**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #1 on 05/23/2025, CNA-A did not clean the resident's buttock area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 05/23/2025, revealed the resident was [AGE] years old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of dementia (over time destroy nerve cells and damage the brain), bronchitis (inflammation of the lining bronchial tubes), muscle wasting and atrophy (decrease in muscle mass, weakness and tingling in limbs), hypertension (high blood pressures), and anemia (the blood does not have enough healthy red blood cells to carry oxygen). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment and had frequently urinary incontinence and occasionally bowel incontinence. Record review of Resident #1's comprehensive care plan, dated 03/07/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care at least every 2 hour and clean peri-care with each incontinence episode. Observation on 05/23/2025 at 11:33 a.m. revealed CNA-A removed Resident #1's old and dirty brief and cleaned the resident's suprapubic area, left, right groin area, and the resident's genital area with circular motion, then turned the resident to right side and put the new and clean brief. CNA-A closed the new and clean brief without cleaning Resident #1's buttock area. Interview on 05/23/2025 at 11:45 a.m. CNA- A stated he did not clean Resident #1's buttock area because he was nervous and forgot. CNA-A said he should have cleaned Resident #1's buttock area. CNA-A said he had peri-care training in January 2025. Interview on 05/23/2025 at 1:01 p.m. the ADON stated the DON was on vacation, so the ADON functioned as DON. The ADON said CNA-A should have cleaned Resident #1's buttock area to prevent possible infection. The ADON said she was responsible for providing training related to peri-care and monitoring skill checkoffs. CNA-A had a skill checkoff on 01/14/2025, and CNA-A passed perineal care for male. Record review of the facility policy, titled Incontinent Care Skills Checklist, undated, revealed . 10. With new wipe or cloth, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. Remove dirty towel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #92) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #92's use of antipsychotic medication in his baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #92's admission Record dated 05/09/2025 revealed he was a [AGE] year-old man admitted [DATE] with diagnoses which included dementia (general term for loss of memory, language, problem-solving and other thinking abilities) and unspecified psychosis (when a person has trouble telling the difference between what's real and what's not). Record review of Resident #92's entry MDS assessment dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment, and was assessed as taking an antipsychotic medication. Record review of Resident #92's Baseline Care Plan initiated 4/1/2025 revealed a problem area for uses antipsychotic medications r/t psychosis with an initiated date of 05/06/2025. Record review of Resident #92's Medication Administration Record for May 2025 revealed an order for OLANZapine Oral Tablet 2.5MG (Olanzapine). Give 1 tablet by mouth at bedtime for psychosis give 1 tablet to equal 2.5mg po at hs. This order for Olanzapine had a start date of 04/01/2025. During an interview with MDS Nurse-D on 05/08/2025 at 11:57 a.m., MDS Nurse-D stated Resident #92 had an order for Olanzapine, an antipsychotic medication on the day he was admitted [DATE], but this was not addressed on his Baseline Care Plan, and was not added to his Care Plan until 05/06/2025. MDS Nurse-D stated Baseline Care Plans should be completed within 48 hours, and include essential information such as fall risk, and Physician Orders which would include the different type of medications taken. She stated it was important to have this information in the Baseline Care Plan to provide staff with all the information needed to meet his needs after his admission. MDS Nurse-D stated that the admitting Nurse was responsible for completing baseline care plans. Interview on 05/09/2025 at 09:13 a.m. with the DON revealed that the admitting Nurse was responsible for completing Baseline Care Plans, and that Resident #92's Baseline Care Plan should have included his use of an antipsychotic medication. The DON stated that the facility was monitoring for side effects of the anti-psychotic medication and providing good care, but through oversight, it just did not make it onto the Baseline Care Plan within the 48 hours, but had been added later. Record review of the facility policy titled Baseline Care Plan reviewed 10/05/2023 revealed The baseline care plan will: a. be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. initial goals based on admission orders. ii. Physician Orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #89) reviewed for care plans: The facility failed to ensure Residents #89's Care Plan reflected he should receive PASRR services. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: Record review of Resident #89's admission record, dated 5/9/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted last on 10/1/24 with diagnoses including major depressive disorder, schizoaffective disorder, insomnia, anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. Record review of Resident #89's quarterly MDS assessment, dated 2/5/25, revealed Resident #89's cognition was fully intact for daily decision making. Record review of Resident #89's Care Plan, revealed a problem area, initiated on 6/13/24 and revised on 2/17/25, for the resident used antipsychotic medication related to schizoaffective, bipolar type, and a history of psychosis with interventions to be evaluated and treated by a mental health service, and monitor/document/report any adverse reactions of antipsychotic medications. The care plan did not indicate if the resident was receiving PASRR services. Record review of Resident #89's document titled PASRR Evaluation, dated 1/17/25, revealed he was evaluated for qualifying mental illness by a qualified mental health professional. During an interview on 5/9/25 at 12:33 p.m. MDS D stated Resident #89 stated she believed the resident had refused PASRR services. MDS D stated she would need to check but if the resident had refused services, they would still need to add it to the care plan, so people are aware that he was positive for services but refused them and the facility had addressed it. During a follow up interview on 5/9/25 at 12:45 p.m. MDS D stated Resident #89 had not refused PASRR services, and they were waiting for services to be implemented after his recent evaluation. MDS D stated he was receiving psychiatric services in the meantime. Record review of the facility's policy, titled Comprehensive Care Plans, dated 10/22/24, stated Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed . 3. The comprehensive care plan will describe at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right i:'etlise treatment c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 2 residents (Resident #61) reviewed for pressure injuries. The facility nurse did not provide wound care to Resident #61 on the evening of 05/07/2025 as ordered. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain. Findings included: Record review of Resident #61's admission record dated 05/08/2025 revealed he was a [AGE] year-old-man initially admitted on [DATE], and re-admitted on [DATE] with diagnosis which included: Pressure ulcer of sacral region Stage 4 (most severe type of pressure injury, characterized by full-thickness skin loss located at base of spine, just above buttocks). Record review of Resident #61's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. He was assessed as being dependent (helper does all the effort) for transfers and having a diagnosis of Pressure Ulcer of sacral region, Stage 4. Record review of Resident #61's Comprehensive Care Plan initiated 11/19/2021, revealed a problem area for stage 4 pressure ulcer to sacrum . with interventions which included Administer treatments as ordered and monitor for effectiveness:. Record review of Resident #61's Physician Order Summary dated 05/08/2025 revealed an order to CLEANSE SACRAL STAGE IV PRESSURE ULCER WITH VASHE [cleansing wound solution]. PAT DRY WITH 4X4 GAUZE. APPLY SKIN PREP TO PERI WOUND. PLACE VASHE SOAKED GAUZE IN NEGATIVE SPACE OF SACRAL PRESSURE WOUND. COVER WITH ABD [abdominal] PAD AND SECURE WITH KERLIX TID AND PRN UNTIL HEALED. Order date 05/02/2025. Record review of Resident #61's Treatment Administration Record (TAR) for May 2025 revealed an order to Cleanse sacral stage IV pressure ulcer with VASHE [cleansing wound solution]. Pat dry with 4x4 gauze. Apply skin prep to peri wound. Place VASHE soaked gauze in negative space of sacral pressure wound. Cover with ABD pad and secure with Kerlix [bulky gauze bandage] TID and PRN until healed with start date of 5/2/2025. Further review revealed Resident #61 was to receive this wound treatment at 0800 [8:00a.m], 1400 [2:00p.m.] and 2000 [8:00 p.m.] every day. On 5/7/2025 at 2000 [8:00p.m.], there were no initials to indicate the wound treatment had been completed. Observation on 05/08/2025 at 08:42 a.m. of wound care for Resident #61 provided by LVN-E revealed that Resident #61 had a dressing dated 5/7/2025 over a wound he had on the back of his upper left thigh, but there was no dressing observed over the Stage IV wound on his sacrum. During an interview with LVN-E on 05/08/2025 at 09:48 a.m., LVN-E stated she had removed the dressing over his sacral wound just prior to the State Surveyor observing his wound care, because she had checked to see if he was clean, and found the sacral wound dressing to be soiled with drainage from his wound and she wanted to clean that up before the State Surveyor observed his wound care. LVN-E stated that Resident #61's had orders for his Stage 4 sacral wound to be cleaned and dressed three times a day, and that the dressing that she had removed earlier had been dated 05/07/2025, but had no time on the dressing and had been heavily soiled with drainage. She reviewed Resident #61's treatment record for May and stated that there was no entry for the 2000 [8:00p.m.] dressing change on 05/07/2025, but could not say if that was a documentation error, or the wound care had not been done. Interview with the DON on 05/08/2025 at 11:46 a.m. revealed that she had contacted the Nurse, LVN-F who had been assigned to provide Resident #61's wound care treatment on the evening of 05/07/2025, and LVN-F told her she had not completed his wound care that night because she had gotten busy and forgot, and the DON stated that she had never done that before. The DON stated she notified Resident #61's Physician of this medication error and that he would be going to see the Wound Care Doctor the next day. The DON stated that by not providing wound care to Resident #61's sacral wound as prescribed, it could result in his wound because worse or slowing healing. Telephone interview on 05/08/2025 at 6:00 p.m. with LVN-F revealed she was Resident #61's assigned Nurse on the evening of 05/07/2025, and had not completed his prescribed wound care at 2000 [8:00p.m.] that evening because she had gotten very busy and did not have time to complete. She stated this was the only time she had not been able to complete his wound care as scheduled, and that not providing his wound care as prescribed could result in his pressure ulcer getting worse. Record review of facility policy titled Topical Administration reviewed 10/01/2019, revealed Apply topical treatment (medication and dressing if indicated) as per physician's order

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 3 medication cart (300 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for Resident #86's medication package of sertraline (Sertraline is an SSRI (serotonin reuptake inhibitor) that increases serotonin levels between neurons (nerves) by blocking serotonin from being absorbed.) which had medication order change from 150 mg to 50 mg. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Observation on 5/8/25 at 08:32 a.m. revealed a package in the 300-hall medication cart contained medication for Resident #86 with a label for 50 mg of sertraline, and instructions to give 1 tab by mouth daily with 100 mg to equal 150 mg. MA J administered 50 mg of sertraline to Resident #86. Record review of Resident #86's physician orders, dated 5/9/25, revealed an order for sertraline 50 mg give 1 tab by mouth one time a day with a start date of 4/4/25 and no end date. During an interview on 5/9/25 at 10:11 a.m. the DON stated staff should place a change in direction sticker on any medications with a change in the order so staff with be altered and not give the wrong amount of medication to the resident. Record review of the facility's policy titled Labeling of Medication, dated 10/01/2019, stated: Policy All drugs and biological in the Facility are labeled in accordance with all Federal and State regulations . A. When there is a change to a physician order, the nurse receiving the order will affix a Direction Change sticker or equivalent to the label if there is no change in the medication. This sticker will be placed so as not to obliterate any other required information on the medication label. B. When such label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. C. The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will contain an accurate label .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 8 residents (Residents #69 and #45) reviewed for infection control. 1. The facility failed to ensure CNA -G, after completing peri and foley care for Resident #69, did not replace a bed wedge that had fallen on the floor back onto Resident #69's bed without cleaning/sanitizing it first. 2. The facility failed to ensure RN I changed his gloves and sanitized his hands after removing an old bandage and placing a new bandage, while performing peg tube (an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) site care for Resident #45. These failures could place residents at risk for cross contamination and infection. The finding included: 1. Record review of Resident #69's admission Record revealed she was an [AGE] year-old woman admitted on [DATE] with diagnoses which included: cerebral infarction (also known as a stroke, which occurs when blood flow to brain is blocked causing brain tissue to die) and neuromuscular dysfunction of bladder (occurs when signals from nervous system to the bladder are disrupted leading to issues with bladder control and emptying). Record review of Resident #69's 5-day MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment and was assessed as being dependent for transfers and toileting hygiene. Record review of Resident #69's Care Plan initiated revealed problem areas which included: need for Enhanced Barrier Precautions due to foley catheter and ulcers, and is at risk for infection (initiated 3/19/2025). Record review of Resident 369's Order Summary dated 05/08/2025 revealed orders including: Foley cath care q shift and PRN Observation on 05/08/2025 at 8:25 a.m. of foley and peri-care for Resident #69 revealed CNA-G and CNA-H both sanitized their hands, put on gown and gloves and then CNA-G prepared the area by unharnessing and removing an oblong wedge that had been attached to the side of Resident #69's mattress with straps, midway along the length of the bed. The wedge dropped onto the floor and CNA-G was then observed to kick the wedge under the bed to clear it from where she was standing. CNA-G and CNA-H then provided foley and peri-care for Resident #69. After completing the peri-care and repositioning Resident #69, CNA-G picked up the wedge from floor underneath Resident #69's bed and placed it back on the bed, midway along the side of the bed, and attached it back to the mattress with harness straps without cleaning or sanitizing the mattress. During an interview with CNA-G on 05/08/2025 at 8:38 a.m., CNA-G stated that normally the bed wedge just hung over the side of the bed by the harness straps after she removed it for peri-care, not touching the floor, but this time the straps released completely and the wedge fell to the floor. She stated she should have cleaned and sanitized the wedge before replacing it on the bed next to Resident #69 because it had come into contact with dirt and germs on the floor. She stated that by not cleaning the wedge after it was on the floor, it could have caused the spread of germs from the floor to Resident #69. During an interview with the DON on 05/08/2025 at 11:46 a.m., the DON stated that CNA-G should have cleaned and sanitized the bed wedge before placing it back on the bed, noting that Resident #69 was on Enhanced Barrier Precautions, which indicated an increased risk of infection, and that placing the dirty wedge back on the bed could increase the risk for spread of infection. The DON stated CNA-G had worked at the facility a long time, and had been trained on infection control. 2. Record review of Resident #45's admission record, dated 5/9/25, revealed a [AGE] year-old female resident was initially admitted on [DATE], and readmitted on [DATE] with diagnoses including dementia, cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes.), and dysphagia (difficult swallowing) following cerebral infarction. Record review of Resident #45's Quarterly MDS Assessment, dated 4/2/25, revealed she had severely impaired cognition for daily decision making. Section K revealed the resident had a feeding tube. Record review of Resident #45's Care Plan revealed a problem area, initiated on 4/18/24, the resident required tube feeding related to dysphagia with interventions to Monitor/document/report PRN any signs and symptoms of: aspiration- fever, SOB (shortness of breath), tube dislodged, infection at tube site, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. Record review of Resident #45's Order Summary, dated 5/7/25, revealed an order to cleanse PEG tube site with normal saline and pat dry with 4x4 gauze. Paint with skin prep and leave open to air one time a day, with a start date of 3/10/25, and no end date. During an observation on 5/8/25 at 2:11 p.m. RN-I removed Resident #45's gauze pad from her PEG tube site. The bandage was dated 5/7/25. RN-I discarded the old gauze bandage, with the same gloves, RN-I opened a new package of split gauze, placed it around the residents PEG tube and secured it to the residents abdomen with tape. RN-I did not change his gloves or sanitize his hands after removing the old gauze bandage and applying the new one. During an interview on 5/8/25 at 2:32 p.m. RN-I stated he should have changed his gloves and sanitized his hands after he removed the old bandage and before he applied the new bandage. RN-I stated his hand sanitizer was in his pocket and not accessible during care. RN-I stated he needed to change his gloves and sanitize his hands because you do not know what was on the old bandage, they can get an infection, and become septic (Sepsis occurs when your immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death.). During an interview on 5/9/25 at 12:24 p.m. The DON stated staff should remove their gloves, sanitize their hands, and apply new gloves when removing an old bandage and placing a new one on, to prevent infection to the resident. Record review of the facility policy titled Infection Prevention and Control Program implemented 5/13/2023 revealed This facility has established and maintains 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 as per accepted national standards and guidelines. Further review revealed all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Record review of the facility policy titled Hand Hygiene, dated 10/24/22, stated All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . 6. Additional considerations: a. The use of gloves does not replace band hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The FSS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Findings included: During an interview on 05/06/2025 at 11:07 AM, the FSS was hired 06/30/22 and stated she was not a certified dietary manager or certified food service manager, and she did not have an associate's or higher degree in food service management or in hospitality. She had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting but had not completed a course of study in food safety management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. She attempted to become certified but the facility had gone through several consultant RDs and there had not been one assigned to the facility long enough to serve as a preceptor. During an interview on 05/08/2025 at 10:37 AM, the consultant RD stated did not work at the facility full time. She provided approximately 12 - 16 hours of consultative hours to the facility per month. During an interview on 05/08/2025 at 2:20 PM, the Administrator stated he was aware the FSS was not a certified dietary manager, certified food manager and could not produce evidence she completed a course of study including topics integral to maintaining dietary operations and stated he would take care of it. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of reach-in cooler #1 at or below 41 degrees F. 2. The facility failed to ensure a package of pork sausage and a package of sliced salami were discarded by their use-by dates. 3. The facility failed to record the temperature of reach-in cooler #1 on the Refrigerator Temperature Record on 05/08/2025. 4. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 05/06/2025 at 11:12 AM of reach-in cooler #1 revealed the digital display outside the cooler indicated a temperature of 52 degrees F. Further observation inside the cooler revealed an analogue thermometer indicating a temperature of 51 degrees F. The Dietary Refrigerator and Freezer Temperature Record posted on the side of the cooler indicated the internal temperature of the cooler was 40 degrees F on 05/06/2025. There was no time noted on the log. During an interview on 05/06/2025 at 11:13 AM the FSS stated the internal temperature of reach-in cooler #1 was not good, it should be at or below 41 degrees F, and she would speak to the maintenance supervisor. She did not know what time the temperature was taken that morning, but it was taken by the early DA. All kitchen staff was responsible for keeping an eye on the temperatures of the coolers. Staff was trained during meetings twice a month. During an interview on 05/06/2025 at 11:14 AM, DA A stated she had noted the temperature of reach-in cooler #1 was 40 degrees F and recorded this temperature on the log at 5:00 AM that morning. During an interview on 05/06/2025 at 11:32 AM, the Administrator stated all food from reach-in cooler #1 had been discarded and the cooler would not be in use until it was repaired and maintaining the proper temperature. Record review of facility policy 03.003 Food Storage revised 06/01/2019 revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators. a. Keep fresh meat, poultry, seafood, dairy products and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41 °F or less. h. Place a thermometer inside refrigerators near the door where the temperature is warmest. Check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41 °F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the refrigerator. i. Record review of Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5°C (41°F) or less. 2. Observation on 05/06/2025 at 11:16 AM in the kitchen revealed inside reach-in cooler #2 a package 5 lb. package of pork chorizo sausage that had been opened and was stored in a sealed zip-locked bag. Written in black marker on the zip-locked bag was, Received 4/11/25 and Opened 4/12/25. Observation on 05/06/2025 at 11:25 AM in the reach-in stand-alone refrigerator revealed a package of uncured sliced salami that had been opened and was stored in a sealed zip-locked bag. Written in black marker on zip locked bag was, 12/22/24. During an interview on 05/06/2025 at 11:26 AM, the FSS stated the opened packages of pork sausage and salami should not have been in the cooler and refrigerator and should have been discarded by dietary staff. All staff was trained on proper storage of food upon hire and during bi-monthly training classes. Record review of facility policy 03.003 Food Storage revised 06/01/2019 revealed, e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. 3. Observation on 05/08/2025 at 10:00 AM revealed there was no entry on the Dietary Refrigerator and Freezer Temperature Record posted on the outside of reach-in cooler #1. During an interview on 05/08/2025 at 10:02 AM, the FSS stated DA B worked the early shift that morning and was responsible for recording the temperature on the log. During an interview on 05/08/2025 at 10:05 AM, DA B stated she noted the internal temperature of reach-in cooler #1 at 5:00 AM when she arrived for duty in the kitchen and it was 40 degrees F. She failed to record the temperature on the log because she was in a hurry. She understood the importance of recording the internal temperatures of the cooler on the log, especially since that particular cooler was discovered to have malfunctioned at some point in the morning of 05/06/2025. 4. Observation on 05/08/2025 at 10:20 AM in the kitchen revealed [NAME] C blended spinach in the high-speed blender for residents ordered a pureed-texture diet. Observation on 05/08/2025 at 10:25 AM revealed [NAME] C emptied the contents of the blender in a pan and took the blender and a measuring cup to the three-compartment sink. [NAME] C used a Quaternary Test Kit to test the concentration of sanitizing solution in the third sink. The test strip revealed a concentration of approximately 200 ppm, indicating an adequate concentration of chlorine to sanitize equipment and dishes. [NAME] C washed the measuring cup and blender components (blade, lid, and container) in the first sink, rinsed the cup and blender components in the second sink, and submerged the cup and blender components in the third sink containing the sanitizing solution. [NAME] C removed the measuring cup and blender components from the third sink containing the sanitizing solution immediately after submersion. [NAME] C then took all items back to the preparation table in the kitchen to puree the next menu item. During an interview on 05/08/2025 at 10:30 AM, [NAME] C stated equipment and dishes needed to be submerged in the sanitizing solution for ten seconds. During an interview on 05/08/2025 at 10:38 AM, the FSS stated equipment and dishes needed to be submerged in the sanitizing solution for 30 seconds to absorb the sanitizer. During an interview on 05/08/2025 at 2:00 PM, the administrator stated equipment and dishes needed to be submerged in the sanitizing solution for 60 seconds or per manufacturer's instructions. Record review of the label on the container of Auto-Clor System Solution QA used by the facility revealed, Directions for use: Treated surfaces must remain wet for 60 seconds. Drain thoroughly and allow to air dry before reuse. Record review of facility policy 04.005 Manual Cleaning and Sanitizing of Utensils and Portable Equipment updated 10/10/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75°F, or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75°F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. C. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 24 residents (Resident #95) reviewed for advanced directives, in that: The facility failed to ensure Resident #95's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by the physician which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #95's face sheet, dated 3/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, cognitive communication deficit, lack of coordination, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), anoxic brain damage (complete lack of oxygen to the brain resulting in death of brain cells due to oxygen deprivation), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Further review of Resident #95's face sheet revealed the resident was identified as DNR status. Record review of Resident #95's most recent quarterly MDS assessment, dated 3/2/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #95's comprehensive care plan, dated 2/2/24 revealed the resident was DNR status with interventions which included to ensure a signed DNR was in the medical record. Record review of Resident #95's Order Summary Report, dated 3/27/24 revealed the following: - DNR (Do Not Resuscitate), with order date 2/1/24 and no end date Record review of Resident #95's OOH DNR, dated 2/1/24 revealed the Physician's Statement section which required the physician's signature, printed name, date, and license number were blank. Further review of Resident #95's OOH DNR document revealed the section requiring the physician's signature indicating it was acknowledged the document had been properly completed was blank. During an interview on 3/28/24 at 8:53 a.m., ADON B revealed, the SW initiated the OOH DNR paperwork and was completed as soon as the resident admitted to the facility. ADON B revealed, DNR orders were obtained by nursing staff, but the SW was responsible for obtaining the OOH DNR. During an interview on 3/28/24 at 9:05 a.m., the DON revealed the SW was solely responsible for completing the OOH DNR paperwork and nursing staff was in charge of putting the orders into the electronic record. During an observation and interview on 3/28/24 at 9:09 a.m., the SW revealed she was responsible for ensuring the OOH DNR was completed prior to uploading the document into the electronic record for those residents who requested DNR status. The SW stated, after reviewing Resident #95's electronic record, Resident #95 is a DNR, it's a recent code status and I know that because I handled it. The SW confirmed, Resident #95's OOH DNR was missing the physician's signature, printed name, license number and date. The SW stated, it was me that uploaded Resident #95's OOH DNR document and I take full responsibility for that. The SW revealed, the OOH DNR was invalid because of the missing physician information and resulted in Resident #95 would be identified as full code status and would be going against the family's wishes. During an interview on 3/28/24 at 4:04 p.m., the Administrator revealed, the SW was responsible for ensuring the OOH DNR documents were filled out completely and correctly. The Administrator revealed, not following the OOH DNR would be going against the resident/family's wishes. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 03/25/2019, revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility policy and procedure, titled Communication of Code Status, date implemented 7/3/23 revealed in part, .It is the policy of this facility to adhere to resident's rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to complete an accurate assessment which reflected the resident's status for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. The facility failed to ensure Resident #78's diagnosis of depression was included in the residents annual MDS assessment on 01/31/2024. This failure could result in inadequate care due to an incomplete assessment of the resident's psychological condition. The findings included: Record review of Resident #78's face sheet, dated 3/28/2024, reflected a [AGE] year-old male resident initially admitted on [DATE], with a primary diagnosis of Type 2 Diabetes (the bodies inability to regulate sugars). Record review of Resident #78's Annual MDS Assessment, dated 1/31/2024, reflected that the resident did not have depression under the section Active Diagnosis. The MDS Assessment further reflected that Resident #78 was cognitively intact. Record review of Resident #78's Order Summary Report, dated 3/28/2024, reflected the resident had an order for Paroxetine 20 mg (an antidepressant used to treat depression) with a start date of 1/12/2024 for treating depression. Record review of Resident #78's Comprehensive Person-Centered Care Plan, dated 3/28/2024, reflected, [Resident #78] uses anti-depressant medication [refer to] insomnia and adjustment disorder. Interview on 3/28/2024 at 1:48 PM, RN H stated Resident #78 was taking Paroxetine for the purpose of treating depression. RN H stated that during a review of Resident #78's MDS Assessment, depression was not identified as an active diagnosis. RN H further stated that the MDS Assessment was completed by the MDS Coordinators and as a charge nurse he did not review them for their accuracy. Interview on 3/28/2024 at 2:00 PM, MDS Coordinator I stated she had reviewed and completed Resident #78's MDS Assessment on 1/12/2024 and had missed indicating Resident #78's depression due to a clerical error. MDS Coordinator I stated the risk associated with insufficiently completing resident assessments could result in residents' actual diagnosis going untreated and a change in condition being missed. Interview on 3/28/2024 at 2:07 PM, the DON stated she was not aware of Resident #78 being treated pharmaceutically for a diagnosis that Resident #78 was not assessed to have. The DON stated this practice has a risk of residents not being assessed adequately and having missed changes in condition. Record review of facility policy titled, Psychotropic Medication, dated 8/15/2022, reflected, 12. Use of psychotropic medications in specific circumstances: . B. Enduring condition (i. e., non-acute, chronic, or prolonged) I. The resident symptoms and therapeutic goals shall be clearly and specifically identified and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 1 of 22 residents (Resident #44) reviewed for care plan revisions. 1. The facility failed to ensure Resident #44's care plan was comprehensive and updated to reflect Resident #44 resided on a locked unit, listed her allergies, listed her code status, and contained interventions for her dementia diagnosis. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Record review of Resident #44's face sheet revealed a [AGE] year-old female was admitted on [DATE] with diagnosis that included dehydration, dementia, muscle weakness, generalized anxiety disorder, seizures, insomnia, and cognitive communication deficit. Record review of Resident #44's admission MDS, dated [DATE], indicated Resident #44's cognition was severely impaired. The MDS also indicated Resident #44 was receiving antianxiety medications and antidepressants. Record review of Resident #44's care plan indicated, revised on 03/26/24 did not contain any information about psychiatric diagnosis, the locked unit, allergies, code status or medications for psychiatric diagnosis. The care plan stated she had dementia but did not contain any interventions. During an interview on 03/29/24 at 2:33 p.m. the DON stated the care plan was missing information and should contain all of the residents needs so staff can provide appropriate interventions. Record review of the facility's policy, titled Comprehensive Care Plans, dated 10/24/22, stated Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #47) reviewed for incontinent care, in that: The facility failed to ensure CNA G properly cleaned Resident #47 vaginal area after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Record review of Resident #47's face sheet revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included mood disorder due to known physiological condition with major depressive like episode, bipolar disorder severe with psychotic features (a mood disorder that features extreme shifts in mood, during which psychosis can occur. People with psychosis experience a disconnected view of reality. It can involve hallucinations and delusions.), insomnia (is a common sleep disorder that can make it hard to fall asleep or stay asleep), generalized anxiety disorder, schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), mild intellectual disabilities, pseudobulbar affect (A nervous system disorder that causes inappropriate involuntary laughing and crying), schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), sleep apnea (a is a potentially serious sleep disorder in which breathing repeatedly stops and starts), and cognitive communication deficit. Resident #47 was noted as her own Responsible party. Record review of Resident #47's Annual MDS, dated [DATE], indicated Resident #47's cognition was severely impaired. The MDS also indicated Resident #47 was always incontinent for urinary and required substantial maximal assistance for toileting. Record review of Resident #47's care plan, revised on 03/27/24 revealed: The resident has bladder incontinence related to confusion with interventions to Clean peri-area with each incontinence episode. Observation on 03/27/24 04:08 p.m. revealed, while providing incontinent care for Resident #47, CNA G cleaned the vaginal area and did not separate and clean between the vaginal folds. During an interview on 03/27/2024 at 4:27 p.m. CNA G revealed she was supposed to open and clean the labia (labia minor-inner fold) and confirmed she did not. CNA G stated she was supposed to clean between the folds to remove germs and prevent infections. During an interview with the DON on 03/29/2024 at 02:31 p.m., the DON confirmed that during incontinent care the vaginal folds need to be cleaned to make sure they are properly cleaned and to remove any bacteria in the area. Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 10/22/2020. Review of facility document, titled Incontinent Care Skills Checklist, no date, revealed . For women Use ONE WIPE PER STROKE. Cleanse labia majora (outer labia.) Repeat until clean. o Cleanse each side of vulva using a different wipe for each stroke. Repeat until clean. Once outer area is satisfactorily clean, separate labia and wipe down center (labia minora) FRONT TO BACK ONLY. Repeat as needed. Record review of the facility's policy titled Perineal Care, dated 10/24/2024, stated: Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Definition Perineal care refers to the care of the external genitalia and the anal area . 11. Females: a. Assist resident in bending her knees slightly and spreading her legs. b. Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth. c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus). d. Repeat on opposite side using separate section of washcloth or new disposable wipe. e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke. f. Pat dry with towel. g. Turn the resident on her side .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to administer a psychotropic medication to treat a specific, diagnosed condition for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. Resident #78 was being administered a psychotropic medication (Paroxetine, an antidepressant used to treat depression) since 01/12/2024 without having an active and current diagnosis of depression. This failure could result in residents receiving unnecessary medications. The findings included: Record review of Resident #78's face sheet, dated 3/28/2024, reflected a [AGE] year-old male resident initially admitted on [DATE], with a primary diagnosis of Type 2 Diabetes (the bodies inability to regulate sugars). Record review of Resident #78's Annual MDS Assessment, dated 1/31/2024, reflected that the resident did not have depression, insomnia, or adjustment disorder under the section Active Diagnosis. The MDS Assessment further reflected that Resident #78 was cognitively intact. Record review of Resident #78's Order Summary Report, dated 3/28/2024, reflected the resident had an order for Paroxetine 20 mg (an antidepressant used to treat depression) with a start date of 1/12/2024 for treating depression. Record review of Resident #78's Comprehensive Person-Centered Care Plan, dated 3/28/2024, reflected, [Resident #78] uses anti-depressant medication [refer to] insomnia and adjustment disorder. Interview on 3/28/2024 at 1:48 PM, RN H stated Resident #78 was taking Paroxetine for the purpose of treating depression. RN H stated that during a review of Resident #78's MDS Assessment, depression was not identified as an active diagnosis. RN H further stated that the MDS Assessment was completed by the MDS Coordinators and as a charge nurse he did not review them for their accuracy. Interview on 3/28/2024 at 2:00 PM, MDS Coordinator I stated she had reviewed and completed Resident #78's MDS Assessment on 1/12/2024 and had missed indicating Resident #78's depression due to a clerical error. MDS Coordinator I stated the risk associated with insufficiently completing resident assessments could result in residents' actual diagnosis going untreated and a change in condition being missed. Interview on 3/28/2024 at 2:07 PM, the DON stated she was not aware of Resident #78 being treated pharmaceutically for a diagnosis that Resident #78 was not assessed to have. The DON stated this practice has a risk of residents receiving unnecessary medications. Record review of facility policy titled, Psychotropic Medication, dated 8/15/2022, reflected, 12. Use of psychotropic medications in specific circumstances: . B. Enduring condition (i. e., non-acute, chronic, or prolonged) I. The resident symptoms and therapeutic goals shall be clearly and specifically identified and documented.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication cart (100 hall and 500 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for 2 medications packages which had their medication orders changed. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Observation on 03/28/24 at 08:04 a.m. revealed a package in the 500-hall medication cart contained medication for Resident #39 with a label for Divalproex and instructions for 250 mg give 1 tab twice daily and 1 tablet of 125 mg to equal 375 mg. Observation on 03/28/24 at 08:16 a.m. revealed a package in the 100-hall medication cart contained medication for Resident #82 with a label for Divalproex and instructions for 125 mg, give 2 capsules to equal 250 mg every 12 hours. During an interview on 03/28/24 at 8:16 a.m., CMA J stated the medication package in the 500 cart for Resident #39's divalproex and the medication package in the 100 cart for Resident #82's divalproex did not match the current dosage orders. CMA J stated they usually use change order stickers to alert staff to the change, but they were out of stickers. Record review of Resident #39's physician orders, dated 03/29/24, revealed an order for Divalproex Sodium Oral Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day. Record review of Resident #82's physician orders, dated 03/29/24, revealed an order for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG Give 1 capsule by mouth every 12 hours. During an interview on 03/29/24 at 2:22 p.m. the DON stated staff should place a change in direction sticker on any medications with a change in the order. The DON stated they had run out of stickers and staff should have notified her in advance to order more prior to running out. The DON stated the stickers help to alert staff the order has been changed and to prevent them from giving the wrong dose. Record review of the facility's policy titled Labeling of Medication, dated 10/01/2019, stated: Policy All drugs and biological in the Facility are labeled in accordance with all Federal and State regulations. The Facility will comply with the standards established by the pharmacy. Only the dispensing pharmacy/registered pharmacist can modify, change, or attach prescription labels. Procedure .1. Prescription drugs will be kept in container labeled by a Pharmacist or in the original manufacturer's container. Drugs will not be transferred into any other container. Single doses prepared for immediate administration are the exception

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all dietary staff were confirmed to have appropriate competencies and skillsets to carry out the functions of food and nutrition service for 1 of 1 facility (Activity Director) reviewed for food preparation. The activity director was concluded on 03/27/2024 to be preparing food for resident use without having evidenced a food handlers' certificate to the facility. This failure could place all residents who consume food prepared during activities at increased risk of food-borne illness and not receiving adequate nutrition. Findings included: Observation on 3/27/2024 at 2:45 PM revealed 2 reach-in refrigerator/freezer combination units and a deep freezer which contained: 3 dozen eggs, 2 gallons of whole milk, 1 bottle of caramel drizzle dated 3/18/2024, 1 bottle of chocolate syrup dated 07/2023, 1 bottle of mustard dated 2/22/2024, 1 frozen non-alcoholic [NAME] mixer dated 10/21/2023, and 4 large gallon sized bag containers of unlabeled, undated meat. Additionally revealed was a lock on the 2nd reach in refrigerator/freezer combination unit as well as deep freezer. Interview on 3/27/2024 at 2:54 PM, the Activity Director stated she had been working at the facility as the Activity Director for the last two years. The Activity Director stated the deep freezer and first reach in refrigerator/freezer unit was only accessible by herself and her activity aides, and not by any of the nursing or dietary staff. The Activity Director further stated the foods stored in these refrigerators and freezers was exclusively for the purpose of preparing meals for residents and during staff community events and had done this for the last year. The Activity Director stated the locks existed due to a historic problem of facility staff stealing food stored. The Activity Director stated she prepares food from these refrigerator/freezer units during activity events and will cook raw meats such as chicken on an electric skillet that she has. The Activity Director stated that she equips a hairnet and temperature checks the meat after cooking and before serving to residents but did not obtain a food handlers' certificate. The Activity Director stated she was never required by facility administration to present evidence of a food handlers' training certificate. The Activity Director further stated she was unaware of the expired, past-dated, and unlabeled food items in the activities deep freezer and reach in refrigerator/freezer units. The Activity Director stated her activity aides audit the activities refrigerator and deep freezer once weekly but did not audit their work nor require documentation of these inspections since inspections started when she started at the facility. Observation on 3/27/2024 3:01 PM revealed an electric skillet that reaches a maximum temperature of 500 degrees Fahrenheit. Additionally revealed a storage of hairnets behind the activity director's desk. Record review of the staff certifications obtained by facility kitchen staff reflected that the AD did not have a food handlers' certificate. Interview on 3/28/2024 at 11:32 AM, the Administrator stated he was aware of the Activity Director preparing food for residents' consumption during activities. The Administrator further stated he did not request the activity director to complete a food handlers' certificate due to him believing she did not require one based on her not being a dietary staff member. The Administrator stated the potential risk associated with staff preparing food without first being food handler trained included a potential for food-borne illness. Record review of facility policy titled, Food Preparation and Handling, dated 6/1/2019, reflected to ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. Record review of facility policy titled, Food Storage, dated 6/1/2019, reflected, date, label, and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safely for 1 of 1 facility reviewed for kitchen sanitation. The facility failed to discard all past dated food in the activities refrigerators, and ensure all food items contained a label in the activities freezer and kitchen Freezer #5 as observed on 03/27/2024. This failure could place all residents who consume food prepared by facility staff at increased risk of food-borne illness and not receiving adequate nutrition. The findings included: Observation on 3/27/2024 at 10:45 AM revealed reach-in freezer unit #5 to contain the following items: 1 bag of diced meat, unlabeled; 1 bag of meat tenders, unlabeled; 1 bag of meat balls, unlabeled; 3 bags of meat cutlets, unlabeled. Interview on 03/27/2024 at 11:25 AM, the DM stated she was unaware of the unlabeled food items observed within reach-in freezer unit #5 and stated it was her expectation that all items in her kitchen have a label but stated the cooks likely missed this item in the last two days and forgot to place a label. The DM stated the nutrition rooms in the facility are not a part of the dietary departments responsibilities and are inspected and audited by the nursing department. Observation on 3/27/2024 at 2:45 PM revealed 2 reach-in refrigerator/freezer combination units and a deep freezer which contained: 3 dozen eggs, 2 gallons of whole milk, 1 bottle of caramel drizzle dated best by 3/18/2024, 1 bottle of chocolate syrup dated best by 07/2023, 1 bottle of mustard dated use by 2/22/2024, 1 frozen non-alcoholic [NAME] mixer dated use by 10/21/2023, and 4 large gallon sized bag containers of unlabeled meat. Additionally revealed there were locks on the 2nd reach in refrigerator/freezer combination unit and deep freezer. Interview on 3/27/2024 at 2:54 PM, the Activity Director stated the deep freezer and first reach in refrigerator/freezer unit was only accessible by herself and her activity aides, and not by any of the nursing or dietary staff. The Activity Director further stated the foods stored in these refrigerators and freezers was exclusively for the purpose of preparing meals for residents and during staff community events. The Activity Director stated the locks existed due to a historic problem of facility staff stealing food stores. The Activity Director stated she prepares food from these refrigerator/freezer units during activity events and will cook raw meats such as chicken on an electric skillet that she has. The Activity Director stated that she equips a hairnet and temperature checks the meat after cooking and before serving to residents but did not obtain a food handlers' certificate. The Activity Director stated she was never required by facility administration to present evidence of a food handlers' training certificate. The Activity Director further stated she was unaware of the expired, past-dated, and unlabeled food items in the activities deep freezer and reach in refrigerator/freezer units. The Activity Director stated her activity aides audit the activities refrigerator and deep freezer once weekly but did not audit their work nor require documentation of these inspections since inspections started when she started at the facility. Record review of the facility food handling certifications obtained by the facility kitchen staff on 03/27/2024 reflected that the AD did not have a food handlers' certificate. Interview on 3/28/2024 at 11:32 AM, the Administrator stated he was not aware of the unlabeled or past dated items stored in the kitchen or nutrition room. The Administrator stated it was his expectation that all food in the facility be labeled and discarded once the printed date was past. The Administrator stated the potential risk associated with past dated and unlabeled items being retained included a potential for food-borne illness. Record review of facility policy titled, Food Preparation and Handling, dated 6/1/2019, reflected to ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. Record review of facility policy titled, Food Storage, dated 6/1/2019, reflected, date, label, and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 22 residents (Resident #44, Resident #47 and Resident #95) reviewed for resident rights. 1. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #44 Representative prior to admitting to a locked unit. 2. The facility failed to find and obtain informed consent from Reasonable and Responsible party for, Resident #47, who did not have the cognitive ability to make medical decisions, who was taking medications for psychiatric diagnosis, and resided in the locked unit. 3. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #95's Representative prior to admitting to a locked unit. This failure could place residents at risk of being unnecessarily confined to a locked unit and receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include: 1. Record review of Record review of Resident #44's face sheet revealed a [AGE] year-old female was admitted on [DATE] with diagnosis that included dehydration, dementia, muscle weakness, generalized anxiety disorder, seizures, insomnia, and cognitive communication deficit. The face sheet also revealed Resident #44 had a Responsible Party that was a family member. Record review of Resident #44's admission MDS, dated [DATE], indicated Resident #44's cognition was severely impaired. The MDS also indicated Resident #44 was receiving antianxiety medications and antidepressants. Record review of Resident #44's care plan, revised on 03/26/24 did not contain any information about psychiatric diagnosis, the locked unit, or medications for psychiatric diagnosis. Record review of Resident #44's physician orders, dated 03/27/24 revealed orders for: -ADMIT TO GENERATIONS UNIT (same as locked unit) DUE TO RESIDENT DOES BETTER IN STRUCTURED ENVIRONMENT R/T DX DEMENTIA, order date 02/23/24. Record review of Resident #44's clinical records revealed the facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #44's Representative prior to admission to a locked unit. During an interview on 03/28/24 at 1:50 p.m. Medical records clerk stated she was behind on uploading consent into the computer. The clerk looked in her stack of papers and could not find a consent for Resident #44 to reside in the locked unit. During an interview on 03/29/24 at 2:33 p.m. the DON stated the facility requires a consent form be signed by the RP for all residents on the locked unit. 2. Record review of Record review of Resident #47's face sheet revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included mood disorder due to known physiological condition with major depressive like episode, bipolar disorder severe with psychotic features (a mood disorder that features extreme shifts in mood, during which psychosis can occur. People with psychosis experience a disconnected view of reality. It can involve hallucinations and delusions.), insomnia (is a common sleep disorder that can make it hard to fall asleep or stay asleep), generalized anxiety disorder, schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), mild intellectual disabilities, pseudobulbar affect (A nervous system disorder that causes inappropriate involuntary laughing and crying), schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), sleep apnea (a is a potentially serious sleep disorder in which breathing repeatedly stops and starts), and cognitive communication deficit. Resident #47 was noted as the Responsible party. No emergency contact was listed. Record review of Resident #47's Annual MDS, dated [DATE], indicated Resident #47's cognition was severely impaired. The MDS also indicated Resident #47 was receiving antipsychotic medications and antianxiety medications. Record review of Resident #47's care plan indicated, revised on 03/27/24 revealed: - Resident #47 has frequent episodes of crying then laughing r/t DX (diagnosis) of PBA (pseudobulbar affect). In addition, she is easily agitated r/t multiple psych DX of Bipolar, Dementia and Psychosis. Risk for complications. Interventions included administer medications per MD orders, monitor for side effects, and refer to psych as needed. - Resident #47 has impaired cognitive function r/t DX of dementia. Risk for complications. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness. Cue, reorient and supervise as needed. - Resident #47 has thought process alteration r/t psychological causes aeb res has dx: schizophrenia and schizoaffective d/o (disorder) and takes routine antipsychotic medication. - Resident #47 has a DX of Anxiety. Risk for complications. Interventions included Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Record review of Resident #47's physician orders, dated 03/28/24 revealed orders for: - ADMIT TO GENERATIONS UNIT DUE TO RESIDENT DOES BETTER IN STRUCTURED ENVIRONMENT RELATED TO DX SCHIZOPHRENIA, order date 05/14/2018. - Ativan Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth three times a day for ANXIETY GIVE 1 TAB = 1MG PO TID, order date 05/18/23. - Nuedexta Oral Capsule 20-10 MG (Dextromethorphan HBr-Quinidine Sulfate) Give 1 capsule by mouth every 12 hours for PBA GIVE ONE CAPSULE = 20-10MG PO Q12H, order date of 06/09/23. - Exelon Patch 24 Hour 4.6 MG/24HR (Rivastigmine) Apply 1 patch transdermally one time a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE REMOVE PATCH BEFORE APPLYING AND ROTATE SITES and remove per schedule, order date 08/24/17. During an interview on 03/29/24 at 10:13 a.m. Resident #47 pointed to the nurse when asked if she knew what medications she takes. Resident #47 said she did not sign any medication forms and did not know what medications she took. Resident #47 said no one was in charge of her. During an interview on 03/29/24 at 10:21 a.m. LVN D stated she has worked on the locked unit for a while. LVN D stated Resident #47 resided on the unit because she had wandering and exit seeking behaviors. During an interview on 03/29/24 at 10:38 a.m. the SW stated Resident #47 was her own representative. The SW stated Resident #47 resided in the locked unit to avoid overstimulation. The SW stated she did not know who the person listed as guardian on the consent form for the lock unit was. The SW stated she had never know Resident #47 to have a guardian or have any family visitors. The SW stated the nursing staff fills out the medication consent forms. The SW stated she thinks Resident #47 can make her own decisions and she thinks she knows what you are telling her. The SW stated their legal department would ask them to find someone from the community to sign consent of behalf of residents who cannot make their own medical decisions. The SW stated they had attempted this but did not document it anywhere. During an interview on 03/29/24 at 10:43 a.m. ADON A stated Resident #47 was on the locked unit due to exit seeking behavior. ADON A explained she and another nurse signed a medication consent form on the line for the resident representative because the resident verbally agreed but did not want to sign the document. ADON A stated Resident #47 was her own representative and had never seen anyone else since she was admitted being involved in her care. ADON A stated if they encounter a resident, who was not able to make medical decisions for themselves, they could ask the SW to reach out to the family or an RP but in this case she did not because she knew the resident's history. During an interview on 03/29/24 at 12:38 p.m. MDS E stated Resident #47 has always been her own RP and she has never known anyone else to be involved in her care. MDS E stated Resident #47 multiple psychiatric issues and over the years her cognition has lessened by about 40%. During an interview on 03/29/24 at 12:54 p.m. RN F stated Resident #47 was initially on the locked unit due to exit seeking behavior but more recently was there because of her behaviors and did not exit seek as much anymore. RN F Resident #47 could voice her needs well. RN F said her and another nurse signed the consent form on the Resident Representative line as a way to witness the Resident was informed of the medication change and she verbally agreed to it. RN F stated Resident #47 did not know what medication she took but staff would explain what the medication was for and Resident #47 would say OK. RN F said Resident #47 did not have any memory issues. RN F said she was not familiar with a BIMS score and did not know what Resident #47 BIMS score was. During an interview on 03/29/24 at 2:37 p.m. the DON stated Resident #47 was on the locked unit due to wandering and exit seeking behaviors. The DON stated she will still wander if she was in her wheelchair, and she also gets overstimulated with large groups. The DON stated she has never known anyone else to be involved in her care. The DON stated Resident #47 can give her verbal consent and two nurses witness this by signing on the resident representative line on the consent form. The DON stated Resident #47 had dementia but she was not incompetent and can make decisions. The DON stated a resident on a locked unit can sign their own consent for medications and consent to be on the locked unit. The DON stated they reached out to the ombudsman on 03/29/24 for help with resources for resident who need an RP and was given information. The DON stated if Resident #47 had an RP they would have them sign the consent but because she did not have a RP they had residents or staff sign them. Record review of a document titled Consent for the Generations Unit Placement, dated 08/01/2017, revealed a printed name and the word Guardian in parenthesis. This would indicate that this person consented to Resident #47 being on the locked unit and would have been her guardian. Record review of Resident #47's medical records revealed no guardian, emergency contact, or resident representatives was ever listed for Resident #47. Record review of document titled Informed consent for Psychoactive Medications, dated 06/08/23, revealed a section of the document showed the Resident name was printed on the document and there was no signature on the line for the Residents signature. Another section stated Person authorized to consent on behalf of the resident. The Resident's name was printed on the line labeled Responsible Party & Relationship. Two staff signatures were on the line labeled Responsible Party Signature. 3. Record review of Resident #95's face sheet, dated 3/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, cognitive communication deficit, lack of coordination, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), anoxic brain damage (complete lack of oxygen to the brain resulting in death of brain cells due to oxygen deprivation), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #95's most recent quarterly MDS assessment, dated 3/2/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #95's comprehensive care plan, revision date 10/26/23 revealed the resident had impaired cognitive function/dementia and resided in the Generations Unit (secure unit). Record review of Resident #95's Order Summary Report, dated 3/27/24, revealed the following: - Admit to Generations Unit due to resident does better in a structured environment due to dementia, with order date 10/4/23 and no end date Observation and interview on 3/26/24 at 12:07 p.m., revealed Resident #95 sitting up in bed eating lunch in the secure unit. Resident #95 was unable to determine how long he had been living in the secure unit. During an observation and interview on 3/28/24 at 5:14 p.m., ADON A revealed Resident #95 had been living in the secure unit since he was admitted to the facility on [DATE]. ADON A revealed Resident #95 was placed in the secure unit due to wandering and the need for a structured environment. ADON A revealed, in order for a resident to reside on the secure unit, a consent and a physician's order needed to be obtained. ADON A revealed she could not find a written consent in Resident #95's electronic record for Resident #95 to be in the secure unit. ADON A revealed she had obtained the order for Resident #95 to reside in the secure unit but had delegated obtaining the consent to a charge nurse. ADON A revealed she could not remember which charge nurse she had told to obtain the consent. ADON A revealed, once the consent was obtained, the document would have been uploaded into the resident's electronic record. During an interview on 3/28/24 at 5:27 p.m., the Medical Records Clerk revealed she was responsible for recovering any resident documents that needed to be uploaded into the resident's electronic record. The Medical Records Clerk revealed, any documents that needed to be uploaded into the electronic record were placed in a basket at the nurse's station. The Medical Records Clerk revealed she made daily rounds to the nurse's station to retrieve those records. The Medical Records Clerk revealed she made it a point to upload consents into the record as soon as they became available to her. The Medical Records Clerk revealed she was at least two months behind in her filing, dating back to January 2024. During an interview on 3/28/24 at 5:35 p.m., the DON revealed, a consent and a physician's order needed to be obtained before a resident was allowed to reside in the secure unit. The DON revealed, a telephone consent could be obtained and any consent, including consent to the secure unit, could be secure by the ADON or the charge nurse. The DON revealed, once consent to the secure unit was obtained, it was uploaded into the resident's electronic record. The DON revealed, Resident #95's family requested the resident reside in the secure unit and the consent should have been in the record. The DON revealed, it was their policy to obtain a consent for Resident #95 to reside in the secure unit because they obtained consents for all the other residents in the secure unit. A policy for Resident Rights was requested and not provided.

Based on interview and record review the facility failed to ensure 1(NA A) of 1 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA G was a certified nursing aide (CNA) within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known. Findings included: Record review of the facility staff roster provided upon entrance revealed: Nurses' Aide G was listed as a Nursing Assistant with an 04/24/2023 hire date. During an interview with HR on 03/29/2024 at 12:15 p.m., HR stated Nurses' Aide G did have a start date of employment at the facility on 04/24/2023 and she did not know if he had taken any type of CNA test for certification but did know Nurses' Aide G was listed on the staff list. During an interview with LVN C on 03/29/2024 at 1:15 pm, she stated that the nurse aide had completed his skills checklist, but she did not know why he had not taken the certification test. During an interview with the DON on 03/29/2024 at 1:18 p.m., she stated that she did not know why the nurse aide had not taken his certification test. She stated that they had been trying to contact the nurse aide, but he was not answering his phone. Nursing facilities must ensure that their temporary nurse aides register for testing and maintain documentation of registration and test dates on file. Any existing temporary nurse aides not certified before May 1, 2024, must complete a traditional Nurse Aide Training and Competency Evaluation Program (NATCEP) to be approved to take an exam and become certified.

Based on observations, interview and record reviews, the facility failed to ensure the resident environment was as free of accident and hazards as possible for 3 of 5 halls (100 hall, 200 hall, and 300 hall) reviewed for accident and hazards, in that: 1. The facility failed to prevent a container of unsecured bleach wipes from being found on the 100 hallway. 2. The facility failed to ensure the door to the utility area was locked and the room housing hazardous material was locked on the 200 hallway. 3. The facility failed to ensure the supply room containing small objects and food items was unlocked on the 300 hallway which was a secure unit for residents with cognitive concerns. These deficient practices could result in residents coming into contact with dangerous materials which could place them at risk of injury or death. The findings were: 1. Observation on 02/08/2024 at 1:32 p.m. of the incontinent care cart on 100 hallway revealed a container of bleach wipes labeled, Danger and Keep Out of Reach of Children. During an interview with CNA A on 02/08/2024 at 1:35 p.m., CNA A stated, I haven't been told if it is or isn't allowed to be stored there and confirmed that the container of bleach wipes was usually stored on the incontinent care cart. During an interview with LVN B on 02/08/2024 at 1:50 p.m., LVN B stated the container of bleach wipes was usually stored on the incontinent care cart and when asked if a resident could come into contact with the wipes and potentially harm themselves, LVN B confirmed it was possible and stated, I had not thought of that. 2. Observation on 02/08/2024 at 2:00 p.m., revealed the utility area was unlocked and contained a room marked hazardous material, which was also unlocked, on the facility's 200 hallway. Further observation revealed the room did not contain hazardous material at the time of the observation, but did contain supplies to store hazardous material. During an interview with RN D on 02/08/2024 at 2:00 p.m., RN D confirmed the utility area was unlocked and contained a room housing hazardous material, which was also unlocked on the facility's 200 hallway. RN D confirmed residents, staff, or visitors could come into contact with potentially harmful materials via the unlocked doors and unsecured hazardous materials storage area. 3. Observation on 02/08/2024 at 1:55 p.m. revealed the supply room containing small objects (gambling chips) and food items (potato chips and salsa) was unlocked on the facility's 300 hallway which was a secure unit for residents with memory concerns. During an interview with LVN C on 02/08/2024 at 1:56 p.m., LVN C confirmed the supply room containing small objects and food items was unlocked and confirmed it contained small objects and food items, including potato chips and salsa, which could potentially be choking hazards for the residents of the secure memory care hallway. Record review of the facility clinical records system revealed that twenty-five residents lived in the 300-hallway secure unit and fourteen of those residents required a mechanical soft or puree diet to prevent aspiration and/or chocking. During a joint interview with the Administrator and DON on 02/08/2024 at 4:30 p.m., the Administrator and DON confirmed that the above listed items could potentially be dangerous for residents, staff, and/or visitors, such items should be secured, and all staff were responsible for securing potentially hazardous items. The Administrator stated that the facility did not have a policy regarding physical environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 5 Residents (Resident #27) reviewed for quality of care: The facility failed to ensure Resident #27 was wearing compression stockings (a specialized hosiery designed to help prevent the occurrence of and guard against further progression of venous disorders such as swelling/inflammation and blood clots) as ordered by the physician. This failure could place residents of risk for not receiving appropriate care and treatment. The findings were: Record review of Resident #27's face sheet, dated 1/25/23 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included dementia, muscle wasting and atrophy (wasting [thinning] or loss of muscle tissue), diabetes and heart failure. Record review of Resident #27's most recent quarterly MDS assessment, dated 12/30/22 revealed the resident was severely cognitively impaired for daily decision-making skills and required one-person physical assist with bed mobility and transfers. Record review of Resident #27's comprehensive person-centered care plan, revision date 1/4/23 revealed the resident had decreased cardiac output related to congestive heart failure with interventions that included, knee high compression stockings to bilateral lower extremities as ordered. Record review of Resident #27's Order Summary Report, dated 1/25/23 revealed the following order, KNEE HIGH COMPRESSION STOCKINGS TO BILATERAL LOWER EXTREMITIES. TO BE APPLIED AT 8am **MAY REMOVE FOR HYGIENE PURPOSES** one time a day for CHF (congestive heart failure), with start date 10/16/21 and no end date. Record review of Resident #27's Treatment Administration Record for January 2023 revealed documentation entered daily from 1/1/23 to 1/24/23 for, KNEE HIGH COMPRESSION STOCKINGS TO BILATERAL LOWER EXTREMITIES. TO BE APPLIED AT 8AM ***MAY REMOVE FOR HYGIENE PURPOSES** one time a day for CHF (congestive heart failure with start date 10/16/21 and no end date. During an observation and interview on 1/24/23 at 10:03 a.m., Resident #27 stated he was supposed to use compression socks but was unable to explain why he needed the compression socks or where they were. Resident #27 was observed with discoloration and swelling to the lower extremities and wearing ankle length light blue socks and no compression stockings. Observations on 1/25/23 at 2:56 p.m. and 4:40 p.m. revealed Resident #27 wearing ankle length light blue socks and no compression stockings. Observations on 1/26/23 at 7:45 a.m. and 12:32 p.m. revealed Resident #27 wearing ankle length gray socks and no compression stockings. During an interview on 1/26/23 at 1:18 p.m., LVN A stated Resident #27 was supposed to be wearing compression stockings. LVN A stated she was responsible for ensuring the resident was wearing the compression stockings because she had been signing off on the MAR (medication administration record) the resident was wearing the compression stockings per the physician's orders. LVN A stated the CNA was tasked with physically applying the compression stockings to the resident. LVN A stated, Resident #27 does not refuse, he really does not refuse anything. LVN A stated, if the resident was not wearing the compression stockings consistently as ordered, the resident could decline and the disease process of blood flow would be worse. LVN A stated the CNA was supposed to inform her the compression stockings were applied to the resident but could not recall which CNA had told her the compression stockings had been applied to Resident #27. During an observation and interview on 1/26/23 at 1:36 p.m., CNA B stated Resident #27 was supposed to be wearing compression stockings and the CNAs were responsible for ensuring the resident was wearing the compression stockings. CNA B stated Resident #27 was provided with about 7 pairs of compression stockings and if the resident needed more, they could be obtained from central supply. CNA B stated she had showered Resident #27 earlier in the morning and was supposed to put the compression stockings on the resident but got side-tracked and forgot. CNA B stated, Resident #27 was supposed to wear the compression stockings because the resident's legs swell and the stockings help to keep the swelling down. During an interview on 1/26/23 at 12:35 p.m., the DON stated it was the expectation of the nursing staff to ensure a resident who was prescribed compression stockings was provided with the compression stockings because the nurse was documenting on the medication administration record the compression stockings were being used. The DON stated, the CNA would make sure the compression stockings were applied and the nursing staff would ensure the compression stockings were being worn. The DON stated, if residents prescribed compression stockings were not utilized it could result in the resident experiencing swelling and discomfort. At the time of the exit on 1/27/23 at 12:35 p.m., additional policies for the use of adaptive equipment/compression stockings were not provided from the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to effectively 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 3 of 6 residents (Resident #36, #95 and #15) reviewed for infection control, in that: 1. CMA C (Certified Medication Aide) I did not ensure proper disinfection of multi-use equipment (electronic wrist blood pressure cuff) after it was used to obtain Resident #36's blood pressure and before it was used to obtain Resident #95's blood pressure. 2. CMA D attempted to retrieve a pill dropped on the medication cart counter prescribed to Resident #15 with his right ungloved hand. This failure could result in the spread of infections in the facility. The findings were: 1. a. Record review of Resident #36's face sheet, dated 1/26/23 revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes, acquired absence of left leg below knee, acquired absence of right leg above knee, hypertension (high blood pressure) and muscle weakness. Record review of Resident #36's Order Summary Report, dated 1/26/23 revealed orders for the following: -amlodipine besylate tablet 5 mg by mouth every day for hypertension and hold instructions for systolic (measure of the pressure in the arteries when the heart beats) blood pressure less than 100. The amlodipine besylate had an order date of 10/7/21 and no end date. -Losartan potassium tablet 50 mg by mouth one time a day for hypertension and hold instructions if systolic blood pressure less than 110 or diastolic (the amount of pressure in the arteries between heart beats) blood pressure less than 60. The Losartan potassium had an order date of 10/6/21 and no end date. b. Record review of Resident #95's face sheet, dated 1/26/23 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included dementia, seizures and hypertension. Record review of Resident #95's Order Summary Report, dated 1/26/23 revealed orders for the following: -Lisinopril 5 mg by mouth one time a day for hypertension and hold instructions for systolic blood pressure less than 110. The Lisinopril had an order date of 9/5/22 and no end date. Observation on 1/25/23 beginning at 8:40 a.m., during the medication pass, CMA C obtained Resident #36's blood pressure with an electronic wrist blood pressure cuff. CMA C then took the electronic wrist blood pressure cuff, placed it in a plastic container and stored it in the medication cart without disinfecting it. CMA C then withdrew the same electronic wrist blood pressure cuff from the medication cart, took it out of the plastic container without disinfecting it and obtained Resident #95's blood pressure. CMA C then took the electronic wrist blood pressure cuff, placed it in the plastic container and stored it in the medication cart without disinfecting it. During an interview on 1/25/23 at 9:03 a.m., CMA C stated she used the same electronic wrist blood pressure cuff throughout the shift. CMA C stated she had forgotten to disinfect the electronic wrist blood pressure cuff and was supposed to disinfect it before and after use. CMA C stated, not disinfecting the electronic wrist blood pressure cuff between residents was considered cross contamination and could result in illness being spread from resident to resident. CMA C stated she had received in-service training on infection control often and as recent as two weeks ago. During an interview on 1/27/23 at 7:54 a.m., the DON stated it was the expectation of the staff to disinfect resident equipment, including a blood pressure cuff because it was considered cross contamination and could result in passing pathogens from one resident to the other. The resident could become infected and make them sick. 2. Record review of Resident #15's face sheet, dated 1/26/23 revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, chronic pain syndrome, Vitamin D deficiency, bipolar II disorder (disorder characterized by depressive and hypomanic episodes) and sexual dysfunction not due to a substance or known physiological condition. Record review of Resident #15's Order Summary Report, dated 1/26/23 revealed the following orders: -Depakote 500 mg two times a day related to BIPOLAR II DISORDER, order date 11/15/22 and no end date. -Paxil 30 mg one time a day related to BIPOLAR II DISORDER, order date 1/20/23 and no end date. -Provera 30 mg one time a day for inappropriate sexual behavior, order date 7/29/17 and no end date. -Vitamin D-3 25 mcg (1000 units) one time a day for Vitamin D deficiency, order date 10/28/22 and no end date. Observation on 1/26/23 at 7:58 a.m. during the medication pass revealed CMA D prepared medications intended for Resident #15. CMA D placed 3 pills into a medication cup and then took a fourth medication and dropped it on the medication cart counter. CMA D then attempted to pick up the pill from the medication cart counter with his right ungloved hand. CMA D stopped, took an empty medication cup and scooped up the pill dropped on the medication cart counter and placed it in the medication cup with the other 3 pills. CMA D then dispensed the medication to Resident #15. During an interview on 1/26/23 at 8:05 a.m., CMA D stated, the pill dropped on the medication cart counter was identified as Resident #15's Provera 30 mg. CMA D stated, if the pill had fallen on the floor, then it would have been discarded, but since it fell on the medication cart counter it was ok to dispense to the resident. CMA D then stated, he should not have tried to pick up the pill with his bare hand because it was considered cross contamination and could result in the resident becoming ill. During an interview on 1/27/23 at 7:54 a.m., the DON stated, medications dropped on the floor or on the medication cart counter should be discarded and the medication would need to be replaced. The DON stated, it is an infection control issue and cross contamination since the pill CMA D touched was placed in the same cup with the other pills. The DON stated staff were in-serviced frequently on infection control. At the time of exit on 1/27/23 at 12:35 p.m., additional policies for infection control had not been received from the DON.