LVN P stated she should have administered 6 units of the Humalog KwikPen according to the sliding scale and then another 5 units of the insulin lispro pen. LVN P took the Humalog KwikPen and applied another needle tip. LVN P rotated the dial to 1 unit, to equal a total of 6 units. LVN P then obtained an insulin lispro pen with Resident #52's name on it from the medication cart. LVN P took the lid off the pen and opened the need tip to apply to the pen. LVN P applied the needle and rotated the dial to 5 units. LVN P did not prime either pen while preparing the insulin for administration. LVN P administered 1 unit of the Humalog KwikPen and 5 units of the insulin lispro pen to Resident #52's left lower quadrant of her abdomen. LVN P returned to the medication cart. LVN P stated she noticed Resident #52 had two different orders for insulin administration. LVN P stated Resident #52 received 5 units of insulin routinely and then received additional insulin based on the results of her finger stick blood sugar. LVN P stated Resident #52 had two different insulin pens on the medication cart, Humalog, and insulin lispro (the same medication). During an observation and interview on 11/01/23 beginning at 4:08 PM, RN Q was standing at her medication cart. RN Q stated she had obtained Resident #52's finger stick blood sugar and the result was 260. RN Q obtained the Humalog KwikPen with Resident #52's name on it from the medication cart. RN Q took the lid off the pen and opened the needle tip to apply to the pen. RN Q applied the needle and rotated the dial to 11 units. LVN P stated she combined the routinely ordered 5 units with the sliding scale requirement of 6 units to equal a total of 11 units. RN Q did not prime the pen (push through 2 units of insulin to remove air from the needle). RN Q stated she did not normally prime the insulin pen prior to administration. RN Q stated she was believed they were required to prime the insulin pen before the initial dose only. During an interview on 11/02/23 beginning at 9:45 AM, LVN P stated the process for administering an insulin injection was to look at the orders, find the correct pen with the resident's name on it, dial the pen to the correct amount and administer the insulin. LVN P stated she did not normally prime the insulin pen prior to each use. LVN P stated she would only have primed the pen if it was the initial use. LVN P stated she was unaware the manufacturer's instructions on the insulin pen required priming the pen before each use. LVN P stated she had received training in the past for the insulin pen, approximately 2011 or 2012. LVN P stated it was important to ensure the manufacturer's instructions were followed to ensure the residents received the accurate dosage of medication. LVN P stated if the accurate dose was not received, the diabetes could not have been managed. LVN P stated it could have made the blood sugars high or low. During an interview on 11/02/23 beginning at 9:56 AM, the Pharmacy Consultant stated an insulin pen should definitely have been primed prior to the first use. The Pharmacy Consultant stated if facility staff primed the insulin pen before each use, they would run out of the medication. The Pharmacy Consultant stated she was driving but she believed the manufacturer's instructions were to prime only before the initial dose. The Pharmacy Consultant stated it was important to prime the pen to ensure it was working correctly and the residents received the correct dose of insulin. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected the nursing staff to follow policy, procedure, and manufacturer's instructions when administering insulin pens. The DON stated training was provided for administering insulin approximately at the beginning of the year. The DON stated to her knowledge she did not recall that the training addressed using the insulin pen, only the insulin vials. The DON stated the nurse management was responsible for monitoring to ensure insulin was administered correctly to the residents. The DON stated it was monitored by random observations and during monthly visits by the pharmacy consultant. The DON stated it was important to ensure insulin was administered according to the manufacturer's instructions, so the residents received the correct dosage of insulin. The DON stated receiving the incorrect dosage of insulin could have caused the blood sugars to become high or low. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected nursing staff to follow manufacturer's instructions when administering the insulin pens. The Administrator stated the DON was responsible for monitoring to ensure the nursing staff administered insulin correctly. The Administrator stated it was important to ensure insulin was administered according to manufacturer's instructions because staff was supposed to do things the correct way. The Administrator stated there were procedures to follow. Record review of the Administration Procedures for All Medications policy, revised 08/2020, revealed .consult a drug reference, manufacturer package insert, or pharmacist for more information .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 20 residents (Resident #8, Resident #9, and Resident #40) and 1 of 1 empty resident's room reviewed for drugs and biologicals. The facility failed to ensure Resident #8's Afrin (nasal spray medication) was stored properly. The facility failed to ensure Resident #40's Azelastine (nasal spray medication) was stored properly. The facility did not ensure a Plavix pill (antiplatelet) was stored in a locked container and original packaging. The facility did not ensure Resident #9's multivitamins, ear drops, and triple antibiotic ointment were properly safe and secured. These failures could place residents at risk of medication misuse and diversion. Findings included: 1. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, moderate, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (pain that lasts a long time and affects your mood, sleep, and daily living), and acute kidney failure (sudden and serious condition that affects your kidneys' ability to filter waste and fluid from your blood). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #8 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #8 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of the care plan with date initiated 09/14/2023 indicated Resident #8 had impaired cognitive function or impaired thought process to administer medications as ordered. Resident #8's care plan did not indicate she could self-administer medications. During an observation on 10/30/2023 at 4:32 PM, Resident #8 had Afrin nasal spray on her bedside dresser. During an observation on 11/01/2023 at 9:18 AM, Resident #8 had Afrin nasal spray on her bedside dresser. Record review of the Order Summary Report dated 10/31/2023 indicated Resident #8 did not have an order for Afrin. There was no order to indicate Resident #8 was able to self-administer medications. 2. Record review of a face sheet dated 11/02/2023 indicated Resident #40 was an [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia in other diseases classified elsewhere, moderate, other diagnosis without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ((loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #40 was able to make herself understood and understood others. The MDS assessment indicated Resident #40 had a BIMs score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #40 required supervision for bed mobility, dressing, and toilet use, and limited assistance with transfers and personal hygiene. Record review of the care plan with a target date of 11/11/2023 indicated Resident #40 had impaired cognitive function and loss of memory. Resident #40's care plan did not indicate she could self-administer medications. Record review of Resident #40's Order Summary Report dated 11/02/2023 indicated Resident #40 had an order for Azelastine solution 0.1% 1 spray in both nostrils two times a day with a start date of 09/16/2022. There was no order to indicate Resident #40 could self-administer medications. During an observation and interview on 10/30/2023 at 10:29 AM, Resident #40 had Azelastine on the dresser by her bed. Resident #40 said she used it sometimes when she got the snuffles. During an observation on 10/31/2023 at 9:19 AM, Resident #40 had Azelastine on the dresser by her bed. During an observation on 11/01/2023 at 9:55 AM, Resident #40 had Azelastine on the dresser by her bed. During an interview on 11/01/2023 at 10:07 AM, LVN E said the residents should not have nasal sprays at the bedside. LVN E said the nurses and management staff were responsible for ensuring the residents did not have nasal sprays at the bedside. LVN E said she was not aware Resident #8 and Resident #40 had nasal sprays on their dressers. LVN E said it was important for the residents not to keep medications at the bedside because the resident may not be in the state of mind to self-administer. LVN E said if the resident's mental capacity allowed for them to keep medications in the room, they would have to have a doctor's order. During an interview on 11/01/2023 at 10:33 AM, the ADON said the residents were not allowed to keep nasal sprays at the bedside because they were medications. The ADON said management staff performed daily rounds to check the residents' rooms. The ADON said she had done the rounds on Resident #8 and Resident #40, and she had not noticed they had nasal spray at their bedside. The ADON said it was important for the residents not to keep medications at their bedside because the medications had doses and the staff did not need to allow the residents to use the medication as often as they want, and medications required monitoring. During an interview on 11/02/2023 at 12:36 PM, the DON said Resident #8 should not have Afrin in her room, and Resident #40 should not have Azelastine in her room. The DON said those medications should be on the medication carts. The DON said she was not aware those medications were in the residents' rooms. The DON said the department heads, nurses, and CNAs were all responsible for ensuring the residents did not keep medications in their rooms. The DON said it was important for medications to be stored properly for the safety of the residents. During an interview on 11/02/2023 at 1:39 PM, the Administrator said for residents to have medications at the bedside they would have to be assessed for their ability to have it. The Administrator said the IDT was responsible for making sure if medications were at the bedside the residents were appropriately assessed. The Administrator said it was important for them to know if medications were at the resident's bedside because they needed to know what the residents were taking for the resident's safety. 3. During an observation and interview on 10/30/23 beginning at 11:18 AM, a small, round, light pink pill with the letters SG was observed on the ground next to the leg of a chair in an empty resident's room, room [ROOM NUMBER]. The Administrator was notified. The Administrator picked up the pill with a brown paper towel and stated she was going to notify the DON. During an observation and interview on 10/30/23 beginning at 11:33 AM, the DON showed the surveyor the back side of the small, round, light pink pill, which had the numbers 124. The DON stated she looked up the medication and determined it was a Plavix pill, which was an antiplatelet medication. During an interview on 11/01/23 beginning at 4:43 PM, the Director of Environmental Services stated empty rooms were deep cleaned when residents moved out of the room or left the facility. The Director of Environmental Services stated finding medication on the floor was not a common thing, but he had found medication on the floor. The Director of Environmental Services stated when medication was found on the floor, the process was to notify the charge nurse. The Director of Environmental Services stated the empty resident room on Hall 6 was deep cleaned and no medication was observed on the ground. The Director of Environmental Services stated it was important to ensure medication was not left on the floor to ensure medication was accounted for and to ensure the residents received all their medication. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she was unsure how the Plavix pill ended up on the ground in an empty resident room. The DON stated it could have been the last resident to occupy the room or possibly a family member's medication. The DON stated the empty room should have been deep cleaned after the resident moved out or went home. The DON stated she expected the housekeeping staff to ensure the rooms were deep cleaned. The DON stated she expected nursing staff to ensure all medication was administered to a resident. The DON stated she expected staff to notify the nurse if medication was found on the ground. The DON stated medication administration and storage was monitored by random observations and monthly by the pharmacy consultant. The DON stated it was important to ensure medications were properly administered and stored so residents could get the appropriate treatment and to protect other residents from taking medication that did not belong to them. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated there was no medication noticed on the ground the morning on 10/30/23 when she was getting the room ready for the survey team. The Administrator stated the room was cleaned and set up that morning. The Administrator stated she checked all areas including drawers, etc. before saying it was ready for use by the survey team. The Administrator stated the surveyor would have been the first to see the pill on the floor and report it to the facility. The Administrator stated it would not have been seen by anyone else to have been given the opportunity to address it. The Administrator stated if the medication did not belong to one of the surveyors, the only other explanation would have been the pill fell out of the chair after being moved. The Administrator stated it was important to ensure medication was not on the ground for resident safety. 4. Record review of Resident #9's face sheet, dated 11/02/2023, indicated Resident #9 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included cervical disc with myelopathy (an injury to the spinal cord due to severe compression that my resulted from trauma). Record review of Resident #9's annual MDS, dated [DATE], indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 had a BIMS score of 13, which indicated her cognition was intact. The MDS indicated Resident #9 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of Resident #9's care plan, revised on 06/17/2022 indicated Resident #9 had a memory loss, poor cognition and decreased sense of safety related to age progression and pain. The care plan intervention included, communicate with the resident/family/caregivers regarding residents' capabilities. During an observation and interview on 10/30/2023 at 9:56 a.m., Resident #9 was lying in bed. There was a bottle labeled equate ear drops on Resident #9's bedside table. There was a bottle labeled women's multivitamins and triple antibiotic ointment on her dresser. Resident #9 stated a family member brought those to her because her right ear was stopped up. Resident #9 stated I haven't started taking the vitamins. During an observation on 10/31/2023 at 2:37 p.m., Resident #9 was lying in bed. There was a bottle labeled equate ear drops on Resident #9 bedside table. There was a bottle labeled women's multivitamins and triple antibiotic ointment on her dresser. Record review of the physician order summary report dated 11/02/2023 did not indicate Resident #9 had an order for ear drops or triple antibiotic ointment. The physician order summary report indicated Resident #9 had an order for multivitamins with a start date 11/02/2023. During an observation on 11/01/2023 at 3:10 p.m., the DON removed the multivitamins, ear drops and triple antibiotic ointment and instructed Resident #9 that the facility needed to store the medications for safety. During an interview on 11/01/2023 at 4:22 p.m., the Director of Resident Support Services stated she conducted daily rounds for Hall 4 which included Resident #9. The Director of Resident Support Services stated she went in to check on the resident, make sure the room was clean and looked for OTC medications. The Director of Resident Support Services stated she completed rounds this week. The Director of Resident Support Services stated she did notice the ear drops, multivitamins and the triple antibiotic ointment. The Director of Resident Support Services stated she was not aware that Resident #9 could not have the medications at bedside. The Director of Resident Support Services stated it was important that medications were not at bedside because she could use too much, and it was also good for the nurses to keep track on when it was given. During an interview on 11/02/2023 at 9:11 a.m., the DON stated OTC medications were not allowed to be kept at bedside. The DON stated OTC medications were kept in the medication cart. The DON stated families were educated to bring medications to the charge nurse or herself so an order could be obtained and kept in the medication cart. The DON stated if the resident was having ear pain, the resident should have notified the charge nurse or herself so the doctor could be notified. The DON stated she monitored by daily rounds that was conducted by the department heads and nursing staff to oversee any OTC at the bedside. The DON stated it was important that medications were not left at bedside for the safety of other residents and the nursing staff would be aware of what the resident was actually taking. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated OTC medications were not allowed to be kept at bedside. The Administrator stated she expected all medications to be delivered and administered by staff if there was an order for it. The Administrator stated it was important that medications were not left at bedside, so the nursing staff was aware of what medications the residents were taking. Record review of the facility's policy Bedside Medication Storage revised in 08/2020, indicated .Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent) .1. A written order for the bedside storage of medication is present in the resident's medical record Record review of the Storage of Medications policy, dated 08/2020, revealed .provider pharmacy dispenses medications in containers that meet regulatory requirements .Medications are kept in these containers .Only those lawfully authorized to administer medications are permitted to access medications .all medications dispensed by the pharmacy are stored in pharmacy container with pharmacy label .medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart . Record review of the Administration Procedures for All Medications policy, dated 08/2020, revealed .Once removed from the package or container, unused or partial doses should be disposed of in accordance with the medication destruction policy .

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature 1 of 1 lunch meal reviewed for palatability and temperature. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #41, Resident #28, and Resident #19 who complained the food was served cold and did not taste good. The facility failed to ensure the Dietary Manager followed the recipe for pureeing the Swiss steak and California Blend Vegetables (the lunch menu). This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. During an interview on 10/30/2023 beginning at 9:25 AM, Resident #41 stated the food was cold and bland at times. During an interview on 10/30/2023 at 4:11 PM, Resident #28 said sometimes the food smelled like dogfood, and she could not eat it. She stated the food was cold. During an interview on 10/30/2023 at 1:07 PM, Resident #19 said the food was bland and cold. During an observation and interview on 10/31/2023 12:52 PM, the Dietary Manager and four surveyors sampled a lunch tray. The sample tray consisted of oven fried chicken, scalloped potatoes, herbed zucchini, garlic bread, and apple crisp. The Dietary Manager said thehe oven fried chicken was lukewarm. The Dietary Manager said the scalloped potatoes were bland and dry. The Dietary Manager said herbed zucchini was bland and overcooked. During an interview on 10/31/2023 at 4:32 PM, the Dietary [NAME] said he was unaware of any food complaints. The Dietary [NAME] said he ensured food was palatable and appetizing by making sure the food looked appetizing to him and by tasting each entrée. The Dietary [NAME] stated the importance of ensuring food looked appetizing and tasted well was to ensure residents wanted to eat the food. During an interview on 11/02/2023 at 01:30 PM, the Administrator said she expected dietary staff to ensure the food was appetizing and palatable. The ADM stated she had a test tray every day for lunch and supper. The Administrator said she did not have any issues with the palatability of the trays. The Administrator stated ensuring the food was palatable and appetizing was important so residents would find the food enticing. Record Review of the Food Preparation and Service Policy with a revised date of April of 2022, did not address the palatability and temperature of the food. 2. During an observation and record review on 10/30/2023 at 11:52 a.m., of the facility menu indicated that on Monday 10/30/2023 Swiss steak and gravy, California blend vegetables, macaroni and cheese, roll, and lemon bars was to be served for lunch. (Cycle: Week 1 Regular dated 10/30/2023) During an observation and interview on 10/30/2023 at 11:52 a.m., revealed the Dietary Manager prepared the pureed meal for the residents. The Dietary Manager had 4 beef hamburger patties in the blender. He said he had 3 residents who received pureed meals. He placed the hamburger patties into the blender and proceeded to puree. The Dietary Manager stopped the blender and added an unmeasured amount of gravy to the blended meat and continued to process. The Dietary Manager said if the food in the blender became runny, he added a small amount of thickener. The Dietary Manager took the blender and emptied the mixture into a metal pan on the steam table. The Dietary Manager said he watched the consistency of the food until it looked to be the consistency of pudding. The Dietary Manager scooped out 3 servings of the California blend vegetables with a large spoon and placed it into the blender and pureed. He then poured an unmeasured amount of thickener into the vegetables and said it was too thin of a consistency and continued to blend. The Dietary Manager then placed the mixture in a pan and placed the pan on the serving line. The Dietary Manager said he normally followed a recipe when he pureed food. The Dietary Manager said that day he did it by memory. The Dietary Manager said following the menu and recipe for all meals was important to maintain the nutrient value of the food and to maintain residents' weights. Record review of the undated Swiss Steak/Gravy Puree Recipe revealed: Place portions needed into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with a 4 TBSP thickener and ¾ cup hot liquid (both); mix well with a wire whip. Add ½ of the slurry to the meat; process for 1 minute. If too dry, add more slurry until the meat is a pudding consistency. With a rubber spatula, scrape down sides of the bowl and reprocess 30 seconds. Reheat to 165 degrees Fahrenheit and serve meat with 1 #8 scoop topped with 1oz of gravy. Record review of the undated California Blended Vegetables Puree Recipe as follows: Remove portions needed from regular prepared recipe and place into a food processor. Process until fine; for every 5 portions needed, add 2.5 TBSP thickener; process until smooth. Scrape down the sides of the bowl with a rubber spatula; reprocess 30 seconds. Reheat to 165 degrees Fahrenheit and serve with a #12 scoop. During an interview on 10/30/2023 at 4:36 PM, the Administrator stated she expected dietary staff to follow the menu and the recipes for pureed food. The Administrator stated the importance of following the recipe was to ensure residents had the appropriate nutrients. Record review of the Food Preparation and Service Policy with a revised date of April of 2022, revealed the policy did not address following pureed recipes or preparing pureed meals.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care for 2 of 2 meals (Lunch on 10/30/2023 AND 10/31/2023) observed for frequency of meals. The facility failed to serve the 10/30/2023 and 10/31/2023 lunch meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings include: Record review of the facility's mealtimes indicated breakfast at 7:15 AM, Lunch at 12:00 PM, and Supper 5:15 PM. During an observation on 10/30/2023 at 12:42 PM, revealed the residents in the dining room were served lunch. During an observation on 10/31/2023 at 12:48 PM, revealed the residents on 600 hall were served lunch. During an interview on 10/31/2023 at 12:42 PM, Resident #42 said lunch should be served by 12:00 noon and he had not received his tray yet. Resident #42 said this happened all the time. During an interview on 10/31/2023 at 04:32 PM., the Dietary Manager said he was not aware the meals were not served timely or being served cold. The Dietary Manager said the dining hall was served around noon. The Dietary Manager said it was important for the meals to be served on time to the residents, so the meals were hot and tasted good, and the residents meet their nutritional requirements. During an interview on 11/02/2023 at 1:30 PM., the Administrator said that she expected the Dietary Manager to ensure the food to be palatable and served as scheduled to prevent resident weight loss. Record review of the Food Preparation and Service Policy with a revised date of April of 2022, revealed the policy did not address scheduled meal times.

Based on observation, interview, and record review, the facility failed to 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 1 of 2 residents (Resident #28) and 4 of 4 staff (CNA G, CNA H, Community Cleanliness Provider O and Clinical Reimbursement Coordinator) reviewed for infection control. 1. The facility failed to ensure CNA G and CNA H changed gloves and performed hand hygiene while providing incontinent care to Resident #28. The facility failed to ensure CNA G and CNA H did not touch the multi-use wipes container with their dirty gloves. 2. The facility failed to ensure the Clinical Reimbursement Coordinator sanitized her hands between each resident meal tray while passing meal trays on Hall 1. 3. The facility did not ensure Community Cleanliness Provider O kept the personal linen cart covered. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation starting on 10/30/2023 at 2:58 PM, CNA G and CNA H provided incontinent care to Resident #28. CNA H wiped Resident #28's front perineal area using different wipes, and when she was removing the wipes from the wipe container, she was touching the container with her dirty gloves. Resident #28 was then turned onto her side. CNA G wiped Resident #28's back perineal area, and when she was removing the wipes from the wipes container CNA G was touching the wipes container with her dirty gloves. Then with her dirty gloves CNA G grabbed the clean brief, opened it up and laid it down. CNA G did not change gloves or perform hand hygiene prior to grabbing the clean brief. CNA G then changed her gloves and applied clean ones. CNA G did not perform hand hygiene after removing her dirty gloves. CNA G then placed the clean brief under Resident #28 with the dirty brief still under Resident #28. The clean brief touched the dirty brief. Resident #28 was then turned to the opposite side and CNA H removed the dirty brief, and using the same gloves applied the clean brief. CNA H did not change gloves or perform hand hygiene after removing the dirty brief. CNA G and CNA H then removed their gloves and applied new ones. CNA G and CNA H did not perform hand hygiene after removing their dirty gloves. CNA G placed Resident #28's multi-use wipe container on top of her snacks on the over bed table. CNA H and CNA G removed their gloves. CNA H took the trash outside of the room and washed her hands down the hall. CNA G did not perform hand hygiene. During an interview on 10/30/2023 at 3:08 PM, CNA G said she should change gloves when going from front to back. CNA G said she should have performed hand hygiene in between glove changes, but she forgot her gel hand sanitizer. CNA G said she should not have touched the wipes container with her dirty gloves. CNA G said she touched the wipes container with her dirty gloves because she was not paying attention. CNA G said she should not touch the wipes container with dirty gloves because it could result in the spread of infection. CNA G said she should not have touched the clean brief with her dirty gloves. CNA G said they should have removed the dirty brief and then applied the clean brief. CNA G said the clean brief should not touch the dirty brief because they did not want the germs getting on the clean brief. CNA G said not performing proper incontinent care placed the residents at risk for getting an infection. CNA G said she had a training on incontinent care about 2 months ago. During an interview on 10/30/2023 at 3:18 PM, CNA H said she should have washed her hands in between glove changes. CNA H said she forgot to bring her hand sanitizer with her, and she did not know why she didn't go into the resident's bathroom and wash her hands. CNA H said she should have changed gloves before putting on the clean diaper. CNA H said she should not touch the wipes container with dirty gloves. CNA H said it was important for proper incontinent care to be performed for cleanliness and for infection. CNA H said it was important to perform hand hygiene for infection control. CNA H said she had training on incontinent care and hand hygiene every 3 months. During an interview on 11/02/2023 at 12:38 PM, the DON said when doing incontinent care, the CNAs should pull wipes prior to beginning incontinent care, and if they needed more wipes, they should remove their gloves perform hand hygiene and get more. The DON said the CNAs should not touch the wipes container with dirty gloves. The DON said hand hygiene should be performed before the start of care, at the end of care, and in between glove changes. The DON said gloves should be changed when moving from dirty to clean. The DON said the clean brief should not be touched with dirty gloves. The DON said the dirty brief and the clean brief should not touch each other. The DON said incontinent care was monitored by check offs performed quarterly by the ADON and herself. The DON said she also performed random walk ins and watched the CNAs provide incontinent care. The DON said during her observations she had noticed some problems including hand hygiene and bagging items appropriately. The DON said she could not recall any issues with CNA G and CNA H. The DON said it was important to perform hand hygiene and proper incontinent care for infection control and to prevent skin breakdown and infections. During an interview on 11/02/2023 at 1:41 PM, the Administrator said the nursing staff was responsible for ensuring incontinent care was provided to the residents properly. The Administrator said she expected for incontinent care to be done properly and for the staff to perform adequate hand hygiene. The Administrator said it was important for proper incontinent care to be performed and hand hygiene done for infection control. During an interview on 11/02/2023 at 2:03 PM, the Infection Control Preventionist said gloves should be changed when going from dirty to clean. The Infection Control Preventionist said hand hygiene should be performed in between glove changes and before and after providing care. The Infection Control Preventionist said wipes should be removed from the container prior to beginning incontinent care, and the wipes container should not be touched with dirty gloves. The Infection Control Preventionist said the dirty brief should not touch the clean brief. The Infection Control Preventionist said she monitored incontinent care by performing competency check offs and random pop ins. The Infection Control Preventionist said she was responsible for ensuring the CNAs were performing proper incontinent care. The Infection Control Preventionist said it was important for proper incontinent care to be performed to decrease the risk of infections. The Infection Control Preventionist said it was important to perform hand hygiene to decrease the spread of infection. 2. During an observation on 10/30/23 between 12:26 PM and 12:34 PM, the Clinical Reimbursement Coordinator took a meal tray from the meal cart and went into a room on Hall 1. The Clinical Reimbursement Coordinator set up Resident #5's meal tray, then left the room and did not sanitize her hands. The Clinical Reimbursement Coordinator took another meal tray from the meal cart and went into another room on Hall 1. The Clinical Reimbursement Coordinator set up Resident #31's meal tray, then left room and applied hand sanitizer. The Clinical Reimbursement Coordinator took another meal tray from the meal cart and went into another room on Hall 1. The Clinical Reimbursement Coordinator set up Resident #25's meal tray, then left the room and did not sanitize her hands. During an interview on 11/02/23 beginning at 9:08 AM, the Clinical Reimbursement Coordinator stated she should have performed hand hygiene while passing meal trays between each resident. The Clinical Reimbursement Coordinator stated she believed she had performed hand hygiene. The Clinical Reimbursement Coordinator stated it was important to perform hand hygiene between each meal tray for infection control. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to make sure hands were sanitized between each resident while passing meal trays. The DON stated hand hygiene was monitored by random observations. The DON stated it was important to ensure hand hygiene was performed between each resident while passing meal trays for infection control. The policy for passing meal trays was requested and not provided upon exit. The DON stated corporate staff explained there was no policy for passing meal trays. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected staff to sanitize their hands between each resident while passing meal trays. The Administrator everyone was responsible for monitoring to ensure hand hygiene was performed. The Administrator stated it was important to ensure hand hygiene was performed for infection control. Record review of the facility's policy titled, Perineal Care, effective 10/01/21, indicated, To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Put on gloves. 7. Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. 8. For a female resident: a. Use wipes and apply skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back . (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe and/or obtain a clean wipe to clean the urethra or labia . Change wipe and apply skin cleansing agent. d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe and/or obtain a clean wipe to clean the labia . 10. Discard disposable items into designated containers. 11. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean the bedside stand. 15. Wash and dry your hands thoroughly . 3. During an observation and interview on 10/30/2023 at 11:46 a.m., Community Cleanliness Provider O was pushing the personal linen cart, uncovered, on Hall 6. Community Cleanliness Provider O stated she did not know if the linen cart should be covered. Community Cleanliness Provider O stated she would go speak with her supervisor to see if the linen cart should be covered and get back with the surveyor. During an interview on 10/30/2023 at 11:51 a.m., Community Cleanliness Provider O stated the linen cart should be covered while transporting and when not being used. Community Cleanliness Provider O stated it was important to ensure the cart was covered to prevent germs contaminating the linens. Record review of the facility's untitled in service dated 09/12/2023 indicated no documented evidence Community Cleanliness Provider O was in-service about ensuring the laundry was covered when brought into the building. During an interview on 11/01/2023 at 11:30 a.m., the Laundry Supervisor stated the linen cart should be covered at all times unless staff were taking out items. The Laundry Supervisor stated he had in-serviced his staff verbally and written about ensuring the cart was covered when they brought it into the building. The Laundry Supervisor stated he was responsible for monitoring and overseeing by daily morning meetings and random spot checks. The Laundry Supervisor stated when an issue was noted, staff was in serviced immediately. The Laundry Supervisor stated it was important to ensure the cart was covered to prevent contamination. During an interview on 11/02/2023 at 9:11 a.m., the DON stated the linen cart was to be covered while not being occupied. The DON stated the housekeeping supervisor was responsible for monitoring to ensure that staff was making sure that the cart was staying covered at all times while transporting. The DON stated it was important to ensure the cart was covered while transporting to prevent a risk of possible infection control issues. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated the linen cart should be covered while transporting residents belonging. The Administrator stated she monitored by doing random hall rounds and in-servicing staff when an issue was noted. The Administrator stated she had not noticed any issues. The Administrator stated it was important to keep the cart covered to ensure the laundry stays clean. Record review of the facility's policy titled Laundry and Linen processing, dated 10/24/2022, indicated The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 3 of 3 residents (Residents #13, #36, and #44) reviewed for antibiotic use. The facility failed to ensure Residents #13, #36, and #44 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of Resident #13's face sheet, dated 11/01/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS Resident Assessment Screening dated 09/18/2023 indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. Record review of a care plan last revised on 07/07/2023 revealed Resident #13 had impaired immunity related to history of UTI. Record review of Resident #13's Order Summary Report dated 11/08/2023 revealed Cipro 500 mg, take 1 tablet by mouth every 12 hours for UTI for 7 days with a start date of 10/27/2023. Record review of the Resident #13 MAR for October of 2023 indicated Cipro 500 mg, take 1 tablet by mouth every 12 hours was administered as ordered from 10-27-2023 thru 11-02-2023. Record review of Resident #13's McGeers Criteria for Infection effective date of 10/31/2023 indicated Resident #13 did not meet criteria for Cipro and the physician was notified on 10/31/2023. Record review of Resident #13 Nurses Notes dated 10/23/2023 indicated urine was dark in color and resident with poor intake. Record review of Resident#13's Electronic Health Record indicated no UA or culture was completed. 2. Record review of Resident #44's face sheet, dated 11/01/2023 revealed a [AGE] year old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Displaced Fracture of Base of Neck of Left Femur, Rheumatoid Arthritis (a chronic inflammatory disorder affecting many joints), Type 2 Diabetes Mellitus (a chronic condition that affects how the body processes blood sugar), Unspecified Sequelae of Cerebral Infarction(occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breath), Unspecified Abnormalities of Gait and Mobility, Repeated Falls, Pain, Alzheimer's Disease ( a progressive disease that destroys memory and other important mental functions). Record review of the MDS Resident Assessment and Care Screening dated 09/22/2023 indicated Resident #44 was able to make self-understood and understood others. The MDS assessment indicated Resident #44 had a BIMS score of 13, which indicated cognitively intact. The MDS assessment Indicated Resident #44 required extensive assistance for bed mobility, transfers, toilet use, dressing and personal hygiene. Record review of Resident #44's Order Summary Report dated 11/08/2023 revealed Macrobid 100 mg take 1 tablet by mouth two times a day for UTI for 7 days with a start date of 10/12//2023. Record review of the Resident #44's MAR for October of 2023 indicated Macrobid 100 mg take 1 tablet by mouth two times a day was administered from 10/12/2023 thru 10/15/2023. Record review of Resident #44's McGeers Criteria for Infection effective date of 10/12//2023 indicated Resident #44 did not meet criteria for Macrobid and the physician was notified on 10/12/2023. Record review of Resident #44's Nurses Notes dated 10/06/2023 signed by the ADON indicated in and out catheter done due to increased confusion with cloudy yellow urine collected and sent to lab for UA and C&S. Record review of Resident #44's Nurses Notes dated 10/12/2023 signed by the ADON indicated in and out catheter done due to increased confusion with cloudy yellow urine collected and sent to lab for UA and C&S. Record review of Resident #44's urine culture indicated bacteria was present in the urine. 3. Record review of Resident #36's face sheet dated 11/01/2023 revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Displaced Fracture of Base of Neck of Left Femur, Unspecified fall, Age-Related Osteoporosis (bones become weak and brittle), Chronic Diastolic Congestive Heart Failure (a condition in which the heart's main pumping chamber becomes stiff and unable to fill properly), Rheumatoid Arthritis (a chronic inflammatory disorder affecting many joints), Muscle Weakness, Abnormalities of Gait and Mobility, Cognitive Communication Deficit. Record review of the MDS Resident Assessment and Care Screening dated 08/23/2023 indicated Resident #36 was able to sometimes make self-understood and understood others. The MDS assessment indicated Resident #36 had a BIMS score of 02, which indicated severely cognitively impaired. The MDS assessment Indicated Resident #36 required limited assistance for bed mobility, and extensive assistance with transfers, toilet use, dressing and personal hygiene. Record review of Resident #36's Order Summary Report dated 11/08/2023 revealed Macrobid 100 mg take 1 tablet by mouth two times a day for UTI for 7 days with a start date of 10/25/2023. Record review of the Resident #36's MAR for October of 2023 indicated Macrobid 100 mg take 1 tablet by mouth two times a day was administered from 10/25/2023 thru 10/31/2023 per orders. Record review of Resident #36's McGeers' Criteria for Infection effective date of 10/31//2023 indicated it had not been completed. Record review of Resident #36's Nurses Notes dated 10/21/2023 signed by the DON indicated resident complained of burning with urination. Physician was notified and new order received for UA collection. Record review of Resident #36's Nurses Notes dated 10/25/2023 signed by the DON indicated UA C&S positive for E. Coli and new order received from physician to start Macrobid. During an interview on 11/01/2023 at 01:08 PM, the ADON said the antibiotic stewardship process included reviewing antibiotic orders, ensuring appropriate diagnoses and lab work to support usage was present, and the McGeer criteria (are used for retrospectively counting true infections. To meet the criteria for definitive infection, more diagnostic information (e.g., positive laboratory tests) is often necessary) was being followed. She said antibiotic should be prescribed to treat the right organism growing. The ADON said the Infection Control Preventionist was responsible for Antibiotic Stewardship, which was currently her. She said if Antibiotic Stewardship was not implemented, wrong antibiotics were ordered, and infection was not treated. The ADON said inappropriate antibiotic usage could cause resident to become resistant to antibiotic and harder to treat infections. Record review of a facility Antibiotic Stewardship policy last revised on 10/01/2022 indicated .antibiotics will be prescribed and administered to residents under guidance of the facility's antibiotic stewardship program .if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following .duration of treatment .indication of use .when a nurse calls a physician/prescriber to communicate a suspected infection .following information available . signs and symptoms .infection type .when a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber .to determine if antibiotic should be started, continued, modified or discontinued . It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use Assess residents for any infection using .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their own established smoking policy for the facility's only smoking area and 1 of 12 residents (Resident #52) reviewed for smoking policies. 1. The facility did not ensure Resident #52 smoked in the designated smoking area with appropriate supervision. 2. The facility did not ensure cigarette butts were disposed of in metal containers in the smoking area. 3. The facility did not ensure plastic trash was placed in the appropriate trash containers in the smoking area. These failures could place residents at risk of an unsafe smoking environment. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of sepsis, unspecified organism (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 currently used tobacco. Record review of the comprehensive care plan, initiated on 05/18/23, revealed Resident #52 smoked. The goals included: Resident will have supervised smoking privileges to minimize safety risks. The interventions included: Resident will smoke only in designated smoking area with access to appropriate smoking receptacles. Record review of Resident #52's Safe Smoking Assessment, dated 07/30/23, revealed The resident requires direct supervision while smoking. During an observation on 10/31/23 beginning at 3:01 PM, multiple residents were outside in the designated smoking area. The Social Worker was supervising the smoke break and was sitting in a metal chair in the designated smoking area. Resident #52 was sitting up in her wheelchair, outside the designated smoking area on the sidewalk near a grassy area and was approximately 20 feet from a large propane tank. Resident #52 was observed smoking a red-tipped cigarette and flicking her ashes on the ground. The propane tank was in the grass with a metal chain-link fence around it. There was a large sign that read PROPANE: No Smoking; No Open Flames. There were approximately 11 red-tipped cigarette butts in the grass where Resident #52 was sitting. There were also 8 red-tipped cigarettes located in the designated smoking area. There was empty candy paper located in one of the table-top ashtrays located on the tables. There were several pieces of plastic trash located in the red trash can, which was filled to the very top with cigarette butts and trash. During an observation and interview on 10/31/23 at 3:38 PM, the Administrator accompanied the surveyor into the smoking area. There were approximately 11 red-tipped cigarette butts in the grass approximately 20 feet away from the propane tank. The Administrator stated Resident #52 should not have been smoking outside the designated smoking area. The Administrator stated cigarette butts should not have been thrown on the ground or in the grass. The Administrator stated she would provide in-service education to the facility staff. During an interview on 10/31/23 beginning at 4:23 PM, the Social Worker stated she was responsible for supervising residents during the 3:00 PM smoke break. The Social Worker stated Resident #52 usually sat outside the designated smoking area because she wanted to sit in the sun, but she stated Resident #52 did not normally smoke. The Social Worker stated she had not noticed Resident #52 smoking outside the designated area during the 3:00 PM smoke break. The Social Worker stated an explosion or fire could have happened if residents smoked outside the designated smoking area and threw their cigarette butts on the ground. During an interview on 11/01/23 beginning at 4:43 PM, the Director of Environmental Services stated he was responsible for ensuring the smoking area was kept clean. The Director of Environmental Services stated he cleaned the smoking area at least three times a week. The Director of Environmental Services stated there should not have been trash in the red trash can, which was for cigarette butts only. He stated there also should not have been cigarette butts on the ground or in the grass or trash in the ashtrays. The Director of Environmental Services stated he usually emptied the red trashcan, but it had not been emptied in a week or two. The Director of Environmental Services stated it was important to ensure the smoking area was free of hazards to make the facility look better and prevent the potential for fires. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated the Director of Environmental Services was responsible for ensuring the smoking area was kept clean and free of hazards. The Administrator stated it was important to keep the smoking area clean and free of hazards for fire prevention. Record review of the Smoking policy, undated, revealed It is the policy of this community to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. The policy further revealed Smoking by residents is allowed outside in designated, marked smoking areas . and IDT will develop an individualized plan for .required supervision for residents who smoke.

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 in the facility's only kitchen The facility failed to ensure that kitchen staff appropriately restrained their hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: 1. During an observation on 10/30/2023 starting at 09:03 AM revealed: two dented cans of Campbell's Cream of Mushroom Soup in the kitchen pantry. the [NAME] was not wearing the hairnet appropriately to restrain the sides and back of hair. the Dishwasher was not wearing the hairnet appropriately to contain facial hair, approximately one half inch mustache. During an observation on 10/30/2023 at 09:11 AM, revealed the dishwasher was in the kitchen without a hairnet on appropriately. The dishwasher was not wearing a hair net to contain facial hair approximately one half inch mustache. During an observation on 10/30/2023 at 09:30 AM., revealed the [NAME] was in the kitchen without a hairnet on appropriately. The Cook's hair was sticking out the sides and the back of the hairnet. During an observation on 10/31/2023 at 09:30 AM, revealed the [NAME] was in the kitchen without a hairnet on appropriately. The Cook's hair was sticking out the sides and the back of the hairnet. During an interview on 10/30/2023 at 02:00 PM., the [NAME] said the hairnet should be worn appropriately by tucking all the hair inside the hairnet to prevent any type of cross contamination. During an attempted telephone interview on 10/31/2023 at 11:30 AM., the Dishwasher did not answer the phone. During an attempted telephone interview on 10/01/2023 at 02:30 PM., the Dishwasher did not answer the phone. During an interview on 10/31/2023 at 04:32 PM., the Dietary Manager said the damaged food cans should be separated from cans of food to be served. The Dietary Manager said all staff should wear hairnets that covered their hair appropriately while in the kitchen. The Dietary Manager said those items or important to keep the residents healthy and prevent cross contamination and food borne illness. During an interview on 11/02/2023 at 1:30 PM., the Administrator said that she expected the Dietary Manager to check behind the staff to ensure that the tasks to prevent infection and cross contamination and food borne illness were completed. Record Review of the Food Preparation and Service Policy with a revised date of April of 2022, indicated . all food purchased will be wholesome, manufactured, processed, and prepared in compliance with all state, federal and local laws, and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food born illness. 1. Food is delivered at the appropriate temperature and inspected prior to storage for signs of contamination. D. No dented cans. 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. 11. Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded.19. Safe food temperatures will be maintained at acceptable levels during food storage, preparation, holding, service, delivery, cooling and reheating

Based on observation, interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through the means other than a postal service for 8 of 8 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings include: During a confidential group interview 8 of 8 residents said mail was not being distributed on Saturdays. They said they received mail everyday Monday through Friday. They said their mail was delivered to them by the AD. During an observation on 8/30/22 at 3:44 p.m. the mailbox at the road in front of the facility was observed to not be locked and able to be checked by anyone. During an interview on 8/30/22 at 3:53 p.m. the AD said mail was delivered daily at 3:00 p.m. Monday through Friday. The AD said she worked one Saturday a month and on that Saturday mail was passed out to the residents. The AD she was unaware if the residents received mail on the Saturdays she was not at the facility. During an interview on 8/31/22 at 1:15 p.m. LVN D said she did work on the weekends. LVN D said she had not seen any mail delivered on the weekends to the residents in a while but did not give an exact time frame. LVN D said the staff working the front door screening staff and visitors for signs and symptoms of COVID-19 used to receive the mail but was unsure if they still did. LVN D said it was important for residents to receive their mail on the weekend because it was their right. During an interview on 8/31/22 at 2:58 p.m. the Administrator said mail should be delivered daily to the residents. The Administrator said it was the AD's responsibility to distribute the mail. The Administrator said the facility medication aide used to pass out mail on the weekends, but the facility had not had a medication aide in several months. The Administrator said mail had not been being distributed on Saturdays to residents. The Administrator said the importance of the residents receiving their mail every day was it was their mail and the facility was their home. . Record review of the facility's policy Resident Rights revised December 2016 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .access to a telephone, mail, and email .communicate in person and by mail, email, and telephone with privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, which allowed residents to use his or her personal belongings to the extent possible for 4 of 14 residents room (#'s 9, 15, 32 and 3) reviewed for environment. 1. The facility failed to repair Resident #9's over the bed light. 2. The facility failed to repair the ceiling light in the room of Residents #15 and #32. 3. The facility failed to repair deep scrapped areas on the wall of Resident #3's room. These failures could place the residents at risk of living in an unsafe environment and for embarrassment due to room not appearing homelike. Findings include: 1. During an observation and interview on 08/29/2022 at 12:27 p.m., the Activity Director was getting ready to assist Resident #9 with her lunch and she noticed her over the bed light did not illuminate when she pulled the string. The Activity Director stated, I will let maintenance know about this. During an observation and interview on 08/30/2022 at 9:30 a.m., Resident #9's over the bed light did not illuminate when the surveyor pulled the string. The resident was non-interviewable. During an interview on 08/31/2022 at 11:28 a.m., the Activity Director said she forgot to report that Resident #9's over the bed light did not function. She said she usually reported it to the charge nurse, and they would report it to maintenance. 2. Record review of the face sheet dated 08/31/2022 indicated Resident #15 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (prostate cancer), essential hypertension (force of the blood against the artery walls is too high) and paraplegia (inability to voluntarily move the lower parts of the body). During an observation and interview on 08/30/22 at 9:14 a.m., Resident #15 said the ceiling light did not function correctly. The ceiling light flickered on and off after two seconds it was on. Resident #15 said he had reported it to maintenance when he fixed his bed about a few months ago. Resident #15 stated, He told me will be right back, but he never came back. Resident #15 stated he had not reported the ceiling light to anyone else. 3. Record review of the face sheet dated 08/31/2022 indicated Resident #32 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (force of the blood against the artery walls is too high) and schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood). During an interview on 08/30/22 at 9:16 a.m., Resident #32 was Resident #15 roommate and he said he had reported the ceiling light to a nurse, but he did not remember when nor her name. Resident #32 said the light does bother him if it was on. Resident #32 said the light has been flickering on and off at least three months. Record review of the facility's maintenance log revealed Resident #9's over the bed light and the ceiling light in the room of Residents #15 and #32 was not documented. During an interview on 08/31/2022 at 11:12 a.m., CNA B stated Resident #15 and Resident #32 ceiling light has been flickering on and off for about a month or two. She stated she had verbally reported it to maintenance. She indicated she could not remember the exact date. CNA B stated she did not write it in the logbook because she verbally told him that day, she noticed the light issue. CNA B stated a resident could fall due to poor lighting. During an interview on 08/31/2022 at 11:32 a.m. the Director of Plant Operations stated he was responsible for ensuring over bed lights and ceiling lights were functionable. He stated he was unaware of Resident #9 over the bed light and Resident #15 and #32 ceiling light not functioning. The Director of Plant Operations stated he was advised of rooms needing repair by the staff verbally telling him. The Director of Plant Operations stated he also made rounds in the facility daily but did not check lights as he should. He was unable to give an explanati0on why he did not check lights during his rounds. The Director of Plant Operations stated a resident could fall due to poor lighting. 4. Record review of the consolidated physician orders dated 8/31/2022 indicated Resident #3 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left dominant side (left sided weakness and paralysis following a brain bleed), seizures, muscle wasting, and muscle weakness. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #3 was sometimes understood by others and usually understood others. The MDS indicated Resident #3 had a BIMS score of 03 and severely cognitive impairment. The MDS indicated Resident #52 required extensive assistance with bed mobility, toileting, eating, dressing and personal hygiene. Record review of the care plan updated on 4/06/22 indicated Resident #3 had anxiety related to cognitive deficit as evidenced by: trouble concentrating, forgetfulness, episodes of confusion, decreased attention span, restlessness, poor impulse control, and feelings of discomfort, apprehension or helplessness. During an observation and interview on 8/30/22 at 9:41 a.m. Resident #3's wall next to his bed was scuffed and had scraped areas that exposed the sheetrock. Resident #3 said wall was that way from the raising and lowering of his bed During an observation and interview on 8/31/22 at 9:21 a.m. Resident #3's wall next to his bed was scuffed and had a scraped areas that exposed the sheetrock. During an observation and interview on 8/31/22 at 1:10 p.m. the Director of Plant Operations said he was responsible for maintaining the walls in the facility. The Director of Plant Operations said he was notified of things in the facility that required his attention by the maintenance book, the nurses verbally telling him, or by the Administrator giving him a list after she completed her rounds. The Director of Plant Operations said he also made rounds in the facility daily but did not enter every resident room. The Director of Plant Operations said he was aware of the wall in Resident #3's room needed to be repaired. The Director of Plant Operations said he had a plan for the repair. The Director of Plant Operations said he would need to go to the nearby town to obtain supplies and had not had a vehicle to do so. The Director of Plant Operations observed the wall with the state surveyor present and he said the wall had gotten worse since the last time he inspected it. The Director of Plant Operations said the last time he inspected the wall in Resident #3's room was approximately 2-3 weeks ago. The Director of Plant Operations said he had repainted the wall approximately 3-4 weeks ago. The Director of Plant Operations said he did not keep a log of his completed work. The Director of Plant Operations said a more cognitively intact resident would not like having a wall with a scrape exposing the sheetrock. During an interview on 8/31/22 at 2:58 p.m. the Administrator said everyone in facility was responsible for ensuring lights were properly working and walls were intact. The Administrator said maintenance issues were reported verbally or by texting. The Administrator said the facility also had a maintenance logbook to write down areas that need to be repaired. The Administrator said she made weekly rounds and gave the Director of Plant Operations a list of items and/or areas that need repaired. The Administrator said it was important to keep lights working properly and walls in the facility maintained so the resident had a homelike environment. Record review of the facility's policy Maintenance Service revised December 2009 indicated, Maintenance services shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of the maintenance personnel include, but are not limited to .Maintaining the building in good repair and free from hazards .Maintaining lighting levels that are comfortable .Record shall be maintained in the Maintenance Director's Office .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items were dated, labeled, and sealed appropriately. This failure could place residents at risk for foodborne illness. Findings include: During an observation and interview in the refrigerators and freezers on 08/22/2022 starting at 9:51 a.m. revealed; 1 can of whipped topping undated: 1 gallon of pickle relish was undated; 1 bag of sweet potato fries was undated and was exposed to air; 1 bag of chopped broccoli was undated and was exposed to air ; 1 tub of vanilla ice cream was undated; 2 clear bags identified by the Director of Food Services, as hashbrowns was unlabeled, undated, and was exposed to air ; 2 pans of lasagna was undated; 1 clear bag identified by the Director of Food Services, as fish patties was undated, unlabeled, and was exposed to air ; 2 clear bags identified by the Director of Food Services, as chicken patties was undated, unlabeled, and was exposed to air: and 1 clear bag identified by the Director of Food Services, as Salisbury steaks was undated, unlabeled, and was exposed to air . During an observation in the dry storage room on 08/22/2022 starting at 9:57 a.m. revealed: 2 unopened boxes of no bake cheesecake mix was undated; and 2 opened boxes of yellow cake mix was exposed to air. Record review of a registered dietician consultant report dated 06/27/2022 completed by the Dietician indicated labeling and dating needed attention and, food removed from the original container was not dated and opening date was not consistently done. Record review of a registered dietician consultant report dated 07/12/2022 completed by the Dietician indicated labeling and dating food removed from the original package was not consistent and, prepared foods and leftovers need proper dating. Record review of a registered dietician consultant report dated 08/10/2022 completed by the Dietician indicated labeling and dating needed attention, inappropriate containers used for food storage and food removed from the original container not dated continued to be a problem. During an interview on 08/31/2022 at 1:34 p.m., Dietary Aide B stated all food products should be labeled, dated, and stored in a plastic storage bag once it was removed from the original container. Dietary Aide B stated all staff were responsible for ensuring this was done. Dietary Aide B stated these failures could potentially cause foodborne illness and freezer burn. During an interview on 08/31/2022 at 1:47 p.m., [NAME] A stated all staff were responsible for labeling and dating food items. He stated that way staff would know what food and how old it was. He stated the cooks were responsible for labeling and storing food in a plastic storage bag once the item was removed from the original container to prevent freezer burn and spoilage. During an interview on 08/31/2022 at 1:54 p.m., the Director of Food Services stated cleanliness was important in the kitchen, so they were not spreading germs or contaminating anything. She stated she was responsible for making sure the kitchen was cleaned appropriately. She stated all food should be labeled with the date received and the date it was opened. She stated whoever touched the item needed to label and date the item as to when it was opened. She stated if it was taken out of the original box then it should be labeled what it was, the date received, when they opened it and stored in a plastic storage bag. She stated rounds were made daily and she would point out things that needed to be labeled, dated, or stored properly. The Director of Food Services indicated these failures could potentially cause a food borne illness. During an interview on 08/31/2022 at 3:16 p.m., the Administrator stated she expected the kitchen to be cleaned and staff preventing cross contamination. She stated she expected all food to be labeled, dated, and stored properly. She stated she does weekly rounds and had not noticed any issues with labeling, dating or food not been stored properly that she could recall. The Administrator stated these failures could cause outdated food been served and potentially a food borne illness. Record review of the facility's policy titled Food Receiving and Storage dated October 2017 indicated . foods shall be received and stored in a manner that complies with safe food handling practices 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) 14e. Other opened containers must be dated and sealed or covered during storage Record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 5 of 18 residents reviewed for personal food safety. (Residents #6, Resident #26, Resident #33, Resident #17, and Resident #193) The facility did not implement the personal food policy related to personal refrigerators for Residents #6, Resident #33, Resident #17, Resident #193 and #26. These failures could place the residents at risk for food borne illnesses. Findings include: 1. Record review of the face sheet dated 8/11/22 indicated Resident #6 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of heart failure, dementia, dizziness, and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #6 was understood by others and understood others. The MDS indicated Resident #6 had a BIMS of 99 and was unable to complete the interview. Record review of the temperature log date August 2022 for Resident #6's personal refrigerator indicated the temperatures had bee monitored on August 1-15, 2022, and August 29, 30, and 31, 2022. During an observation on 8/29/22 at 1:40 p.m. Resident #6's personal refrigerator was observed without a temperature log. During an observation on 8/30/33 at 9:14 a.m. Resident #6's personal refrigerator was observed with a temperature log dated August 2022 and indicated the temperatures were not monitored on all days of the month of August 2. Record review of the face sheet dated 8/31/22 indicated Resident #26 was a [AGE] year-old female admitted to the facility on 3/522 with diagnoses of lack of coordination reduced mobility, COPD, and chronic kidney disease. Record review of the MDS dated [DATE] indicated Resident #26 was understood by others and understood others. The MDS indicated Resident #26 had a BIMS of 14 and was cognitively intact. Record review of the temperature log dated August 2022 for Resident #26's personal refrigerator indicated the temperatures had been monitored on [DATE], 30, and 31, 2022. During an observation on 8/29/22 at 11:05 a.m. Resident #26's personal refrigerator was observed without a temperature log. No expired foods were noted. During an observation on 8/30/22 at 9:10 a.m. Resident #26's personal refrigerator was observed with a temperature log dated August 2022 and indicated the temperatures were not monitored on all days of the month of August During an interview on 8/29/22 at 12:26 p.m. the Laundry Supervisor said it was his responsibility to check the resident's personal refrigerators temperature and for expired foods. The Laundry Supervisor said he had only been in his position approximately 1 week. 3. Record Review of Resident #33's face sheet (no date) indicated she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of schizophrenia (disorder that affects the ability to think), dysphagia (difficulty swallowing) and muscle wasting (atrophy). Record Review of Resident #33's MDS dated [DATE] indicated she had a BIMS score of 13 indicating that she was cognitively intact. Record Review of the temperature log posted in Resident #33's room indicated for the month of August 2022 the temperature was checked on dates August 1-15, 2022, and left blank for the rest of the month. 4. Record Review of Resident #17's face sheet (no date) indicated she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of HTN (high blood pressure), muscle wasting and atrophy and dysphagia (difficulty swallowing). Record Review of Resident #17's MDS dated [DATE] indicated she had a BIMS score of 14 indicating she was cognitively intact. 5. Record Review of Resident #193's face sheet (no date) indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of type 2 DM (blood sugar disorder), HTN (high blood pressure) and Congestive Heart Failure (heart doesn't pump blood as well). During an observation on 08/29/22 at 11:46 AM, Resident #33 was in her room reading. Her mini fridge had a temp log on the side of it indicating that the temperatures were checked from August 1- 15, 2022 and the other dates were blank. During an observation on 08/29/22 at 11:00 a.m., Resident #17 was in the bed. Resident #17 mini fridge had a temperature log hanging up on the side that was dated for the month of June 2022. During observation on 08/29/22 at 11:49 a.m., Resident #193 was in the bed watching TV. Resident#193's mini fridge was in the room and had no temperature log. Interview with the DON on 8/31/22 at 1:50 p.m., the DON stated housekeeping was responsible for making sure the temperatures were checked for the mini fridges. DON stated she did not know who was responsible for making sure housekeeping was making rounds. DON stated if the temperature checks were not done it could cause the food to go bad in the mini fridges, the residents could save the leftovers too long, or it could cause bacteria. Interview with the Administrator on 8-31-22 at 2:08 p.m., Administrator stated housekeeping is responsible for checking the temperatures in the mini fridges. Administrator stated department heads are responsible for making rounds and making sure that housekeeping is doing the temperature checks. Administrator stated that if the temperature checks are not done the food could spoil. Record review of the policy on Food from Outside Sources last revised on March 2021 indicated community personnel would be responsible for the managing of appropriate temperatures and food stored in the resident's refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 14 residents reviewed for palatable food. (Residents #1, #5, and #24) The facility failed to provide palatable food to Residents #1, #5 and #24. This failure could place residents who eat food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: 1. Record review of the face sheet dated 08/31/2022 indicated Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with unspecified complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (force of the blood against the artery walls is too high) and unspecified dementia without behavioral disturbances (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the admission MDS assessment dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The assessment indicated Resident #1 was moderately cognitively impaired with a BIMS score of 10. The assessment did not indicate what diet was required for Resident #1. Record review of the care plan dated 05/23/2022 indicated Resident #1 was on a regular diet with regular consistency. There were interventions to monitor/discuss food preferences and serve diet as ordered and offer substitute if less than 50% eaten. During an interview on 08/29/2022 at 11:20 a.m., Resident #1 said sometimes the meat was tough and she was unable to eat it. Resident #1 said she reported this to staff but could not remember the names. 2. Record review of the face sheet dated 08/31/2022 indicated Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (force of the blood against the artery walls is too high) and vitamin deficiency. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #5 usually understood others and usually made herself understood. The assessment indicated Resident #5 was cognitively intact with a BIMS score of 14. The assessment did not indicate what diet was required for Resident #5. Record review of the care plan dated 06/27/2022 indicated Resident #5 was on a regular diet with regular consistency. There were interventions to monitor/discuss food preferences and serve diet as ordered and offer substitute if less than 50% eaten. During an interview on 08/29/2022 at 10:49 a.m., Resident #5 said the meat was tough and the vegetables were mushy. Resident #5 said she reported this to staff but could not remember the names. 3. Record review of the face sheet dated 08/31/2022 indicated Resident #24 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar) and rheumatoid arthritis (chronic inflammatory disorder affecting many joints, including those in the hands and feet. Record review of the quarterly MDS assessment indicated Resident #24 understood others and made herself understood. The MDS indicated Resident #24 was cognitively intact with a BIMS score of 15. The assessment indicated Resident #24 required a mechanically altered diet. Record review of the care plan dated 06/02/2022 indicated Resident #24 was on a regular mechanical soft diet. There were interventions to monitor/discuss food preferences and serve diet as ordered and offer substitute if less than 50% eaten. During an interview on 08/29/22 at 11:12 a.m., Resident #24 stated The food here is very bland and needs to be seasoned more. Resident #24 said she reported this to staff but could not remember the names. 4.During an observation and interview on 08/30/2022 at 12:40 p.m., a lunch tray was sampled by the Dietary Manager and four surveyors. The sample tray consisted of garlic herb chicken, angel hair pasta, California vegetable blend, a roll, and a brownie. The garlic herb chicken was dry and tough. The angel hair pasta was overcooked, and the vegetable blend was bland. The Dietary Manager stated the chicken was somewhat dry, vegetable blend was bland. The Dietary Manager stated, It was hard to cook pasta correctly. During an interview on 08/31/2022 at 1:12 p.m., LVN E stated she heard a lot of food complaints. She stated Resident #24 told her the food needed more seasoning, but she could not recall when Resident #24 told her. She stated Resident # 1, and Resident #5 never complained to her about food. She stated she offered the residents an alternative when they complained to her. She stated she reported all food complaints to the Dietary Supervisor. She stated residents not eating their food could potentially cause weight loss and depression. During an interview on 08/31/2022 at 1:54 p.m., the Director of Food Services stated she did not hear a lot of complaints from residents. She stated the Activity Director would report to her if there were any complaints made during resident council. The Director of Food Services stated she monitored the kitchen/food by sampling test trays at least three times a week. She stated there was not any issues with the test trays. She stated she visits with the residents randomly to see if there were any complaints with the food and spot check trays to see how much residents are consuming that meal. She stated residents not eating their food could potentially cause weight loss. During an interview on 08/31/2022 at 3:16 p.m., the Administrator stated there has been food complaints and residents were offered multiple alternative meals. The Administrator stated a test tray is done 1-2 times a week and there were no issues. The Administrator stated she attended a resident council meeting every so often to see if there were any complaints with the food. The Administrator stated residents not eating their food could potentially cause weight loss. Record review of the facility's policy titled Food and Nutrition Services dated October 2017 indicated . each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 4. Reasonable efforts will be made to accommodate resident choices and preferences .7. Food and nutrition services staff will inspect food tray to ensure . food is palatable and attractive .