**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that:The facility failed to conduct weekly skin assessments for Resident #1 on 7/10/25 and 07/17/25. These failures placed residents at risk of physical harm, pain, and a decreased quality of life. Findings included: Record review of Resident #1's admission record, dated 08/05/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: seizures (sudden, temporary disruption of the brain's normal electrical activity, resulting in changes in behavior, movement, feelings, or consciousness), lack of Coordination (having difficulty controlling your movements and making them work together smoothly), protein calorie malnutrition (not getting enough food or the right food to maintain a healthy body), and unspecified dementia severe without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (memory loss and thinking difficulties). Record review of Resident #1's Quarterly MDS assessment, dated 05/01/2025, reflected the resident had a BIMS score of 15, which indicated cognitively intact. Resident #1 required setup or clean assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and person hygiene. Record review of Resident #1's care plan, dated 08/05/2025, reflected Resident #1 was care planned for potential for pressure ulcer development r/t required assist with bed mobility with an intervention of follow facility policies/protocols of prevention/treatment of skin breakdown. Review of Resident #1's weekly skin assessment in the EMR on 08/05/2025, reflected Resident #1 did not have a weekly skin assessment 07/10/25 & 07/17/25. During an interview and observation Resident #1 on 08/05/2025 at 11:30am., Resident #1 stated he could not remember if he had his weekly skin assessment on 07/10/25 & 07/17/25. Resident #1 stated he did not have any current skin issues. Resident #1 did not have any visible bruising or skin issues. During an interview with LVN A on 08/05/2025 at 1:15 PM, LVN A stated the purpose of a weekly skin assessment was to identify any new skin issues and monitor current skin issues. LVN A stated that the weekly skin assessment was completed on the same day of the week each week by the charge nurse. LVN A stated that 6/2 charge nurse was responsible for the 100 and 200 halls and 2/10 charge nurse was responsible for the 300 and 400 halls. LVN A stated that she was not sure what nurse was worked on 07/10/25 & 07/17/25. LVN A stated if a resident's weekly skin assessment was not completed then the resident could have a skin issues go untreated. During an interview with the DON on 08/05/2025 at 2:55 PM, the DON stated the purpose of a skin assessment was to identity and address any new skin concerns. The DON stated all residents were supposed to receive weekly skin assessments. The DON stated it was the charge nurse's responsibility to complete the weekly skin assessments. The DON was not aware that Resident #1 had not had a skin assessment on 07/10/25 & 07/17/25. The DON stated that if a resident did not receive weekly skin assessments, then the resident could have a skin condition go untreated. The DON stated she expected for weekly skin assessments to be conducted as scheduled. During an interview with the ADM on 08/05/2025 at 3:45 PM, the ADM stated the purpose of a skin assessment was to ensure residents did not have any adverse skin issues from the previous week. The ADM stated all residents were supposed to receive weekly skin assessments. The ADM stated it was the charge nurse's responsibility to complete the weekly skin assessments. The ADM stated it was the DON and ADON responsibility for ensure the charge nurses were completing the weekly skin assessments as scheduled. The ADM was not aware that Resident #1 had not had a skin assessment 07/10/25 & 07/17/25. The ADM stated that if a resident did not receive weekly skin assessments, then the resident could have skin integrity issues that go untreated. The ADM stated she expected for weekly skin assessments to be conducted as scheduled. The ADM stated the facility did not have a weekly skin assessment policy. A record review of the facility's Resident Examination and Assessment policy, dated February 2014, reflected, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical Exam 8. Skin: a. intactness: b. moistures c. color d. texture; and e. presence of bruises, pressure sores, redness, edema, rashes. Documentation The following information should be recorded in the resident's medical record:1. The date and time to procedure was preformed2. The name and title of the individual(s) who performed the procedure.3. All assessment data obtained during the procedure.4. How the resident tolerated the procedure.5. If the resident refused the procedure, the reason (s) why the intervention taken.6. The signature and title of the person recording the data.Reporting1. Notify the supervisor if the resident refuses the examination.2. Notify the physician of any abnormalities such as, but not limited to e. wounds or rashes on the resident's skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 25 residents (Resident #3) reviewed for resident rights; in that: The facility failed to ensure Resident #3''s call light was within reach. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #3's admission record, dated 09/25/24, reflected an [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #3 had diagnoses which included: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), ataxic gait (type of waking that's awkward and uncoordinated), lack of coordination (uncoordinated movement, coordination impairment, or loss of coordination), muscle weakness (loss of muscle strength that can make it difficult to move a muscle normally), and gastro-esophageal reflux disease with esophagitis (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). Record review of Resident #3's quarterly MDS assessment, dated 05/29/24, reflected Resident #3 had a BIMS score of 00, which indicated the resident was cognitively severely impaired. Resident #3's Quarterly MDS reflected Resident #3 required substantial/maximal assistance in the areas of oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #3's Quarterly MDS reflected Resident #3 was dependent for shower/bathe self. Record review of Resident #3's care plan, dated 09/25/24, reflected Resident #3 was care planned for falls r/t gait/balance problems and hx of falls and had an intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation on 09/23/24 at 1:30pm, revealed Resident #3 was lying in bed and her call light was out of the resident's reach. Resident #3's call light was lying on the floor on the right side of the bed. During an observation on 09/23/24 at 3:39pm, revealed Resident #3 was lying in bed and her call light was out of the resident's reach. Resident #3's call light was lying on the floor on the right side of the bed. An interview with the DON on 09/25/24 at 1:45pm, the DON stated that if a resident's call light was not within reach, then the resident would not be able to get assistance if needed. The DON stated that it was everyone's responsibility to ensure call lights were always within reach. The DON stated if a resident's call light was not within reach the resident may not get timely assistance. An interview with the ADM on 09/25/24 at 1:45pm, the ADM stated that if a resident's call light was within reach, then the resident would not be able to get assistance if needed. The ADM stated that anyone who entered the resident's room was responsible for ensuring call lights were within reach. The ADM stated that CNAs make rounds at least every two hours and during rounds CNAs should ensure call lights were within reach, residents were comfort, and dry. The ADM stated if a resident's call light was not within reach the resident could fall trying to reach the call light or the resident would not receive timely care. Record review of the policy for call System, Resident, dated September 2022, reflected Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wired or wireless. 3. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 residents (Residents #37) reviewed for resident assessments. The facility failed to ensure Resident #37's Quarterly MDS reflected that Resident #37 had difficulty chewing. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #37's face sheet dated 09/25/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #37's diagnoses included chronic obstructive pulmonary disease (lung disease that causes air flow limitations and breathing related symptoms), Hypokalemia (lower than normal potassium level in bloodstream), lack of coordination (condition that makes it difficult to control your movements), muscle weakness (loss of muscle strength that can make it difficult to move a muscle normally), and cognitive communication deficit (a condition that makes it difficult for a person to communicate due to brain injury or other issues) A record review of Resident #37's Quarterly MDS assessment, dated 08/28/24, reflected the resident had a BIMS score of 14, which indicated cognition was cognitively intact. Resident #37's Quarterly MDS reflected Resident #37 required supervision or touching assistance in the areas of oral hygiene, eating, personal hygiene, and upper body dressing. Resident #37's Quarterly MDS did not reflect the resident had difficulty with chewing. A record review of Resident #37's care plan, dated 09/25/2024, reflected Resident #37 was care planned for diet: regular, regular texture, regular liquids. Resident #37's care plan did not reflect the resident's chopped meat diet. A record review of Resident #37's physician's orders, dated 09/25/2024, reflected Resident #37 had an order dated 06/03/24 for regular diet, regular texture, regular consistency with directions: chopped meat. A record review of Resident #37's dental treatment note, dated 09/16/24, reflected Resident #37 was missing teeth numbers 1, 2, 3, 4, 5, 11, 13, 14, 15, 16, 17, 18, 25, 16, 31, & 32. An interview with Resident #37 on 09/25/24 at 12:45pm, Resident #37 stated that she had missing and chipped teeth prior to admission. Resident #37 stated she must have chopped meat due to her having difficulty chewing. An interview with the MDS Coordinator on 09/25/24 at 1:30pm, the MDS Coordinator stated that she was responsible for completing MDS and care plan assessments. The MDS Coordinator stated a resident's MDS assessment should reflect if a resident had difficult chewing or chipped teeth. The MDS Coordinator stated that if a resident's MDS assessment was inaccurate then the resident my not receive the appropriate care or possibly lose weight due to not eating. An interview with the DON on 09/25/24 at 1:45pm, the DON stated that if resident has difficulty chewing that should be reflected on the MDS. DON stated if the Resident #37's MDS assessment did not reflect the resident's chewing difficulties then the resident would not eat, lose weight, and not receive the proper care needed. An interview with the ADM on 09/25/24 at 1:45pm, the ADM stated that if resident has difficulty chewing that should be reflected on the MDS. The ADM stated if Resident #37 has difficulty eating it should be reflected on her MDS assessment. The ADM stated if the resident's MDS assessment did not reflect the resident's chewing difficulties then the resident would not eat, lose weight, and not receive the proper care needed. A record review of the facility's Resident Assessment policy, dated October 2023, reflected Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment instrument) must sign and certify the accuracy of the portion of the assessment. Policy Interpretation and Implementation 1. Any health care professional who participates in the assessment process is qualified to assess the medical functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Residents #37) reviewed for comprehensive care plans. Resident #37's comprehensive care plan did not reflect Resident #37's diet included chopped meat. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #37's face sheet dated 09/25/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #37's diagnosis included chronic obstructive pulmonary disease (lung disease that causes air flow limitations and breathing related symptoms), Hypokalemia (lower than normal potassium level in bloodstream), lack of coordination (condition that makes it difficult to control your movements), muscle weakness (loss of muscle strength that can make it difficult to move a muscle normally), and cognitive communication deficit (a condition that makes it difficult for a person to communicate due to brain injury or other issues) A record review of Resident #37's Quarterly MDS assessment, dated 08/28/24, reflected the resident had a BIMS score of 14, which indicated cognition was cognitively intact. Resident #37's Quarterly MDS reflected Resident #37 required supervision or touching assistance in the areas of oral hygiene, eating, personal hygiene, and upper body dressing. Resident #37's Quarterly MDS did not reflect the resident had difficulty with chewing. A record review of Resident #37's physician orders, dated 09/25/2024, reflected Resident #37 had an ordered dated 06/03/24 for regular diet, regular texture, regular consistency with directions: chopped meat. A record review of Resident #37's care plan, dated 09/25/2024, reflected Resident #37 was care planned for diet: regular, regular texture, regular liquids. Resident #37's care plan did not reflect the resident chopped meat diet. A record review of Resident #37's dental treatment note, dated 09/16/24, reflected Resident #37 was missing teeth numbers 1, 2, 3, 4, 5, 11, 13, 14, 15, 16, 17, 18, 25, 16, 31, & 32. An interview with resident #37 on 09/26/24 at with Resident #37, the resident stated that she had missing and chipped teeth prior to admission. Resident #37 stated she must have chopped meat due to her having difficulty chewing. Resident #37 stated that she difficulty chewing meats and hard tough items. An interview with MDS Coordinator on 09/25/24 at 1:30pm, the MDS Coordinator stated that she was responsible for completing MDS and care plan assessments. The MDS Coordinator stated a resident's care plan should reflect if a resident required chopped meat diet. MDS Coordinator stated if a resident's care plan did not reflect a resident required chopped meat the resident my not received chopped meat, the resident would have difficulty eating, and the resident could possibly lose weight from not eating. An interview with DON on 09/25/24 at 1:45pm, the DON stated that if resident has an order for chopped meat that should be reflected on the resident's care plan. The DON stated that resident's care plan did not reflect the resident needed chopped meat then the resident would possibly get the wrong textured meat, resident would have a difficult time chewing, and the resident could possibly lose weight. An interview with ADM on 09/25/24 at 1:45pm, the ADM stated that if resident has an order for chopped meat that should be reflected on the resident's care plan. The ADM stated that resident's care plan did not reflect the resident needed chopped meat then the resident would possibly get the wrong text meat, resident would have a difficult time chewing, the resident my not eat, and the resident could possibly lose weight. A record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2016, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 8. The Comprehensive, person-centered care plan will: a. Include measurable objective and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; d. Describe any specialized services to be provided as a result of PASARR recommendation; e. Include the resident's stated goals upon admission and desired outcome; f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problems areas;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #99 and Resident #23) of 6 residents reviewed for infection control. CNA A failed to perform hand hygiene with a glove change when cleansing from back to front during peri-care and Foley catheter care for Resident #99 and the aide donned gloves from her pants pocket. VLN A failed to perform hand hygiene when changing gloves when providing wound care for Resident #23. These failures have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral or secondary infections and communicable diseases. Findings included: Record review of Resident #23's undated face sheet reflected the resident was a [AGE] year-old female with an admission date of 04/29/17. Resident #23 had diagnoses which included Congestive heart failure, non-pressure chronic ulcer of left lower leg, Peripheral vascular disease, and Diabetes mellitus type 2. Record review of Resident #23's MDS quarterly assessment, dated 09/20/24, reflected the resident had a BIMS score of 15, which indicated she had intact cognition. Section M of the MDS reflected Resident #23 had application of nonsurgical dressing and application of ointments/medications. Record review of Resident #99's undated face sheet reflected the resident was a [AGE] year-old male with an admission date of 08/29/24. Resident #99 had diagnoses which included Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar), Pneumonia, Urinary retention, and Benign prostatic hypertrophy. Record review of Resident #99's MDS quarterly assessment, dated 09/05/24, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Section H of the MDS reflected Resident #99 had an indwelling catheter. Observation on 09/24/24 at 11:50 AM of peri-care and Foley catheter care for Resident #99 with CNA A and CNA B revealed no hand hygiene or glove changes were observed when CNA A was applying barrier cream to Resident #99's bottom and bilateral groin area. CNA A then conducted Foley catheter care without conducting hand hygiene or changing gloves. Interview on 09/24/24 at 12:07 PM with CNA A revealed she was trained to place gloves in her pocket when providing resident care and she didn't think it would be an infection control issue. She stated she had forgotten to clean Resident #99's Foley catheter tubing. Interview on 09/25/24 at 09:50 AM with CNA B revealed it was important to follow infection control precautions because it could hurt the resident if they got an infection, or another infection. CNA B further stated she had received training on infection control and peri-care. An observation on 09/25/24 at 09:55 AM of wound care provided by LVN A was observed for Resident #23. The wound was documented in physician orders as a venous wound to the left posterior thigh. LVN A did not conduct hand hygiene properly before donning clean gloves and accessing clean supplies. LVN A did put on clean gloves prior to cleansing Resident #23's wound using aseptic non-touch technique but did not conduct hand hygiene before donning clean gloves. Interview on 09/25/24 at 10:11 AM with LVN A revealed she knew she should have sanitized her hands with each glove change because cross-contamination could occur when hands were not cleansed. LVN A further stated the resident could become very ill from staff not performing good infection control measures with hand hygiene. LVN A stated she had received training on infection control and hand hygiene. Record review of training/in-servicing reflected: In-service on 06/04/24 - Preventing Urinary Tract Infections: 1. Provide peri-care appropriately - Instruct residents to wipe from front to back 2. Provide proper catheter are In-service on 07/10/24 - Antibiotic Stewardship and Infection Control In-service on 09/26/24 - Peri-care and Urinary Tract Infections An interview on 09/25/24 at 01:15 PM with the DON revealed it was important to practice infection control/hand hygiene when providing care to residents because it cut down on the spread of infection. She stated hands should be washed or cleaned with an alcohol-based hand sanitizer between each resident. The DON stated it was her responsibility to ensure infection control measures were followed by staff in the facility. The DON further stated if infection control measures including hand hygiene were not followed, it could increase the spread of infection. The DON stated her expectation was for staff to follow infection control protocols correctly. An interview on 09/25/24 at 01:26 PM with the ADM revealed it was important to practice infection control/hand hygiene when providing care to residents to keep the spread of infection down in the facility and protect the residents. The ADM further stated her expectation was for all employees to practice hand hygiene and to always follow infection control measures. Review of facility policy titled Administering Medications dated December 2021 reflected staff shall follow established facility infection control procedures (handwashing, antiseptic techniques, gloves, isolation precautions) for the administration of medications as applicable. Review of facility policy titled Handwashing and Hand Hygiene dated October 2023 reflected, All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors, and Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Review of facility policy titled Policies and Practices - Infection Control dated October 2018 reflected, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for one (Resident #34) of nine residents reviewed for accidents resulting in injury. The facility failed to report the injuries sustained by Resident #34 to HHSC as required. This deficient practice could place all 47 residents in the facility with the potential to be abused, neglected, exploited, or mistreated, or have injuries of unknown source to be at risk for compromised protection from abuse, neglect, exploitation or mistreatment. The findings included: Record review of Resident #34 face sheet, generated at time of admission on [DATE], revealed that Resident #34 was [AGE] years old and was admitted to the facility on [DATE]. Resident #34 face sheet listed Resident #34 as her own Responsible Party (she can make decisions on her own and has not been declared incompetent). Resident #34 diagnosis list included: Chronic Obstructive Pulmonary Disease (a condition which produces difficulty breathing), cachexia (muscle loss), spinal stenosis (narrowing of the canal through which the spinal cord travels), lack of coordination, anxiety disorder, Chronic Pain Syndrome, and neuropathy (condition causing numbness and/or weakness, tingling, and/or burning sensation usually affecting the hands and feet), nicotine dependence, among other diagnoses. Record review of Resident #34 MDS (an assessment tool required of nursing facilities receiving Medicare/Medicaid funds) dated 05/04/23 revealed a BIMS (cognition screening tool) score of 15, which indicated intact cognition (awareness of person, place, time, and situation with no memory deficit). Under Section G of the MDS dated [DATE], Functional Status, it was indicated that Resident #34 required a level of Supervision to One-person Physical Assistance with eating (which also included drinking in the description). Under Section GG of the MDS dated [DATE], Functional Abilities and Goals, it was indicated that Resident #34 required Set-up Assistance and/or Clean-up Assistance in order to eat and drink. Record review of Resident #34's Care Plan dated 04/25/23 revealed that Resident #34 had a terminal illness, Chronic Obstructive Pulmonary Disease, and is under care of Hospice Provider. Record review of Resident #34's Care Plan dated 04/25/23 revealed an addition of Impaired Skin Integrity related to Burn added on 05/27/23; interventions which were care-planned included safety evaluation for handling hot liquids, identifying and educating Resident #34 on causative factors, wound management, and encouraging good nutrition necessary for wound healing. Record review of Facility Incident Report written by LVN A, dated 05/27/23 at 07:53 a.m., revealed that while Resident #34 was sitting up in bed, she spilled coffee in her lap as she attempted to take the lid off a coffee cup. As described in the 05/27/23/7:53 a.m. Facility Incident Report, no injury was initially seen by LVN A and RN on duty, but cool moist wash cloths were applied and Resident #34 was instructed by LVN A to call for assistance with her coffee and to leave the lid off so a spill wouldn't occur if the lid needed to be removed. Incident Report of 05/27/23/07:53 a.m. revealed that Primary Physician was notified of the incident at 11:25 a.m. by LVN A. Review of Facility Incident Report written by LVN A also included interventions, added by RN on 05/29/23, to prevent recurrence and included: checking of coffee temperature logs with ongoing monitoring for unspecified duration of time, replacing electric coffee urn with standard drink dispenser in dining room, and replacing glass mugs with lighter-weight plastic mugs. Incident Report addendum dated 05/29/23 by RN also included that Resident #34 had demonstrated safe use of coffee cup and that temperatures of coffee were all within range when temperature log checked. Record review of facility Safety of Hot Liquids Policy dated October 2014 revealed that interventions would be implemented to minimize the risk from burns and included: maintaining hot liquids at a serving temperature of no more than 180 degrees Fahrenheit, serving hot beverages in a cup or insulated cup, encouraging residents to sit at a table when drinking hot liquids, and staff supervision or assistance with hot beverages. Record review of facility Coffee Log Temperature Inservice, dated 05/29/23, was done and included the staff from the Dietary Department with a sign-in sheet; instructions given in the in-service included twice daily coffee temperature checks with documentation of that temperature and keeping coffee temperature between 160 and 180 degrees Fahrenheit. Record review of facility Coffee Temperature Log from 05/27/23 to 07/20/23 revealed that the coffee had been kept at temperatures consistently between 160 and 180 degrees Fahrenheit. Record review of Skin assessment dated [DATE] by LVN A revealed redness to bilateral inner thighs from spilled coffee with no blistering at time of incident. Additional record review of weekly Skin Assessments dated 05/30/23, 06/06/23, 06/13/23, 06/20/23, 06/27/23, 07/04/23, 07/11/23, 07/18/23 by facility nursing staff indicated ongoing monitoring and documentation of burn wounds to Resident #34's thighs. There were no other concerning wounds to Resident #34 appearing on the weekly Skin Assessments. Record review of Resident #34's electronic medical record revealed that Resident #34 was first seen by Wound Care MD on 05/31/23 at the request of Primary Physician. Record review of Wound Care MD's Initial Wound Evaluation and Management Summary, dated 05/31/23, stated Focused Wound Exam Site 1: Burn wound of the left, medial thigh, partial thickness, with an area of 9.0 x 7.0 x 0.1 cm and with a light serosanguineous exudate (thin and watery fluid that is pink in color due to the small amount of red blood cells; not indicative of infection). Record review of Wound Care MD's 05/31/23 Focused Wound Exam Site 2 note revealed: Burn wound of the right, medial thigh, partial thickness, with an area of 9.0 x 9.0 x 0.1 cm and having a light serous exudate (thin, watery drainage). Wound care notes dated 05/31/23 from Wound Care MD's Initial Wound Evaluation and Management Summary listed Dressing Treatment Plan as: Petroleum-impregnated gauze applied once daily for 30 days with a bordered gauze dressing over it once daily for 30 days. Record review of Wound Care MD notes reveal that Resident #34 was seen again by Wound Care MD on 06/07/23, 06/16/23, 06/28/23, 07/05/23, and 07/12/23. Record review of Wound Care MD notes for these dates indicated that same type dressings as originally ordered daily for the facility wound care were reordered on each visit to continue after the initial 30-day period was complete; as time passed and the wounds showed improvement, the wound care frequency was changed to three times weekly but the process and wound care supplies used were unchanged. Record review of 06/28/23 Wound Care MD notes indicated that Wound Care MD had resolved (healed to a point where the wound no longer required treatment) the Left Thigh/Site 1 burn wound for Resident #34; after 06/28/23 Wound Care MD orders for the facility nurses applied only to Site 2, Right Thigh. Record review of Wound Care MD notes dated 06/28/23, 07/05/23, and 07/12/23 indicated that the Wound Care MD had performed clean surgical debridement procedures (a process where dead tissue is removed using a scalpel, allowing healthier tissue to grow) at each visit on Site 2, right thigh, under the topical anesthetic benzocaine (a spray that numbs the area of skin or tissue to be worked on). Record review of Wound Care MD notes stated for each visit (05/31/23, 06/07/23, 06/16/23, 06/28/23, 07/05/23, 07/12/23) that there was no indication of pain associated with this condition in Resident #34. Record review of MD Wound Care orders, Hospice Provider orders, and Primary Care Physician orders during the time period of 05/27/23 through 07/20/23 did not reveal that an additional analgesic, added to the analgesics which Resident #34 took for Chronic Pain Syndrome, was ordered as a pre-medication prior to nurses performing wound care or Wound Care MD performing wound care debridement procedures. Observation was done on 07/20/23 at 09:50 a.m. with Resident #34 regarding the burn injuries; pink scarring in areas which approximated the sizes detailed on Wound Care MD's notes were observed to both upper thighs of Resident #34 after Treatment Nurse removed dressing from right thigh. Tissue appeared to be intact and there was no drainage when observed on 07/20/23 at 09:50 a.m. in Resident #34's room as she lie in bed. Interview with Resident #34, on 07/20/23 at 09:50 a.m., revealed that she had been told by Wound Care MD that her burns from the hot coffee were second degree burns (burns which affect the epidermis layer and the dermis layer of skin). Resident #34 stated that Wound Care MD had been coming weekly since the hot coffee incident on 05/27/23. Resident #34 stated that the burn wounds initially hurt but now the pain is under control. Resident #34 stated it hurt like the dickens initially and for a period of time; resident did not clarify how long the period of increased pain to her thighs lasted. Resident #34 stated that she currently experienced a lot of itching as the skin continued to heal. Resident #34 stated that the hot coffee burn incident happened at the end of May when she was getting ready to eat breakfast in bed. Resident #34 stated that nurse aide who assisted her that morning had poured her coffee into her personal mug for her, which Resident #34 preferred, rather than drinking it out of the facility cup. Resident #34 stated that she did not think that the nurse aide who helped her that morning, 05/27/23, put the lid on well on her personal mug. Resident #34 believed this as she stated that on the morning of 05/27/23, she did not hear the lid make a popping sound as it went into place on the mug when the nurse aide put the lid on. Resident #34 did not remember who her nurse aide was on the morning that the incident occurred. Resident #34 did say that she was sure it was not a Hospice Provider nurse aide who helped her on the morning of the incident, 05/27/23, as she remembered that it was someone who was very familiar to her and provided regular care to her; she stated that she is not as familiar with the hospice staff. Treatment nurse was interviewed on 07/20/23 at 10:00 a.m. and removed the dressing over the right thigh burns for observations. Treatment nurse was able to give the wound care directions as cleaning the wound with Normal saline and covering with petroleum-based gauze and then covering (with additional wound care supply) three times weekly. Treatment nurse was able to give summary of orders which were consistent with most recent MD Wound Care orders of 07/13/2023 and stated that the dressings are changed by facility nurses after resident takes a shower with the Hospice Provider nurse aide three times weekly. Treatment nurse stated during 07/20/23/10:00 a.m. interview that she expected Wound Care MD to resolve (complete treatment of) the left thigh wound during his next visit. LVN A, primary nurse for Resident #34, on day of coffee burn, was interviewed on 07/20/23 at 10:15 a.m. LVN A stated that on 05/27/23 at breakfast time, Resident #34 was either in bed or in her wheelchair when the coffee sloshed out of her cup and into her lap. LVN A stated during interview on 07/20/23 at 10:15 am that Resident 34's skin was immediately assessed after 05/27/23 incident and that the skin was reddened to upper thighs but was not blistering. LVN A stated that she put cool compresses on the reddened sites after the burn injury on 05/27/23 and continued to monitor the burn sites for the remainder of her shift, noticing blistering to burn sites to be occurring a few hours after the initial burns. LVN A stated that she then notified the Primary Care Physician and the Hospice Provider, on the morning of 05/27/23. LVN A stated that Primary Care Physician stated, in their conversation of 05/27/23, that he would ask the Wound Care MD to see Resident #34 on his next visit to the facility. LVN A stated that she did not notify a family member of Resident #34 of the incident of 05/27/23 as Resident #34 is her own Responsible Party. CNA D was interviewed on 07/20/23 at 11:00 a.m. CNA D was the primary nurse aide for Resident #34 on 05/27/23 during the time of the incident, which occurred during breakfast. CNA D stated that she was not in the room when the burn injuries to Resident #34 occurred. CNA D stated that she was passing breakfast trays and drinks out during the incident of 05/27/23 a.m. CNA D reported hearing Resident #34 calling out for help and when CNA D responded, Resident #34 told her 'I dumped coffee on my legs!' CNA D stated that Resident #34 had been eating breakfast in bed on 05/27/23. CNA D stated that she asked Resident #34 if she was okay and then went to get LVN A on the morning of 05/27/23 after the coffee burns occurred and when it was brought to her attention by Resident #34. CNA D stated that after the incident occurred on 05/27/23 she observed redness to Resident #34's legs. When asked how the burns happened, CNA D stated that she believed that Resident #34 spilled it out of her personal coffee mug as she liked to drink her coffee from that particular mug; CNA D stated that she did not remember if it was her (CNA D) who gave Resident #34 her coffee and was unsure if it was herself or a different nurse aide who may have put coffee in Resident #34's cup. CNA D stated that Resident #34 liked to be as independent as possible and Resident #34 may have poured coffee from the facility cup on her breakfast tray into the personal mug. Wound Care MD was interviewed on 07/20/23 by phone at 11:05 a.m. Wound Care MD stated that he was initially consulted by facility to manage wound occurring to Resident #34 on approximately May 29, 2023. Wound Care MD stated that when he first saw Resident #34 on the day of 5/31/23, the burns to Resident 34's thighs were blistered. Wound Care MD stated that he believed that Resident #34 missed the table with her coffee mug and spilled the coffee on to her thighs to cause the burns on 05/27/23. Wound Care MD, during his interview on 07/20/23, stated that initially petroleum-based gauze dressing was applied for wound care to the burns and eventually debridement was done. Wound Care MD stated that no premedication prior to burn wound care treatment as been required by Resident #34. Wound Care MD stated that he did not believe there was any neglect or abuse involved in the burn incident affecting Resident #34 on 05/27/23. Wound Care MD stated that the burns were classified as second degree burns (burns which damage the outer layer of skin, epidermis, and the second layer of skin, dermis). The DON was interviewed on 07/20/23 at 11:25 a.m. DON stated that an investigation was not conducted into the burn incident of 05/27/23 as Resident #34 is cognitively intact so she is able to tell others that she spilled the coffee on herself. DON stated that there was no reason to suspect abuse or neglect after Resident #34 stated that she had spilled the coffee on herself. DON stated that she did an assessment to ensure that Resident #34 is safe to use her personal mug after the incident of 05/27/23 which resulted in the burn. DON stated that the electric coffee pot was changed to one which would help prevent possible overheating of the coffee as an intervention to prevent recurrence. DON stated that the coffee temperature log has been ongoing twice daily since 05/27/23 to ensure that coffee is not too hot to serve to residents, and there has been no indication of coffee that is served too hot (over 180 degrees) since the incident. The ADM was interviewed on 07/20/23 at 11:45 a.m. ADM stated I think there was an investigation and I did interventions. Resident has a BIMS of 15 and was just trying to take the lid off and spilled it (the coffee). We do temperature checks several times daily on the coffee and are never out of range. We took out the electric coffee pot and put out an urn to prevent overheating. ADM also stated during 07/20/23 interview that facility had recently purchased insulated cups with bigger handles as a safety precaution for the resident coffee drinkers. ADM stated that Wound Care MD was brought in to assist with assessment and treatment of Resident #34's wounds. ADM stated that she believed that DON had completed in-service to prevent a reoccurance but was unable to state the topic of the in-service, the date it was given, or which facility staff participated. ADM stated that she did not report incident involving burn injury from coffee because Resident #34 was able to explain what happened to cause the burns, so there was no evidence of abuse or neglect. ADM stated that the root cause of the burn injury was the lid being removed from the coffee by Resident #34 instead of someone doing it for her. ADM stated during interview that she felt that burn injury could have been a serious injury. ADM was unable to provide a written facility investigation when she was asked during the interview on 07/20/23 at 11:45 am. Review of the facility's policy Abuse Investigations dated 06/2005 reflected Policy Interpretation and Implementation; NFs must report abuse allegations immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility filed to ensure assessments accurately reflected the status of 1of 15 residents reviewed for assessments (Resident #7) The facility failed to ensure Resident #7's assessment was properly coded for his Gastrostomy-tube status. These failures could place residents at risk of not having individual needs met. Finding included: Review of Resident #7's Face sheet dated 07/18/2023 reflected Resident #7 was admitted on [DATE] and readmitted on [DATE] with the following diagnoses Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Cerebrovascular Disease (a range of conditions that affect the flow of blood through the brain. This alteration of blood flow can sometimes impair the brain's functions on either a temporary or permanent basis.), mild intellectual disabilities (someone with a low IQ score (around 70) as well as poor adaptive behaviors that cause them to have educational problems.), Gastrostomy Status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage.) Review of Resident #7's Comprehensive Care plan reflected a focus area dated 07/27/2015 and revised on 10/09/2019 Resident #7 requires tube feeding related to diagnoses of dysphagia secondary to CVA. Interventions included .check for tube placement and gastric content .the resident is dependent with tube feeding and water flushes . Further review of Resident #7's Comprehensive Care Plan reflected a focus are dated 07/27/2015 and revised on 04/11/2023 Resident #7 has a potential nutritional problem related to NPO status. Receives all nutrition via G-Tube by nurse. Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #7 was assessed to require extensive assist with ADLs. Further review reflected Resident #7 was assessed to not have a feeding tube. Observation on 07/18/2023 at 10:30 AM revealed Resident #7 in his room in bed. Resident #7 was observed to have a gastrostomy tube inserted into to his abdomen. Review of Resident #7's Consolidated physician orders reflected an order dated 11/14/2018 NPO diet, g-tube feeder. Further review reflected an order dated 10/24/2022 enteral feed order every 6 hours flush g-tube with 100 mg water every six hours In an interview on 07/20/2023 at 8:54 AM the MDS Coordinator stated after reviewing Resident #7's Annual MDS dated [DATE] she stated the MDS should have been coded for Resident #7's G-Tube status since he has had a G-Tube for years and receives all his nutrition through the G-Tube. The MDS Coordinator stated she was not sure why she missed it and stated it was an entry error. Review of the facility's policy Resident Assessments dated 11/2019 reflected A comprehensive assessment of every resident's needs is made at intervals .The results of the assessment are used to develop, review, and revise the residents comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 1 of 15 residents (Residents #14) reviewed for care plans. Resident #14's comprehensive care plan did not address the resident's smoking. These deficient practices could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. The findings were: Review of Resident #14's face sheet, dated 07/20/2023, revealed an 65year-old female was re-admitted to the facility on [DATE] with diagnoses including sepsis (body's extreme response to an infection), pure hypercholesterolemia (inherited disorder associated with elevated low density lipoprotein cholesterol levels and premature coronary heart disease), urinary tract infection (infection when bacteria, often from the skin or rectum enters the urethra and infect the urinary tract), and secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes (cancer cells spread to the lymph nodes from cancer that started somewhere else in the body). Review of Resident #14's MDS, dated [DATE]. Revealed Resident 14's BIMS score was 15 (Out of 15) which indicated resident 14 is cognitively intact. Review of Resident #14's Care Plan, dated 07/09/2023, did not address smoking. Review of the facility's smoking listed, not dated, revealed Resident 14 was not on the smoking list. Review of Resident #14's safe smoking assessment, dated 07/20/2023, revealed Resident 14 was assessed for smoking and was identified as a safe smoker. Observation on 07/19/2023 9:45 AM of Resident 14 outside in the designated smoking area. Interview with Resident #14 on 07/19/2023 at 11:25 AM Resident #14 stated she is a smoker and has been smoking for a long time. Resident 14 doesn't remember when she started smoking but stated it was before she moved into the facility. Resident 14 stated that she has been assessed for smoking. Resident 14 stated she has smoked at the facility in the past and has not had any smoking accidents. Interview with DON on 07/20/2023 at 9:05 AM the DON stated that if a resident was a smoker, then they should be care planned to ensure they have been assessed appropriately. DON stated that if a resident was not care planned for smoking the resident could potentially injury themselves by burning themselves while smoking or they may not be notified of the facility's smoking schedule. Interview with MDS Coordinator on 07/20/2023 at 9:30 AM the MDS Coordinator stated that residents that are smokers should be care planned for smoking. MDS Coordinator stated that residents should be care planned for smoking, so they receive a smoking assessment. MDS Coordinator stated if a resident was not care planned for smoking, then the staff may not notify the resident of smoking times, or they resident could possibly injure themselves from smoking. MDS Coordinator stated that Resident 14 was a smoker. A record of review of the facility's Care Plans, Comprehensive Person-Centered dated 12/16 stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process; b. Identify individuals or roles to be included; c. Request meetings; d. Request revisions to the plan of care; e. Participate in establishing the expected goals and outcomes of care; f. Participate in determining the type, amount, frequency and duration of care; g. Receive the services and/or items included in the plan of care; and h. See the care plan and sign it after significant changes are made. 5. The resident will be informed of his or her right to participate in his or her treatment. 6. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable. 7. The care planning process will: a. Facilitate resident and/or representative involvement; b. Include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; d. Describe any specialized services to be provided as a result of PASARR recommendations; e. Include the resident's stated goals upon admission and desired outcomes; f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards of practice for problem areas and conditions. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. b. The resident's physician (or primary healthcare provider) is integral to this process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 15. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 16 residents reviewed with limited range of motion (Resident #7), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #7 had interventions in place for his right-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in his right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #7's Face sheet dated 07/18/2023 reflected Resident #7 was admitted on [DATE] and readmitted on [DATE] with the following diagnoses Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Cerebrovascular Disease (a range of conditions that affect the flow of blood through the brain. This alteration of blood flow can sometimes impair the brain's functions on either a temporary or permanent basis.), mild intellectual disabilities (someone with a low IQ score (around 70) as well as poor adaptive behaviors that cause them to have educational problems.), Gastrostomy Status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage.) Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #7 was assessed to require extensive assist with ADLs. Further review reflected Resident#7 was assessed to have limitations of ROM on upper and lower extremities with impairment on one side. Review of Resident #7's Comprehensive Care plan reflected a focus area dated 07/27/2015 and revised on 11/20/2019 Resident #7 has limited physical mobility related to weakness, contractures, CVA history. Resident currently has right arm contracture. (The plan of care did not address a right-hand contracture). Interventions included: Monitor/ document/ report to MD PRN of immobility; contractures forming or worsening .skin-breakdown .Further review reflected no right-hand specific interventions. Observation on 07/18/2023 at 9:30 AM revealed Resident #7 in bed. Observation of Resident #7's right hand revealed his right hand was in a closed position. Resident #7 was able to open his right hand slightly moving his index and middle finger to reveal long finger nails. Resident #7 was not able to move his right ring finger or pinky finger. Observation and interview on 07/20/2023 at 8:50 AM the DON stated Resident #7 did have contractures she stated she was not sure abut his hand. The DON went down to Resident #7's room and observed Resident #7's hand and stated yes, his hand was contracted and stated she would trim his fingernails. The DON then started trimming Resident #7's fingernails. In an interview on 07/20/2023 at 8:55 AM the MDS Coordinator stated after reviewing Resident #7's care plan that he was not care planed for a right-hand contracture. She stated if his hand is contracted it should be care planed and he should have interventions in place. Review of Resident #7's Physical Therapy Treatment Encounter Notes dated from 06/19/2023 through 07/17/2023 reflected no treatment or interventions for Resident #7's right hand contracture. In an interview on 07/20/2023 at 9:08 AM The COTA RD stated she was not sure if Resident #7's right hand contracture was being addressed. She further stated that therapy was in the building, and she would go with them to check Resident #7's hand. In an interview on 07/20/2023 at 9:21 AM the RCDO stated she went down to Resident #7's room [ROOM NUMBER]/20/2023 at 9:10 AM and put a contracture device in his hand (a carrot) she stated Resident #7 took it out. The RCDO stated she instructed staff to document the intervention and to update his care plan. In an interview on 07/20/2023 at 10:30 AM the COTA RD stated she examined Resident #7's right hand. She stated his hand was not a fixed contracture but was high tone (High tone or hypertonia is increased tension in the muscles which makes it difficult for them to relax and can lead to contractures and loss of independence with everyday tasks.). The COTA RD stated she performed a recertification for Resident #7 to continue therapy and he would be getting treatment for his right hand. She stated without treatment for his decreased ROM it could lead to increased contractures and or skin breakdown. Review of the facility's policy Resident Mobility and Range of Motion dated 07/2017 reflected Residents will not experience an avoidable reduction in range of motion. Residents with limited range of motion will receive treatment and services to increase and /or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .The care plan will include specific intervention, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #30) of 4 residents reviewed for respiratory care, in that: The facility failed to: A.) date the oxygen tubing for Resident #30. B.) bag resident #30's oxygen tubing when not in use. These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Resident #30 Record Review of Resident #30's admission record dated 07/18/23 revealed the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses were acute respiratory failure (when lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning), COPD (progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), heart failure (a group of signs and symptoms, caused by an impairment of the heart's blood pumping function, and diabetes (a group of diseases that result in too much sugar in the blood. Record review of Resident #30's clinical physician orders dated as of 07/18/23 revealed: 1. an order to change and date O2 tubing and mask every Sunday and PRN. 2. an order for Albuterol Sulfate inhalation Nebulization Solution (2.5 mg/ml) 0.083% (Albuterol Sulfate) 1 vial inhaled orally every 4 hours as needed for cough/congestion/wheezing. 3. an order that stated may apply O2 per NC, mask or non-rebreather at needed rate not to exceed 10L/min to keep O2 saturation above 90% in emergent situation as needed for SOB/low O2 saturation. 4. SOB: Does resident have shortness of breath every shift for monitoring. Record review of resident #30's quarterly MDS dated [DATE] revealed the resident's BIMS was 14 indicating she was cognitively intact. The MDS indicated the resident required extensive assistance during mobility in bed, transferring, personal hygiene, and dressing and required the assistance of one person while performing activities of daily living (dressing and toileting). The MDS revealed resident received oxygen therapy while being a resident of the facility and within the last 14 days. Record review of resident #30's care plan dated 06/06/2023 read in part: Resident #30 is resistive to care r/t DX of Schizophrenia - Resident #30 has a dx of acute respiratory failure with hypoxia, O2 saturation is to be maintained above 90%. Interventions: Oxygen therapy as ordered. During and observation on 07/18/23 at 10:09 AM Resident #30's oxygen tubing, which was not in use and was not dated, was observed on the upper area of resident's bed with nasal canula stuck in between mattress and bed rail. Oxygen humidifier bottle, which was on concentrator was dated 06/11/23 and empty oxygen tubing bag was dated 06/11/23. In an interview on 07/18/23 at 10:11 AM with Resident #30, she stated things were alright and the staff treated her well. She stated the staff changed her oxygen tubing out, but she did not know how often. She stated she used oxygen sometimes but not every day. In an interview on 07/18/23 at 10:48 AM with RCD, she stated oxygen tubing and concentrators should be changed and dated every week on Sundays. She stated resident # 30's oxygen tubing storage bag was dated for 06/11/23 but that did not mean the tubing was from the same date and the bag was empty. She stated the oxygen tubing looked new, but it was not dated, and the humidifier bottle was dated 06/11/23. In an interview on 07/19/23 at 10:14 AM with DON, she stated oxygen tubing should be changed every Sunday night by the overnight nurse. She stated the oxygen tubing should be dated when changed and tubing should be placed in the bag when not in use. She stated the staff had been in-serviced on changing, dating, and placement of oxygen tubing. She stated a potential outcome if oxygen tubing is not changed or placed properly could be risk of exposure to germs or dirty tubing. Record review of facility policy Administration of Oxygen and Maintenance of Tubing and Equipment received from RCD and dated: 10/2017 revealed: Administration of Oxygen 1) Oxygen will be administered per physician order. Maintenance of Tubing and Equipment 1) Tubing will be kept in a bag when not in use. 2) Tubing will be dated and will be changed weekly.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for one of one resident council. There was no documentation of the facility's effort to resolve grievances collected at Resident Council meetings on 03/17/2023, 04/18/2023, 05/23/2023 and 06/27/2023. This failure placed residents at risk of indignity and a diminished quality of life. Findings included: Review of the Resident Council Minutes reflected the following with no resolutions or follow-up documented: -03/17/2023: Showers not on schedule and bed sheets still not being changed in a timely manner (several residents). -04/18/2023: beds are still not being made up or sheets changed when showers are given. -05/23/2023: some improvement in bed sheets but still not being changed as often as they should -06/27/2023: How often are sheets to be changed per several residents. Including pillowcases. Some still complained about showers . During a confidential group interview on 07/19/2023 at 1:00 PM several residents stated that they have been complaining for months that their bed sheets should be changed on shower days, but nobody is following up on the concerns. The residents stated the AD is present at all council meetings and she took the minutes. The residents stated the AD would say she would take care of it, but nothing ever happened, and no one ever got back to them about what was going to be done about their concerns. In an interview on 07/19/2023 at 1:40 PM the AD stated she writes down the resident council minutes in her note book for each meeting. The AD stated she did not fill out grievance forms for resident complaints but would write the issues on a piece of paper and give them to the proper department. The AD stated she had no proof that she notified the person responsible for the concerns and stated once she gave the note to the proper department, she did not follow up with them to make sure it was taken care of. The AD stated the residents have been complaining at each of their meetings about showers not being done on time and sheets not being changed. In an interview on 07/19/2023 at 1:43 PM the Administrator stated she expected that all residents' concerns be addressed and followed up on. The Administrator stated the facility had a grievances process and the person receiving the resident's complaint should be the one to ensure it was given to the person responsible for concerns and follow should be conducted to ensure all concerns are resolved. Review of the facility's policy Filing Grievances/ complaints dated June 2005 reflected Our facility will help residents .file grievances or complaints when such requests are made .Grievances and or complaints may be submitted orally or in writing .Upon receipt of a grievance and or complaint the administrator and/or designee will investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint .The resident, or person filing the grievance and/or complaints on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when 1 of 3 linen storage carts was observed to have personal items stored on the cart. The linen cart on Hall 200 was observed to have an opened/used bottle of water and cell phone stored in the cart. This deficient practice placed residents at risk for cross contamination and/or spread of infection that could cause severe illness and decreased quality of life. Findings include: During an observation on 11/16/2022 at 11:14 am, the linen cart on Hall 200 was observed to have an opened/used bottle of water and cell phone stored on the top shelf of the cart. The cell phone was lying face down on a pile of clean washcloths and the opened bottle of water was adjacent to this stack of clean washcloths. During an interview on 11/16/2022 at 10:50 am, Housekeeping/Laundry Supervisor stated they store the clean laundry separate from other laundry items to prevent cross contamination. She stated the clean linen storage carts on the hall are covered to prevent clean linen from becoming contaminated or soiled. She stated the staff were not supposed to store any personal items on the carts as the carts are only for clean linen. During an interview on 11/16/2022, at 11:17 am, AD stated she observed personal items stored on the Hall 200 linen cart. AD was standing in front of the cart at the time of this interview observing the 200 Hall clean linen cart AD stated personal items on not to be stored on the linen carts as it is an infection control issue. AD stated diseases could be spread by the contamination of the clean linen and that cell phones can be very contaminated. AD stated staff was trained not to store any items on the cart and it is her expectation that personal items will not be stored on clean linen carts. AD was observed removing the items from the Hall 200 linen cart. During an interview on 11/16/2022 at 11:30 am, CNA 1 stated she was the one that stored the used bottle of water and cell phone on the Hall 200 clean linen cart. She stated she normally puts it in her backpack, but she was running late today and forgot her backpack. She stated she normally stores her backpack in the break room but did not want to leave her phone in there because it could be stolen. She stated she normally has her phone in her pocket but today she put it on the cart. She further stated that she had received training on linen carts, and they are not supposed to store personal items on the clean linen cart because it could contaminate the clean linen. She stated residents could get sick from the contamination due to bacteria and viruses - they could get very sick and even die. During an interview on 11/16/2022 at 1:30 pm, the DON stated it is her expectation that staff will comply and not store personal items on the (clean) linen carts. She stated, if they do, they are contaminating the cart and it's an infection control issue. She stated, our staff has been trained not to store any personal items on top of or in the clean linen carts and there should be no clutter on the carts. She stated it did not meet her expectations to find personal items on the clean linen cart as it could make our residents very sick and that cell phones can be very nasty. A review of facility policy Departmental (Environmental Services) - Laundry and Linen dated January 2014, revealed under the section heading Washing Linen and other Soiled Items, item #7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination such as covering clean linen carts. Keep linen carts free of any clutter or possible contaminated items. A review of facility policy Policies and Practices - Infection Control dated rev. September 2005, revealed under Policy Interpretation and Implementation Section #2: The objective of our infection control policies and practices are to: a. Prevent, investigate, and control infections in the facility; and b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to allow residents the right to receive visitations of his or her choosing at the destination of his or her choosing, subject to the resident's right to deny visitation for 6 of 6 (Resident #5, #26, #41, #21, #143 and #42) residents reviewed for visitors. The facility failed to ensure Resident #5, #26, #41, #21, #143, and #42 was allowed visitors to their rooms. This failure could affect residents and place them at risk of loss of dignity and diminished quality of life. Findings included: Resident #5 Review of Resident #5's face sheet reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included Type 2 Diabetes Mellitus, Major Depressive Disorder, Unspecified Mental Disorder due to known Physiological condition, Mild Cognitive Impairment, Cognitive Communication Deficit, Dementia, Bipolar Disorder, and Parkinson's Disease. Review of Resident #5's Annual MDS dated [DATE] reflected a Staff Assessment for Mental Status was conducted due to Resident #5 being unable to complete the Brief Interview for Mental Status. This triggered a care area of Cognitive Loss and Dementia. Review of resident # 5's Immunization record revealed resident is fully vaccinated for COVID-19. Review of Resident #5's care plan dated 02/05/2021 reflected the following focus and interventions: Resident #5 is at risk for alteration in psychosocial wellbeing related to restrictions on visitation/activities due to COVID-19. Resident #5 will not experience any adverse effects throughout the review period. Interventions included: Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Resident #21 Review of Resident #21's face sheet reflected a [AGE] year-old male admitted on [DATE]. Diagnoses included Anxiety Disorder, Dementia, Other Seizures, Basal Cell Carcinoma of Skin, and Disorders of Density and Bone Structure. Record review of Resident #21's most recent MDS reflected a BIMS score of 15 out of 15 indicating cognition was intact. Review of Resident #21's care plan dated 02/05/2021 reflected the following focus and interventions: Resident #21 is at risk for alteration in psychosocial wellbeing related to restrictions on visitation/activities due to COVID-19. Resident #21 will not experience any adverse effects throughout the review period. Interventions included: Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Review of resident # 21's Immunization record revealed resident is fully vaccinated for COVID-19. Resident #26 Review of Resident #26's face sheet reflected an [AGE] year-old male admitted on [DATE]. Diagnoses included Cognitive Communication Deficit, Major Depressive Disorder, Cerebral Infarction, and Type 2 Diabetes Mellitus. Review of Resident #26's quarterly MDS dated [DATE] reflected a BIMS score of 3 out of 15 indicating a severe cognitive impairment. Review of Resident #26's care plan dated 02/05/2021 reflected the following focus and interventions: Resident #26 is at risk for alteration in psychosocial wellbeing related to restrictions on visitation/activities due to COVID-19. Resident #26 will not experience any adverse effects throughout the review period. Interventions included: Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Review of resident # 26's Immunization record revealed resident is fully vaccinated for COVID-19. Resident #41 Review of Resident #41's face sheet reflected a [AGE] year-old male admitted on [DATE]. Diagnoses included Major Depressive Disorder, General Anxiety, Type 2 Diabetes Mellitus, and Essential Primary Hypertension. Review of Resident #41's quarterly MDS dated [DATE] reflected a BIMS score of 15 out of 15 indicating cognition was intact. Review of Resident #41's care plan dated 02/05/2021 reflected the following focus and interventions: Resident #41 is at risk for alteration in psychosocial wellbeing related to restrictions on visitation/activities due to COVID-19. Resident #41 will not experience any adverse effects throughout the review period. Interventions included: Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Review of resident # 41's Immunization record revealed resident is fully vaccinated for COVID-19. Resident #42 Review of Resident #42's face sheet reflected a [AGE] year-old male admitted on [DATE]. Diagnoses included Non-Rheumatic Aortic Stenosis, Mild Cognitive Impairment, Anxiety Disorder, Insomnia, and Major Depressive Disorder. Review of Resident #42's quarterly MDS dated [DATE] reflected a BIMS score of 15 out of 15 indicating cognition was intact. Review of Resident #42's care plan dated 02/05/2021 reflected the following focus and interventions: Resident #42 is at risk for alteration in psychosocial wellbeing related to restrictions on visitation/activities due to COVID-19. Resident #42 will not experience any adverse effects throughout the review period. Interventions included: Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Review of resident # 42's Immunization record revealed resident is fully vaccinated for COVID-19. Resident #143 Review of Resident #143's face sheet reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included Anxiety Disorder, Depression, Insomnia, Dysphagia, and Chronic Obstructive Pulmonary Disease. Review of Resident #143's admission MDS dated [DATE] reflected a BIMS score of 14 out of 15 indicating cognition was intact. Review of Resident 143's care plan dated 05/18/2022 reflected the following focus and interventions: Resident #143 is at risk for alteration in psychosocial wellbeing related to restrictions on visitation/activities due to COVID-19. Resident #143 will not experience any adverse effects throughout the review period. Interventions included: Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Review of resident # 143's Immunization record revealed resident is fully vaccinated for COVID-19. Interview on 05/17/22 at 02:35 PM, FM 2 stated she had concerns about visitation. She stated she cannot go into Resident #23's room because there's a man in there who doesn't want to leave. Her family member is over the corporate office and according to her there is no corporate policy that requires visitors to remain in a designated area. There's a sign out front that says if there is a roommate, they can't visit in the resident's room unless the resident's roommates consents. Visitors are not allowed to go into the dining room either. She stated visitation takes place in a designated area in the front of the facility. Observation on 05/17/2022 at 3:32 PM revealed signage designating visitation area was posted in facility entrance in the front lobby. Interview on 05/18/2022 at 10:17 AM, Resident #41 stated during resident council he was told by administrative staff he was not allowed to have a visitor in his room because he has a roommate, but he can have visitors in the designated visiting area. He stated he did not know why the facility was restricting in room visitation. Interview on 05/18/2022 at 10:18 AM, Resident #21 stated during resident council he has been told by administrative staff if you have a roommate visitors must be entertained in the designated visitation areas. He stated he did not know why in room visitation was being restricted but this bothers him because he would like his friends and family to be able to visit in his room. Interview on 05/18/2022 at 10:18 AM, FM 1, family member of Resident #5, stated there's been a few concerns in the facility before but she has reported it to staff. Most things are taken care of, but she still has an issue with visitation. She stated the visitation rules have changed because of COVID-19. She stated if she wanted to visit today, she would have to call and make sure they could get Resident #5's roommate out of the room so she could visit in the room. She stated if she didn't call first, they may tell her Resident #5 is already in bed and she would not be allowed to visit, or the facility would have her visit in another area. Interview on 05/18/2022 10:19 AM Resident #143, stated during resident council she has only been at the facility for 6 weeks but was told by staff that her family member who is a resident also, can only visit with her in the designated visiting area because she has a roommate. She further stated this affects her because her family member tries to visit with her in her room and he is not allowed to. Interview on 05/18/2022 10:20 AM Resident #42, stated during resident council he was informed by the facility he was not allowed to have a visitor in his room because he has a roommate but can have visitors in the designated visiting area of the facility. He stated this bothers him because the facility was supposed to be his home. Record review of a grievance dated 02/28/ 2022 regarding visitation for Resident #26 in which the residents family member was concerned about not being allowed to have visitation with the resident in the residents room. The resolution on the grievance was to agree to a time and date for in-room visits and the residents roommate would be asked to give Resident #26 and the family time to visit in the room. Interview on 05/18/2022 at 12:50 PM, LVN 1 stated visitation was open and if a resident was in a private room, they could have family visit in their room but if they have a roommate, they must visit in the designated visitation areas, which are located in the 2 sitting rooms in the front of the facility. She stated the only time a resident with a roommate is allowed visitation in their rooms is if the roommate agrees to leave and give them the room to visit in for a while. Interview on 05/19/2022 at 1:11 PM CNA 4 she stated visitation was open at this time and visitors have to be screened in before entering facility. She stated the visitors must visit in the front of the facility in designated areas or outside unless the resident doesn't have a roommate. She stated if a resident doesn't have a roommate, they can have visits in their rooms. She stated she has been advised this by the office people and she was in-serviced on this. Interview on 05/19/2022 at 1:17 PM LVN 2 stated visitation was open at this time. She stated if a resident has a roommate and the roommate agrees to come out of the room, the visitors can visit in the residents rooms, but if not, they must visit in the lobby or day room. She stated she has been advised this by the Administrator and it was sent by corporate and discussed in the morning meeting. Interview on 05/19/2022 at 1:31 PM CNA 3, she stated visitation was being held up front only. She stated she has been advised this by the ADON and DON when she first started working here. She stated if residents are in a room alone, they can have in room visits. Interview on 05/19/2022 at 3:26 PM the DON she stated visitation was open at this time and if a resident has no roommate they can visit in their room. She stated if they do have a roommate and the roommate is out of the room, they allow visits in their rooms. She stated if there is a roommate that is not out of the room, they require visitation in the front designated areas. She stated they try to work with the roommates to give privacy for the other residents to visit with their loved ones. She stated she has been advised by the facility policy to conduct visitation this way and they have also spoken to the Ombudsman about visitation being held this way. She stated the Administrator is the one that spoke to the Ombudsman. She stated they had a recent infection control survey and also spoke with an investigator about visitation to make sure they were following the guidelines, but she doesn't remember the investigators name. She stated the Administrator may have the name of the investigator. Interview on 05/19/2022 at 3:44 PM the Administrator, she stated visitation was open at this time. She stated anyone can come at any time and there was no set schedule or hours for visitation. She stated visitors are screened before entering and if residents have a private room, they can visit in residents room. She stated if the resident shares a room, they ask the residents roommates to come out for a while and allow the visitor in to visit, but if the roommate refuses, the visit must take place in the designated visiting areas in the front lobby area. She stated she was following the visitation policy and guidelines from CMS that they have in their book. She stated the facility considers all of their residents immunocompromised and all residents except 4 are fully vaccinated against COVID-19. Record review of facility policy, titled Resident Rights Under Federal Law, read in part, 1. Basic Rights Each resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of Long-Term Care Regulatory Provider Letter QSO 20-39 dated 09/17/2020 (NF) revised on 03/10/2022 titled Nursing Home Visitation-Covid-19 (Revised) which the facility was following read in part, Therefore, a nursing home must facilitate in-person visitation consistent with the applicable CMS regulations .per 42 CFR 483.10(f)(4), which states The resident has a right to receive visitors of his or her own choosing at the time of his or her own choosing. Record Review of Long-Term Care Regulatory Provider Letter QSO 20-39 updated 03/10/2022 as referenced by the facility and which the facility was following read in part, If a resident's roommate is not up to date with all recommended Covid-19 vaccine doses or immunocompromised (regardless of vaccination status) visits should not be conducted in the resident's room if possible. For situations where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to the core principles of infection prevention.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for kitchen food safety. The facility: - Failed to ensure all food items in the kitchen were sealed, labeled, and discarded prior to the expiration date. -Failed to ensure [NAME] 7 measured the temperature of four items (broccoli, rice, roast beef, and gravy) on the steam table prior to serving lunch. -Failed to ensure [NAME] 7 served one item (ground fried chicken) on the steam table within an acceptable temperature range of greater than or equal to 135 degrees Fahrenheit. -Failed to ensure the Dietary Manager, [NAME] 7, and Dietary Aide washed their hands using proper technique . This failure placed residents at risk of food-borne illness. Findings included: 1. During observations of the kitchen on 5/17/2022 from 7:30 a.m.-7:54 a.m., the following were noted: At 7:30 a.m., reach in refrigerator contained diced tomatoes with a preparation date of 5/12/22. At 7:36 a.m., dry storage room contained an opened, unsealed bag of coconut dated 4/29/22. At 7:40 a.m., kitchen contained an unlabeled bag of an unknown substance dated 5/14/22. At 7:54 a.m., kitchen contained a bag of tortillas with a manufacturer's expiration date of 2/14/22. In an interview on 5/17/2022 at 7:40 a.m., [NAME] 7 stated the facility's policy was to discard leftovers after three days and all opened food packages should be properly sealed shut. [NAME] 7 stated the unknown substance was cornbread, it should have been labeled, and it should have been discarded after three days. In an interview on 5/18/2022 at 11:17 a.m., [NAME] 7 stated all food items should be thrown away according to the product's printed manufacturer's expiration date. In an interview on 5/19/2022 at 9:10 a.m., the Dietitian stated the facility's policy was to discard all leftover food items after three days and any food item that had exceeded its printed expiration date. The Dietitian stated everything that entered the kitchen or was removed from its original container should be labeled and dated. A record review of the facility's policy on food storage dated 6/01/2019 reflected the following: To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Use all leftovers within 72 hours. Discard items that are over 72 hours old. A record review of the Food and Drug Administration's 2017 Food Code reflected The date assigned by a retail repacker cannot extend beyond the manufacturer's recommended expiration or 'pull date' for the food. 2. During observations of meal service on 5/18/2022 from 11:50 a.m.-12:08 p.m., the following were noted: At 11:50 a.m., [NAME] 7 measured the temperature of all food items on the steam table except for broccoli, rice, roast beef, and gravy. At 11:52 a.m., the temperature of ground fried chicken was 115 degrees Fahrenheit and [NAME] 7 placed it in the oven. At 11:56 a.m., [NAME] 7 removed ground fried chicken from the oven and placed it back on the steam table. [NAME] 7 measured the temperature again and the temperature was 125 degrees Fahrenheit. At 12:01 p.m., [NAME] 7 proceeded to begin serving lunch. At 12:08 p.m., [NAME] 7 served plates with broccoli, rice, roast beef, gravy, and ground fried chicken. In an interview on 5/18/2022 at 12:01 p.m., [NAME] 7 stated she received training on taking food temperatures once a year when she renewed her food handlers license. When asked what the holding temperature of hot and cold items should be, [NAME] 7 stated cold items should be less than or equal to 40 degrees Fahrenheit and hot items should be less than or equal to 165 degrees Fahrenheit. In an interview on 5/19/2022 at 9:10 a.m., the Dietitian stated the facility's policy on measuring food temperatures included taking temperatures prior to meal service and documenting those temperatures. A record review of the facility's policy on taking temperatures dated 6/01/2019 reflected the following: The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will take wand record the temperatures of all foods prior to service. Foods not at the correct temperature will be corrected or discarded as necessary. A record review of the facility's policy on food holding and service dated 6/01/2019 reflected the following: Serve all hot foods at a temperature of 135 degrees Fahrenheit or greater and all cold food at 41 degrees Fahrenheit of less. 3. During observations of the kitchen on 5/17/2022 from 11:52 a.m.-2:28 p.m. and on 5/18/2022 from 11:38 a.m.-11:56 a.m., the following were measured using a stopwatch timer and noted: On 5/17/2022 at 11:52 a.m. Dietary Manager washed her hands for 10 seconds. On 5/17/2022 at 2:28 p.m. Dietary Manager washed her hands for two seconds. On 5/18/2022 at 11:38 a.m. Dietary Aide washed her hands for 14 seconds. On 5/18/2022 at 11:56 a.m. [NAME] 7 washed her hands for 14 seconds . In an interview on 5/19/2022 at 9:10 a.m., the Dietitian stated employees should be washing their hands as stated in their policy, especially if they were contaminated. The Dietitian stated, we expect them to follow infection control procedures. The Dietitian stated the Dietary Manager and facility Dietitian were responsible for training, monitoring, and ensuring compliance of the kitchen's policies on food storage, taking temperatures, and hand washing. The Dietitian stated she did not anticipate cold food, out of date food, or improper handwashing would lead to any severe outcome issues or foodborne illness. In an interview on 5/19/2022 at 3:27 p.m., the DON stated she was not familiar with the kitchen's policies, but she did know that employees discarded expired food. The DON stated the Dietary Manager was responsible for training all kitchen employees . The DON stated the Dietary Manager, Dietitian, and ADM were responsible for monitoring the kitchen and ensuring compliance of the kitchen's policies. When asked what kind of negative outcome could occur if the kitchen's policies were not followed, the DON stated that's not a good outcome if we are giving residents expired foods. It could be potentially hazardous. In an interview on 5/19/2022 at 3:43 p.m., the ADM stated the kitchen's policies included labeling and dating things when they were opened and discarding leftovers after three days. The ADM stated it was the Dietary Manager and Dietitian's responsibility to train employees on food storage, taking food temperatures, and hand washing. The ADM stated the Dietitian and herself were responsible for monitoring and ensuring compliance of these policies. The ADM stated if the kitchen's policies were not followed, residents could become sick. A record review of the facility's policy on hand washing dated 10/01/2018 reflected the following: Scrub hands, exposed arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one (1) of one (1) facility reviewed for pest control program. The facility was observed to have live common house flies in areas of the facility including the kitchen, resident rooms, and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Included: Review of Resident #7's face sheet reflected resident #7 was a [AGE] year-old male with an admission date of 01/25/2013. Resident #7's Diagnoses included Muscle Wasting and Atrophy (wasting or thinning of muscle mass), COPD (chronic inflammatory lung disease), Bipolar Disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Hypertension (high blood pressure), and Seizures which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #7 was able to complete the interview and cognitively intact. Review of Resident #42's face sheet reflected Resident #42 was a [AGE] year-old male with an admission date of 03/23/2015. Resident #42's Diagnoses included Muscle Wasting and Atrophy, Glaucoma (increase pressure in eyeball, causing gradual loss of sight), GERD (acid reflux), Anxiety, and Hypertension which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #42 was able to complete the interview and cognitively intact. Review of Resident #21's face sheet reflected resident #21 was a [AGE] year-old male with an admission date of 10/24/2015. Resident #21's Diagnoses included Muscle Wasting and Atrophy, Seizures, Anxiety, Hypertension, and GERD which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) reflected Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #21 was able to complete the interview and cognitively intact. Review of Resident #39's face sheet reflected Resident #39 was a [AGE] year-old male with an admission date of 05/24/2013. Resident #39's Diagnoses included Muscle Wasting and Atrophy, Cerebral Infarction (stroke/poor blood flow to the brain), Acute Kidney Failure (decrease in kidney function), Dysphagia (difficulty swallowing), and Diabetes which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) reflected Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #39 was able to complete the interview and cognitively intact. Review of Resident #12's face sheet reflected Resident #12 was a [AGE] year-old female with an admission date of 02/04/2020. Resident #12's Diagnoses included Muscle Wasting and Atrophy, COPD, Schizoaffective Disorder (combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), Cerebral Infarction, and Hypertension which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #12 was able to complete the interview and cognitively intact. Review of Resident #8's face sheet reflected Resident #8 was a [AGE] year-old female with an admission date of 02/01/2018. Resident #8's Diagnoses included Muscle Wasting and Atrophy, Diabetes, Chronic Kidney Disease, Seizures, and Heart Failure which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #8 had a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #8's cognitive level was moderately impaired, and resident was able to complete the interview. Review of Resident #5's face sheet reflected Resident #5 was a [AGE] year-old female with an admission date of 02/13/2019. Resident #5's Diagnoses included Muscle Wasting and Atrophy, Diabetes, Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Bipolar Disorder, and Hypertension which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #5 had a Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #5's cognition was severely impaired, and resident was not able to complete the interview. Review of Resident #41's face sheet reflected Resident #41 was a [AGE] year-old male with an admission date of 10/21/2020. Resident #41's Diagnoses included Muscle Wasting and Atrophy, Diabetes (body's ability to produce or respond to the hormone insulin is impaired), Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Major Depressive Disorder (mental disorder characterized by persistently depressed mood and long term loss of pleasure or interest in life), and Hypertension which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #41 was able to complete the interview and cognitively intact. Review of Resident #143's face sheet reflected Resident #143 was a [AGE] year-old female with an admission date of 04/29/2022. Resident #143's Diagnoses included COPD, Hypertension, GERD, Anxiety, and Dysphagia which revealed resident had physical and mental disorders. Review of the most recent Minimum Data Set (MDS) dated [DATE] reflected Resident #143 had a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #143 was able to complete the interview and cognitively intact. Observation on 05/17/2022 8:36 AM revealed 1 live fly flying around room [ROOM NUMBER] where surveyors were working. Observation on 05/17/2022 9:08 AM revealed 2 flies on the blanket covering Resident # 12. Observation on 05/18/22 11:35 AM revealed three flies flying in the kitchen. Interview on 05/18/22 at 11:37 AM, [NAME] 7 said she had noticed flies in the kitchen especially with the warmer weather. She said I think they're calling pest control to take care of it. Observation on 05/17/2022 at 12:03 PM revealed 1 fly flying around at end of hall 2 between rooms [ROOM NUMBERS]. Observation on 05/17/2022 at 12:06 PM revealed 1 fly landing on a table in the dining area where 3 residents were sitting., Resident #21 killed a fly with the fly swatter. Observation on 05/17/2022 at 12:07 PM revealed a fly swatter in the back of Resident #21's chair between the residents back and the back of the wheelchair. Observation on 05/17/2022 at 12:16 PM revealed 1 fly flying in the dining room which landed on a table where Resident # 7 was eating. Observation on 05/17/2022 at 12:19 PM revealed 1 fly crawling on Resident # 7's hand while resident was eating his beans and sausage. Interview with Resident # 39 on 05/17/2022 at 12:25 PM he stated the flies know better than to come over to their table and that is because Resident #21 will kill them if they do. Resident # 39 stated he sees flies sometimes. Observation on 05/17/22 at 01:24 PM revealed a live fly flying in Resident # 41's room. Resident # 41 stated he keeps a fly swatter hanging on his door because all the flies in the building bother him. Observation on 05/17/22 at 02:25 PM revealed live flies outside of the dining room door where residents go to smoke with 5 flies landing on the door. Observation on 05/17/2022 at 12:28 PM revealed 2 flies on Resident # 7's hand and on his head. Those 2 flies continued to swarm around Resident # 7 and landed on different areas of Resident # 7. Observation on 05/17/2022 at 2:46 PM revealed 1 fly flying around room [ROOM NUMBER] where surveyors were working. Observation on 05/18/2022 at 8:59 AM revealed 1 fly flying around room [ROOM NUMBER] where surveyors were working. Interview with NA 4 on 05/18/2022 at 9:08 AM, NA 4 stated she had been noticing a lot of flies and it's because the residents that go out to smoke open the dining room door a lot. She stated she doesn't see the facility doing anything to get rid of the flies, but the residents try to kill the flies. NA 4 stated she doesn't know anything about pest control. Observation on 05/18/2022 at 9:11 AM revealed 1 fly crawling on a chair in the dining room close to the entrance of the dining room. There were a few residents in the dining area, no residents were eating at this time. Observation on 05/18/2022 at 9:13 AM revealed 1 fly crawling on the window in the dining room. The door to the outside was closed, there were a few residents in the dining area, no residents were eating at this time. Interview with Resident # 8 on 05/18/2022 at 9:16 AM, she stated the flies were bad and they bother her all the time. Resident # 8 stated the facility needs to clean the trash cans in hallways and sometimes they have fly traps hanging in the windows. Interview with Resident # 41 on 05/18/2022 at 10:17 AM he stated resident council that the door to the smoking area off of the dining room is propped open when residents go out to smoke and all the flies come in. He states this affects him when he is eating and in his room. Resident # 41 stated he has a fly swatter hanging in his room. Interview with Resident # 21 on 05/18/2022 at 10:18 AM he stated during resident council that there is a lot of flies in the dining room, and this bothers him while he is eating. He stated that when residents go outside to smoke the door is left open too long and the flies come in. Interview with Resident # 143 on 05/18/2022 at 10:19 AM she stated during resident council that she is new to the facility but has noticed the flies in the dining area while eating and this bothers her. Interview with Resident # 42 on 05/18/2022 at 10:20 AM he stated during resident council there are a lot of flies in the dining area and facility. He stated the door to the smoking area stays open too long and flies come into the building that way. Resident # 42 stated that this bothers him during mealtime. Interview with LVN 1 on 05/18/2022 at 12:50 PM LVN 1 stated she noticed lot of flies, but flies are just bad in [NAME] to begin with, so she doesn't think anything of it. She stated she had seen pest control in the facility, and they come pretty often. LVN 1 stated she seen pest control here last week, but she doesn't know if they were treating for flies. She stated the maintenance man checks the halls and tries to check for pests, but she doesn't know if they are doing anything extra to get rid of the flies. Interview with LVN 2 on 05/19/2022 at 1:17 PM she stated she has noticed more flies in the facility lately now that it is getting hot. She stated if she noticed pests, she reports it to HSK 5 the housekeeping supervisor and also in the morning meeting. LVN 2 stated the facility was having pest control come to the facility routinely to try to treat for flies. She stated she had seen pest control here in the past few weeks. She stated she feels as though pest control was effective. LVN 2 stated when the residents in wheelchairs go outside on the patio it takes a little longer for the doors to close and the flies are hard to prevent. She stated she feels as though the flies bother the residents and a few of them make comments and carry fly swatters. LVN 2 stated she feels like the flies could spread infection. Interview with CNA 3 on 05/19/2022 at 1:31 PM she stated she has noticed a few flies in the facility lately and every time the door opens you take a chance on flies coming in. She stated she hasn't noticed anything major like swarms of flies. CNA 3 stated if she noticed pests, she reports it to the charge nurse and everyone else too. She stated the facility was making fly swatters available and they kill them as they see them. She stated she hasn't seen pest control come in the facility, but she works different hours and days. Observation on 05/19/2022 at 2:10 PM revealed 3 flies observed crawling on Resident # 5's bedspread which was covering the resident and pulled up to the neck area with the resident in bed. Interview with HSK 5 on 05/19/2022 at 2:25 PM she stated she has noticed more flies in the facility lately and it comes more frequently at this time of year. She stated they get some kind of chemical to help to try and treat for flies. HSK 5 stated pest control comes to the facility the first of every month and they treat for flies. She stated they can also come as needed to treat for pests. She stated she feels as though pest control is effective sometimes. Interview with the DON on 05/19/2022 at 3:26 PM she stated she had seen some flies in the facility lately. She stated they have to hold the door open for the residents in wheelchairs and due to the heat increasing, there were more flies. She stated if she noticed pests or flies, she reports it to the ADM so they can get pest control out here. She stated the facility was having housekeepers and other staff member clean areas where flies were killed to try to treat for flies. She stated pest control comes to the facility every couple of months that she knows of, and they treat for flies and other pests. The DON stated the have a lamp that is made to attract and kill flies in the dining room on the right hand side of the calendar on the left of the windows where the door is located, but the lamp doesn't work. She stated she does feel as though pest control is effective, and she doesn't see any other bugs or pests. She stated she had just recently started noticing more flies and she hasn't seen any flies in the residents rooms, just by the dining room door and front entrance door. She stated she feels as though the flies bother the residents, and she has had a few residents report flies in the past few days. She stated that she reported the complaints of flies to the Administrator so she could contact pest control. The DON stated she feels like the flies could spread infection if they were to get into a wound or something. Interview with ADM on 05/19/2022 at 3:44 PM she stated she had noticed more flies in the facility lately. She stated this past week with the really hot weather she had noticed them around the back door but not in the hallways or in the residents room. She stated the flies have not been a problem until now with the hot weather coming in. She stated her maintenance man was going to get some spray right now to try to treat for the flies. She stated there was a light that was installed by pest control in the dining room that was supposed to help reduce flies and it was currently not working. She stated the light was essentially not effective. The ADM stated pest control comes to the facility monthly and treats the facility for pests, but not every time for flies. She stated they haven't had any problems with flies until this past week with the weather getting hot. She stated she can call pest control at any time to come in between then as needed and they will treat for flies if requested. She stated she is was going to call them today so they can come and treat after the maintenance man. She stated the pest control company was here last around last week. She stated she is was aware that there was a problem with flies right now and the door was being opened a lot, so more flies have been coming in. She stated she does feel as though pest control was effective. The ADM stated she feels as though the flies bother some of the residents and there was a group of guys that have recently been verbal about it. She stated she did not see any flies at the group of guys table in the dining room. She stated Residents 21, 42, and 39 were the group of guys and she didn't hear Resident # 39 complain, but Residents 21 and 42 did. The ADM stated there was a potential that the flies could spread infection. Observation on 05/19/2022 at 3:57 PM, revealed non-working light insect attracter device hanging on the dining room wall near the entrance/exit door of facility leading outside to smoking area. Record Review of the Pest Control policy dated 2001, revised May 2008 which revealed facility shall maintain an effective pest control program. # 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.