**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #3) reviewed for quality of care. CNA A transferred Resident #3 using a mechanical lift without the assistance of another staff member. This failure could place residents at risk of accidents, injury, and pain. The findings were: Record review of Resident #3's face sheet dated 8/22/25 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. The resident's diagnoses included Wernicke's encephalopathy (an acute, life-threatening neurological emergency caused by a severe thiamine (Vitamin B1) deficiency, most often due to chronic alcohol abuse but also associated with poor nutrition or malabsorption. Its classic symptoms include loss of muscle coordination), generalized muscle weakness, muscle wasting and atrophy not elsewhere classified unspecified site (wasting or loss of muscle tissue), and Transient Ischemic Attack (TIA - short period of symptoms similar to those of a stroke. It's caused by a brief blockage of blood flow to the brain). Record review of Resident #3's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 out of 15 indicating the resident was cognitively intact, used a wheelchair, and required extensive assistance of a 2- person physical assist for bed mobility, and transfers. Record review of Resident #3's undated care plan revealed a problem with a start date of 6/6/25 edited on 6/17/25 for ADL function that the resident required a mechanical lift, with a goal of safe travels and an approach to maintain safe transfers. In an observation and interview on 8/21/25 at 10:04 a.m. CNA A opened the door to Resident #3's room and exited the room pushing the mechanical lift out in to the hallway. Resident #3 was in his wheelchair in his room with the mechanical lift sling underneath him. There were no other staff members in Resident #3's room. CNA A stated no one had helped her transfer the resident. CNA A stated she transferred Resident #3 from his bed to his wheelchair alone with the mechanical lift. CNA A stated she was not supposed to transfer the residents with the mechanical lift alone. CNA A stated she did not ask anyone for assistance with the mechanical lift as when she looked down the hall, she did not see anyone and went ahead and transferred the resident without the assistance of another staff member. In an observation and interview on 8/21/25 at 10:08 a.m. Resident #3 was sitting in his room in his wheelchair with the mechanical lift sling underneath him. Resident #3 stated CNA A had transferred him using the mechanical lift by herself without the assistance of another staff member and stated there were no issues with the transfer and he felt safe during the transfer. Resident #3 stated the facility staff including CNA A did not usually use the mechanical lift to transfer him without the assistance of another staff member but he had wanted to get up. In an observation on 8/21/25 at 10:10 a.m. the DON was in-servicing staff on 2-person transfers using mechanical lifts. In an interview on 8/22/25 at 12:00 p.m. the DON stated it was important to use 2-persons for a mechanical lift to ensure control of the mechanical lift, ensure the resident was properly positioned, and for proper guidance of the lift and the resident. The DON stated the possible consequences of not using 2-persons for a mechanical lift could be the resident could fall or sustain an injury from not guiding the resident's legs up and or hitting something. Review of CNA A's training skills checklist revealed she was trained and had passed a 2-person mechanical lift on 3/25/25 and did not need improvement. Review of the facility policy on safe resident handling and transfers with an implementation date of 7-2025 indicated It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and to provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 10. Two staff members must be utilized when transferring residents with a mechanical lift.

Based on interview and record review the facility failed to use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not utilize the services of an RN on 2/22/25, 2/23/25, 3/1/25, 3/30/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, 6/1/25, 6/8/25, 6/15/25, 6/29/25, 7/6/25, 7/13/25, 7/20/25, 7/27/25, 8/3/25, 8/10/25, and 8/17/25 for a total of 19 days. This failure could place residents at risk of not receiving needed care and services.The findings were: Review of the PBJ staffing data report for FY quarter 2 2025 (January 1 - March 31) with a run date of 8/14/25 revealed the facility triggered for no RN hours for Saturday 2/22/25, Sunday 2/23/25, Saturday 3/1/25, and Sunday 3/30/25. Review of the facility time sheets for RNs revealed the facility had no RN coverage for Saturday 3/1/25. Review of the facility time sheets for RNs revealed the facility had no RN coverage for Sundays on 3/30/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, 6/1/25, 6/8/25, 6/15/25, 6/29/25, 7/6/25, 7/13/25, 7/20/25, 7/27/25, 8/3/25, 8/10/25, and 8/17/25. In an interview on 8/22/2025 at 12:35 p.m. the Administrator stated the facility lost their Sunday nurse and had been doing well with RN hours prior to that. The Administrator stated they had been actively seeking an RN for the weekends and just hired a new weekend nurse, and she had been training this week. The Administrator stated she felt the staff were competent and her licensed nurses (LVNs) were well equipped to deal with situations. The Administrator stated she was unsure of any possible consequences of not having an RN for 8 consecutive hours a day 7 days a week due to always having competent licensed nursing staff on duty and the DON was on call 24/7 and there was also physician telehealth available 24/7 but she understood it was better to have an RN on-site for assessment. In an interview on 8/22/25 at 1:07 p.m. the DON stated the possible consequences of not having an RN 8 hours a day 7 days a week could be not having the advanced assessment and skill set but she was available 24/7 by phone and all staff and many families had her cell phone number plus she had a group chat with all staff that she starts every Monday. Review of the facility policy on nursing services for RN hours implemented 7-2025 indicated It is the policy of the facility to comply with Registered Nursing staffing requirements as per the Social Security Act. 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan for 1 of 5 Residents (Resident #1) whose records were reviewed, in that: Resident #1's Care Plan still reflected resident was a 1 person transfer when she was a 2-person transfer. The deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: Record review of Resident #1's face sheet, accessed [DATE], reflected an [AGE] year-old female admitted [DATE] and expired [DATE], with diagnoses to include hemiplegia and hemiparesis (paralysis and partial weakness of one side), cerebral infarction (necrotic tissue in the brain), and dementia (group of symptoms affecting memory, thinking and social abilities). Record review of Resident #1's quarterly MDS assessment, dated [DATE], reflected Resident #1 was substantial/maximal assistance (helper does MORE THAN HALF the effort) for chair/bed-to-chair transfers and had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #1's care plan, last reviewed [DATE], reflected ADLs functional status/rehabilitation potential with intervention Ambulation/Transfers amount of assist:1 person, dated [DATE]. It further reflected The following tasks will be documented in POC CareAssist with intervention 2 person assist with transfers, dated [DATE]. Interview on [DATE] at 04:49PM, CNA A had been working at the facility since October or [DATE]. He revealed Resident #1 was transferred with a mechanical lift. He revealed there was a cheat sheet that told the nursing staff how residents were transferred to include 1 person, 2 person, or mechanical lift. He revealed it was important to know how to care for residents so he could help them out more. Interview on [DATE] at 12:30PM, LVN B revealed Resident #1 was transferred with a mechanical lift and 2 people were needed for this transfer. She revealed she did not read care plans and the information about resident care was reported verbally amongst nursing staff. She revealed she would let the DON know to update care plan when a resident needed something different like transfers. She further revealed it was important to update care plans for resident care. She revealed if the nursing staff did not know what to do for a resident, then they would refer to the care plan to figure it out. Interview on [DATE] at 01:03PM, LVN C revealed Resident #1 was transferred via mechanical lift most of the time. She revealed 2 people were needed for a mechanical lift. She revealed the nursing staff relayed information about resident care via word of mouth. Interview on [DATE] at 11:00AM, CNA D revealed Resident #1 was a 2-person mechanical transfer. She revealed she read the residents' care plans to know how to care for the residents. Interview on [DATE] at 02:16PM, the DON reviewed the care plan screen and that it reflected a 1-person transfer for Resident #1, which needed to be updated so the resident was not inappropriately transferred since Resident #1 was a mechanical lift that required a 2 person transfer The DON further revealed she oversaw that care plans were updated as needed. Record Review of the facility policy, revised [DATE], Care Plans, Comprehensive Person-Centered, reflected, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide nursing care with a sufficient number of nursing personnel on a 24-hour basis to all residents in accordance with resident care plans for 1 out of 4 days (04/07/25) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care for approximately 5 hours during the 2P-10P shift on 04/07/25. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing. Findings include: Record review of Resident #2's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities), unsteadiness of feet, and generalized muscle weakness. Record review of Resident #2's quarterly MDS assessment, dated 04/05/25, reflected Resident #2 was partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfers and had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #2's care plan, last reviewed 03/24/25, reflected I have a history of fall R/T impaired mobility and impaired balance with intervention resident is educated to wait for staff to supervise with transfers., dated 03/31/25. Record review of Resident #3's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include insomnia, dementia (group of symptoms affecting memory, thinking and social abilities), lack of coordination, major depressive disorder, and need for assistance with personal care. Record review of Resident #3's annual MDS assessment, dated 01/16/25, reflected Resident #3 was substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and was dependent (Helper does ALL of the effort) to wheel her wheelchair 50 feet with two turns and wheel 150 feet. It further revealed Resident #3 had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #3's care plan, last reviewed 03/24/25, reflected [Resident #3] is at risk for disturbed sleep patter R/T insomnia with intervention Encourage resident to go to bed at the same time everyday and wake up at the same time everyday., dated 03/27/24. Record review of Resident #4's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include age-related physical debility, lack of coordination, muscle weakness, and need for assistance with personal care. Record review of Resident #4's quarterly MDS assessment, dated 02/07/25, reflected Resident #4 was had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #5's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include cerebral palsy (group of permanent neurological disorders that affect body movement and muscle coordination), need for assistance with personal care, moderate intellectual disabilities, and depression. Record review of Resident #5's quarterly MDS assessment, dated 01/24/25, reflected Resident #5 had a BIMS score of 02 out of 15, indicating severely impaired cognition. It reflected Resident #5 had frequent urinary incontinence and frequent bowel incontinence and needed substantial/maximal assistance (helper does MORE THAN HALF the effort) to roll left and right. Record review of Resident #5's care plan, last reviewed 03/24/25, reflected Urinary Incontinent Care with an intervention To assess resident incontinence and protect skin integrity, dated 03/31/25. Interview on 04/16/25 at 09:50AM, Resident #2 revealed last Monday, 04/07/25, there were no CNAs after a certain time on the 2PM-10PM shift. She revealed her call light was not answered when she wanted to transfer herself from her wheelchair to bed. (Resident #2 was unable to recall any specific times related to using her call light and transferring herself.) She revealed she transferred herself without falling. She revealed her roommate Resident #3 went to bed around 11PM on 04/07/25, when Resident #3 typically went to bed around 7PM. Interview on 04/16/25 at 04:23PM, CNA A revealed last Monday 04/07/25 he knew from Resident #2 about CNAs not being in the facility. He stated the Staffing Coordinator said there were no CNAs scheduled from 2PM-10PM. He stated that was not typical for the facility. Interview on 04/16/25 at 05:19PM, LVN F revealed he worked Monday 04/07/25 2PM-10PM. He further revealed they were without a CNA from 5PM-10PM. He revealed the nurses did everything to include passing out medications, wound care, feeding, and answering call lights. He revealed there was nothing he knew of that was missed, but that some residents went to bed later than planned. Interview on 04/16/25 at 06:33PM, the DON revealed on Monday 04/07/25 CNA A was at the facility until about 5:30PM. She revealed Nurse Aide E was originally on the schedule to cover 5PM-10PM time frame but had left at 5PM instead. The DON revealed she was switching to 12-hour shifts, so she could have a pool of nursing staff she could call in to work if that happened again. She revealed to make sure resident care was not missed on this evening, the nursing staff talked about grievances in the morning huddle, and she went into everyone's rooms to make sure residents were fine. She revealed she found there was no effect on resident care at that time. Interview on 04/18/25 at 11:40AM, the DON revealed it was important to make sure there were CNAs scheduled throughout the day. She revealed she scheduled 2 CNAs for the 2PM-10PM shift and at least 3 for the 6AM-2PM shift. She further revealed it was important to have enough CNAs so there was not a delay in care and so this did not affect nursing duties like medication pass when the nurses may need to help CNAs or do CNA work instead. Interview on 04/18/25 at 12:50PM, Nurse Aide E revealed she was not aware that she was scheduled to work on 04/07/25 on the 2P-10P shift. She revealed she left the facility at 5PM. Interview on 04/18/25 at 05:40PM, Resident #3 revealed she typically went to bed at 7PM but she was put to bed at 10P or 11P on 04/07/25. She revealed she preferred going to bed at 7PM after she took her medications because they made her drowsy. Interview on 04/18/25 at 05:43PM, Resident #4 revealed the call lights were not being answered on 04/07/25 evening. She revealed her roommate, Resident #5 had her call light on but was never responded to. Resident #4 revealed she had to change Resident #5's brief because she was wet. Resident #5 was present during this interview and unable to be interviewed. Record review of the Facility Assessment Tool reflected the total minimum number needed or average or range of nurse aides were 2 on afternoon shift. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide E clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide H clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide I clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide J clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected CNA A clocked out at 5:06PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected CNA G clocked in at 10:07PM on 04/07/25. Record review of facility's policy Staffing, revised July 2021, reflected Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment . 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 16 residents (Resident #13) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #13. This deficient practice could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #13's face sheet, dated 07/10/2024, revealed she was admitted to the facility on [DATE] with diagnoses which included: other specified chronic obstructive pulmonary disease, essential hypertension, dementia in other diseases classified elsewhere, unspecified severity, with anxiety, unspecified macular degeneration, shortness of breath, and localized edema. Record review of Resident #13's admission MDS assessment, dated 06/29/2024, revealed the resident's BIMS score was 12, which indicated moderate cognitive impairment. The admission MDS assessment further revealed Resident #13 required substantial/maximal assistance (helper does more than half the effort) for lower body dressing, putting on/taking off footwear, sit to stand, chair/bed-to-chair transfer, dependent (helper does all the effort) for upper body dressing and partial/moderate assistance (helper does less than half the effort) for personal hygiene. Record review of Resident #13's care plan, revision date of 07/02/2024, revealed Resident #13 had a problem of Category: Falls. Falls/Safety/Elopement Risk and approach revealed Encourage use of call light. Keep call light within reach. Observation and interview on 07/07/2024 at 10:35 a.m. revealed Resident #13's call light on the floor at the foot of the bed near privacy curtain with Resident #13 at bedside sitting in her wheelchair. Resident #13 stated she wished she could get someone who could help her turn her light on. Resident #13 stated she did not know where her call light was, but she only knew of the string to her light over her bed. During an interview and observation on 07/07/2024 at 10:42 a.m. LVN B revealed Resident #13 did not have her call light within reach and would need to get a stuffed animal on it because they usually have one on them as she placed the call light from the floor to the bed. LVN B stated Resident #13 would not have been able to reach the call light. Resident #13 took the string in her hand. LVN B further stated everyone was responsible to place the call light within reach. Observation and interview on 07/10/2024 at 10:55 a.m. revealed Resident #13 in her room with over the bed table next to her while sitting in her wheelchair next to her bed which ran across the wall under the over bed light with the call light on the other side privacy curtain in the chair next to the other bed in the room. The DON was preparing Resident #13's medications for administration as Resident #13 called to her to please come in the room. The DON was observed entering and visited with her, explained to her the medications being received. The DON as she prepared to leave room and had answered resident's questions, she noticed call light and placed it beside Resident #13 with the teddy bear sitting it on her lap which was attached to the call light. The DON informed Resident #13 she was placing the call light on her lap. When DON exited Resident #13's room she stated the call light was out of reach and stated it was everyone's responsibility to ensure call lights were within reach. The DON further stated it was important for call lights to be within reach, so residents were able to call for assistance or alert staff to their needs. Record review of facility's Answering the Call Light policy, revised date March 2021, read Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 5. When the resident is in bed or confined to a chair be the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure staff wore hair restraints to cover hair when in the kitchen. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 07/07/2024 at 9:13 a.m. during initial tour of the kitchen revealed CNA A entered the kitchen and washed hands at the sink without a hair net. During an interview on 07/07/24 at 9:23 a.m. CNA A revealed she should have had a hair net on due to contamination. CNA A further stated she had just come in from taking some trash and had something on her hand and was trying to find the nearest sink to wash her hands. CNA A stated a hair net should be always worn when you are in the kitchen or entering the kitchen due to contamination risk. Observation and interview on 07/08/2024 at 3:17 p.m. revealed upon entry to the kitchen the DM not wearing a hair net or a beard restraint. The DM was observed to have been standing next to the stove and the prep table at the time of entry to the kitchen not wearing a hair net or a beard restraint. The DM quickly went into the dietary office and returned with a cook bonnet that ties in the back along with a beard restraint which was only covering his beard not his mustache. The DM revealed by not wearing the hair restraints it could cause contamination of food items in the kitchen The DM further stated the reason for the need to cover the mustache was due to bacteris was not easily washed off and his mustache could carry bacteria. During an interview on 07/10/2024 at 10:46 a.m. the DM revealed regarding the incident on 07/08/2024 when he was observed not wearing a hair net and beard restraint that he had just entered the kitchen, pulled a pot and the meat from thawing to begin preparation, had not put on his hair restraints yet. The DM further stated it was important to wear them as they kept hair out of the food due to hair potentially carrying bacteria. The DM stated hair getting into the food had the potential of causing sickness or illness. The DM stated hair restraints should be worn at all times when in the kitchen. During an interview on 07/10/2024 at 11:05 a.m. the ADM revealed staff were to wear hair restraints every time they go in the door of the kitchen. The ADM further stated by not wearing them it could be an infection control issue and that the hair restraints are worn so hair did not get on the food. Review of facility's policy Personnel Guidelines, not dated, read Dress Code and Appearance: Wear hair restraints that are designed to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service or single-use articles. This helps prevent hair from contacting food and food-contact surfaces and to deter team members from touching their hair. Hair restraints may include hair bonnets and nets, beard restraints and clothing that covers body hair. Hair should be fully covered with hair restraints within the department. Other hair restraints require approval from the Dietitian or designee. Hair coverings should completely restrain hair, should not be worn outside the kitchen and remain clean. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 20 days (1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, 2/17/24, 4/6/24, 4/21/24, 5/11/24, 5/12/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, and 6/16/24), reviewed for nursing services. The facility had no RN coverage for 1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, 2/17/24, 4/6/24, 4/21/24, 5/11/24, 5/12/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, and 6/16/24. (20 days from January 2024 to June 2024) This failure could result in residents not receiving the required services to meet their needs. The findings were: Record review of the CMS PBJ staffing data report run date 7/3/24 for quarter 2 (January 1 through March 31st) revealed the facility triggered for no RN hours on 1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, and 2/17/24. Record review of the facility timesheets revealed no RN coverage for 1/1/24 (Monday), 1/6/24 (Saturday), 1/13/24 (Saturday), 1/14/24 (Sunday), 1/20/24 (Saturday), 2/3/24 (Saturday), 2/4/24 (Sunday), 2/10/24 (Saturday), 2/17/24 (Saturday), 4/6/24 (Saturday), 4/21/24 (Sunday), 5/11/24 (Saturday), 5/12/24 (Sunday), 6/1/24 (Saturday), 6/2/24 (Sunday), 6/8/24 (Saturday), 6/9/24 (Sunday), 6/15/24 (Saturday), 6/16/24 (Sunday), and 5 hours of coverage on 1/27/24 (Saturday). During an interview on 7/7/24 at 11:30 a.m. the DON stated she worked at a minimum of 40 hours a week Monday through Friday but often worked outside her normally scheduled hours but is salaried and does not clock in or out. During an interview on 7/10/24 at 9:30 a.m. the HRC stated there were other RN's the facility used that are no longer employed but she and her corporate contact were unable to access their timesheets. During an interview on 7/10/24 at 12:30 p.m. the Administrator stated the facility had been without a weekend RN supervisor but hired one in June 2024 and has had no issues since that time with RN coverage. The Administrator stated she was unsure of the consequences of not having an RN on duty at the facility because the nurses had immediate access to the DON by phone, the clinical resource nurse (RN), the physician's group, and 911 for emergencies and pointed across the street to the city EMS services building and stated EMS was across the street. Review of the facility policy for staffing revised July 2021 indicated . 4. Direct care staffing information per day including agency and contract staff is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. Review of another facility policy for staffing revised 9-28-23 indicated . 4. The facility utilizes the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a Baseline Care Plan for resident 1 of 3 (Resident #6) who was admitted on hospice to the facility for respite care on 8/31/2023. The facility failed to initiate a Baseline Care Clan within 48 hours of admission date on 8/31/2023 to include information for the resident's stay for respite, for her hospice care, and for her stage 2 left heel wound while at the facility. This failure could place the resident at risk of not receiving person-centered care that is needed for communicating with staff to ensure the resident's needs are met. Findings include: Record review of Resident #6's face sheet on 2/28/2024 at 3:25PM revealed she was an [AGE] year old woman admitted to facility 8/31/2023 with diagnoses which include: Parkinson's disease, hypotension (low blood pressure), and Rhabdomyolosis (breakdown of muscle that release a damaging protein- myoglobin into the blood that can cause kidney damage). Record review of Resident #6's MDS assessment on 2/28/2024 at 3:25PM dated 9/5/2023 revealed she had a BIMS score of 9 and required extensive assistance with ADLs. A search for a Baseline Care Plan revealed it was not done. Record review of Resident #6's physician orders 2/28/2024 at 3:25PM revealed no order for wound care and an order to reposition every 2 hours and to assist from bed to chair. During an interview with [NAME] RN with Embrace Hospice 2/29/2024 at 11:19AM about wound care for [NAME], she stated she did not put the order in the system with the facility because she continued to treat her as she did when the resident was at home with cleansing the wound with wound cleanser spray, painted the left heel with betadine, cover with a 2x2 gauze, and secure by wrapping with kerlix. She said it was done 3 times per week. During an interview with the DON on 2/29/2024 at 12:11PM she stated ,a Baseline Care Plan should be done within 48 hours of admission. It lets the nurses know the need of the resident and how to care for the resident. Based on record review of the facility's policy for admissions on 2/29/2024 at 3:15PM titled- Care Plans- Baseline and dated 12/2016 (revised) revealed: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. Policy interpretation stated in part: the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 4 residents (Resident #10) reviewed for infection control. The facility failed to post a sign on Resident #10's door to indicate she was on Contact Isolation (any of the techniques used in addition to standard precautions that decrease the likelihood of infection by microorganisms transmitted through direct or indirect contact with the patient or patient care items, e.g., methicillin-resistant Staphylococcus aureus). This deficient practice could affect staff, residents, and visitors who may enter Resident #10's room without the appropriate PPE and expose them to infection. The findings included: Record review of Resident #10's electronic face sheet (undated) reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: partial intestinal obstruction (happens when the intestines are partially blocked), toxic encephalopathy (neurologic disorder caused by exposure to toxic substances that damage the brain), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), methicillin resistant staphylococcus aureus infection (a type of bacteria that's resistant to a number of widely used antibiotics), and unspecified site, carrier or suspected carrier of methicillin resistant staphylococcus aureus (may be a carrier of the bacteria and can spread or transmit the bacteria to others). Record review of Resident #10's quarterly MDS assessment with an ARD of 02/23/2024 reflected she scored an 11/15 on her BIMS which signified she was moderately cognitively impaired. She could understand and be understood. She required extensive assistance with her ADL's. Record review of Resident #10's comprehensive care plan revised 02/29/2024 reflected Problem, has a pressure ulcer infection on sacrum, Approach, use principles of universal/standard precautions for contact precautions per facility policy. Record review of Resident #10's physician orders dated 02/29/2024 reflected Pt to have contact isolation due to positive MRSA to nares until her ABT therapy done in 10 days. Special Instructions: Pt to maintain isolation status x 10 days. Start dated 02/26/2024. Observation on 02/28/2024 at 10:00 a.m. of Resident #10's door revealed she had a bin sitting outside against the wall with masks, gloves, and gowns in the drawers (PPE). There was no sign on her door. Observation on 02/29/2024 at 08:00 a.m. of Resident #10's door revealed she still had a bin outside of her door, and there was no isolation sign posted. In an interview on 02/29/2024 at 09:30 a.m. with the DON, she stated she informed the staff to set up isolation for Resident #10 when she returned from the hospital on [DATE] and the positive MRSA nasal swab was noticed in her lab work. She stated that staff who collaborated with the resident were informed she was on contact isolation. She stated there should have been a sign on Resident #10's door which indicated she was on contact isolation. In an interview on 02/29/2024 at 1:24 p.m. with C NA A, she stated she was informed that Resident #10 was on contact isolation, but there was no sign on the door. She stated the PPE was available and they wore a gown and gloves when they collaborated with the resident. In an interview on 02/29/2024 at 1:30 p.m. with LVN B, she stated she was informed that Resident #10 was on contact isolation, but that a sign was not on the door because of HIPAA rules. Record review of the facility policy and procedure titled Isolation-Categories of Transmission-Based Precautions revised January 2012 reflected 8. Signs - The facility will implement a system to alert staff to the type of precaution resident requires.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a system in place to assure assessments are conducted in accordance with the specified timeframes for each resident for 3 of 22 residents (#11, #25, #26) reviewed for MDS timeliness, in that; 1. Resident #11 discharged from the facility on 1/13/2023 however the resident's discharge MDS Assessment was not completed until 5/31/2023. 2. Resident #25 was discharged from the facility on 2/18/2023 however the resident's discharge MDS Assessment was not completed until 6/8/2028. 3. Resident #26 was discharged from the facility on 2/18/2023 however there was not a discharge MDS completed. These failures could result in incorrect billing to the residents' insurance and could prevent additional services the residents could receive in the community. The findings included: 1. Record review of Resident #11's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged from the facility on 1/13/2023. The resident's diagnoses listed in the face sheet included Parkinson's disease (a disorder of the central nervous system caused by nerve cell damage that affects movement, often including tremors), cognitive communication deficit, congestive heart failure (a chronic condition in which the heart cannot pump blood as well as it should), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertension (high blood pressure). Record review of Resident #11's progress notes located in the resident's closed electronic record dated 1/13/2023 at 1:28 p.m. revealed the resident was discharged to another facility. Record review of Resident #11's Discharge MDS Assessment with an assessment date of 1/13/2023 revealed the sections on the MDS were completed and signed by the Travel MDS Coordinator on 5/31/2023 and signed by an unknown RN as completed was 5/31/2023. 2. Record review of Resident #25's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 2/18/2023. The resident's diagnoses listed on the face sheet included hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), spinal stenosis (when spaces in the spine narrow and create pressure on the spinal cord and nerve roots), generalized muscle weakness, and age-related physical disability. Record review of Resident #25's progress note located in the resident's closed electronic record dated 2/18/2023 at 1:30 p.m. revealed the resident was discharged home with her daughter. Record review of Resident #25's Discharge MDS Assessment with an assessment date of 2/18/2023 revealed the MDS sections were completed and signed by the Travel MDS Coordinator with 3 completion dates of 5/12/2023, 5/30/2023 and 5/31/2023 however the record was not signed as completed by an RN. 3. Record review of Resident #26's face sheet dated 6/7/2023 revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and discharged from the facility on 1/25/2023. The resident's diagnoses listed on the face sheet included hypothyroidism (underactive thyroid diagnose through blood tests), chronic kidney disease stage 3 (mild to moderate damage to the kidneys which are less able to filter waste and fluid of the blood), and congestive heart failure. Record review of Resident #26's progress notes in the resident's closed electronic record dated 1/24/2023 at 3:48 p.m. revealed the resident was being discharged the following day on home health services. Review of Resident #26's MDS 3.0 Resident Assessments located in the residents closed electronic record revealed the resident had an entry MDS assessment dated [DATE], and an admission MDS Assessment and a Scheduled 5-day MDS assessment dated [DATE], however, there was no discharge MDS Assessment completed. In an interview on 6/5/2023 at 10:35 a.m. with the Regional Nurse and the corporate MDS Travel LVN reported the facility had an MDS Coordinator until recently, when they discovered she was behind on her MDS's. The MDS Travel LVN reported they discovered the former MDS Coordinator had only completed admission MDS Assessments and Quarterly MDS Assessments. Record review of the facility policy entitled MDS Completion and Submission Timeframes, revised September 2010, revealed, #1. The Assessment Coordinator or designee is responsible for ensuring that the resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines and timeframes for completion and submission of assessments is based on current requirements published in the Resident Assessment Instrument Manual. Record review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2019, page 39, revealed a Discharge Assessment when a resident was not anticipated to return was completed no later than 14 calendar days after the resident was discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 22 residents (Resident #7) reviewed for MDS assessments, in that: The facility failed to complete a Significant Change MDS for Resident #7 within 14 days after the resident was discharged from hospice services. This deficient practice could place residents discharged from hospice services at-risk of not having their individual needs met. The findings were: Record review of Resident #7's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE], most recent admission date of 2/6/2015 and had diagnoses that included alcohol dependence with alcohol-induced persisting dementia, Wernicke's encephalopathy (a degenerative brain disorder caused by lack of vitamin B1), schizoaffective disorder bipolar type (a chronic mental health disorder characterized by abnormal thought processes and cycles of mania and depression), heart disease, and dysphagia (swallowing problems) following cerebrovascular disease (a group of disorders that affect the blood vessels and blood supply to the brain). Record review of Resident #7's Annual MDS assessment dated [DATE] revealed the resident was on hospice services. Record review of a Discharge summary dated [DATE] located in Resident #7's electronic medical record revealed the resident was discharged from hospice services on 3/20/2023. Record review of Resident #7's order history from 2/1/2023 to 6/6/2023 revealed the resident had a physician order for hospice services with a start date of 4/14/2021 and a discharge date of 4/4/2023. Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 9, which indicates moderately impaired cognitive status. Further review of the resident's MDS revealed the resident was not on hospice services. Record review of Resident #7's MDS History revealed a Significant Change in Status MDS Assessment was not completed when the resident discharged from hospice services. In an interview on 6/7/2023 at 10:22 a.m. with the cooperate MDS Travel LVN revealed a Change of Condition MDS Assessment should be completed after a resident was discharged from hospice services. After reviewing Resident #7's medical record the MDS Travel LVN reported a Quarterly MDS Assessment had been completed instead of a Change in Condition MDS Assessment when Resident #7 was discharged from hospice services. Record review of the facility policy, Change in a Resident's Condition or Status, revised 4/20/2023, revealed, 2. A 'significant change' in condition is a major decline or an improvement in the resident's status that: b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or to the care plan and 7. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA (specific health and safety rules that nursing home and nursing home staff must follow to protect nursing home residents) regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual, Version 1.17.1, dated October 2019, RAI OBRA - required Assessment Summary, revealed a Significant Change in Status completion date no later than, 14th calendar day after determination that significant change in residents' status occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 22 (Resident #25) residents reviewed for MDS transmittal in that: Resident #25's discharge MDS assessment dated [DATE] was not submitted as of 6/7/2023. This deficient practice could place residents at risk of not having their assessments transmitted timely. The findings were: Record review of Resident #25's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 2/18/2023. The resident's diagnoses listed on the face sheet included hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), spinal stenosis (when spaces in the spine narrow and create pressure on the spinal cord and nerve roots), generalized muscle weakness, and age-related physical disability. Record review of Resident #25's progress note located in the resident's closed electronic record dated 2/18/2023 at 1:30 p.m. revealed the resident was discharged home with her daughter. Record review of Resident #25's MDS 3.0 Assessments located in the resident's electronic record revealed a discharge MDS was started on 2/18/2023 however the assessment remained in process and was not submitted to the CMS system. In an interview on 6/5/2023 at 10:35 a.m. with the Regional Nurse and the corporate MDS Travel LVN reported the facility had an MDS Coordinator until recently, when they discovered she was behind on her MDS's. The MDS Travel LVN reported they discovered the former MDS Coordinator had only completed admission MDS Assessments and Quarterly MDS Assessments. Review of the facility policy, MDS Completion and Submission Timeframes, revised July 017, revealed, Our facility will conduct and submit resident assessments in accordance with federal and state submission timeframes and 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES (internet-based system that includes and survey and certification functions) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 22 residents (Resident #8) whose assessments were reviewed, in that: The facility identified Resident #8 had two stage 3 pressure ulcers on the resident's MDS Assessment however the resident did not have any stage 3 pressure wounds. This failure could place residents at risk of inadequate care due to inaccurate assessments. The findings were: Record review of Resident #8's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, hypothyroidism (underactive thyroid diagnose through blood tests), heart disease with heart failure, pressure wounds of right buttock stage 1 (affects the upper layer of the skin which appears reddened with no open wound), and two stage 3 pressure wounds (open wounds that have burrowed past the skins second layer and reached the fat layers beneath). Further review of Resident #8's medical record revealed the resident was on hospice services. Record review of Resident #8's admission MDS assessment dated [DATE] revealed the resident had one stage 1 pressure wound and two stage 3 pressure wounds. Further review of the MDS revealed one of the stage 3 pressure wounds were present at admission. Record review of Resident #8's June 2023 Consolidated Physician Orders did not revealed treatment for the resident's pressure wounds. Record review of Resident #8's care plans revealed there was not a care plan for pressure wounds. Record review of resident #8's hospice note dated 2/12/2023 and located in the resident's electronic record revealed the resident had a small ½ dime size stage 2 on the right gluteal fold (fold separating the thigh from the buttock) and surrounding area is red but blanchable (when pressure is applied to the red skin, it immediately turns red again when pressure was removed). In an interview on 6/5/2023 at 10:35 a.m. with the Regional Nurse and the corporate MDS Travel LVN reported the facility had an MDS Coordinator until recently, when they discovered she was behind on her MDS's. The MDS Travel LVN reported they discovered the former MDS Coordinator had only completed admission MDS Assessments and Quarterly MDS Assessments. They reported the former MDS Coordinator spent very little time in the facility. In an interview on 6/6/2023 at 10:30 a.m. with the DON, after reviewing Resident #8's MDS Assessment, revealed she was not aware of the resident ever having any pressure wounds. In an interview and record review on 6/6/2023 at 10:22 a.m. with the cooperate MDS Travel LVN reported the MDS Assessment was completed by the facilities former MDS Coordinator. The MDS Travel LVN reported she was able to find where hospice had indicated Resident #8 had one stage 2 pressure wound but was not able to figure out where the two stage 3 pressure wounds were noted. In an interview on 6/6/2023 at 1:35 p.m. with the DON and Resident #8's hospice nurse revealed the resident was admitted with a stage 1 that became a stage 2 that had since healed. The hospice nurse reported Resident #8 never had a stage 3 pressure wound while she cared for the resident in the community and since the resident had been in the facility. The DON revealed when the resident was admitted to the facility the admitting nurse put the resident's diagnoses into the computer and likely input a stage 3 pressure wound twice by accident. The DON reported she did not know why the admitting nurse indicate on Resident #8's face sheet that the resident had a stage 3 pressure wound. Record review of the facility's policy, Guidelines for Charting and Documentation, revised April 2012, revealed, The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to care, signs, symptoms, etc., and the progress of the resident's care and 5. Assistance in the development of the Plan of Care for each resident and 7. A source of all resident charges.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 22 residents (Resident # 25) reviewed for MDS completion, in that; The facility failed to ensure the RN signed Resident #25's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status. The findings included: Record review of Resident #25's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 2/18/2023. The resident's diagnoses listed on the face sheet included hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), spinal stenosis (when spaces in the spine narrow and create pressure on the spinal cord and nerve roots), generalized muscle weakness, and age-related physical disability. Record review of Resident #25's progress note located in the resident's closed electronic record dated 2/18/2023 at 1:30 p.m. revealed the resident was discharged home with her daughter. Record review of Resident #25's Discharge MDS Assessment with an assessment date of 2/18/2023 revealed the MDS sections were completed and signed by the Travel MDS LVN with 3 completion dates of 5/12/2023, 5/30/2023 and 5/31/2023. Further review of the MDS Assessment revealed the record had not been signed as completed by an RN. Record review of the facility policy entitled MDS Completion and Submission Timeframes, revised September 2010, revealed, #1. The Assessment Coordinator or designee is responsible for ensuring that the resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines and timeframes for completion and submission of assessments is based on current requirements published in the Resident Assessment Instrument Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission for 1 of 22 residents (Resident #8) reviewed for care plans, in that; The facility failed to develop a baseline care plan within 48 hours for Resident #8 after the resident was admitted to the facility. This deficient practice could result in residents not receiving care and services as needed. The findings were: Record review of Resident #8's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, hypothyroidism (underactive thyroid diagnose through blood tests), heart disease with heart failure, and chronic kidney disease stage 3 (mild to moderate damage to the kidneys which are less able to filter waste and fluid of the blood). Further review of Resident #8's face sheet revealed the resident was admitted on hospice services. Record review of Resident #8's admission MDS assessment dated [DATE] revealed the resident had short- and long-term memory loss and severely impaired decision-making skills. Record review of Resident #8's Care Area Assessment Summary developed from the residents admission MDS dated [DATE] also revealed the resident exhibited pain, had a pressure ulcer, and used psychotropic medication. Review of Resident #8's June 2023 Consolidated Physician Orders located in the resident's electronic record revealed the resident was admitted with Lasix (a diuretic), levothyroxine (used to treat an underactive thyroid), and Protonix (used to treat gastroesophageal disease). Review of Resident #8's care plans located in the resident's electronic record revealed the resident had a 3 care plans; one that addressed the resident's nutritional with a start date of 6/2/2023, another care plan that addressed the residents use of ¼ side rails for bed mobility with a start date of 5/19/2023, and another care plan under the category heading, General, that addressed the resident's activity of daily living care needs, with a start date of 5/1/2023. In an interview on 6/5/2023 at 10:35 a.m. with the Regional Nurse and the corporate MDS Travel LVN reported the facility had an MDS Coordinator until recently, when they discovered she was behind on her MDS's and care plans. In an interview on 6/6/2023 at 2:54 p.m. with the DON revealed the baseline care plans were uploaded in the residents' record the same as the care plans that followed an MDS was completed. The DON reported after the admission MDS was completed the baseline care plans would then be changed as needed to meet the resident's needs identified in the MDS. The DON reported Resident #8's care plans would have been developed this way also. The DON and MDS Travel Coordinator, who was also present, reviewed Resident #8's care plans and noted there were only 3 care plans that were created after the 24-hour admission baseline care plan should have been completed. Review of the facility policy, Care Plans-Baselines, revised December 2016 revealed, 1. To assure that the resident's immediate needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission and 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 22 Residents (Resident #8) reviewed for care plans, in that: 1. The facility failed to develop a comprehensive person-centered care plan that was specific for Resident #8 to address hospice information, details of hospice care provided and coordination of services. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings were: 1. Record review of Resident #8's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, hypothyroidism (underactive thyroid diagnose through blood tests), heart disease with heart failure, and chronic kidney disease stage 3 (mild to moderate damage to the kidneys which are less able to filter waste and fluid of the blood). Further review of Resident #8's medical record revealed the resident was admitted on hospice services. Record review of Resident #8's admission MDS assessment dated [DATE] revealed the resident had short- and long-term memory loss and severely impaired decision-making skills. Further review of the MDS revealed the resident was on hospice services prior to coming to the facility and continued hospice services while a resident in the facility. Review of Resident #8's care plans revealed there was not a care plan that addressed hospice information and hospice services, details of the care provided and coordination of services. In an interview on 6/5/2023 at 10:35 a.m. with the Regional Nurse and the corporate MDS Travel LVN reported the facility had an MDS Coordinator until recently, when they discovered she was behind on her MDS's. The MDS Travel LVN reported they discovered the former MDS Coordinator had only completed admission MDS Assessments and Quarterly MDS Assessments. In an interview on 6/6/2023 at 3:52 p. with Resident #8's hospice nurse confirmed the resident was admitted to the facility on hospice services. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2020, 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment and 8. i. Identify the professional services that are responsible for each element of care. Additionally, the policy noted, 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessments (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #23) reviewed for urinary catheters, in that: Resident #23 had an indwelling urinary catheter for 5 days without a physician's order or related care orders to be provided. This deficient practice could affect residents who had urinary catheters at risk of not receiving care needed. The findings were: Record review of Resident #23's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female with an initial admit date of 4/24/2023, a readmit date of 5/29/2023, and had diagnoses that included heart disease, type 2 diabetes mellitus (the body either does not produce enough insulin or it resists insulin) with diabetic polyneuropathy (progressive death of nerve fibers), chronic pain, and osteoarthritis. The face sheet also noted the resident was on hospice services. Review of Resident #23's admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 12, which indicated she had some moderate impaired cognitive status. Further review of the resident's record revealed the resident had an indwelling catheter. Record review of Resident #23's progress note located in the resident's electronic medical record dated 5/31/2023 at 2:00 p.m. revealed the hospice RN discontinued the resident's indwelling catheter. Record review of Resident #23's progress note located in the resident's electronic medical record dated 5/31/2023 at 9:57 p.m. revealed the resident was doing well since her indwelling catheter was discontinued. Record review of Resident #23's June 2023 Consolidated Physician Orders revealed an order dated 5/31/2023, Call hospice if unable to void in 6 hours. Observation on 6/4/2023 at 2:45 p.m. of Resident #23 revealed the resident had an indwelling catheter. In an interview on 6/4/2023 at 2:45p.m. with Resident #23 revealed the indwelling catheter had been removed because the resident was exhibiting some pain from it however a new indwelling catheter had to be replaced a short time later due to bladder related issues. In an interview on 6/5/2023 at 10:30 a.m. with LVN B revealed the last day she worked Resident #23's indwelling catheter was being discontinued. The LVN went ton to say when she came in to work this morning, she noted the resident had an indwelling catheter but did not know why. In an interview on 6/5/2023 at 10:33 a.m. with the DON revealed Resident #23's indwelling catheter was replaced by the resident's hospice nurse after being removed for about 24 hours. The DON reported the resident had a diagnosis of neurogenic bladder, which had not been added to the resident's diagnoses. The DON reported when the hospice nurse replaced the indwelling catheter the hospice nurse had forgot to add the orders for the indwelling catheter to the resident's record. In an interview on 6/5/2023 at 11:01 a.m. with LVN B, when the LVN was asked about the potential concerns to not having an order for Resident #23's indwelling catheter, the LVN first responded, I don't know and then replied, That is bad. We should have an order for it. Review of the facility policy, Guidance for Charting and Documentation, revised April 2012, under the heading, Physician Orders revealed, 1. Supervision of a Physician: c. Current list of orders must be maintained in the clinical record of each resident and 2. Content of Orders: i . 2. Specify the size (i.e., #18 Fr foley catheter to straight drain) and the frequency of change. 3. Catheter care-specific what is to be done or according to facility procedure.

Based on interview and record review, the facility failed to ensure a registered nurse was present in the facility for at least eight consecutive hours per day and seven days per week, for 1 of 1 facility reviewed for registered nursing coverage, in that; A registered nurse [RN] was not present in the facility for at least eight consecutive hours per day and seven days per week on 4 occasions (4/01/2023, 4/08/2023, 4/15/2023, and 5/14/2023) in the 3 months (3/01/2023 - 6/04/2023) prior to the survey period. This deficient practice had the potential to affect all residents in the facility by leaving staff without supervisory coverage for coordination of events such as assessments, interventions, care and treatment requiring the advanced education, skills and judgement of an RN. The findings were: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 5/30/2023 revealed inadequate RN coverage, less than 8 consecutive hours, 7 days a week, for over approximately 2 months, between 10/03/2022 through 12/10/2022. Review of sign in sheets for the previous 3 months prior to survey, the facility failed to use the services of an RN on the following dates: Saturday 4/01/2023, Saturday 4/08/2023, Saturday 4/15/2023, and Sunday 5/14/2023. Review of email dated 6/08/2023 at 12:02 PM, the ADM stated, We did not have an RN on any of those dates [4/01/2023, 4/08/2023, 4/15/2023, and 5/14/2023]. In an interview on 6/08/2023 at 10:59 AM, RRN stated the facility did not have proof of RN coverage for 4/01/2023, 4/08/2023, 4/15/2023, or 5/14/2023. In an interview on 6/08/2023 at 6:20 PM the DON stated there was not a policy on RN coverage for 8 consecutive hours a day, 7 days a week. The DON stated she did not work those dates, to the best of her recollection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide routine drugs and biologicals to its residents, or obtain them for 1 of 12 residents (Resident #31) observed for pharmacy services, in that; The facility failed to obtain gabapentin medication as required for Resident #31. This deficient practice placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 6/08/2023, revealed Resident #31 was a [AGE] year-old female admitted [DATE]. Record review of the quarterly MDS assessment, dated 4/29/2023, revealed Resident #31 was admitted for non-traumatic brain dysfunction as the primary reason for admission. Other active diagnoses included alcoholic cirrhosis [degenerative disease resulting in scarring and functional failure] of the liver with ascites [abnormal buildup of fluid in the belly, prognosis is poor]. Resident #31 had a summary BIMS score of 15, indicative of intact cognition. Pain assessment revealed occasionally experienced pain or hurting over the last 5 days in the look back period of the MDS assessment at a moderate severity. Record review of the care plan with a start date of 5/22/2023, revealed Resident #31 had a problem area of at risk for chronic pain related to cirrhosis with associated approaches of: administer medications as ordered. Record review of physician's orders revealed Resident #31 had the following orders: * Cymbalta [a medication to treat depression and anxiety; in addition, used to relieve nerve pain] delayed release capsule 30 milligrams; Amount 3 capsules to equal 90 milligrams by mouth one time a day with the start date of 5/1/2023. * Gabapentin [a medication to treat nerve pain] capsule; 100 milligrams; amount 1 capsule by mouth three times a day with a start date of 2/18/2023. Record review of the medication administration record for Resident #31 from 5/15/2023 to 6/8/2023, revealed missed gabapentin doses on: *5/17/2023 1:00 PM to 3:00 PM: [blank space, no reason code documented]; *5/24/2023 6:00 AM to 10:00 AM and 1:00 PM to 3:00 PM: Drug/Item Unavailable; *6/05/2023 6:00 AM to 10:00 AM and 1:00 PM to 3:00 PM: Drug/Item Unavailable; *6/06/2023 1:00 PM to 3:00 PM: Drug/Item Unavailable with a comment of Pending delivery, has been ordered. In an interview on 6/05/2023 at 10:11 AM, Resident #31 stated she is frustrated when the facility runs out of her pain medication. Resident #31 stated when this happens and she is in pain, she does not enjoy being with her family or friends and feels like her condition makes her a burden to those around her. In an observation on 6/06/2023 at 2:38 PM, Resident #31 was scheduled to receive her afternoon medications in which she received Ativan [a medication to treat anxiety that may help calm nerve pain] 0.5 milligrams by mouth and Tramadol [a medication to treat moderate to moderately severe chronic pain] 50 milligrams by mouth, but Resident #31 did not receive the scheduled gabapentin 100 milligrams by mouth. In an interview on 6/06/2023 at 2:45 PM, LVN D stated she was unable to administer Resident #31's gabapentin as it was not available to dispense. LVN D stated she had ordered the medication several days ago when the prescription was running low. LVN D stated she was surprised the medication had not arrived from the pharmacy yet. In an interview on 6/06/2023 at 4:40 PM, Resident #31 stated she was not in significant pain, despite not getting the medication she needed to treat pain. Resident #31stated this running out of medication happens frequently maybe once every other month or so. Resident #31stated she did not understand how she could run out of a medication that is on a preset schedule. Resident #31 stated that if she misses too many doses in a row, then she ends up on a higher end of the pain curve and it takes stronger medication, like hydrocodone to get her pain back down to her baseline pain experience. In an interview on 6/07/2023 at 5:45 PM, the DON stated the expectation was the nurses administer medications and especially pain medications as the physician ordered. The DON stated that she could not think of a reason why the correct medication was not available from the pharmacy before the prescription runs out. The DON stated the expectation is for the nurse to initiate a refill of medications several days prior to the last available dose to ensure the medication is on site when needed. Review of Administering Oral Medications policy, revised 2010, revealed the following steps in the Preparation: 3. Assemble the equipment and supplies as needed. Review of Pain Assessment and Management policy, revised July 2022, revealed in Implementing Pain Management Strategies heading, statements 2. Pharmacological interventions .a.) administer pain medications as ordered. 5. Implement the medication regimen as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 12 residents (Resident #31) observed during medication administration, in that; The facility failed to administer medications (gabapentin, a medication to relieve nerve pain) as prescribed for Resident #31. This deficient practice placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 6/08/2023, revealed Resident #31 was a [AGE] year-old female admitted [DATE]. Record review of the quarterly MDS assessment, dated 4/29/2023, revealed Resident #31 was admitted for non-traumatic brain dysfunction as the primary reason for admission. Other active diagnoses included alcoholic cirrhosis [degenerative disease resulting in scarring and functional failure] of the liver with ascites [abnormal buildup of fluid in the belly, prognosis is poor]. Resident #31 had a summary BIMS score of 15, indicative of intact cognition. Pain assessment revealed occasionally experienced pain or hurting over the last 5 days in the look back period of the MDS assessment at a moderate severity. Record review of a care plan with a start date of 5/22/2023, revealed Resident #31 had a problem area of at risk for chronic pain related to cirrhosis with associated approaches of: administer medications as ordered. Record review of physician's orders revealed Resident #31 had the following orders: * Cymbalta [a medication to treat depression and anxiety; in addition, used to relieve nerve pain] delayed release capsule 30 milligrams; Amount 3 capsules to equal 90 milligrams by mouth one time a day with the start date of 5/1/2023. * Gabapentin [a medication to treat nerve pain] capsule; 100 milligrams; amount 1 capsule by mouth three times a day with a start date of 2/18/2023 with a diagnosis of muscle weakness. Record review of the medication administration record for Resident #31 from 5/15/2023 to 6/8/2023, revealed missed gabapentin doses on: *5/17/2023 1:00 PM to 3:00 PM: [blank space, no reason code documented]; *5/24/2023 6:00 AM to 10:00 AM and 1:00 PM to 3:00 PM: Drug/Item Unavailable; *6/05/2023 6:00 AM to 10:00 AM and 1:00 PM to 3:00 PM: Drug/Item Unavailable; *6/06/2023 1:00 PM to 3:00 PM: Drug/Item Unavailable with a comment of Pending delivery, has been ordered. In an interview on 6/05/2023 at 10:11 AM, Resident #31 stated she is frustrated when the facility runs out of her pain medication. Resident #31 stated when this happens and she is in pain, she does not enjoy being with her family or friends and feels like her condition makes her a burden to those around her. In an observation on 6/06/2023 at 2:38 PM, Resident #31 was scheduled to receive her afternoon medications in which she received Ativan [a medication to treat anxiety that may help calm nerve pain] 0.5 milligrams by mouth and Tramadol [a medication to treat moderate to moderately severe chronic pain] 50 milligrams by mouth, but Resident #31 did not receive the scheduled gabapentin 100 milligrams by mouth. In an interview on 6/06/2023 at 2:45 PM, LVN D stated she was unable to administer Resident #31's gabapentin as it was not available to dispense. LVN D stated she had ordered the medication several days ago when the prescription was running low. LVN D stated she was surprised the medication had not arrived from the pharmacy yet. In an interview on 6/06/2023 at 4:40 PM, Resident #31 stated she was not in significant pain at the moment, despite not getting the medication she needed to treat pain. Resident #31stated this running out of medication happens frequently maybe once every other month or so. Resident #31stated she did not understand how she could run out of a medication that is on a preset schedule. Resident #31 stated that if she misses too many doses in a row, then she ends up on a higher end of the pain curve and it takes stronger medication, like hydrocodone to get her pain back down to her baseline pain experience. Resident #31 stated she does not like to ask for the narcotic medication due to her history of addiction. Resident #31 stated she will ask for the narcotics when her pain is significant and there is a long amount of time before the next scheduled or available dose, but always worried they see me as 'drug seeking' [a health care stigma associated with those in recovery that can undermine care and treatment]. In an interview on 6/07/2023 at 5:45 PM, the DON stated the expectation was the nurses administer medications and especially pain medications as the physician ordered. The DON stated that she could not think of a reason why the correct medication was not available from the pharmacy before the prescription runs out. The DON stated the expectation is for the nurse to initiate a refill of medications several days prior to the last available dose to ensure the medication is on site when needed. Review of Pain Assessment and Management policy, revised July 2022, revealed in Implementing Pain Management Strategies heading, statements 2. Pharmacological interventions .a.) Administer pain medications as ordered. 5. Implement the medication regimen as ordered.

Based on observation, interview, and record review the facility failed to ensure, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 of 3 medication carts (Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart was locked when it was left unattended at the Nurses' Station in a common area. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 6/07/2023 at 12:50 PM, the Treatment Cart was observed to be unlocked and unattended at the Nurses Station. This was a common pass-through area to common areas of the smoking patio, break room, television room and exit. There were ambulatory and self-mobilizing residents, visitors, and staff in the immediate vicinity. In an observation and interview on 6/07/2023 at 12:53 PM, the RVP stated the cart should be locked when not attended. The Treatment Cart contained prescription and over-the-counter medications and wound care paraphernalia. The RVP closed the drawers opened by this surveyor and locked the Treatment Cart. The RVP stated he would find the DON to determine whose responsibility the Treatment Cart was. In an interview on 6/07/2023 at 12:54 PM, the DON stated she had inadvertently left the Treatment Cart unlocked and unattended when she gathered supplies from the Treatment Cart and rushed to a resident's room who reported needing care to her. The DON stated she had left the Treatment Cart unlocked and unattended for 2 minutes or less. The DON stated an adverse outcome could occur to anyone, staff, resident, or visitor, if medications were inappropriately obtained or utilized. Record review of Storage of Medications policy, revised November 2020, revealed statement, Facility stores all drugs and biologicals in a safe, secure and orderly manner. Under the heading Policy Interpretation and Implementation, in step 6.) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 22 residents (Resident #23) reviewed for accurate medical records, in that: Resident #23's electronic medical record did not have a diagnosis for her indwelling catheter. This failure could place residents at risk for harm due to inaccurate records. The findings included: Record review of Resident #23's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female with an initial admit date of 4/24/2023, a readmit date of 5/29/2023, and had diagnoses that included heart disease, type 2 diabetes mellitus (the body either does not produce enough insulin or it resists insulin) with diabetic polyneuropathy (progressive death of nerve fibers), chronic pain, and osteoarthritis. The face sheet also noted the resident was on hospice services. Review of Resident #23's admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 12, which indicated she had some moderate impaired cognitive status. Further review of the resident's record revealed the resident had an indwelling catheter. Review of Resident #23's diagnoses located in her electronic medical record did not reveal a diagnosis for the indwelling catheter. Record review of Resident #23's progress note located in the resident's electronic medical record dated 5/31/2023 at 2:00 p.m. revealed the hospice RN had discontinued the resident's indwelling catheter. Record review of Resident #23's June 2023 Consolidated Physician Orders revealed an order dated 5/31/2023, Call hospice if unable to void in 6 hours. Observation on 6/4/2023 at 2:45 p.m. of Resident #23 revealed the resident had an indwelling catheter. In an interview on 6/4/2023 at 2:4. with Resident #23 revealed the indwelling catheter had been removed because the resident was exhibiting some pain from it. However a new indwelling catheter had to be replaced a short time later due to bladder related issues. In an interview on 6/5/2023 at 10:30 a.m. with LVN B revealed the last day she worked Resident #23's indwelling catheter was being discontinued. The LVN went on to say when she came in to work this morning, she noted the resident had an indwelling catheter but did not know why. In an interview on 6/5/2023 at 10:33 a.m. with the DON revealed Resident #23's indwelling catheter was replaced by the resident's hospice nurse after being removed for about 24 hours. The DON reported the resident had a diagnosis of neurogenic bladder. After the DON reviewed Resident #23's electronic medical record, she reported she was not able to locate a diagnosis for neurogenic bladder. Record review of the facility policy, Change in a Resident's Condition or Status, revised 4/20/2023 revealed, 6. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Record review of the facility policy, ICD-10-CM Procedure, not dated, revealed If other diagnoses are warranted, notify the physician to request the addition of the diagnosis code for the patient and a diagnosis must be provided by the physician or physician extender (e.g. Nurse Practitioner) before a diagnosis code is valid. Review of the facility policy, Guidance for Charting and Documentation, revised April 2012, under the heading, Physician Orders revealed, 1. Supervision of a Physician: c. Current list of orders must be maintained in the clinical record of each resident and 2. Content of Orders: i . 2. Specify the size (i.e., #18 Fr Foley catheter to straight drain) and the frequency of change. 3. Catheter care-specific what is to be done or according to facility procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 7 residents (Resident #2) reviewed for hospice services, in that: The facility failed to obtain Resident #2's copy of the hospice Plan of Care and a signed copy of the Hospice Election Form. This failure could place the residents who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #2's face sheet dated 6/7/2023 revealed a [AGE] year-old female who initially admitted on [DATE], readmitted on [DATE] and had diagnoses that included vascular dementia (a term describing problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to your brain), heart failure, chronic pain, and speech and language deficits following cerebrovascular disease (includes medical conditions that affect the blood vessels and blood supply to the brain). The face sheet also noted the resident was on hospice services. Record review of Resident #2's care plan initiated 2/22/2023 revealed the resident wandered into other residents' rooms and would get into the other residents personal space related to cognitive loss and dementia. A a care plan dated 5/14/2021 revealed the resident had impaired decision-making related to dementia and cognitive deficits following cardiovascular event. Record review of a hospice note dated 2/12/2023 and located in Resident #2's electronic medical record revealed the resident was admitted to hospice with a terminal diagnosis of dementia. Further review of the resident's medical record did not reveal Hospice Election Form, Physician's Certification of Terminal Illness, and hospice care plans which describe services they would provide. In an interview on 6/7/2023 at 1:02 p.m. with the DON revealed resident's that were on hospice services had all their hospice records uploaded in their electronic record. The DON reported she would upload documents when she was able to. After the Regional Nurse, who was also present, reviewed Resident #2's medical record she noted she was not able to locate the resident's Hospice Election Form, Physician's Certification of Terminal Illness, and hospice care plans. In an interview on 6/7/2023 at 1:23 p.m. the corporate MDS Travel LVN reported she found some hospice records for Resident #2 in her financial record which was kept in the facility business office. The MDS Travel LVN presented records found which included a signed copy of the Physician Certification of Terminal Illness and an unsigned copy of the Hospice Election Form. Additionally, she was not able to locate hospice care plans. In an interview on 6/7/2023 at 2:20 p.m. with the corporate MDS Travel LVN she confirmed she was unable to locate a sign copy of Resident #2's Hospice Election Form or hospice care plans at the facility. Record review of the facility policy, Hospice Program, revised July 2017, revealed a facility designee, who was a member of the interdisciplinary team with clinical and assessment skills, was responsible for d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 staff, in that; The facility failed to provide an annual performance review and subsequent trainings based on the outcome of the review for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 nurse aides reviewed for competencies. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: Lead CNA K, CNA F, CNA G. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: CNA E. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of annual performance review and subsequent trainings based on the outcome of the review. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of an annual performance review and subsequent trainings based on the outcome of the review. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of an annual performance review and subsequent trainings based on the outcome of the review. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of an annual performance review and subsequent trainings based on the outcome of the review. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 19 of 31 facility staff reviewed for trainings consistent with their expected roles, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings consistent with their expected roles. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 4.) Training .appropriate to the level of education and expected roles of those attending. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to include effective communications as mandatory training for 17(DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 direct care staff reviewed for trainings, in that; The facility failed to provide the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .a.) Effective communication with residents and family (direct care staff). In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education records, in that;:: The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with education on the rights of the resident and the responsibilities of a facility to properly care for its residents. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of training education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .b.) Resident rights and responsibilities. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that staff members are educated on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting incidents, and dementia management and resident abuse prevention, for 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with training that education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .c.) Preventing abuse, neglect, exploitation .(1) Activities that constitute abuse, neglect, and exploitation .(2) Dementia management and resident abuse prevention. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 19 of 31 facility staff reviewed for trainings on infection control, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings on infection control. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of Lead CNA J's personnel record had a hire date of 12/03/2002, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .e.) Infection prevention and control program standards, policies, and procedures. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 19 of 31 facility staff reviewed for education, in that; The facility failed to communicate the compliance and ethics program's standards to the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of communication related to the compliance and ethics program's standards. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .f.) The compliance and ethics program standards, policies and procedures. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide in-service training that was sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and included dementia management training, resident abuse prevention training, and care of the cognitively impaired for 5 (CNA H, Lead CNA K, CNA E, CNA F, and CNA G) of 5 CNAs reviewed for annual training, in that; The facility failed to provide CNA H, Lead CNA K, CNA E, CNA F, and CNA G with 12 hours per year of annual training that included dementia management training, resident abuse prevention training, and care of the cognitively impaired. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs [Continuing Education Units], received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: Lead CNA K, CNA F, CNA G. Spread sheet did not include the follow staff: CNA H, or CNA E. The total number of CEUs for Lead CNA K, CNA F, CNA G did not total 12 hours per year on the required annual training topics. The CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of 12 hours of annual training from 5/1/2022 through 6/4/2023. The CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of 12 hours of annual training from 5/1/2022 through 6/4/2023. The CNA E's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of 12 hours of annual training from 5/1/2022 through 6/4/2023. The CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of 12 hours of annual training from 5/1/2022 through 6/4/2023. The CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of 12 hours of annual training from 5/1/2022 through 6/4/2023. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and Lead CNA J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J stated no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/08/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection Control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills, and critical thinking necessary to provide excellent resident care. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure the facility fryer was clean and old oil discarded. 2. The facility failed to ensure homemade Jell-O was discarded after 3 days. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: 1. In an observation on 6/4/2023 at 9:45 a.m. of the facility fryer located in the facility kitchen revealed there were two separate wells with oil. Further inside the oil wells revealed the well on the right was dark and was unable to see the bottom of the pan. Further review of the kitchen fryer revealed there was a thick splatter of oil on the outside of the fryer and on the table the fryer was sitting on. In an interview on 6/4/2023 at 9:52 a.m. with the FSS revealed they used only the fryer on the left and used the right side for run off from the fried food item. The FSS reported he had changed the oil in the well on the left side but had not had a chance to change out the well on the right side. He also noted he was aware of the oil splatters on the outside of the well and on the table. 2. In an observation on 6/4/2023 at 9:52 a.m. of the reach-in refrigerator located in the facility kitchen was a ¼ container of facility-made Jell-O with a made by date of 5/29/2023. In an interview on 6/4/2023 at 9:52 a.m. with the FSS revealed any food that came from a can was discarded after 7 days and any food made at the facility was discarded after 3 days. The FSS stated the Jell-O should have been discarded. Record review of the facility policy, Basics for Handling Food Safety, revised August 2013, revealed, Safe steps in food handling, cooking, and storage are essential to prevent foodborne illnesses and to keep food safe, Clean-Wash hands and surfaces often. Record review of the facility policy, Subject: Administrator Orientation Manual; Guideline: Weekly Administrator Kitchen Sanitation Rounds; Approval date: July 2010 revealed, Administrator will make weekly kitchen sanitation rounds to ensure sanitation meets regulatory requirements. Record review of the facility policy, Food Storage, dated 2018, under the heading, Refrigerator revealed, e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.