Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (HC Arbor, HC Woodlands, Rehab). The dietary staff did not accurately test and log the dish machine for hot water sanitizing on 06/01/25 and the morning of 06/02/25. DA B served food without taking the holding temperatures on the rehab unit. Cook C did not take holding temperatures in the main kitchen on the foil covered plates and on any of the alternate food items. DA D served food whose temperatures were below appropriate holding temperatures on HC Arbor. She did not take temperatures on all 4 foil covered plates with food items. DA D used gloved hands to serve rolls, French fries, chicken strips, and onion rings after handling other items in the satellite kitchen on HC Arbor. DA E did not take holding temperatures on the alternate food items on HC Woodlands before serving. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation and interview in the main kitchen on 06/02/2025 at 10:25 AM, the assistant FSM said the dish machine was a high temperature sanitizing unit. At 10:25 AM a rack of dishes was sent through the dish machine and the temperature dials did not move. The thermometer device that rode through the machine noted the high temperature to be 156 degrees. A second run was performed and the temperature registered 136 degrees. The assistant FSM said they would call maintenance to come check the machine. During a record review and observation in the main kitchen on 06/02/2025 at 10:30 AM, the log sheet for documenting the wash/rinse temperatures for the dish machine was observed hanging on the dish room door. One entry had been made for breakfast on 06/01/2025. No entries were made for the noon and evening meals on 06/01/2025. No entry had been made for breakfast temperatures on 06/02/2025 although all dishware and silverware from breakfast had been washed and returned to the satellite kitchens. DW A said at that time he had not taken the wash/rinse temperatures that morning. The assistant FSM said they would bring back all the dishware and silverware from the satellite kitchens and sanitize them in the 3-compartment sink, air dry them and return them to the satellite kitchens. During an observation on 06/02/2025 at10:32 AM, the 3-compartment sink was prepared, tested and was sanitizing at 400 ppm. During an interview on 06/02/2025 at 10:37 AM, DW A said they had been having trouble with the temperatures fluctuating on the dish machine. He said they would go way down low and then come back up. He ran another rack of items through the dish machine and the wash temperature was 175 degrees and the rinse temperature was 160 degrees. He said he had not told anyone about the temperature discrepancies. He said he had not tested the sanitizing on the dish machine that morning even though he had washed all of the dishes from the satellite kitchens. During an interview on 06/02/2025 at 10:45 AM, the FSM said their old chemical dish machine that had been removed from another part of the kitchen had a heater booster on it to keep the temperatures elevated. He said the water heater supplying the kitchen was also shared with the independent living. He said they had no problems with temperatures when they had the old chemical dish machine hooked up with the heater booster. He said he would get a plumber to move the heater booster to the current dish washing machine. He said they had been using the new machine without the heater booster for about 4 months. He gave no reason as to why the staff had not recorded the wash and rinse temperatures. During an observation and interview on 06/02/2025 at 12:23 PM DA B on the Rehab unit served a lunch plate of Salisbury steak, mashed potatoes, and broccoli salad without taking the holding temperatures. He was asked if he had taken the holding temperatures already and he said he had not taken any temperatures. He said they took the temperatures in the back and he said he normally took the temperatures before he served the food. His temperature log book indicated he had not taken the temperatures on the food for the noon meal on 06/02/2025 before serving any food. During an interview on 06/02/2025 at 1:15 PM, the FSM said a plumber was to come next week to install the hot water booster to the dish machine. He said they would continue to wash and rinse in the dish machine and keep an eye on the fluctuating temperatures and if the temperatures dropped below the required levels they would utilize the 3-compartment sink for sanitizing while the machine recovered and the temperature returned to the acceptable sanitizing temperature of 180 degrees. During an observation and interview on 06/03/25 at 11:10 AM, [NAME] C began taking holding temperatures for food items to be taken to the 3 satellite kitchens (HC Arbor, HC Woodlands, and Rehab units). The stainless-steel steam table pans were being held in heated food transport units before being transported. The HC Arbor heated food transport unit contained 4 foil covered plates and [NAME] C said those were puree and she did not take the temperatures on those plates. She said the dietary person on the unit would take the temperatures and put it in the microwave if it needed to be re-heated. During an interview on 06/03/2025 at 11:30 AM, the FSM said the dish machine was a single-tank stationary rack, dual-temperature machine and he said both dishwashers were re-trained on 06/02/25 on the logging procedures and communicating issues with temperatures to management. He said the hot rinse should reach 180 degrees for sanitizing. He said the dietary servers were re-trained on the morning of 06/03/25 on taking holding temperatures before food was served to the residents on the units. During an observation on 06/03/2025 at 11:40 AM, the heated food transport unit brought the folllowing food items to the HC Arbor unit: chicken and dumplings, spinach, and puree soup, and was placed on the steam table. The 4 foil covered plates were placed in a heated cabinet. DA D said she needed to go back to kitchen and get her vegetable soup and rolls that were not placed on the cart. DA E took the heated food transport unit with her food items to the HC Woodlands unit. During an observation and interview on 06/03/2025 at 11:50 AM, holding temperatures were taken on the HC Woodlands unit after the stainless-steel pans for the main entrée had been placed on the steam table. At 12:05 PM DA E said she had chicken strips, French fries and onion rings in pans still in the heated transport unit. She did not take any holding temperatures on these items. During an observation and interview on 06/03/2025 at 12:02 PM, the holding temperatures were taken on the HC Arbor unit. The following was noted: chicken strips 121 degrees; French fries 116 degrees; One foil covered plate was uncovered and the temperatures were: pureed chicken and dumplings 122 degrees, pureed spinach 113 degrees, pureed vegetable soup 113 degrees, and DA D did not take any food temperatures of the remaining 3 foil covered plates. During an observation and interview on 06/03/2025 on the HC Woodlands unit kitchen at 12:10 PM, DA D put on gloves to start service and wore them throughout the service picking up French fries, onion rings, and chicken strips with her gloved hands after touching serving utensils, plates, meal tickets, and cabinet doors. DA D said the soup and chicken and dumplings should have been 180 degrees and the chicken strips and French fries should have been 165 degrees. She said those food items were not at the proper serving temperatures but she served them anyway. She said she should have called the FSM with the improper temperatures. She said people could get sick if they ate food that was not held at the proper temperatures. She said she could use her gloved hands to touch food items as long as she had the gloves on. She said she did not have to change them. During an interview on 06/02/2025 at 1:25 PM the FSM said dietary staff should use utensils to serve any food item. He said gloved hands were not to be used to serve rolls, French fries, chicken strips, etc. He said every food item should be tested for a holding temperature before service to the residents; not just the main food items. Review of the Dishmachine Temperature Record (High Temperature Machine) dated June 2025 indicated Wash Temp of 165 degrees and Final Rinse temperature of 160 degrees was done by DW A on 06/01/2025. There were no temperatures entered for lunch or dinner on 06/01/2025. There were no temperatures entered for breakfast on 06/02/2025. Review of the facility policy Dishmachine Temperatures, revised date 01/2024, indicated .High Temperature Machine: . Single-tank, stationary-rack, dual-temperature machine Wash temperature 150 degrees and Final rinse temperature 180 degree-194 degrees.Procedures: Supervisor/Food and Nutrition Associate as assigned High Temperature Dishmachine-record on Dishmachine Temperature Record Form.Supervisor: If documentation of the temperature and test strips/max temps results has been assigned to a Food and Nutrition Associate confirms that it is completed at each meal period. Review of the facility policy Meal Quality and Temperature, revised date 01/2024, indicated .Dining Room and Pantry: When bulk food is transported to a dining serving location, temperatures are taken and recorded in the kitchen before transport as well as at the final serving location.Records temperatures no more than 30 minutes prior to meal service. If hot food is below standard, it must be reheated up to 165 degrees for a minimum of 15 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents (Residents #6) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #6 as having restraints on her MDS assessment. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of an admission Record dated 4/29/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses s of dementia (a group of thinking and social symptoms that affect activities of daily life), anemia (low red blood cells that carry oxygen in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 00. She required substantial/maximal assistance to partial/moderate assistance with ADL's. She was always incontinent of bowel/bladder. Physical restraints used in bed-(other) that was used less than daily. During an interview on 4/29/2024 a 4:14 PM, the DON said there were not any residents in the facility that had restraints and they were a restraint free facility. She said she was not aware of Resident #6 having restraints but would talk to the MDS Coordinator. During an interview on 4/30/2024 at 10:30 AM, the MDS Coordinator said she was responsible for completion of the MDS assessments. She said she usually went through all of the assessments and checked restraints not used on all of the residents in the facility. She said on Resident #6 she accidentally checked that she had restraints on the MDS dated [DATE]. She said the facility was restraint free. She said she completed a modification of the MDS assessment dated [DATE] for Resident #6 on yesterday 4/29/2024. She said the facility did have some residents that used assist bars but not any restraints such as bed or chair alarms. She said by completing the MDS Assessments she was stating that they were accurate and correct to the best of her ability. She said she was not aware that Resident #6 had a MDS assessment that indicated she had restraints until the DON mentioned it to her on 4/29/2024. She said there could be a risk of the facility not getting paid correctly and could affect the care of the residents if assessments were not coded correctly. She said going forward she would be slowing down while completing the assessments and would be checking everything from now own. During an interview on 4/30/2024 at 3:00 PM, the Regional MDS Coordinator said she visited the facility every 2 months or about once a quarter. She said she conducted audits for documentation of the MDS assessments. She said she looked at things that could affect reimbursement such as ADL's, BIMS and PH9 (instrument for screening, diagnosing, monitoring, and measuring the severity of depression) in the assessments. She said she would expect the MDS Coordinator to catch the restraints that was incorrectly coded on the MDS assessment because the facility was restraint free. She said restraints was not something that would be caught during an audit, but the MDS Coordinator should be monitoring the facility matrix that would indicate if a resident had restraints. She said going forward she would send training and education to the MDS Coordinator. She said there was a risk of the assessments affecting quality measures if they were not coded accurately. Record review of the Resident Matrix dated 4/29/2024 indicated Resident #6 had physical restraints. During an interview on 5/1/2024 at 10:25 AM, the Administrator said the IDT team members had portions of the MDS they were responsible for and there was a Regional MDS Coordinator that assisted as needed. She said the Regional MDS Coordinator conducted audits and reviewed the MDS assessments randomly. She said the facility was restraint free and Resident #6 did not have any restraints. She said the MDS Coordinator did a modification of the MDS Assessment that reflected Resident #6 did not have a restraint. She said going forward she would look at an audit system with the Regional MDS Coordinator to see what would be best for accuracy. Record review of a facility polity titled Certifying Accuracy of the Resident Assessment revised November 2019 indicated, .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sing and certify the accuracy of that portion of the assessment. 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each resident is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 12 residents (Resident #196) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission on Resident #196 and provide a care plan summary to the resident or representative. This failure could place residents at risk of not receiving correct and/or necessary care/treatment. Findings: Record review of a facility face sheet dated 4/30/2024 indicated Resident # 196 was a [AGE] year old male and admitted on [DATE] with a diagnosis of aftercare for femur fracture (broken upper leg). Record review of a baseline care plan indicated Resident # 196 was admitted on [DATE] and the baseline care plan was not completed until 4/18/2024 and the family was not provided a summary of the baseline care plan. Record review of an admission MDS assessment dated [DATE] indicated Resident # 196 had a BIMS of 13 indicating intact cognition. During an interview on 04/29/2024 at 2:43 PM LVN C stated she was responsible for completing the baseline care plans on new admissions and making sure the resident or family received a copy of the summary . She said the admitting nurse initiated the baseline care plan, but she reviewed and completed them. She said they should be completed within 48 hours of admission but sometimes she got behind. She said if the baseline care plan was not completed it could cause care delivery issues. During an interview on 04/30/2024 at 2:49 PM the MDS Coordinator said the admitting nurse was responsible for completing the baseline care plan within 48 hours of admission and if the admission occurred after hours or on the weekend the charge nurse or weekend supervisor was responsible for completing the baseline care plan. She said if the baseline care plan was not done it could delay resident care. She said the family or resident should receive a summary of care and if they were not provided a summary they would not be involved in their care goals. During an interview on 05/01/2024 at 11:12 AM the DON said the baseline care plans were to be completed by the admission nurse and should be completed within 48 hours of admission. She said the resident or family should receive a copy of the summary. She said previously the social worker was completing them but recently it was changed to LVN C. She said on the weekend the charge nurse was responsible for completing the baseline care plan and then LVN C audits for accuracy. She said if baseline care plans were not completed it could affect resident receiving needed services. During an interview on 05/01/24 at 11:50 AM the Administrator said that the admission nurse was responsible for completing the baseline care plan and the DON/ADON were responsible for reviewing for compliance. She said the resident and family should receive a copy of the summary. She said previously there was a different system in place, but they found that the baseline care plans were not being completed per the regulation. She said if the baseline care plans were not completed within 48 hours of admission it could cause care delivery issues. She said she expected that all baseline care plans were completed per the regulation and would review the current process and make changes as needed. Record review of a facility policy titled Care Plans - Baseline dated December 2016 indicated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission, 4. the resident and their representative will be provided a summary of the baseline care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #37) On 4/04/2024 CNA G failed to ensure a safe transfer by leaving Resident #37 standing in the sit to stand lift unattended and left the room to retrieve supplies and Resident #37 fell. This failure could place residents who required supervision at risk of injury or accidents and hospitalization. Findings included: 1.Record review of Resident #37's face sheet dated 4/29/2024 indicated she was an [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, history of falling, muscle weakness, and dementia (impaired ability to remember, think, or make decisions). Record review of the significant change MDS dated [DATE] indicated Resident #37 had clear speech and makes self-understood. Resident #37's BIMS was 03 indicating severe cognitive impairment. Resident #37 required substantial/maximal assistance with transfers. Record review of Resident #37's care plan dated 3/07/2024 indicated Resident #37 needed assistance with activities of daily living with an intervention: Elder is a two person transfer or sit to stand transfer and Increase assistance as needed to ensure elder safety. Resident #37 had a history of falls with interventions that included: For no apparent acute injury, determine and address causative factors of the fall. Record review of facility post fall evaluation dated 4/04/2024 indicated Resident #37 had an unwitnessed fall from the mechanical sit to stand lift at 1:45 pm on 4/04/2024, with no injuries. Record review of an incident statement dated 4/04/2024 given by CNA G indicated: While taking Resident #37 to her room from the dining room, CNA noticed that resident was wet, and CNA used the stand up lift to provide care. CNA removed resident's brief, and realized resident had a bowel movement. CNA stated she did not see any wipes in the room, so she left the room while the resident was in the stand up lift to obtain wipes. CNA went to the room across the hall to look for wipes and a nurse was in the room. CNA let the nurse know she was looking for wipes to attend to resident. CNA stated that there were no wipes in that room either on the A or B side. CNA then went back into the resident's room to check on her and let her know that she will be back. CNA stated she recalled earlier in the day that the housekeeper advised her that there were wipes at the nurses station. CNA then went to the nurses station and found the wipes. CNA reports that she believes that it took less than 5 minutes to retrieve the wipes and return to resident's room. When CNA returned, she noted resident on the floor. CNA retrieved the nurse, LVN H and reported that resident fell. Brief was placed on resident. CNA and nurse were able to return resident to the bed. Nurse assessed resident for injury, and care was then provided to resident in bed. During care, the resident did not indicate pain. After care was provided, resident was transferred from the bed to the recliner. The nurse assessed resident for injury. During an interview on 4/29/2024 at 10:04 AM Resident #37 said she did not remember having a fall. Surveyor attempted an interview with CNA G via phone on 4/29/2024 at 10:33 AM, CNA G did not answer phone or call back. During an interview on 04/30/24 at 11:01 AM LVN H said staff were supposed to use 1-2-person assistance with the sit to stand lift. She said with the old lifts they were always a 2 person assist. She said the new lifts were bought about 6 months ago and only require 1-2 person assist . She said on 4/4/24 the CNA G went to her and told her that Resident #37 was on the floor. She said CNA G told her she left Resident #37 in the sit to stand lift to go and retrieve wipes and when she returned Resident #37 was on the floor. She said she went and assessed Resident #37 for injuries with none found. She said CNA G was suspended on 4/4/24 and terminated. She said after the fall staff was in-serviced on lifts and physical therapy demonstrated how to appropriately use lifts. During an observation on 04/30/24 11:12 AM, Observed CNA I and CNA J as they performed a sit to stand transfer via a sit to stand lift. Observed CNA J place the sling around Resident #37's torso and chest area, she then tightened the straps and latched the buckles. CNA J had Resident #37 sit straight up in her wheelchair and attached the lift sling to the lift and had Resident #37 grab on to the handlebars. CNA I ensured Resident #37's feet were on the lift platform and attached the leg safety strap behind Resident #37's lower legs. CNA J then lifted Resident #37 to a standing position. CNA J and CNA I then rolled Resident #37 into the bathroom and lowered her onto the commode. During an interview on 04/30/24 at 11:21 AM, CNA I said when she transfers Resident #37 she always had 2 staff members in the room. She said she gets how each resident transfers from therapy. She said she could always see how any resident transfers by looking on the [NAME] in the computer. During an interview on 04/30/24 at 11:29 AM, the PTA said she had been at the facility for about 2 years. She said that all mechanical lifts in her opinion should be 2 person assist. She said Resident #37 was a 1-2 person assist with transfers depending on the day and what is going on with Resident #37. The PTA said Resident #37's cognition and strength varied from day to day and some days she would be appropriate for a sit to stand lift and some days she was not appropriate for the sit to stand lift. During an interview on 04/30/24 at 11:38 AM CNA K said she had worked at the facility for about 1 week. She said that when using any kind of mechanical lift there should always be 2 staff assistance. She said you can find what level of assistance a resident needs by looking at the point of care system in the computer. During an interview on 04/30/24 at 11:43 AM CNA L said she had worked at the facility for about 6 months. She said for any transfers requiring a lift there should always be 2 staff assistance. She said when she first started at the facility she was trained on the mechanical lifts by therapy. During an interview on 05/01/24 at 08:02 AM, The DON- Said CNA G took Resident #37 to her room to do incontinent care and had put Resident #37 in a sit to stand lift. She said CNA G left the room to get wipes and when she returned the resident was on the floor. She said she is not sure if the sling was snug enough to hold the resident because she had slid out of the sling and onto the floor. The DON said Resident #37 was on the floor in the sitting position. The DON said after Resident #37's fall they had increased their training with the sit to stand and the mechanical lifts. She said they had in-serviced on fitting the sling properly around residents. She said they had also done some gait belt training with staff. She said she and the ADON had been randomly monitoring transfers weekly. She said therapy had monitored transfers to ensure the proper transfer techniques are used. The DON said they talk about residents that has had a change in functional status in their daily huddle meeting. The DON said she expected staff to follow the proper policies and procedures to ensure the resident's safety during transfers. During an interview on 05/01/24 at 09:08 AM, The ADON said on 4/04/2024 she was in a meeting and LVN H called and let her know that Resident #37 was on the floor. She said by the time she got to the room the staff already had the resident back in her wheelchair and at the nurse's station. The ADON said she inspected the lift while it was still in the resident's room. She said they determined that the sling may not have been secure on Resident #37. She said CNA G was suspended pending investigation and ultimately terminated. The ADON said the restorative aide trains all CNAs on the lifts. She said after Resident #37's incident there was an in-service regarding all lifts . During an interview on 05/01/24 at 10:13 AM, The Admin said CNA G was transferring Resident #37 and was in the sit to stand lift. She said CNA G left the room to get supplies for less than 2 minutes and when she returned Resident #37 was on the floor. She said Resident #37 slid through the sling and resident was sitting on the floor in front of the lift. The Admin said LVN H assessed Resident #37 for injury with none found. She said mobile x-rays were done to rule out injury and were negative. She said Resident #37's daughter did not want disciplinary actions taken against CNA G. She said CNA G was suspended immediately, and once her investigation was complete, she decided to terminate CNA G. She said the expectation for her staff was to never leave any resident unattended in a mechanical lift. She said the potential negative outcome was a resident could fall with or without injury. Record review of right wrist x-ray dated 4/04/2024 indicated: Impression: 1. The study is within normal limits. Record review of bilateral hip with pelvis x-ray dated 4/04/2024 indicated: no acute pelvic or hip joint pathology. Record review of CNA orientation and Annual Review Checklist dated 3/11/2024 indicated: CNA G L. Practices safety measures 2. Gait belt for assisted transfers 3. Full body mechanical lift/2-person transfer 4. Sit to stand lift. Record review of Understanding Job Expectations dated 4/09/2024 indicated CNA G was terminated via phone on 4/10/2024. Record review of in-service titled Lifts and Safe Transfers, Gait Belts, Safety, Sit to Stand, Hoyer Lift dated 4/05/2024 indicated staff had been trained on transferring residents safely. Record review of facility policy titled Lifting Machine, Using a Mechanical. General guidelines: 1. Utilize manufacturers recommendations for number of staff needed to safely move a resident with a mechanical lift. Steps in the Procedure: 1. Before using a lifting device, assess the resident's current condition, including: a. Physical b. Cognitive/Emotional. 8. Double check the sling and machines weight limits against the resident's weight. 9. Place the sling under the resident. Visually check the size to ensure it is not too large or too small. 12. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. Record review of manufacturers guide of mechanical lift [NAME] Flex undated indicated: Designed to make everyday transfer and care tasks easier, [NAME] Flex from Arjo equips a single caregiver with the ability to position a patient from a seated to a safe, secure and comfortable standing position, in one ergonomic movement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 2 resident personal refrigerators reviewed for food safety (Resident #9). The facility failed to ensure the refrigerator for Resident #9 did not contain expired cheese sticks, prune juice, or nutritional shakes. This failure could place resident at risk for food borne illnesses. Findings include: Record review of Resident #9's face sheet dated 4/30/2024 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: scoliosis (a sideways curve of the spine), chronic pain, and anemia (low red blood cells). Record review of Resident #9's quarterly MDS dated [DATE] indicated Resident #9's BIMS was 15 indicating no cognitive impairment. Record review of Resident #9's care plan dated 11/08/2022 indicated: Elder chooses to have a refrigerator in his room and is able to monitor the temperature and cleanliness daily with intervention of: Remind elder to check and record temperature daily and remove any expired items. During an observation and interview on 4/29/2024 at 10:40 AM, Resident #9 said he tried to keep up with taking the temperatures on his personal refrigerator. Resident #9 said his family member brought him food from Walmart at times. He said he tries to keep his refrigerator clean and throw out expired items. Resident #9 said he got food out of his refrigerator to eat himself. Resident #9 said staff would come periodically to check the temperature log and make sure all food in the refrigerator was labeled and dated. Resident #9's refrigerator contained 8 individual cheese sticks with the expiration date 11/05/2023, a half empty opened bottle of prune juice 64 fluid ounces with the expiration date of 6/17/2023, nutritional shake 8 fluid ounces with the expiration date of 3/28/2023, and a nutritional shake 8 fluid ounces with the expiration date of 9/04/2023. During an interview on 05/01/24 at 09:40 AM LVN H said that administration normally checks the personal refrigerators, she said she checks Resident #9's to make sure it is done but she does not check the refrigerator for expired foods. During an interview and observation on 05/01/24 at 09:42 AM CNA L said she checked the residents' personal refrigerators 2-3 times a week. She said she checked for expired foods and for smells. She said she had checked Resident #9's refrigerator on 4/30/2024 and did not find any expired foods. On 5/01/2024 at 9:42 AM CNA L entered Resident #9's room and she checked the refrigerator and removed 8 individual cheese sticks with the expiration date 11/05/2023, a half empty opened bottle of prune juice 64 fluid ounces with the expiration date of 6/17/2023, nutritional shake 8 fluid ounces with the expiration date of 3/28/2023, and a nutritional shake 8 fluid ounces with the expiration date of 9/04/2023. CNA L said she on 4/30/2024 she had only checked to make sure the temperature log had been completed but did not check for expired foods. She said the risk for residents consuming expired foods is residents could get sick. During an interview on 05/01/24 at 09:51 AM LVN M said she checked the personal refrigerators to make sure food is not expired and their temperature logs were being done. She said all resident personal refrigerators are checked daily. She said that normally the personal refrigerators were checked at night on the 10-6 shift. She said the temperature logs are pulled at the end of the month and are uploaded into the computer system. During an interview on 05/01/24 at 09:57 AM CNA I said she checked residents' personal refrigerators 1-2 times a month. She said the last time she checked Resident #9's was 2-3 months ago. She said one time she checked, and he had some expired prune juice. She said the risk to the resident for consuming expired food was residents could get sick. During an interview on 05/01/24 at 10:02 AM LVN O said they only have a community refrigerator on the rehab hall and the night shift checked it periodically. She said the risk to the resident for consuming expired food was residents could get gastritis or allergies. During an interview on 05/01/24 at 09:08 AM The ADON said the residents checked temperatures, make sure all food is dated, and cleaned their personal refrigerators . She said nurses also checked the personal refrigerators to ensure expired foods are removed. She said the ADON and DON make rounds to ensure that it was being done. During an interview on 05/01/24 at 10:07 AM, The Admin said residents are responsible for the care of personal refrigerators. She said that nursing checked for compliance, and they checked the temperature logs and for expired foods. She said Resident #9 is pretty on top of keeping up with his refrigerator. She said her expectation was there should never be expired foods in the residents' personal refrigerators. She said the potential negative outcome was the resident could get sick. Record review of the facility policy titled Resident Room Refrigerators for Personal Use undated indicated: A. Resident and or family responsibilities: 3. All items that are opened or dated must be discarded three days from the date. B. The food protection measures that are to be inspected by facility staff are: 7. If items are outdated or not dated, items must be discarded.

**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 and infections for 1 of 10 residents (Resident #6) and 1 of 8 staff (CNA A) reviewed for infection control. CNA A did not sanitize/wash hands between glove changes when providing incontinent care on 4/29/2024. This failure could place residents at risk for exposure to and transmission of diseases and infections. Findings included: Record review of an admission Record dated 4/29/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a group of thinking and social symptoms that affect activities of daily life), anemia (low red blood cells that carry oxygen in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 00. She required substantial/maximal assistance to partial/moderate assistance with ADL's. She was always incontinent of bowel/bladder. Record review of a care plan dated 12/2/2021, revised 10/11/2023 for Resident #6 indicated she had bladder incontinence related to impaired mobility and cognition with interventions to clean peri-area with each incontinence episode. During an observation on 4/29/2024 at 4:25 PM, CNA A and CNA B were in the room of Resident #6 to provide incontinent care. CNA A donned (put on) gloves and pulled down the brief between Resident #6's thighs. CNA B was in the room and had gloves on both hands. CNA A opened a package of disposable wipes and pulled out one wipe and wiped across her lower abdomen and placed the wipe in the trash. CNA A pulled out another wipe from the package and wiped down on the resident's right inner thigh and placed the wipe in the trash. CNA A removed another wipe and wiped down the resident's left inner thigh and then used another wipe and wiped from the front down the middle of the resident's peri area and placed the wipes in the trash. CNA B rolled the resident to her right side and CNA A rolled the brief underneath the resident's buttocks. CNA A removed his gloves and placed them in the trash and applied clean gloves without washing or sanitizing his hands. CNA A removed wipes and wiped the rectal area multiple times from front to back using three wipes. CNA A removed the brief and placed in in the trash and removed his gloves. CNA B rolled the resident onto her back and secured the brief. CNA A and CNA B both pulled up the resident's pants. CNA A went into the restroom and washed his hands. CNA B removed her gloves and washed her hands. During an interview on 4/29/2024 at 4:46 PM, CNA A said he had been employed at the facility since August 2023 and worked prn . He said during the incontinent care provided to Resident #6 he should have sanitized or washed his hands when he removed his gloves. He said he had training in the past on skills and was taught to change gloves when going from the front to the back and use one wipe per swipe. He said he was in a rush during the care provided and should have taken his time. He said residents could be at risk for UTI's and infections if staff did not properly sanitize or wash their hands. During an interview on 5/1/2024 at 9:07 AM, the ADON said she had been employed at the facility for 3 years. She said every department head conducted annual skills and she was responsible for overseeing the skills check offs. She said new hires were observed by trainer CNA's. She said she conducted random audits for infection control and monthly checks on handwashing. She said all staff should sanitize or wash their hands between glove changes. She said going forward she would continue to audit for hand hygiene and the facility identified a problem last month regarding infection control. She said residents could be at risk for infections and spreading infections to others if staff did not wash or sanitize their hands between glove changes. During an interview on 5/1/2024 at 10:25 AM, the Administrator said she expected all staff to follow infection control protocols. She said the ADON conducted audits on pericare at times and the ADON was going to do an audit with CNA A and submit it to QA. She said there was a risk of spreading infections to the residents if staff did not wash or sanitize their hands when changing gloves. Record review of a CNA Orientation and Annual Review Checklist dated 8/4/2023 for CNA A indicated he demonstrated infection control with hand washing. Record review of a Handwashing/PPE Monthly Audit Sheet dated 12/2023 indicated that CNA A was observed for handwashing by the ADON. Record review of a facility policy titled Hand Washing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the hand washing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or; alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; m. After removing gloves

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 28 dietary staff (Dietary Staff D, E and F) reviewed for reviewed for food and nutrition services. The facility did not ensure Dietary Staff D, E and F had a current food handlers' certificate while working in the facility's kitchen on 04/29/24 to 05/01/2024. This failure could place all residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: Record review of 28 Dietary Staff food handlers' certificates indicated Dietary Staff D hire date 06/09/2022, Dietary Staff E hire date 10/29/2021 and Dietary Staff F hire date 10/01/2020 did not have a food handler's certificate. During an interview on 05/01/24 at 08:40 am, the Dining Director said that the three dietary employees did not have a current certificate. He said he had spoken with all three employees on 05/01/24, and they had informed him that they had no current food handler's certification . He said it was his responsibility to ensure all kitchen staff had a current food handler certification and will develop a system to track them. He said that the three employees will complete the certifications by Friday 05/03/2024 or will be taken off the schedule until completed. The Dining Director said the residents could be at risk for food borne illness if the staff did complete training on proper food handling requirements as required by regulations. During an interview on 05/01/24 at 09:00 am the Administrator said she expects the dietary staff to have updated food handler certificates and for all staff to receive training to prevent food borne illness. She said the Dining Director is responsible for overseeing all staff's certifications. Review of reference obtained from the TAC chapter 228 .Certified Food Protection Manager and Food Handler Requirements. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee. The requirement to complete a food handler training course . Review of an undated Facility policy titled Licensure, Certification, and Registration of Personnel. Policy Statement . Employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment. Policy Interpretation and Implementation 1. Personnel who require a license, certification, or registration to perform their duties must present verification of such license/certification/registration to the Human Resources Director/designee prior to or upon employment. 2. A copy of the current license, certification, or registration number must be filed in the employee's personnel record. 3. A copy of recertifications (e.g., annual, bi-annual, etc., as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's main kitchen observed for kitchen sanitation. The soda drink dispenser had undated (date when opened) and expired soda syrup concentrates connected and available to be served. The freezer had open to air, improperly labeled and expired foods. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation and interview on 04/29/2024 at 09:20 am of the drink dispenser, 6 containers of concentrated soda syrup connected to dispenser had no opened date documented. Container of concentrated lemon soda expired 3/20/2024, container of concentrated root beer expired 4/18/2024, and a container of diet coke expired 09/10/2023. All three containers were connected to the dispenser and available to serve. The Dining Director said he had worked at the facility for two months and he was responsible for ensuring all expired items were discarded. The Dining Director said he would remove the expired soda concentrate and replace with new ones . During an observation on 04/29/24 at 09:30 am of the freezer revealed a clear zip lock bag of frozen chicken dated 3/26/24 with no use by date. The frozen chicken was not sealed and was open to air. A frozen clear zip lock bag of beef stock dated 3/12/24 use by date 3/22/24. A zip lock bag of frozen fish unlabeled for contents dated March 8 with no year, no use by date. The Dining Director said he was responsible for training the dietary staff and at for ensuring items were dated as required. He said he would discard the undated items. During an interview on 4/29/24 at 10:00 am the Dining Director said serving expired sodas could cause gastric distress or diarrhea. The Dining Director said the expired frozen items should have been removed from the freezer and could cause an illness if served. He said all frozen Items should be labeled with contents in the container, the date it was packaged and a serve by date. He said they had training today for the dietary staff regarding labeling and removing expired items. During an interview on 4/29/24at 10:10 am the Dietary Director said serving expired foods could cause illness. He said they had begun an in-service for the dietary staff regarding labeling and removing expired items. The Dietary Director said it was the responsibility of all team members to make sure the items were labeled and removed when expired. During an interview on 05/01/2024 at 08:00 am the Administrator said her expectation was for all foods to be labeled when opened and thrown away when expired. She said it was the responsibility of the Dietary Director to make sure all expired food was removed from the kitchen. The Administrator said, the potential negative outcome for residents consuming expired foods could be food borne illnesses. Record review of an undated Compass Group Food Safety and Quality Assurance Standards Manual Food Expiration and Rotation policy indicated . Foods that have expired must be discarded and not used or served. This includes both manufacturer and unit-labeled food expiration dates on dry, refrigerated and frozen foods . discard any foods that are past expiration, those that do not have a date, or have an illegible date.

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 5 of 5 months (February 2022, May 2022, August 2022, November 2022, January 2023) reviewed for pharmacy services. The facility failed to have a licensed pharmacist and witnesses initial the attached pages of medication destruction inventory sheets. This failure could place residents at risk for misappropriation and drug diversion. Findings: During a record review of facility medication destruction log for the last 12 months indicated the facility had 5 medication destructions in the last year (02/23/2022, 05/26/2022, 08/24/2022, 11/18/2022, and 01/25/2023) and the pharmacist and 2 witnesses did not initial the attached sheets of the medication destruction inventory sheets. During an interview on 02/22/2023 at 1:20 pm the ADON stated the pharmacy consultant, herself and either the DON or another nurse performed the medication destruction. She stated they check each medicine off before placing them in the destruction box. She stated she was not aware that attached forms had to be initialed. She stated she didn't see any risk to the resident because she knows they were destroyed. She stated it could cause a drug diversion. During an interview on 02/22/2023 at 1:40 pm the DON stated that she was responsible for oversight of medication destruction along with the pharmacist and ADON. She stated she was not aware of the rule that attached pages of the drug destruction had to be initialed and just did it the way the pharmacist told her. She stated the risk could be a drug diversion. The DON stated she would contact the pharmacist and correct their process. During an interview on 02/22/2023 at 3:00 pm the pharmacist consultant stated she had been at the facility for 2 years and was not aware the rule required the initials of the pharmacist and 2 witnesses on each additional page attached for drug destruction. She stated she would see that the failure was corrected. She stated the risk could be a drug diversion. During an interview on 02/23/2023 at 8:10 am the Administrator stated the DON and pharmacist consultant were responsible for medication destructions. She stated she was not aware of the need for initials on each attached page but expected that the regulation was followed. She stated they had already updated their forms and training had been done to correct the failure. She stated she did not see a risk to the patient or facility. Record review of facility policy dated April 2019, titled, Discarding and Destroying Medications indicated, .2.Non-controlled and Schedule V controlled substances will be disposed of in accordance with state regulations and federal guidelines. 3. Schedule II, III, and IV controlled substances will be disposed of in accordance with state regulations and federal guidelines . Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 02/22/2023 at https://texreg.sos.state.tx.us/ indicated; (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse.