**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Residents #23, and Resident #27) reviewed for care plans in that:The facility failed to ensure Resident #23 had a care plan in place for pressure ulcer/injury.The facility failed to ensure Resident #27 had a care plan in place for urinary incontinence.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Residents #23, and Resident #27) reviewed for care plans in that:The facility failed to ensure Resident #23 had a care plan in place for pressure ulcer/injury.The facility failed to ensure Resident #27 had a care plan in place for urinary incontinence.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included the following:Review of Resident #23's Resident Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of dementia, diabetes type 2 (a condition when the body does not produce enough insulin or cells do not response properly to insulin), anxiety, depression, high blood pressure, heart failure, chronic kidney disease, Parkinson's disease (a neurological problem that affects movement), and weakness. Review of Resident #23's Annual MDS Assessment, dated 04/04/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #23 scored 15 out of 15 indicating intact cognition. Section M - Skin Conditions, subsection M0150. Risk of Pressure Ulcers/Injuries; Is this resident at risk of developing pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Subsection M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Section V - Care Area Assessment (CAA) Summary, subsection A. CAA Results revealed Item 16. Pressure Ulcer column A. Care Area Triggered was checked and column B. Care Planning Decision was checked indicating Item 16. applied.Review of Resident #23's Care Area Assessment Worksheet dated 04/08/2025, Item 16. Pressure Ulcer/Injury under Care Plan Considerations; Will Pressure Ulcer/Injury - Functional Status be addressed in the care plan? Yes was entered. Review of Resident #23's Comprehensive Care Plan reviewed/revised 04/08/2025 revealed it did not address pressure ulcer/injury as a focus of care. Review of Resident #23's physician's order, dated 04/21/2025, revealed Apply skin prep to left heel every day shift.Review of Resident #27's Resident Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of difficulty chewing/swallowing, urinary tract infection, weakness, history of blood clots in the lungs, and iron deficiency anemia (low iron in the blood). Review of Resident #27's admission MDS Assessment, dated 01/17/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #27 scored 11 out of 15 indicating moderate cognitive impairment. Section H - Bladder and Bowel, subsection H0300. Urinary Continence revealed 3. Always incontinent (no episodes of continent voiding) was entered. Section V - Care Area Assessment (CAA) Summary, subsection A. CAA Results revealed Item 06. Urinary Incontinence and Indwelling Catheter column A. Care Area Triggered was checked and column B. Care Planning Decision was checked indicating Item 06. applied.Record review of Resident #27's Care Area Assessment Worksheet dated 01/21/2025, Item 6. Urinary Incontinence and Indwelling Catheter under Care Plan Considerations; Will Urinary Incontinence and Indwelling Catheter - Functional Status be addressed in the care plan? Yes was entered. Record review of Resident #27's Comprehensive Care Plan reviewed/revised 04/29/2025 revealed it did not address urinary incontinence as a focus of care. During an interview on 07/01/25 at 01:46 PM, the DON stated the MDS Coordinator, LVN D, was responsible for starting the care plans. She stated she was responsible for monitoring for accuracy. The DON stated all nurses could contribute to the care plan, but she must be notified prior to adding to or changing a care plan. She stated care plans were reviewed by the IDT during quarterly meetings. The DON stated they try to read the entire care plan to identify adjustments that were needed. LVN D stated she had been doing MDSs and care plans for 9 years. She stated she, LVN D received 30 days of training prior to assuming the position. The DON stated the MDS Coordinator was required to complete training periodically offered by the online vendor. The DON stated her expectations were for care plans to be as complete and accurate as possible at all times.During a follow up interview on 07/01/25 at 02:11 PM, the DON stated the consequences of an incorrect or incomplete care plan for a resident may be in the area of ADL's. The DON gave an example of the number of staff required for assisting a resident with transfers. She stated if the information was not correct, a resident or staff may be at risk of injury during a transfer. She stated not so much for medication changes because the changes were addressed in the physician's orders. The DON stated one possible reason for the failure to have an accurate care plan may be when a medication order changes. Review of the facility policy titled Comprehensive Care Plans, dated 09/2023, revealed on page 2 If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation and interview on 06.29.2025 between 01:25 PM and 4:15 PM AM of the kitchen revealed:Refrigerator #1 1. Refrigerator contained one pitcher of lemonade (approximately 100 mL) with a use by date 06.28.25 Dry storage1. 1 large clear plastic bag with what appeared to be coconut flakes, sealed with no label or use by date.2. 1 5-pound bag of graham cracker crumbs, marked as received date 05.31.2025, opened 06.03.2025 and no use by date.3. 1 opened package peanut granules with no use by date4. 1 small clear plastic bag with vanilla wafers with no open or use by date5. 1 large storage bin of cornmeal on the floor with wheels, no label or date. 6. 1 16-ounce container of beef base, opened with no expiration date.Freezer #1 1. 1 package of prepared dinner rolls with no label or use by date. Freezer #2 1. 1 tub opened beef taco filling with no use by date2. 1 package of six prepared of a brown, small, loaf sized product. No label or use by date.Freezer #3 1. 1 package of 8 taquitos stored in clear plastic bag with no label or use by date2. 1 package California blend vegetables with no use by date. Refrigerator #4 3. Shredded lettuce in a clear plastic bag with no label or used by date4. 1 large clear plastic bag of carrot sticks with no label or used by date.During an interview on 06/29/2025 at 01:45 PM, [NAME] B stated when the truck delivered the groceries, the staff labeled and dated products with the date received. [NAME] B stated whoever put up the food was supposed to write the date received on the products. T [NAME] B stated when a container was opened, it should have an open date on the container or the bag. [NAME] B stated sometimes the date were rubbed off when stored in the refrigerator or freezer. [NAME] B stated she did not know how the failure occurred. [NAME] B stated if food was passed its use by date and was served to the residents, it could have caused them to get sick. During an interview on 07/01/25 at 02:16 PM, the DM stated food products should have been labeled with the date it was received. The DM stated prepared food products should have been labeled with a preparation date and use by date. The DM stated if food was not labeled and was out of date and served to residents, it could have caused food borne illness. The DM stated all the kitchen staff were responsible for labeling and dating food products. The DM stated all dietary staff were trained when they were hired on labeling and storing food products. During an interview on 07/01/25 at 02:30 PM, the ADMN stated her expectations would be that the kitchen staff would follow the policy for storage and labeling of food products. The ADMN stated food products should be properly labeled and dated. The ADMN stated if outdated food was served to the residents, they could become ill. The ADMN stated that the Dietician provided her with a report each month. The ADMN stated she randomly checks food products in the kitchen about two times a month. The ADMN stated she believed the system works, but maybe some of the products got overlooked. The ADMN stated she did not know what caused the failure. Record review of facility's policy titled: Food Storage dated 2013Policy:Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination.Procedure:1. Dry storage must be well ventilated .2. Storage rooms must have only one access door .3. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves4. All containers must be legible and accurately labeled and dated.6.5. Scoops .7.6. 8.7. All stock must be rotated with each new order received a. Food should be dated as it is placed on the shelves.d. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high-risk food.e. Foods will be stored and handled to maintain the integrity of the packaging until ready for use 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.14. Refrigerated Food storage: .All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe u se by dates, or frozen (where applicable), or discarded.Refrigerated foods should be stored upon delivery .Frozen Foods:All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS , for 1 of 1 (FY Quarter 2 2025) reviewed for Staffing Data Report.The facility failed to submit staffing information to CMS for FY Quarter 2 2025 (January 1- March 31).The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS , for 1 of 1 (FY Quarter 2 2025) reviewed for Staffing Data Report. The facility failed to submit staffing information to CMS for FY Quarter 2 2025 (January 1- March 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's Staffing Data Report for FY Quarter 2 2025(January 1- March 31) revealed the facility triggered for Failed to Submit Data for the Quarter. During an interview on 07/01/2025 at 2:17 PM, the ADMN stated her expectation was that the facility followed CMS guidelines. The ADMN stated it was oversight on her part, with trying to get everything completed for opening a new building. The ADMN stated she had looked several times and the links for reporting data were not available and she must have missed the time frame when the links for reporting had opened. The ADMN stated it was her responsibility to ensure the staffing data was reported. The ADMN stated she did not feel there was a negative effect to residents. The ADMN stated the facility did not have a policy for reporting staffing data, they followed the CMS guidelines.