**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 infection of communicable diseases and infections for one of one resident (Resident #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene with gloves change, while providing incontinence care to Resident # 1. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (elevated blood pressure), anxiety (a normal human emotion, but it can become a disorder when feelings of worry and fear are intense, persistent, and interfere with daily life), and Vascular dementia, moderate, with psychotic disturbance (Dementia: a decline in mental ability severe enough to interfere with daily life). Resident #1 had a BIMS score of 10/15 which indicated Resident #1's cognition was moderately impaired. Further review revealed Resident #1 urinary continence/ bowel continence, always incontinent. Review of Resident #'1s Comprehensive Care Plan, created date 11/25/24, reflected the following: Problem: [Resident #1] requires Extensive assistance required with ., hygiene, . Goal: [Resident #1] Will be odor free, dressed and out of bed daily over the next 90 day. [Resident #1] will assist with ADLs to the highest degree possible. Intervention. Assist with ADLs. Observation on 07/15/25 at 09:17 AM of Resident #1's incontinent care, provided by CNA A revealed Resident #1 was lying in bed. CNA A entered Resident #1's room, donned gloves, got a clean brief, Resident #1's shoes, clothes, adjusted the bed, and got trash can next to the bed. CNA A removed gloves, donned clean gloves, without any form of hands hygiene. CNA A uncovered Resident #1 got the clean brief and put it on the bed. CNA A unfastened Resident #1's brief and pushed it between Resident's legs. CNA A cleaned Resident #1's front area with wipes, one at a time, and pushed the wipes between Resident #1's legs. CNA A helped Resident #1 turn to his right side. CNA A removed the dirty brief; the brief was wet with urine; put it in the trash can and cleaned Resident #1's buttocks area using one wipe per stroke. CNA A removed gloves, donned clean gloves without any form of hands hygiene, and put the clean brief on Resident #1. CNA A changed gloves without any form of hands hygiene and proceeded to get Resident #1 dressed, and out of his bed to wheelchair. Interview on 07/15/25 at 09:35 AM CNA A acknowledged he was changing gloves without any form of hands hygiene during Resident #1's incontinent care. CNA A stated he washed his hands after he finished the morning care for another resident, before coming to Resident #1's room. CNA A stated he was supposed to follow proper hand hygiene and wash or sanitize his hands before putting on the clean gloves. He stated that adhering to proper hand hygiene was important to prevent the spread, and development of infection to residents. In interview on 07/15/25 at 11:06 AM the DON stated infection control was important during residents' care. The DON stated during care the staff were supposed to sanitize hands upon entering the resident's room. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer. The DON stated hand hygiene was to be completed for infection control. Record review of the facility's policy, revised 01/23/25, and titled Hand Hygiene, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: Upon arrival at the workplace and before going home. After using the toilet, blowing nose, and covering a cough or sneeze. Before and after eating. Before and after client contact. After removing gloves. Before invasive procedures. After touching contaminated items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #1) of 6 residents reviewed for foot care. The facility failed to provide adequate foot care for Resident #1 who had a standing order for podiatric services. Resident #1's toenails were chipped, thick, and long. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (elevated blood pressure), anxiety (a normal human emotion, but it can become a disorder when feelings of worry and fear are intense, persistent, and interfere with daily life), and Vascular dementia, moderate, with psychotic disturbance (Dementia: a decline in mental ability severe enough to interfere with daily life). Resident #1 had a BIMS score of 10/15 which indicated Resident #1's cognition was moderately impaired. Further review revealed Resident #1 needed supervision or touching assistance for personal hygiene. Review of Resident #'1s Comprehensive Care Plan, created date 11/25/24, reflected the following: Problem: [Resident #1] requires Extensive assistance required with bathing, hygiene, dressing, and grooming. Goal: [Resident #1] Will be odor free, dressed and out of bed daily over the next 90 day. [Resident #1] will assist with ADLs to the highest degree possible. Intervention. Podiatrist to examine feet and trim nails. Schedule appointment as needed per physician's orders. STATUS: Active (Current). Record review of doctor orders revealed Resident#1 had a standing order dated (11/11/24) for podiatric referral May have . podiatry evaluation and treatment as indicated Notes: Instructions: Therapeutic Range: Source: Nursing Protocol as Needed Starting 11/12/2024. Review of the podiatry Schedule for visit date: 06/04/25 under title Patients with ‘do not treat (DNT)' Status revealed Resident #1 DNT date 03/27/25, and DNT reason No Consent on file. Review of the last six months weekly skin assessment revealed no indication of Resident #1's toenails status. An observation and interview on 07/15/25 at 09:17 AM revealed Resident#1 was lying in bed. CNA A removed Resident #1's socks during the morning routing care to get him out of bed. Resident #1's toenails #2, #3, #4, and #5 on both feet were long approximately 0.4 centimeter in length extending from the tip of his toes. Resident #1's both feet toenails #4, and #5 were growing out sideways; toenails #3 was growing straight, and #4 was curling forward. Resident #1's left big toenails showed signs of separation from the nail bed at the base of the nail plate. When asked if he would like his toenails trimmed, Resident #1 stated sure. Interview on 07/15/25 at 09:35 AM CNA A stated it was his responsibility to let the nurse know about the residents' toenails needing to be trimmed. He stated he had been working with Resident #1 for few months but did not notice that his toenails needed trimming. CNA A stated the risk when the toenails got bigger, the Resident could be uncomfortable. Interview on 07/15/25 at 09:41 AM RN B looked at Resident #1 toenails and stated they were long and chipped, and needed a podiatry consult. She stated nurses do weekly skin assessment and report to SW and the SW scheduled the consult. RN B stated Resident #1 should be on the podiatry consult list. RN B stated the podiatric services came in every three months to residents' toenails care. She stated last time she did the skin assessment on Resident#1 was last week, during which she did not noticed his toenails condition. RN B stated the risk to Resident #1 was he could scratch himself, potential skin issue, or if the toenails got cut in the shoes will be uncomfortable. Observation on 07/15/25 at 12:07 PM with the SW revealed she checked the podiatry referral file. Interview with the SW revealed she did not see Resident#1 name on the referral list. The SW stated the referral was sent, and the podiatric services asked on 3/28/2025 for a consent. She stated, she asked Resident #1's family member to fill out a consent but never got it back. The SW stated she tried to contact them again but did not have the document for the day of the request for the consent. When asked about the second quarter podiatry scheduled treatment, she stated the consent was not singed yet. She stated her assistant will be able to provide the reason. Interview on 07/15/25 at 12:28 PM the SWA stated, she could not remember any referral done for Resident #1, and there was an order. She stated it was the responsibility of the SW, and she was just helping her. Observation revealed the SWA searched Resident #1's file in the system. Interview revealed Resident # 1 was referred to podiatry. The SWA stated Resident # 1 was not seen during first visit of the year on 03/28/25, and on the second visit on June 4, 2025, because there was no consent done. When asked for the follow up with the family for the consent, she stated, she contacted the family member after the first visit over the phone and was unable to remember or provide any reason for not getting the consent for the podiatric treatment for Resident #1 for the last six months. Observation and interview on 07/15/25 at 2:06 PM revealed the DON looked at Resident #1's toenails and stated they were long, chipped and the nail of the left big toe was separating from the nail bed. She stated her expectation; Resident #1 needed a podiatry consult especially for the big toe on the left foot. The DON stated it was the responsibility of the CNAs and nurses to do nail care or report it to the appropriate department for follow up. She stated the risk was Resident infection, and pain. She stated the staff were in-serviced to do weekly skin assessment, and if they find something like that to bring it to her attention so she could follow up on it. Interview on 07/15/25 at 2:36 PM the Administrator stated the nurses should let the SW work know about Resident #1's toenails needing care. She stated it was the responsibility of the SW to make referrals and get the consent from the family. She further stated if the nurses were able to do the care without harming the Resident they should do it. She stated the risk to the Resident was discomfort. Review of the facility policy titled Foot care date October 2024, revealed Residents receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation. 1. Residents are provided with foot care and treatment in accordance professional standards of practice. 3. Residents are assisted in making appointments and with transportation to and from specialists (Podiatrist.) as needed. 4. Trained staff may provide routine foot care (.toenail clipping) within professional standards of practice for residents without complication processes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for one (Resident #36) of six residents reviewed for quarterly assessments. The facility did not ensure Resident #36's Quarterly MDS Assessment, dated 10/28/24, was completed withing 92 days of the previous assessment. These failures could place residents at-risk of not having their assessments completed timely. Findings included: Record review of Resident #36's Face Sheet dated 12/1/7/24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #36's EHR reflected her Quarterly MDS Assessment with Assessment Reference Date 10/28/24 was created and submitted on 12/17/24. Resident #36's previous Quarterly MDS Assessment reflected and Assessment Reference Date of 7/25/24 and was completed on 8/5/24. In an interview on 12/17/24 at 1:57 PM, The MDS Nurse stated she realized she had missed Resident #36's Quarterly MDS Assessment and had completed and submitted it that day. She stated the risk of missing MDS assessments was that residents may need an updated care plan and changes in condition could be missed. In an interview on 12/17/24 at 2:05 PM, the DON stated she was told by the MDS Nurse that morning that she had missed Resident #36's Quarterly MDS Assessment which was due in October. She stated she had encouraged her to set up a calendar with reminders of when the assessments were due. The DON stated the MDS Nurse was responsible for timely completion of the assessments. She stated she monitored the Discharge MDS assessments to ensure they were completed but it was the MDS Nurse's responsibility to monitor the others. She stated the risk for missing MDS assessments was changes in the resident's condition could be missed which were important for care planning. Record review of the facility's policy titled, Minimum Data Set (MDS), dated revised 11/26/2024, reflected: Service Standard [company name] will complete accurate resident assessments and submit assessments in accordance with current federal and state submission timeframes .3. Timeframes for completion and submission of assessments is based on current requirements published in the RAI manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #36) of six residents reviewed for accuracy of assessments. The facility failed to ensure that Resident #36's Quarterly MDS Assessment included interviews conducted within the required timeframes. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #36's Face Sheet dated 12/17/24 reflected a [AGE] year-old female admitted to the facility on [DATE] . Record review of Resident #36's EHR reflected her Quarterly MDS Assessment with Assessment Reference Date 10/28/24 was created and submitted on 12/17/24. Record review of Resident #36's Quarterly MDS dated [DATE] reflected, Look back period for all items is 7 days unless another time frame is indicated. MDS Section C reflected a BIMS had been conducted and she had score of 3 indicating severely impaired cognition. Section D reflected a mood interview (PHQ-9) been conducted with a score of 0, indicating none or minimal depression. Her diagnoses included Non-Alzheimer's dementia and depression. Section Z0400 (used to identify who completed each section of the assessment) reflected no entry was made for sections C or D. In an interview on 12/17/24 at 1:57 PM, The MDS Nurse stated she realized she had missed Resident #36's Quarterly MDS Assessment and had completed and submitted it that day. She stated she obtained the information for the assessment from the resident's clinical record. The MDS Nurse stated sections C and D should have had dashes entered because the interviews were not completed during the look back period. She stated she must have entered the information from her previous assessment in error and would submit a correction. She stated accuracy of a MDS assessment was important because, if a change was captured then the resident may need an updated care plan. In an interview on 12/17/24 at 2:05 PM, the DON stated she was told by the MDS Nurse that morning that she had missed Resident #36's Quarterly MDS Assessment which was due in October. The DON stated the MDS Nurse was responsible for timely completion and accuracy of the assessments. She stated she monitored the Discharge MDS assessments to ensure they were completed but it was the MDS Nurse's responsibility to monitor the others. The DON stated she was not aware of the errors made with the BIMS and mood interviews. She stated the risk for inaccurate MDS assessments was changes in the resident's condition could be missed which were important for care planning. In a record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . In addition, the assessment must represent an accurate picture of the resident's status during the observation period of the MDS .Section C: Cognitive Patterns .Coding Tips Attempt to conduct the interview with ALL residents. The interview is conducted during the look-back period of the Assessment Reference Date (ARD) .If the resident interview was not conducted within the look-back period (preferably the day before or day of the ARD .the standard 'no information' code (a dash '-') entered in the resident interview items .Section D: Mood .Coding Tips Attempt to conduct the interview with ALL residents. The interview is conducted during the look-back period of the Assessment Reference Date (ARD) .If the resident interview was not conducted within the look-back period (preferably the day before or day of the ARD .the standard 'no information' code (a dash '-') entered in the resident interview items . Record review of the facility's policy titled, Minimum Data Set (MDS), dated revised 11/26/2024, reflected: Service Standard [company name] will complete accurate resident assessments and submit assessments in accordance with current federal and state submission timeframes .2. The MDS coordinator will ensure that appropriate edits are made prior to submitting the MDS data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #67) of 3 residents reviewed for discharge planning. The facility failed to develop and implement a discharge plan for Resident #67 who's goal was to return to the community. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Record review of Resident #67's Face Sheet dated 12/18/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 10/31/24. Record review of Resident #67's admission MDS assessment dated [DATE] reflected he was cognitively intact, he used a cane for mobility, and he required partial to maximum assistance with ADLs. His diagnoses included urinary tract infection, diabetes, and depression. His overall goal was discharge to the community and active discharge planning was already occurring for the resident to return to the community. Record review of Resident #67's Discharge assessment-return not anticipated MDS dated [DATE] reflected the discharge was unplanned. Record review of Resident #67's Care Plan dated 12/18/24 reflected: Problem-Impaired bed mobility. Goals included: A discharge plan will be developed with [Resident #67] and family/caregivers related to bed mobility needs. Interventions included: Prior to discharge, determine that all necessary durable medical equipment and assistive devices are available and ready for use by [Resident #67]. Utilizing the interdisciplinary team, determine discharge needs such as home health services and/or outpatient therapy. There were no other entries related to discharge planning or goals located within the Care Plan. Record review of Resident #67's physician's orders revealed no order for discharge was located. Record review of Resident #67's physician progress note dated 10/30/24 reflected: Date of Service 10/29/24. History of present illness: .Pt is a 90 yo M who presented to OSH with confusion and found with bronchitis, UTI. Pt started on abx and improved. Remainder of stay was uneventful but OSH records limited on review. Once pt was stable, pt was noted to benefit from continued medical oversight and therapy before dc to home, so pt was transferred to [nursing facility name] for such needs. Pt today is in room, I assisted the tech with care. Pt denies pain, feels well. States he is waiting on room to be made upstairs so he can move in by end of week. DON unaware. No other complaints . Record review of resident #67's nursing notes reflected the following entries: Entry dated 10/30/24 4:49 AM: Received resident in room lying in bed with eyes open, sitter at bedside. Resident remains on skilled nursing services for dx: UTI. Alert and oriented x 2-3, respiration even and unlabored, continues on po ABT Amoxicillin 875 mg day 2/3 and Doxycycline 100mg capsule day 2/2 related to UTI with NARN, incontinent of bowel and bladder, incontinent care provided as needed, no s/s of acute distress nor discomfort noted, able to verbalize needs, on cont. 02 2lpm via N/C, safety maintained, bed in comfortable low position, call light within reach, will continue to monitor and update any changes. Entry dated 10/31/24 at 8:03 PM reflected: Pt. discharged to Assisted Living facility today per MD orders patient V/S stable no complaints of pain or discomfort BBS clear BSx4 family RP notified of change medications reviewed and transferred with patient. Record review of Resident #67's EHR revealed no discharge planning documentation was located within his record. During an interview on 12/18/24 at 10:05 AM, the Administrator stated no discharge planning had been completed for Resident #67. She stated the social worker was previously responsible for conducting discharge planning and his was missed because she left . She stated His Discharge MDS reflected an unplanned discharge because he wanted to leave sooner than initially expected. He just said he was ready to go and wanted to leave. She stated she was unsure whether he had any home health needs and would look for any additional documentation. No additional documentation related to discharge planning was provided. During an interview on 12/18/24 at 11:07 AM, the DON stated the social worker was responsible for discharge planning. She stated Resident #67 resided in the facility's Assisted Living unit and returned there after receiving skilled therapy in their unit. She stated she did not believe he required any additional services, and he left on the same level of care he had prior to his admission. The DON stated the risk of not completing discharge planning was residents may be on different medications or treatments that they were not on prior to admission and treatments could be missed. Record review of the facility's policy titled, Discharge Summary dated revised 11/26/24 reflected: The purpose of the discharge summary and the post discharge plan of care with instructions is to assist the resident in adjusting to his/her new living environment by providing continuity of care information. 1. When anticipating a resident's discharge or upon the death of a resident, complete a discharge summary including: .d. a post-discharge plan of care developed with participation of the resident/resident's representative, or legal guardian; and with the resident's consent, the resident's representative, which will assist the resident to adjust to his/her new living environment. This includes where the individual plans to reside, any arrangements that have been made for the resident's follow up care, and any post-discharge medical and non-medical services .4. Member(s) of the Interdisciplinary Team will review the Discharge Plan of Care with the resident/resident's representative before the discharge is to take place. 5. A copy of the post-discharge plan of care and summary will be given to the resident and the receiving facility. A copy will be retained in the resident's medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay, medication reconciliation, and a post-discharge plan of care for one (Resident #67) of 3 residents reviewed for discharge summaries. The facility failed to complete a discharge summary for Resident #67 when he discharged home from the facility. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home. Findings included: Record review of Resident #67's Face Sheet dated 12/18/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 10/31/24. Record review of Resident #67's admission MDS assessment dated [DATE] reflected he was cognitively intact, he used a cane for mobility, and he required partial to maximum assistance with ADLs. His diagnoses included urinary tract infection, diabetes, and depression. His overall goal was discharge to the community and active discharge planning was already occurring for the resident to return to the community. Record review of Resident #67's Discharge assessment-return not anticipated MDS dated [DATE] reflected the discharge was unplanned. Record review of Resident #67's Care Plan dated 12/18/24 reflected: Problem-Impaired bed mobility. Goals included: A discharge plan will be developed with [Resident #67] and family/caregivers related to bed mobility needs. Interventions included: Prior to discharge, determine that all necessary durable medical equipment and assistive devices are available and ready for use by [Resident #67]. Utilizing the interdisciplinary team, determine discharge needs such as home health services and/or outpatient therapy. Record review of Resident #67's physician's orders revealed no order for discharge was located. Record review of Resident #67's physician progress note dated 10/30/24 reflected: Date of Service 10/29/24. History of present illness: .Pt is a 90 yo M who presented to OSH with confusion and found with bronchitis, UTI. Pt started on abx and improved. Remainder of stay was uneventful but OSH records limited on review. Once pt was stable, pt was noted to benefit from continued medical oversight and therapy before dc to home, so pt was transferred to [nursing facility name] for such needs. Pt today is in room, I assisted the tech with care. Pt denies pain, feels well. States he is waiting on room to be made upstairs so he can move in by end of week. DON unaware. No other complaints . No other issues at this time . Record review of Resident #67's nursing notes reflected the following entries: Entry dated 10/30/24 4:49 AM: Received resident in room lying in bed with eyes open, sitter at bedside. Resident remains on skilled nursing services for dx: UTI. Alert and oriented x 2-3, respiration even and unlabored, continues on po ABT Amoxicillin 875 mg day 2/3 and Doxycycline 100mg capsule day 2/2 related to UTI with NARN, incontinent of bowel and bladder, incontinent care provided as needed, no s/s of acute distress nor discomfort noted, able to verbalize needs, on cont. 02, 2 lpm via N/C, safety maintained, bed in comfortable low position, call light within reach, will continue to monitor and update any changes. Entry dated 10/31/24 at 8:03 PM reflected: Pt. discharged to Assisted Living facility today per MD orders patient V/S stable no complaints of pain or discomfort BBS clear BSx4 family RP notified of change medications reviewed and transferred with patient. Record review of Resident #67's EHR revealed no discharge summary documentation was located within his record. Record review of a Clinical Notes Report dated 12/18/24 from Resident #67's Assisted Living facility reflected the following: Entry dated 10/31/24 7:34 PM: Resident transferred back to AL. to [room number] this afternoon alerts and oriented x 4 denies any pain or discomfort resp. even and unlabored no sob, noted no coughing or congestion noted. Resident stated, I am very happy I am returning to my room, and I feel better now. All medications verified with [physician name] and all order updated. Resident [eats] in the dining room and appetite fair encourage by mouth fluids tolerated well. vitals checked stable. will continue to monitor. During an interview on 12/18/24 at 10:05 AM, the Administrator stated no discharge planning had been completed for Resident #67. She stated the social worker was previously responsible for completing discharge summaries and his was missed because she left. She stated His Discharge MDS reflected an unplanned discharge because he wanted to leave sooner than initially expected. He just said he was ready to go and wanted to leave. She stated other staff were assisting with social work duties such as referrals and a new one would be starting the following week. During an interview on 12/18/24 at 11:07 AM, the DON stated no discharge summary was completed for Resident #67 because the Social Worker was responsible for it and she left. She stated resident #67 was returning to his assisted living apartment within the same facility and she believed he left on the same level of care he had prior to his hospitalization and skilled stay. She stated he would have been discharged with his medications and would look for any other documentation that may be available. She stated the risk for failing to complete a discharge summary was they may be on different medications than when previously at home and could possibly miss changes in treatments or equipment needed. om In an interview with the DON on 12/18/24 at 3:37 PM, she stated she had been unable to locate any documentation of a discharge summary other than the clinical note from the assisted living facility indicating his medications had been verified and ordered. Record review of the facility's policy titled, Discharge Summary dated revised 11/26/24 reflected: Service Standard It is the service of [company name] to complete a discharge summary to his/her new living environment. The purpose of the discharge summary and the post discharge plan of care with instructions is to assist the resident in adjusting to his/her new living environment by providing continuity of care information. 1. When anticipating a resident's discharge or upon the death of a resident, complete a discharge summary including: a. A recapitulation of the resident's stay that includes, but is not limited to diagnose, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's stay at the time of discharge. c. Reconciliation of all pre-discharge medications with the resident's post discharge medications (both prescribed and over the counter) d. a post-discharge plan of care developed with participation of the resident/resident's representative, or legal guardian; and with the resident's consent, the resident's representative, which will assist the resident to adjust to his/her new living environment. This includes where the individual plans to reside, any arrangements that have been made for the resident's follow up care, and any post-discharge medical and non-medical services. 2. Information for a receiving facility must include, but are not limited to the resident's: a. Contact information for the resident's medical provider; b. Resident's representative information including contact information; c. Advance Directive information; d. All special instructions of precautions for ongoing care, as appropriate; e. Comprehensive care plan goals; f. All other necessary information, including a copy of the resident's discharge summary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 23% based on 10 errors out of 43 opportunities which involved 1 of 4 residents (Resident #32) and 1 of 3 staff (LVN A) reviewed for medication error, in that: LVN A crushed medication and mixed all the fourteen (14) medications together and administered through a gastrostomy tube (surgically placed to provide direct access to a human's stomach for supplemental feeding, hydration, or medication) to Resident #32 These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Record review of Resident #32's face sheet dated 12/18/24 revealed an [AGE] year-old male who admitted on [DATE]. his diagnoses included pneumonitis ( general term that refers to swelling and irritation, also called inflammation, of lung tissue)due to inhalation of food and vomit, hypertension pain, constipation, muscle spasm, gastro-esophageal reflux disease without esophagitis (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus.), muscle weakness, muscle wasting, lack of coordination, difficulty in walking, anxiety disorder and gastrostomy status, Record review of Resident#32's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15, which indicated severe cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #32's care plan dated 12/28/24 revealed Resident #32 receiving tube feedings, with goal for Resident #32 to receive adequate nutrition without side effects associated with tube feedings (aspiration, diarrhea, dehydration) Record review of resident #32's physician orders for December 2024 revealed orders for: Ferrous sulfate 300 mg (60 mg iron)/5 ml oral liquid (5ml ) liquid (ml) g-tube, lactobacillus acidoph-l.bulgaricus 1 million cell tablet (1) tablet g-tube, aspirin childrens 81 mg chewable tablet (1) tablet, chewable g-tube, fexofenadine 180 mg tablet (1) tablet g-tube, gabapentin 400 mg capsule (1) capsule g-tube, magnesium 400 mg (as magnesium oxide) capsule (1) capsule g-tube, melatonin 5 mg tablet (1) tablet g-tube, metoprolol tartrate 50 mg tablet (1) tablet g-tube, glycopyrrolate 1 mg tablet (1 tablet) tablet g-tube, escitalopram 5 mg tablet (1) tablet g-tube, cefdinir 300 mg capsule (1) capsule g-tube, doxycycline hyclate 100 mg capsule (1 cap) capsule g-tube, nexium 40 mg capsule, delayed release (1 packet) capsule, delayed release (enteric coated) g-tube and flush enteral feeding tube with 15ml of tap water before & after each individual medication administration per g-tube. In an observation on 12/17/24 at 09:20 AM revealed LVN A administering the following medication to Resident #32 though the g-tube; Aspirin 81 mg chewable, cefdinir 300 mg capsule, doxycycline hyclate 100 mg , esomeprazole delayed realize 40 mg, iron supplement 15 cc, gabapentin 400 mg, probiotic supp 1 cap magnesium oxide 400 mg, glycopyrrolate 1 mg, ropinirole hcl 0.25 mg, allergy relief 180 mg LVN A prepared the medications on the medication cart and opened the capsules and mixed them in one medication cup and then crushed all the tablets together and placed them in one medication cup . LVN A then proceeded to the resident's room with three medication cups of medicine and informed Resident #32 he was going to administer his medications via the g-tube. LVN A checked for placement and residual and then flushed with about 40 cc of water and then proceeded to administer medications. After administering the liquid potassium, he administered the crushed tablets, but the g-tube clogged up, then he poured the medication back to the drinking plastic cup and poured water to the syringe and tried to unclog the tube several times until it was unclogged. LVN A then added the medication that were in the medication cup with the medications in the plastic cup and mixed all the medications together and administered. After medication administration he then flushed with about 40 cc of water. In an interview on 12/17/24 at 01:46 PM with LVN A he stated where he had worked before, he was able to mix all the medications together cocktail because there was an order but Resident #32 did not have an order to cocktail, so he was supposed to administer the medications separately. LVN A stated when medications being cocktailed could lead to some medications having a chemical interaction that could cause a negative effect on the resident. In an interview on 12/18/24 at 03:07 PM with the DON she stated LVN A had informed her that he did not complete the medication administration right. The DON stated the nurse reported he cocktailed the medications. The DON stated the nurse was not supposed to cocktail the medications unless there was an order to do so, but the resident did not have the order. The DON stated the medications were not supposed to be cocktailed because they could interact and cause and negative effect to the resident. Facility policy review dated 10/23/24 titled Gastrostomy (G-tube) Policy reflected, . This service standard shall serve as a guideline and shall not replace sound clinical judgement based on the resident's condition, status, and plan of care.Unless a resident had an identified and documented risk for fluid overload, G-tube medications will be administered one at a time with a flush of at least 15cc before and after the administration of each medication unless the physician's orders specify otherwise.

**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 infection of communicable diseases and infections for one of six residents (Resident #1) reviewed for infection control. CNA Z failed to perform hand hygiene during while providing incontinence care to Resident # 1. This failure could place the residents at risk for infection. Findings include: Record review of Resident #1's face sheet, dated 03/28/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included fracture of the patella (the bone at the front of knee joint), Alzheimer's disease (is a brain disorder that causes memory loss, thinking problems, behavior changes, and brain cell death) and dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #1's care plan, dated 12/21/23, reflected the resident was incontinent of bowel and blader and had an ADL self-care performance deficit related to cognitive impairment, and the intervention was for the resident incontinence care to be managed by staff. Observation on 03/28/24 at 09:44 AM revealed CNA Z provided incontinent care for Resident #1. CNA Z entered Resident #1's room, gloved without performing hand hygiene and proceeded to provide the residents with care. CNA Z unfastened the brief and cleaned the resident's front area, turned Resident #1 to her side, and removed the dirty brief. Resident #1 was soiled in urine. CNA Z then placed the dirty brief in the trash can and cleaned the resident's buttocks area. After cleaning the resident, without any form of hand hygiene or change of gloves, CNA Z applied the clean brief, turned the resident on her back and fastened the brief. After care, CNA Z completed hand hygiene. In an interview on 03/28/24 at 10:05 AM with CNA Z, CNA Z stated she was supposed to complete hand hygiene before and after care. CNA Z stated after cleaning the resident she was supposed to clean her hands and change gloves before applying the clean brief. CNA Z stated she was supposed to complete hand hygiene to prevent the spread of infection. CNA Z stated she completed a hand hygiene and infection control in-service about four months ago. In an interview on 03/28/24 at 11:49 AM with the ADON, she stated infection control was important during care. ADON A stated during incontinent care the staff were to use the hand sanitizer or wash hands if they were physically soiled. ADON A stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean one. ADON A stated hand hygiene was to be completed for infection control. ADON A stated she was the infection preventionist and in-service on infection control was done twice a year. ADON stated it was her responsibility and the responsibility of the nurses in the units, ADON B and the DON to make sure the CNAs followed proper hand hygiene during residents' care. In an interview on 03/28/24 at 12:12 PM with the DON, she stated staff doing direct resident care were supposed to wash their hands before given care and afterward. She stated the CNAs were supposed to change glove, with hand hygiene when going from dirty to clean during incontinent care and perform hand hygiene before putting on the clean gloves. The DON stated hand hygiene was to be completed to prevent cross contamination from dirty to clean. The DON stated it was the responsibility of the nurses in the units, ADONs and DON to make sure the facility hand hygiene policy was followed by all the staff during resident care. Record review of the facility's policy, revised 01/23/24, and titled Hand Hygiene, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: Upon arrival at the workplace and before going home. After using the toilet, blowing nose, and covering a cough or sneeze. Before and after eating. Before and after client contact. After removing gloves. Before invasive procedures. After touching contaminated items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #62) of four residents reviewed for care plan. The facility failed to implement Resident #62's care plan to address nutrition and, anticoagulant therapy. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of Resident #62's admission MDS assessment, dated 10/15/23 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation (irregular heartbeat), post-polio syndrome (polio), Cardiac Aortic Disease (blocked arteries), and nutritional instability (with weight loss and weight gain of greater than 5-10%). The resident was alert an oriented with a BIMS score of 11 and usually understood others. Resident #62 required assistance of one staff member for set up and clean up. The assessment reflected the resident was 5 feet 5 inches in height and weighed 118 pounds. Review of the physician's orders dated 10/15/23 revealed Resident #62 admitted with an order for anticoagulation medication Eliquis 5 mg two times a day for Atrial fibrillation. Review of the Medication Administration Record dated 10/15/23 revealed Resident #62 was receiving the medication, Eliquis 5 mg, as the physician had order. Review of Resident #62's care plan on 11/02/23 reflected no care plan had been initiated for Resident #62 reflecting no goals for nutrition or anticoagulant therapy. Observation and interview on 11/01/23 at 12:19 p.m. revealed Resident #62 was sitting up in bed, and she was assisting herself to eat. The resident stated she liked the food; it was just too much to eat sometimes. The resident stated they gave her a supplement daily if she did do not eat well. The dietician had spoken to her about her inconsistent weight gain and loss, but she really had been like that most of her life. Interview on 11/02/23 at 9:06 a.m. with the ADON revealed she, the other ADON, the DON and the floor nurses (charge nurses) were responsible for updating resident care plans. She further stated We (nursing administration) thought you might be talking to us about the care plans. We have no MDS nurse right now. We have one starting soon and the care plans are either behind or not started. The ADON stated the DON was aware and not having care plans initiated could lead to residents possibly not getting the care that was needed or recommended . Interview on 11/02/23 at 12:00 p.m. with LVN B reveled she did not update care plans; she was never told to update care plans. Interview on 11/03/23 at 8:20 a.m. with LVN A revealed he had worked at the facility since August of 2023, he had been told by the DON to update care plans on the residents he oversaw if he had the time. LVN A stated he had not had time to update any care plans. Interview on 11/03/23 at 1:34 p.m. with the DON revealed the MDS Coordinator was responsible for initiating and updating the care plan as needed. The DON stated the facility had hired a new MDS Coordinator, but she had not started working yet. The DON stated the nursing administrative team had been trying to update and initiate the care plans but had not accomplished the goals. She was not aware Resident #62's care plan was not initiated to reflect the goals required to care of her, to include nutrition and medication. Review of the facility's only policy titled Charting and Documentation dated October 17, 2023, reflected the following: All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological, shall be documented. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 4 residents (Resident #32 and Resident #43) reviewed for care plans. The facility did not update Resident #32's care plan to reflect specific instructions for hospice and end of life. The facility did not update Resident #43's care plan to reflect specific instructions for hospice and end of life. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs. The findings were: Review of Resident #32's MDS annual assessment dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE]. His diagnoses included Parkinsonism (neurological disease), atrial fibrillation (heart rate dysfunction), and mild protein calorie malnutrition. Her BIMs score of 3 reflected her cognitive status was severely impaired. She required moderate to maximum assist of one staff member for activities of daily living. Section O of the MDS was marked for Hospice Care. Record review of the Physician's orders for Resident #32 dated 05/26/23 reflected to admit to Hospice services. Record review of Resident #32's Care Plan initiated on 08/31/23 reflected, there were not a care plan goals to reflect specific instructions for hospice services. Review of Resident #43's MDS annual assessment dated [DATE], reflected he was an [AGE] year-old male admitted on [DATE]. His diagnoses included: Hypertension (increased blood pressure), parkinsonism (neurological disease), dementia, and chronic obstructive pulmonary disease (unable to breath well). His BIMs score of 3 reflected his cognitive status was severely impaired. He required moderate to maximum assist of one staff member for activities of daily living. Record review of Physician orders Resident #43 dated 08/21/23 reflected to admit to Hospice services. Record review of Resident #32's Care Plan initiated on 08/31/23 reflected, there were not a care plan goals to reflect specific instructions for hospice services. Interview on 11/02/23 at 9:06 a.m. with the ADON revealed she, the other ADON, the DON and the floor nurses (charge nurses) were responsible for updating resident care plans. She further stated we (nursing administration) thought you might be talking to us about the care plans, we have no MDS nurse right now, we have one starting soon and the care plans are either behind or not started. The ADON stated the DON was aware and not having care plans initiated could lead to residents possibly not getting the care that was needed or recommended. Interview on 11/02/23 at 12:00 p.m. with LVN B reveled she did not update care plans, she was never told to update care plans. Interview on 11/03/23 at 8:20 a.m. with LVN A revealed he had worked at the facility since August of 2023, he had been told by the DON to update care plans if he had the time on the residents he oversaw. LVN A stated he had not had time to update any care plans. Interview on 11/03/23 at 1:34 p.m. with the DON revealed the MDS Coordinator was responsible for initiating and updating the care plan as needed. The DON stated the facility had hired a new MDS coordinator ,but she had not started working yet. The DON stated the nursing administrative team has been trying to update and initiate the care plans but had not accomplished the goals. She was not aware Resident #32's care plan was not initiated to reflect the goals required to care of her and concerning Hospice goals. Review of the facility's policy only titled Charting and Documentation dated October 17, 2023, reflected the following: All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological, shall be documented. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure two of the four handwashing sinks had a garbage receptacle next to the sink. 2.The facility failed to ensure food items in the refrigerators (4), freezers (4) and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the ice machine filters and vent/grate and outer surface was free from dirt and dust. 5. The facility failed to ensure the ice machine chute guard was clean. 6. The facility failed to ensure the ice cream in the ice cream freezer was covered. 7. The facility failed to ensure items not in their original containers were labeled and dated. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the small kitchen on 11/01/23 at 10:19 AM revealed the following: -The smaller kitchen area to the right of the main kitchen: -at handwashing sink #1 there was a black large rolling pallet on the floor with a gray dish drying/storing rack on top of it in front of the sink, blocking it. -There was no garbage receptacle next to the handwashing sink #1. -The ice machine had a plastic vent located on the front side of the machine, the vent slats and filters (2) had dirt and dust on them. Ice machine: around the ice machine, just above the ice chest compartment, there was a dried white calcified/hardened substance. -Ice Machine: the chute guard had 4 gray greasy smudges and the right lower corner of the chute guard had some dark colored specks. -Across from handwashing sink #1 was a prep table with a juice machine and cappuccino machine on it. On the table in front of the juice machine were several dried sticky shiny red spots. -The floor on the side of the room (right side) had dried stains of varying colors. -Next to the reach-in freezer, on a shelf near a side door leading out to the dining room: 2nd row from the top there were 2 small white bins with 3 drawers each. -Bin #1 (one on the left): Top drawer- there were white individual sugar packets, no received by date, no consumed by or discard by date. Middle drawer- blue individual zero calorie sweetener packets, no received by date, no consumed by or discard by date. Bottom drawer- green individual raw sugar packets no received by date, no consumed by or discard by date. -Bin #2 (one in the middle): Top drawer- yellow individual zero calorie sweetener packets, no received by date, no consumed by or discard by date. Middle drawer- tan individual sweetener packets, no received by date, no consumed by or discard by date. Bottom drawer- pink individual zero calorie sweetener packets, no received by date, no consumed by or discard by date. Bin #3 (one on the right): Top drawer- white individual pepper packets, no received by date, no consumed by or discard by date. Middle drawer- individual packets of ketchup, pepper, sweet & sour sauce, no label of item description, no received by date, no consumed by or discard by date. Bottom drawer- individual yellow mustard packets, no received by date, no consumed by or discard by date. -2-20 oz. bottles of ketchup, previously opened, there was no received by date, no opened date. -1-16 oz. clear condiment bottle with a white lid containing dry dark granulated material, there was no label of item description, no opened date, no consume by or discard by date. -1-8 oz. clear condiment bottle with a white lid containing a dry white granulated material, there was no label of item description, no opened date, no consume by or discard by date. -3rd row from top: Left bin- clear square bin with brown individual liquid creamer containers, there was no received by date, no opened date, no consume by or discard by date. -Middle bin- clear square bin with white individual liquid creamer containers, there was no received by date, no opened date, no consume by or discard by date. -Right bin- clear square bin with blue individual liquid creamer containers, there was no received by date, no opened date, no consume by or discard by date. -4th row from top: 1 small, opened box of granulated parmesan cheese packets, no received by date, no opened date, no consume by or discard by date. -1 medium, opened box with individual packets of iodized salt with a clear plastic bag with individual packets of iodized salt, previously opened. There was no received by date, no opened date, no consume by or discard by date on the bag or the box it was sitting in. -On prep. table next to the reach-in refrigerator was a clear 4-gallon container with a lid of a thick pale yellow soft formed material, labeled use by 7 days Prepped: 11/01/23 Discard: 11/07/23, no label of item description. -Large Shelf on left side of the small kitchen: 3rd row from top row: more than 10 boxes of various teas, previously opened, no received by dates, no opened dates, no consume by or discard by dates. -2nd shelf, closest to door, top row: -1- 2 lbs. bag of cappuccino mix, previously opened, wrapped in plastic wrap, no received by date, no opened date, no consume by or discard by date. Observations of the Ice Cream Freezer on 11/01/23 at 10:40 AM revealed the following: -1 Extra-large container of strawberry ice cream with a lid, the left side of the lid was up, exposing the ice cream to air. -5 Extra-large containers of varying ice creams with lids, there was no received by date, no opened date, no consume by or discard by date. Observations of the Reach-in freezer on 11/01/23 at 10:52 AM revealed the following: -On a sheet pan there was a medium white foam cooler with dry ice and two orange sticky notes. The first note reflected, don't touch DRY ICE its dangerous to contact the second note read, ask FSD, -On the same sheet pan there was a white plastic bag tied close with a sticky note that had a person's name on it. -On the same sheet pan there was a chocolate chip cookie ice cream sandwich, there was no received by date, no consume by or discard by date. -2-35 oz. lemon meringue pies with lids, there was no received by date, no consume by or discard by date. -1 extra-large container of strawberry ice cream, there was received by date, no opened date, no consume by or discard by date. Observations of the Reach-in refrigerator on 11/01/23 at 10:54 AM revealed the following: -Right side door, top row: -1-12 oz. can of diet cola, no received by date, identifier, if for resident. 1-small clear square container with a green lid with shredded yellow cheese, labeled use by 3 days Prepped: 10/19/23 Discard: 10/22/23, no label of item description and passed its facility set expiration date. -1- small clear square container with ranch dressing packets, there was no received by date, no consume by or discard by date. -2nd row from top: 3-2 pack 42.2 oz. cartons of liquid decaf coffee, no received by date, no consume by or discard by date. -1-2 pack 42.2 oz. cartons of liquid caffeinated coffee, no received by date, no consume by or discard by date. -2 medium white bowls of lemon pieces covered with plastic wrap, labeled use by 3 days Prepped: 10/30/23 Discard: 110/01/23, no label of item description. -3rd row from top: -1 full size sheet pan covered in plastic wrap, with 22 white and 4 black small bowls, containing a swirled pale-yellow formed material, labeled use by 3 days Prepped: 11/01/23 Discard: 11/03/23, no label of item description. -4th row from top: -1 full size sheet pan covered in plastic wrap with 10 small black bowls of a thick white creamy material and yellow shredded cheese and a thick pale yellow thick material, use by 3 days Prepped: 11/01/23 Discard: 11/03/23, no label of item description for each item in the bowl, no individual consume by or discard by dates for each item in the bowl. -On the same sheet pan, 10 mini stainless-steel containers with chopped bacon, no label of item description, no consume by or discard by date. -1 large clear square container covered with plastic wrap that had multiple small clear plastic 2 oz. condiment cups with lids, contained varying colored and thickness of substances. There was no label of item descriptions, no received by, no opened date, and no consume by or discard by for each item or group of same items noted. -1-35 oz. lemon meringue pies with lids, there was no received by date, no consume by or discard by date. --35 oz. previously opened lemon meringue pie with lid, there was no received by date, no opened date, no consume by or discard by date. -Left side door, 4th row: -2-118.4 oz. plastic container of cranberry juice from the juice machine, no received by date, no consume by or discard by date. Observations of the Main Kitchen on 11/01/23 at 10:59 AM revealed the following: -Handwashing sink #3, near entrance door, has no garbage receptacle near it or next to it. -On shelf next to reach-in refrigerator, top row: -1 small square clear container with a lid containing 00 pizza flour, labeled: Use by 14 days Prepped: 09/12/23 Discard: 09/25/23. -1 small square clear container with a lid containing brown dry coarse light brown crumbs, labeled, Use by 5 days Prepped: 09/28/23 Discard: 10/02/23, no label of item description. -On 2nd row from top row: 1 medium clear square containers with a lid containing croutons, labeled, Use by 30 days Prepped: 10/30/23 Discard: 11/28/23, no label of item of description. -1 large clear square containers with a lid containing croutons, labeled, Use by 30 days Prepped: 10/30/23 Discard: 11/28/23, no label of item of description. -1 large square clear container with a lid containing croutons labeled: Use by 5 days Prepped: 10/31/23 Discard: 11/04/23, no label of item description. Observations of the Reach-in refrigerator #2 on 11/01/23 at 11:01 AM revealed the following: -3rd row from top: -Medium clear square container with a lid containing a thick white liquid labeled use by 30 days Prepped: 10/18/23 Discard 11/16/23, no label of item description. -1-64 oz previously opened, plastic container of cranberry juice, dated 09/21/23, no opened date, no consume by or discard by date. -Top row: -2-16 oz. plastic containers with lids contained honey vinaigrette labeled, use by 7 days Prepped: 09/11/23 Discard: 09/17/23. -4th row from top: -1 5lb previously opened white plastic tub with a lid of creamy peanut butter, labeled use by 30 days Prepped: 09/23/23 Discard: 10/22/23. -1- 32 oz. cylindrical stainless-steel pan of baked beans covered with plastic wrap, labeled use by 3 days Prepped: 09/19/23 Discard: 09/21/23, and no label of item description. -1 medium square clear container with a lid containing a thick red liquid, labeled, Prepped: 10/31/23 Discard: 11/09/23, there was no label of item description. Observations of the Walk-in refrigerator #3 on 11/01/23 at 11:28 AM revealed the following: - 1st shelf, to the right of the door, 2nd row from the top row: -1 extra-large clear rectangle container with various bags of different colored tortilla products: 1- large clear plastic bag, previously opened, of red triangle tortilla chips. There was no label of item description, no received by date, no opened date, no consume by or discard by date. -2 small bags of more than 20 medium purple tortillas, no label of item description, no received by date, no consume by or discard by date. - 1 small bag of more than 20 medium purple tortillas, with a large tear in the bag, left opened to air, no label of item description, no received by date, no opened date, no consume by or discard by date. -Approximately 15 small bags of more than 20 medium tortillas, no label of item description, no received by date, no consume by or discard by date. -5th row from top: -1 extra-large clear square container with a sheet pan placed on top for a lid; it contained 3 bags of whole peeled potatoes; the pan did was up on the left side leaving the potatoes open to air. There was a whole in one of the bags, no label of item description, no opened date. Observations of the Dry Storage Room on 11/01/23 at 11:43 AM revealed the following: -1 medium box with more than 10-24 oz bags of vanilla pudding mix, previously opened, no received by date, no consume by or discard by date, no manufacturer's expiration date. -Last shelf on left side in the back, bottom row: 1 extra-large clear square container with a lid contained yellow cornmeal, labeled opened 07/05/23, there was no label of item description, no received by date, no consume by or discard by date. -1-50 lbs. bag of triple cleaned pinto beans, previously opened, labeled opened 10/23/23, bag left open to air, no received by date, no consume by or discard by date. -3rd row from top: -1-3-gallon clear plastic container with a lid contained white rice, labeled opened 09/17/23, no label of item description, no received by date, no consume by or discard by date. Observations of the Walk-in freezer #2 on 11/11/23 at 11:37 AM revealed the following: -Shelf near the door on the right side, bottom row: a large box of various types of breads in a clear plastic bag, left open to air, no label of item description, no received by date, no opened date, no consume by or discard by date. In an interview on 11/01/23 at 011:40 AM with the Sous Chef, she stated the EC received the inventory, sous chefs, there are 3, dispersed inventory to assigned areas. Then the porter placed the inventory in the areas and on the shelves. The Sous Chef stated they used First in First Out (FIFO) system. In an interview on 11/03/23 at 02:50 PM with the EC, she stated personal items were not allowed in the areas (refrigerators, freezers, dry storage, prep. areas) with food items for the residents. She stated condiments, once opened, like the ketchup, were kept for no more than 30 days. The EC stated the AM Sous Chef, and the Lead cook did the inventory. She stated it was everyone's job in the kitchen to check for outdated/expired food items. She said, it is everyone's job to do the labeling. She stated it was the Dietary Aides' responsibility to know the residents' diets/allergies/likes and dislikes. The EC stated leftovers were kept in the refrigerator for 3 days and opened items were kept in the freezer for 3 months. She stated they put opened dates on opened items when they are initially opened. When she was shown the plastic bag in the freezer with a name on it, she told one staff member we need to find out who (person's name on the bag) is . She stated they would do an in-service and the Chefs and Leads will do monitoring to ensure the subject matter of the in-service (labeling, securing closed, dating, etc.) will be put into practice. The EC stated cross-contamination was a risk/harm to residents regarding the vents and filters being dirty. Review of the facility's Food and Nutrition Services Policy dated October 17, 2023: Revised 08/29/23, reflected A Director of Food and Nutrition will be designated to oversee all food and nutrition services with frequently scheduled consultation from a qualified dietitian or other clinically qualified nutrition professional. Food and Supplies Storage: Service Standard: Supplies for 7 days of staple food and 2 days for perishable food will be kept on hand. Food and supplies will be stored according to current standards of practice. Procedure: Safe Food Storage: General standards for food storage will include the following: 1. Dry Food Storage should be maintained in a clean and dry area free of contaminants.2. Refrigerator Storage Safe Practices include: . d. Labeling, dating and monitoring foods. Food Safety: . 6. Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. 7. Refrigerator in resident rooms must be monitored by the facility staff for adequate temperature and expiration dates of food. 9. The facility will follow food-handling practices in the distribution of the food. 10. The community will make effort to assure the safe consumption of food. Sanitation: Service Standard: [NAME] strives to prepare, distribute, and serve food under sanitary conditions. Procedure: 1. Food is prepared, distributed, and served to resident under sanitary conditions.3. Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. 4. Safe food handing for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section 5-205.11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section 5-501.16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. (C) If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories. Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

**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 instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #15 and Resident #145) of four residents reviewed for base line care plans. The facility failed to complete Resident #15 and Resident #145 baseline care plan within 48 hours of admission that included the minimum required healthcare information of initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. This failure placed residents at risk of not receiving effective and person-centered care. Findings included: Review of Resident #15's undated Face Sheet, reflected she was a [AGE] year-old female admitted to the facility on [DATE] . Her diagnoses included unspecified fracture of lower end of right femur( thigh ) pain in right leg, history of falling, muscle weakness, difficulty in walking, hypertension, and nausea with vomiting. Review of Resident #15's Initial Care Plan, dated 06/28/22 reflected Resident #15 had the potential for infection. The care plan did not address physician orders, dietary orders, therapy services, and social services. Review of Resident #145's undated Face Sheet, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included encounter for other orthopedic aftercare, displaced fracture of the right thigh, pain in right hip, history of falls, muscle weakness, difficult in walking, hypertension, and diabetes due to underlying condition with hyperglycemia, excess of glucose in the bloodstream. Review of Resident #145's Initial Care Plan, dated 08/30/22 reflected Resident #145 was a fall risk. The care plan did not address physician orders, dietary orders, therapy services, and social services In an interview on 09/08/2022 at approximately 1:00 pm with the DON, she stated care plans are initiated and completed by the charge nurse upon a resident's admission into the facility and she tracked for completion. The DON did not state how she tracked care plans. The DON stated she became aware of incomplete baseline care plans today and she and the ADON were in the midst of auditing all care plans and would in-service clinical staff on the importance of creating and completing care plans timely and completely. The DON would not state the potential risk(s) posed to the residents by not having a care plan. Review of the facility's New admission Assessment policy, revised 04/26/22 reflected After admission, the following departments will assess the resident: 1. Nursing (RN/LVN) will conduct an initial nursing assessment. 2. Activities will conduct an evaluation of resident activity needs and preference. 3. Dietary Services will conduct an evaluation of resident food allergies, likes, and dislikes and 4. Social Services will conduct a social services assessment. The information will be used in the development of the resident's care plan