**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 2 (Resident #1 and #2) of 4 residents reviewed for quality of care. 1. The facility failed to ensure staff conducted neurological assessments on Resident #1 after his unwitnessed fall on 12/05/24. 2. The facility failed to ensure staff conducted neurological assessments on Resident #2 after her unwitnessed fall on 01/31/25. These deficient practices could place residents at risk of head injuries, brain bleed and developing undiagnosed conditions. Findings include: Resident #1 Review of Resident #1's admission Record, dated 02/28/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 01/28/25. Resident #1 had diagnoses including cellulitis of right lower limb, neurocognitive disorder with Lewy bodies, dementia, and delusional disorders. Review of Resident #1's Significant Change MDS Assessment, dated 11/11/24, reflected he had a BIMS score of 3, which indicated he had severe cognitive impairment. Resident #1 also had 0 falls since admission. Review of Resident #1's care plan, initiated 07/05/22, reflected he was at risk for falls and staff were required to follow facility fall protocol and evaluate and treat him as ordered or PRN. Review of Resident #1's Progress Notes reflected LVN A documented the following note on 12/05/24 at 10:24 a.m., Resident rolled out of low bed onto floor mat. He was observed laying on left side and comfortable .Resident alert and not in distress. He was laying on the floor on left side. Bed in lowest position. Resident is confused at baseline. He was resistant to us getting him up with Hoyer lift and was hollering which is his normal .No other injuries noted. Resident legal guardian notified of above. Review of Resident #1's Fall Nurse's Note, documented by LVN A on 12/05/24 at 10:29 a.m., reflected he had an unwitnessed fall in his room and was found by staff sitting on the floor next to his bed. Review of Resident #1's Assessments, dated 02/28/25, reflected there were no neurological assessments initiated and completed after Resident #1's fall on 12/05/24. Resident #2 Review of Resident #2's admission Record, dated 02/28/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses including Alzheimer's disease. Review of Resident #2's Quarterly MDS Assessment, dated 12/20/24, reflected she had a BIMS score of 4, which indicated she had severe cognitive impairment. Resident #2 had 0 falls since admission. Review of Resident #2's Care Plan, dated 12/24/24, reflected she was at moderate risk for falls and staff were required to follow facility fall protocol and evaluate and treat her as ordered or PRN. Review of Resident #2's Progress Notes reflected RN B documented the following note on 01/31/25 at 2:35 a.m., Resident rolled out of bed onto fall mat. No injuries, redness, edema, complaint of pain, bruising noted. Resident assessed and assisted back to bed. (Family Member) notified and stated thanks for letting her know. Hospice notified .Physician notified. No new orders. Resident stated she was getting up to do the laundry. Review of Resident #2's Fall Nurse's note, documented by RN B on 01/31/25 at 2:35 a.m., reflected she had a fall from her low bed to mat or floor and stated she was getting up to do the laundry. Review of Resident #2's Assessments, dated 02/28/25, reflected there were no neurological assessments initiated and completed after Resident #2's fall on 01/31/25. During an interview on 02/28/25 at 11:18 a.m., the ADM stated she did not know and would find out if neurological assessments were initiated and completed on Resident #1 after his unwitnessed fall on 12/05/24 and on Resident #2 after her unwitnessed fall on 01/31/25. During an interview on 02/28/25 at 11:23 a.m., the ADM stated she did not see Resident #1's and #2's neurological assessments for their unwitnessed falls and determined there were no neurological assessments initiated and completed. The ADM stated she just learned by the surveyor that Resident #1's and #2's neurological assessments were not initiated and completed after their unwitnessed falls. The ADM stated charge nurses initiated and completed neurological assessments on residents. The ADM stated she was unsure when she most recently in-serviced staff on neurological assessments. The ADM stated she knew it was important to initiate and complete neurological assessments on residents and said, Because they could have a head injury or brain bleed. It could cause an adverse event if neurological assessments were not initiated. During an interview on 02/28/25 at 11:33 a.m., the DON stated she was unsure if she in-serviced staff on neurological assessments and falls. The DON stated charge nurses were responsible for performing neurological assessments on residents. The DON stated she expected neurological assessments to be initiated and completed whenever staff did not know if a resident hit their head and had an unwitnessed fall. The DON stated charge nurses documented neurological assessments on physical sheets that were scanned into residents' electronic health records. The DON stated she did not know why neurological assessments were not performed on Resident #1 and #2 after their unwitnessed falls. The DON stated she did not review Resident #1's and #2's electronic health records to ensure their neurological assessments were initiated, completed, and uploaded and did not follow-up with staff. The DON stated she knew it was important to initiate and complete neurological assessments on residents and said, To make sure there was no declining change in condition due to a head injury. During an interview on 02/28/25 at 11:54 a.m., LVN A stated he was working as the charge nurse on the day and shift Resident #1 had his unwitnessed fall. LVN A stated he was notified by one of the CNAs on duty that Resident #1 rolled out of bed. LVN A stated he went into Resident #1's room and observed the bottom half of his body on the bed and the top half of his body hanging off the bed and towards the floor. LVN A stated he assessed Resident #1 for injuries, changes in condition, vitals, and pain. LVN A stated he was unsure if he needed to initiate neurological assessments on Resident #1 because Resident #1 was still in the bed, there was a fall mat next to the bed, Resident #1 was leaning towards the fall mat, Resident #1's head was hanging on the floor, and he used his nursing judgement. LVN A stated charge nurses were expected to initiate neurological assessments on residents for unwitnessed falls. LVN A stated the DON oversaw and ensured neurological assessments were initiated and completed on residents. LVN A stated he was unsure if he was in-serviced on neurological assessments after Resident #1's unwitnessed fall incident. LVN A stated he knew it was important to initiate and complete neurological assessments on residents and said, Because residents could have hit their head and it could have caused a brain bleed or concussion. An attempt to contact RN B was made on 02/28/25 at 1:51 p.m. The customer called was unavailable. Review of the facility's In-Services, from 12/01/24 through 02/28/25, reflected there were no trainings and in-services related to falls and neurological assessments completed. Review of the facility's Neurological Assessments policy and procedure, revised October 2010, reflected, Purpose: The purpose of this procedure is to provide guidelines for a neurological assessment: .2) when following an unwitnessed fall . General Guidelines: 1. Neurological assessments are indicated: b. Following an unwitnessed fall; Steps in the Procedure: .3. Perform neurological checks with the frequency as ordered or per falls protocol. Documentation: The following information should be recorded in the resident's medical record: .3. All assessment data obtained during the procedure. Review of the facility's Assessing Falls and Their Causes policy and procedure, revised March 2018, reflected, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. General Guidelines: .4. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Equipment and Supplies: .2. Tools to assess resident's level of consciousness and neurological status, if necessary; Steps in the Procedure: After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. .6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. Defining Details of Falls: .2. For each individual, distinguish falls in the following categories: a. Rolling, sliding, or dropping from an object (e.g., from bed or chair to floor); b. Falling while attempting to stand up from a sitting or lying position; or c. Falling while already standing and trying to ambulate. Documentation: When a resident falls, the following information should be recorded in the resident's medical record: .2. Assessment data .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 2 of 3 residents (Residents #27 and Resident #28) reviewed for Medicaid and Medicare Coverage Liability Notices. 1. The facility failed to ensure Resident #27 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when he was discharged from Medicare Part A skilled nursing services. 2. The facility failed to ensure Resident #28 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when he was discharged from Medicare Part A skilled nursing services. This failure could place the residents, or their representatives, at risk of not being fully informed about services covered by Medicare Part A, and unknowingly being charged for Skilled Nursing Services. Findings included: Resident #27 Record review or Resident #27's AR, dated 6/26/2024, reflected a [AGE] year-old man, born on [DATE], who admitted to the facility on [DATE]. He was diagnosed with diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel,) and vascular dementia (which was a disease caused by a lack of blood which carried oxygen and nutrients to the brain.) Record review of Resident #27's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 14. A BIMS Score of 14 indicated the resident had no cognitive impairment. Record review of Resident #27's census date reflected a payer source change from Texas Medicaid to Medicare Part A on 5/1/2024. Medicare Part A, as a payer source, terminated on 8/1/2024. The resident stayed at the facility. Resident #28 Record review or Resident #26's AR, dated 9/26/2024, reflected a [AGE] year-old man, born on [DATE], who admitted to the facility on [DATE]. He was diagnosed with a neurological disorder with Lewy Body (which was a disease having affected the brain having caused problems with thinking, movement, behavior, and mood,) and hypertension (which was a disease effecting the outward pressure on arteries and blood vessel walls). Record review of Resident #26's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. Record review of Resident #26's census date reflected a payer source change from Texas Medicaid to Medicare Part A on 2/7/2024. Medicare Part A, as a payer source, terminated on 5/1/2024. The resident stayed at the facility . Interview on 9/25/24 at 3:00 PM with the BOM revealed she oversaw the issue of the SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055) to those residents who exhausted Medicare Part A days of coverage who remained in the facility (not electing hospice.) She stated she was provided with a blank copy of the SNF ABN when she started working at the facility, but she was not provided with any more charts, documentation, or the Processing Manual Chapter 30 to calculate exactly when a resident was supposed to be given an SNF ABN. The intent of the SNF ABN was it was supposed to let the residents know they were reaching their 100 days of Medicare Part A coverage. Then, given the opportunity to accept fiscal responsibility or appeal the decision. When a resident was not provided with the SNF ABN, they risked being charged for skilled nursing services and the opportunity to the decision to Medicare. Neither Resident #26, nor Resident #27 had a reduction in their quality of care. Their 60-day waiting period to have their Medicare Part A had started, per Medicare rules. The failure rested upon training. Interview on 9/26/2024 at 1:58 PM with the ADMIN revealed she expected the BOM already knew the parameters for having issued Residents a SNF ABN, if they met criteria. The ADMIN stated that she, and corporate offices, should have made sure she was trained, but the ADMIN took the responsibility for the failure. There were no safeguards in place to identify the need for proper SNF ABN disbursement. SNF ABNs were given to residents to know if they might have endured a cost associated with received services previously covered by Medicare Part A. Neither Resident #27, nor Resident #28, lost any Medicare Part A days, leading up to their 100. Both residents were in the position to meet Medicare Part A requirements in and receive services in the future. Neither resident experienced any harm. Upon request, the ADMIN stated the facility utilized the Medicare Claims Processing Manual, dated 12-20-2023, as a guideline to disperse the SNF ABN. Record review of the facility's Resident Rights Policy, dated 2003, reflected the facility was supposed to inform each resident upon admission, and periodically during the residents' stay, if there are any changes of services available in the facility and of charges for those services, including any charges for services not covered under Medicare. Record review of the Medicare Claims Processing Manual (Section 70.2), dated 12-20-2023, reflected an SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items, or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. EVENT DESCRIPTION Initiation In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary. Reduction In the situation in which a SNF proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary. Termination In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to adequately equipp residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 2 of 8 Residents (Resident #4 and Resident #50) who were reviewed for resident call systems. The facility failed to ensure Resident #4 and Resident #50's shared bathroom had a pull string attached to the call light switch making the call light button accessible if the resident were lying on the floor. This failure could place residents at risk of harm by not being able to call for help when needed. Findings included: Resident #4 Record review of Resident #4's AR, dated 9/24/2024 reflected a [AGE] year-old man, born on [DATE], who admitted to the facility on [DATE]. He was diagnosed with Schizophrenia (which was a severe mental disorder having caused hallucination, delusions, and disorganized speech,) hypertension (which was a disease effecting the outward pressure on arteries and blood vessel walls,) and an anxiety disorder (which was a mental heal condition marked by heightened responses, or worry, to certain situations and stimuli.) Record review of Resident #4's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. Resident had no impairment in either upper or lower extremity (shoulder, elbow, wrist, and hand, hip, knee, ankle, or foot.) Resident did not utilize a device for mobility. Resident was independent with toileting hygiene, toilet transfer, sit to standing, and walking 150 feet (which meant the resident completed the activity without assistance.) Resident was always continent of bladder and bowel. Record review of Resident #4's CCP reflected an area of Focus for fall risk, revised on 1/31/2024, evidenced by confusion. The Goal, revised on 5/3/2024, indicated the resident would not sustain serious injury. The Intervention, initiated on 7/24/2023, delegated nursing home staff to ensure the resident's call light was within reach and encourage resident to use it; an area of Focus for ADL self-care, revised on 5/24/2023, evidenced by self-care performance. The Goal, revised on 5/3/2024, indicated resident would maintain current level of function in transfers and toilet use. The Intervention, initiated on 5/23/2023, delegated nursing home staff to encourage resident to use bell to call for assistance. Observation and interview on 9/24/2024 at 10:56 AM revealed Resident #4 lying in his bed under the covers watching television. Resident was soft spoken and slightly difficult to engage; however, the resident was able to verbalize, by speech, and demonstrated, with body language, he was not in any distress. Observations of the resident's bathroom, shared with the adjoining room (Resident #50's room,) reflected a call light switch on the wall next to the commode. The call light switch was approximately 2.5 feet from the floor. The call light switch was angled upwards, having indicated the switch needed to be pulled downwards to be activated. The call light switch did not have an attached string extending to the floor. He correctly demonstrated the use of his call light button affixed to his bed. Observation on 9/26/2024 at 8:32 AM of Resident #4's shared bathroom reflected the call light switch did not have a string having extended to the floor. Interview on 9/26/2024 at 8:33 AM with Resident #4 revealed he was capable of ambulating to the restroom to utilize the commode. He was not aware there was supposed to be a string on the call light switch in the bathroom. Having then known there was supposed to be a string attached to the call light switch, he stated he would have wanted to reach it if he fell. If he had fallen in the bathroom and could not reach the switch 2.5 feet up the wall to call for help, he would have felt helpless and angry. Resident #50 Record review or Resident #50's AR, dated 9/24/2024, reflected a [AGE] year-old man, born on 2/24/1986, who admitted to the facility on [DATE]. He was diagnosed with unspecified focal traumatic brain injury (which was a traumatic brain injury,) hypertension (which was a disease having reduced blood pressure having inhibited blood flow to certain parts of the body,) and depression (which was a mental disorder having resulted in sadness and diminished interest in normal day-to-day activities.) Record review of Resident #50's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 11. A BIMS Score of 11 indicated the resident had moderate cognitive impairment. Resident had no impairment in either upper or lower extremity (shoulder, elbow, wrist, and hand, hip, knee, ankle, or foot). Resident utilized a wheelchair for mobility. Resident required set up or clean up assistance with toileting hygiene, which meant the helper provided set up prior, and cleaned up after, while the resident completed the activity. Resident required supervision or touching assistance with sitting to standing and toilet transfer, which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity. Resident was occasionally incontinent of bladder and bowel. Record review of Resident #50's CP reflected an area of Focus for moderate fall risk, revised on 5/2/2024, evidenced by confusion, physical function decline, gait, and balance problems. The Goal, revised on 7/30/2024 indicated the resident would not sustain serious injury. The Intervention, initiated on, 5/1/2024, delegated nursing home staff to ensure resident's call light was within reach and encouraged resident to use it: an area of Focus for pain, revised on 5/2/2024, evidenced by fractures and trauma. The Goal revised on 7/30/2024, indicated the resident would not have discomfort. The Intervention, revised on 5/2/2024, delegated nursing home staff to call for assistance when in pain; an area of Focus for communication problems, revised 6/14/2024, evidenced by garbled communication. The Goal, revised on 7/30/2024, indicated the resident would maintain current level of communication (having responded to yes or no questions.) The Intervention, initiated on 6/14/2024, delegated nursing home staff to ensure a safe environment with call light in reach; and, an area of Focus for ADL self-care performance, initiated on 5/1/2024, evidenced by physical function decline R/T confusion. The Goal, revised on 7/30/2024, indicated the resident will keep his current level of function in toilet use. The Intervention, initiated on 5/1/2024, delegated nursing home staff to encourage to resident to use bell to call for assistance. Observations and interview on 9/24/2024 at 11:12 PM with Resident #50 revealed him lying in his bed watching television. Resident #50 was afflicted with communication problems. Having knelt to his level and having utilized yes or no questions, the resident was able to verbalize, with speech, that he was not in distress or in any pain. Observations of the resident's bathroom, shared with the adjoining room (Resident #4's room,) reflected a call light switch on the wall next to the commode. The call light switch was approximately 2.5 feet from the floor. The call light switch was angled upwards, having indicated the switch needed to be pulled downwards to be activated. The call light switch did not have an attached string extending to the floor. He correctly demonstrated the use of his call light button located on his bed. Observation on 9/26/2024 at 8:51 AM of Resident #50's shared bathroom reflected the call light switch did not have a string having extended to the floor. Interview on 9/26/2024 at 8:52 AM with Resident #50, having used yes or no questions, revealed he had used the commode in his room. He was able to get from the bed to his wheelchair, get to the bathroom with the use of his wheelchair; get from his wheelchair to the commode (he stated he had held on,) get from the commode to his wheelchair; and get back to his bed with his wheelchair. His communication problems inhibited him from having elaborated. Interview on 9/26/2024 at 9:01 AM with CNA C revealed residents have call light buttons in their rooms to call for assistance from staff. The call light buttons were supposed to be in arm's reach of the resident at all times. In addition to the call light button in each resident's room, there was also a call light switch located in each resident's bathroom. The call light switch was located on the wall next to the commode at the same level as the commode's seat. The call light switch had a string attached that extended to the floor. CNA C explained a resident might use the switch to call for help while on the commode but did not know why there was a string attached. She stated she had not received any instruction or training to have ensured the string was attached and hung towards the level of the floor. Having then known the string was a requirement for the resident to use if they were lying on the floor, she stated a resident's inability to call for help could have caused extended periods of pain, sadness, or feelings of neglect. CNA C stated the facility staff performed room checks, called Angel Rounds, to make sure the residents' call light systems were in proper working condition but was unaware if the string on the call light switch in the bathroom was one of the checks on the Angel Round list. Interview on 9/26/2024 at 11:56 AM with the MNTD revealed the bathrooms in the resident's rooms required not only a call light switch, but also required a string, or a cord, which hung in the direction of the floor. The string, or cord, hung in the direction of the floor to make the call light switch accessible if the resident were laying on the floor. The call light switch string in the shared bathroom of Resident #4 and Resident #50 was not present. Interview on 9-26-2024 at 12:20 PM with the MNTD revealed he went to the shared bathroom of Resident #4 and Resident #50 and replaced the string on the call light switch. Interview on 09/26/24 as 12:55 PM with the DON revealed staff were trained to make sure the call light switches in the residents' bathrooms were functioning properly, but not trained to have ensued a string was present, or a string had stretched to the floor. A safeguard in place to address call light switches in the resident's bathrooms, was a checklist and visual inspection called Angel Rounds. The checklist suggested having ensured the call light switch in the bathroom was working properly, but the check list did not annotate the call light switch had to have a string that stretched to the floor. Residents, who had fallen to the floor in the bathroom, who were unable to use the call light switch, because there was no string, risked exposure to prolonged pain, risked further injury, and risked feelings of helplessness. The failure for the call light switch not having a string, which extended to the floor, fell upon awareness and staff training. The DON reported there have been no occurrences of residents falling in the bathrooms and not having been able to receive assistance through the call light switch system. Interview on 9/26/2024 at 2:59 PM with the ADMIN revealed she expected staff to follow policy and to have ensured the call light switch string, in the bathroom, was in the most accessible spot for the resident. The most accessible spot for the call light switch string was attached to the switch and having extended to the floor. A safeguard in place to check for functional call light switches in the bathroom was the use of a visual inspections, with a checklist, called Angel Rounds. The Angel Round's checklist directed the inspector to make sure the call light switch, in the bathroom, was working correctly, but did not annotate the requirement to check for the string. The ADMIN, herself, performed the Angel Round check for the bathroom in Resident #50's room yesterday, 9/25/2024, for cleanliness, but did not notice the string missing. She performed another Angel Round check, today 9-26-2024, where she only looked at the room for cleanliness. Upon request, the ADMIN was unable to produce the checklist she used for Resident #50's room. The failure to identify, and correct, the missing string on the call light switch fell upon nursing staff, maintenance, and the use of the Angel Rounds checklist., and oversite. Neither Resident #4, nor Resident #50, experienced and falls in the shared bathroom. Observation on 9-26-2024 at 4:00 PM in Resident #4 and Resident #50's shared bathroom reflected the string on the call light switch had been replaced and extended to the floor. Record review of the facility Angel Round's Checklist, page 1, undated, reflected a line item, called [Is the call light in the bathroom in working order?] Record review of the facility's Preventative Maintenance Policy, dated 2003, reflected the facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance. The facility will maintain all preventive maintenance logs in a notebook binder. The book will be maintained in a neat and organized manner and will be easily accessible at all times. Record review of the maintenance log, located on the desk next to the nurse's station, reflected a chronological order of maintenance requests. There was no request made for (Resident #4) or (Resident #50) requesting repair of the bathroom call light switch string. Record review of the facility's Resident Call System, dated September 2022, reflected each resident was provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the 27 residents, in the memory care unit, reviewed for a safe, clean, comfortable, and homelike environment The facility failed to report maintenance issues to the MNTD and make repairs to a loose hand railing, in the memory care unit community bathroom . This failure could have placed the residents in the memory care unit to falls. Findings included: Observation on 9/24/2024 at 11:38 AM revealed a handrail, inside the community bathroom on the facility's memory care unit, was loose. The handrail was still attached firmly to the wall in the bathroom but had 1 to 2 inches of vertical movement. There were no sharp edges. Interview on 09/24/24 at 11:41 AM with CNA A revealed the handrail was loose. She stated she was trained to report maintenance issues to the MNTD by writing the area of concern in the facility's maintenance book and telling the MNTD. She stated the book was in the main room, at the front of the facility, near the nurse's station . Interview and observation on 09/26/24 at 8:42 AM with the ADM revealed the handrail in the memory care unit's community bathroom was loose. The ADM was unaware the handrail was loose; she had not received any reports for the need of maintenance. The ADM was observed having closed the restroom, having pended repairs . Observation on 09/26/24 at 9:37 AM revealed the ADM and the MNTD having begun to repair the handrail in the memory care unit's community restroom. Interview, observation, and record review on 09/26/24 at 11:56 AM with MNTD revealed the handrail in the memory care unit's community bathroom was tightly secured to the wall. The MNTD stated the process to report maintenance concerns was to write the issue on the maintenance book. He checked the book daily and made repairs as they were raised. CNA A had informed him yesterday, 9/25/2024, that the handrail was loose. He looked at it yesterday, but was unable to secure it, so he had planned to fix it today, 9/26/2024. He received a text message from the ADM today, at 8:50 AM, having instructed him to fix the handrail. The loose handrail could have caused a resident to lose their balance or have had an actual fall. Record review of the facility's maintenance book revealed no maintenance requests having pertained to the bathroom's handrail. Interview on 09/26/24 at 2:07 PM with the ADM revealed she expected her staff to utilize the maintenance book and report maintenance issues to the MNTD. Issues that were a hazard, or posed risk to resident safety, were supposed to be reported and fixed immediately. A safeguard in place to identify maintenance issues consisted of a check list called Angel Rounds. The failure to repair the handrail timely was the failure of staff to use the Angel Round checklist and the maintenance book per policy. There had been no accidents in the memory care unit's community bathroom. Record review of the maintenance log, located on the desk next to the nurse's station, reflected a chronological order of maintenance requests. There was no request made for the handrail in the memory care unit's community bathroom. Record review of the facility Angel Round's Checklist, undated, reflected no line item to check the memory care unit's community bathroom. Record review of the facility's Preventative Maintenance Policy, dated 2003, reflected the facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance. The facility will maintain all preventive maintenance logs in a notebook binder. The book will be maintained in a neat and organized manner and will be easily accessible at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 23, Resident # 29, and Resident #104) reviewed quality of life. The facility failed to ensure Resident #23's, Resident #29's, and Resident #104's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. 1. Record review of Resident # 23's Face Sheet dated, 09/25/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of other frontotemporal neurocognitive disorder (a rare brain disease that causes gradual damage to the frontal and temporal lobes of the brain), dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance ( a medical condition that refers to a moderate stage of dementia- decline with thinking, remembering, and reasoning, to the point that it interferes with a person's daily life- in patients with other diseases that cause cognitive decline), and impulse disorder ( difficult to control you actions or reactions). Record review of Resident #23's Quarterly MDS Assessment, dated 08/30/2024, reflected the resident had a BIMS score of 8 which reflected her cognition was moderately impaired. Resident #23 required supervision with showers. She was independent with personal hygiene. Resident #23 required supervision with eating. Record review of Resident #23's Comprehensive Care Plan, 09/03/2024 reflected Resident #23 had an ADL self-care performance deficit related to dementia. Intervention: Resident #23 required limited to extensive assistance with dressing, personal hygiene, and bathing. Resident #23 resided on the secured unit related to wandering into unsafe areas. She was at risk for complication. Intervention: monitor for discomfort and exit seeking. Resident #23 had impaired vision. She was at risk for complications. She had glasses, however, did not wear them all the time. Intervention: Monitor, document, and report to MD the following signs and symptoms of acute eye problems. Observation on 09/24/2024 at 9:46 AM revealed Resident #23 was lying in bed. Resident # 23 had blackish/ brownish substance underneath the forefinger, ring finger, and middle fingernails on her right hand. In an interview on 09/24/2024 at 9:48 AM revealed Resident #23 stated her nails looked bad. Resident #23 did not respond to any other questions such as: if she reported her dirty nails to staff, how long the blackish substance had been on her nails, and why she thought her nails looked bad. 2. Record review of Resident # 29's Face Sheet, dated 09/25/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebella stroke syndrome ( a type of stroke that occurs when blood flow to the part of the brain is disrupted), visual agnosia ( a condition that affects how your brain processes what you see), and tremor ( involuntary shaking can affect hands, arms, or head, and usually happens when trying to hold a position). Record review of Resident #29's Quarterly MDS Assessment, dated 08/09/2024, reflected Resident #29 had a BIMS score of 4 which reflected his cognitive status was severely impaired. Resident #29's vision was severely impaired (no vision or sees only light, color or shapes; eyes do not appear to follow objects). He was dependent on staff for personal hygiene, dressing, showers, toileting hygiene, and transfers. Record review of Resident #29's Comprehensive Care Plan, dated 08/13/2024, reflected Resident #29 had an ADL self-care performance deficit related to dementia (the loss of thinking, remembering, and reasoning. To the extent that it interferes with a person's daily life and activity). Intervention: Resident #29 required extensive to total assistance with personal hygiene. Observation on 09/25/2024 at 10:30 AM revealed Resident # 29 was in the dining area sitting at a table. Resident #29 had blackish/ brownish substance underneath the middle, and ring fingernails on his right hand. There was a hard blackish/brownish substance on the tip of his middle finger. An attempted interview on 09/25/2024 at 10:34 AM with Resident #29 revealed he was not interview able. 3. Record review of Resident #104's Face Sheet, dated 09/25/2024, reflected an [AGE] year-old female was admitted on [DATE] with diagnoses of parkinsonism, unspecified ( a progressive brain disorder that causes movement problems, mental health issues, and other health issues), anxiety disorder (excessive worry, and feelings of fear, dread, and uneasiness), and essential hypertension ( a type of high blood pressure that develops gradually over time and was not caused by another medical condition). Record review of Resident #104's Quarterly MDS Assessment, dated 06/14/2024, reflected the resident had a BIMS score of 5 which indicated her cognition status was severely impaired. Resident #104 was assessed to require partial/moderate assistance (helper does more than half the effort) with the following: personal hygiene, eating, oral hygiene, showers, dressing, and transfers. Record review of Resident 104's Comprehensive Care Plan, revised on 09/13/2024, reflected Resident #104 had an ADL self-care performance deficit related to dementia. Intervention: Resident #104 required one to two staff participation with personal hygiene. Resident #104 had impaired cognitive function related to dementia (the loss of thinking, remembering, and reasoning and interferes with a person's daily life and activities), and Parkinson's disease. Observation on 09/25/2024 at 2:00 PM Resident #104 was in her room lying in bed. Resident #104 had blackish/brownish substance underneath her middle and ring fingernails on her right hand. An attempted interview on 09/25/2024 at 2:04 PM with Resident #104 revealed she was not interview able. Record review of Resident #23, Resident # 29, and Resident #104's electronic medical record reflected there was no documentation of when fingernail care was provided, name of person that administered nail care, and the condition of the nails. In an interview on 09/26/2024 at 8:45 AM the Director of Nurses stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may. She stated there was a possibility a resident may develop vomiting or diarrhea. She stated all residents were expected to receive nail care during showers and as needed. The Director of Nurses stated the CNAs completed nail care on all residents except for the residents with a diagnosis of diabetes (a disease when your blood sugar was too high). She stated it was the nurse's supervisor responsibility to monitor residents nail care. In an interview on 09/26/2024 at 08:52 AM, CNA A stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA A stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA A stated there were also a possibility a resident may become severely dehydrated and may need to be transferred to emergency room to determine what type of bacteria was underneath the residents' fingernails. CNA A stated she had been in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated the only residents she knew that refused nail care was Resident #10. In an interview on 09/26/24 at 08:56 AM, LVN C stated the nurses, and the CNAs were responsible for nail care. He stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN C stated it was the CNAs responsibility to clean and trim all other residents' nails during showers or as needed. He stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria . He also stated if a resident swallowed the bacteria there was a possibility a resident may become ill with diarrhea. He stated she was only aware of Resident # 10 that refused nail care. LVN C stated the nurse supervisor was responsible for monitoring nail care. In an interview on 09/26/2024 at 9:02 AM, LVN A stated the nurses was responsible for diabetic nail care such as trimming, filing, and cleaning. She stated the CNAs were responsible for all other resident's nail care. LVN A stated if a blackish/brownish substance was underneath the resident's nails, there was a possibility it could be some type of bacteria. LVN A stated if a resident ingested the blackish substance and it was bacteria, a resident may become ill with vomiting, diarrhea, and possibly E. coli (a type of bacteria that is commonly found in the intestines). She stated Resident #10 refused nail care and she was not aware of any other resident that refused any type of nail care. LVN A stated she had been in-serviced on nail care but did not recall the date or time of the in-service. In an interview on 09/26/2024 at 9:08 AM, CNA D stated the nurses completed all diabetic fingernails, and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers. CNA D stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day, the staff were expected to do any type of nail care as needed. She stated if a resident had a blackish substance underneath their nails, it was probably some type of bacteria. She stated if a resident swallowed bacteria it was had potential that the resident may develop major stomach problems such as diarrhea. CNA D stated if a resident became severely ill the resident may need to be transferred to an emergency room for more care. She stated all residents except Resident #10 agreed to staff completing nail care. She stated she had been in-serviced on nail care but did not remember the date of the in-service. She stated it had been about a year. 1. Record review of the facility's Policy on ADLs revised February 2018 reflected The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. 2. Nail care includes daily cleaning and regular trimming. 3. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care. 3. The condition of the resident's nails and nail bed, including: 1. Redness or irritation of skin of hands and feet. 2. Bluish or dark color of nail beds. 3. Corns or calluses. 4. Ingrown nails. 5. Bleeding; and/or 6. Pain. 4. Any difficulties in cutting the resident's nails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 3 of 13 residents (Resident #18, Resident #26, and Resident 30) reviewed for dietary services. The facility failed to ensure Resident #18, Resident #26, and Resident #30 received their prescribed diet for 09/24/2024 lunch. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food,) and diminished quality of life. Resident #18 Record review or Resident #18's AR, dated 09/24/2024, reflected an [AGE] year-old man, born on 7/11/1942, who admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (which was a progressive disease having caused mild memory loss, inability to execute conversations, and the inability to respond to the environment) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.) Record review of Resident #18's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 3. A BIMS Score of 3 indicated the resident had severe cognitive impairment. Resident was prescribed a mechanically altered diet, while a resident. Resident required supervision or touching assistance with eating, which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity. Record review of Resident #18's CP reflected an area of Focus for potential weight loss, revised on 7/10/2024, evidenced by illness. The Goal, revised on 7/2/2024, indicated the resident was supposed to maintain weight. The Intervention, revised on 7/10/2024, was a delegated dietary staff to provide a mechanical soft diet. Record review of Resident #18's Order Summary Report reflected an order, started 4/7/2022, for a regular diet with mechanical soft texture. Record review of Resident #18's weights, located in PCC, reflected no weight loss/gain in the last 30 days; 1.59% of body weight gain in the last 90 days; and a 1.54% of body weight loss in the last 180 days. Interview, observations, and record review on 09/24/24 at 12:18 PM with Resident #18 revealed him sitting at the lunch table. His meal ticket, located on the table next to him, designated the resident to receive a Mechanical Soft Diet. The ticket indicated the resident was supposed to have received [peeled] roasted new potatoes. Observation of his entrée for lunch revealed the roasted new potatoes on his plate had the skin in place. Interview revealed the peels were hard to eat because he did not have enough teeth. He was observed sticking out his tongue having displayed a quarter sized piece of roasted new potato skin. He took it from his tongue with his fingers. He was not observed having choked or aspirated. Resident #26 Record review or Resident #26's AR, dated 09/24/2024, reflected a [AGE] year-old man, born on 1/18/2027, who admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (which was a progressive disease having caused mild memory loss, inability to execute conversations, and the inability to respond to the environment) and heart disease (which occurred when the heart muscle did not perform efficiently). Record review of Resident #26's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 4. A BIMS Score of 4 indicated the resident had severe cognitive impairment. The resident was prescribed a mechanically altered diet, while a resident. Resident required supervision or touching assistance with eating, which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity. Record review of Resident #26's CP reflected an area of Focus for weight loss and nutrition, initiated on 9/29/2022, evidenced by mental status. The Goal, revised on 5/8/2024, indicated the resident was supposed to maintain weight and receive proper nutrition. The Intervention, revised on 8/22/24, delegated dietary staff to provide a mechanically altered diet. Record review of Resident #26's Order Summary Report reflected an order, started 7/10/2024, for a regular diet with mechanical soft texture. Interview and observation on 09/24/24 at 10:33 AM with Resident #26 revealed him, with his RP, in the common room on the memory care unit. Interview with the RP revealed his dad received excellent care at the facility. He did not have any issues or concerns. Record review of Resident #26's weights, located in PCC, reflected no weight loss/gain in the last 30 days; 1.49% of body weight loss in the last 90 days; and a 6.38% of body weight loss in the last 180 days. Interview, observation, and record review on 09/24/24 at 12:30 PM with Resident #26 revealed him sitting at the lunch table being assisted with his meal by CNA A. His meal ticket, located on the table next to him, designated the resident to receive a Mechanical Soft Diet. The ticket indicated the resident was supposed to have received [peeled] roasted new potatoes. Observation of his entrée for lunch revealed the roasted new potatoes on his plate had the skin in place. Resident #26 was non-interviewable. Interview with CNA A revealed she was helping him eat his lunch. She was observed having cut his roasted new potatoes, with skin, into small bite size pieces. CNA A stated she did not remember if Resident #26 displayed difficulty eating the roasted new potatoes, with skin. He was not observed having choked or aspirated. Resident #30 Record review or Resident #30's AR, dated 09/24/2024, reflected a [AGE] year-old woman, born on [DATE], who admitted to the facility on [DATE]. She was diagnosed chronic obstructive pulmonary disease (COPD) (which was a respiratory condition characterized by persistent breathlessness and cough) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.) Record review of Resident #30's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 3. A BIMS Score of 3 indicated the resident had severe cognitive impairment. Resident was prescribed a mechanically altered diet, while a resident. Resident required set up or clean up assistance with eating, which meant the helper provided set up prior, and cleaned up after, while the resident completed the activity. Record review of Resident #30's CP reflected an area of Focus for unplanned weight loss/gain, initiated on 6/14/2024, evidenced by COPD. The Goal, revised on 6/14/2024, indicated the resident was supposed to maintain weight and proper nutrition. The Intervention, initiated on 6/14/2024, delegated dietary staff to provide a mechanical soft diet. Record review of Resident #30's Order Summary Report reflected an order, started 3/22/2022, for a regular diet with mechanical soft texture. Record review of Resident #30's weights, located in PCC, reflected a .70% body weight loss in the last 30 days; .71% of body weight gain in the last 90 days; and a 2.90% of body weight gain in the last 180 days. Interview, observation, and record review on 09/24/24 at 12:41 PM with Resident #30 revealed her sitting at the lunch table. Her meal ticket, located on the table next to her, designated the resident to receive a Mechanical Soft Diet. The ticket indicated the resident was supposed to have received [peeled] roasted new potatoes. Observation of her entrée for lunch revealed the roasted new potatoes peels on her plate. She had removed the skin with her knife and fork. Interview revealed she removed the potato skins because she had difficulty chewing and swallowing them. She was not observed having choked or aspirated. Interview on 09/24/2024 at 12:20 PM LVN D revealed she did not compare the meal tickets to the meal trays for any of the residents in the main dining room, residents in the memory care unit, or the residents in their rooms. She stated she was expected to ensure each meal tray matched what was on the meal slip. LVN D stated a resident, who received the wrong texture diet, may have choked or aspirated. She had been in-serviced (trained) on meal service; the nurses were required to compare each resident's meal ticket to match residents' meal tray prior to the meal tray being served to the resident. Interview on 09/24/24 at 12:37 PM with LVN A revealed the kitchen was supposed to check each meal tray as it left the kitchen to make sure the meal matched the specifics of the residents' meal ticket and prescribed diets. Again, staff in memory care unit dining room were supposed to check the meals and tickets prior to having served the residents. She stated that neither she, nor other nursing staff in the memory care unit, checked the meal tickets for today's lunch meal. Interview on 09/24/24 at 2:10 PM with the dietary manager revealed the process of the facility for having plated and delivered the residents' meals. The dietary cooks were supposed to check the resident's meal ticket and plate the food accordingly. The kitchen aids, who added beverages and desserts, were supposed to double check the meal tickets. The dietary manager was supposed to oversee the meal process to make sure all the meal trays matched the meal tickets and prescribed diets. Any failures, having related to discrepancies related to texture or therapeutic diets, fell upon the whole team in the kitchen. The failure rested upon the dietary cooks, kitchen aids, and the dietary manager. Once the trays left the kitchen, any discrepancies related to texture, or therapeutic diets, fell upon the nursing staff. The dietary manager stated a resident who was supposed to get a mechanical soft diet required potatoes to be peeled. The skins, on the roasted new potatoes, were a hazard, because the residents could not chew, or swallow them. Interview on 09/26/24 at 12:00 PM with the DOT revealed residents, who were prescribed mechanical soft diets, were residents who displayed difficulty chewing and swallowing in the resident assessment. A resident who required mechanical soft diets, who received regular texture meals, risked having choked, aspirated, or difficulty eating. Nursing staff were required to check the residents' meals against the resident specific meal ticket for accuracy. Interview on 09/26/24 at 12:35 PM with the DON revealed staff, who were passing out the meal trays, were supposed to make sure the food tray matched the resident's meal ticket. Residents who received a different texture meal, such as regular texture instead of mechanical soft, would have had difficulty chewing and swallowing and risked aspiration or choking. A mechanism in place, to make sure residents received the correct diet, was initial staff training and periodic spot checks by upper management. Staff were trained to know the difference between regular texture, mechanical soft texture, and a pureed texture. The failure for the residents to receive the correct texture fell upon dining staff misreading, or not identifying discrepancies, with the resident 's specific meal ticket. The DON had not received complaints from residents about texture differences; there had not been any resident to suffer adverse health effects from texture discrepancies. Interview on 09/26/24 at 02:31 PM with the ADM revealed alternate textured diets were ordered for residents, per their attending physician or provider, based on resident assessments. She expected her staff to make sure prescribed textures were congruent with the resident's specific meal ticket. Residents who consumed different textures could aspirate, choke, or consume fewer calories. Practices in place, to avoid texture inconsistent meal service, consisted of spot checks and table visits from nursing and administrative staff. The failure for the staff to ensure plates were provided with the correct texture fell upon misreading the resident 's meal ticket. Record review of the facility's Therapeutic Diet Policy, dated October 2017, reflected a mechanically altered diet was ordered, the provider was supposed to specify the texture modification. The facility was supposed to have sufficient staff, with the appropriate training set, to carry out the functions of meal service, including validation of tray card diet type and texture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 5 of 5 resident (Resident #20, #22, #32, #33, and #42) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene when passing medications on Residents #20, #32, and # 33. The facility failed to ensure CNA-A and CNA-B sanitized equipment between residents. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident 22's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Parkinsonism, Anxiety, Depression, HTN, and Hyperlipidemia. Record review of Resident 22's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 22's Care Plan, reflected a Focus area was initiated for resident requiring a full body sling lift for transfers on 7/30/24 with a goal for the resident to sit out of bed daily. Record review of Resident 32's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), HTN, Macular degeneration (eye deterioration), Depression, Seizures, and Atrial Fibrillation. Record review of Resident 32's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated the resident's cognitive ability was not impaired. Record review of Resident 32's Care Plan, reflected a Focus area was initiated for impaired cognitive function on 6/11/2024 with a goal to maintain current level of cognitive function. Record review of Resident42's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Peripheral Vascular Disease (Blood vessel disease), Anxiety, Hypomagnesemia, Hypokalemia (low potassium), and Opioid -Induced Disorder. Record review of Resident 42's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident 42's Care Plan, reflected a Focus area was initiated for pain management on 8/23/2024 with a goal for resident to verbalize adequate relief of pain. Record review of Resident 20's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Alzheimer's, Depression, HTN, and Hypothyroidism. Record review of Resident 20's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 20's Care Plan, reflected a Focus area was initiated for impaired cognitive function/dementia related to dementia on 6/14/2024 with a goal for resident to maintain current level of cognitive function. Record review of Resident 33's undated face sheet, revealed he was an [AGE] year-old male admitted [DATE] with diagnoses of neurocognitive disorder, Tremor, Anxiety, Muscle Wasting, and History of Falling. Record review of Resident 33's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive ability could not be accurately assessed. Record review of Resident 33's Care Plan, reflected a Focus area was initiated for requiring use of full body lift-med sling on 6/21/2024 with a goal for resident to be out of bed daily. Observation on 9/25/24 at 8:53 am revealed the MA removed her gloves after applying gel to Resident 20's knee. She then picked up the cup the resident had been holding and put gloves in the cup to discard. MA discarded the cup, wiped down the measuring tool, and then touched the mouse and cart to start new med's on other residents with no hand hygiene done prior to touching the cart. Observation on 9/25/24 at 9:10 am revealed the MA had gloves on to apply eye drops to Resident 32. She took the Kleenex box into the room to hand the resident a Kleenex to dry her eyes. Eye drops administered with gloves on, and Kleenex box picked up and then taken out to the medication cart while wearing the same gloves. She touched items on the med cart before removing the gloves. No hand hygiene seen/no hand rubbing seen after gloves removed. Observation on 9/25/24 at 9:18 am revealed the MA gave Resident #42 her pain med's (no gloves) and touched the used medication cup to discard it. She then returned to the medication cart without applying hand hygiene prior to touching the cart. Observation on 9/25/24 at 1:39 PM revealed CNA-A and CNA-B placed Resident #22 in the Hoyer sling. As they were hooking the Hoyer straps, the resident was touching multiple areas on the Hoyer bars. The Hoyer was then removed from the resident's room without sanitizing the contaminated areas of the equipment. Hand Hygiene was observed for both staff. Observation on 9/25/24 at 2:04 PM revealed CNA-A and CNA-B moved the Hoyer Lift from Resident #22's room to Resident #33's room without sanitizing the equipment. They then proceeded to place Resident #33 in the Hoyer sling and move him to the bed. Hand hygiene was performed. In an Interview with the MA on 9/25/24 at 9:20 am regarding lack of hand hygiene seen during the medication pass, she stated that she reached into drawer 3 to do hand hygiene (out of the state surveyors viewing area). She has a bottle of alcohol gel in the left corner of drawer 3. She stated she stored it there instead of on the top of the medication cart to keep residents from picking up the alcohol gel. The MA agreed she may have not done that between touching resident 20's med cup and touching the medication cart and the measuring tool which could have contaminated those items. In an interview on 9/26/24 at 1:29 PM with LVN-A she stated, the policy on hand hygiene after contacting resident items was to sanitize hands after touching patient items. She stated this was important, so you don't spread anything. LVN-A stated the negative outcome to residents if this was not done was that the residents could get sick from infections. LVN-A also stated the policy on cleaning Hoyer's was that they were to be cleaned every time it was used before going to the next resident. She stated the Hoyer should be wiped down with wipes between rooms and if residents touch the equipment. She said it should be wiped down because residents can touch the equipment, touch themselves, and spread disease and infection to themselves and other residents which could make them sick. In an interview on 9/26/24 at 1:36 PM with LVN-B she stated, the policy on hand hygiene after contacting resident items was to clean with alcohol gel or soap and water. She stated this was important to prevent spread of infections and for resident rights. LVN-B stated if this was not done the residents could get infected or contaminated. She stated the policy on cleaning Hoyer lifts was to clean with manufacture guidelines between residents as it could come in contact with residents when in use. LVN-B also stated this was important to prevent spread of infection and if not done then resident could get infections. In an interview on 9/26/24 at 1:40 PM with CNA-C she stated, the policy on hand hygiene after contacting resident items was to wash hands or use hand sanitizer and it was important for infection control. She stated not doing it could cause residents infections and transmit disease. She stated reusable equipment should be wiped off with alcohol wipes between residents. CNA-C also stated the policy on cleaning a Hoyer Lift between rooms was to clean and sanitize with wipes to prevent spreading bacteria and disease. In an interview on 9/26/24 at 1:55 PM with the DON she stated, the policy on hand hygiene after contacting resident items was to wash your hands between patients and equipment. She stated this was important to reduce infections. She stated not doing it could cause infections. She stated the policy on cleaning equipment that was re-usable on multiple residents was to clean between rooms. She stated the Hoyer lift should be cleaned between rooms and residents. If they touch the equipment, it should be cleaned. She stated this was important to prevent transmission of disease and to prevent infections for residents. In an interview on 9/26/24 at 1:45 PM with the ADMIN she stated, the policy on hand hygiene after contacting resident items was to wash your hands. She stated this was important so germs were not spread to other items or residents which could cause illnesses. The ADMIN stated the policy on cleaning equipment that was re-usable on multiple residents was to wipe equipment clean. She stated the policy on cleaning the Hoyer lifts as it goes from room-to-room, was to clean if soiled and routine cleaning weekly. She stated if residents touch Hoyer's they should be cleaned so germs were not spread from 1 resident to another and not cleaning it could pass illness or germs. A record review of the facility policy titled, Handwashing/Hand Hygiene Version 3.0 in the 2001 Med-Pass, Inc with a last revision date of 2023 reflected the following: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated immediately before and after touching a resident or their environment. Hand Hygiene is indicated immediately after glove removal. A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2023 reflected the following: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Durable medical equipment is cleaned and disinfected before reuse by another resident.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 2. The facility failed to seal, label, and date tortillas and failed to label and date two large bags of ice-covered chicken in one of one freezer located in the dry storage area. These failures could place residents at risks for health complications and foodborne illnesses. Findings included: 1. Observation on 09/24/2024 at 9:15 AM Dietary [NAME] was not wearing gloves. She touched her shirt and touched a cleaning towel. She did not wash or sanitize her hands prior to touching the fourchettes of the gloves when she was placing the gloves on her hands. She touched clean plates and inside of a scoop. In an interview on 09/24/2024 at 9:19 AM the Dietary [NAME] stated she did touch her shirt and touched the cleanser towel to clean different surfaces. She stated she did pick up the gloves where the fingers go inside the gloves, and she did not wash or sanitize her hands. The Dietary [NAME] stated she did touch clean plates and inside of the scoop she was going to use to begin cooking lunch. She stated she had been in-serviced on washing hands prior to wearing gloves and in between tasks. She did not recall the date of the in-service. Observation on 09/24/2024 at 12:15 PM the Dietary Aide was placing desserts, utensils inside of napkin, plate of the lunch meal and drink, and carrying the tray outside of the kitchen (approximately 4 feet) where the meal tray cart was located. There was not enough room in the kitchen for the covered meal cart. The Dietary Aide was not wearing gloves. She touched the right side of her pants and shirt four times. She did not wash her hands after touching her clothes. The Dietary Aide touched six residents' napkins holding residents' silverware. The Dietary Aide touched inside the dessert plate and touched inside of the cups of tea. In an interview on 09/24/2024 at 1:15 PM the Dietary Aide stated she did touch her pants and shirt and did not wash her hands. She stated she was expected to wash her hands anytime she touched anything that may be contaminated. The Dietary Aide stated her clothes were considered contaminated. She stated she did touch napkins and she may have touched inside the cups of tea. The Dietary Aide stated she did touch inside the dessert plate. She stated there was a possibility there was bacteria on her hands and she could have cross contaminated the napkins, inside of cups, and plates. The Dietary Aide stated if there were bacteria on her hands and it was on a resident's napkin, plate, or inside of the cup, it was possible a resident may become ill with stomach problems from the bacteria. She stated she had been in-serviced on hand hygiene when serving food. Observation on 09/25/2024 at 8:25 AM the Dietary Dishwasher Aide was in the dishwasher room. She was not wearing gloves. The Dietary Dishwasher Aide picked up her cellphone with her fingers and the palm of her right hand. She placed the cellphone with her fingers on her right hand inside of her right-side pants pocket. She did not wash or sanitize her hands. The Dietary Dishwasher Aide picked up clean plates and the fingers on her right hand touched inside of six clean plates. She also touched the tines (sharp pointed parts of a fork) of approximately 4 forks. In an interview on 09/25/2024 at 8:30 AM the Dietary Dishwasher Aide stated she did place her cell phone in her pants pocket. She stated cell phones and clothes were considered dirty. She stated she was to wash her hands after touching her cell phone and her pants. The Dietary Dishwasher Aide stated she did touch several plates and the tips of some forks. She stated if bacteria transferred from her fingers and hand onto plates and forks there was a possibility if a resident ate out of the plate or used the fork a resident may become sick such problems with their stomach and may become ill with diarrhea. 2. Observation on 09/24/2024 between 9:10 AM and 9:30 AM on the food prep area in the kitchen, tortillas were in a non-sealed clear plastic bag without a label or date. The facility failed to seal, label, and date tortillas and failed to label and date four of ten pounds of hamburger meat not in the original package. Observation on 09/24/2024 between 9:10 AM and 9:30 AM revealed there were approximately one inch of ice-covered chicken in two clear bags without a label or date. The two clear bags of chicken were not in the original package. In an interview 09/26/24 at 08:06 AM the Dietary Manager stated any time dietary staff placed gloves on their hands the staff were expected to wash their hands. The Dietary Manger stated if any staff touched the outside of gloves with soiled hands there was a possibility the bacteria may transfer from the gloves onto the clean dishes or food. The Dietary Manger stated if a resident ate contaminated food the resident may become sick with any type of stomach issues such as vomiting and diarrhea. The Dietary Manger stated if any dietary staff touched their clothes/ cell phone or anything not considered clean, the dietary staff were expected to wash their hands immediately. She stated the Dietary Aide touched the napkins, inside of dessert plates, and inside of the cups of tea, she was expected to wash her hands immediately after she touched her clothes. She stated the Dietary Aide may have contaminated the napkins, plates of food, and the cups of tea. She stated all foods were to be labeled, dated, and sealed. The Dietary Manager stated all food products should be dated as soon as they were received. The Dietary Manager stated any food in the freezer with ice covering the food may affect the quality of food and taste. She stated all staff should be checking for quality and expiration dates but ultimately the responsibility falls on her to ensure that nothing was out of date or stored improperly. In an interview on 09/26/2024 at 10:50 AM the Administrator stated her expectations were all staff in the kitchen to wash their hands when visibly soiled and between tasks. She stated if dietary staff touched their cell phone, their clothes, or cleaning dish towel, their hands would be considered soiled. The staff would need to wash their hands immediately before they touched clean dishes, clean napkins, cups . etc. She stated the dietary staff were to wash their hands if they touched their clothes or cell phone. The Administrator stated the Dietary Manager was responsible for the operation of the kitchen. She stated the policy on refrigerators was the same they would use on freezers related to label and dating. Record review of the Facility's Policy on Dietary Food Service Personnel Policy and Procedure, dated 2012, reflected sanitation and food handling: wash your hands (with soap and hot water) before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning. Handle all utensils and dishes so the food or customer contact surfaces are not touched. Record review of the Facility's Policy on Storage Refrigerators, dated 2012, reflected food must be covered when stored, with a date label identifying what is in the container. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that CNA be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure the residents right to be free from misappropriation of property for 1 (Resident #1) of 6 residents reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Ondansetron (generic Zofran), a medication used to treat nausea by CMA-A. This failure placed the resident at risk of not receiving the prescribed medication. Findings include: Record Review of Resident #1's Face Sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include Alzheimer's Disease (brain disorder that causes problems with memory), heart disease (disease that affects the heart), Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectorisis (arteries leading to the heart are blocked), Edema (swelling caused by fluid accumulation) and Insomnia (trouble falling or staying asleep). Record Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 4, indicating severely impaired cognition and the resident was not interviewed. Record Review of Resident #1's Care Plan dated 05/07/2024, Focus reflected Resident #1 was at risk for pain related to comorbidities (simultaneous medical conditions). Interventions reflected Resident #1 should be monitored for nausea; vomiting; dizziness and falls. Record Review of Resident #1's physician's orders dated 9/21/2024 reflected an order for Ondansetron (generic Zofran) 4 mg dissolving tablet, 2 tablets every 8 hours PRN for nausea. Review of written statement signed by CMA-A dated 6/29/2024 stated, Yes, I took a Zofran. Because I felt very nauseated to where I was going to throw up on my med cart. I didn't expect to get sent home because I am there for my residents sick or not, they need love and care. Interview with CMA-A was attempted on 7/16/2024 at 11:35 am and again at 2:15pm. CMA-A's phone rang with no ability to leave a message. No return call was received. Interview on 7/16/2024 at 2:30pm with CMA-B employed since October of 2023, she stated the most recent in-service on Misappropriation was within the last two weeks. She stated she is unaware of CMA's routinely taking medication for personal use from the medication cart. She identified accountability measures by stating there are cameras in the hallways, and she stands in front of them when possible. She said a medication count was conducted at the end of every shift and anytime they pass the medication cart off to another employee. Interview on 7/16/2024 at 2:48pm with LVN, employed for approximately 10 days, she stated she received training on misappropriation during her initial training and with her previous employer previously. She stated an understanding of misappropriation and said she has never taken a medication from the medication cart, nor has she seen anyone else take medication. Interview on 7/16/2024 at 3:04pm with DON, employed with the facility for 18 years, stated she in-serviced staff on 6/29/2024 following the incident with CMA-A. She identified accountability measures currently in place at the facility as cameras were located throughout the building, carts were kept locked, a medication count was conducted at beginning and end of each shift, the building was locked and secured, and the ADM reviewed camera footage after any incident. She said she feels the incident with CMA-A was an isolated incident and the disciplinary action was appropriate. Interview on 7/16/2024 at 3:20pm with ADM reflected accountability measures include medication count at the beginning and end of each shift and that CMA's must document each time a PRN medication is given to a resident. She stated that the disciplinary action against CMA-A was appropriate as she had been an employee in good standing for over 6-years and feels like it was an isolated incident. She said CMA-A is supervised by a nurse on the night shift and there is another CNA working nights as well. She said there are no routine medications given to residents during the night shift, so the medication cart is rarely opened. Review of the most recent Criminal History Conviction search dated 1/19/2024 for CMA-A, reflected no search results found. Review of Notice to Employee Receiving This Employee Disciplinary Report dated 7/1/2024 was signed by CMA-A and ADM. The document stated, Your failure to accomplish the corrective plan of action, including any specified deadlines, may result in further disciplinary action up to and including discharge. Discharge will automatically accompany third written counseling in a 12-month period, or any infraction of a serious nature that would warrant immediate discharge. Review of Employee Disciplinary Report dated 7/1/2024 was completed by ADM. The document stated, CMA-A will not be allowed to work as a medication aide. She will not have access to medications, medication cart, medication room, and medication keys. CMA-A received a demotion to CNA and took a pay in accordance. Review of Attendance Form dated 6/29/2024, for in-service titled Abuse, Neglect, Residents Rights, Exploitation Misappropriation was signed by 30 employees from various departments. Review of facility policy titled Resident Rights, revised 2/2021 stated: Policy Statement - Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation Section 1 - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: Section C - be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022 stated: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #1 and #3), reviewed for a call light system, in that: The facility failed to ensure Resident #1 and Resident #3's call buttons were accessible in the event of an emergency or to meet care needs. This failure could affect residents by not having access to call for assistance resulting in needs not being met. Findings include: Record Review of Resident #1's profile revealed she was a [AGE] year-old female. She was admitted to the facility on [DATE] and had diagnoses of Chronic A-Fib, AMS, HTN, Anxiety Disorder, Schizoaffective Disorder, Neurocognitive Disorder w/Lewy Bodies (progressive Dementia that affects movement, thinking skills, mood, memory, and behavior), Anal Prolapse and Nontraumatic Chronic Subdural Hemorrhage (bleeding of the brain that does not result in significant impact of the head). She had a BIMS (assessment of cognitive status on a scale from 00 - 15) of 6 (indicating severe impairment). Record Review of Resident #1's Care Plan revealed she was at a moderate risk for falls with interventions to ensure her call light was within reach to use when assistance was needed. The record reflected that Resident #1 had an ADL Self-Care Performance Deficit related to Dementia with interventions to encourage her to use the call bell for assistance as needed. Initial observation of Resident #1's room on 07/25/23 at 9:15 AM revealed no presence of a call device. Further observation revealed a call device socket positioned on the wall near the foot of Resident #1's bed, at the height of her dresser, which was against the wall. The actual call device was hanging from the socket and on the floor. It was discovered that Resident #1 did have a call button, but during initial observation and interview, it was not in sight. During an interview on 07/25/23 at 9:20 AM, Resident #1 stated she did not have a call device in her room. Resident #1 stated she had not had any falls or incidents since being at the facility. She stated she did most things on her own and had not needed the call button . Record review of Resident #3's profile revealed she was a [AGE] year-old female. She was admitted to the facility on [DATE] and had diagnosis of Type II Diabetes, HTN, Chronic Gout, Depression, UTI, Anxiety, Protein-Calorie Malnutrition, Dysphagia (a swallowing disorder), Obstructive and Reflux Uropathy (conditions that affect the urinary tract due to blockage or backward flow of urine), and Neuromuscular Dysfunction of Bladder (conditions where the nerves or muscles don't work properly causing discomfort). She had a BIMS (assessment of cognitive status on a scale from 00 - 15) of 10 (indicating moderate impairment). Record Review of Resident #3's Care Plan revealed she was a moderate risk for falls related to confusion and deconditioning with interventions including ensuring the call light was within reach for assistance as needed. The record also reflected that she had an ADL Self Care Performance Deficit related to Dementia with interventions to encourage to use her call bell for assistance. Observation of Resident #3 on 07/26/23 at 9:20 AM revealed she was in a hospital bed. Items observed in her bed and in reach were a bowl of cereal and a cup of juice. Further observation revealed a call device was not in Resident #3's bed. The call device socket was observed in the wall of her room, behind her bed; the bed was approximately 1.5 feet from the wall. During an interview on 07/26/23 at 9:20 AM Resident #3 stated she had just returned from the hospital and was given a call button to press if she needed help. Resident #3 looked around her bed but was not able to locate the call button within reach . Interview with NA C on 07/26/23 at 1:02 PM revealed residents could use their call device if they need assistance or have an emergency when in their rooms. NA C stated call devices should be in reach , but did not state who was responsible for ensuring they were in reach. Observation of Resident #1's room on 07/26/23 at 1:02 PM with NA C revealed the call device sitting on top of her bed, positioned near the head of her bed; the dresser was now positioned away from the wall. Observation of Resident #3's room on 07/26/23 at 1:03 PM with NA C revealed the call device was not present in her bed. NA C was observed picking up the call light off the ground, which was behind Resident #2's bed, and hanging on the floor. NA C was observed placing the call device on the right side of Resident #3, attaching it to her bed. She confirmed with Resident #3 that she could reach her call device if placed in that spot. Interview with the LVN B on 07/26/23 at 1:12 PM revealed residents could use their call device for when they need help. She stated the device should be placed within arm's reach. She stated some residents use their call devices and some don't and those that don't will yell out if they need assistance. She stated for residents who are not as verbal as others, staff increase their checks on those residents . She stated in the past, Resident #1 has not used the call device, but recalled that Resident #3 has used the call device. Interview with the DON on 07/26/23 at 3:14 PM revealed residents were provided a call device to use when they have toileting needs, needing water or food or are in discomfort. She stated all residents should have a call device despite their level of mobility and care. She stated call devices should be within reach. She stated it is important that call devices are in reach for staff to be able to meet the needs of the resident. She stated from a medical standpoint, the risks of not having a call device in reach is that a resident may not get their food or water, get their comfort needs met, or be responded to timely during emergent situations like falls . She did not state who was responsible for ensuring call devices are within reach. During an interview with the ADM on 07/26/23 at 3:30 PM a policy and/or procedure was requested. The ADM stated the facility did not have any policies regarding call devices specifically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 out of 1 resident (Residents #05) reviewed for respiratory care. The facility failed to change and/or label Resident # 05's oxygen equipment per the facility policy and procedure. This failure has the potential to affect residents by placing them at risk for infections and complications associated with respiratory equipment failure due to exposure to equipment that has been used for an amount of time beyond appropriate or intended use limits. Findings included: Record review of Resident #05's History and Physical revealed a [AGE] year-old male. His diagnoses included paranoid schizophrenia, extrapyramidal ( relating to movement of nerve cells in the spine) and movement disorder depressive disorder, gastroesophageal reflux disease, hepatomegaly ( enlarged liver), shortness of breath, dyspnea ( shortness of breath), hyperlipidemia (high fat in blood), peripheral vascular disease ( slow and progressive circulation disorder) , arteriosclerosis of coronary artery bypass ( heart surgery), acute on chronic obstructive pulmonary disease, general anxiety disorder, bi-polar disorder, essential hypertension( high blood pressure, insomnia( inability to sleep). Record review of Resident # 05's quarterly MDS , dated 07/06/2023 revealed a BIMS score of 14 out of 15 indicating no cognitive impairment. Record review of the care plan, dated 07/14/2023 revealed Resident 28 with a diagnosis of COPD requiring 02 therapy and also to be monitored for signs and symptoms of infection. Record review of Resident #05's physician's orders revealed the following orders: -May use oxygen @1-2 l/m via nasal canula as needed for shortness of breath. - Change oxygen tubing every Wednesday on night shift Observation on 07/24/23 at 12:04 PM, revealed Resident #05 was in the room walking around. The resident's oxygen concentrator was in the room and next to Resident #05's bed. The humidifier bottle on the concentrator was labeled with a last change date of 07/15/23. The oxygen tubing had no date on written. Interview on 07/24/23 at 12:04 PM, Resident #05 stated he has asthma so he uses oxygen on occasion. Resident stated staff usually changes tubing weekly. Observation on 07/26/23 at 12:04 PM, the humidifier bottle on the concentrator was still labeled with last change date of 07/15/23. The oxygen tube was undated. Interview on 07/24/23 at 12:04 PM, LVN B stated Resident #05 is supposed to have his O2 equipment changed weekly every Wednesday . LVN B stated Resident #05 only uses the machine for panic attacks and should only be PRN. LVN B stated that by not changing the equipment last Wednesday, the facility policy has been violated. Interview on 07/24/23 at 12:04 PM, the DON stated that nursing staff should provide direct monitoring of the resident's oxygen therapy by doing rounds. The DON stated the charge nurse is responsible for changing the oxygen equipment per physician's order. The DON stated the facility's policy was to change 02 equipment weekly and/or as needed per physician's order. The DON stated it is deficient practice to not change resident # 05s oxygen equipment since 07/15/2023 . When asked if oxygen tubing should have been labeled she responded yes. The DON stated if oxygen equipment and tubing is not changed weekly per the doctor's order and labeled properly that it can cause resident have increased risk of acquiring an infection. Record review of facility policy for maintain oxygen equipment, not titled, or dated, revealed : Procedure: Change oxygen tubing, cannula/mask with date and initials weekly. Change humidifier bottle with date and time weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #02) of two residents reviewed for unnecessary medications. The facility failed to attempt a gradual dose reduction (GDR) for Resident #02's Clonazepam . These failures could place residents at risk for possible adverse side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included Record review of Resident #02's quarterly MDS assessment, dated 05/19/23, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 10. She had no signs and symptoms of delirium, no hallucinations or delusion, no physical behavioral symptoms and had not rejected care. She had diagnoses which included stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, other neurological conditions, amputation, hip and knee replacement, fractures and other multiple trauma, other orthopedic conditions, debility, cardiorespiratory conditions, and medically complex conditions. Record review of Resident #02's care plan, revised on 06/29/23, reflected: .Resident is on antianxiety medication (clonazepam) .Interventions .staff will monitor all the side effect signs, if any notify the resident's physician. Will have improved mood state happier, calmer appearance, no signs and symptoms of depression, anxiety or sadness) through the review date Record review of Resident #02's active physician's orders, dated 07/26/23, reflected, .clonazepam (anxiety) tablet 0.5 mg give 1 tablet by mouth twice daily . The start date was 06/04/21. Record review of Resident #02's Medication Administration Records, dated July 2023, reflected the resident received Clonazepam 0.5 mg bid daily. Record review of Resident #02's Nurses Notes, from 05/16/23 through 07/25/23, revealed the notes did not indicate any behaviors for Resident #02 including anxiety. Record review of Resident #02's last documented Psychiatrist report dated 06/07/23 reflected: Resident was seen today for follow-up for anxiety, delusions, depression/sadness, long-term memory problems, short-term memory problems and restlessness, Paranoid schizophrenia, schizoaffective disorder bipolar type. Assessment/Plan for anxiety revealed: *Clonazepam continued at current dose for anxiety-GDR future trial . Record review of the clinical physician's orders revealed from last attempt to lower dose of clonazepam 0.5 mg at bedtime was 05/18/21. Review of Resident #02's Pharmacy Consultation report dated 09/13/22 reflected: .[Resident #02] receives clonazepam 0.5 mg at twice a day for anxiety Please attempt a gradual does reduction (GDR), annually/biannually in an effort to discontinue these drugs .Please provide short rationale describing why a GDR attempt is likely to support keeping dose at the current level . The physician responsed for the rationale for the decline in the GDR was last reduction was unsuccessful and was signed and dated by the MD on 10/05/22. Observation and interview on 07/26/23 at 01:04 PM revealed Resident # 02 getting out of bed, appearred tired. Resident #02 stated she had been feeling tired and confused for the past couple of years. Resident #02 stated she thinks it was because of her medication. Resident #02 said the doctor made changes to her medication but she still feels drowsy and would like a look into her medication regimen. Resident stated she spoken to the Psych Nurse regarding her medications and that the changes she made to the meds was not working. Interview with the LVN A on 07/26/23 at 01:12 PM revealed Resident #02 should not be on clonazepam for that long without lowering. She stated she doesn't know why Resident #02 medications haven't been lowered but that the psych nurse is responsible for looking into attempting a GDR. Interview with Pharmacist A on 07/26/23 at 01:12 PM revealed Resident #02 should have had an attempted reduction of clonazepam. Pharmacist A stated he requested a lowered dose to the doctor in September 2022 and another time this month . Pharmacist A stated that it is the responsibility of the psych nurse to decide if the resident needs to stay on the medication or not. Pharmacist A stated that by not attempting to GDR clonazepam Resident #02 can experience long term confusion and instability of gait (uncoordinated walking). Interview with Psych Nurse A on 01/19/23 at 10:11 AM she stated Resident #02 had not had a GDR this year due to failed attempts in the past. Psych Nurse A stated the previous clinician before her had documented issues with discontinuing clonazepam before, so she keeps Resident #02 on clonazepam to keep her stable. Psych Nurse A stated, I changed the Zyprexa and trazodone, the medications were adjusted by me since I noticed [Resident #02] sleeping a lot recently. Psych Nurse A also stated that Whenever there's an adjustment that needs to be made, the pharmacy gives me the recommendation and I make the adjustment. When asked what potential outcome could occur if Resident #02 does not have a GDR attempted, Psych Nurse A responded Heart attack, stroke, Extrapyramidal Syndrome (abnormal movement of body due to medication). Psych A stated she felt the benefits outweighed the risk for Resident # 02 to use the medication. Psych Nurse A stated, I have noticed she has slept often but [Resident #02] also hallucinated and had other psychiatric issues that is why I held off on decreasing the Clonazepam. When surveyor asked what clonazepam is used for Psych Nurse A responded anxiety. Psych A stated that she has noticed Resident #02 become more anxious in the facility over the past few weeks. Interview with the DON on 07/26/23 at 03:00 PM she stated the facility's policy regarding GDR on psychotropic medications are for the psych nurse to reduce medications based on her clinical judgement. The [NAME] stated If changes needed to be made to a residents medication regimen the Psych nurse will be responsible for ensuring that is done in accordance with CMS regulation and also patients preference. The DON stated pharmacy also makes recommendations. The DON stated that from a medical standpoint that psychotropic medication should have a GDR if agreed upon by physician . The DON stated the risk that could occur if Resident # 02 does not have a GDR is lethargy (low energy), constipation and addiction to the medication. Record Review of the undated Gradual Dose Reduction policy revealed: After the first year a gradual dose reduction must be attempted annually unless clinically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 7 residents (Residents #39, #36, #15 and #17) reviewed for infection control in that: a) LVN A and MA A did not clean and disinfect the wrist blood pressure monitor when it was used on Resident #39, Resident #36, and Resident #15. b) NA A and NA B used soiled gloves for handling clean gloves while providing incontinent care for Resident #17. These failures could place the residents at the facility at risk of transmission of diseases and infection. Findings included: Record review of Resident #36's face sheet dated 07/25/23 reflected Resident #36 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Heart Disease, Edema (swelling), Insomnia, Hypertension (High blood Pressure), Anxiety Disorder, Major Depressive Disorder, Pain, Chronic Kidney Disease, Hypothyroidism (Low level of thyroid hormone), and Alzheimer's disease with early onset. Record Review on 07/25/23 that of Resident #36's MDS assessment dated [DATE] revealed Resident #36's BIMS score was 3 indicating his cognition was severely impaired Review on 07/25/23 of Resident#36's care plan dated 08/01/23 reflected: [Resident #36] has hypertension noted. He is at risk for complications. The relevant intervention was, give anti-hypertensive medications as ordered and monitor for side effects such as give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (low blood pressure while standing up) and increased heart rate and effectiveness. An observation on 07/25/23 at 09:15 AM revealed, while taking the blood pressure of Resident #36 with a wrist blood pressure monitor, LVN A failed to sanitize it before and after use. LVN A opened the drawer of the medication cart and took out the box that contained the wrist blood pressure monitor. She then took out the monitor from the box and without sanitizing it, applied it on Resident #36. After the completion of measuring his blood pressure, she put the monitor back in the box, without sanitizing it. LVN A then placed the box back in the medication cart drawer. During an interview on 07/25/23 at 9:30 AM, LVN A stated she was aware of the importance of sanitizing the blood pressure monitor however forgot to do so as she was in a hurry. When the investigator asked her about the importance of sanitization of the monitor, she stated sanitization of medical equipment was necessary to minimize the spreading of contagious diseases. LVN A stated she practices as a nurse for about 8 years and worked at the facility for about a month. She said, she did not receive any training from the facility for disinfecting medical equipment however she had several in- services and trainings during her career as a nurse. Record review of Resident #39's face sheet dated 07/25/23 reflected Resident #39 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Anoxic Brain Damage (Damage due to the cessation of cerebral blood flow to brain tissue), Hypertension, and Senile Degeneration of Brain (a cause for dementia). Record Review on 07/25/23 that of Resident #39's MDS assessment dated [DATE] revealed Resident #36's BIMS score was 10 indicating his cognition was moderately impaired Review on 07/25/23 of Resident#39's MAR of July 2023 reflected: Lisinopril Tablet 2.5 MG Give 1 tablet by mouth one time a day related to Essential (primary) Hypertension. hold for SBP<90, DBP<50 or H R<60. Record review of Resident #15's face sheet dated 07/25/23 reflected Resident #15 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with schizoaffective disorder (A type of mental illness), Insomnia, Hypothyroidism (Low level of thyroid), Gastro-Esophageal Reflux Disease (Acid reflex of the stomach), anxiety disorder and Chronic Pain. Record Review on 07/25/23 that of Resident #15's MDS assessment dated [DATE] revealed Resident #15's BIMS score was 4 indicating his cognition was severely impaired. Review on 07/25/23 of Resident#15's MAR of July 2023 reflected: Propranolol HCl Tablet Give 10 mg by mouth two times a day for restlessness activation Hold if SBP is less than 90, DBP is less than 50. An observation on 07/25/23 at 10:00 AM revealed that while taking blood pressure using a wrist blood pressure monitor MA A failed to sanitize the wrist blood pressure monitor before and after using it on Resident #39 and Resident #15. MA A took the blood pressure of Resident #39 with the wrist blood pressure monitor. She did not sanitize the monitor prior to using it on Resident #15. After the completion of taking blood pressure without sanitizing, she kept the monitor in the drawer of the medication cart. During an interview on 07/25/23 at 10:45AM, MA A stated she was aware of the necessity of sanitizing the blood pressure wrist monitor every time after the use on residents. MA A said she practiced that in her whole career as a MA however forgot to do it that day most likely because she was nervous. When the investigator asked what the consequence of her action was, she stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. MA A stated she received trainings on infection control two months ago however no training was received on sanitization of medical equipment. Record review of Resident #17's face sheet dated 07/25/23 reflected Resident #17 was admitted to the facility on [DATE]. He was a [AGE] year-old female diagnosed with Hypothyroidism (low level of thyroid hormone), Type 2 Diabetes Mellitus, Hyperlipidemia (High level of fat in blood), Hypertension (High blood pressure), Major Depressive Disorder, Alzheimer's Disease, Gastro-Esophageal Reflux Disease, Insomnia, and Heart Failure. Record Review on 07/25/23 that of Resident #17's MDS assessment dated [DATE] revealed Resident #17's BIMS score was 5 indicating her cognition was severely impaired Review on 07/25/23 of Resident#17's care plan dated 08/01/23 reflected: [Resident# 17] is at risk for skin breakdown related to her incontinence and related intervention was peri care per episode and document per protocol. During an observation on 07/25/23 at 11:00 AM, NA A and NA B provided incontinent care to Resident # 17. NA A and NA B entered Resident #15's room and donned gloves after washing their hands. NA A pulled out some wet wipes from a packet and arranged them on the side table. Once the soiled brief was removed, NA A used the wipes passed on by NA B for cleaning Resident #17's perineal area. Once the cleaning was over, NA A removed her soiled gloves, handed over to NA B and requested her to discard them into a plastic bag that was closer to NA B. NA B after disposing NA A's soiled gloves, without changing her gloves, picked up new pair of gloves and handed them over to NA B. NA A used the gloves she was provided by NA A for handling new briefs. She used the same gloves for positioning the resident and adjusting the bed spread and blanket. During an interview on 07/25/23 at 11:00 AM, NA A stated she thought they (NA A and NA B) were doing the incontinent care correctly. When the investigator walked through the entire process of incontinent care, NA A, stated she understood where the mistake was. She said she should not have accepted the gloves that were passed on to her by NA B as NA B was wearing contaminated gloves. NA A stated compromise on infection control practices led to the possibility of spreading diseases. When asked about the training she had received, NA A stated she never received any training on peri care at the facility within the last 6 months. During an interview on 07/25/23 at 11:00 AM, NA B stated she should have changed gloves after handling the dirty gloves that were handed over by NA A. NA B stated not following infection control protocols was not good for the residents as there was a danger of spreading diseases through contamination. During an interview on 01/05/2023 at 2:00 PM the DON stated, NA A and NA B did not follow clean practices while providing peri care. The DON stated her expectation was that the nursing staff must follow facility policy/procedure for handwashing and sanitization of medical equipment. When the investigator asked about the risk of not following the infection control protocol like sanitizing medical equipment in between residents or changing gloves when required while providing care to residents, the DON stated there was a huge risk of the transmission of communicable diseases through contamination. The DON stated an in-service program for all the nursing staff members was initiated to address this issue. The DON said, she made regular rounds on the floor to identify deficient practices done by nursing staff. She stated any deficiency or unprofessional practices were addressed with remedial trainings or in extreme situations disciplinary measures. Review of the facility's policy infection control policy and procedure 2010 revised on 10/21/22: Gloving: Gloves are worn for three important reasons: To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . . To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes and nonintact skin. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident, or a fomite can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washed after gloves are removed . . Failure to change gloves between resident contacts is an infection control hazard . . Routine cleaning and disinfection of resident care equipment . . 5. Any resident care equipment/article that is visibly contaminated with blood or body fluids will immediately be cleaned with an approved disinfectant.

Based on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure injectable insulin of the staff was not stored with food items in the refrigerator. The facility failed to ensure food items in the refrigerator were not expired. These failures could place residents at risk for transmittable diseases, food-borne illness, and food contamination. Findings included: A.Observations and interview of the refrigerator in the kitchen on 07/24/23 beginning at 9:30 AM revealed there was an insulin injection syringe in a plastic bag stored with other food products in the refrigerator. The insulin label reflected Toujeo (insulin glargine) injection 300 Units/mL (U-300). For subcutaneous use only. Do not remove insulin with syringe. Always use new needle. Do not mix with other insulins. Staff member DA A stated it was her insulin injection syringe. B.Observations of the refrigerator in the kitchen on 07/24/23 beginning at 9:30 AM revealed the following items were not labelled and/or expired: 1. One plastic bag with 15 patties. There was no name and date written on it. The DM recognized it as sausage patties. 2.Three opened plastic containers of cheese spread. The date 6/15 was written on them. The DM stated the containers were opened on 6/15/23. During an interview on 07/24/23 at 10:30 AM DA A stated she usually kept her insulin syringe elsewhere. She stated that day she was in a hurry, and she kept the insulin syringe in the refrigerator situated in the kitchen. DA A stated storing personal belongings in kitchen refrigerator is risky as it could contaminate the food products in the refrigerator. During an interview on 07/24/23 at 10:00 AM the DM stated the refrigerator was exclusively for storing resident' food products and should not be used to store personal belongings of the staff members. She said there was a refrigerator in the staff room for employees. When the investigator asked about the risk of keeping an injection syringe with food products in the refrigerator, the DM stated the food products could get contaminated from the syringe. She added since it was an injection syringe, disease could be transmitted to the food through the blood from the needle. When asked about facility policy regarding safe storage of food products the DM stated it was facility policy that prepared food should not be stored in the refrigerator for more than 72 hours and food in containers once opened should be used within 7 days and labelling and dating also important to ensure food safety. During an interview on 07/26/23 at 3:00PM, the DON stated, storing personal belongings with food for residents was not acceptable. She stated by storing DA A's insulin syringe in the refrigerator with food products meant for residents, DA A breached the infection control protocols. The DON stated DA A was risking spreading blood and fluid borne and other diseases with her action. Review of facility in-service records revealed there were no in- services (training) on safe storage of food products since 01/01/2023. Review of the facility's undated policy titled Dietary Services Policy & Procedure Manual 2012 reflected: 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 . . Storage refrigerators shall be kept clean and organized. Spills are to be wiped up immediately . .Food that is spoiled, contaminated, or suspect shall not be served and shall be discarded immediately. Review of FDA food code 2022: Chapter 2 Management and Personnel on reflected: .2-103.11 person in charge.the person in charge shall ensure that: . (b)persons unnecessary to the food establishment operation are not allowed in the food preparation, food storage, or ware washing areas, except that brief visits and tours may be authorized by the person in charge if steps are taken to ensure that exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles are protected from contamination; pf . . (f)employees are verifying that foods delivered to the food establishment during non-operating hours are from approved sources and are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination, unadulterated, and accurately presented; pf .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to one (Residents #46) reviewed for indwelling catheters. The facility failed to ensure Resident #46's indwelling catheter was secured or anchored to prevent pulling or tugging. The failure placed residents at risk for discomfort, urethral trauma, and urinary tract infections. Findings included: Review of Resident #46's Face sheet dated 6/03/2022 revealed he was a [AGE] year-old-male re-admitted on [DATE] with the diagnoses of chronic obstructive disease (a chronic disease that impairs oxygen exchange), pressure ulcer to sacrum (the triangular bone just below the lumbar vertebrae), alcohol abuse, and urinary retention (urine that retained in the bladder). Resident #46's MDS (Minimum Data Sheet) Assessment was not provided after 2 requests (June 2, 2022 at 11:30 AM and June 2, 2022 at 1:30 PM) from the facility. Review of Resident #46's Care Plan updated 5/17/2022 did not address resident with an indwelling catheter. Review of Physician Orders dated 6/03/2022 revealed the following: Indwelling catheter to remain in place until urologist assess. No order at this time to maintain anchor holding indwelling catheter in place. Physician updated his orders on 6/03/2022 at approximately 1:30 PM. An observation of Resident #46's incontinence care by CNA A on 06/02/22 at 10:55 a.m. revealed he had an indwelling catheter draining yellow urine to a catheter bag on the right side of his bed. The catheter tubing was not secured to Resident #46's leg with an anchor. When he was turned to his left side, the tubing moved frequently and was stretched during the incontinence care. The resident did not make any comments. During an interview with CNA A on 96/02/2022 at 11:00 AM, she said, they are careful because the catheter moves around when they clean him. CNA A was asked if she knew if Resident #46 was supposed to have an anchor for his catheter. She said she did and that he did not have one when he returned from the hospital on 5/28/22. CNA A did not say why she did not tell the nurses. During an interview with LVN B on 06/02/2022 at 11:30 AM, she said, if a resident does have a catheter, it is important that they have an anchor to prevent urinary tract infections. During an interview with DON on 06/02/17 at 2:45 p.m. she said Resident #46 should have an anchor in place to protect him and to keep from getting urinary tract infections and the nurses are responsible to endure that anchors are in place. During an interview with LVN C on 06/03/2022 at 12:45 PM, she said she was aware residents with indwelling catheter should have an anchor to prevent trauma and prevent urinary tract infections. During an interview with LVN D on 06/03/2022 at 12:55 PM said she was aware residents with indwelling catheter should have an anchor to prevent trauma and prevent urinary tract infections. Review of facility's policy and procedure dated February 13, 2007 entitled Catheter Care, revealed the following: Check the resident frequently to be sure he or she is not laying on the catheter and keep the catheter and tubing free of kinks, keep tubing off floor and minimize friction or movement at insertion site. Lippincott Manual of Nursing Practice 9th Edition, page 783 revealed the following regarding securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device.

Based on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were secured properly in that: Five blister packs and 32 syringes of 1ml (milliliters)(Lorazepam) of controlled substance (Tramadol 50 mg, Lorazepam 0.5 mg and 1.0 mg) were laying on the shelf in the cabinet without being secured to an affixed and secure box to the narcotic storage cabinet. This failure could result in residents having their medications diverted affecting residents who were prescribed controlled substances by potentially not receiving them. The findings include: During an observation and interview on 6/3/22 at 10:30 AM with the Administrator the Narcotics scheduled for destruction were observed secured behind a locked cabinet in the Administrator's office. Five blister packs and thirty-two 1 ml syringes of controlled substance (32 1ml (milliliters)(Lorazepam) of controlled substance (1 blister pack Tramadol 50 mg), (Lorazepam 0.5 mg 2 blister pack and 2 blister pack of 1.0 mg) were laying on the shelf without being stored in a secure box attached to the cabinet. During an interview on 06/04/22 at 10:45 AM with Administrator, He said they have the controlled substances stored in this locked cabinet which was the primarily responsibility of the DON. He just exchanged offices with the DON and did not have a chance to create a more secure drug destruction space. He said he will have a secure box chained to the locked cabinmate. He confirmed the five blister packs of, and 32 (1 ml) syringes were controlled substances. He revealed the control substances needed to be in a more secure device and attached to the cabinet. The Administrator did not provide a policy on and procedure at 06/03/2022 at 10:45 AM related to drug destruction.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, sealed appropriately, and had not expired. The facility failed to ensure 1 of 2 of the freezers were cleaned and free of debris a moderate amount of food crumbs and various frozen vegetables on the inside of the freezer floor. This failure could affect residents, who received their meals from the facility's kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: Observations of the facility's kitchen refrigerator on 06/01/2022 at 9:15 A.M. revealed one Styrofoam container of what appeared to be a dessert was not been sealed, labeled, or dated. Observations of 1 of 2 facility's kitchen freezers on 06/01/2022 at 9:20 A.M. revealed, a moderate amount of food crumbs and various frozen vegetables on the inside of the freezer floor. In an interview and observation with the Dietary Manager, on 06/01/2022 at 9:30 AM, revealed she was aware food that had been opened was required to be dated, labeled, and sealed. She stated whoever takes the food and puts it in the fridge was supposed to date, label, and seal it properly. She observed the item that was not dated or sealed correctly and said it should never have been placed in the fridge like that. She stated that it was just an oversight on the dietary staff's part, and she was the person who is ultimately responsible for making sure all policies and procedures were followed. She stated, I'm the one who is supposed to make sure the freezer is cleaned, I just had not gotten around to it today. She further stated, these failures put all 45 residents at risk for foodborne illness. In an interview with the Facility Administrator, on 06/03/2022 at 10:45 AM, revealed the Dietary Manager was responsible for ensuring all food was dated, sealed, and labeled and for the cleaning of all refrigerators and freezers. The failure of those tasks being completed could put all 46 residents in danger of foodborne illness. Review of the facility policy titled Cleaning the Refrigerator dated 2012 stated [in-part] that: Food must be covered when stored, with a date label identifying what is in the container. Refrigeration equipment is to be routinely cleaned give special attention to the floor of the box, corners, doors, openings, gaskets, hinges and latches. Clean all wire shelves carefully. According to the Food Code, (https://www.fda.gov/food/fda-food-code/food-code-2017 accessed 3/9/22), Food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days.