**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident was free from misappropriation of all controlled drugs is maintained and periodically reconciled for 1 (Resident #3) of 7 residents reviewed for controlled substances. The facility failed to ensure LVN B conducted proper counting of the medications at shift change. The facility failed to ensure LVN B reported an identified drug discrepancy for Resident #3. This failure may put the residents at risk of drug diversion and their pharmaceutical needs not being met. Findings included: Record review of Resident #3's electronic health record revealed an [AGE] year-old female, admission date 07/03/24. Diagnoses: congestive heart failure (heart doesn't pump blood as well as it should), type 2 diabetes (adult-onset diabetes), presence of cardiac pacemaker (device provides electronic pulse to heart as needed to regulate heart rate), senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills), muscle wasting and atrophy (loss of muscle mass and strength). Record review of Provider Investigation Report 573259 dated 3/25/25 revealed blister packet on medication room counter at 6:16am on 3/25/25 by LVN C. LVN C inquired with off going night nurse (LVN B) to inform her the count was off. LVN B stated that she noted it during the night but did not want to wake the previous nurse (LVN A). LVN A stated she was not aware and did not administer the med. LVN C reported to DON and ADM . Search initiated and all other narcotics accounted for. Police notified and began drug screening. LVN B did not show up for drug screen and others tested negative. Self-termination for failure to report timely for drug screening. Reviewed Narc count sheet and revealed the count at 21. Staff re-educated. Statement from LVN A revealed LVN B would not count with her upon shift change the evening of 3/24/25 but LVN A counted on her own and it was correct. Record review of written statement dated 3/24/25 by LVN B revealed Resident #3's Tramadol was 1 tablet short. Resident #3 had passed away at 8:45pm that evening and her hospice nurse showed up at shift change so they never counted. Record review of written statement dated 3/26/25 by DON revealed medication count for Resident #3 Tramadol was off by one tablet. Count sheet said 21 but actual count was 20. Medication card located in locked cabinet but not in basket. LVN B verbalized to LVN C she knew the count was off and she thought LVN A had given it and forgot to write it down. LVN A stated she did not. LVN B stated she counted at 2am and realized the difference in count. DON received text from LVN B stating she had counted cabinet with LVN A but not lock box because hospice was there, and she didn't get to. Did not want to call LVN A in the night. DON contacted LVN B at 1:20pm and told her she needed her to come write a statement and do urine screen and she said she would be right in. At 3:05pm, DON text LVN B again asking when she would be coming and to come as soon as possible. As of 6:38pm, ADM nor DON have had conversation with LVN B. Record review of written statement dated 3/26/25 by LVN C revealed she went into med room to count meds at 6:15am on 3/25/25. Resident #3 tramadol was sitting with the count sheet folded over it next to the basket of narcotics. I pulled it first and noticed the count was off by 1. LVN C asked LVN B why it was short, and she stated she noticed last night about 2am and thought LVN A who worked forgot to sign it out and didn't want to text her in the middle of the night. LVN C told her she would get with LVN A to ask her. LVN C asked LVN A, and she stated no. LVN C then took it to DON. Record review of statement dated 3/26/26 from MA B stated on 3/23/25 she gave Resident #3 her morning meds of tramadol and her meds were discontinued shortly after, so she didn't give her anymore. MA B counted after 6am-2pm and 2pm-10pm shift and count was correct. Record review of written statement dated 3/26/25 by LVN A revealed on 3/23/25 she was notified that Resident #3 would be on hospice care. At this time during 6am-2pm shift maintenance meds had not been discharged . At that time, MA B and LVN A gave Resident #3's morning meds crushed in pudding. LVN A stated she was present, and Resident #3 took her medications without incident. After that scheduled dose of meds a new order from hospice came and it was to discontinue all maintenance meds, only comfort meds were to be given. The 23rd was the last time scheduled Tramadol was given. On 3/25/25 LVN A was notified by LVN B that Tramadol was off by 1 pill and had I administered another dose and I stated no. On the morning of 24th my count was correct. Evening of 23rd I counted with the other nurse and correct. Evening of 24th LVN B did not count with me. I counted for my own accountability. On the night of 3/24/25 Resident #3 passed away and LVN B came in after 8pm. We did not count together hospice nurse was there and we were answering her questions, but LVN A had counted. On, 3/25/25 - LVN B contacted me and asked had I used it for another patient. Record review of 5 Panel Test Result Records for LVN A dated 3/26/25 was negative. Record review of Resident #3's electronic record revealed Tramadol discontinued 3/23/25 and hospice care and comfort measures put in place. Record review of eMAR dated March 2025 for Resident #3 revealed last Tramadol given was 3/23/25 at 8am. Record review of Resident #3's electronic health record revealed she passed away 3/24/25 at 8:45pm. Family at bedside. In an interview on 5/10/25 at 11:25am with MA A, she stated she is not aware of any missing medications. Staff count the cart at change of shift with oncoming nurses. MA A stated they always count and have always had to count. They are no longer to keep the keys when going to another unit and must count and turn in the keys when going to another unit and again when coming back to the other unit, so the keys are always with the nurses. MA A stated that the key thing started a couple of months ago. MA A stated if the count is off, you immediately report to DON and ADM. In an interview on 5/10/25 at 12:10pm with RN, she stated staff count the carts and med rooms at change of shift. If there are any missing meds, they call the DON. It has always been the policy. RN stated when the missing medication happened, they tested everyone, and one nurse did not show, and she got terminated. No one tested positive. In an interview on 5/10/25 at 6:04pm with the ADON , she stated LVN B was notorious for being late, like an hour late, and staff never knew when she would get there so staff counted themselves because they have to be back for another shift. ADON stated she tried hard to get LVN B to come on time, but she always had excuses and they tried to get her to come do a drug test and she was too busy. ADON stated that LVN B never wanted to count meds. ADON stated LVN B was trained and counseled on the issues of being late and not counting meds several times, sometimes by ADON herself. In an interview on 5/11/25 at 11:25am with LVN A, she stated on 3/24/25 Resident #3 passed away and she remembers LVN B coming in and LVN A stated she stayed to help, and hospice had come in and LVN B was very late, and she did not count with LVN A. LVN A stated she herself did count anyway but LVN B said, No, we're good and so LVN A counted on her own and that was norm for LVN B. LVN A stated the count was accurate and she left. LVN A stated she was called in to do the urine test. LVN A stated she had been trained on counting at change of shift and that was the expectation. In an interview on 5/11/25 at 1:15pm with the DON, she stated staff count the med carts, the med rooms, and the discontinued meds which is in the med rooms at every change of shift. DON stated she was informed there was a missing tramadol and looked and ADM and DON couldn't find anything and started calling staff in to do drug testing and one of the staff, LVN B, was notified and she said she'd be in and never came in and notified her again several times and always had an excuse and it was 5-6 in the evening and the next message she got the next day she could come in and then still didn't come and had to go to the doctor to be drug tested but she just couldn't get her in and policy states they have 3 hours after the request to come in when made and she tried every opportunity to get her to come in and so she self-termed. DON stated she felt LVN B very well could have taken the pill because she wouldn't come in. DON stated Resident #3 passed away and that same night was when the pill went missing. DON stated they have monitored closely and in-serviced staff regarding counts and try to pull the discontinued medications off the units and staff have to count with her and they have to sign off on it. DON stated she went weekly to remove discontinued meds but did try to do it more frequently like 2-3 times a week. The tramadol for Resident #3 had just been discontinued the day before on 3/23/25 and Resident #3 passed away 3/24/25 and they noticed it was gone the morning of 3/25/25. DON stated she did random audits now and went behind staff now to make sure counts were done. DON stated she had been informed that LVN B would come late and refuse to do counts. DON stated she counseled LVN B and LVN B assured DON she was doing it. In a record review of Controlled Substances policy dated November 2022 revealed .Dispensing and Reconciling Controlled Substances .3. Nursing staff count controlled medications inventory at the end of each shift, using these records to reconcile inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of an investigation to the State Survey Agency within 5 working days of the incident for 1 (Resident #4) of 5 Residents reviewed. The Administrator failed to report the findings of an investigation concerning Resident #4 to the State Survey Agency within 5 working days of the incident. This failure could put the residents at risk of compromised protection and oversight of the state agency. Findings included: Record review of Resident #4's electronic health record revealed a [AGE] year-old female, admission date 02/01/25. Diagnoses: unspecified dementia (decline in cognitive function), senile degeneration of brain (progressive decline in cognitive abilities that occurs with aging), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), major depressive disorder (persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life), muscle weakness. Record review of the Provider Investigation Report dated 3/21/25 revealed Resident #4 was noted pounding on the secure unit door and was agitated but redirected. Staff looked in resident room during next round, within 30 minutes, and found the air conditioning unit on the floor and the window open. Staff began search of resident and located her in the secure unit courtyard area potentially hiding from staff within 30 minutes. No injury noted but agitated and resisting to come inside for breakfast. discharged to behavioral health hospital and staff in-serviced on missing residents. No investigatory findings noted in file. In an interview on 5/10/25 at 6:50pm with the ADM , she stated she did not submit a 5-day for the incident because she determined it was not an elopement. ADM stated she only reported because she was iffy (unsure) if she needed to and then came to the realization that elopement didn't happen. ADM stated that in her mind it didn't even need to be reported and the resident was never out of a safe environment, so she did not do the 5-day. The ADM stated the weather was mild and secure unit residents have access to that area, and it was safe. In an interview on 5/11/25 at 9:28am with CNA, she stated that a little after 6:00am she heard Resident #4 kicking the secure unit door and redirected her. CNA stated she was rounding getting residents up for breakfast and around 615am-620am, CNA went into Resident #4's room and saw the air conditioner on the floor and the window open and ran and told the nurse and started searching. CNA stated she walked all around outside and come to find out Resident #4 was in the garden area, and no one thought to look there for maybe 30 minutes. CNA stated Resident #4 never eloped and was safe. Record review of progress notes dated 3/21/25 at 7:10am revealed resident was found in secure unit courtyard, no injuries upon assessment. Resident is on one-on-one monitoring. Record review of progress note dated 3/21/25 at 11:00am revealed resident transported to behavioral health hospital. In an interview on 5/11/25 at 1:15pm with the DON, she stated that the ADM is responsible for completing the 5-day report. In an interview on 5/11/25 at 2:11pm with the ADM, she stated she reported the 5-day today. Record review of the facility's Abuse/Neglect policy dated 10/4/22 revealed Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist .1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC .f. The written report must be sent to HHSC no later than the fifth working day after the initial report.

Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 4 of 6 (SS Cart 1, SS Cart 2, SS Cart 3 and GV Cart) medication/treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication carts SS Cart 1 and SS Cart 2 were not left unlocked, unsecured, and unattended. The facility failed to ensure treatment carts, SS Cart 3 and GV Cart were not left unlocked, unsecured, and unattended. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: During an observation on 11/16/2024 at 12:15 PM and 12:30 PM SS Cart 1 and SS Cart 2 were parked against the wall with drawers facing the hallway , both carts were unlocked and were not in line of site of a staff. A resident was observed propelling himself in his wheelchair down the hall within arms length of SS Cart 1 and SS Cart 2. On the opposite hall SS Cart 3 was parked against the wall with the drawers facing the hallway unlocked and not in line of site of staff. SS Cart 1 and SS Cart 2 contained the following medications: Lasik, Levetiracetam, Losartan, Sertraline, Risperidone, Lisinopril, Tamsulosin, Baclofen, Trazadone, Mirtazapine, Fluoxetine, Fluphenazine, Divalproex, Metoprolol, Sucralfate, Gabapentin, Olanzapine, Bicalutamide, Eliquis, Rosuvastatin, Ranolazine, Buspar, Desmopressin, Albuterol, Mucinex, and Nasal Spray . SS Cart 3 contained the following items contained wound care creams (zinc oxide ointments, skin protectant ointment, and Vitamin A&D ointment) inhalers and eyedrops. During an interview on 11/16/2024 at 12:30 PM RN A stated she was not responsible for SS Cart 1 and SS Cart 2 and was not sure why the nurse did not secure the carts or where the nurse was at that time. RN A then secured the medications carts. RN A stated she was responsible for SS Cart 3 and she had gotten distracted by talking with a visitor and forgot to lock the cart. RN A stated residents could have been affected by the medication carts being left open by getting medications that were not theirs. During an interview on 11/16/2024 at 12:40 PM MA B stated she was responsible for SS Cart 1 and SS Cart 2, she stated she did not know why she had left the carts open. MA B stated medication and treatment carts should have been locked when she was not with them. MA B stated the affect on residents could have been possible overdose. MA B stated she was responsible to ensure carts were locked. MA B stated what led to the failure was it was Saturday and she had gotten in a hurry because she wanted to go home. During an observation on 11/16/2024 at 12:45 PM GV Cart was parked at the edge of the nurse's station with the drawers facing the residents in the secure unit. The GV Cart was unlocked, and the top drawer was slightly open, four residents were standing/sitting with arm's reach of the GV Cart. RN C was on the other side of the room with her back to Cart GV. During an interview on 11/16/2024 at 12:50 PM RN C stated the cart should have been locked. During an interview 11/21/2024 at 2:55 PM the DON stated her expectation was that medication and treatment carts should have been locked when unattended. The DON stated the nurse assigned to cart is responsible to ensure the cart was locked and the DON monitors. The DON stated the effect on residents could have been injury. The DON did not have a response to what led to failure of the medication carts being left unlocked. During an interview on 11/21/2024 at 3:15 PM the ADMN stated her expectation was that medication carts should have been locked when the cart was unattended. The ADMN stated the nurse who carried the keys to the cart was responsible to ensure the cart was secure, and the DON was responsible to monitor. The ADMN stated the effect on residents could have been residents advertently getting medication they were no supposed to. The ADMN stated what led to failure was oversight by the staff. Record Review of the facility's policy titled, Security of Medication Cart dated April 2007 revealed, The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with the doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurse's station or inside the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident #3 and Resident # 7) of 7 residents reviewed for resident records. The facility failed to ensure skin assessments were documented in medical record for Resident #3 and Resident # 7. This failure could place residents at risk of having errors in care and treatment. The Findings included: Resident #3 Record review of Resident #3's face sheet dated 11/21/2024 revealed a [AGE] year-old-male admitted on [DATE], with the following diagnosis Alzheimer's disease, heart disease, high blood pressure, and repeated falls. Record review of Resident #3's admission MDS assessment dated [DATE] revealed; Section C- Cognitive Patterns: Resident #2 had a BIMS score of 0 (meaning severe cognitive impairment). Record review of Resident #3's care plan dated 10/25/2024 revealed Resident #2 required weekly skin inspections. Record review of Resident #3's electronic medical chart revealed no evidence of weekly skin inspections completed between his admission on [DATE] and November 18, 2024. During an observation on interview on 11/21/2024 at 1:48 PM, Resident #3 had a rash to the back and both arms, and rash on the outer side of his legs and calves. RN A stated Resident #3 skin had been assessed, and benadryl had been added to his regime for itching on 11/10/24 and hospice had orders ointment for resident's skin. RN A stated she had assessed Resident #3's skin but had forgotten to complete the skin assessment because the treatment nurse had been completing the assessements and had been out on personal leave for several weeks. Resident #7 Record review of Resident #7's face sheet dated 11/21/2024 revealed [AGE] year-old-female admitted on [DATE] with the following diagnosis senile degeneration of brain, dementia, repeated falls, and Type 2 diabetes mellitus. Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed; Section C- Cognitive Patterns: Resident #1 had a BIMS score of 6(meaning severe cognitive impairment). Record review of Resident #7's care plan dated 10/19/2024 revealed Resident #1 required weekly skin inspections. Record review of Resident #7's electronic medical chart revealed no evidence of weekly skin inspections completed between 10/03/2024 and 11/06/2024. During an observation and interview on 11/21/2024 at 1:09 PM, Resident #7 had right elbow small circular scabbed wound and left shoulder blade abrasion. DON stated Resident #7 had a fall which led to the scabbed wound and shoulder blade abrasion. DON stated Resident #7 had been assessed and was treated for the abrasion. During an interview on 11/21/2024 at 12:45 PM, RN A stated every resident should have a skin assessment weekly. RN A stated skin assessments populate when needed to be completed and the nurse that was working that day was responsible to complete the skin assessment. RN A stated the skin assessment were not documented as expected in electronic medical record. RN A stated residents skin was assessed daily when providing incontinent care and during resident showers. During an interview on 11/21/2024 at 2:55 PM, the DON stated every resident was supposed to have had weekly skin assessments documented in their electronic chart. The DON stated skin assessments were triggered weekly for nursing staff to complete. The DON stated the treatment nurse was responsible to ensure they were completed, but she had been out for a family emergency and the nurses were supposed to have documented the assessments. The DON state residents skin was being assessed daily during incontinet care, showers and treatments. The DON stated she felt skin assessments were being done, they were just not documented in the medical chart. The DON was responsible to monitor to ensure they were being done. The DON stated what led to failure of skin assessments being undocumented was the treatment nurse was not in the building. During an interview on 11/21/2024 at 3:15 PM, the ADMN stated it was her expectation that skin assessments be completed and documented weekly for every resident. The ADMN stated the effect on residents having undocumented skin assessments could be potentially missing a skin condition that could have worsened or turned into an infection. The ADMN stated the DON was responsible to monitor to ensure skin assessments were being completed. The ADMN stated what led to failure of not skin assessments not being documented was the treatment nurse had been out, and some slipped thru the cracks. Record review of facility policy titled, Skin Assessment: New Admits or Resident Returning from Hospital Stay. Dated March 7, 2007, revealed It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate interventions be initiated in a timely manner.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 4 dietary staff (DA A) reviewed for dietary support personnel. The facility failed to ensure that dietary staff (DA A) serving in kitchen were working with a current Food Handlers Certificate. This failure could place residents at risk of not having their nutritional needs met and food borne illnesses due to lack of dietary staff training. Findings included: During an observation on 10/08/2024 at 10:15 AM of the kitchen, DA A was in the kitchen preparing the lunch meal. During an interview on 10/08/2024 at 10:15 AM the DM stated DA-A's Food Handler Certificate was in progress. She stated DA-A had been in the facility for 2 months in the position. Record review on 10/08/2024 at 11:30 AM, of DA A's employee file revealed she had no Food Handlers certificate. During an interview on 10/09/24 at 1:34 PM, the ADMN stated the dietary staff should have their Food Handlers Certification as soon as possible. She stated they asked DA A every day, if she had completed it, which she failed to provide. The ADMN stated the DM should have monitored closer and ensured it was completed. She stated DA A mostly spoke Spanish and felt maybe that was why she had not provided the certificate, but there were adequate translation capabilities, and should have still been done. She stated the negative impact for residents in not having the Food Handlers certificate was the compromising of food and cross contamination with infection control related to sanitation and service in general. The ADMN stated that proper education with all of the dietary information and regulations and the DM not following up, led to the failure. She stated her expectation would have been for all dietary staff to be certified before placing them on the floor for food preparation and food service. During an interview on 10/09/2024 at 10:35 AM, the dietician stated, the standard regulations for dietary staff to get certified should have been within 30 days of hire. She stated if the kitchen staff had not received it, it could hinder in proper preparations of food provided to residents and cause cross contamination. She stated the negative impact could have been residents getting sick if they consumed unfit food. The dietician stated her expectations were for all kitchen staff to follow the regulations and education provided to them. During an interview on 10/10/24 at 11:38 AM, the DM stated, DA A only knew Spanish, and she could not translate the test. She stated the DM monitored what staff had their Food Handlers certificates and was herself that was responsible in having dietary staff complete and provide for their files. The DM stated the negative impact for residents could have been not knowing to check temperatures, or using wrong size of ladles, causing the resident to have too much food, or not enough which would lead to residents' incomplete nutritional value, causing weight loss. She stated she had not been aware of the time frame for staff to get certified which led to the failure. The DM stated her expectations were to pay more attention to all Food Handlers certificates and when each staff member was due to have it completed. Record review of DA A's personnel files, accessed on 10/10/2024 revealed no evidence of her Food Handlers Certificate with a hire date of 08/28/2024. Record review of DA A's Job Description Dietary Service Worker, signed by DA A and dated on 08/28/2024 revealed: The following is a non-exhaustive criterion that relates to the job of a Dietary Service Worker, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Dietary Service Worker and are related to the functions that are essential to the job of a Dietary Service Worker. KNOWLEDGE BASE: o Ability to ensure duties are completed in a timely, efficient manner-according to the schedule. o Ability to function as team member. o Ability to perform work tasks within the physical demand requirements as outlined below. o Genuine care for and interest in elderly and handicapped people. o Ability to comply with the Patient [NAME] of Rights and the Employee Responsibilities. o Ability to comply with Company and departmental policies and procedures. o Ability to properly wash, sanitize, and store all dishes, utensils, and cooking equipment. o Assist in tray assembly and deliver carts to the appropriate nursing or dining areas. o Dispose of refuse according to departmental policy and procedures. o Assemble and deliver floor supplies according to the posted standards. o Put food and supplies away following the correct rotation (firs in, first out). o Ability to prepare all foods according to the menu and the standardized recipes in a safe, efficient, and sanitary manner. o Ability to ensure the proper preparation, portioning and serving of foods as indicated on the spreadsheets and the recipes. PHYSICAL DEMANDS: Sitting: 1 - 2 hours in an 8 hour work shift. Standing: 3-7 hours in an 8 hour work shift. Alternates continuous to walking. Walking: 3-7 hours in an 8 hour work shift. Alternates occasionally to standing. Lifting: 50 lbs. Reliability, trustworthiness and consistency with regard to attendance is extremely important to thisjob. The ability to regularly and timely attend work, cooperative and politely work and deal with others, and to effectively multi-task and work in a stressful environment are also essential functions to this job. STATEMENT: This position reports directly to the Dietary Service Manager. APPLICANT DECLARATION: I have read the qualifications and requirements of the position of DIETARY SERVICE WORKER. I understand and-certify that the foregoing is a non-exhaustive criteria that is consistent with the business needs of this facility and is a legitimate measure of the qualifications fora Dietary Service Worker; and relates to the functions that are essential to the job of a Dietary Service Worker. To the best of my knowledge; I believe that I can perform these duties. There was no policy provided concerning when the Food Handlers Certificate should have been obtained prior to exit.

**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 for 1 of 1 kitchen reviewed, in that: The facility failed to ensure: 1. All opened items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. 2. The ice machine was cleaned properly. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: During observation on 10/08/2024 at 10:15 AM the facility kitchen revealed: Refrigerator #1 of 2 1 container of sliced pickles, outside the original container and covered with plastic wrap, unlabeled, or dated. 1 large container labeled Ranch dated 10/7/24 with no use by date. 1 large container labeled Gravy dated 10-6 with no use by date. 1 large container labeled Gravy dated 10-07-24 with no use by date. 1 large container labeled Minestrone Soup dated 10-06 with no use by date. 1 large container labeled Greens dated 10-07 with no use by date. 1 large container labeled Diced chicken dated 10-7 with no use by date. 1 large container labeled Pineapple Tidbits dated 10-08 with no use by date. 1 large container labeled Chili dated 10/07 with no use by date. Refrigerator #2 of 2 5 opened 46 oz. cartons of Ready Care Tea with no opened date. 1 large container labeled Cherry Jello dated 9-25-24 with no use by date. 1 opened gallon of milk with no opened date. 1 large container of Orange Jello dated 09-25-2024 with no use by date. Kitchen dry storage (Pantry) 1 of 1 1 opened 5 lbs. container Creamy Peanut Butter with no opened date. 1 opened 10 lb. container of Baking Powder with no opened date. 1 opened 1 gallon container of soy sauce with no opened date. 1 opened bag of wheat bread with no opened date. 1 opened bag of hamburger buns with no opened date. Freezer 1 of 1 1 clear opened gallon bag of what appeared to be chicken strips, unlabeled, received date, opened date or use by date. 1 clear opened bag of what appeared to be meat balls with no received date, opened date or use by date. 10 frozen briskets, unlabeled or received date. 2 frozen pizzas, unlabeled and no received date. 3 clear bags of what appeared to be tator tots, unlabeled and no received date. 3 packets if frozen bacon, unlabeled and no received date. 2 packages of ham with no received date. During an interview on 10/08/2024 at 10:20 AM, DA A stated all items should have been labeled and dated with a received and use by date. During an interview on 10/08/2024 at 10:28 AM, the DM stated all opened food items should have opened dates. She stated all refrigerated items should have the date opened and use by date. The DM stated she monitored all areas of the kitchen. She stated the negative impact to residents could have been spoiled food which would have possibly made the residents sick. She stated staff had not paid attention to detail and that led to the failure. The DM stated her expectations was for staff to follow the rules and regulations as well as facility policies. During an interview on 10/10/2024 at 10:27 AM, the ADMN stated the policies and procedures were to follow the guidelines of having all food products labeled and dated. She stated the DM monitored her staff and followed up with in-services. The ADMN stated the negative impact for residents was that they could have potentially received old food which placed them at risk for gastrointestinal issues. She stated the delay in following up with the DM and supervisors led to the failure. The ADMN's expectations were to increase the audits and in-services on top of the ones they already had. During an interview on 10/10/2024 at 10:30 AM the Dietician stated all food items should have been dated, labeled with a use by date if in the refrigerator. During an interview on 10/08/2024 at 10:35 AM, DA B stated all refrigerated items should have had a use by date. She stated she knew the regulations and policies required staff to do so. Ice Machine During an observation on 10/08/2024 at 10:39 AM, the panel of the ice machine revealed dirty black substance on the inside panel of the ice machine. During an interview on 10/08/2024 at 10:40 AM, the DM stated the maintenance man (MM) cleaned the ice machine on a regular basis and did not know when the last time it had been cleaned. She stated the MM had a logbook of his maintenance and cleaning of the ice machine. The DM stated the MM also changed the filters on the ice machine when needed. The DM stated it was her and DA C who monitored. She stated the negative impact was that residents could have received dirty ice. The DM stated, not cleaning the ice machine and being lazy, as well as not taking the time to get the task completed led to the failure. She stated her expectations was that she expected it to be clean as she would not want ice for herself with the dirty panel inside of it. During an Interview on 10/08/2024 at 3:25 PM, the MM stated he did not have a logbook for cleaning the ice machine. He stated he only cleaned the filter and decalcified the lines. The MM stated he had never wiped down and/or cleaned inside of the ice machine, nor had he been told to do so. During an interview on 10/09/2024 at 10:08 AM, the ADMN stated it was the kitchen staff's duty to clean the ice machine. She stated there was a schedule for cleaning the equipment, with the ice machine being on Sundays. She stated she had done an audit two weeks ago and had not noticed the inside panel being dirty, but today, had noticed the inside panel being unclean with black stuff. She stated it was not the MM duty to clean the inside of the ice machine. The DM stated she felt the staff had not followed the cleaning schedule and that was what led to the failure. She stated she monitored the cleaning of equipment but had gotten busy with other things and assumed it had been done. The ADMN stated her expectations was to have all equipment cleaned in a timely manner. Record review of facility policy titled Storage Refrigerators dated 2012 revealed: All storage refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage. Procedure: 5. Food must be covered when stored, with a date label identifying what is in the container. Record review of facility policy titled Dry Storage and Supplies dated 2012 revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedures: 4.Open packages of food are stored in closed containers with tight covers and dated as to when opened. Review of FDA Food Code 2022: Full Document accessed on 10/16/2024 in annex 7 page 37, 38 revealed: Applicable Code Sections: 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 10/16/2024 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. There was no policy provided concerning the cleaning of equipment provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (Resident #55) reviewed for quality of care. in that: The facility failed to address or document Resident #55's incident resulting in a fractured ankle on 07/13/2023 until 07/17/2023. The facility failed to have a physician's order for an ankle boot to Resident #55's right ankle and to have physicians' orders to monitor for circulation or check skin integrity underneath ankle boot for Resident #55. The facility failed to update Resident #55's comprehensive care plan regarding non weight bearing status or the use of ankle boot for Resident #55. These failures could place residents at risk for pain, injury, pressure ulcers, and decreased level of functioning and quality of life. Findings included: Review of Resident #55's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: chronic pain, type 2 diabetes, and depression. Further review of the electronic face sheet revealed no evidence of fractured ankle. Review of Resident #55's Quarterly MDS dated [DATE], revealed: Section C: Cognitive Patterns a BIMS score of 14' indicated no cognitive impairment. Section G: Functional Status: Transfers required total dependence with 2 or more person's physical assist. Review of Resident #55's electronic comprehensive care plan last revised on 08/07/2023, revealed: Focus: has the potential for pressure ulcer development r/t Immobility. Goal: will have intact skin, free of redness, blisters, or discoloration by/through review date. Interventions: Educate resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Further review of the electronic comprehensive care plan revealed no evidence of Resident #55 having a boot to right lower extremity. During an observation and interview on 09/11/23 at 11:33 AM, revealed Resident #55 resting in bed with boot to right lower extremity. Resident #55 stated she broke her ankle a couple of weeks ago and they just threw a boot on it. She stated the staff never removed the boot and had never checked the skin underneath it. There were no concerns with circulation or skin integrity to Resident #55s lower extremity. Review of Resident #55's electronic physicians' orders revealed: non weight bearing to right lower extremity with a start date of 07/17/2023. Review of the electronic physicians' orders revealed no evidence of an order for the boot to her right ankle and no orders to check for circulation of skin integrity underneath the boot. Further review of the electronic physicians' orders revealed no evidence of an order for x-rays of the ankle or referral to orthopedic doctor. Review of Resident #55's electronic nurses notes revealed no evidence of documentation related to resident's right ankle injury until 07/17/2023. Review of the electronic progress note dated 07/17/2023 at 09:27 am, revealed: Physician contacted facility to report that patient had a possible fracture to ankle. New orders received 1.) NWB to RLE, 2.) Consult with orthopedics. Review of electronic nurses noted dated 07/26/2023 at 2:10 pm, revealed: When returned from orthopedic doctor Resident #55 was in walking boot on right foot no orders were returned with Resident #55. Resident #55 stated she is to further exam of her right foot. Review of the X-ray report for Resident #55 dated 07/14/2023 at 3:30 pm, revealed: Procedure: X-ray ankle. Conclusion: Suspected lateral malleolar fracture although the evaluation is limited due to the patients positioning. Review of Resident #55's electronic record revealed no evidence of an incident report regarding Resident #55's ankle injury. During an interview on 09/13/23 at 05:35 PM, the DON stated Resident #55 went to a neurologist appointment on 07/13/2023 around 12:00 PM, CNA F was transferring Resident #55 from mechanical lift to the electric wheelchair when Resident #55 stated her foot hurt. She stated an x-ray was performed on 07/14/2023. The DON stated on 07/17/2023 the physician called the facility and said Resident #55 had a fractured ankle. The DON stated orders were received to make Resident #55 non weight bearing and to consult orthopedics. The DON stated Resident #55 saw the orthopedic doctor on 07/26/2023 and returned to the facility with and ankle boot on but no orders. The DON stated there should have been more follow up when informed ankle was hurt. The DON stated the documentation should have been better. She stated the nurses' notes should have told a complete story of the incident and everything that was done. She stated the incident where her ankle was hurt should have been documented but did not require an incident report because there was not an actual incident that took place. She stated when Resident #55 came back from the doctor with a boot and no orders the nurse should have contacted the doctor to get orders. She stated there should have been an order for the boot and for checking pulses and monitoring skin integrity for the boot. The DON stated the boot should have been care planned. She stated this was just a lack in documentation and it was her place to ensure the nurses were documenting accurately. The DON stated these failures could have resulted in lack of treatment, increased pain, and possible skin issues. During an interview on 9/13/2023 at 6:05 PM, Resident #55 stated she had an appointment with the neurologist but could not recall the date. She stated there were 2 staff members that assisted her in the mechanical lift to her electronic chair. She stated she was not positioned correctly in her chair due to her hips working. She stated CNA F was there when Resident #55 stated she could reposition herself. She stated when she placed pressure on her right foot, she experienced excruciating pain. She stated she went to the appointment then back to the facility. She stated she went overnight without being seen or sent to the emergency room the next day. She stated she informed the nurses she was hurting and had injured her ankle, and nothing was done until the evening of the next day because she insisted. During an interview attempt on 09/13/2023 at 6:00 PM, CNA F did not answer her phone. A voicemail was left with no return phone call. During an interview on 09/13/2023 at 6:30 PM, the Administrator stated she did not consider Resident #55's ankle injury a suspicious injury. They stated they did not feel the need to investigate because Resident #55 stated what happened. The Administrator stated there was no abuse or neglect. She stated Resident #55 hurt her ankle when adjusting herself in her chair. The Administrator stated she felt that Resident #55's ankle injury was handled appropriately. Review of the facility policy titled, Immobilization Devices, Splints/Slings/Collars/Straps dated 2003, Revealed in part: immobilization devices are splints, sling, cervical collars, and clavicle straps that are applied to restrict movement support and preserve the integrity of an injured area . Major considerations involved in administering these applications are proper alignment and optical peripheral neurovascular function in the body part immobilized. Goals: 1. The resident will achieve safe and effective application of supportive immobilization devices. 2. The resident will maintain baseline neurovascular and skin integrity status. 3. The resident will be free from injury associated with immobilization devices. Procedure: .8. All immobilization devices except clavicle straps, should be removed periodically. All devices will be monitored on every two hour schedule. Monitoring will be documented in the clinical record or flow sheet. 9. Neurovascular assessment should be performed during. And after the application of the immobilization device. 10. Skin integrity should be assessed periodically when the device is removed.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 09/11/2023 between 10:30 AM and 11:30 AM of the kitchen revealed: Freezer 1. Two packages of salami that were not labeled with a receive date or food item description. 2. One package of salami that was not labeled with a receive date or food item description; and meat was covered with ice crystals. 3. One package of hamburger patties that were in a plastic bag with a seal that was not sealed and open to air. 4. One hamburger patty laying on shelf in the freezer not covered or stored in storage container. During an interview on 09/11/2023 at 10:45 AM, the DM stated food items should have been labeled with a received date, an open date and item description if food was out of the original package. The DM stated what led to failure was staff get in a hurry and do not take the time to write on food items or seal them correctly. The DM stated the hamburger patty should not have been laying on shelf uncovered. The DM stated she was responsible to monitor staff. The DM stated food not being stored or labeled correctly could have led to residents getting sick or food lose quality. Observation on 09/13/23 between 10:00 AM and 10:30 AM of the kitchen revealed [NAME] A did not perform hand hygiene after removing gloves and putting on clean gloves before and/or after pureeing broccoli. [NAME] A did not perform hand hygiene after removing gloves and putting on clean gloves before and/or after pureeing beans. During an interview on 09/13/2023 at 10:35 AM, [NAME] A stated she should have washed her hands every time she changed her gloves. [NAME] A did not provide a response as to why she did not wash her hands after changing gloves. During an interview on 09/13/2023 at 10:45 AM, the DM stated staff should have washed their hands with soap and water every time they change their gloves. The DM stated not performing hand hygiene could have caused cross contamination and residents could have gotten sick. The DM stated staff getting in hurry and forgetting led to failure of not washing hands. During an interview on 09/13/2023 at 4:45 PM, the ADMN she stated hand hygiene should occur before you put on gloves and after you remove gloves. The ADMN stated food items should have been labeled with an open date, a receive date and description of food item (if not in original packaging). The ADMN stated not performing proper hand hygiene and/or storing and labeling food correctly could have led to residents getting sick. The ADMN stated staff in hurry and new staff may have led to failures in the kitchen. Record review of facility policy titled, Storage Refrigerators, without a date revealed Food must be covered when stored, with a date label identifying what is in the container. Record Review of facility policy titled, Fundamental of Infection Control Precautions, dated 10/21/22 revealed: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situation that require hand hygiene . After removing gloves . wearing gloves does not replace the need for hand washing because gloves may have small inapparent defect or be torn during use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 (Resident #53 and 78) of 8 residents reviewed for medical records. Facility failed to document follow-up observations and monitoring for Resident #53 after she had falls. Facility failed to document follow-up observations and monitoring for Resident #78 after he had falls, behaviors, and antibiotic therapy. These failures placed residents at risk for continuity of care and early detection of complications related to medications and injuries. Findings included: Resident # 53 Record review of Resident #53's Facesheet dated 09/13/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included Vascular dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Muscle wasting and atrophy, Senile degeneration of brain, Schizoaffective disorder bipolar type, osteoporosis without current pathological fracture. Record review of Resident #53's Quarterly MDS dated [DATE] revealed No BIMS score with problems with short- and long-term memory issues. She had at least 1 fall in the previous 3 months. She needed extensive 2-person assistance for transfers and supervision with 1-person for walking. Record review of Resident #53's Care plan last updated 09/11/23 revealed: is a high risk for falls r/t Confusion. Fall without injury 01/12/23, Fall without injury 01/26/23, fall without injury 02/22/23, fall without injury 04/07/23, fall with injury 07/09/23 (laceration), fall without injury 09/11/23. The resident will be free of minor injury through the review date. #53 will have a reduction in falls through the review date. Anticipate and meet Resident #53's needs. Be sure Resident #53's call light is within reach and encourage her to use it for assistance as needed. Educate Resident #53/family/caregivers about safety reminders and what to do if a fall occurs. Encourage Resident #53 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that Resident #53 is wearing appropriate footwear, shoes or non-skid socks when ambulating or mobilizing in w/c. Follow facility fall protocol. Resident #53 needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach. low bed with fall mat in place while in bed, hipsters on at all times. PT to evaluate and treat as ordered or PRN. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate Resident #53/family/caregivers/IDT as to causes. Record review of Resident #53's Progress from 04/12/23 to 09/15/23 revealed: 04/12/23 through 05/13/23 Effective Date: 05/07/2023 14:30 Type: Nursing Note Note ext: resident found laying on her back on floor in room resident assessed moves all ext well no s/s or c/o pain no injuries noted. resident wearing hipsters and no slide socks notified RP, PCP, ADONS DON ADMIN No additional notes after fall on 5/7/23 over the next 3 days. 06/13/23 through 07/13/23 Effective Date: 07/09/2023 20:00 Type: Nursing Note Note Text : RESIDENT SENT TO ER POST FALL DUE TO HEAD LACERATION 2 STAPLES APPLIED REMOVE STAPLES IN 10 DAYS. Effective Date: 07/09/2023 18:45 Type: Nursing Note Note Text : CNA REOPORTED TO THIS RN THAT RESIDENT HAD FALLEN RESIDENT FOUND LAYING ON HER LEFT SIDE ON MAT WITH HEAD NEXT TO NIGHTSTAND RESIDENT ASSESSED MOVES ALL EXT W/O S/S OR C/O PAIN NOTED 2CM LACERATION TO LEFT SIDE OF HEAD. CLEANED WITH NSS AND GAUZE RESIDENT SENT TO THE ER FOR EVALUATION AND SUTURESNOTIFIED DON ADMIN RP AND PCP No additional notes after fall on 7/9/23, or follow-up monitoring for staples. 07/14/23 to 08/14/23. No progress notes at all. 08/15/23 through0 9/15/23 No note regarding fall on 09/11/23. During an observation and interview on 09/11/23 at 11:47AM with Resident #53, surveyor observed Resident #53 in her room, in the middle of the floor behind her wheelchair with her door closed, and the lights off. There was a floor mat leaning against Resident #53's roommate's bed. Resident#53 was making a noise, like a cutting ahahahahah noise. Surveyor pushed resident call light and went to the hallway and seen housekeeping and asked that they get a nurse, as resident was in the floor. Surveyor asked Resident #53 if she was in pain and she said yes. She was asked where she was hurting and did not answer and again began making the ahahahah sound. Resident #53 was observed scooting around on the floor frequently while awaiting assistance from staff and had been in the process of trying to get up out of the floor per self when RN B entered her room. Resident #53 then finished getting up after RN B provided her hand to resident. Resident #53 was observed with a bulkiness to her hips and RN B said Resident #53 had hipsters on to protect her hips during a fall, a low bed, and also a fall mat. She said Resident #53 had a history of frequent falls. Resident #53 appeared wet from incontinent episode through her sweatpants. An aide had entered Resident #53's room then went out to get another set of hipsters and nurse stayed with resident. RN B asked Resident #53 if she was hurting, Resident #53 said yes but then would not say, point or indicate where the pain was. Resident#53 began to pace around room and began moving things from 1 part of the room to another part of the room and then began opening and shutting dresser drawers. RN B said Resident #53 was able to ambulate well per self and rarely would sit in her wheelchair. Nurse aide returned to room as the nurse was opening the door to look out for aide, Resident #53 just began walking out of room, so aide decided they would take resident to the shower room. Aide said that hospice had just been in and did Resident #53's shower not too long ago. Resident#53 did well ambulating in her room without need of assistance of the staff as well as walking through the hallway and she did not ambulate with the appearance of difficulty or pain. RN B said, Resident #53 had not had a true fall in quite some time. She said Resident #53 did scoot off her bed or the chair in her room or sometimes even her wheelchair, and she would just sit down in the floor and scoot around on her bottom sometimes. Resident # 78 Record review of Resident #78's Facesheet dated 09/13/23 revealed An [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: Dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Muscle wasting and atrophy, Other idiopathic peripheral autonomic neuropathy. Record review of Resident #78's admission MDS dated [DATE] revealed no BIMS score with difficulty with short- and long-term memory. He needed ADL assistance of extensive 2-person assistance for transfers and supervision of 1-person for ambulating. He did utilize a wheelchair. Resident #78 had at least 1 fall since admission. Record review of Resident #78's Careplan last updated 9/13/23 revealed: The resident is high risk for falls r/t Confusion, Gait/balance problems. 08/16/23 fall with injury, 08/17/23 fall with injury, 08/19/23 fall with injury, fall with injury 09/02/23 fall with injury (hematoma, skin tear) 09/13/23. The resident will be free of falls through the review date. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it or assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear (Specify and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non- skid socks) when ambulating or mobilizing in w/c. Follow facility fall protocol. Hipsters to be worn at all times to prevent injury from falls. Resident #78 to wear soft helmet while OOB and ambulating to prevent further injury from falls. Pt evaluate and treat as ordered or PRN. The resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach). The resident needs activities that minimize the potential for falls while providing diversion and distraction. Record review of Resident #78's Progress notes dated 08/14/23 through 09/14/23 revealed: Effective Date: 08/17/2023 14:20 Type: Nursing Note Note Text: notified PCP of change in condition, PCP ordered resident to be sent to ER for EVAL. (RP) notified. Effective Date: 08/17/2023 03:11 Type: Nursing Note LATE ENTRY Note Text: CNA notified this nurse that resident was on the floor. He was on his back with head by the closed bathroom door and his legs were straight out in front of him. Vital signs obtained, head to toe assessment done with no new injuries noted. Assisted resident back to his bed. No s/s of pain or discomfort. Bed in lowest position and call light in reach. Notified (RP), PCP, and admin. Effective Date: 08/18/2023 22:11 Type: Nursing Note Note Text: this nurse heard a noise and observed resident lying on the floor in the hallway. this nurse assessed resident for injury a hematoma was forming on the left side of forehead (same area from a previous fall) and the dressing on resident's left elbow had been scraped open. resident moves all extremities without pain or discomfort admin., DON, on call DR and (RP) were all notified neuros. Initiated. Effective Date: 08/19/2023 10:00 Type: Nursing Note Note Text: RN IN ER CALLED AND INFORMED THAT TEST RESULTS CAME BACK ON HIS URINE AND HE HAS ECOLI IN HIS URINE NEW ORDER RECIEVED FROM ER DR FOR MACROBID BID X 10 DAYS RESIDENTS RP CALLED AND NOTIFIED Effective Date: 09/02/2023 05:45 Type: Activity Note Text: this RN heard a crash found resident lying on his back on the floorresident assessed resident moves all ext w/o s/s or c/o pain noted raised knot with a 1 cm laceration on top first aid admin neuros started. notified RP PCP DON AND ADMINISTRATOR Effective Date: 09/07/2023 10:11 Type: Nursing Note Note Text: Resident having increase in behaviors hitting at staff and using foul language. Staff attempting to redirect resident, resident continues to hit and kick at staff, cursing while doing it. Effective Date: 09/09/2023 12:34 Type: Nursing Note Note Text: Resident standing in room holding on to his wheelchair running it into the bathroom door over and over cursing and yelling at staff. Resident redirected, attempted to get in bed staff helped resident to bed, fall mat next to bed. WCTM Effective Date: 09/13/2023 06:30 Type: Nursing Note Note Text: Resident using foul language hitting punching at staff trying to bite staff. Staff attempts to redirect resident not easily redirectable. DR. notified of behavior prn lorazepam 0.5mg Q6 hrs. prn. (Draft) No follow up notes from any shifts regarding resident behaviors, falls, or antibiotic use. During an observation on 09/11/23 at 12:09PM of Resident #78, he had a soft open helmet on. He was observed several times getting out of wc and ambulating towards a closet in the dining/activity area. Resident #78 did not respond to any questions and only looked at surveyor during questions. During an interview on 09/13/23 at 02:53 PM with ADM, she said the expectation was to document daily per shift x 3 days (72 hours) when there has been a fall or a change of condition. She said if a resident had an antibiotic, the nurses should have charted on each shift the entire time the resident was taking the antibiotic and then for3 days after. ADM reviewed Resident #78's progress notes from admission 8/15/23 to 9/13/23 and verified that the staff did not chart per their policy for documentation. During an interview on 09/13/23 at 3:39PM with DON she said she expected that the nurses documented in a progress note for a fall at the time of the incident and then each shift for the next 3 days afterwards. She said if a resident was taking an antibiotic, the nurses should have been documenting a progress note each shift the entire time the resident took an antibiotic and then for an additional 3 days each shift after the resident completed the antibiotic. During an interview on 09/13/23 at 5:36PM with LVN E, she said any time a resident had a fall, the nurses were to complete an incident report and if the fall had been unwitnessed or the resident hit their head, the nurse was supposed to start neurological checks. She said the nurses were supposed to do a nurses note with details about the fall and then put the fall on the 24-hour report to alert all other nurses to the fall. LVN E said that would be followed up by all 3 shifts of nurses writing a progress note for the next 3 days after the fall. She said any resident that had a new medication would have all 3 shifts of nurses to write a nurses note for 3 days after the new medication was started and if a resident had an antibiotic, then the nurses were supposed to write a nurses note each shift the entire time a resident was on an antibiotic and then for 3 days after the resident stopped the antibiotic. LVN E said if a nurse did not chart as she had explained, it could have been because they had just been too busy, or they simply forgot to chart something. She said if the residents did not have that type of charting completed during events of falls or antibiotics, then their medical records were not accurate, and it could place the residents at risk because they would not have documentation to assist in early detection of problems. LVN E said that each unit had a cheat sheet inside the 24 hour report binder that assisted the nurses with what to chart and how often to chart for different events. During an interview on 09/13/23 at 5:53PM with DON, she said herself and the ADON monitored all unit's 24-hour report sheets, and they would monitor the nurses charting to ensure that the nurses were charting as they were supposed to. She said they had trained all their nurses when they first started on the type of charting and how often they were supposed to chart, as well as different in-services throughout her time as the DON. She said even though she was responsible for monitoring the nurses charting, she had obviously not monitored everyone because of the issues that had been brought to her attention. Record review of facility policy labeled Documentation last revised 2/13/07 revealed: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge) . Complete documentation in narrative nursing notes in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. Daily documentation X 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Daily summaries per shift will be required on residents requiring acute care. Record review of facility policy labeled User Friendly Guide on when to complete assessments undated revealed: Behavior Assessment Q 8 hours for 3 days post resident to resident incident . Fall Nurses Note when a resident falls and every 8 hours for 3 days post fall . UTI Assessment every 8 hours while on treatment and then for 3 days post treatment.

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 2 of 2 (CNA-C, and MA-D) staff observed for infection control. 1. The facility failed to ensure MA-D did not sanitize the blood pressure cuff before or after use between residents. 2. The facility failed to ensure CNA-C performed proper peri-care (incontinent care) or proper hand hygiene for Resident #18. These failures could place residents of the facility at risk of infections due to unclean BP cuffs and incontinent care. Findings included: Observation on 09/13/2023 between 7:37 AM and 8:00 AM, MA-D did not sanitize the blood pressure cuff before or after use between 3 of 3 residents (Resident #56, 47, and 71) during morning resident medication pass. An interview on 09/13/23 at 8:20 AM, MA-D stated the blood pressure cuff should have been cleaned and sanitized before and after each resident. She stated she had not cleaned the Blood Pressure Cuff because the was nervous. She stated the negative impact to residents could have been possible cross contamination between residents. An interview on 09/13/2023 at 2:34 PM, the DON stated the staff should have followed the facility policy. She stated the ICP should have monitored staff members for proper infection control practices. She stated the negative impact could have been passing infections from one resident to another. The DON stated the MA was PRN was called in short notice. She stated it was that that led to the failure. Her expectations were for the residents to be correctly taken care of with staff following the facility policies. Record Review of In Service Training Attendance roster for Disinfecting Small Equipment dated 08/24/2023 revealed: Cleaning of small equipment related to disinfecting. All small equipment to include but not limited to: .4. Blood Pressure Cuffs Must be cleaned between Clients. Process for disinfecting is to wipe the device completely outer and inside surfaces with available disinfecting wipe. Please use wipes and apply designated kill times to ensure that adequate time is taken between use. Record Review revealed MA-D had not been in attendance Disinfecting of Small Equipment dated 08/24/2024. There were no further policies provided concerning disinfecting of small equipment before exit of facility. Record Review of the resident #18's Face Sheet dated 09/11/2023, revealed he was an 88 yr. old male. His original admit to the facility was 07/18/2020. Resident #18 had a diagnosis of Cerebral Infarction (stroke). The MDS assessment Section C, Cognitive Patterns dated 08/22/2023, revealed a BIMS score of an 11 (moderately impaired) and Section G, Functional status of personal hygiene was extensive assistance. Record review of Resident #18's Care Plan dated 07/03/2023 revealed Resident #18 had an ADL self-care performance deficit related to activity intolerance. The goal for Resident #18 would be to improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Observation on 09/13/2023 at 1:26 PM, CNA-C performed incontinent care for Resident #18, folding the same wipe two and three times each before discarding. CNA-C also did not pull Resident #18'a foreskin back to clean underneath cleaning in a downward swipe. An interview on 09/13/2023 at 1:59 PM, CNA-C stated she should have pulled the foreskin back to help prevent bacteria buildup as well as infection. She stated Resident #18 was known for yelling while being cleaned and did not want him to do that in front of surveyor observation. CNA-C stated she had been taught the one-wipe, one swipe but she was in a hurry to finish not taking the time to get a new one. An interview on 09/13/23 at 2:34 PM, the DON stated the foreskin should have been pulled back and cleaned correctly. The DON stated she had always taught the one wipe one swipe rule. The DON stated it was herself as well as the ADON who monitored the staff checkoffs, doing that on a weekly basis but had no documentation for those. The DON stated the negative impact to residents was a potential for a UTI. The DON stated what led to the failure was not following something they go over frequently which was one wipe one swipe. She stated she would not have felt comfortable with the three-fold for a bowel movement. Her expectations for staff were to follow facility policy and procedures. An interview 09/13/23 04:50 PM the DON stated CNA-C had no previous in-services documented concerning un-circumcised male incontinent care. Record review titled Certified Nurse Aide Competency Verification for CNA-C was dated 02/04/2022. Record review of the policy titled Perineal Care Male dated 08/08/2023 revealed: Purpose: To clean the male perineum without contaminating the urethral area with germs from the rectal area. Procedural Guidelines . F .DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE TISSUE OR WIPES . I .Gently wash perineal area, wiping from clean urethral area toward dirty rectal area to avoid contaminating urethral area to avoid contaminating urethral area with germs from the rectum. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE WASHCLOTH OR PRE-MOISENED CLEANSING WIPE Retract foreskin of uncircumcised male Wash the urethral area in a circular motion

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 3 of 4 residents (Resident #1, Resident #2, Resident #3) reviewed for plan of care revision. The facility failed to include in the care plan, updated fall interventions for Resident #1. The facility failed to include in the care plan, updated inappropriate behavior interventions for Resident #2. The facility failed to include in the care plan, the Do Not Resuscitate orders for Resident #1 & Resident #3. This failure could place the residents at risk of staff and providers not having the most current information for the Resident's plan of care. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date [DATE], Diagnoses: diverticulitis of intestine (small pouches that bulge outward in intestine become infected or inflamed), essential (primary) hypertension (high blood pressure), depression, gastro-esophageal reflux disease without esophagitis (acid reflux), hypothyroidism (underactive thyroid), dementia (memory loss), displaced fracture of lower end of right humerus (upper arm bone), Alzheimer's disease (progressive memory loss), age-related osteoporosis (weak brittle bones) without current pathological fracture, anxiety disorder (feelings of worry and fear that interfere with daily activities), muscle weakness (generalized), repeated falls. Record review of Resident #1's Hospice Recert Summary Report dated [DATE] revealed the Advanced Directive of Do Not Resuscitate from the IDG meeting dated [DATE]. Record review of Facility's Investigation report dated [DATE] revealed Resident #1 had an unwitnessed fall on [DATE]. Resident was placed at nurse's station for observation and change in condition. Resident sent to ER. Continue plan of care. Record review of Resident #1's electronic health record revealed the most recent Care Plan dated [DATE] on page 2 of 34 stated Full Code CPR in place. Care plan further revealed the fall interventions were last updated [DATE], the interventions were not reviewed or revised after the fall on [DATE]. Record review of Resident Care Plan Conference Report dated [DATE] revealed fall incident and DNR signed by Family Representative, Social Services Director, Activity Director, Resident Care Coordinator (MDS), Dietary Services, Physician, CNA, RN. Interview on [DATE] at 1:25 pm with LVN-A revealed LVN-A knows someone's status code by looking in PCC. LVN-1 was able to locate the DNR status code in orders and then she looked in the paper chart on the wall at the nurse's station, which also revealed DNR code status for Resident #1. LVN-1 stated she does not look in the care plans for status code. Record review of Resident #2's electronic health record revealed an [AGE] year-old male, admission date [DATE]. Diagnoses: atherosclerotic heart disease of native coronary artery (plaque buildup narrowing arteries of the right and left arteries of the heart), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (one side partial or total paralysis), aphasia following cerebral infarction (impacts speech after stroke), heart failure (changed structure of heart so it can't pump blood to meet body's needs), type 2 diabetes mellitus without complications (body doesn't produce enough insulin), hyperlipidemia (high levels of fat particles in the blood), essential (primary) hypertension (high blood pressure), cerebral infarction (stroke), latent tuberculosis (tuberculosis germs are in your body but not hurting you and cannot spread to others), solitary pulmonary nodule (mass in the lungs), hearing loss left ear, major depressive disorder (clinical depression), recurrent severe without psychotic features, generalized anxiety disorder, delusional disorders, dementia (memory loss) moderate, seizures (burst of uncontrolled electrical activity between brain cells), chronic systolic (congestive) heart failure (left ventricle can't pump blood efficiently), senile degeneration of brain (cognitive abilities or mental decline), muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #2's electronic health record revealed Resident # 2's Care plan dated [DATE] lacked any documentation of inappropriate sexual behavior that occurred on [DATE], or interventions to address inappropriate sexual behavior. Interview on [DATE] at 3:32 pm with RN-A revealed interventions put in place to keep residents safe were increased monitoring of every 15 minutes, medication changes, resident education and the facility and family are looking to relocate Resident #2 for a more appropriate placement. Interview further revealed that RN-A was not aware if it has been care planned but it usually would be but not sure by who. RN-A stated Resident #2 did not have a history of inappropriate sexual behavior that the facility were aware of but the family was not surprised when they were informed. RN-A stated Resdient #2 was found holding his penis in his hand and trying to put it in another Resident's mouth. The other Resident was compliant and does have a history of this type of behavior but it had not happened in a very long time. Interview further revealed that due to the congnizant level of the other resident and it happened in the dining room, they were seperated. Resident #2 became very agitated by this and yelled and cursed at staff and made comments propositioning them since they would not let him get any from her. The other resident does not remeber the incident and had no change in behavior or injuries and was un interviewable. Interview on [DATE] at 4:03 pm with MDS Coordinator revealed the inappropriate sexual behavior occurred [DATE] and was discussed extensively with the team, but she was not sure if anyone filled out the official form for it. Interview further revealed MDS put in the inappropriate behavior interventions into Resident #2's care plan today on [DATE]. Record review of Resident #3's electronic health record revealed a [AGE] year-old female, admission date [DATE], Diagnoses: basal cell carcinoma of skin of parts of face (basal cell cancer), type 2 diabetes mellitus with diabetic neuropathy (body doesn't produce enough insulin and nerve damage), hyperlipidemia (high levels of fat particles in the blood), essential (primary) hypertension (high blood pressure), psoriasis (skin cell build up which forms scales and itchy dry patches), osteoarthritis of knee (flexible tissue at the end of bones wears down), age-related osteoporosis without current pathological fracture (weak brittle bones), muscle weakness (generalized), chronic kidney disease, stage 3a (mild to moderate kidney damage and less able to filter waste and fluid), muscle wasting and atrophy (wasting or thinning of muscle mass), difficulty in walking, osteoarthritis (flexible tissue at the end of bones wears down), dementia (memory loss) mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit (difficulty thinking and how someone uses language), gastro-esophageal reflux disease without esophagitis (acid reflux), urgency of urination, pain in right shoulder. Record review of Resident #3's care plan dated [DATE] on page 12 of 26 revealed Full Code CPR order. Record review of Resident #3's electronic orders dated [DATE] revealed DNR. Interview on [DATE] at 2:17 pm with Administrator revealed the facility just did an audit on DNR's. The Administrator walked out of the room when asked what negative impact not updating the status code in the care plan could have. Interview on [DATE] at 4:03 pm with MDS Coordinator revealed she was responsible for updating the care plan with the status code and MDS stuff but if it is an acute incident then it is nursing that is to update the care plan. MDS further revealed the team has not yet had a team meeting after the fall incident dated [DATE] for Resident #1 but plan to. MDS stated she does not believe it had any negative effect for the care plan not to be updated with the status code because she felt MDS, and state are the only ones that look at it for that. She further stated that she updated Resident # 2's care plan to include the inappropriate behavior. MDS Coordinator was able to show investigator the correct code status in the electronic record banner in PCC for all resident's sampled, which she stated is where staff look for status code. Interview on [DATE] at 3:55 pm with Administrator revealed her and her team will be conducting a care plan audit starting tomorrow.

**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 two (Resident #115 and Resident #117) of eight residents reviewed for base line care plans. Based on interview and record review the facility failed complete and implement a baseline care plan within 48 hours of two residents (Resident #115 and Resident #117) admission. This failure could place newly admitted residents at risk of not receiving necessary services and treatments. The findings include: Resident #115 Review of Resident # 115's face sheet dated 08/09/2022 revealed [AGE] year-old male admitted [DATE] with diagnosis of COVID-19, Hypertension (high blood pressure), Respiratory Failure with Hypoxia (Not sufficient oxygen) Parkinson's (brain disorder that causes unintended or uncontrollable movements), Seizures, Chronic Obstructive Pulmonary Disease (constriction or airways, lung disease. Review of Resident #115 admission 5 day MDS dated [DATE] did not have a BIMS score completed. Section G of MDS revealed resident #115 required extensive assist with bed mobility and transfers, two persons assist with personal hygiene. Section I revealed a diagnosis of respiratory failure, Section O did not reflect the use of oxygen and Section N was not filled out as the number of injections received in last 7 days. Review of Resident #115 resident's record revealed no baseline care plan available. Review of Resident #115 physician orders revealed Resident # 115 had orders for Lovenox 40 mg subcutaneously injection every day and Oxygen at 2 LPM as needed. Resident #117 Review of Resident #117's Face Sheet dated 08/09/2022 revealed [AGE] year-old female admitted on [DATE] with diagnosis of COVID-19, Seizures, Down Syndrome, and Metabolic Encephalopathy (problem in the brain, brain function is disturbed) Review of Resident #117 admission 5-day MDS dated [DATE] did not have a BIMS score completed. Section G revealed that resident required extensive assist with bed mobility, toileting, and personal hygiene and 1 person assist the eating and dressing, Section I (Active Diagnosis) Pneumonia, Respiratory Failure, Section K 0510 D (Nutritional approaches) and Section N(Medications) was not completed. Review of Resident #117 resident record on 08/09/2022 revealed no baseline care plan available. Review of Resident #117 Physician orders dated 08/09/2022 at 10:45 AM revealed Regular pureed diet with nectar thickened liquids, Sertraline, (antidepressant), Aripiprazole (atypical antipsychotic) During an interview on 08/09/2022 at 3:55 PM, the DON stated baseline care plans were her responsibility to start and complete. She stated she had discovered if she does not open the baseline care plan, no other RN does either. She stated the MDS coordinator would initiate a care plan that staff can access on the [NAME] in the computer. She stated she was responsible for monitoring and approving the care plans. She stated she had no answer on why baseline care plans were not being done. She stated residents not having a baseline care plan could result in resident not receiving resident centered care. The DON stated she was hired 02/15/2022. During an interview on 08/10/22 at 02:30 PM, the ADMIN stated if an RN does the admission, they were responsible for completing the baseline care plan, otherwise it was the DON. She stated her expectations were for the baseline care plan to be completed within 48 hours of admission. The ADMIN stated the failure could affect the resident by not having all needs met. She stated the baseline care plan allowed the nurse to closer evaluate the needs of a resident. Review of facility's policy, Care Plans Revised February 13. 2007 revealed: 1. The facility will develop a Base Line Care plan within 48 hours of each resident's admission that includes but not limited to a short-term and long-term objective and timetables to meet resident's medical, nursing, and mental and psycho-social needs that are identified on admission. Care plan will be reviewed and approved by an R. N. 2. The care plan must describe the following: a. Services/Interventions that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well- being. b. Problem statements to identify services that are required to maintain the resident's highest practicable physical, mental and psychosocial well-being. c. Short- and long-term goals to identify reassessment parameters for the resident's maintenance of well-being. d. Evaluation of the interventions and goals to maintain the resident's well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 residents (Resident #2 and Resident #165) of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans with measurable objectives based on assessed need for indwelling urinary catheter care for Resident #2 and Resident #165. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #2's electronic face sheet accessed on 08/10/2022 revealed a [AGE] year-old female admitted on [DATE] with a diagnosis of urinary bladder problems. Review of the quarterly MDS dated [DATE] revealed a BIMS score 10 indicating moderate cognitive impairment. Review of the Comprehensive Care Plan with a review date of 08/06/2022 did not address urinary catheter monitoring or care. Record review of Resident #165's electronic face sheet accessed on 08/10/2022 revealed an [AGE] year-old male admitted on [DATE] with medical diagnoses that included: an enlarged prostate and problems with the nerves involved with the function of the urinary bladder. Review of the admission MDS dated [DATE] revealed a BIMS score 15 indicating no cognitive impairment. Section H of the MDS indicated Resident # 165 was not able to control urination and had an indwelling urinary catheter. Review of Resident # 165's physician orders dated 4/5/22 revealed instructions to perform catheter care every shift, check placement of catheter securing device, replace if missing or soiled to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. Review of the Comprehensive Care Plan dated 08/04/2022 did not address urinary catheter monitoring or care. During an interview on 08/10/2022 at 2:30 PM, the Administrator stated a resident with an indwelling urinary catheter should have a care plan for the care and observation of the catheter. She stated her expectation was the catheter would be care planned. The Administrator stated the MDS Coordinator was responsible for monitoring the care plans. The Administrator stated she does not know why the failure happened. She stated that she did not think resident care would be affected due to having physician orders for catheter care. Review of facility's policy, Care Plans dated 02/13/2007 revealed The care plan must describe the following: a) Services/Interventions that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. b) Problem statements to identify services that are required to maintain the residents highest practicable physical, mental, and psychosocial well-being. c) Short and long term goals to identify reassessment parameters for the residents maintenance of well-being. d) Evaluating of the interventions and goals to maintain the resident's well-being.

Based on observation and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 3 medication carts (Cart 1) reviewed for storage of medications. The facility failed to secure a medication cart before leaving the medication cart. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications and drug diversion. Findings Included: During an observation on 08/08/2022 at 2:24 PM of a medication cart located by the nurse's station on 200 Hall revealed the cart was unlocked with no staff in the vicinity to monitor access. Review of unlocked medication cart revealed blood sugar monitoring equipment and supplies such as glucometers, lancets, insulin needles, and alcohol pads. The second drawer contained medications administered via inhalation. The third drawer contained topical medications such as sprays, ointments, powders, and creams. The fourth drawer contained insulin syringes and collagen powder. The bottom right drawer contained a 32 fluid ounce bottle of 91% Isopropyl alcohol, a 24-gauge intravenous needle, an indwelling urinary catheter securement device, a Huber needle (a needle used to access an implanted device), and one 1.7 ounce can of skin barrier spray. The open shelf on the left side of the cart reveled fifteen 0.18-ounce packets of skin protectant ointment and sixteen 8 milliliter packets of zinc oxide. The cart was located within 6 feet of one open resident doorway across the hall and one closed resident doorway to the left of the cart. Two residents, Resident #7 and Resident #33, passed by the cart during the time the cart was being inspected. During an interview on 08/08/22 at 3:15 PM, LVN A stated the cart should not have been left unattended while it was unlocked. LVN A explained all nursing staff were responsible for the medication carts. He stated packets of treatment supplies should not be kept where residents had access because this could place residents at risk. During an interview on 08/09/22 at 08:42 AM, the Administrator stated unattended medication carts should be secured/locked. During an interview on 08/10/22 at 08:32 AM, the DON stated medication carts must be kept locked any time approved staff was not using them. The DON stated training on medication and treatment cart security, organization, and maintenance was done during onboarding. The DON stated responsible staff were verbally reminded periodically while working on the cart about cart security. She stated cart security was also included during annual evaluations and skills check offs. The DON stated the wound care nurse is responsible for the treatment cart, but she recently quit, and the new wound care nurse will start at end of month. The DON stated the administrator is the interim wound care nurse. Review of the facility's policy, Storage of Controlled Substance dated 2003 stated under item 6 Drugs shall be accessible only to authorized personnel. Only the authorized personnel will have access to the keys to the medication room and medication carts. Drugs shall not be kept on hand after the expiration date on the label, and no contaminated or deteriorated drugs shall be available.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. The facility failed to ensure food temperatures were taken correctly and food temperatures were held at or above 140 degrees. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure that kitchen staff did not modify face coverings and ensured the mask covered both mouth and nose. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation on 08/08/22 between 9:55 AM and 10 :30 AM revealed: Refrigerator #1 1. One plastic bag with a seal containing Parmesan Cheese not sealed. 2. One plastic bin containing 40 strawberry individual boxed health shakes, not labeled with an open date, with manufacture label that stated to discard after 14 days unthawed. The container had a pink substance in the bottom of container and shakes were sticky to touch. 3. One plastic bin containing 25 chocolate individual boxed health shakes, not labeled with an open date, with manufacture label that stated to discard after 14 days unthawed. 4. One plastic bin containing 15 vanilla individual boxed health shakes, not labeled with an open date, with manufacture label that stated to discard after 14 days unthawed. 5. Two open 5lb containers of sour cream without an open date. 6. Two open 5lb container of liquid eggs not sealed and open to air. Dry Storage: 1. One open package of pancake mix without an open date. 2. One open package of cookie mix stored in a plastic bag not sealed with use by date of 06/01/2022. 3. One plastic bag with seal contained a white powdery substance not labeled with an open date or item description. During an observation on 08/08/2022 between 11:00AM and 12:00 PM of kitchen: 1. Cook A and [NAME] B were both wearing a N95 mask that had been modified and was worn with straps cut and tied behind their ears. 2. Cook A, with ungloved hands, was taking temperature of lasagna and removed thermometer, wiped it with a paper towel, and then placed thermometer into the zucchini. [NAME] A with her ungloved hand, touched her face and mask then proceeded to resume taking food temperatures without performing hand hygiene. [NAME] A then removed thermometer from the zucchini, wiped it with the same paper towel, and then placed thermometer into the ham which had a temperature of 120 degrees. [NAME] A then removed thermometer from the ham, wiped it with same paper towel, and then placed thermometer into the green beans. 3. DM entered kitchen from office and failed to perform hand hygiene upon entering the kitchen. 4. DM then adjusted hair, touched face and went to put up clean dishes without performing hand hygiene. 5. Cook D entered the kitchen not wearing a face covering. [NAME] D left kitchen and when returned to kitchen failed to wash hands upon entrance to the kitchen, before touching clean dishes. During an observation of kitchen on 08/10/22 at 8:35 AM revealed: 1. Cook B was standing in kitchen by oven cooking food not wearing mask. [NAME] B then later put on an altered N95 mask, the N95 mask had been modified and was worn with straps cut and tied behind her ears. 2. Cook C walked out of the walk-in fridge not wearing a mask carrying a food. 3. The DM walked into the kitchen with mask below nose and mouth. During an interview on 08/08/2022 at 11:15 AM with [NAME] A she stated she knows she was supposed to use alcohol wipes to sanitize thermometer, but that she doesn't like to use them because she feels like she is putting alcohol into the food. [NAME] A stated she guessed using the same paper towel caused cross contamination and continued to use the same paper towel wipe the thermometer after taking temperatures of food. [NAME] A stated the ham temperature was at 120 degrees. [NAME] A did not provide a response to if that temperature was warm enough. During an interview on 08/08/2022 at 11:30 AM with the DM and DA, the DM stated that she was not sure what the temperature of the ham should be. The DM stated there used to be something on wall that told them, the DM stated she did not know what the policy stated. The DM stated she thought 120 degrees should be warm enough. The DA located policy and stated the ham should be at 140 and needed to be reheated. DM went to tell the cooks to reheat ham. During interview on 08/08/22 at 11:55 AM, with [NAME] D, she stated she forgot to put on a mask. [NAME] D stated she knew she was to wear a mask. [NAME] D stated she knew she was supposed wash hands when entering the kitchen but forgot since she washed them the first time she entered the kitchen. During an interview on 08/10/2022 at 8:40 AM with [NAME] B, she stated she had taken her mask off because she was cooking and the heat from the oven was making her hot and it was hard to breathe. [NAME] B stated she altered her N95 mask because it made it easier to breathe. [NAME] B stated she had been trained on the correct way to wear mask and knew she should not have cut the straps. During an interview on 08/10/2022 at 8: 45 AM with [NAME] C, she stated that she knew that she had to wear a N95 mask but sometimes it gets hard to breathe so she pulls it down. During interview on 8/10/22 at 9:00 AM with the DM, she stated that food items were to be dated when received and again when opened. The DM stated if food was taken out of original package it should have item name written on it and an open date. The DM stated food should have been sealed and not open to air. The DM stated food not being stored or labeled could affect residents by food loose flavor. The DM stated what led to failure was staff were stuck in their old ways and did not want to change. The DM stated she had taken off mask earlier because it was hard to breathe. The DM stated due to COVID in building everyone was to wear N95 mask, and mask should not be altered. The DM stated N95 mask were to be worn with one strap over top of head and one strap below ears. The DM stated mask should not have been altered. The DM stated mask were to be worn to protect residents and staff from spreading germs. The DM stated staff have been trained on the proper way to wear a N95 mask. The DM stated what led to failure was staff get hot in the kitchen and staff cannot breathe. The DM stated her expectation was staff were to wash hands every time they enter the kitchen, touched their mask, touched their face, or changed task. The DM stated this could affect residents by spreading foodborne illness. The DM stated she did not know what led to failure because staff have been trained to wash hands. The DM stated her expectation was food temperatures were to be taken when food was cooked and again on the serving line before food was served to residents. The DM stated the thermometer was to be cleaned with alcohol swab after taking each food's temperature. The DM stated the same paper towel should not have been used to clean the thermometer while temperatures were taken because that caused cross-contamination. The DM stated if food was not at the correct temperature, then it needed to be reheated. The DM stated there was not a specific training for taking temperatures of food, that staff just know to do it. The DM stated food not being cooked or held at appropriate temperature would cause residents to get sick from foodborne illness. The DM stated she did not know what led to failure of temperatures not taken correctly because there was a policy in place, but she doesn't know if they had read the policy. The DM did not state the method of monitoring to ensure that failures do not occur During an interview on 08/10/22 at 1:07 PM with the ADM, she stated her expectation was that food temperatures should be taken when cooked and prior to serving food. The ADM stated that food temperatures should be maintained at 140 degrees or above. The ADM stated the thermometer needed to be cleaned between each food with an alcohol swab. The ADM stated a paper towel should not be used to clean thermometer between different foods. The ADM stated if food was not at or above required temperature it needed to be reheated to correct temp before serving. The ADM stated food being below appropriate temps could have affected residents by getting sick or loose appetite and not want to eat because food was not warm. The ADM stated the supervisor cook was responsible to ensure temps are correct, ultimately the DM and ADM are responsible to ensure temperatures were be taken correctly. The ADM stated she was not sure what led to failure, because [NAME] A has worked in kitchen for a while. The ADM stated regardless of department staff were to wear a N95 mask at all times, because of COVID in building. The ADM stated masks should be worn as directed by manufacturer and should not have been altered to loop over ears, if mask were altered it affects the ability of mask to seal properly. The ADM stated staff wearing mask inappropriately could have caused residents food to be contaminated or spread infections. The ADM stated staff should have washed hands when entered the kitchen, before and after handling food, or after touching their face or mask. The ADM stated the DM was responsible to ensure staff are wearing mask appropriately and performing hand hygiene. The ADM stated what led to failure was staff not wanting to follow leadership, and the DM not being assertive. The ADM stated her expectation was that food be dated when received, dated when opened and when food was removed from original container it needs to be labeled with open date and description on the item. The ADM stated the effect on residents was they could be served spoiled food. The ADM stated the DM was responsible to ensure food was stored and labeled correctly. The ADM stated what led to failure was because of staffing issues the DM was not able to focus on supervisor duties, she was having to work shifts. Record review of the facility' policy titled, Daily Food Temperature Control, dated 2012 revealed: We will assure that food is served at a safe temperature. Temperature of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature log. This is done to help ensure that food is safe and is served within acceptable ranges. Procedure: 1. There is a thermometer available for the use of the department to test the temperature of foods which is sanitized between food testing. 2. Prior to meal service the cook shall take the temperature of all hot and cold foods. 3. Temperatures are recorded on the temperature log form. 4. All hot food shall be cooked and held for service at temperatures of 140 degrees F or above. 5. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 and held at least 15 seconds. Record review of the facility's policy titled, Dry Storage and Supplies, dated 2012 revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry . Dry bulk foods are stored in seamless metal or plastic containers with tight covers on bins which are easily sanitized. Containers are labeled. Open packages of food are stored and closed in containers with tight covers and dated as to when opened. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, dated 2010 revealed: hand hygiene continues to be the primary means of preventing the transmission of infection the following is a list of some situations that require hand hygiene: when coming on duty . Before and after eating or handling food (hand washing with soap and water) . A mask that covers both the nose and mouth . the wearing of a mask, eye protection and face Shields in specified circumstances is mandatory. Record review on 08/10/2022 of [NAME] A's employee file revealed [NAME] A had a current food handler certification. Record review on 08/10/2022 of [NAME] B's employee file revealed [NAME] B had a current food handler certification. Record review on 08/10/2022 of [NAME] C's employee file revealed [NAME] C had a current food handler certification. Record review on 08/10/2022 of DM's employee file revealed DM had a current food handler certification. Record review on 08/10/2022 of [NAME] D's employee file revealed [NAME] D had not completed her food handler certification.