Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. Cook I failed to wear a hair restraint while in the facility's kitchen on 03/25/25. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 03/25/25 at 7:00 AM revealed [NAME] I not wearing a hairnet while in the kitchen. [NAME] I was observed to be walking around the kitchen where food was being cooked. [NAME] I's hair was down with the length of her hair reaching her neck area. Interview on 03/25/25 at 7:15 AM with [NAME] I revealed the first thing the staff were required to do upon entering the kitchen was to put on a hairnet restraint. She stated she had arrived at her shift a quarter before six and noticed salads were not prepped, and she got overwhelmed and began to prep the salads. She stated she got busy and forgot to put on a hairnet. She stated the potential risk of not wearing a hairnet could be hair falling inside the food. Interview on 03/25/235 at 10:58 AM with the Nutrition Services Manager revealed all staff must wear a hairnet upon entry of the kitchen. She stated hairnets and beard nets were located at each entrance of the kitchen. She stated the risk of not wearing a hairnet would be contamination and hair falling on the food. Record review of the facility's Uniform Dining Services policy, revised November 2024, reflected: Hair . must be pulled up and contained in a hair net. Record review of the Federal Food Code 2022 reflected: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation . (4) Removing all unsecured jewelry . (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints . (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on observations, interviews, and record reviews, 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 5 of 19 residents (Residents #11, #18, #19, #33 and #94) reviewed for infection control. MA A failed to sanitize a reusable blood pressure cuff between uses on Residents #11, #18, #19, #33 and #94. This failure could place residents at risk of cross contamination of infections from other residents. Findings included: Observation of medication administration in the East Tower by MA A on 03/26/25 from 7:01 AM to 8:10 AM revealed she did not sanitize her re-useable blood pressure cuff between blood pressure checks for Residents #11, #18, #19, #33 and #94. Record review of Resident #94's EHR revealed she was on Enhanced Barrier Precautions due to having an open wound. Interview on 03/26/25 at 8:10 AM with MA A revealed she did not usually check resident blood pressures. She stated the nurses normally did it because she was the only medication aide for the entire facility. She stated she was checking blood pressures due to her nurse being behind schedule. She stated she knew the cuff should be sanitized between each resident. MA A stated the risk to residents if the blood pressure cuff was not sanitized was that it could expose the residents to germs from other residents. Interviews on 03/27/25 from 11:00 AM to 11:41 AM with RN B, CNA C, CNA D, CNA E, CNA F, CNA G and RN H revealed they had been in-serviced on 03/26/25 by the ADON about sanitizing cuffs between resident use. They all stated the cuff had to be sanitized between residents to avoid cross contamination from one resident to another. Interview on 03/27/25 at 11:48 AM with the ADON revealed MA A notified him that she had not sanitized the blood pressure cuff between resident uses, so he provided an in-service training to all nurses and CNAs. He stated the cuff had to be sanitized with disinfecting wipes and left to dry for one minute to avoid cross contamination between residents. Interview on 03/27/25 at 11:55 AM with the DON revealed any equipment that was shared between multiple residents had to be sanitized between uses to avoid cross contamination between residents. Record review of the facility's Infection Control Standard Precautions policy, dated March 2022, reflected: .3. Resident-Care Equipment .b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned, disinfected, and reprocessed .

Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 4 of 4 reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Interview on 02/07/24 at 1:56 PM with the Activity Director revealed the resident council meeting would be held in the bird room which is the living/lounge room. She stated it was the best place with the most privacy. She stated she would keep a watch on the hall to make sure staff were aware of the meeting. Observation and interview on 02/07/24 beginning at 2:00 PM, during a confidential resident group meeting with four residents, revealed the meeting was held in the living/lounge room. There were no doors to close off the room. A sign was posted to indicate that a confidential meeting was being held. However, multiple staff and visitors walked through the hall to get to another hall and entering/exiting the elevators located across the living/lounge room. Also, the nurses' station was located next to the lounge room. During the confidential group meeting, three residents revealed the meeting was held each month in the dining area. While the meeting was being held, a confidential resident proceeded to state No privacy here while staff were exiting the elevator. The residents stated they were used to having staff around during their resident council meetings. Interview on 02/08/24 at 12:07 PM with the Activity Director revealed resident council meetings were held in the dining room area or at times in the living/lounge room. She stated after they completed an activity she would conduct a resident council meeting. She stated she would get more participation when residents were in the dining room. She stated normally four to five residents attended the resident council meetings monthly. She stated the facility did not have a private room area. However, since the census lowered in the last three weeks, they had rooms available. The Activity Director stated all the residents who participated in the resident council meetings monthly felt comfortable talking and there were no potential risks. Interview on 02/08/24 at 1:45 PM with the Administrator revealed the resident council meetings were always held in the dining room or in the bird room living/lounge room. She stated her expectations were for residents to be comfortable during meetings and if they wanted the meeting to be held in the dining room it should be respected. She stated she was not aware that the resident council meetings needed to be in a private area. She stated it had never been brought up to her attention. Record review of the resident council minutes for October 2023 through January 2024 revealed no requests for a private area. Record review of the facility's Resident Council Meetings policy, revised August 2013, revealed in part the following: It is the policy of the Company, when a resident(s) wish to organize a group meet, the facility will allow them to do so without interference. 1. The facility will provide the group with a private place to meeting

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all biologicals, to meet the needs of each resident for 2 of 4 glucose test strips reviewed for pharmacy services. Staff failed to remove expired glucose test strips, used to check residents' blood glucose levels, from the nurse medication cart. This failure could place the rresidents at risk of inaccurate blood testing results. Findings included: Observation on [DATE] at 10:00 AM of Nurse Medication cart revealed two vials of glucose monitoring strips had expired on [DATE]. The strips had been marked with an opening date of [DATE], which was two days after they had expired. Interview on [DATE] at 10:05 AM, LVN A stated she had not checked the glucometer strips recently because none of the residents on her hall required finger stick glucose monitoring. LVN A stated the nurse that opened the new vials should have checked for their expiration date. A new vial is marked with the opening date because they are only good for 30 days after they have been opened. LVN A stated using expired test strips could lead to an erroneous reading from the glucose monitor. Interview on [DATE] at 11:00 AM, the DON stated her expectation was for the nurses not to place expired test strips, or anything expired, on their carts. The test strips were checked weekly for acuracy when the glucose meter was checked for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 (Medication Aide Cart) of 6 carts reviewed for pharmacy services. The facility failed to ensure MA-B secured her medication cart before walking away from it. This failure could allow residents to access medications not prescribed to them. Findings included: Observation on 02/08/24 at 10:30 AM revealed the medication aide's cart for the [NAME] Hall was unsecured. All of the drawers were able to be opened without the use of a key. Drawers contained both over the counter medications as well as prescribed medications. Interview on 02/08/24 at 10:35 AM, MA B stated she secured her cart before walking away, but she might not have pushed the button all the way in. MA B stated they had a problem a couple of weeks ago of carts not locking but she thought they had been repaired. She stated the risk of the cart being left unsecured was a resident getting a medication not prescribed for them. Interview on 02/08/24 at 11:10 AM, the DON stated the pharmacy company sent a tech out the previous week to work on two carts that were not securing properly. The DON stated she thought MA B's cart was one of the carts that was looked at. The DON stated the risk of a cart being left unsecured was a resident getting medications not prescribed for them and possibly having side effects that could be life threatening. Review of the facility's Medication Administration policy, dated February 2024, reflected: .5. Controlled drugs must be placed under lock and key immediately after they have been inventoried .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate documentation and disposition of controlled substances for one of two medication carts (Med Cart #2) reviewed for pharmacy services. The facility failed to remove Resident #1 discontinued meds from the Med Cart #2. These failures placed the residents at risk for diversion of controlled substances. Findings included: Record review of Resident #1's admission Record dated 12/07/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke and dementia with difficulty swallowing related to stroke. Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 09 indicating he had moderate cognitive impairment. His Functional Status indicated he required assistance with all his ADLs. Interview with MA C on 12/07/23 at 11:24 AM revealed that the medication carts controlled medication boxes on the medication carts should be audited and signed off between the oncoming and off-going nurse/medication aide at every shift change. Observation on 12/07/23 at 11:57 AM of Controlled Drugs Count Record for the month of December 2023 for medication cart #1 revealed shift change count was documented correctly by off-going nurse/MA and on-coming MA/Nurse for 3 residents for all shift changes. Observation on 12/7/2023 at 12:05 PM and record review for medication cart #2 revealed (3) .5 mg of Lorazepam were in the locked narc otics box and counted for Resident #1. Resident #1's Lorazepam was discontinued 3 days prior. All the Lorazepam were accounted for. However, per policy, the resident's Lorazepam should have been taken to the DON when it was discontinued. Interview with DON on 12/7/2023 at 1:30 PM revealed that the Lorazepam should have been removed from the medication cart when it was discontinued. The DON acknowledged that a system failure occurred, and numerous shift changes failed to remove the discontinued controlled medication from the locked box and take it to her to place in the medication destruction box. Interview on 12/7/2023 at 1:46 PM with LVN B revealed that the controlled meds boxes on the medication carts are supposed to be audited and signed by the oncoming and off-going nurse/medication aide at every shift change. She also stated that this is facility policy. When asked if there were (3) .5mg Lorazepam that were in the drawer and on the controlled meds count for Resident #1, she confirmed there were. She stated they counted them in the shift change controlled meds count. When asked if they were supposed to be in the drawer, she stated, No. She went on to explain that the Lorazepam had been discontinued, but not taken to the DON. Review of facility's current Medication Administration: Controlled Drugs Record Keeping-SNF policy, dated February 2021, reflected: .3. The nurse receiving them will inventory and document receipt .4. Controlled drugs must be placed under lock and key immediately after they have been inventoried and the form for each medication has been signed and received. Review of facility's current Narcotic Count policy, dated February 2021, reflected: .1 At end of every shift .between oncoming and off-going staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to secure all controlled medications. LVN A failed to secure controlled medication behind a double lock by placing it in an unsecured cabinet in the medication room. This failure placed residents at risk of their controlled medications being misappropriated and thereby worsening their medical condition. Findings included: Record review of Resident #2's care plan, dated 11/21/23, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of hip replacement. Record review of Resident #2's annual MDS, dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15. Her Functional Status indicated she required assistance with all her ADLs. Interview on 12/07/23 at 8:55 AM with DON revealed the resident was admitted on [DATE] by LVN B. The DON stated Resident #2 came from home with bag of medications all inside their bottles. The DON said that LVN B told Resident #2 that she couldn't keep the medications in her room. So LVN B counted the medications in each bottle, wrote the number of each one on the bottle, and then placed them bag in the sack. The DON stated LVN B did not create a count sheet for the Oxycodone (controlled medication). LVN B then locked the bag of medications in the controlled medications box on the medication cart. The DON revealed Resident #2 told LVN B that her family was coming that evening, and she would pick up the sack of medications at that time. However, Resident #2's never arrived that evening. The DON revealed on 10/30/23 LVN A removed the bag of medications from the locked box on the cart and placed them in an unlocked cabinet in the medication room. On 11/1/2023, Resident #2's asked for Resident #2's meds. LVN A went to retrieve the sack of medications, and it was not in the cabinet. The bag of missing medications was never located by the facility. The DON stated their consultant Pharmacist is involved. The Pharmacist said to reconcile and do a controlled meds dispense report which the DON completed. The DON stated the facility policy states that if a resident brings medications from home, the family should take the medications back home. Policy, per DON, also stated that if family doesn't take medications back home immediately, the medications are to be destroyed. The DON revealed home medications that were controlled medications were supposed to be counted and documented on the controlled medications sheets. The oncoming nurse/MA counts the controlled medications with off-going nurse/MA and they each sign the narc sheet. The DON revealed that LVN A did not follow this policy, which could possibly have led to the missing controlled medications. The DON stated there wasn't a negative impact to the resident. However, she stated that the facility did owe Resident #2 re-imbursement for the missing medication. The DON stated that Resident #2 was updated on the process. Observation on 12/07/2023 at 9:55 AM revealed medications for destruction are kept in the DON's office. They were observed to be under two locks in DON's office. The discontinued drugs log showed they were destroyed monthly when the pharmacist comes with the DON and pharmacist. They were last destroyed on 11/13/2023. Interview on 12/7/2023 at 10:43 AM revealed LVN A said she saw a bag of medications in her medication cart (not in the locked compartment). LVN stated that on 10/30/2023 she took the bag of medications (without looking inside the bag) and put the bag in the medication room in an unlocked cabinet. LVN A stated that the following day the family arrived to pick up the medications. LVN A went to retrieve the medications, and they were not in the cabinet. She stated she saw the bag of medications only once. She also revealed she should have looked in the bag. LVN A stated that if she would have opened the bag, she would have seen the controlled medication. Then she would ask another nurse to count and put them on the controlled medications sheet and reported it to the DON per policy. After this occurrence she was in-serviced. Since she has been here has been in-serviced on controlled medications twice. LVN A stated controlled medications should be stored in the medication cart in the lock box. LVN A said controlled medications should be always under two locks. She confirmed the bag of medications was placed in the locked medication room in an unlocked cabinet. She revealed only the MA's and nurses have access to the med room. Interview on 12/07/23 at 3:48 PM with LVN B revealed she admitted Resident #2 and completed the assessments on 10/27/23. LVN B stated that Resident #2 had brought a sack of her medications from home. LVN B stated that the sack of medications included: Over the counter medications, vitamins, and a 30-day supply of Oxycodone. Resident #2 said she would have her family come and pick up her sack of medications and take them back to her home. LVN B then called Resident #2's family and requested that she pick up Resident #2's medications The family member said that she would come that night to see the resident and pick up the medications. LVN B stated she then counted the Oxycodone and put the number of the pills in the bottle on the bottle along with each of the other bottles of medications accordingly. LVN B stated she then put the bag of medications in the lock box on the cart. LVN B revealed she should have made a count sheet for the Oxycodone because it was a narcotic. She stated she did not make a count sheet because she thought was going to pick up the medications that evening. She also stated she knew the resident would not be using the Oxycodone brought from home because the facility would provide any medications that were needed. LVN B then stated that was the last time she saw the sack of medications. LVN B stated there was a risk of misappropriation to the resident because it was not counted. And it was taken from the resident ultimately. LVN B stated it was her responsibility to place the controlled medication on the count sheet. LVN B stated the facility policy says to keep track of the meds. LVN B stated she did not think that anybody would steal it. She thought that a family member would come and take it home that evening and that the medications would not be kept in house. Review of facility's current Narcotic Count, Conducting policy, dated April 2022, reflected: .2.c .narcotics are to remain in the narcotics/bin drawer and counted during each count until they are appropriately destroyed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #36) of one resident reviewed for wound care, in that: LVN A failed to complete the treatment for one wound at a time, to change gloves and perform hand hygiene appropriately, and to clean her scissors while providing wound care for Resident #36. These failures could place residents with wounds at an increased and unnecessary risk of cross contamination causing possible complications such as pain, worsening of existing wounds, and infections. Findings included: A review of Resident #36's admission Record dated 12/22/22 revealed a [AGE] year-old male re-admitted to the facility on [DATE]. Resident #36 had diagnoses of atherosclerotic heart disease of native coronary artery (plaque build-up in the coronary artery), chronic kidney disease stage 3, acute osteomyelitis (inflammation in bone caused by infection) right ankle and foot, stage 4 pressure ulcer of right heel, and unstageable pressure ulcer of left heel. A review of Resident #36's admission MDS dated [DATE] revealed his BIMS score was 15, which meant he had no cognitive impairment. The admission MDS reflected he required extensive assist of 2 plus staff for bed mobility, transfers between surfaces, dressing and toilet use. This document further revealed he had a stage 4 pressure ulcer of his right heel and an unstageable pressure ulcer of his left heel A review of Resident #36's care plan revised on 10/11/22 indicated problem, goals, and interventions: -Problem: The resident has unstageable pressure ulcer to right heel and a left heel stage II of the left heel r/t disease process coronary artery disease, acute kidney disease, anemia, and immobility. -Goal: The resident's pressure ulcer will show signs of healing and remain free of infection through review date of 02/15/22. -Interventions: Administer treatments as ordered and monitor effectiveness. Follow facility policies and procedures for the prevention/treatment of skin breakdown. A review of Resident #36's Wound Evaluation dated 12/19/22 reflected, unstageable pressure ulcer of the left heel that measured 1.41 CM length X0.94 CM width. It also revealed the ulcer had a stable progress. The wound eval further revealed a Stage 4 pressure ulcer of his right heel that measured 3.75 length CM X 2.75 CM width and it had a wound bed of slough (necrotic tissue that needs to be removed) with a light amount of exudate (drainage). A review of Resident #36's Medication Review Report reflected an order dated 12/13/22 for: Wound #1: Cleanse left heal wound with N/S, pat dry. Apply Silver Alginate dressing, and cover wound with bordered gauze dressing every day shift related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE (L89.620) AND as needed related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE (L89.620) If dressing becomes soiled or dislodged. A review of Resident #36's Medication Review Report reflected an order dated 12/13/22 for: Wound #2: Cleanse Right Heel wound with N/S, pat dry, Cover with Silver Alginate, ABD pad, wrap with Kerlix and secure with tape every day shift related to PRESSURE ULCER OF RIGHT HEEL, STAGE 4 (L89.614) AND as needed If dressing becomes soiled or dislodged. An observation on 12/22/22 at 11:25 AM revealed LVN A, after removing Resident #36's bilateral soft boots and placing them under his lower legs, she opened and placed a chuck (A disposable incontinent pad) under his feet. LVN A removed the island dressing from Resident #36's left heel which left the silver alginate dressing stuck to the wound bed. LVN A picked up her scissors and cut through the kerlix wrap on Resident #36's right foot, took it off with the ABD pad and placed them on the chuck under his feet. The silver alginate dressing remained stuck to the wound bed on his right heel as well. LVN A washed her hands, gloved, took a 4X4 gauze and NS bullet, wet the gauze and cleaned Resident #3's left heel wound, removing the silver alginate dressing. Without changing her gloves or performing hand hygiene, LVN A got another 4X4 gauze , wet it using a NS bullet, placed it over the right wound with silver alginate stuck to wound. LVN A Held it there for a few moments then held it against the silver alginate on his right heel wound bed, then worked the silver alginate off. LVN A used another 4X4 gauze , wet it with the NS and cleaned the right heel wound again. LVN A then changed her gloves and sanitized her hands, picked up the scissors, and without sanitizing them, opened the silver alginate dressing and cut it to the size of the left heel wound and stuck it into the wound bed then placed an island dressing over it. LVN A, without changing gloves and performing hand hygiene, picked up the silver alginate dressing and placed it into the right wound bed, put an ABD pad over it, then used a gauze roll to wrap Resident #36's foot, and taped it at the end. An interview on 12/22/22 at 12:05 PM with LVN A, after asking about doing the wounds together, said this was only her second time working with Resident #36, she was an agency nurse, did not do wounds very often and had never done them with state observing. When asked about the scissors she stated I realized as soon as I cut the silver alginate that I should have cleaned them first to prevent contaminating the wound, but it was already done so she had continued. An interview on 12/22/22 at 12:40 PM revealed the DON expected her staff to wash their hands, after cleaning the table, set up their supplies, wipe their scissors before starting and after cutting a bandage off, before cutting another clean dressing so there was no contamination. The DON stated if there were multiple wounds, they should do one wound at a time, to prevent cross contaminating the wounds. The DON stated she also expected her staff to wash their hands before they started, between dirty to clean tasks/areas, and if they were visibly soiled. After explaining what LVN A had done, the DON said she was going to send in one of the facility's nurses, but figured they needed to see what the agency nurse knew. She said they were nurses so they should know the correct way to do things. An interview on 12/22/22 at 1:40 PM the DON said they were starting check offs with all the nurses including the agency nurses on wound care and multiple wounds. She also said she had talked with LVN A who told her she knew she had done wrong, but she was nervous and did not know what to do. The DON said she told LVN A she could have started over on the wound care if nothing else. The DON said they do have checkoffs with the agency nurses when they come to work the first time, but they were going to redo them with all nurses now. Review of the facility's Licensed Nurse Competency Checklist for LVN A dated 11/16/22 revealed: 8. Performed hand hygiene, put on gloves. 9. Removed dirty dressing and place in plastic bag. 10. Removed gloves and placed in plastic bag. 11. Performed hand hygiene. 12. Put on gloves. 13. Performed treatment . 15.Removed gloves and place in plastic bag. 16. Performed hand hygiene/Clean scissors or other equipment. Review of the facility policy and procedures for Skin-Wound Issues last revised 11/2015 revealed: .wash and dry your hands thoroughly .Put on gloves .Apply dressings as indicated .Clean and disinfect reusable supplies ( .scissor blades .) with alcohol or other disinfectant as indicated.