**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #24) of 14 residents reviewed for care plan completion. 1. The facility failed to complete Resident #24's baseline care plan within the required 48-hour timeframe. 2. The facility failed to provide Resident #24 a summary of their baseline care plan after completion. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #24's electronic face sheet dated 09/04/2024 revealed the resident was a [AGE] year-old male admitted on [DATE]. Record review of Resident #24's quarterly MDS dated [DATE] revealed: BIMS score of 09 which indicated moderate cognitive impairment. Record review of Resident #24's electronic medical record on 09/04/2024 revealed no evidence that baseline care plan had been performed and no evidence that summary of baseline care plan was given to Resident #24 or his representative. During an observation on 09/02/2024 at 9:55 a.m., Resident #24 was in his room lying in bed. Had walker in form and wearing glasses. He stated that he participated in therapy and does go to care plan meetings. Not able to answer if he had baseline care plan meeting. During an interview on 09/04/2024 at 10:08 a.m., the CRN stated she was unable to find that the baseline care plan was completed or that a conversation had been done with Resident #24. She stated that she was only able to find a discussion about DNR after the resident had been admitted . During a follow up interview on 09/04/2024 at 1:26 p.m., the RCN stated her expectation would be for baseline care plans to be completed within 48 hours of admission and discussed with the resident or their representative. She stated the DON, weekend supervisor or RN should complete the baseline care plan. She stated the facility's IDT monitors that baseline care plans were completed during morning clinical meeting. The RCN stated IDT members included the DON, ADON and ADMN. She stated she did not know why baseline care plan had not been performed. She stated the effect on not completing could disrupt continuity of care. Review of the DON's personnel file on 09/04/2024 revealed the was hired on 06/03/2024. The DON was not present on 09/04/2024 in facility for interview. Record review of the facility policy titled Care Plans - Baseline dated July 2024 revealed: 1. Completion and implantation of the comprehensive care plan within forty-eight (48) hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan. 2. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 3. The Director of Nursing, RN Weekend Supervisor or a registered nurse on duty will complete the baseline care plan.

Based on interview and record review the facility failed to complete a performance review of each CNA at least once every 12 months, for 1 of 3 (CNA C) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA C, based on the personnel file review results. This failure could affect residents by placing them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 09/04/2024, indicated CNA B, did not have a competency evaluation on file. The Personnel File Review indicated CNA B's date of hire was 03/27/2023. During an interview on 09/04/2024 at 2:25 p.m., the CRN stated the DON was responsible for conducting and documenting nursing training and staff performance reviews. She stated the effect on residents would depend the topic of the review and impact on the quality of care and life for the resident. The CRN explained the facility had recently changed from paper records to electronic records and had a nursing leadership change as the reasons the documents were not available. She stated the DON was out of state and not available for an interview. During an interview on 09/04/2024 at 2:40 p.m., the AD stated she was hired as the Business Office Manager and served as the Human Resources Director. She stated she did not know where to locate missing the records and understood reviews were a requirement. Record review of the facility's Staff Development Program, dated June 2021, revealed 6. In addition to the in-service training requirements outlined above, nurse aides (CNAs) are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of nurse aides and address any specific areas of weakness identified in performance and through the Center assessment.

Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 7 of 19 employees (DON, DM, MAINT, CNA C, TRNS, COTA, and HSKP F) reviewed for training. The facility did not ensure effective communication training was completed by the DON, MAINT, TRNS, and COTA during orientation. The facility did not ensure effective communication training was completed by the DM, CNA C, and HSKP F annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of the employee files revealed no evidence the following staff had completed effective communications training during orientation: * DON hire date 06/03/2024; * MAINT, hire date 09/28/2023; * TRNS, hire date 03/27/2024; * COTA, transferred from a sister facility on 08/23/2024 Record review of the employee files revealed no evidence the following staff had completed effective communications training annually: * DM, hire date 08/03/2022; * CNA C, hire date 03/27/2023; * HSKP F, hire date 04/01/2023 During an interview on 09/04/2024 at 12:17 p.m., the TRNS stated she had worked for the facility for 5-6 months. She stated she completed the online training on communication during her orientation period but did not have documentation of completion. During an interview on 09/04/24 at 12:24 p.m., the ADMN stated the DON was out of state for a court hearing. Did not attempt to contact DON about missing training records. During an interview on 09/04/24 at 12:32 p.m., the DM stated training was done online. He explained that staff received email notices and group text when trainings were available and due. The DM stated he had done all the training listed with the exception of the annual HIV training. He stated the ADON was responsible for tracking completed trainings. The DM was not able to provide an answer on how not completing trainings would affect the residents. During an interview on 09/04/24 at 1:00 p.m., the Maint. stated he recalled completing training on Communication within the past year. He did not know who or where the records were kept or how lack of training could affect the residents. During a phone interview on 09/04/24 at 1:12 p.m., Hskp F Stated she had worked in the facility for 3 years and had completed all required training every year. She stated she did not know who was responsible for the training records or where the records would be found. During an interview on 09/04/24 at 1:13 p.m., COTA stated she transferred from a sister facility last month and her records had not been transferred. She stated she received notification of training due and was scheduled to take all required trainings by the end of the week. During an interview on 09/04/24 at 2:25 p.m., the CRN stated the HR director was responsible for tracking completed training. She explained the effect on residents would depend on the topic of the training and how it related to care or quality of life. The CRN stated the reason documentation was not available was because the facility recently transitioned from paper records to electronic records. She also stated the facility had 2 employees that have been working at facility for more than 20 years and records were archived. The CRN added that a recent change in leadership was a factor in trainings not getting done or documented. During an interview on 09/04/2024 at 2:40 p.m., the AD stated she was hired as the Business Office Manager and served as the Human Resources Director. She stated she did not know where to locate missing the records and understood trainings were a requirement. Record review of the facility's Staff Development Program, dated June 2021, revealed 1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. 2. The primary objective of our Center's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. 5. Training topics may include: a. Effective communication with residents and family.

Based on interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 5 of 19 staff (DM, LVN G, HSKP E, TRNS, and HSKP F) reviewed for training requirements in that: The facility failed to ensure five staff which included: DM, LVN G, HSKP E, TRNS, and HSKP F received the required training on resident rights timely. This failure could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the DM's employee file revealed a hire date of 08/03/2022. The file did not contain any record of training on resident's rights. Record review of LVN G's employee file revealed a hire date of 09/04/2023. The file did not contain any record of training on resident's rights. Record review of HSKP E's employee file revealed a hire date of 08/05/2024. The file did not contain any record of training on resident's rights. Record review of TRNS's employee file revealed a hire date of 08/23/2024. The file did not contain any record of training on resident's rights. Record review of HSKP F's employee file revealed a hire date of 04/01/2023. The file did not contain any record of training on resident's rights. During an interview on 09/04/24 at 12:32 p.m., the DM stated the training was done online. He explained that staff received email notices and group text when trainings were available and due. The DM stated he had done all the training listed with the exception of the annual HIV training. He stated the ADON was responsible for tracking completed trainings. The DM was not able to provide an answer on how not completing trainings would affect the residents. On 09/04/2024 at 9:07 a.m. and 1:05 p.m., attempted to contact LVN G for a phone interview. No answer. Voice message left with purpose of call and detailed return call information. During a phone interview on 09/04/2024 at 1:12 p.m., HSKP F stated she had worked in the facility for 3 years and had completed all required training every year. She stated she did not know who was responsible for the training records or where the records would be found. On 09/04/2024 at 01:58 p.m. attempted to contact HSKP E for a phone interview. The number provided was not correct and no other contact numbers were provided. During an interview on 09/04/24 at 2:25 p.m., the CRN stated the HR director was responsible for tracking completed training. She explained the effect on residents would depend on the topic of the training and how it related to care or quality of life. The CRN stated the reason documentation was not available was because the facility recently transitioned from paper records to electronic records. She also stated the facility had 2 employees that have been working at facility for more than 20 years and records were archived. The CRN added that a recent change in leadership was a factor in trainings not getting done or documented. During an interview on 09/04/2024 at 2:40 p.m., the AD stated she was hired as the Business Office Manager and served as the Human Resources Director. She stated she did not know where to locate missing the records and understood reviews were a requirement. Record review of the facility's Staff Development Program, dated June 2021, revealed 1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. 2. The primary objective of our Center's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. 5. Training topics may include: b. Resident rights and responsibilities;

Based on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management for 2 (DM and HSKP F) of 19 employees reviewed for staff training. The facility failed to have documentation for DM and HSKP F on what constitutes abuse, neglect, exploitation, misappropriation of resident property and how to report the above. These failures could place residents at risk of injury or harm due to being cared for by untrained staff. Findings included: Record review of the DM's employee file revealed a hire date of 08/03/2022. The file did not contain any record of training on abuse, neglect, exploitation, misappropriation of resident property. Record review of HSKP F's employee file revealed a hire date of 04/01/2023. The file did not contain any record of training on abuse, neglect, exploitation, misappropriation of resident property. During an interview on 09/04/24 at 12:32 p.m., the DM stated training was done online. He explained that staff received email notices and group text when trainings were available and due. The DM stated he had done all the training listed except for the annual HIV training. He stated the ADON was responsible for tracking completed trainings. The DM was not able to provide an answer on how not completing trainings would affect the residents. During a phone interview on 09/04/24 at 1:12 p.m., Hskp F Stated she had worked in the facility for 3 years and had completed all required training every year. She stated she did not know who was responsible for the training records or where the records would be found. During an interview on 09/04/24 at 2:25 p.m., the CRN stated the HR director was responsible for tracking completed training. She explained the effect on residents would depend on the topic of the training and how it related to care or quality of life. The CRN stated the reason documentation was not available was because the facility recently transitioned from paper records to electronic records. She also stated the facility had 2 employees that have been working at facility for more than 20 years and records were archived. The CRN added that a recent change in leadership was a factor in trainings not getting done or documented. During an interview on 09/04/2024 at 2:40 p.m., the AD stated she was hired as the Business Office Manager and served as the Human Resources Director. She stated she did not know where to locate missing the records and understood trainings were a requirement. *Record review of the facility's Staff Development Program, dated June 2021, revealed 1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. 2. The primary objective of our Center's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. 5. Training topics may include: c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) Activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) Procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property; and (3) Dementia management and resident abuse prevention.

Based on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 3 of 19 staff (DM, HSKP E, and HSKP F) reviewed for training. The facility failed to ensure five staff which included the DM, HSKP E, or HSKP F received the required training on infection control timely. These failures could place residents at risk of illness due to lack of staff training. Findings included: Record review of the DM's employee file revealed a hire date of 08/03/2022. The file did not contain any record of training on infection control. Record review of HSKP E's employee file revealed a hire date of 08/05/2024. The file did not contain any record of training on infection control. Record review of HSKP F's employee file revealed a hire date of 04/01/2023. The file did not contain any record of training on infection control. During an interview on 09/04/24 at 12:32 p.m., the DM stated training was done online. He explained that staff received email notices and group text when trainings were available and due. The DM stated he had done all the training listed with the exception of the annual HIV training. He stated the ADON was responsible for tracking completed trainings. The DM was not able to provide an answer on how not completing trainings would affect the residents. During a phone interview on 09/04/2024 at 1:12 p.m., Hskp F Stated she had worked in the facility for 3 years and had completed all required training every year. She stated she did not know who was responsible for the training records or where the records would be found. On 09/04/2024 at 01:58 p.m. attempted to contact HSKP E for a phone interview. The number provided was not correct. During an interview on 09/04/24 at 2:25 p.m., the CRN stated the HR director was responsible for tracking completed training. She explained the effect on residents would depend on the topic of the training and how it related to care or quality of life. The CRN stated the reason documentation was not available was because the facility recently transitioned from paper records to electronic records. She also stated the facility had 2 employees that have been working at facility for more than 20 years and records were archived. The CRN added that a recent change in leadership was a factor in trainings not getting done or documented. During an interview on 09/04/2024 at 2:40 p.m., the AD stated she was hired as the Business Office Manager and served as the Human Resources Director. She stated she did not know where to locate missing the records and understood reviews were a requirement. Record review of the facility's Staff Development Program, dated June 2021, revealed 1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. 2. The primary objective of our Center's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. 5. Training topics may include: e. The infection prevention and control program standards, policies and procedures;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 lunch meal reviewed. This facility failed to follow the menu when preparing lunch meal on 09/02/2024. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. The findings include: Record review of Resident #5's Face Sheet revealed an [AGE] year-old female who was admitted on [DATE] with Diagnoses that included: Nausea and Vomiting, Dietary Calcium Deficiency, Hypokalemia (low potassium), Vitamin D deficiency, Generalized Anxiety order. Record review of Resident #5's Physician orders dated 09/01/2024 revealed: Regular Diet with regular texture. Record review of Resident #5's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns BIMS score was 10 (moderately impaired cognition) Section I Active Diagnoses- Anemia (not enough red blood cells), Hyperlipidemia (excess fats in blood). Record review of Resident #5's Care Plan dated 08/08/2024 revealed: Problem: Resident's lab showed low Calcium level. Goal: Resident Calcium level will be within normal limits. Approach: Encourage resident to eat foods high. in Calcium such as milk and dairy products. Record review of Resident # 13's Face Sheet revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Hyponatremia (lower than normal level of sodium in the bloodstream), Acute Kidney Failure, Hyperkalemia (low potassium), Vitamin D B12 deficiency anemia, Type 2 diabetes mellitus, Moderate protein-calorie malnutrition. Record review of Resident #13's Physician orders dated 09/01/2024 revealed: Diet: Regular, LCS (low concentrated sweets) Record review of Resident #13's Quarterly MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS score was 15 (cognitively intact). Section I-Active Diagnoses: Anemia, Diabetes Mellitus, Chronic Kidney Disease. Record review of Resident #13's Care Plan dated 06/19/2024 revealed: Problem: I am at risk for hyper/hypoglycemia episodes secondary to my diagnosis of Diabetes Type II/Insulin Dependent. Goal: My blood sugar will be within normal limits 90-150 with insulin control over the net 90 days. Approach: Encourage diet compliance. Educate and re-educate as needed on consequences of not following therapeutic diet. During an observation on 09/02/2024 at 10:55 AM revealed a posted weekly menu in the dining room with lunch menu for 09/02/2024.It read: Bake pork chop, Cheesy Grits, Broccoli and cauliflower, Cornbread, Frosted cake. The meal that was served was: Baked Pork chops, Mashed Potatoes, Biscuit, Frosted cake. No substitution list was available for residents to review. During an interview on 09/03/2024 at 11:15 AM the DM stated the weekly menus were posted outside the kitchen for the residents to be able to see what was being served that day and that week. The DM stated residents did not receive cornbread at yesterday's lunch meal due to waiting on truck delivery today. The DM stated the company they received groceries from had not been sending everything that was ordered. The DM stated that resident tickets for today's meal did not match what was being served because he did not have all those items. The DM stated the ADM told him what to serve. The DM did not know if anyone had told the residents about the change. During an interview on 09/03/2024 at 11:30 AM Resident #5 stated the residents did not know what would be served at meals until the meals were placed in front of them. Resident #5 stated she would like to know what was being served before the meal arrives in case, she wanted something else to eat. During an interview on 09/03/24 at 9:26 AM Resident #13 stated, the food doesn't taste or look good. Some food wasn't served hot. I have told facility I don't like pork. Resident #13 stated she was offered a sandwich, but she didn't want the sandwich without Mayonnaise. Resident #13 stated the sandwich was the substitution. Resident #13 stated they (dietary staff) do not serve the foods on her ticket and that pisses me off. Resident #13 stated no menu was provided to her in advance. During a phone interview on 09/04/2024 at 12:17 PM the Dietician stated that menus should be followed. The dietician stated the DM should contact the dietician to get changes to the menu approved. The Dietitian asked if she could call back after consulting with her supervisor. The Dietician did not call back before survey exit. During an interview on 09/04/2024 at 1:23 PM the ADMN stated the menus should be followed. The ADMN stated the facility does not always receive what was ordered for the kitchen. The ADMN stated residents could ask staff what was on the menu for any meal before it is served. The ADMN stated the weekly menus were posted by the kitchen door. The ADMN stated he did not communicate with the dietician about changing lunch menu that was served on Tuesday. The ADMN stated the meal served on Tuesday was one the residents really liked. The ADMN stated he did not think he needed to call the dietician about menu change. Record review of the facility's policy titled: Menu Substitutions dated 2018: The menu will be served unless an emergency situation arises. If a specific item is not available, the cook with consult with the Nutrition & Food Service Manager or consultant RND/DTR regarding an appropriate substitution. All changes to the menu will be recorded on the Menu Substitution Approval Form. The menus are reviewed and approved by the Consultant Dietician. Intermittent changes must also be reviewed and approved by the

Based on observation, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety of 1of 1 kitchens reviewed. The facility failed to ensure items stored in 1 of 1 freezer were properly stored and labeled. The facility failed to ensure current temperature logs of 1 of 1 freezer and 2 of 2 refrigerators were maintained daily. The facility failed to ensure dietary staff (1 of 2) wore hair nets when preparing, serving meals. These failures could place resident that eat out of the kitchen at risk for food borne illnesses. The findings include: During an observation on 09/02/2024 at 09:55 AM in the kitchen revealed temperature logs for 1 of 1 freezer and 2 of 2 refrigerators were not up to date. There were no temperature logs for September 2024. During an observation on 09/02/2024 at 09:58 AM dietary staff were not wearing a hair net. During an observation on 09/02/2024 at 10:00 AM revealed in the freezer 1 box of tamales not sealed, dated. One package of what appeared to be breaded meat patties with plastic bag opened with no labels or dates. One bag of Oatmeal Raisin cookie dough ¾ full, not sealed or dated. One box of egg rolls opened, not sealed with no label or dates. During an observation on 09/02/2024 at 10:05 AM revealed the walk-in refrigerator had yellow cheese slices with no date or label. One bag of lettuce with no date or label. During an interview on 09/02/2024 at 9:55 AM the DM stated the temperature logs for the freezer and refrigerators had not been printed for September. The DM stated all products in the freezer, refrigerators and dry storage should be labeled with received date, date opened and best but date. During an interview on 09/02/2024 at 09:56 AM the dietary aide stated she did not have on a hair net due to the facility did not have any. The dietary aide stated not wearing a hair net could lead to hair falling into a resident's meals. The dietary aide stated this could cause the resident to not want to eat and could lead to resident weight loss. During an interview on 09/03/2024 at 11:20 AM the DM stated the dietary staff were without hairnets for a couple of days. The DM stated he did not know why the dietary aide did not have a hair covering, but she had her hair pulled up and out of her face. During an interview on 09/04/2024 at 01:23 PM the ADMN stated the temperature logs for freezers and refrigerators should be up to date. The ADMS stated if the temperatures were not documented the staff might not notice if the refrigerator or freezer was not working properly. The ADMN stated this would lead to spoiled food. The ADMN stated the dietary staff were responsible for ensuring the temperature logs were kept up to date. The ADMN stated he did not know what caused this failure. The ADMN stated the dietary staff should wear hair nets, or head covering when in the kitchen. The ADMN stated the facility had run out of hair nets, but they were available today. Review of the facility's policy dated Revised June 2019: Policy: to ensure that all food served by the facility is of good quality and safe for consumption, all food will be sorted according the state, federal and US Food Codes and HACCP guidelines. Refrigerators: Date, label and tightly seal all refrigerate foods using clean, nonabsorbent, covered containers that are approved for food storage. Place a thermometer inside refrigerators near the door where temperature is warmest. Check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41-degree Fahrenheit or below. Temperature should be checked each morning and again on the PM shift. Record the temperature on a lob that is kept near the refrigerator. Freezers: Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Place a thermometer inside freezer near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0 degrees Fahrenheit or below. Temperatures should be checked each morning and again on the PM shift. Record temperatures on a log that is kept near the freezer. Review of the facility's policy titled Employee Sanitation dated 2018: Employee Cleanliness Requirements . Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 development and transmission of communicable diseases for 1(Resident #1) of 3 residents reviewed for infection control practice. CNA (Certified Nurse Aide) A failed to perform hand hygiene and change her gloves at the appropriate times while providing incontinence care for Resident #1. These failures could place residents at risk for the spread of infection. Finding include: Review of Resident #1's face sheet, dated 05/30/24, revealed the resident was a 91- year- old female admitted to the facility on [DATE] with diagnoses of diarrhea, rash, and other nonspecific skin eruptions, and need for personal care. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/01/24, revealed Resident #1 required moderate assistance with most activities of daily living (ADL)) and one-person assist. Resident #1 was occasionally incontinent of bladder. Review of Resident #1 care plan dated 03/26/24 revealed Resident #1 experiences bladder incontinence and at risk for skin breakdown. Observation of incontinence care for Resident #1 on 05/29/24 at 10:00 a.m. revealed CNA A assembled supplies including some wipes. She did not wash her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. She wiped resident front to back. CNA A gloves were visibly soiled with urine and fecal matter. She did not change gloves , wash hands, , or perform hand hygiene. CNA A retrieved the clean brief and fastened to Resident #1 with the soiled gloves. CNA A doffed her gloves and walked out of the room without washing hands or performing hand hygiene. In an interview on 05/29/24 at 10:09 a.m. with CNA A, she said she should have washed her hands before starting care and changed the gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A explained she had been employed in the facility since April 2024 and received infection control training about 2 few weeks ago. She stated the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. CNA A was asked why he did not change gloves while providing care, he said he was nervous. During an interview with the interim DON on 05/30/24 at 11:30a.m., she revealed she was aware of some of the concerns raised about infection control. She said the staff were expected to follow the facility policy on incontinent care which included assembling needed supplies, washing hands, donning gloves, and sanitizing hands in between dirty and clean barriers. The DON stated the staff receive annual training and periodically if needed. Review of the facility's Handwashing/Hand hygiene revised 01/20/23 reflected the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. .3. Wash hands with soap and water, when hands are visibly soiled and after contact with resident with an infectious diagnosis. 4. Use an alcohol-based hand rub containing at least 60% to 95% ethanol alcohol or isopropyl alcohol. 5. Hand hygiene must be performed prior to donning and after doffing gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2023, November 2023, and December 2023) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, 7 days a week for the months of October 2023, November 2023, and December 2023 (Saturday's and Sunday's) for a total of 22 days. This failure could place the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings include: Record review of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2024 (October 1, 2023 - December 31, 2023), run date 05/29/2024, revealed no evidence of RN coverage for Saturday's and Sunday's for the months of October 2023, November 2023, and December 2023 for a total of 22 days: *10/01/23 (Sunday); 10/07/23 (Saturday); 10/08/23 (Sunday); 10/14/23 (Saturday); 10/15/23 (Sunday); 10/28/23 (Saturday); 10/29/23 (Sunday). *11/04/23 (Saturday); 11/05/23 (Sunday); 11/11/23 (Saturday); 11/12/23 (Sunday); 11/25/23 (Saturday); 11/26/23 (Sunday). *12/03/23 (Sunday); 12/09/23 (Saturday); 12/10/23 (Sunday); 12/16/23 (Saturday); 12/17/23 (Sunday); 12/23/23 (Saturday); 12/24/23 (Sunday); 12/30/23 (Saturday); 12/31/23 (Sunday). In an interview and record review on 05/30/24 at 11:00 am, the HR Coordinator stated there have been no RN's that worked on the weekends for the months of October 2023, November 2023, and December 2023. She said they have been attempting to hire a weekend RN but have not been able to hire one. She was not aware of any negative outcomes for the residents. In an interview on 05/30/24 at 11:43 am, the Administrator said the facility has been attempting to hire a weekend RN but have been unsuccessful. He said in the interim the facility has a PRN RN that would be available if needed. The facility also uses Services that staff would be able to utilize during the weekends if RN assistance was needed. He said there has been no negative outcomes for the residents. He said he does not think there would be any potential negative outcomes for not having an RN on the weekend due to the interventions that have been put in place. In an interview on 5/30/24 at 1:42 pm, the DON said the facility does not have a RN to work on the weekends. She said there has been no negative outcomes of not having an RN on the weekends. She did not think there would be any potential negative outcomes for not having an RN on the weekend due to the resources available to the facility, including an Employment Service Agency. A record review of the facility policy Staffing, dated as revised 09/28/2023, revealed the following [in part]: Policy Statement: Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents care plans were reviewed and revised by the interdisciplinary team after each assessment for 6 of 13 Residents (Residents #1, # 12, #19, #22, #24, #25) reviewed for comprehensive care plans, in that; The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #1's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #12's comprehensive assessment on 06/30/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #19's comprehensive assessment on 07/01/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #22's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #24's comprehensive assessment on 06/30/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #25's comprehensive assessment on 06/30/2023. This failure could place residents at risk of not having his or her needs met to achieve the highest quality of life. Findings include: Resident #1 Record review of Resident #1's face sheet dated 02/09/2022, revealed a [AGE] year-old female was admitted on [DATE] with medical diagnoses of dementia, anxiety, depression, high blood pressure, a history of falls, difficulty walking, and heart disease. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #1's comprehensive assessments and care plans revealed the most recent quarterly comprehensive assessment was completed on 07/11/2023. Record review of Resident #1's record revealed most recent care conference was dated 04/12/2023. During an interview on 07/25/23 at 09:09 AM, Resident #1 stated she was not sure if she had attended care plan meetings. Resident #12 Record review of Resident #12's face sheet revealed a [AGE] year-old female was admitted on [DATE] with medical diagnoses of Parkinson's disease, difficulty speaking, mood disorder, problems with blood circulation in her arms and legs. Record review of Resident #12's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #12's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 06/30/2023. Record review of Resident #12's record revealed most recent care conference was dated 04/12/2023. During an interview on 07/27/2023 at 11:14 AM, Resident #12 stated she did not attend care plan conferences because her family member takes care of all her business. Resident #19 Record review of Resident #19's face sheet revealed a [AGE] year-old male was admitted on [DATE] with medical diagnoses of enlarged prostate, difficulty communicating, lung cancer, heart attack, irregular heartbeat, and needed assistance with personal care. Record review of Resident #19's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #19's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 07/01/2023. The most recent care conference was dated 03/30/2023. Resident #22 Record review of Resident #22's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of mood disorder, difficulty walking, arthritis, digestions problems, and weakness. Record review of Resident #22's Quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #22's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 07/11/2023. Record review of Resident #22's record revealed most recent care conference was dated 04/18/2023. Resident #24 Record review of Resident #24's face sheet revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of Alzheimer's disease, low back pain, fainting, heart burn, and depression. Record review of Resident #24's Quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #24's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 06/30/2023. Record review of Resident #24's record revealed most recent care conference was dated 04/12/2023. Resident #25 Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted on [DATE] with medical diagnoses of dementia, high blood pressure, heart failure, anxiety, and diabetes. Record review of Resident #25's Annual MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #25's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 06/30/2023. Record review of Resident #25's record revealed most recent care conference was dated 04/18/2023. During an interview on 07/27/2023 at 10:00 AM, the CRN stated her expectations were for care plan conferences to be done timely as per policy and residents participate when they were able. The CRN explained the facility policy reflected a care conference was to be scheduled within 7 days of the completion of the comprehensive assessment. She stated the failure to hold the care plan conferences was due to the previous DON resigning several months ago and difficulties finding a replacement. She stated the Interim DON's first day was 07/24/2023. The CRN stated consequences to residents of failing to conduct the care conference would be residents would not be included in care decisions and needed care may be missed During an interview on 07/27/23 at 01:01 PM, LVN A stated the RN was responsible for creating the care plans. LVN A stated she felt it was important for the residents to participate in order for the resident to know what was going on and what was being discussed. She stated the meeting gave residents a chance to make their wants and needs known, a chance to voice their opinion. During an interview on 07/27/2023 at 01:26 PM, CNA A stated she looked at care plans to learn about residents. Her position was as needed or PRN. She explained if there were a new resident, the care plan helped her to know what the resident needed. CNA A stated she will not take care of a resident by herself without knowing what to do and how the resident liked things done. She stated the care plan usually gave the information to properly take care of the residents. CNA A stated residents should be in care plan meetings and meetings should be every few months if not more often due to how quickly a resident can change. During an interview on 07/27/2023 at 01:42 PM, CNA B stated he reviewed care plans regularly to keep up on how residents were doing and if anything changed. He stated it would be important for residents to participate in care planning and meetings should be quarterly. CNA B stated residents should have a say in their care. Review of facility policy titled Resident Participation - Assessment/Care Plans dated February 2021 revealed, 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 15. The Interdisciplinary Team must review and update the care plan: . d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record reviews the facility failed to maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 6 of 7 months reviewed for antibiotic stewardship. The facility failed to maintain a system to monitor antibiotic use during the months of January 2023 through June 2023. These failures placed residents at risk of adverse outcomes associated with the inappropriate use of antibiotics. Findings included: Record review of Facility Infection Control Log for January 2023 through July 2023 revealed facility maps with color coded rooms and the legend revealed the color to coordinate with the type of infection. There was also a page for each month that included each resident order for that corresponding month of a resident with an abx. There was no tracking form for the months of January 2023 through June 2023 that included if a resident had a lab completed before starting an abx, if they met/didn't meet the McGreers criteria for abx therapy, or if the infections were facility or community acquired. During an interview on 07/27/23 at 09:53 AM with ADON, she said that she was not responsible for the tacking/trending IC book. She said the nurse was supposed to use the McGreers form inside their Event tab of their EHR. She said that would include what abx was utilized, if a lab had been ordered and what those results were, as well as the reason for the abx with a start and stop date. ADON said after that, the nurse's should have been documenting per shift on an infection care note within the progress notes of the resident's EHR. ADON said she was not sure if it had been completed and/or tracked for every resident on every abx since January of 2023. During an interview on 07/27/23 at 10:51 AM with RRN, she said one of the reasons of termination for the former DON was due to job performance. RRN said the former DON was not tracking the infections that included tracking of and or performing lab cultures, the McGreers form for antibiotic stewardship or the mapping of the infections throughout the building. She said January to June of 2023 was not completed. RRN said she been working with ADON to get all the information for July of 2023. During an interview on 07/27/23 at 01:05 PM with RRN she said that the only way a resident with an infection and abx would go on the tracker was if an infection event was started in a resident's EHR. She said the form was an ongoing form until abx was completed. RRN said the tracker would not pick up a resident with an infection and/or their use of an abx unless the event was triggered. She said the form included if a lab was completed, what abx was used, the McGreers was met or not and it would assist in knowing if the infection was in house or community acquired. RRN said it was from pulling the abx list from the EHR system that through investigation it was revealed that the former DON was not utilizing the tracker. Record review of facility policy labeled Infection Prevention And Control Committee revised February of 2022 revealed: develop policies and procedures for surveillance and monitoring of infection control practices . Establish and monitor the facility antibiotic stewardship program . Maintain written accounts of meetings conducted and action taken by the committee . The infection prevention and control committee will advise administration and management about ensuring that records are maintained to document the following . Findings made during surveillance of antibiotic usage patterns. Record review of facility policy labeled Infection Control Documentation Workflow last revised 06/30/22 revealed: infection tracker infection control log the infection tracker in EHR is your infection control log. the log is auto generated from the completion of infection events in EHR. When a surveyor asks you for your infection log, the infection tracker is what you will produce. Note if infection tracker with McGreers criteria events are not initiated and completed timely, your infection tracker will not be accurate. Record review of facility policy labeled Antibiotic Stewardship revised Dec of 2021 revealed: this intern infection prevention and control program overseas the antibiotic stewardship program. The antibiotic stewardship program promotes the appropriate use of antibiotics including antibiotic use protocols and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The center develops and implements protocols to optimize the treatment of infection by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic reduces the risk of adverse events, including the development of antibiotic resistant organisms, from unnecessary or inappropriate antibiotic use and develops, promotes, and implements a center wide system to monitor the use of antibiotics . center leadership, including the administrator, is committed to safe and appropriate antibiotic use. This includes the development of antibiotic use protocols and a system to monitor antibiotic use. Leadership communicates with nursing staff and prescribing practitioners the centers expectations about use of antibiotics in the monitoring and enforcement of stewardship policies . The infection preventionist and director of nurses is responsible for the infection control program and oversight of the antibiotic stewardship program. The infection preventionist and director of nursing set the practice standards for assessing, monitoring and communicating changes in a resident's condition by frontline staff. Antibiotic orders and orders for lab cultures are reviewed by nursing leadership in the daily clinical meeting. They are reviewed for appropriateness and adherence to the center's antibiotic use protocols. The medical director set standards for antibiotic prescribing practices for all clinical providers credentialed to deliver care in the center and is accountable for overseeing adherence. To be effective in this role, the medical director should review antibiotic use data and ensure best practices are followed in the medical care of the resident . the center monitors measures of antibiotic use sample measures of antibiotic use: track the right of new starts of antibiotics/1000 resident days. Track center acquired infections. Track how and why antibiotics are prescribed. Track how often and how many antibiotics are prescribed. Track the adverse outcomes and costs from antibiotics. Track antibiotic days of therapy/1000 resident days. Adhere to clinical assessment documentation (sign symptoms, vital signs, physical exam findings.) Adherence to prescribing documentation. Identify and record community acquired infections. Identify and record types of infections and number of cases example UTI, Uri, L R I, wound infection. Review antibiotic resistance patterns in center to understand which infections are caused by resistant organisms. Monitor adherence to McGreers criteria to identify resident's signs and symptoms of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week or designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day. The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. These failures placed all residents at risk of their clinical needs not being met. Findings included: Record review of PBJ report ran 07/11/23 for Fiscal Year Quarter 2 (January 1,2023 to March 31, 2023) revealed no RN coverage for 01/01 (SU); 01/02 (MO); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/07 (SA); 01/08 (SU); 01/09 (MO); 01/10 (TU); 01/11 (WE); 01/12 (TH); 01/13 (FR); 01/14 (SA); 01/15 (SU); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/21 (SA); 01/22 (SU); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/28 (SA); 01/29 (SU); 01/30 (MO); 01/31 (TU) 02/01 (WE); 02/02 (TH); 02/03 (FR); 02/04 (SA); 02/05 (SU); 02/06 (MO); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/11 (SA); 02/12 (SU); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/20 (MO); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 02/27 (MO); 02/28 (TU) 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/04 (SA); 03/05 (SU); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11 (SA); 03/12 (SU); 03/13 (MO); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/18 (SA); 03/19 (SU); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR). Record review of daily staffing sheets revealed no RN coverage on: January 2023:1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 28, 29. February 2023:4, 5, 11, 12, 18,19, 25, 26. March 2023: 4, 5,11, 12, 18, 19,25, 26. June 2023: 10, 24th 25, 26 27, 28, 29, 30. July 2023: 8. 9, 10, 14, 15, 16, 21, 22, 23. Record review of former RN staff revealed: RN/DON first date worked was 01/23/23 and last date worked was 06/19/23. RNB first date worked was 04/17/23 and last date worked was /06/30/23 as a weekend RN. During an interview on 07/26/23 at 02:48 PM with RRN, she said the former RN/DON started 01/16/23 and worked Monday through Friday. She never worked any weekend. She said they did not have a weekend RN during the months of [DATE] through March of 2023. She said RNB was hired and worked April 2023 on weekends and some weekdays, but he quit at the end of June 2023. RRN said they had another RN that had worked some in June and now July, however they still didn't have one for weekends. RRN said she had been working periodically in July and has worked 7/11/23-7/13/23, 7/17/23-7/20/23, and had been in facility daily from 7/24/23 to present (07/26/23). She said they had an interim DON that was from Corporate that started Monday 7/24/23. She said the facility had advertisements in papers and online, however, RNs were wanting a wage that was above what could be offered at that time. Record review of RN Job Description revised 05/20/21 revealed: supervise other professional and nonprofessional staff in the day-to-day delivery of resident care; schedule job assignments and develop nursing unit priorities; Orient new staff and participate in the recruitment and selection of nursing personnel; communicate policies, assistant coaches needed; monitor work assignments, provide feedback, evaluate performance, and rate of rec and discipline employees as needed . monitor environment and care practices of nursing personnel to ensure compliance with established safety, fire, disaster, infection control and all other departmental policies and procedures; insert cleanliness and safety of work and treatment areas. Record review of DON Job Description revised 12/16/21 revealed: under the supervision of the administrator, the director of nursing, manages the overall operation of the nursing department in accordance with company policies, standards and nursing practices and government regulations to ensure the quality resident care is delivered in an efficient manner. Works with the administrator, consultants, and facility staff and planning all aspects of nursing services to include interface with other disciplines and departments; established priorities and job assignments; monitor department activities, communicate policies, evaluate performance, provide feedback and assist, coach, redirect and discipline as needed: maintain records, manage budget and supplies, and function as a senior department head. Ensure equipment and work areas are clean, safe, and orderly, and any hazardous conditions are addressed; ensure universal precautions and infection control, isolation, fire safety and sanitation practices and procedures are followed. conduct regular rounds and monitor resident activity, assess residents physical and psychosocial status, and monitor care activities and documentation to ensure the delivery of nursing care according to the physicians orders, care plans, and established standards and facility policies; manage admissions, transfers, and discharge of residents; family members and management regarding resident status; personally participate in the assessment and delivery of care when needed . ensure appropriate staffing levels are maintained through the development of recruitment resources, and through appropriate selection, orientation, training, and staff education.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to appropriately label, date, seal/close items stored in pantry, refrigerator, and freezer. The failure could place residents at risk for food-borne illness from food contamination. Findings include: During an observation in the facility's only kitchen on 07/24/2023 from 09:40 AM to 10:15 AM revealed the following: Four containers of spices on a shelf had lids open to air: Lemon pepper, sea salt, garlic powder, ground cumin. One 32-oz open bag of cheese sauce mix half full, folded over once and with no date of when opened One 32-oz open bag of potato flakes with no date of when opened One 1 lb. 8 oz bag of fried onions with no date of when opened One 5 lb. white cake mix was open to air with no date of when opened One 5 lb. bag of devil's food cake mix, half full, wrapped in clear plastic with no date of when opened One 5 lb. bag of blueberry muffin mix, wrapped in clear plastic with no date of when opened During an observation in the facility's only kitchen of the free-standing freezer revealed to the following: One clear plastic bag of tater tot was open to air with no date of when opened Top left shelf of the freezer, an item was wrapped in clear plastic was not labeled with no date of when opened Left 3rd shelf in the freezer, an item was wrapped in clear plastic was not labeled with no date of when opened One opened box labeled frozen enchiladas with no date of when opened. One opened box labeled cut green beans with no date of when opened One 10 lb. open box labeled chicken strips in a clear plastic bag that was open to air with no date of when opened One box labeled Salisbury steaks in an opened clear plastic bag that contained 8 patties and was open to air with no date of when opened Three meat patties in an opened clear plastic bag labeled pork chop steak with no date of when opened During an observation in the facility's only kitchen of the walk-in refrigerator revealed the following: One 16-oz. tub of whipped topping was opened with no date of when opened One clear plastic bag of shredded lettuce with no date of when opened One 1-gallon jar labeled ranch dressing with no date of when opened One 1-gallon jar labeled dill pickle relish with no date of when opened One 8 lb. 7 oz. jug labeled picante sauce with the lid not properly secured, exposing the contents to air with no date of when opened One clear plastic bag labeled shredded cheese was open to air with no date of when opened One clear plastic bag labeled shredded cheese wrapped in clear plastic with no date of when opened One clear plastic bag of shredded lettuce, that was brown, wrapped in clear plastic with no date of when opened One package cheese slices was not labeled with no date of when opened One clear plastic bag of shredded lettuce was open to air with no date of when opened One metal bowl containing cubes of cantaloupe and watermelon was open to air with no date of when opened One gallon of 2% milk half full that had an expiration date of 07/25/23. One 6 lb. 2 oz. can labeled applesauce was open, covered with foil with no date of when opened One 1-pint jar of an unknown dark brown substance that was not labeled with no date of when opened One 46-oz. container labeled thickened sweetened tea that was open and with no date of when opened Two 12-count packages of hot dog buns dated 05/30/23. One 46-oz. container labeled thickened sweetened tea that was open with no date of when opened One grey grocery bag tied closed that was not labeled with no date of when opened One clear plastic bag containing square breaded patties that was open to air with no date of when opened One box labeled bread sticks that contained a clear plastic bag that was open to air with no date of when opened One box labeled cheese & garlic biscuit dough that contained a clear plastic bag that was open to air with no date of when opened During an interview on 07/25/2023 at 10:55 AM, the DM stated he was responsible for labeling and dating inventory. He explained all dietary staff were responsible for rotating stock, removing and disposing of expired or past use by date items. The DM stated when he was hired, he had one day of training. The DM stated consequences to residents could be they get sick if the food was not labeled, dated, or expired. During an interview on 07/27/2023 at 10:10 AM, the ADM stated his expectations of labeling and storing food items was for the tasks to be completed when food items were delivered to the facility. The ADM stated it was unacceptable for food items to be left open to air and an opened date and use by date not visible. He stated all dietary staff were responsible for proper labeling and storage of food inventory. The ADM stated the failure occurred because the dietary staff were new to the facility and training was ongoing. Review of the facility's policy titled Food Storage dated 2018 revealed under Section 2. Refrigerators item D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for storage. Section 3. Freezers item e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Review of FDA Food Code 2022 revealed the following: 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. On-premises preparation Prepare and hold cold 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY 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. The day of preparation shall be counted as Day 1. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, 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 FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 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. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. (E) Paragraphs (A) and (B) of this section do not apply to individual meal portions served or rePACKAGED for sale from a bulk container upon a consumer's request. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 5 residents reviewed (Resident #2, Resident #5, Resident #6, Resident #13, and Resident #20) for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on assessed needs with measurable objectives or specific timeframes in areas such as weight loss, visual function, and risk for skin breakdown for Resident #2. 2. The facility failed to develop care plans based on assessed needs with measurable objectives or specific timeframes in areas such as psychotropic drug use, nutritional status, and communication for Resident #5. 3. The facility failed to develop care plans based on assessed needs with measurable objectives or specific timeframes in areas such as psychotropic drug use, behavioral symptoms, and visual function for Resident #6. 4. The facility failed to develop care plans based on assessed needs with measurable objectives or specific timeframes in areas such as delirium, incontinence, and psychotropic drug use for Resident #13. 5. The facility failed to develop care plans based on assessed needs with measurable objectives or specific timeframes in areas such as psychotropic drug use, weight loss, and infection for Resident #20. These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs. Findings include: Review of Resident #2's electronic face sheet accessed on 05/25/2022 revealed Resident #2 was a [AGE] year-old female who was initially admitted to the facility on [DATE] with most recent admission on [DATE] with medical diagnoses that included: stroke, difficulty swallowing, loss of appetite, osteoarthritis, high blood pressure, heartburn, depression, and unspecified pain. Review of Resident #2's MDS dated [DATE] revealed a BIMS score 6 indicating severe cognitive impairment. Review of Resident #2's Comprehensive Care Plan dated 05/02/2022 revealed the following problems and goals lacking the ability to be evaluated or quantified. Problem: Resident is at risk for weight loss r/t decreased appetite with an unmeasurable goal of Resident will achieve stable weight within 30 days. Problem, Visual Function with an unmeasurable goal of Resident will have optimal visual ability. Problem, Oral/Dental Status with an unmeasurable goal of Maintain oral hygiene/status. Problem, ADL Function/Rehab Potential with an unmeasurable goal of Resident will achieve maximum functional mobility. Problem, Nutritional Status Diet with an unmeasurable goal of Maintain Stable Weight. Problem, Resident is at risk of losing weight related to dysphagia, and sometimes decreased appetite with an unmeasurable goal of Resident will not exhibit signs of malnutrition or dehydration. Problem, Resident at risk for skin breakdown r/t urinary incontinence with an unmeasurable goal of Resident will be clean, dry, and odor free. Problem, I enjoy social interaction with my fellow residents and choose to take part in activities when they are offered with an unmeasurable goal of I will participate in bingo, dominos, ball toss, puzzles, exercise, and continue to attend social and religious gatherings. Review of Resident #5's electronic face sheet accessed on 05/25/2022 revealed a [AGE] year-old female was admitted to the facility on [DATE] with medical diagnoses that included dementia, high blood pressure, history of falls, weakness, anxiety, and difficulty sleeping. Review of Resident #5's MDS dated [DATE] revealed a BIMS score 9 indicating moderate cognitive impairment. Review of Resident #5's Comprehensive Care Plan dated 05/09/2022 revealed the following problems with goals lacking the ability to be evaluated or quantified. Problem, Psychotropic Drug Use with an unmeasurable goal of Benefit without side effects. Problem, Nutritional Status Diet regular with an unmeasurable goal of Maintain stable weight. Problem, Dehydration/Fluid Maintenance with an unmeasurable goal of Resident will consume adequate fluids. Problem, Communication with an unmeasurable goal of Resident's needs/wants will be met at all times. Problem, Cognitive Loss with an unmeasurable goal of Resident will be as alert and oriented as possible. Problem, Cardiac with an unmeasurable goal of No complications. Problem, Behavioral Symptoms with an unmeasurable goal of Resident will have fewer episodes of depression and anxiety. Problem, ADL Function/Rehab Potential with an unmeasurable goal of Resident will achieve maximum functional mobility. Review of Resident # 6's electronic face sheet on 05/25/2022 revealed an [AGE] year-old female admitted to the facility on [DATE], with medical diagnoses that included: Alzheimer's disease, high blood pressure, mini stroke, anemia, delusional disorder, schizoaffective disorder and dementia. Review of Resident #6's MDS dated [DATE] revealed a BIMS score 7 indicating moderate cognitive impairment. Review of Resident #6's Comprehensive Care Plan with last review dated 05/26/2022 revealed the following problems with goals lacking the ability to be evaluated or quantified. Problem, ADL Function/Rehabilitation Potential with an unmeasurable goal of I will perform the following ADL tasks at my highest practicable well-being. Problem, Psychotropic drug use with an unmeasurable goal of 'Reduce risk of side effects. Problem, I am at risk for injuries as I have impaired visual functioning. I do wear glasses with an unmeasurable goal of I will have decreased injuries due to my impaired vision through nursing interventions. Problem, I have episodes of resisting care with showering with an unmeasurable goal of I will be given the care I need with compassion, respect, and dignity. Problem, Type II Diabetes with an unmeasurable goal of I will be offered an appetizing meal, and an alternative meal. Desirable nutrition will help me maintain my weight at an acceptable range and keep my blood sugar within normal range. Problem, I do not have plans to return to the community, because I require more care than what I would receive at home with an unmeasurable goal of My needs will be met while I am a resident at this nursing home. Review of Resident # 13's electronic face sheet on 05/25/2022 revealed an [AGE] year-old female admitted to the facility on [DATE], with medical diagnoses that included: profound intellectual disabilities, convulsions, difficulty swallowing, unspecified pain, Type 2 diabetes, high blood pressure, and low thyroid function. Review of Resident #13's MDS dated [DATE] revealed a BIMS score 99 indicating a cognition assessment was not possible. Review of Resident #13's Comprehensive Care Plan with last review dated 05/03/2022 revealed the following problems with goals lacking the ability to be evaluated or quantified. Problem, ADL Function/Rehabilitation Potential with an unmeasurable goal of Resident will achieve maximum functional mobility. Problem, Psychotropic drug use with an unmeasurable goal of Benefit without side effects. Problem, Cardiac with an unmeasurable goal of No complications. Problem, Cognitive Loss with an unmeasurable goal of Resident will be as alert and oriented as possible. Problem, Visual Function with an unmeasurable goal of Resident will have optimal visual ability. Problem, Delirium with an unmeasurable goal of Resident will be as alert and oriented as possible. Problem, B/B Incontinence/Catheter Care with an unmeasurable goal of Resident will establish an individual bowel and bladder routine. This goal was also unrealistic due to the resident's cognitive status as evidenced by a BIMS score of 99 indicating a cognition assessment was not possible and medical diagnosis of profound intellectual disabilities. Problem, Psychosocial well-being with an unmeasurable goal of Resident will express/exhibit satisfaction. Problem, Pressure Sores/Skin Care with an unmeasurable goal of Prevent/heal pressure sores and skin breakdown. Problem, Pain with an unmeasurable goal of Resident will be as comfortable as possible. Problem, Oral/Dental Status with an unmeasurable goal of Maintain oral hygiene/status. Problem Nutritional Status Diet with an unmeasurable goal of Maintain Stable Weight. Problem, Mood State with an unmeasurable goal of Resident will express/exhibit satisfaction. Problem, Diabetes with an unmeasurable goal of No complications. Problem, Dehydration/Fluid Maintenance with an unmeasurable goal of Resident will consume adequate fluids. Problem, Communication with an unmeasurable goal of Resident's needs/wants will be met at all times. Problem Behavioral Symptoms with an unmeasurable goal of Resident will have fewer episodes of getting irritated. Problem Resident is PASSR positive with an unmeasurable goal of Nursing is to participate in IDT meetings with local mental health resource. Review of Resident # 20's electronic face sheet on 05/25/2022 revealed an [AGE] year-old female admitted to the facility on [DATE], with medical diagnoses that included: dementia without behaviors, irritability and anger, low back pain, disorientation, tremor, contracture, depression, difficulty communicating, difficulty walking, and low thyroid function. Review of Resident #20's MDS dated [DATE] revealed a BIMS score 3 indicating severe cognitive impairment. Review of Resident #20's Comprehensive Care Plan with last review dated 05/23/2022 revealed the following problems with goals lacking the ability to be evaluated or quantified. Problem, Infection Alert with an unmeasurable goal of Resolve infection. Problem, Psychotropic drug use with an unmeasurable goal of Benefit without side effects. Problem, Resident is at risk for weight loss with an unmeasurable goal of Resident body weight will be within normal range for age. Problem, Resident is at risk for UTI related to her diagnosis of need for assistance with personal care and history of UTIs with an unmeasurable goal of Resolve infection. Problem, Resident is at risk for impaired physical mobility related to a diagnosis of contracture, unspecified joint, muscle weakness (generalized), and tremor) as evidenced by her use of Primidone and Sinement with an unmeasurable goal of Resident will be able to perform activities of daily living within her limits. Problem, Pain with an unmeasurable goal of Resident will be as comfortable as possible. Problem, Cardiac with an unmeasurable goal of no complications. Problem, Visual function with an unmeasurable goal of Resident will have optimal visual ability. Problem, Pressure Sores/Skin Care with an unmeasurable goal of Prevent/heal pressure sores and skin breakdown. Problem, Oral/Dental Status with an unmeasurable goal of Maintain oral hygiene/status. Problem, Nutritional Status Diet with an unmeasurable goal of Maintain Stable Weight. Problem, Delirium with an unmeasurable goal of Resident will be as alert and oriented as possible. Problem, Dehydration/Fluid Maintenance with an unmeasurable goal of Resident will consume adequate fluids. Problem, Communication with an unmeasurable goal of Resident's needs/wants will be met at all times. Problem, Cognitive Loss with an unmeasurable goal of Resident will be as alert and oriented as possible. Problem, B/B Incontinence Care with an unmeasurable and unrealistic goal of Resident will establish an individual bowel and bladder routine. Problem, ADL Function/Rehab Potential with an unmeasurable goal of Resident will achieve maximum functional mobility. During an interview on 05/26/22 at 9:30 AM the DON stated she was responsible for creating care plans. The DON stated she started in the position in September 2021 and had been working on updating the care plans to meet the expectation of measurable goals with timeframes. The DON stated care plans without measurable goals with timeframes could affect residents because the staff would not be aware of the expectations or goals of resident care or how the goals were expected to be reached and by when. The DON stated she was trained in creating care plans by the facility's Director of Clinical Practice. During an interview on 05/26/22 at 10:33 AM with TNA A, she stated she looked at the care plans to know what a resident needed, and what their preferences were. TNA stated she expected the care plans to be specific to each resident's needs. TNA A stated the staff communicated very well and written notices about changes in care plans were posted at the nurse's station. TNA A explained staff had to sign indicating they read and understood when a care plan change was posted. TNA A stated when a change of condition in a resident was identified, the information was reported to the charge nurse and/or the DON and then the charge nurse documented what was reported. TNA A stated she was trained about how to use a care plan by the aide she replaced. TNA A stated the extent of training when hired depended on the new aide's experience and background. TNA A stated she had worked in healthcare for 10 years and was familiar with care plans. During an interview on 05/26/22 at 10:40 AM with LVN B, she stated the DON created the care plans, but all nursing staff had input. LVN B stated accuracy of care plans was important to provide individualized care, and care plans needed to be specific to resident preferences. LVN B stated she was a member of the IDT committee. LVN B stated the committee met prior to each care plan conference to discuss accuracy of care plans and possible changes. Review of the facility's policy titled Care Plans, revised December 2020, Comprehensive Person-Centered; Policy Interpretation and Implementation, item 8: The Comprehensive, person-centered care plan will: (k) Reflect treatment goals, timetables and objectives in measurable outcomes.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 26 out of 87 days reviewed for RN coverage. The facility failed to ensure RN coverage for 7 days in March 2022, 11 days in April 2022, and 8 days in May 2022. This failure could affect residents in the facility by leaving residents and staff without supervisory coverage for coordination of events such as emergency care and disasters. Findings include: Record review of the facility provided staff time sheets for March 2022, April 2022, and May 2022 revealed the following days were without RN coverage: 03/06/22 (Saturday), 03/12/22 and 03/13/22 (Saturday and Sunday), 03/19/22 and 03/20/22 (Saturday and Sunday), 03/26/22 and 03/27/22 (Saturday and Sunday), 04/02/22 and 04/03/22 (Saturday and Sunday), 04/04/22 and 04/05/22 (Monday and Tuesday), 04/09/22 and 04/10/22 (Saturday and Sunday), 04/16/22 and 04/17/22 (Saturday and Sunday), 04/23/22 and 04/24/22 (Saturday and Sunday), 04/30/22 and 05/01/22 (Saturday and Sunday), 05/07/22 and 05/08/22 (Saturday and Sunday), 05/09/22 (Monday), 05/14/22 and 05/15/22 (Saturday and Sunday), and 05/21/22 and 05/22/22 (Saturday and Sunday). During an interview on 05/24/2022 at 2:20 PM the DON stated the facility had no weekend RN coverage at this time for the weekends. She stated the facility was using a nurse staffing agency to staff RNs on the weekends but corporate said it was too expensive. She stated the facility had not had a weekend RN since the end of February 2022. The DON stated she lived in town and could come to the facility if an emergency were to happen on a weekend. She stated that not having an RN available could affect the residents by not having a proper assessment in an emergent situation. The DON stated if a resident were to pass away the facility would need an RN to pronounce the resident's death. She stated necessary needs may not be met without an RN in at the facility. During an interview on 05/24/22 at 2:23 PM the Administrator stated the facility had not had weekend RN coverage since February 2022. She stated she was aware of the federal requirement to have RN coverage for 8 hours a day, 7 days a week. She stated the facility was unable to find an RN to hire for the weekends. The Administrator stated the facility did not have a policy related to RN coverage.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to properly label and store food These failures placed residents at risk for food borne illness. Findings included: During an observation on 05/24/2022 at 9:25 AM of the kitchen revealed: 1. One can of Early June Peas with a dent in the can. 2. One can of Salad Slice Beets with a dent in the can. During an observation on 05/24/2022 at 9:45 AM of the kitchen temperature log on the door of freezer #1 not recorded every day revealed: 1. Two small vanilla ice cream cups in a bag not sealed, exposed to air, labeled or a use by date. 2. One open box of frozen oblong shaped bread not sealed and exposed to air, labeled, or dated. During an observation on 05/24/2022 at 9:55 AM of the kitchen revealed in Freezer # 2: 1. One open box of frozen round meat patties not sealed and exposed to air, labeled, or dated. During an observation on 05/24/2022 at 10:00 AM of the kitchen, revealed in the walk-in refrigerator: 1. One tray of drinking glasses (approximately 20 glasses) with a clear liquid and no covering on the glasses. 2. One tray of drinking glasses (approximately 20 glasses) with a dark colored liquid and no covering on the glasses. 3. One large silver bowl with a pudding like substance not labeled, dated with date put in refrigerator, or covered. Interview on 05/25/2022 at 9:27 AM, the DM stated she had been managing the kitchen since December 2021 and had her food handler certificate but not her DM certification. She stated she should be labeling all products with the date received, date opened and used by date. The DM also stated whoever was putting the products up should label with the received date, date opened and used by date. She stated she did not know why all the products were not labeled. She stated she was responsible for that not being done. She stated if she found a can with a dent, she would remove it and send it back the next time they got an order. She stated she had not been at the facility for several days, so she thought that was why the dented cans did not get removed. The DM stated that using foods from a dented can could cause someone to get sick. Interview with the ADMIN on 05/26/22 at 8:45 AM stated she would expect the dietary staff to label and store foods in the kitchen properly. She stated she did not know why it was not being done. The ADMIN stated all residents ate from the kitchen Review of the facility's policy titled Food Storage, dated 2018 revealed: 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage.