**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #3 and Resident #38) of 13 residents reviewed for accuracy of assessment. 1. Resident #3 was a smoker and his annual MDS assessment did not indicate his use of tobacco. 2. Resident #38 had a lesion on her right cheek which was not noted in her quarterly MDS assessment. These failures could place residents at risk of not receiving necessary care and treatment. Findings Included: 1. Record review of Resident #3's admission record dated 02/10/25 revealed a [AGE] year-old male resident admitted to the facility originally on 3/02/18 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath and chronic fatigue (a long-term condition that causes extreme fatigue that doesn't improve with rest). Record review of Resident #3's clinical record revealed his last quarterly MDS was completed on 12-16-2024 listing him with a BIMS of 14 indicating he was cognitively intact, and he had a functionality of being independent with all his activities of daily living. Record review of Resident #3's last annual MDS had an ARD of 07/09/24 and a completion date of 07/10/24. Section I of this MDS included a diagnosis of Tobacco Use under question I8000 Additional active diagnoses. Section J question J1300 Current Tobacco Use was answered with a 0 which indicated Resident #3 did not use tobacco. Record review of Resident #3's clinical record revealed a care plan with an admission date of 1-21-2019 with last revision on 12-13-2024 with the following: Focus: o Smoking: Resident is a smoker and is at risk for injury . Goal: o Resident will abide by facility's smoking policy and remain safe during smoking times . Interventions: o Perform smoking assessment according to facility policy . Record review of Resident #3's smoking assessment dated [DATE] revealed he was determined to be an independent smoker. During an interview on 02/12/25 at 10:06 AM MDS LVN stated she missed that Resident #3 was a smoker on his last annual MDS. 2. Record review of Resident #38's admission record dated 02/11/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, protein-calorie malnutrition (inadequate intake of food which results in inflammation), unspecified dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), muscle wasting and atrophy in lower legs, muscle weakness, and anorexia (eating disorder characterized by inordinately low body weight and fear of gaining weight). Record review of Resident #38's quarterly MDS with an ARD of 12/13/24 and completed on 12/16/24 revealed the following: Section C-Cognitive Patterns: Resident #38 had a BIMS score of 3 which indicated severely impaired cognition. Section GG-Functional Abilities: Resident #38 used a w/c and required Substantial/maximal assistance across all ADLs. Section M-Skin Conditions: Question M1040 Other Ulcers, Wounds, and Skin Problems including D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion) was answered as None of the above were present. Record review of Resident #38's care plan completed on 12/18/24 revealed the following: Ms. [last name of Resident #38] has a hard dry callous type raised area on right outer cheek bone that resident frequent dries [sic] and [family member] prefers no treatment at this time. 12/3/24 1st Quart (quarter): no changes Date initiated: 11/21/2024 . Affected area will show no signs of infections or other complications over the next review period . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration . Report changes in skin status (i.e. infection, non-healing, new areas) to physician. Provide treatment per order and monitor for changes or complications. Record review of Resident #38's Order Summary Report dated 02/10/25 revealed the following orders: An order with start date 11/18/24 apply barrier cream to dry flaky patch to left outer cheek bone every shift for skin An order with start date 10/25/23 Perform head to toe skin assessment. Document any changes in skin integrity in the medical record. every day shift every Wed for wound prevention/ early identification Notify the physician of any changes in skin integrity. Record review of Resident #38's progress notes revealed the following: A note by ADON dated 11/18/24 resident noted to have a 2cm in diameter dry flaky patch area to left outer cheek bone orders to apply barrier cream every shift. family informed and agreed A note by RN E dated 11/22/24 Reported slight tenderness to lesion to right lower cheek with wound care. denied pain after task completed A note by RN E dated 12/05/24 Data: resident has a lesion to right side of her face the area is dry, crusted Action: applied moisture barrier cream to the affected area no bandage applied Response: stated that had minimal tenderness to the site with the application of the barrier cream. Record review of Resident #38's MAR from November 18, 2024, to February 10, 2025, revealed the following: apply barrier cream to dry flaky patch area to left outer cheek bone every shift for skin -Start Date- 11/18/2024 1500 (03:00 PM) The MAR indicated this had been done 3 times every day except for 11/18/24 when it was done two times due to order start time in the afternoon. During an observation on 02/10/25 at 02:22 PM Resident #38 was seated in her w/c in the lobby. She had a large open wound on the right side of her face. It was not covered. During an interview on 02/10/25 at 03:07 PM ADON stated the open area on Resident #38's right cheek began as a dry flaky area. During an observation on 02/10/25 at 03:45 PM Resident #38 was seated in her w/c in the lobby. She had her right elbow on the arm rest of the w/c and her right cheek resting in her right hand. She was moving the fingers of her right hand around in the wound on her right cheek. During an interview on 02/10/25 at 03:45 PM Resident #38's family member stated he had noticed the wound on her right cheek. During an observation and interview on 02/11/25 at 10:49 AM Resident #38 was seated in her w/c in her room. She stated her cheek was hurting. The wound on Resident #38's right lower cheek was shaped like a pear with the top of the pear pointing to the top her head. The outer edges of the sore were raised, pink, and [NAME]-like. Whole wound was approximately the size of a fifty-cent piece and raised from face. The outer edges of the sore were raised further than the center of the sore approximately .75 cm from the surface of the face and approximately .5 cm in width except for the bottom of the sore on side closest to her mouth where the edge was wider, approximately .75 cm. The interior of the sore was dark brown/red with whitish, wet looking splotches throughout. During an interview on 02/12/25 at 08:28 AM ADON stated MDS LVN was responsible for completing MDS assessments. She stated an inaccurate MDS could negatively affect a resident because it would not show an accurate picture of the patient. During an interview on 02/12/25 at 08:40 AM MDS LVN stated she followed the RAI when completing MDS assessments. MDS LVN stated Resident #38's MDS did not mention her wound because It just popped up. I've never noticed it. She stated she referred to treatment logs, medication sheets, and incident reports when completing MDS assessments. She stated that due to the small size of the facility she would often just hear what is going on. She stated an inaccurate MDS assessment would not negatively affect a resident but might negatively affect the facility's funding. When asked if a lack of funding might negatively affect a resident she stated, No, not here. During an interview on 02/12/25 at 08:45 AM ADM was asked if there was possible negative outcome for a resident to have an inaccurate MDS assessment. She stated, Anything is possible. Record review of facility policy titled MDS Completion and dated 11/5/2024 revealed the following: . 'ARD' . refers to the . (last day of MDS observation period) . According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's function capacity, using the RAI specified by the State. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: Section J: Health Conditions . The intent of the items in this section is to document a number of health conditions that impact the resident's functional status and quality of life. Other items in the section assess . tobacco use . J1300: Current Tobacco Use Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If they resident states they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Section M: Skin Conditions . Skin wounds and lesions affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes. Many of these ulcers, wounds, and skin problems can worsen or increase risk for local and system infections. Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medial record review. 3. Examine the resident and determine whether any ulcers, wounds, or skin problems are present. Coding Instructions Check all that apply in the last 7 days. If there is no evidence of such problems in the last 7 days, check none of the above. Open Lesion(s) Other than Ulcers, Rashes, Cuts Open lesions that develop as part of a disease or condition and are not coded elsewhere on the MDS, such as wounds, boils, cysts, and vesicles, should be coded in this item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible for one (Resident #3) of 2 residents reviewed for accident hazards. -Resident #2's last smoking evaluation was completed 9-27-2024. This failure could affect residents that smoke at the facility by placing them at risk for accidents that lead to injuries such as burns, tissue damage, and feeling of isolation. Findings include: Record review of the clinical record for Resident #3 revealed a [AGE] year-old male resident admitted to the facility originally on 3-2-2018 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), paranoid schizophrenia (a disease that affects a person's ability to think, feel, and behave clearly), generalized anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), difficulty walking, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy (the loss of muscle mass and strength due to disease, injury, or lack of use), weakness, and chronic fatigue (a long-term condition that causes extreme fatigue that doesn't improve with rest). Record review of Resident #3's clinical record revealed his last annual MDS was a quarterly completed 12-16-2024 listing him with a BIMS of 14 indicating he was cognitively intact, and he had a functionality of being independent with all his activities of daily living. Record review of Resident #3's clinical record revealed a care plan with an admission date of 1-21-2019 with last revision on 12-13-2024 with the following: Focus: o Smoking: Resident is a smoker and is at risk for injury . Goal: o Resident will abide by facility's smoking policy and remain safe during smoking times . Interventions: o Perform smoking assessment according to facility policy . Record review of Resident #3's clinical record revealed his last smoking evaluation was completed 9-27-2024. During an interview on 02-12-2025 at 09:28 AM LVN A (LVN Charge Nurse responsible for Resident #3 this shift) reported that smoking assessments were to be done on admission and quarterly by the charge nurse and the MDS coordinator. LVN A stated that if a smoking assessment was not completed as per policy then staff would not know if a resident was safe to smoke or if that resident had a decline in their ability to smoke safely. During an interview on 02-12-2025 at 09:30 AM with the MDS Coordinator stated she would need to complete a smoking assessment when a residents MDS was due so that smoking could be addressed on the MDS. The MDS Coordinator reported that basically that would mean that the smoking assessment was due quarterly. The MDS Coordinator reviewed Resident #3's chart and reported that Resident #3 was due for a smoking assessment in December but it looked like the staff missed it and it was not completed. The MDS Coordinator reported that Resident #3's last smoking assessment was completed 9-27-2024. The MDS Coordinator reported that Resident #3 missing his quarterly smoking assessment was not a big issue because Resident #3 was basically independent and that unless a resident had a change in their ability to function then missing the assessment was not an issue. The MDS Coordinator reported that if a resident had a decline in their cognitive or mobility function then the assessment would really need to be done so that smoking safety would be addressed. During an interview on 02-12-2025 at 09:54 AM the ADON reported that smoking assessments were to be completed annually and quarterly. The ADON reported that if a smoking assessment was not completed as per policy, then a resident could have a major decline in function, and they may not be safe to smoke independently and may require increased supervision. Record review of the facility provided policy titled Smoking Policy revision 7-14-2023, revealed the following: Policy: It is the policy of this facility to provide a safe and healthy environment for resident, visitors and employees as related to smoking. Procedure: Evaluate patients that smoke/use smokeless tobacco, utilizing the Smoking Evaluation/Smokeless Tobacco tool (a) upon admission; (b) quarterly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #38) of 13 residents reviewed for accuracy of medical records. The facility failed to correctly enter an order for barrier cream into Resident #38's EHR. The order was entered for her left cheek and the lesion was located on her right cheek. This failure could place residents at risk of receiving unnecessary treatment or not receiving necessary treatment. Findings Included: Record review of Resident #38's admission record dated 02/11/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, protein-calorie malnutrition (inadequate intake of food which results in inflammation), unspecified dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), muscle wasting and atrophy in lower legs, muscle weakness, and anorexia (eating disorder characterized by inordinately low body weight and fear of gaining weight). Record review of Resident #38's quarterly MDS completed on 12/16/24 revealed the following: Section C-Cognitive Patterns: Resident #38 had a BIMS score of 3 which indicated severely impaired cognition. Section M-Skin Conditions: No mention was made of the lesion on Resident #38's right cheek. Question M1040 Other Ulcers, Wounds, and Skin Problems including D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion) was answered as None of the above were present. Record review of Resident #38's care plan completed on 12/18/24 revealed the following: Ms. [last name of Resident #38] has a hard dry callous type raised area on right outer cheek bone that resident frequent dries [sic] and [family member] prefers no treatment at this time. 12/3/24 1st Quart (quarter): no changes Date initiated: 11/21/2024 . Affected area will show no signs of infections or other complications over the next review period . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration . Report changes in skin status (i.e. infection, non-healing, new areas) to physician. Provide treatment per order and monitor for changes or complications. Record review of Resident #38's Order Summary Report dated 02/10/25 revealed the following orders: An order with start date 11/18/24 apply barrier cream to dry flaky patch to left outer cheek bone every shift for skin Record review of Resident #38's progress notes revealed the following: A note by ADON dated 11/18/24 resident noted to have a 2cm in diameter dry flaky patch area to left outer cheek bone orders to apply barrier cream every shift. family informed and agreed A note by RN E dated 11/22/24 Reported slight tenderness to lesion to right lower cheek with wound care. denied pain after task completed A note by RN E dated 12/05/24 Data: resident has a lesion to right side of her face the area is dry, crusted Action: applied moisture barrier cream to the affected area no bandage applied Response: stated that had minimal tenderness to the site with the application of the barrier cream. A note by DON dated 01/06/25 Skin lesion on right outer face is 2.5cm long and 2cm wide area has developed into a pear shape with white rough band surround .5cm deep wound bed that is pink with no bleeding or drainage noted, there also is a deep dark protruding area at the inner baseof [sic] wound, Doctor [last name of medical director] suggest a biopsy to be performed, However [family member] refuses stating that is not bothering her and he will just monitor it closely. A note by RN E dated 01/22/25 S/O tenderness to lesion to right side of face with application of cream A note by RN E dated 01/23/25 C/O tenderness to lesion to right side of face with application of medication Record review of Resident #38's MAR from November 18, 2024, to February 10, 2025, revealed the following: apply barrier cream to dry flaky patch area to left outer cheek bone every shift for skin -Start Date- 11/18/2024 1500 (03:00 PM) The MAR indicated this had been done 3 times every day except for 11/18/24 when it was done two times due to order start time in the afternoon. During an interview on 02/12/25 at 08:24 AM LVN D and LVN B stated nurses were responsible for entering orders into the EHR. They stated a possible negative outcome of an inaccurate order was, The resident would not get what they need. During an interview on 02/12/25 at 08:28 AM ADON stated nurses were responsible for entering ordering into the EHR. She stated if an order was entered incorrectly the resident can get the wrong treatment. ADON stated she probably got confused regarding which cheek the area was located on when she entered the order for Resident #38. During an interview on 02/12/25 at 08:45 AM ADM stated inaccurate orders in the EHR could lead to illness or death. Record review of facility policy titled Following Physician Orders and dated 9/28/2021 revealed the following: . 2. For consulting physician/practitioner orders . the nurse, in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet.

Based on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 1 (ST) of 15 employees reviewed for staff training. The facility failed to train ST on Abuse, Neglect, and Exploitation. These failures could place residents at risk of injury or harm due to being cared for by untrained staff. Findings included: Record review of ST's employee file revealed a hire date of 09/13/2023. The file did not contain a record of training on abuse, neglect, exploitation, and misappropriation of resident property. During an interview on 02/12/24 at 11:34 AM, ADM stated that ST worked at another facility full time and only worked at this facility occasionally. The ADM stated is the ST was trained at the other facility but could not produce any records of training for abuse, neglect, and exploitation. She stated a possible negative outcome for not having staff fully trained could be that residents could get hurt or there could be a possible death. Record review of facility provided titled, Training Requirements, dated 11/29/22 revealed in part, the following: Policy Statement: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 2. The amount and types of training necessary are based on a facility assessment, state, and federal requirements. 4. All facility staff are trained to interact in a manner that enhances the resident's quality of life, quality of care and demonstrates competency in the topic areas of the training program. 6. Training content includes, at a minimum: j. Abuse, neglect, and exploitation prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure quality of care is a fundamental principle that applies to all treatment and care provided to facility residents based on the comprehensive assessment of a resident, to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 (Resident #38) of 13 residents reviewed for quality of care. The facility failed to document physician ordered weekly skin assessments to include a lesion on Resident #38's right cheek. The facility failed to revisit the option of treatment of the lesion on Resident #38's right cheek with her responsible party as the lesion progressed. These failures could place residents at risk of harm due to health issues not being recognized and treated timely. Findings Included: Record review of Resident #38's admission record dated 02/11/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, protein-calorie malnutrition (inadequate intake of food which results in inflammation), unspecified dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and anorexia (eating disorder characterized by inordinately low body weight and fear of gaining weight). Resident #38's family member was listed as her financial POA and emergency contact. Record review of Resident #38's quarterly MDS with an ARD of 12/13/24 and completed on 12/16/24 revealed the following: Section C-Cognitive Patterns: Resident #38 had a BIMS score of 3 which indicated severely impaired cognition. Section GG-Functional Abilities: Resident #38 used a w/c and required Substantial/maximal assistance across all ADLs. Section M-Skin Conditions: No mention was made of the lesion on Resident #38's right cheek. Question M1040 Other Ulcers, Wounds, and Skin Problems including D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion) was answered as None of the above were present. Record review of Resident #38's care plan completed on 12/18/24 revealed the following: Ms. [last name of Resident #38] has a hard dry callous type raised area on right outer cheek bone that resident frequent dries [sic] and [family member] prefers no treatment at this time. 12/3/24 1st Quart (quarter): no changes Date initiated: 11/21/2024 . Affected area will show no signs of infections or other complications over the next review period . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration . Report changes in skin status (i.e. infection, non-healing, new areas) to physician. Provide treatment per order and monitor for changes or complications. Record review of Resident #38's Order Summary Report dated 02/10/25 revealed the following orders: An order with start date 11/18/24 apply barrier cream to dry flaky patch to left outer cheek bone every shift for skin An order with start date 10/25/23 Perform head to toe skin assessment. Document any changes in skin integrity in the medical record. every day shift every Wed for wound prevention/ early identification Notify the physician of any changes in skin integrity. Record review of Resident #38's progress notes revealed the following: A note by ADON dated 11/18/24 resident noted to have a 2cm in diameter dry flaky patch area to left outer cheek bone orders to apply barrier cream every shift. family informed and agreed A note by RN E dated 11/22/24 Reported slight tenderness to lesion to right lower cheek with wound care. denied pain after task completed A note by RN E dated 12/05/24 Data: resident has a lesion to right side of her face the area is dry, crusted Action: applied moisture barrier cream to the affected area no bandage applied Response: stated that had minimal tenderness to the site with the application of the barrier cream. A note by DON dated 01/06/25 Skin lesion on right outer face is 2.5cm long and 2cm wide area has developed into a pear shape with white rough band surround .5cm deep wound bed that is pink with no bleeding or drainage noted, there also is a deep dark protruding area at the inner baseof [sic] wound, Doctor [last name of medical director] suggest a biopsy to be performed, However [family member] refuses stating that is not bothering her and he will just monitor it closely. A note by RN E dated 01/22/25 S/O tenderness to lesion to right side of face with application of cream A note by RN E dated 01/23/25 C/O tenderness to lesion to right side of face with application of medication The progress notes did not reveal any notes on Wednesdays regarding skin assessment results for any of the Wednesdays from 11/18/24 to 02/10/25. Record review of Resident #38's MAR from November 18, 2024, to February 10, 2025, revealed the following: apply barrier cream to dry flaky patch area to left outer cheek bone every shift for skin -Start Date- 11/18/2024 1500 (03:00 PM) The MAR indicated this had been done 3 times every day except for 11/18/24 when it was done two times due to order start time in the afternoon. Perform head to toe skin assessment. Document any changes in skin integrity in the medical record. every day shift every Wed for wound prevention/ early identification Notify the physician of any changes in skin integrity. -Start Date- 10/25/2023 0700 (07:00 AM) The MAR indicated this had been done every Wednesday 11 times by LVN A and once by LVN B. Record review of the Assessments tab in Resident #38's EHR revealed the following: Monthly Nurse Summary reports dated 11/17/24, 12/08/24, and 01/19/25. The Monthly Nurse Summaries had a section titled G. SKIN/WOUND. All three summaries stated, No new changes in skin observed and the box for Notable changes in skin integrity was left blank. Physician Note reports dated 11/12/24, 12/12/24, and 01/15/25. All three of the reports revealed No changes or concerns noted. Under the Objective sections of all three reports was noted, Skin: Normal, no rashes, no lesions, noted. During an observation on 02/10/25 at 02:22 PM Resident #38 was seated in her w/c in the lobby. She had a large open sore on the right side of her face. It was not covered. During an interview on 02/10/25 at 03:07 PM ADON stated the open area on Resident #38's right cheek began as a dry flakey area. She stated Resident #38's family member did not want to send her out to have the area evaluated. ADON stated, Dr. [last name of facility medical director] does not know what it is but if they won't go see another doctor there is nothing else that can be done. She stated the wound had been progressing over the last two months. During an observation on 02/10/25 at 03:45 PM Resident #38 was seated in her w/c in the lobby. She had her right elbow on the arm rest of the w/c and her right cheek resting in her right hand. She was moving the fingers of her right hand around in the wound on her right cheek. During an observation and interview on 02/10/25 at 03:45 PM Resident #38's family member stated he had noticed the wound on her right cheek. When asked if he was against her seeing a doctor about the wound he stated, I don't know about that! I said we don't need to be cutting on her at this point in the game, but I'd like to have it looked at and maybe they could burn it off or do something to help it. ADM was standing beside Resident #38's family member and she stated, We can do that. During an interview on 02/11/25 at 10:49 AM Resident #38 was seated in her w/c in her room. She stated her cheek was hurting. When asked if this surveyor could look at her cheek she stated, Just don't touch it. The wound on Resident #38's right lower cheek was shaped like a pear with the top of the pear pointing to the top her head. The outer edges of the sore were raised, pink, and [NAME]-like. Whole sore was approximately the size of a fifty-cent piece and raised from face. The outer edges of the sore were raised further than the center of the sore approximately .75 cm from the surface of the face and approximately .5 cm in width except for the bottom of the sore on side closest to her mouth where the edge was wider, approximately .75 cm. The interior of the sore was dark brown/red with whitish, wet looking splotches throughout. During an interview on 02/11/25 at 11:05 AM LVN D stated skin assessments were documented on the MAR with a check mark. She stated she thought any actual concerns or wound measurements were kept in a folder in DON's office. During an interview on 02/11/25 at 11:06 AM ADON stated skin assessments were documented on the MAR with a check mark. When asked where actual wound measurements were documented she provided a 3-ring binder. Record review on 02/11/25 at 11:13 AM of the 3-ring binder provided by ADON on 02/11/25 at 11:06 AM revealed no mention of Resident #38 or mention of any wound that was not a pressure injury. During an interview on 02/11/25 at 11:24 AM LVN D stated she had performed skin assessments. When asked where she documented her findings she stated, It is usually the ADON or DON who documents. She stated she would take measurements and document them on a piece of paper but would have ADON or DON on duty recheck because I learned it (wound measurement) in nursing school but it is not something I do every day, so I am not confident in my measurements and I always want someone else to check them (her measurements). During an interview on 02/11/25 at 07:38 PM LVN B stated nurses were responsible for performing skin assessments as ordered by the physician. She stated she had performed skin assessments. She stated, I write down what I find and let my charge nurse know because I just graduated (nursing school) recently in December, and I am not sure if I am doing it right. LVN B stated she meant ADON or DON when she said, charge nurse. She stated she had performed skin assessments on Resident #38. When asked if she noted anything about the wound on Resident #38's cheek, LVN B stated, I think I just write it down on a paper because I am not real familiar with how to do a skin assessment. I wrote down that I noticed it has gotten worse to me over the past few months. There is an ointment and I tell them (ADON and DON) that I put it on there. She stated she felt this method of documenting skin assessments did not have a possible negative outcome to the resident. LVN B stated, I think it is pretty effective since [first name of DON] and [first name of ADON] are higher up and more familiar with what needs to be done. During an interview on 02/12/25 at 08:16 AM LVN A stated nurses were responsible for completing skin assessments as ordered by the physician. She stated if there were concerns with the skin of a resident the nurse would let ADON or DON know and possibly inform the doctor. She stated she had performed several skin assessments on Resident #38. She stated the skin assessment was documented as complete with a check mark on the MAR. LVN A stated, We document in the nurses' notes if we find something (during the skin assessment). She stated, If it (skin) is an issue [first name of DON] and [first name of ADON] keep track, I'm pretty sure they have a skin book in their office. LVN A stated a possible negative outcome of not documenting a skin assessment was, If you find something and you don't document it, then nobody else will know and you can't follow up the treatments and all of that. LVN A stated she did not document anything in Resident #38's EHR following the skin assessments she performed for Resident #38 because the skin assessment asks if there is a change, and week to week it (the wound on Resident #38's cheek) looks okay gradually it has just gotten worse. Week to week it looks the same. During an interview on 02/12/25 at 08:28 AM ADON stated, Me and [first name of DON] do a lot of the skin checks and nurses keep an eye on the skin. Me and [first name of DON] do a lot of the in-depth stuff and of course if they (nurses) see something they notify us. ADON stated skin assessments were documented if we find something we do treatment orders and we put it in the care plan. She stated she did not think there was a possible negative outcome of not documenting skin assessments other than with a check mark of completion on the MAR. When asked about Resident #38's wound on her cheek, ADON stated, [First name of DON] has been in contact with the doctor about that. She stated this contact may not have been documented since we did not change anything. During an interview on 02/12/25 at 09:32 AM ADM stated facility did not have a quality-of-care policy. During an interview on 02/12/25 at 10:47 AM Resident #38's physician stated Resident #38's family member was often present when he (Resident #38's physician) was doing his rounds in the facility. He stated Resident #38's family member did not want to do anything about treating her cheek when asked by nursing staff. He stated he had not spoken to Resident #38's family member about treatment again but had spoken on 02/10/25 and 02/11/25 with facility staff. He stated, They sent me a picture of her cheek. It was about 25% that size when it started. It is likely basil cell or squamous cell (types of cancer). It is rapidly growing. I couldn't believe it when I saw it yesterday (in the picture sent by the facility). He stated since Resident #38's family member was now willing to seek treatment we are in the dilemma of finding a surgeon or dermatologist who is willing to operate on an aged person. Record review of facility policy titled Following Physician Orders and dated 9/28/2021 revealed the following: . the nurse will . Carry out and implement physician orders . Document resident response to physician order in the medical record as indicated . Record review of facility policy titled Skin Assessment/Evaluation and dated 4/13/2023 revealed the following: . This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse/wound nurse upon admission/re-admission, weekly for resident with no pressure injury . 2. Procedure . Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. c. Document type of wound and wound assessment weekly. e. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). h. Document other information as indicated or appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 (Resident #26, Resident #31, and Resident #38) of 13 residents reviewed for environment. The facility failed to clean expired and unlabeled food out of Resident #26's personal refrigerator. The facility failed to ensure Resident #31 and Resident #38 kept their personal snacks in sealed containers. The facility failed to ensure Resident #38's personal refrigerator had a thermometer inside with which to monitor temperature of the refrigerator as per facility policy. These failures could place residents at risk of pests and/or food borne illness. Findings Included: 1. Record review of Resident #26's admission record dated 02/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle wasting an atrophy, muscle weakness, lack of coordination, and cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning). Record review of Resident #26's annual MDS completed on 01/24/25 revealed the following: Section C-Cognitive Patterns: Resident #26 had a BIMS score of 8 which indicated moderately impaired cognition. Section GG-Functional Abilities: Resident #26 used a w/c and was independent across all ADLs. Record review of Resident #26's care plan completed on 01/28/25 revealed the following: Resident #26 had impaired cognition and needed supervision/assistance will all decision making. Resident #26 had impaired visual function Resident #26's family requested a dorm-size refrigerator in her room for snacks and fluids. Staff were to Monitor refrigerator for proper temperature at or below 41 degrees, and maintain sanitary conditions with no out dated or spoiled items. During an observation on 02/10/25 at 12:06 PM Resident #26's personal refrigerator contained the following: A bottle of ketchup with an expiration date of 05/11/24. An opaque plastic cup ¾ full of a tan liquid with what appeared to be a partially eaten donut resting half in and half out of the top of the cup. The portion of the donut inside the cup appeared to have absorbed some of the liquid as it was discolored part way up. The donut appeared to be dry and crusty and was not touching the liquid in the cup. A small Styrofoam bowl covered with a napkin. The napkin was stuck to the contents of the bowl in two places. The contents of the bowl appeared to be banana pudding with brownish slices of banana visible and an orange-colored mash, and An opaque plastic cup almost full of clear liquid. During an observation and interview on 02/11/25 at 10:27 AM Resident #26 was seated in her w/c in her room. She stated staff do not clean out her refrigerator. She stated they only check the temperature of her refrigerator. She opened the refrigerator and pointed to the thermometer inside. The items observed in her refrigerator on 02/10/25 at 12:06 PM were still in the refrigerator. Resident #26 stated she cleaned out her refrigerator. She stated, It is not very clean today. I will probably go through here and clean this stuff out because I won't eat it. 2. Record review of Resident #31's admission record dated 02/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, absolute glaucoma bilateral (severe form of disease where eye has lost all vision and has uncontrolled pressure) and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #31's quarterly MDS completed 02/03/25 revealed the following: Section C-Cognitive Patterns: Resident #31 had a BIMS score of 9 which indicated moderately impaired cognition. Section GG-Functional Abilities: Resident #31 used a w/c and was independent or required only set-up or clean-up assistance across all ADLs except for bathing where she required supervision or touching assistance. Record review of Resident #31's care plan completed on 11/14/24 revealed the following: Resident #31 had episodes of forgetfulness. Resident #31 had impaired visual function. During an observation on 02/10/25 at 12:11 PM Resident #31 had an opened bag of tortilla chips on her nightstand. The top of the bag was folded over one time and secured with a clip. During an observation on 02/10/25 at 02:09 PM Resident #31 was seated in her recliner in her room. The bag of tortilla chips was still on her nightstand with the top folded over one time and sealed with a clip. During an observation and interview on 02/11/25 at 10:30 AM Resident #31 was seated in her recliner in her room. The bag of tortilla chips was still on her nightstand with the top folded over one time and sealed with a clip. She stated staff had not said anything to her about keeping the chips in a sealed container. 3. Record review of Resident #38's admission record dated 02/11/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, protein-calorie malnutrition (inadequate intake of food which results in inflammation), unspecified dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), muscle wasting and atrophy in lower legs, muscle weakness, and anorexia (eating disorder characterized by inordinately low body weight and fear of gaining weight). Record review of Resident #38's quarterly MDS completed on 12/16/24 revealed the following: Section C-Cognitive Patterns: Resident #38 had a BIMS score of 3 which indicated severely impaired cognition. Section GG-Functional Abilities: Resident #38 used a w/c and required Substantial/maximal assistance across all ADLs. Record review of Resident #38's care plan completed on 12/18/24 revealed the following: Resident #38 had impaired cognition and therefore needed supervision/assistance with all decision making. Resident #38 had impaired visual function. During an observation on 02/10/25 at 12:10 PM Resident #38 had an open container with what appeared to be chocolate-covered cookies on top of her dresser, next to her bed. She also had a small refrigerator which contained a jar of jelly and a can of bean dip. The refrigerator did not contain a thermometer. During an observation on 02/11/25 at 10:49 PM Resident #38 was seated in her w/c in her room. The open tray of what appeared to be chocolate-covered cookies was still on top of her dresser as was her small refrigerator which still contained a jar of jelly and a can of bean dip. The refrigerator did not contain a thermometer. During an interview on 02/11/25 at 07:38 PM LVN B stated, We kinda all are responsible for cleaning out resident refrigerators. She stated, CNAs, us nurses, pretty much anyone can clean them out. If we look and see any food that is labelled, or drinks especially opened ones. LVN B stated, We try to put a date on the food when family brings it, so we know when to throw it out. She stated nurses were responsible for doing temperature checks on resident refrigerators every Monday. LVN B stated if the resident refrigerators were not cleaned out the residents could get very sick. She stated food that did not require refrigeration but was left out and open in a resident's room could get moldy or grow bacteria. LVN B stated residents were allowed to have open food in their rooms if they kept it in their drawers and it was just snacks like chips and candy. During an interview on 02/12/25 at 07:56 AM CNA C stated CNAs were responsible for cleaning out resident refrigerators. She stated, We check them every day or every week to see if they need defrosting and make sure the temperature gauge is working. We let the nurses know (the temperature) and they document it. CNA C stated a possible negative outcome of not cleaning out resident refrigerators was, They could eat something that was old or drink something that was molded. She stated residents were allowed to have open food in their rooms. She stated a possible negative outcome of not keeping the open food in seal containers was, It could get old. During an interview on 02/12/25 at 08:16 AM LVN A stated everyone was responsible for cleaning out resident refrigerators. She stated nurses check the temperature on the refrigerators on Mondays. She stated residents could get sick to their stomach if the refrigerators were not cleaned out. During an interview on 02/12/25 at 08:28 AM ADON stated day shift nurses were responsible for cleaning out resident refrigerators and checking refrigerator temperatures on Mondays. She stated a possible negative outcome of refrigerators not being cleaned out was, They (residents) could eat something that is expired. She stated all staff were responsible for ensuring resident's personal snacks were kept in sealed containers. ADON stated, We try to all do rounds. Things get missed that they (residents) have tucked up away. She stated food left out of sealed containers could go stale. During an interview on 02/12/25 at 08:45 AM ADM stated housekeeping was responsible for cleaning out resident refrigerators. She stated it was really hard to keep up with because some residents tended to hoard food. She stated, We do not let any expired foods stay in the refrigerators. ADM stated a possible negative outcome of resident refrigerators not being cleaned out was, Oh yeah, there is always a danger of bacterial infection or something. ADM stated We all try to do that regarding ensuring resident food is kept in seal containers. She stated a negative outcome of residents' personal food not being stored in sealed containers was, Pest control and resident safety. Record review of facility policy titled Resident Refrigerators and dated 10/14/2022 revealed the following: .This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions: . b. The refrigerator maintains proper temperatures. A thermometer shall remain in the refrigerator. Temperatures will be at or below 41 degrees F . Staff shall inspect the refrigerator weekly, clan as needed, and discard any foods that are out of compliance. Residents and staff shall comply with safe food handling and storage principles: . Foods with use by dates shall be discarded accordingly. Any food with potential concerns (i.e., smell, packaging, appearance . ) shall be discarded. Food shall be in covered containers or securely wrapped. Record review of facility policy titled Food From Outside Sources or Personal Food and dated 05/16/2023 revealed the following: . The purpose of this policy is to ensure the safe and sanitary handling of foods brought to residents by visitors, including the use and storage of these items. The task of keeping their personal foods stored in a safe and sanitary manner will be the responsibility of facility staff. Sealed containers must be used to store non-perishable items that are not consumed immediately such as a bag of potato chips, cookies . Residents are responsible for purchasing their own sealed containers for food storage in their rooms. This will also help to eliminate pests. Record review of facility policy titled Resident Rights and dated 11/5/2024 revealed the following: . The resident has a right to a safe, clean, comfortable, and homelike environment, .

Based on interview and record review the facility failed to implement written policies to prohibit and prevent abuse, neglect, and exploitation of residents for 6 (DM, DT E, CNA F, RN G, DON, and RN H) of 12 staff reviewed for EMR/NAR registry. The facility did not complete EMR/NAR background checks for DM, DT E, CNA F, RN G, DON, and RN H. This failure could place residents in the facility at risk for abuse, neglect, or exploitation. Finding include: Record Review of the facility provided policy titled Policy and Procedures: Abuse, Neglect, and Exploitation date of implementation 10-24-2022, revealed the following: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. 1. Screening a. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. No policy was provided by the facility that addressed when staff should be screened (upon hire and annually) and which specific staff should be screened. Record review of DM's employee file revealed she was hired 9-23-13 with her last EMR/NAR completed 1-4-2021. No annual EMR/NAR had been checked in the last 12 months. Record review of DT E's employee file revealed she was hired 5-30-2023 with her last EMR/NAR completed 3-11-2022. No EMR/NAR had been checked upon her hire date. Record review of CNA F's employee file revealed she was hired 10-15-2020 with her last EMR/NAR completed 9-26-2022. No annual EMR/NAR had been checked in the last 12 months. Record review of RN G's employee file revealed she was hired 8-28-2004 with her last EMR/NAR completed 1-7-2019. No annual EMR/NAR had been checked in the last 12 months. Record review of the DON's employee file revealed she was hired 4-17-1989 with her last EMR/NAR completed 1-27-2022. No annual EMR/NAR had been checked in the last 12 months. Record review of RN H's employee file revealed she was hired 5-23-2019 with her last EMR/NAR completed 5-14-2019. No annual EMR/NAR had been checked in the last 12 months. During an interview on 01-10-2024 at 01:42 PM the HRD reported that due to several changes in management there had been a lapse in consistency with employee records and things had been missed like the EMR/NAR. The HRD reported that if an employee was hired that had been listed on the EMR/NAR due to the EMR/NAR not being checked annually or at hire then it would be an issue, that it could cause a problem with the residents. The HRD stated, We don't want anyone in our building that could be abusive. During an interview on 01-10-2024 at 02:48 PM the Administrator reported that she was the person responsible for running all EMR/NAR background checks and that she had always run them monthly until she left the facility for 6 months and that she did not know what was done during the time she was gone. The Administrator reported that her plan to correct the current deficiencies with EMR/NAR's not being ran was to implement a new orientation guidebook that had all the federally required information included. During an interview on 01-10-2024 at 03:22 PM the Administrator reported that if staff are not checked on the EMR/NAR then they could be listed on the registry for misconduct and the facility could have someone listed on the EMR/NAR registry in the building providing care to residents. The DON was out of the building and not available for interview.

Based on interview and record review the facility failed to provide training to their staff for dementia care for 3 (DT E, HK I, and AD) of 12 employees evaluated for required trainings. DT E was hired 5-30-23 and not training had been provided for Dementia Care on hire. HK I was hired 7-21-2023 and no training had been provided for Dementia Care on hire. AD was hired 11-6-2023 and no training had been provided for Dementia Care on hire. This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care. This failure could result in deterioration in resident condition and exacerbation of the disease process. Findings included: Record review of the DT E's employee file revealed the following: DM was hired 5-30-2023 and no training has been provided on Dementia Care since she was hired. Record review of the HK I's employee file revealed the following: HK I was hired 7-21-2023 and no training has been provided on Dementia Care since he was hired. Record review of the AD's employee file revealed the following: AD was hired 11-6-2023 and no training has been provided on Dementia Care since she was hired. During an interview on 01-10-2024 at 01:42 PM the HRD reported that due to several changes in management there had been a lapse in consistency with employee records and things have been missed. The HRD reported that if an employee was hired that had not been trained adequately then a resident could possibly not receive the care they need and that could affect a resident's condition. During an interview on 01-10-2024 at 02:15 PM the Administrator reported that she had called her corporate office and the required trainings were not included on the 2019 orientation guide, but it had been included on the 2023 new orientation guide, but the facility had not been made aware of the new guide and was still using the 2019 guide. The Administrator reported that this was why some of the trainings were being missed. The Administrator confirmed that she was responsible for the trainings. During an interview on 01-10-2024 at 02:48 PM the Administrator reported that the facility did not require contract staff to complete the required trainings, that contract staff are supposed to keep up with all the requirements, and that dietary and housekeeping staff were contract staff. The Administrator reported that all staff are trained on the facility provided computer system for dementia and that it was assigned to staff for completion. The Administrator reported that all staff are to complete 3 facility provided computer trainings per month and that corporate sets up the trainings. The Administrator reported that indirect staff do not complete dementia training on hire but will have it assigned to them in the facility provided computer system at a later date. The Administrator reported that her plan to correct the current deficiencies with training requirements was to implement the new orientation guidebook that had all the federally required information included. During an interview on 01-10-2024 at 03:20 PM the Administrator reported that if staff are not trained on dementia it could lead to resident frustration, the residents could lash out, and the staff would not know how to react. During an interview on 01-10-2024 at 03:21 PM the Administrator reported that if staff are not trained on the required training, then anything would be possible, staff would not be aware of the dynamics, staff would not know how to handle a situation. During an interview on 01-10-2024 at 03:23 PM the HRD reported that it was the responsibility of the administer to pull the new hire requirements for the contract companies. The DON was out of the building and not available for interview. Record review of the facility provided policy titled Policy and Procedures: Abuse, Neglect, and Exploitation implemented 10-24-2022, revealed the following: Policy Explanation and Compliance Guidelines: 1. The facility provided resident protection that include: c. Training for new and existing staff on .and dementia management . No other pertinent policy information was provided.

Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. 4. The facility failed to ensure that proper hand hygiene was practiced during distribution of food. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections. Findings included: On 1/8/24 at 11:04AM an initial observation was made of the kitchen. The dry pantry had evidence of mouse excrement on the floor and shelves. The dietary manager stated she did not believe the droppings were from mice, because she had not seen any mice in the kitchen or pantry. Observation of dry foods pantryrevealed the following: The emergency supply of foods, stacked on one shelf with a sign which read, Emergency Supply Updated 7/7/22. (2) Food service cans cranberry sauce; one with expiration date of 11/8/21 and one with expiration date of 10/31/22. (5) 5oz. cans of tomato juice with an expiration date of 10/30/23. (2) 5-pound, 5oz bags tortillas with an expiration date of 5/24/23. In addition, there were 2 partial bags of tortillas with the same expiration date, closed with document binder clips. (1) 20oz. can crushed pineapple dated 2/13; no visible expiration date. (1) 1-pound box corn starch with an expiration date of 11/12/22. (1) 28oz. can green chili peppers; no visible received on or expiration date. (1) 28oz. can diced tomatoes with green chilis dated 11/27/23; no visible expiration date. (2) partial food service bags tortilla chips closed with document binder clips. (9) 28oz. boxes Cream of Wheat with a use by date of November. No additional date could be read. Observation of the freezer revealed the following: (1) 20-pound box breaded squash, open to air. 1 dozen frozen bagels with a received date of 5/8/23; no visible expiration date. 1 dozen frozen bread sticks with a received date of 9/11; no visible received year or expiration date. (2) 6-pound boxes beef chili and bean red burritos, open to air. 8 frozen egg rolls with a best by date of 2/28/23. Observation of the refrigerator revealed the following: 3-pounds sliced ham lunchmeat; opened date 12/11/23. Zip sealed baggie with 3 slices cooked ham dated 12/2/23. 6 heads lettuce; received date of 12/11/23. (1) food service bag chopped Romaine lettuce, open to air. There was a dirty bath towel, covered in mud, laying by the back door of the kitchen. An interview with the DM on 1/8/24 at 11:22AM revealed a negative outcome of residents eating expired food or food in contact with rodent excrement, could make residents sick. She stated that the towel laying on the floor by the back kitchen door, should not be there. It was being used to wipe mud from dietary worker's feet, as they came in from outside the facility. She was then asked for the Policies and Procedures for food retention times, food storage and pest control. Record Review of the facility's Dry Food and Supplies Storage Policy and Procedures, dated 11/15/17 revealed the following: (1) The practice of First In, First Out will be utilized. Products which do not have an imprinted use by or expiration date on the product, will be dated when received and rotated as new inventory is purchased (the oldest product will be moved to the front, for first use.) Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date or without a date, will be discarded. (2) Bulk food products that are removed from the original containers must be placed in plastic or metal food grade containers with tight fitting lids. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food. (3) All opened products must be resealed effectively and properly labeled, dated and rotated for use. (4) Use by, Best by and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Review of the facility's Storage of Frozen and Refrigerated Foods Policy and Procedures, dated 10/2017 revealed the following: (1) Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by date. Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened. Foods prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 7 days from the date prepared. (2) Items stored in the refrigerator must be dated upon receipt. They must also be dated with an expiration date unless they have one from the manufacturer. (3) Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. (4) All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above. No Policy and Procedures for Pest Control in the kitchen were produced. An interview with the MM on 1/8/24 at 2:02PM revealed that pest control services were provided by an outside entity, on the second Friday of every month. Evidence of pest control services was produced. An invoice from Perfect Pest Control, dated 12/1/23 revealed mouse/rat bait stations were placed at an interval of 1 block every 8-12 feet and discussion with kitchen staff, by the pest service, did not indicate rodent activity. The MM stated he monitored the bait stations and had not seen any rodent activity. An observation of the maintenance manager on 1/8/24 at 2:29PM revealed him carrying a glue trap in a sealed clear bag, out of the building, for disposal. A pest sighting log from the same date revealed a rodent had been sighted in the dry storage area of the kitchen, along with a crack, hole or crevice being identified as the source of entry. Observation of the kitchen on 1/9/24 at 9:02AM revealed the emergency supply of foods still on the pantry shelf, with the sign which read, Emergency Supply Updated 7/7/22. The dietary manager stated she thought she had gotten all the emergency supply removed from the shelves. She stated she had swept and mopped the panty, yesterday (1/8/24) and did not see any mice droppings when she cleaned. Observation of lunch service on 1/9/24 at 12:10PM revealed dietary service workers not practicing hand hygiene while distributing resident trays. LVN A was observed coming into the dining room and without practicing hand hygiene, began feeding a resident. LVN B was observed standing in line to pick up a resident tray. LVN B touched her face and then placed her hands in her pockets while she waited. LVN B then picked up a tray and delivered it to a resident. CNA C and CNA D were serving resident trays with no hand hygiene practiced between each tray. The AD was observed carrying a resident tray and when the tray was set on the table, the AD touched her hair and then touched the rim of a resident's drink glass with her bare hand. She then served the drink to the resident. An interview with the DON on 1/9/24 at 12:21PM revealed she was not aware that hand hygiene should be practiced between delivery of individual resident trays. When presented with evidence of her staff touching their face, hair and clothing, she stated communicable disease could be transferred from each worker to a resident. The DON stated she would immediately re-train all nursing staff on infection control in the dining room. The DON was observed speaking with LVN A, LVN B, CNA C, CNA D and the AD regarding hand hygiene and infection control in the dining room. Record Review of Food Services Hand Washing Policy dated 11/2017 revealed in part: Food employees shall keep their hands and exposed portions of the arms clean. Employees should never use bare hand contact with any foods, ready to eat or otherwise. Since the skin carries microorganisms, it is critical that all involved in food preparation and services consistently utilize good hygienic practices and techniques. Staff should have access to the proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. Antimicrobial gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a food service setting. Because the skin carries microorganisms, it is critical that staff involved in food preparation and service, consistently utilize good hygienic practices and techniques including proper hand washing. Dietary staff will wash their hands before starting work and: After touching hair, face, or body. After cleaning tables, equipment or touching dirty dishes. After engaging in any other activity that may contaminate food. Hand washing signage will be displayed at all hand washing sinks. An adequate supply of hand washing soap and paper towels is available during hours of operation. (1) Separate and distinct hand washing facilities will be maintained and stocked with hand soap and paper towels and used only for hand washing. (2) Prepare paper towel for hand drying (i.e., Roll down paper towel if manual dispenser). (3) Turn on water and run until warm. (4) Rinse hands and forearms under clean, running warm water. (5) Apply the amount of cleaner recommended by the manufacturer. (6) Rub hands together vigorously for at least 10 to 15 seconds. a. Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure and b. Creating friction on the surfaces of the hands and arms, fingertips, and areas between the fingers. (7) Thoroughly rinse under clean, running warm water; and (8) Immediately follow the cleaning procedure with thorough drying with a clean paper towel. (9) To avoid re-contaminating their hands food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a hand wash sink. An observation of the dining room on 1/9/24 at 12:30PM revealed there was no separate and distinct hand washing sink in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #19, #35 and #41) of 17 residents reviewed for advanced directives. Resident #19 had a DNR in her record with no date for the second witness's signature Resident #35 had a DNR in her record with no date, no printed signature, and no license number for the physician signature. Resident #41 had a DNR in her record with no second signature for the physician. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #19 Record review of the face sheet dated [DATE] in the clinical record for Resident #19 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down), major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (intensive, excessive, and persistent worry and fear about everyday situations), hypertension (a condition in which force of the blood against the artery walls in too high), Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce the blood flow to the limbs), and muscle weakness. Record review of the clinical record for Resident #19 revealed the last MDS completed was an admission on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functional status indicating she required one to two-person assistance with all activities. Record review of Resident #19's care plan dated 10-7-2022 revealed no care plan for her current DNR status Record review revealed a DNR in Resident #19's clinical record dated [DATE] (by the physicians date of signature) that had no date for the second witness in the Two Witnesses section. Resident #35 Record review of the face sheet dated [DATE] in the clinical record for Resident #35 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include fracture of the left femur, osteoporosis (a condition in which the bones become weak and brittle), depression (a group of condition associate with the elevation or lowering of a person's mood), insomnia (persistent problem falling and staying asleep), atrial fibrillation (an irregular and often rapid heart rate that commonly causes poor blood flow), diverticulosis (a condition in which small bulging pouches develop in the colon), and dorsalgia (physical discomfort occurring anywhere on the spine of back ranging from mild to disabling). Record review of the clinical record for Resident #35 revealed a Medicare 5-day MDS completed on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functional status that indicated she required one-person assistance with all activities. Record review of Resident #35's care plans dated [DATE] revealed the following care plan: Focus: DNR Intervention: Ensure physician order is review for DNR. Obtain out of hospital DNR. Place OOHDNR on chart with copy of physician order. Date initiated [DATE] Record review revealed a DNR in Resident #35's clinical record completed [DATE] (by Resident #35's date of signature) revealed in the Physicians Statement section there was no date of when the physician signed, no printed signature, and no license number for the physicians' signature. Resident #41 Record review of the face sheet dated [DATE] in the clinical record for Resident #41 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of the rectum (a disease in which malignant cancer cells form in the tissue of the rectum), fluid overload (a condition in which the fluid portion of the blood is too high), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (a condition in which force of the blood against the artery walls in too high), atrial fibrillation (an irregular and often rapid heart rate that commonly causes poor blood flow), and chronic kidney disease (longstanding disease of the kidneys resulting in renal failure). Record review of the clinical record for Resident #41 revealed an admission MDS completed on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functional status that indicated she required two-person assistance with all activities. Record review of Resident #41's care plans dated [DATE] revealed the following care plan: Focus: DNR Intervention: Ensure physician order is review for DNR. Obtain out of hospital DNR. Place OOHDNR on chart with copy of physician order. Date initiated [DATE] Record review revealed a DNR in Resident #41's clinical record completed [DATE] (by the physicians date of signature) revealed in the section All persons who have singed above must singe blow, acknowledging that this document has been properly completed there is no second signature for the physician. During an interview on [DATE] at 02:26 PM when asked if Resident #35 was reported to have coded what would ADON A do. ADON A reported that the current facility DNR process was to check the electronic chart which she did and found that Resident #35 was listed as a DNR on Resident #35's face sheet and in Resident #35's physician orders ADON A then reported that she would check the paper chart to see if it was tagged in red to indicate Resident #35's was a DNR, then staff would check the paper charts DNR section to see if there was further red paperwork indicating Resident #35's was a DNR, then staff would check the printed DNR which ADON A did and found the DNR. ADON A then reported that if Resident #35's had no pulse or respirations they would not perform CPR, they would notify the MD, get an order to pronounce, and notify the family. When asked to review Resident #35's DNR again and verify when the physician signed the DNR ADON A did and reported that the form was missing the physician date of signature and the physicians license number. When asked if the DNR was valid ADON A stated, without the date or license number it really wouldn't be. When asked if the resident coded at this time how would she handle it ADON A reported that with the DNR signed by the resident and the order in the resident's electronic chart signed by the physician she would have to call the family and ask their wishes. ADON A then reported that she would get the DNR corrected immediately. During an interview on [DATE] 09:14 AM the DON reported they had several new admissions and that the business office person, the MDS coordinator, and the charge nurses along with herself all review the DNR's and with all the paperwork that needed to be completed with the new admissions apparently several DNR's were missed for completion. That a review was completed of all DNR's on the evening of [DATE] and all were updated that could be immediately addressed but two were out today to update the physician's signature and those two would be corrected today. When questioned as to the potential complications if the DNR process is not completed and followed the DON reported that the facility would not be following the DNR procedure correctly. During an interview on [DATE] at 09:34 AM when asked about Resident #19, #35, and #41's DNR's missing required information the MDS Coordinator reported the DNR is part of the admission process and that they (the DON, the business office, the floor nurses, and herself) missed several that did not get completed correctly. The MDS Coordinator reported that she was going to color code the DNR's from this point forward as a part of the plan of correction in order to ensure they are completed correctly. Record review of facility provided policy titled Advance Directives/Advance Care Planning, with the date of revision 4/2015, revealed the following: Policy: .This facility will honor a resident wishes and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment. v. An Out of Hospital Do Not Resuscitate (OOHDNR) should be discussed with the patient/resident/surrogate/proxy and completed if this is the patient's preference. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #4) observed for incontinent care. -CNA B failed to prevent contamination of Resident #4's wipes before using them on the resident and failed to wash her hands before placing a new brief on Resident #4 during incontinent care. These deficient practices have the potential to affect residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Resident #4 Record review of Resident #4's face sheet dated 11/9/2022 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include vascular dementia (brain damage caused by multiple strokes), dysphagia (difficulty swallowing foods or liquids), muscle weakness, difficulty walking, history of falls, lack of coordination, hypertension (a condition in which force of the blood against the artery walls in too high), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down), and muscle wasting. Record review of Resident #4's last MDS completed was a quarterly done on 9/12/22 with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring two-person assistance with most of her activities. Record review of Resident #4's care plan dated 8/30/22 revealed the following care plan: Focus: Incontinence Care-Resident is incontinent of bowel/bladder related to activity intolerance. Intervention: Monitor for and report to MD s/s of UTI. During an observation on 11/09/22 at 11:20 AM incontinent care was performed on Resident #4 by CNA B. At one point, CNA B pull two wipes apart and put one wipe on the incontinent pad that Resident #4 had been laying on before the procedure started. Resident #4 had her feet placed in the same spot that CNA B placed the extra wipe. CNA B used the first wipe to clean Resident #4's vaginal area then picked the second wipe up off the incontinent pad and used it to clean Resident #4's vaginal area. This was the last wipe CNA B used on the frontal area of Resident #4. CNA B then rolled the resident to her left side, retrieved a wipe from the open wipe package on the bedside table and used that wipe to clean Resident #4's rectal area, retrieved a wipe from the open wipe package on the bedside table and used that wipe to clean Resident #4's right buttocks, then retrieved a wipe from the open wipe package on the bedside table and used that wipe to clean Resident #4's left buttocks. CNA B then retrieved the new brief and placed it on the resident without changing her gloves. CNA B cleaned the peri-area, then the rectal area, and placed the new brief without changing her gloves or washing her hands. During an interview on 11/09/22 at 11:33 AM when questioned concerning using the wipe that CNA B had placed on the incontinent pad that the resident had been on and placed her feet on CNA B reported that she thought the wipe was considered clean and that she did not feel using it was a problem. When asked about placing the new brief on the resident after completing the vaginal and rectal care for the resident without washing her hands or changing her gloves CNA B reported that she forgot that step, that she was aware that it could cause cross contamination, and that a resident could develop and infection as a result. CNA B verified that she received regular training from the DON on infection control and incontinent care. During an interview on 11/10/22 09:19 AM when asked if staff should perform hand hygiene when performing incontinent care, the DON reported that hand hygiene should be performed before incontinent care is started, after it was completed, and between each glove change. When asked if hand hygiene should be performed between the dirty to clean portions of incontinent care, the DON reported that it should because if you do not it will violate infection control and result in the resident getting an infection. When questioned if the wipes used on a resident can be placed in a dirty area prior to use on a resident the DON reported that the wipes cannot be used due to contamination. The DON verified that she trains all her staff and reported that all CNA staff were trained in the previous week on incontinent care and stated, they know how to do this, they must have just gotten nervous. Record review of facility provided policy titled Hand Hygiene date implemented 2/20/2020 revealed the following: Policy: All staff will perform proper hand hygiene procedure to prevent the spread of infection . This applies of all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your tack requires gloves, perform hand hygiene prior to donning gloves, and immediate after removing gloves. Record review of the facility provided Hand Hygiene Table undated revealed the following Condition: -When, during resident care, moving from a contaminated body site to a clean body site -After assisting with personal body function (E.G., elimination . Record review of the facility provided policy titled Incontinent Care reviewed 4/10/17 revealed the following: 11. Cleanse peri-area and buttocks with cleansing agent . 12, Dry peri-area and buttocks . 13. Apply skin protectant . 14. Remove linen/under pad and discard. 15 Removes and discard gloves 16 Wash hands 17 Apply clean linen/under pad, brief .