**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #8) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #8 was free of abuse on 03/20/25 when Resident #8 was hit on the arm and shoulder by CNA C. This failure was determined to be Past Non-Compliance (PNC). The non-compliance began on 03/20/25 and ended on 03/21/25. The noncompliance was corrected by the facility before the survey began on 03/25/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: Review of Resident #8's face sheet revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with a most recent admission date of 01/06/2025. He had diagnoses which included moderate dementia with behavioral disturbances, schizoaffective disorder, severe manic bipolar disorder with psychotic features, generalized anxiety disorder, intermittent explosive, mood disorder, psychotic disorder with delusions, contracture of muscle at multiple sites, and limitation of activities due to disability. Review of Resident #8's care plan, most recent revision date of 03/06/2025, revealed the following: Problem: The resident is physically aggressive r/t dementia, ineffective coping skills, poor impulse control. Goal: The resident will verbalize understanding of need to control abusive behavior through the review date. Approach: Analyze key times, places, circumstances, triggers, and what deescalates behavior and document; Assess resident's coping skills and support system; Assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation; Give the resident as many choices as possible about care and activities; Provide positive feedback for good behavior and emphasize the positive aspects of compliance; Psychiatric/Psychogeriatric consult as indicated; When the resident becomes agitated, intervene before situation escalates, guide away from the source of distress, engage calmly in conversation and if response is aggressive, staff to walk calmly away and approach later. Problem: Resident has a behavior problem r/t low frustration level and delusional thinking. Goal: The resident will have no evidence of behavior problems by review date. Approach: Anticipate and meet the resident's needs; Caregivers to provide opportunity for positive interaction, attention, stop and talk with him when passing by. Review of Resident #8's Annual MDS assessment dated [DATE] revealed the following: Section C - Cognitive Patterns: Resident #8 had a BIMS score of 8 indicating moderate cognitive impairment. Section E - Behavior: Resident #8 had no reported behaviors during the look back period. Section GG - Functional Abilities: Resident #8 had lower extremity functional limitations in range of motion and required a wheelchair for mobility. He required substantial to moderate assistance for ADLs. During observation and attempted interview on 03/25/25 at 12:38 pm, Resident #8 was observed sitting in a wheelchair in the secured unit dayroom. When this surveyor introduced herself and asked his name, Resident #8 laughed, refused to answer questions, and began to wheel himself away from the surveyor. Resident #8 continued to refuse to speak to surveyor during attempted follow-up interviews on 03/26/25 and 03/27/25. Review of the Provider Investigation Report dated 03/27/25 revealed the following: The incident was reported to facility management (DON and ADON) on 03/20/25 at 5:20 pm by CNA A. The description of the allegation revealed: Resident was combative when being changed and hit CNA C, CNA C was trying to control the situation and ended up hitting the resident's shoulder area. Resident #8 was assessed by the ADON on 03/20/25 at 5:40 pm with no injuries noted. The incident was reported to the Texas CII (Complaint and Incident Intake) department on 03/20/25 at 8:10 pm. Provider response revealed: CNA C was suspended until further notice. After our investigation CNA C will be terminated. Safe surveys were done. Also in-services were done for staff on abuse and neglect, deescalating behaviors, pain, dementia Alzheimer's disease, cognitive impairment, reporting behavior changes, chain of command. The physician/medical director and Ombudsman were notified of the incident. The facility investigation findings confirmed the allegation. In an interview on 03/27/25 at 12:00 p.m., with the DON and the ADON, the ADON stated that the incident occurred on 3/20/25 and was immediately reported to the DON and herself (the ADON) by CNA A (witness to the incident). The DON stated that Resident #8 was assessed by herself and the ADON and no injuries were noted. The ADON stated she spoke to Resident #8 about the incident, and he had no memory of being hit by CNA C. The DON stated that CNA C was suspended on 03/20/25 until further notice pending the facility's investigation and had been terminated for confirmed abuse. Both the DON and the ADON stated that they spoke to CNA C and she admitted to hitting Resident #8 after he struck her in the face and neck and both described CNA C's explanation for her actions as being reflexive and not intentionally abusive. The DON stated that CNA C was terminated because the facility did not tolerate abuse regardless of the situation. The ADON stated that safe surveys were done for 37out of 47 residents in the facility and there were no additional complaints of abusive treatment reported. In an interview on 03/27/25 at 3:20 p.m., the Administrator stated that his investigation into the incident between Resident #8 and CNA C revealed that abuse did occur. He stated that CNA C was immediately removed from the facility and suspended from duty pending the outcome of his investigation. He stated that CNA C admitted to hitting Resident #8 to him (Administrator) as well as the DON and the ADON, and because of her admission and the presence of a witness to the incident, CNA C had been terminated. The Administrator stated, I do not want someone that will hit a resident working in my building no matter the situation. He stated that all facility staff had been in-serviced on abuse and neglect, deescalating behaviors, dementia/Alzheimer's, cognitive impairment, reporting behavior changes, and chain of command. The Administrator stated that safe surveys had been completed for residents throughout the facility and no further issues were identified. In a telephone interview on 03/28/25 at 2:20 p.m., CNA C was interviewed regarding the incident that occurred at the facility on 03/20/25. CNA C stated she was working in another hall when CNA A asked her to come and help providing incontinent care for Resident #8 in the secure unit as he was being combative. CNA C stated when she and CNA A were providing care to Resident #8, he was combative and yelling. CNA C stated that when she and CNA A helped the resident to sit back down in his wheelchair, Resident #8 hit her in the neck and face area. CNA C stated she unintentionally hit Resident #8 on his arm and shoulder while trying to block the resident from hitting her again because he continued to be physically aggressive and was trying to hit her again. CNA C stated she did not hit the resident with a bad intent and that she felt very bad for what had happened. CNA C stated she had been suspended the day of the incident (03/20/25) and then terminated for abuse. CNA C stated she had worked with Resident #8 before and when he was in a bad mood, she would just leave him alone when he refused personal care and would try again later when he was calmer. CNA C stated she had been working at the facility off and on for 10 years and had not had any incidents like that before. CNA C was asked about the types of abuse that could potentially occur at the facility and she mentioned physical abuse, mental abuse, emotional abuse, and verbal abuse. CNA C stated she felt that she had not been abusive toward Resident #8 as she had not intentionally hit him. In a telephone interview on 03/28/25 at 02:34 PM, CNA A was interviewed regarding the incident that occurred at the facility on 03/20/25 involving Resident #8 and CNA C. CNA A stated she was working in the secure unit and called CNA C to come help her provide incontinent care for Resident #8 because he was being combative. CNA A stated she and CNA C changed Resident #8 in the shower room as they would have him stand up by holding to the grab bar and then change his brief. CNA A stated as Resident #8 was sitting back down on his wheelchair he struck CNA C somewhere on her face or neck area. CNA A stated CNA C then struck the resident back and hit him on his shoulder area and that CNA C had said Oh my God I can't believe I did that. CNA A stated it did not seem like CNA C struck the resident out of anger but more of a reaction that was unintentional. CNA A stated Resident #8 did not say anything about the incident and did not appear to be in any distress after CNA C struck him. CNA A stated she had worked with CNA C before and had not noticed her being abusive to residents prior to that incident. CNA A was asked about the types of abuse that could occur at the facility and she mentioned verbal abuse, physical abuse, emotional abuse, psychological abuse, and mental abuse. CNA A stated she was not sure if CNA C had been intentionally abusive to Resident #8, but she had reported the incident right away to the DON. In a follow-up interview on 03/28/25 at 03:12 PM, the DON stated that she had assessed Resident #8 with the ADON after the incident was reported. The DON stated the resident did not mention anything about being hit by someone when she asked him. The DON stated Resident #8 was not in any distress during the assessment and the resident just smiled when he was asked what or if anything had happened. The DON stated they had immediately suspended CNA C then later terminated her. The DON stated CNA C did not have a history of being accused of resident abuse. Review of facility in-services on 03/27/25 at 6:00 PM, revealed the most recent staff in-service provided for abuse and neglect was on 01/30/25 at 2:15 PM. CNA C's signature was noted on the in-service sign-in sheet indicating she had been given training related to abuse prior to the incident. Review of facility policy titled Abuse Prevention Program revised August 2006 revealed, in part: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Our abuse prevention program provides policies and procedures that govern, as a minimum: . Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Review of facility policy titled Abuse and Neglect - Clinical Protocol revised April 2013 revealed, in part: The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed, in part: The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff; other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual.Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities; provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; instruct staff regarding appropriate ways to address interpersonal conflicts; and help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.Investigate and report any allegations within timeframes required by federal requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who receive medication or feeding through a gastrostomy tube receive the appropriate treatment to prevent complications for 1 of 1 resident (Resident 44) reviewed for percutaneous endoscopic gastrostomy (PEG) feeding tube ( A PEG is a tube that is inserted through the abdominal wall and into the stomach and used to administer nutrition). The facility failed to ensure CNA A did not lower the head of Resident #44's bed flat while the PEG tube feeding pump was still infusing the formula, during personal care. This failure could place residents of aspiration. The findings: Record review of Resident #44's electronic face sheet dated 03/27/2025 indicated he was admitted to the facility on [DATE] with diagnoses of stroke, muscle weakness and dysphagia (difficulty swallowing). He was [AGE] years of age. Record review of Resident #44's care plan revised 03/26/25 indicated in part: Problem: Dependent on tube feeding for nutrition and hydration, with potential for complications, side effects. GOAL: Resident will be maintained in a clean, dry state and prevent complication of incontinence by checking and changing resident at regular intervals x 90 days. Approaches: Keep head of bed elevated while feeding is infusing. Record review of Resident #44's quarterly MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = severely impaired. Nutritional Approaches = Feeding tube. Record review of Resident #44's Physicians Orders dated 03/2025 documented in part: Elevate Head Of Bed at least 30 degrees while administering formula/water/medications and for at least 30 minutes following administration. Order start date: 08/30/2024. During an observation on 03/25/25 at 11:20 AM, CNA A performed incontinent care for Resident #44. CNA A entered the resident's room and put on a pair of gloves. CNA A then lowered the head of the bed flat while the resident's PEG pump was still on and infusing the formula. The CNA kept the resident's head of bed flat during the entire time she performed the incontinent care. During an interview on 03/25/25 at 02:48 PM, CNA A said that she normally called the nurse to come and pause the PEG tube pump before she performed incontinent care. CNA A said if she did not tell the nurse and the pump was still infusing when Resident #44 was flat that could lead to the resident having complication such as aspiration. CNA A said she simply just forgot to tell the nurse to come pause the pump as she had gotten nervous during the care. During an interview on 03/27/25 at 03:36 PM, the DON said it was expected for the CNAs to contact the nurse to pause the PEG pump machine prior to them lowering the head of the bed flat for residents on the machine. The DON was made aware of CNA A lowering Resident #44's head of the bed flat while the PEG pump was infusing when she performed incontinent care. The DON said the CNA should have contacted a nurse before lowering the bed flat as that could lead to the resident aspirating. The DON said she believed the failure occurred because the CNA got nervous as the CNA had already told them that she had messed up during the care and not had the nurse pause the pump. During an interview on 03/27/25 at 04:08 PM, the Administrator was made aware of the observation of CNA A and lowering flat the head of the bed of Resident #44 while his PEG pump was infusing. The Administrator acknowledged the issue and said that staff should have known the correct steps. Record review of the facility policy titled Enteral tube feeding and dated 12/2011 indicated in part: Preventing aspiration- Always elevate the head of the bed (HOB) at least 30 to 45 degrees during tube feeding and at least 1 hour after.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 1 of 3 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure RN coverage on 10/12/2024 and 10/26/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings include: Record review on 03/26/25 at 4:05 pm of the Payroll Based Journal report (nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis), run date of 3/21/25, for Fiscal Year 2025 Quarter 1 (October 1, 2024, through December 31, 2024) revealed no evidence of RN coverage on 10/12/24, 10/26/24, 11/9/24, and 12/21/24. Review of nurse staffing schedules for October 2024, November 2024, and December 2024 on 03/26/25 at 4:45 pm revealed no RN coverage for 10/12/24 and 10/26/24. The nurse staffing schedules revealed the facility did have RN coverage for 11/9/24 and 12/21/24. In an interview on 03/27/25 at 12:00 p.m., the DON stated that the expectation for RN coverage was that there was an RN in the facility for no less than 8 consecutive hours every day. She stated that on 10/12/24 and 10/26/24 the RN scheduled to work was an agency employee who called in the day of both shifts. The DON stated that at that time she (the DON) was the only RN on staff, and she was out of town and unable to return to town to cover the shifts herself. She stated that she called each of the staffing agencies the facility contracted with and because the call-ins were last minute, none of the agencies had an available RN to send to cover the shifts. She stated the facility had hired an additional RN recently to avoid the lack of RN coverage. In an interview on 03/27/25 at 3:20 p.m., the Administrator stated that his expectation was that the facility would have an RN in the building for the required 8 hours a day. He stated that the two shifts that did not have RN coverage in October 2024 were due to last minute call-ins by an agency RN. The Administrator stated that at the time of the call-ins, the DON was the only other RN on staff and she was out of town and unable to cover the shifts herself as was the normal routine for RN coverage. He stated the facility had hired another RN to prevent the lack of RN coverage and they had not had any further issues covering the necessary hours. Review of facility policy titled Departmental Supervision, Nursing revised August 2022, revealed, in part: A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #44) of two residents reviewed for incontinent care in that; CNA A failed to wash or sanitize her hands between glove changes while assisting Resident #44. This failure could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident #44's electronic face sheet dated 03/27/2025 indicated he was admitted to the facility on [DATE] with diagnoses of stroke, muscle weakness and dysphagia (difficulty swallowing). He was [AGE] years of age. Record review of Resident #44's care plan revised 03/26/25 indicated in part: Problem: Resident is incontinent of bladder and bowel resident cognition is: unable to recall daily forgetfulness. GOAL: resident will be maintained in a clean, dry state and prevent complication of incontinence by checking and changing resident at regular intervals x 90 days. Approaches: provide incontinent care as needed post each incontinent episode Record review of Resident #44's quarterly MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = severely impaired. Bladder and bowel: Urinary continence = Always incontinent. Bowel continence = Always incontinent. Nutritional Approaches = Feeding tube. During an observation on 03/25/25 at 11:20 AM, CNA A performed incontinent care for Resident #44. CNA A entered the resident's room and put on a pair of gloves. CNA A then undid Resident #44's brief and wiped the resident's scrotum and penis area with some wet wipes. CNA A then turned the resident on his side and wiped the resident's rectal area with some wet wipes. It was noted that the resident had a bowel movement. CNA A took some wet wipes and wiped the resident's bowel movements. The CNA changed her gloves several times due to the resident continued to have bowel movement during the care. CNA A did not sanitize or washed her hands in between glove changes. Resident #44 was noted to have a wound dressing on his coccyx which got soiled with bowel movement. CNA A took the soiled dressing with her gloved hand and removed it, then with the same gloved hand took a clean brief and applied it to the resident. CNA A then removed her gloves and put on another pair of gloves without sanitizing or washing her hands. During an interview on 03/25/25 at 02:42 PM, CNA A said that she normally sanitized or washed her hands in between glove changes but she had forgotten during Resident #44's incontinent care. CNA A said she should have changed her gloves after she touched the soiled dressing on the resident's coccyx and before she touched the new clean brief. CNA A said if she did not sanitize or wash her hands in between glove changes then that could possibly lead to cross contamination. During an interview on 03/27/25 at 03:36 PM, the DON was made aware of the observation of incontinent care performed by CNA A on Resident #44. The DON said it was expected for the CNA to have sanitized or washed her hands in between glove changes and that the CNA should have changed her gloves before she touched the new brief. The DON said since the CNA had not sanitized, washed her hands or changed her gloves at the appropriate time that could have led to cross contamination and the spread of infections. The DON said she believed the failure occurred because the CNA got nervous and forgot her steps. The DON said they would monitor staff by rounds being conducted and in-services conducted on hand washing and glove changes. During an interview on 03/27/25 at 04:07 PM, the Administrator was made aware of the observation of incontinent care performed and the infection control issues caused by CNA A. The Administrator acknowledged the issue and said that staff should have known the correct steps. Record review of the facility's policy titled Personal Protective Equipment - Using Gloves dated 10/2010 indicated in part: Purpose - To guide the use of gloves. To prevent the spread of infection; to protect hands from potentially infectious material. When gloves are indicated use disposable single-use gloves. Wash hands after removing gloves (Note: Gloves do not replace handwashing). When to use gloves - when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. Record review of the facility's policy titled Handwashing/Hand hygiene dated 04/2012 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice), after removing gloves or aprons. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly, soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: Before and after direct contact with residents; before moving from a contaminated body site to a clean body site during resident care, after removing gloves. The use of gloves does not replace handwashing/hand hygiene. Record review of the facility's policy titled Infection prevention and control program dated 01/01/2024 indicated in part: 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. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. (PPE is the use of gloves, face masks, gowns etc. used for protection).

Based on observations, interviews, and record review the facility failed to maintain all mechanical and electrical quipment in safe operating condition for 1 of 1 kitchen reviewed for kitchen sanitation. The spray nozzle above the rinsing sink in the dishwashing room leaked, and the oven did not work. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness or undercooked food. The findings included: During the initial tour of the kitchen on 3/25/25 from 10:00 am to 11:00 am in the dishwashing room, the spray nozzle above the rinsing sink had a steady flow of water coming out and flowing into the sink while in the off position. In an interview on 03/25/25 at 11:00 a.m., the Chef stated the oven is not working and the spray nozzle in the dishwashing room has leaked for several months. The Chef stated the ADM is aware of both. In an interview on 3/27/25 at 6:12 p.m., the ADM stated the request for the oven to be repaired was approved, now waiting for the service company. The ADM said the spray nozzle in the dishwashing area had been repaired repeatedly by maintenance, staff get rough with it and break it again. Admin stated it needs to be replaced, currently waiting on the completion of ownership change for the facility to request the replacement with the new corporate office. Review of Food Code 2022 Recommendations of the United States Public Health Service Food and Drug Administration revision date 01/18/2023 revealed, in part: 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure food was stored in a manner that was not open to the air. 3. The facility failed to remove potatoes in the dry storage when they were beginning to show signs of rot. 4. The facility failed to ensure expired food items were discarded by the expiration date. 5. The facility failed to maintain cleanliness in the kitchen. The dry storage had food particles on the floor, drawers had crumbs and a gritty substance in the bottom, the refrigerator had dried sticky substances on the bottom shelf, the floor in the dishwashing area had trash and debris in a corner and the juice spout had a sticky, reddish-brown substance build up on it. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: During the initial tour of the kitchen on 3/25/25 from 10:00 am to 11:00 am the following observations were made: In the dry storage, brown bag of dried Idahoan potato slices was open and not sealed. - In the dry storage, a multi-pack of graham cracker crusts was open and not sealed. - In the dry storage, a bag of white powder mix was open, placed in a resealable plastic bag, and not sealed. - In the dry storage, pieces of dried food and trash were on the floor. - In the dry storage, a box of potatoes had sprouting potatoes in it. One of the potatoes was beginning to rot, it was soft and had white around the soft spot. - In the freezer, a resealable plastic bag of rolls was not sealed. - In the refrigerator, a storage dish labeled Al Bondigas dated 3/24/25, did not have a use by date. - In the refrigerator, a storage dish labeled tomato sauce dated 3/20/25, did not have a use by date. - In the refrigerator, a pitcher labeled juice dated 3/24/25, did not have a use by date. - In the refrigerator, two pitchers labeled tea dated 3/24/25, did not have a use by date. - In the refrigerator, a pitcher of orange liquid did not have a label. - In the refrigerator, a storage dish labeled chicken noodle soup dated 3/16/25 had a use by date of 3/19/25. - In the refrigerator, the bottom shelf had dried sticky substances on it. - In two drawers used for storage of cooking and serving utensils, crumbs and a gritty substance were in the bottom. - The juice machine dispenser spout had a reddish-brown substance build-up on it that was sticky to touch. - In the dishwashing room, a corner of the floor had a drink (soda) bottle lid, pieces of brown paper, and a black crumbly substance pushed into it. In a follow-up observation on 03/26/25 at 11:40 a.m., the sprouting/rotting potatoes were still in the dry storage. Review of facility policy Food Receiving and Storage, revised 11/2012, revealed, in part: - Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. - Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents, and kept clean. - Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. - All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). - Refrigerator foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. - .Wrappers of frozen foods must stay intact until thawing. Review of Food Code 2022 Recommendations of the United States Public Health Service Food and Drug Administration revision date 01/18/2023 revealed, in part: 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 1 of 3 residents reviewed for transfers (Resident #1). The facility failed to assess Resident #1 for safe transfer practices as she was non-weight bearing. This deficient practice has the potential to affect residents in the building who required extensive assistance which could result in residents having pain, falls or injuries. The findings included: Review of Resident #1's Resident Face Sheet, dated 10/24/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included heart failure, arthritis, dementia, muscle weakness, and limitation of activities due to disability. Review of Resident #1's Quarterly MDS Assessment, dated 8/12/24, revealed: She had a mental status score of 9 of 15 (indicating moderate cognitive impairment) She was dependent on staff for transfers from bed to chair. Review of current MDS did not indicate how many people were needed for transfers. Review of Resident #1's Care Plan, edited 9/6/24, revealed: Problem: Limited physical mobility related to osteoarthritis/disability. Short term goal: will remain free of complications related to immobility, including contractures, thrombus formation (formation of blood clots); skin breakdown, fall related injury through next review date. Long Term Goal: will maintain current level of mobility through review date. Identified approaches included: provide with supportive care, assistance with mobility as needed. Review of current Care Plan did not indicate how many people were needed for transfers. Review of current EHR revealed no assessment regarding transfers. On 10/24/24 at 3:47 p.m. revealed CNA A helped Resident #1 sit up without locking the wheels on resident's bed. CNA A raised the bed to above the level of the wheelchair, moved the wheelchair perpendicular to the bed and locked the wheelchair. Resident #1's feet did not touch the ground. CNA A placed the gait belt around Resident #1's waist and made sure it was tight enough. CNA A slid Resident #1 from the bed into the wheelchair while holding the gait belt. CNA A explained to Resident #1 what she was doing in Spanish the entire time. Interview on 10/24/24 at 4:05 p.m. CNA A stated Resident #1 could not bear weight and even when she did stand, she bent over completely. CNA A said Resident #1 was not a two-person transfer because she felt she could safely transfer Resident #1 on her own and there were times it was only her on the floor. CNA A stated she had told people she needed help and sometimes the nurses would help. CNA A said there were times she told the nurses that Resident #1 was non- weight bearing but nothing changed. Interview on 10/24/24 at 5:09 p.m. LVN B stated Resident #1 was non weight bearing. LVN B stated she thought one person could safely transfer Resident #1. LVN B stated she has performed a one-person transfer with Resident #1 in the past Interview on 10/24/24 at 5:27 p.m. the DON stated Resident #1 was weight bearing and was able to pivot. The DON stated a resident who was non-weight bearing was not safe to transfer with one person. The DON stated residents were assessed for transfer needs on admission, re-admission, and when the aides told the nurses that there was a change with residents ADL needs. The DON said they relied on the aides to tell the staff what a proper transfer was. The Regional Consultant who also present stated residents were assessed on admission, readmission, change of condition, and then usually when the MDS was done assessment needs were looked at. The Regional Consultant added they looked at transfer ability on therapy's recommendation and family request. The Regional Consultant stated the transfer ability was formally on the admission/re-admission assessment but nowhere else. The Regional Consultant stated there was not a form for a transfer ability assessment. Interview on 10/24/24 at 7:01 p.m. the MDS Coordinator stated Resident #1 was not weight bearing and as far as she knew Resident #1 was a one-person transfer. The MDS Coordinator stated she was unaware of a formal transfer assessment that the facility used. The Treatment Nurse who was also present stated she worked at the facility 20 years and was unaware of a formal transfer assessment they were just asked on admission and re-admission. Review of the facility's policy and procedure of Safe Lifting and Movement of Residents, revised February 2014, revealed: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: - Resident's mobility (degree of dependency) - Resident's size - Weight bearing ability - Cognitive status Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: - Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies. - Continually evaluates the effectiveness of workplace safety and injury-prevention strategies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews 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 2 of 14 residents (Resident #21, Resident # 35) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #21 prior to administering Zoloft, an antidepressant used to treat depression. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #35 prior to administering Paxil, an antidepressant used to treat depression. The facility also failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #35 prior to administering Xanax, a sedative used to treat anxiety. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include: Record review of Record review of Resident #21's face sheet revealed admission date of 10/27/2014 with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with daily activities), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), Alzheimer's disease (a progressive disease that destroys memory and mental functions), moderate intellectual disabilities (individuals with an average mental age of 6 to 9 years). She was [AGE] years of age. Record review of Resident #21's quarterly MDS, dated [DATE], indicated she had a BIMS score of 14, which indicated he was cognitively intact. The MDS also indicated Resident #21 was receiving antianxiety medications. Record review of Resident #21's care plan indicated, in part: Focus: cognitive loss/ dementia or altercation on thought process related to impaired decision making, short-term and long-term memory loss. Goal: The resident will maintain current level of cognitive function through review date. Intervention: Administer medications ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #21's medication profile dated 10/13/23 indicated in part: Zoloft 50 milligrams, give 1 tablet by mouth once a day for anxiety. Record review of Resident #21's clinical records revealed no consent on file. Record review of Record review of Resident #35's face sheet revealed admission date of 10/06/21 with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus, dysphagia (impairment of speech), anxiety disorder (severe, ongoing anxiety that interferes with daily activities), end stage renal failure disease(the stage when kidneys can no longer function on their own). She was [AGE] years of age. Record review of Resident #35's quarterly MDS, dated [DATE], indicated he had a BIMS score of 15, which indicated he was cognitively intact. The MDS also indicated Resident #35 was receiving antianxiety and anti-depressant medications. Record review of Resident #35's care plan indicated, in part: Focus: resident has diagnosis of depression. Goal: resident will have fewer episodes of depression. Intervention: administer medications as ordered, monitor labs, report abnormal labs to physician. Focus: The resident uses anti-anxiety medications alprazolam related to anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Record review of Resident #35's medication profile dated 12/24/22 indicated in part: Paxil 20 milligrams 1 tablet by mouth once a day for major depression disorder. Xanax 0.25 milligrams 1 tablet by mouth on Monday, Wednesday and Friday before dialysis. Record review of Resident #35's clinical records, revealed the no consent on file. Interview on 02/22/2024 at 11:35 AM, the DON stated that consents are obtained by the receiving nurse ,by ensuring the resident understands the details of the consents. If not, we have residents' responsible party come in to sign the consent. If it is a verbal consent, we have a hard copy obtained later. We obtain consents for wound care, eye care, dental, any outside, psychotropic medications and anti-psychotics, if the facility needs to reach out to the family to ensure consent a consent is signed. In this case, it is possible that we did not obtain a hard copy of the consents. The DON stated they are going to implement obtaining and keeping hard copies of consents and upload them to ensure accuracy of documentation. Record review of the facility's policy revised December 2016, titled Antipsychotic Medication Use indicated, in part: Residents/ responsible party will be notified of physician recommendations for psychotropic/ pharmacological interventions and consent to use the medication as ordered.

Based on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 92 days in July 2023 - September 2023 The facility had no Registered Nurse coverage on dates 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. This failure could affect all residents and put them at risk of their care not being overseen properly. The findings were: Record Review of the facility's time sheets from July 01, 2023- September 30, 2023 - on 02/22/2024 at 01:00 PM revealed there was no Registered Nurse coverage on 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. During an interview on 02/22/2024 at 01:21 PM with the Director of Nurses confirmed there was no RN coverage for the date listed above. The DON stated the facility has been trying to hire new RNs by having competitive pay, sign on bonuses and benefits. The DON stated the facility has started to use agency nurses, but it is still hard to have consistency regarding RN coverage even with the agency staff.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms inspected for medication storage. The medication rooms had an expired Tuberculin (TB) vial medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on 02/20/24 at 03:12 PM the medication room was inspected with LVN C present. There was a small refrigerator that contained several medications to include an open box that contained a 5ml vial that contained Tuberculin. The date on the box indicated it was opened on 12/22/23. The box indicated Discard opened product after 30 days. LVN C said she was an agency nurse and was not sure who was responsible for making sure expired medications were removed from the medication room. LVN C said she had not noticed the TB medication had expired. During an observation and interview on 02/21/24 at 11:10 AM the DON was made aware of the expired TB vial in the medication room. The DON said each nurse was responsible to make sure they dated the TB vial when it was opened and disposed of it when expired. The DON said there was no one assigned to check the medications in the medication room. The DON said if an expired TB was used it could cause a false reading. During an interview on 02/22/24 at 02:10 PM the Administrator was made aware of the expired TB vial observed in the medication room. The Administrator said if that medication was used it could lead to false reading or not be effective. The Administrator said the failure probably occurred because the staff was not paying attention and did not notice the TB was expired and should have been disposed. Record review of the facility's policy titled Labeling of medication containers dated April 2007 indicated in part: Policy statement -All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information such as: The expiration date when applicable and directions for use. Label for each floor's stock medications shall include all necessary information such as the expiration date when applicable. Record review of the Tuberculin Purified Protein Derivative Tubersol manufacture pamphlet dated April 2023 indicated in part: A vial of Tubersol which has been entered and in use for 30 days should be discarded.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts ( Hall 100 nurse medication cart) reviewed for medication storage and failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure the hall 100 nurse medication cart did not contain expired insulin pens and had open dates after they were put into use. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. This failure failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications and could place the facility at risk of drug diversion and access to medications. Findings include: During an observation and interview on 02/21/24 at 11:02 AM LVN C was in the process of checking resident's blood sugars. LVN C had a caddy on the medication cart for hall 100 in which she carried several insulin pens. There was a total of 6 pens that did not have an open date and 1 that had an expired date. LVN C said she had not noticed that the pens were not dated when opened. LVN C said she worked for an agency, so she did not always work at this facility. During an observation and interview on 02/21/24 at 11:10 AM the DON was shown the 7 insulin pens. The DON said the insulin pens were supposed to be dated when opened and disposed of when expired. The DON said it was each nurse's responsibility to write an open date on the pens when they opened them. The DON said there was no one single person assigned to monitor the insulin pens and make sure they were dated. The DON said that they were going to have to assign someone to monitor this. The DON said if a resident received an insulin that had no expiration date or had been expired then there was a possibility the resident did not receive the therapeutic effect. The DON said the failure occurred because no one was monitoring to see that insulin pens were dated when opened or disposed of when expired. During an observation and interview on 02/21/24 at 02:44 PM the discontinued controlled medications in the DON's office with the DON present was inspected. The medications were kept in a large cabinet which was kept locked. The DON opened the cabinet and inside the cabinet were 7 blister packs that contained controlled medications. The medications consisted of Lorazepam (Antianxiety Agent - Benzodiazepines), Hydrocodone (Narcotic pain medication) and Tramadol (Opioid pain medication). These medication were not kept in the second container that had the second lock. The DON said the medications belonged to a resident that had recently expired and the medications were placed in the cabinet and not in the second container so it was her fault. The DON said if the medications were not kept behind 2 locks, then there was a chance of an unauthorized person taking the medications which could lead to a drug diversion or ingestion of the medications. During an interview on 02/22/24 at 02:12 PM the Administrator was made aware of the undated and expired insulin pens observed during medication pass and the discontinued control medications not kept behind 2 locks in the DON's office. The Administrator said staff were supposed to date the medications when opened or discard them after they expired or else they could not be as effective as indicated. The Administrator said the failure probably occurred because the staff did not pay attention and did not disposed of the expired medications or dated them when opened. The Administrator said the discontinued controlled medications were supposed to be kept behind 2 locks as their protocol indicated. The Administrator said the DON probably got distracted and did not place the discontinued control medications behind 2 locks. Record review of the facility's policy titled Labeling of medication containers dated April 2007 indicated in part: Policy statement -All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information such as: The expiration date when applicable and directions for use. Label for each floor's stock medications shall include all necessary information such as the expiration date when applicable. Record review of the facility's policy titled Medication storage- controlled medications storage dated 01/2023, indicated in part: Medications included in the drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. Controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #43) reviewed for infection control. CNA A failed to wash hands or use hand sanitizer between glove changes during incontinent care while assisting Resident #43. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Record review of Resident #43's face sheet revealed admission date of 09/07/23 with diagnoses of hemiplegia of right side (one-sided paralysis), Type 2 Diabetes Mellitus (condition where pancreas does not produce enough insulin), cerebrovascular disease (blood flow to brain is affected), He was [AGE] years of age. Record review of Resident #43's MDS dated [DATE] indicated in part: BIMS 09 -moderately impaired. Urinary and Bowel continence = Always incontinent. Record review of Resident #43's care plan dated 09/08/2023 indicated in part: Focus: Resident at risk for frequent infections, pressure ulcers, venous stasis ulcers related to Diabetes Mellitus. Goals: Resident will remain stable. Interventions: Inspect skin for signs or symptoms of skin breakdown. During an observation on 02/21/24 at 02:10 PM CNA A performed incontinent care for Resident #43. CNA A put on gloves, failing to wash hands prior. CNA A pulled brief down in front, wiped front peri area with wet wipes, three times. Resident was assisted to turn to right side. CNA A wiped resident's buttocks until free of bowel movement. CNA Doffed(took off) gloves and donned(put on) clean gloves and placed brief under resident, failing to wash hands or use hand sanitizer when changing gloves. CNA A assisted resident to roll to back, brief was secured, resident was dressed, resident was positioned for comfort, CNA A doffed gloves. During an interview on 02/22/24 at 1:40 PM CNA A stated that during incontinent care, handwashing or using hand sanitizer was very important to prevent spread of infection. _CNA stated that she should wash hands before putting gloves on, stated she was nervous and forgot that step. During an interview on 2/22/24 at 2:25 PM the ADON stated that she has a lot of agency staff currently and it is difficult to ensure they are all following policy. The ADON stated that is not an excuse, since handwashing and hand hygiene procedures are universal. The ADON stated that her expectations were that every staff member follow hand hygiene to prevent spread of infection. During an interview on 02/22/24 at 11:24 AM the DON stated that the steps for incontinent care were as follows: Introduction, hand washing, gather supplies, ensure resident is aware of what is going on, peri care- wiping from front to back, change gloves between soiled to clean, use hand sanitizer, change gloves for clean brief, help reposition resident to a comfortable position, gather trash, wash hands. During an interview on 02/08/24 at 02:52 PM the Administrator said the staff were expected to follow policy. The Administrator stated he was disappointed since the DON is constantly doing staff training. Record review of the facility's infection control policy titled Hand washing /hand hygiene revised April 2012 indicated in part: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. Employees must wash their hands: Before and after direct contact with resident; before and after assisting resident with toileting; after contact with residents' mucous membranes and bodily fluids; after handling soiled linens, dressings, bedpans, catheters, and urinals, and after removing gloves. Hand hygiene is always the final step after removing and disposing PPE. The use of gloves does not replace handwashing/ hand hygiene.

Based on observation, interview and the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: 1.The facility failed to label and date food items. 2.The facility failed to discard expired food items. These deficient practices could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings include: Observation on 02/20/2024 at 11:30 AM of the refrigerator revealed: Red gelatin dated 2/11/24, shelf life 3 days. Peanut butter and jelly mixture dated 2/16/24, shelf life 3 days. 5 pounds of ground beef in plastic zip lock bag, unlabeled, undated, no use by date. 20 corn tortillas in asealed bag unlabeled, undated no use-by date. 20 flour tortillas in a sealed bag unlabeled, undated, no use-by date. Observation on 02/20/2024 at 11:45 AM of dry pantry revealed: 10 oz sprinkles unlabeled undated, no use-by date. 16 fluid oz bottle of red food coloring expired 10/02/2020. 1 gallon of Karo Syrup expired 02/12/2022. 1 pound bag potato chips expired 12/2022. Interview on 02/22/24 at 09:16 AM [NAME] A stated that all food in the refrigerator should be labeled. She stated her shift starts at 6:00AM, she is busy prepping meals and must have missed those items. Interview on 02/22/24 at 09:44 AM the DM stated the left-over storage depended on the dish stored, but usually the expectation was three days for leftovers. She stated she expected leftovers to be labeled, dated, and covered with the date to throw it away. The DM stated that it is all staff responsibility to ensure food is labeled, dated, or thrown out when expired or past the date. Interview on 02/22/24 at 2:34 PM the Administrator was informed of the findings in the kitchen. He stated the Dietary Manager is responsible for ensuring expired foods are thrown out and all foods are labeled and dated. Record review of the facility's document titled Food receiving and storage revised July 2014 indicated in part: Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 2 residents (Residents #3) reviewed for a notification of a change of condition, in that: Resident #3 was known to be covid-19 negative but roomed with Resident #4 who was known to be covid-19 positive. Facility failed to report to Physician that his patient Resident #3 was being roomed with a covid positive Resident #4. This deficient practice could place residents at risks of not having the physician contacted when they have a change of condition, and it could result in delay of medical treatment and hospitalization. Findings included: Record review of Resident #3's face sheet, dated 1/26/24, revealed a male resident with an admission date of 3/17/23 and diagnosis that included type 2 diabetes mellitus, muscle wasting, muscle weakness, and repeated falls. Record Review of the facility's covid-19 testing log dated 1/25/24 indicated Resident #3 was tested for covid on 1/21/24, 1/24/24, and 1/25/24 which all resulted as negative. Record Review of the facility's covid-19 testing log dated 1/25/24 indicated Resident #4 (roommate to Resident #3) was tested for covid on 1/21/24 (covid-19 positive), 1/24/24 (covid-19 negative) and 1/25/24 (cvodi-19 negative). Resident #4 was also notated as asymptomatic. During an interview on 1/24/24 at 3:20 PM the ADON stated that the reason Resident #3 (covid-19 negative) was in the room with Resident #4 (covid-19 positive) was because Resident #4 refused to be moved to the locked unit and Resident #3 refused to be moved from their room. She stated that was why they kept Resident #3 and Resident #4 in the same room. During an interview on 1/24/24 at 11:45 PM Resident #3 stated that he understood that he was in the same room as a resident who was covid positive, and the facility did offer him to go to another room, but he did not want to go. During an interview on 1/25/24 at 3:20 PM the ADON stated that she knew she called all the residents' physicians to let them know they had covid-19 in their building but could not find the notation on Resident #3 that his physician was informed. During an interview on 1/26/24 at 11:00 AM Physician A stated that the facility only let him know about his patient Resident #3 staying in the same room as a covid-19 positive about two hours ago (approximately 9:00 AM). He stated the facility did let him know of covid-19 positive residents in the building on 1/21/24, but not that Residents #3 was sharing a room with one of them. He stated when the covid-19 positive resident was found on 1/21/24, he would have directly contacted the resident to let them know it was not a good idea and he would have suggested that the resident be moved to another room and directly suggest that guidance to the resident. Record review on facility's Change in a Resident's Condition or Status policy dated 11/2015 revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the residents medical/mental conditions and/or status. 1. The nurse supervisor/charge nurse will notify the residents attending physician or on-call physician when there has been.

Based on observation, interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for 2 of 15 (Resident #1 and Resident #2) residents reviewed for infection control. Three facility staff (MT, HA A, and HSKG) failed to follow the facility's infection prevention protocol for COVID-19 by failing to wear appropriate PPE. MT entered the hot zone with N95 mask and no other PPE. HA A did not wear appropriate PPE for the warm unit. HSKG did not wear appropriate PPE going into hot zone and shower room. Shower room was not sanitized after Resident #1, who was on isolation for exposure to COVID-19. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19. Findings include: Record review of Resident #1's face sheet, dated 1/26/24, revealed a female resident with an admission date of 12/10/20 and diagnosis that included dementia, anxiety, and type 2 diabetes mellitus. Record review of Resident #2's face sheet, dated 1/26/24, revealed a female resident with an admission date of 7/31/23 and diagnosis that included cellulitis of left lower limb congestive heart failure, and cirrhosis of liver. During an interview on 1/24/24 at 11:15 AM the ADON stated they had 15 residents on isolation in the facility. The ADON stated 8 were on the locked unit and 7 isolated to their rooms due to being recently covi-19d positive. She stated of the 15 residents on isolation none of the residents were covid-19 positive because they just had tested all residents that morning 1/24/24 and they were all negative but were staying on isolation for a few more days. She stated there were 3 employees out that were covid-19 positive, one being the DON. She stated that she has been testing all employees and residents every 3 days or if they are symptom based. Infection Control COVID-19 Employee Testing Log 1/16/24 to 1/19/24: 12 employees tested positive. Infection Control COVID-19 Resident Testing Log 1/18/24 to 1/25/24 17: residents tested positive (cumulative). Infection Control COVID-19 Resident Testing log On 1/24/24 mass testing of all residents was done, all residents that were previously positive now tested negative, resulting in no positives in the building at this time. Infection Control COVID-19 Resident Testing log On 1/25/24 mass testing of all residents was done, Resident #1 and Resident #2 tested positive all other residents were negative. During an observation on 1/24/2024 at 12:19 PM the MT was observed to be wearing an N95 mask. She entered the locked unit (hot zone (a section of a facility, where there is a high risk of contamination by patients with an infectious disease)) did not don any additional PPE (face shield/goggles, gown, and gloves). The Med Tech walked to the resident and handed him his medication cup which he put in his mouth by himself and then exited the hot zone without changing her mask or donning any additional PPE. During an interview on 1/24/24 at 12:25 PM PM the MT stated that she did not put PPE on because she saw the resident right on the inside of the hot zone door and it was quick and easy for her to hand him his medication and to get out rather than take all the time to put the PPE on. She stated she knows she is supposed to put all PPE but felt it was going to be really quick to just hand the medication to the resident. During an interview on 1/24/24 at 3:20 PM the ADON stated her expectations of PPE use, for hot zone areas or to enter a covid-19 positive or quarantine resident's room was to don all PPE which included a gown, gloves, mask, and face shield/goggles. She stated that her expectation was not only that all PPE be worn but be worn correctly, meaning no mask below the chin or face shields not covering face, and eyeglasses do not count as eye coverings or face shields. She stated all covid positive residents had signage on the door with the proper PPE to be down. During an observation on 1/24/24 at 4:10 PM revealed HA A was working on the warm unit. HA A did have a face shield in place, but it was not being worn correctly. The face shield was pulled up way above her forehead and was not covering her nose and mouth. HA A was also wearing a KN95 mask. The KN95 mask was also being utilized incorrectly and was observed as being pulled below her chin and was not covering her mouth or nose. HA A was in the hot zone with covid positive residents all around her, residents were not wearing mask. During an interview on 1/26/24 at 11:20 HA A stated that she should have been wearing everything properly on the hot zone. She stated it just gets hot and she gets to working and has to breath so she will lift the face shield or mask sometimes to breath. She stated she thought she only need to put gown and gloves on while interacting with the residents not just on the hot zone. HA A stated was in the hot zone with covid positive residents all around her, residents were not wearing mask. During an observation on 1/25/24 at 11:15 revealed Resident #1, who was on isolation, due to exposure (been within 6 feet of someone with COVID-19 for at least 15 cumulative minutes or more over a 24-hour period) was observed sitting, in his wheelchair, with no mask on, outside of the shower room, on hallway 100. Resident #1 was waiting to take a shower. The shower room was opened, Resident #1 entered the shower room and asked staff to set up the shower. No sanitation or cleaning was performed near the shower room or where Resident #1 was sitting in the hallway, following this observation. Resident #1 exited the shower at 11:50 AM, with no mask on, and went back to his room. The distance from the shower room to Resident #1's room was roughly 30 feet. No sanitation was done in between going from any of the covid-19 positive to covid -19negative rooms. During an observation on 1/25/2024 at 12:24 PM, revealed the HSKG was observed wearing an N95 mask when she began to don a gown and gloves, prior to entering Resident #1's room; COVID-19 quarantine room. The HSKG was not wearing a face shield or goggles when she entered the room. The HSKG exited the COVID-19 quarantine room without a gown, gloves, face shield or goggles. The HSKG did not discard her N95 mask or obtain a new one after exiting the room. During an interview on 1/25/24 at 1:15 PM HSKG stated that she was not told that a face shield or goggles needs to be worn when going into covid positive room, she stated she thought her glasses were enough. She stated she was never told that glasses were not proper PPE. She stated that she will make sure to put a mask or goggles on from this point on. Attempted to contact MD on 1/25/24 at 2:45 PM, no answer, left message. During an observation on 1/25/24 at 2:15 PM revealed the ADON tested Residents #1 and Residents #2 for covid-19. The ADON was in full PPE and technique was good while in the residents' rooms to test for covid-19. Upon testing, it was found that both residents were covid-19 positive. After testing positive Resident #1 was moved to locked unit (hot zone) and Resident #2 was quarantined to room. Attempted to contact the Medical Director on 1/25/24 at 2:45 PM, no answer, left message. Record reviews the covid-19 positive tracking log, dated 1/25/24, of all residents that tested positive (17) revealed all residents were asymptomatic or mild symptoms that included, headache, runny nose, or tiredness. During an interview on 1/26/24 at 3:15 PM the Administrator stated that the only way covid-19 got in the building was by staff or visitors. He stated they had to use a lot of agency nursing, but staffing had been good during the entire process. He stated this outbreak was difficult because there would be one or two employees here or there, but this was out of nowhere were a bunch of employees and residents all tested positive at once. During an interview on 1/26/24 at 2:45 PM the ADON stated in the absence of the DON she would be the infection preventionist. She stated that if PPE was not being worn properly it would put the residents at risk of getting covid-19. She stated she knew some of her staff were not the best about wearing their PPE and she had talked to them about this. Record review of the facility's Covid-19 Prevention, Response and Reporting policy dated 5/11/23 revealed: 11. Personal Protective Equipment Considerations: i. NIOSH-approved particulate respirators with N95 filters or higher used for: 1. All aerosol-generating procedures 2. in other situations, where additional risk factors for transmission are present, such as resident is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator used by HCP working in affected areas is not already in place. 3. Resident care encounters or in specific units or areas of the facility at higher-risk for SARS-CoV-2 transmission ii. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all resident care encounters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 (room [ROOM NUMBER]) rooms and the memory care unit reviewed for environment. The facility window blinds in resident room [ROOM NUMBER] and the common room in the memory care unit were inoperable and damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well- kept environment. Findings included: Observation on 6/22/23 at 8:10 am revealed that in the common room of the memory care unit, the window blinds were damaged, broken blades, missing blades, cords in knots, inoperable, white 1-inch vinyl blinds. Interview on 6/22/23 at 8:30 am, the ADON stated he had noticed that the window blinds in the common room of the memory care unit were damaged, and it was that way for months and needed to be replaced. Observation on 6/22/23 revealed that in hall 100, room [ROOM NUMBER], the window blinds were damaged, blades bent, blinds unable to open or close properly, inoperable, white 1 inch medal blinds. Interview on 6/22/23 at 1:05 pm in room [ROOM NUMBER], Resident #4 stated he's been at facility for one month. Resident #4 stated the window blinds were damaged and inoperable when he arrived, 6/1/23. Resident #4 stated he wished that facility would fix the blinds, because it looks bad. Record review of Maintenance repair log for April through June 21, 2023, revealed no repair request was found for the damaged blinds in room [ROOM NUMBER] or memory care unit common room. Interview on 6/23/23 at 9:05 am, Maintenance Director stated that room [ROOM NUMBER] was the Administrator's office a few months ago and he said he was not aware of the blinds being damaged. Maintenance Director stated he had removed one damaged blind covering the exit door in the memory care unit common room but did not remove the other damaged blinds covering the window. Maintenance Director stated it was his department that is responsible for maintaining the building and equipment in a safe and operable manner at all times. Interview on 6/23/23 at 10:00am, the Administrator stated he did not know about the damaged blinds in room [ROOM NUMBER] or in the memory care unit. Admin stated he ordered blinds for rooms earlier in the month but was unsure which rooms they were for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 of 2 (Residents #1) reviewed for indwelling catheters. The facility failed to ensure Resident #1 indwelling catheter was secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Review of Resident #1's admission Record dated 01/09/23, indicated he was admitted to the facility on [DATE] with diagnosis of benign prostatic hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty). Resident #1 was [AGE] years of age. Review of Resident #1's MDS dated [DATE] indicated in part: Brief Interview Mental Status = 6 indicated resident had severe impairment. Urinary incontinence = not rated, resident has a catheter. Review of Resident #1's care plan dated 01/04/23 indicated in part: Focus: the resident has foley catheter and is at risk for increased urinary tract infections. goal: the resident will show no signs/symptoms of urinary infection through review date. Interventions: change catheter every month, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks each shift, monitor/document for pain/discomfort due to catheter. Review of Resident #1's physician order report dated 12/10/2022 - 01/10/2023 indicated in part: Check Foley catheter placement, ensure Foley is secured via velcro strap to reduce friction/pulling. Start date 09/27/2022 Observation and interview on 01/09/23 at 03:02 PM CNA C performed incontinent care for Resident #1, CNA C sanitized her hands, donned gloves and explained to the resident what she was going to do. CNA C pulled Resident #1's pants down and the resident was noted to have an indwelling urinary catheter. The urinary catheter was not secured to the resident's leg and when CNA C turned Resident #1 on his side the catheter tube pulled on his penis. Resident #1 told surveyor that the catheter tube would hurt his penis when they changed him because it would tug his urethra. Resident #1 said he did not recall the staff securing the catheter to his leg. CNA C said she had just started working at the facility last week and was not aware of the resident's catheter not being secured to his leg. Interview on 01/11/23 at 02:24 PM DON said her expectations for residents with urinary catheters was for them to be checked by the nurse and the aides for any loops or kinks and for the nurse to make sure it was anchored to the resident. DON was made aware by the surveyor that during an observation Resident#1's urinary catheter was not secured to the resident and the resident had voiced that it caused him discomfort. DON said Resident #1 did not like for the catheter to be secured but that that it did have to be secured. DON said if the catheter was not secured that it could cause trauma and discomfort to the resident's penis. DON said the failure occurred because the staff did not check to see that the catheter was secured. Interview on 01/11/23 at 02:48 PM the Administrator was made aware of the observation of the catheter not secured for Resident #1. The Administrator said the catheter should have been secured as that could lead to injury and discomfort to the resident. Review of the facility's policy titled Catheters - insertion and care dated 04/2021 indicated in part: It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications. Attach catheter strap to leg to assist in securing tubing. Review of Lippincott Manual of Nursing Practice 9th Edition 2009, page 783 indicated the following in regards to securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy during medical treatment, for three of four residents reviewed for medication administration. (Residents #32, #34, and #35) a) LVN D checked Resident #32's blood glucose levels and administered insulin in the public dining area during lunch in the immediate presence of other residents. b) LVN D checked Resident #34's blood glucose levels and administered insulin in the public hall during lunch in the immediate presence of other residents. c) LVN D checked Resident #35's blood glucose levels and administered insulin in the public dining area during lunch in the immediate presence of other residents. These failures could affect residents who receive glucose monitoring and result in embarrassment, loss of self-esteem and/or self-worth. Findings included: Review of Resident #32's Face Sheet dated 1/9/23 review reflected that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus, Dementia, Major Depressive Disorder, Hypertension, Muscle Weakness and Pain. Review of Resident #32's Care Plan, created date of 11/3/22 reflected: Focus: resident was at risk for hyperglycemia/ hypoglycemia related tof Diabetes Type II. Goal: resident will have no complications related to diabetes through the review date. Intervention: Monitor fasting serum blood sugar as ordered by doctor; administer diabetes medications as ordered by doctor. Resident #32's MDS assessment dated [DATE] reflected that resident scored a 10 of 15 on the mental status exam (indicating moderate cognitive impairment), was diabetic, and had injections 5 of 7 days. Review of Resident #32's Physician Orders dated 6/23/22 reflected Novolog Solution (insulin aspart), inject 15 units subcutaneous before meals for diabetes. Review of Resident #34's Face Sheet dated 1/9/23 reflected that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus, Hypertension, Hyperlipidemia, Left-sided partial paralysis, falling, contracture of left foot. Resident #34's MDS assessment dated [DATE] reflected that he scored a 10 of 15 on the mental status exam (indicating moderate cognitive impairment), was diabetic, and had injections 5 of 7 days. Review of Resident #34's Care Plan, created 12/15/22 reflected the focus is resident is at risk for hyperglycemia/ hypoglycemia episodes related to of Diabetes Mellitus. The goal is that resident will have no complications related to diabetes through the review date. The interventions will be to monitor fasting serum blood sugar as ordered by doctor and administer diabetes medications as ordered by doctor. Review of Resident #34's Physician Orders dated 9/10/21 reflected Humalog Kwikpen Solution Injector 100 Unit/ml (insulin lispro), inject as per sliding scale subcutaneous before meals. Review of Resident #35's Face Sheet dated 1/9/23 reflected that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus, Hypertension, Parkinson's, Dementia, falling, and lack of coordination. Resident #35's MDS assessment dated [DATE] reflected she scored a 13 of 15 on the mental status exam (indicating minimal cognitive impairment), was diabetic, and had injections 5 of 7 days. Review of Resident #35's Care Plan, created 11/15/22 reflected the focus was resident is at risk for hyperglycemia/ hypoglycemia episodes related to of Diabetes Mellitus. The goal is the resident will have no complications related to diabetes through the review date. The interventions are to monitor fasting serum blood sugar as ordered by doctor; administer diabetes medications as ordered by doctor. Review of Resident #35's Physician Orders dated 12/30/22 reflected Humalog Kwikpen Solution Injector 100 Unit/ml (insulin lispro), inject 10 Units subcutaneous before meals. Observation on 01/09/23 at 12:04 PM revealed LVN D checked Resident #35's blood sugar via fingerstick. LVN D pulled up Resident #35's shirt, cleaned Resident #35's abdomen with alcohol pad and injected the insulin subcutaneously to abdomen in the public dining area during lunch in the immediate presence of other residents. Observation on 01/09/23 at 12:12 PM revealed LVN D checked Resident #32's blood sugar via fingerstick. LVN D pulled up Resident #32's sleeve, cleaned Resident #32's left arm with alcohol pad and injected the insulin subcutaneously to left arm in the public dining area during lunch in the immediate presence of other residents. Observation on 01/09/23 at 12:24 PM revealed LVN D checked Resident #34's blood sugar via fingerstick. LVN D pulled up Resident #34's shirt, cleaned Resident #34's abdomen with alcohol pad and injected the insulin subcutaneously to abdomen in the public hall adjacent to the dining room in the immediate presence of other residents. Interview on 01/11/23 at 09:27 AM LVN D stated that she chooses to give medications in the Dining Room because she was told that the residents should be treated as they would be treated at home and at home, the residents' would get medications anywhere in their home. LVN D stated I know the policy stated that staff is supposed to take residents to their bedroom to administer medications but the residents do not mind. When surveyor asked LVN D if she asked residents their preference regarding the location of the medication administration, LVN D stated, no she did not ask Resident #32, Resident #34, or Resident #35 if they preferred to go to their room. When surveyor asked LVN D if she would check blood sugars and administer insulin to the residents in a restaurant setting, LVN D stated, no she would not. Interview 01/11/23 at 09:00 AM ADON stated that staff was never supposed to check blood sugars or give insulin in the dining area. ADON stated that on 01/9/23 he observed LVN D passing medication in the Dining Area and told LVN D not to give Residents medications in the Dining Room. ADON stated that he instructed LVN D to take all residents to the Medication Room or the resident rooms to administer medications. ADON stated that on 1/9/23 during lunch service he observed LVN D administering insulin to residents. ADON stated that he will have to monitor LVN D more closely and do additional training with her. ADON stated that he did think that LVN D understood the facility policy. Review of facility's policy and procedure titled Quality of Life- Dignity, revised August 2009 read in part: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation: -Residents shall always treated with dignity and respect. -Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for medication storage and to meet the needs of 2 residents (Resident #1, Resident #40), 1 of 2 Medication Carts and 1 of 1 Medication Rooms (Medication Room) reviewed for compliance. 1. The facility failed to ensure Medication Cart #1 was locked when unattended. 2. The facility failed to ensure the Medication Cart #1 did not include an opened and undated Lantus pen (insulin medication used to treat Diabetes Mellitus) for Resident #40. 3. The facility failed to ensure the Medication Storage Room did not contain an opened and undated Ozempic pen (medication used to treat Diabetes Mellitus) for Resident #1. This failure could place residents at risk of having access to unauthorized medications and unauthorized lab and medical supplies and/or lead to possible harm or drug diversions and also placed residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings included: UNDATED MEDICATIONS Review of Resident #1's face sheet dated [DATE] revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, Alzheimer's disease (a progressive disease that destroys memory), Dementia ( a condition characterized by progressive loss of intellectual functioning, impairment to memory, and thinking), Schizoaffective disorder (a mental health condition with a combination of symptoms), Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anemia (condition in which blood does not have enough healthy red blood cells). Review of Resident #1's care plan dated [DATE] revealed, Focus- Resident #1 will have no complications related to Diabetes through the review date, interventions- administer Diabetes medications per MD order. Review of Resident #1's admission MDS dated [DATE] revealed, insulin as necessary. Review of Resident #1's Physician's Order dated [DATE] revealed, Ozempic Solution Pen Injector, inject 0.25mg subcutaneous one time a day every Friday. Review of Resident #40's Face Sheet dated [DATE] revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, Dementia, Long term use of insulin, Hyperlipidemia, and Upper Respiratory Infection. Review of Resident #40's admission MDS dated [DATE] revealed, insulin as necessary. Record review of Resident #40's Care Plan dated [DATE] revealed, Focus- Resident #1 will have no complications related to Diabetes through the review date, interventions- administer Diabetes medications per MD order. Record review of Resident #40's Physician's Order dated [DATE] revealed, Lantus Solostar Solution Pen Injector, inject 25 Units subcutaneous at bedtime. Observation and interview on [DATE] beginning at 10:50 AM, inventory of Medication Cart #1 with LVN D revealed an opened and undated Lantus pen (insulin medication used to treat Diabetes Mellitus) for Resident #40. LVN D stated that insulin pens should be dated upon opening and she was unsure who opened it. LVN D stated that she usually checks her cart at the beginning of her shift but had not done it today. LVN D stated that Resident #40 only receives Lantus (insulin medication used to treat Diabetes Mellitus) on night shift so she had not looked at his pen. Observation on [DATE] at 11:12 AM, inventory of the Medication Room with ADON revealed one (1) open and undated Ozempic pen (insulin medication used to treat Diabetes Mellitus) for Resident #1. Interview on [DATE] at 10:30 AM DON stated that herself and ADON are responsible for checking the medication room for expired or undated medications and discarding them. DON stated that medication room was checked last on [DATE]. DON stated that nurses and medication aides are instructed to bring medications and narcotics to Me (DON) or ADON. Then the medications are locked in the safe that is inside the locked cabinet that is located in the locked DONs office. DON stated the pharmacist comes monthly to do drug destruction. Interview on [DATE] at 10:30 AM ADON stated that he checked the med room on [DATE], and was due to check it again on [DATE]. ADON stated that he was distracted when surveyors walked in the door so he never got around to checking the medication room. ADON stated that the Ozempic pen (insulin medication used to treat Diabetes Mellitus) was discarded. ADON stated that since Resident #1 only receives injection once a week, on Fridays, and there was likely no harm to resident. ADON stated that the medications found in Medication Cart #1 belonged to resident #40. The family provides his medication from their own pharmacy, and it doesn't come with a label, so staff forgets to label the Lantus pen (insulin medication used to treat Diabetes Mellitus) appropriately. ADON stated that this has occurred before and he has educated staff. ADON stated that the pen will be removed and replaced and labeled appropriately. ADON stated that Resident #40 only gets Lantus (insulin medication used to treat Diabetes Mellitus) at bedtime, an in-service to reeducate nightshift staff will be done. Record Review of Pharmacy Consult book revealed last audit by the consultant pharmacist reflected the following: Medication room report stated Yes expired meds, and no open date found on meds on [DATE]. Medication room report stated Yes expired meds, and no open date found on meds on [DATE]. Record review of the facility policy titled Administering Medications revised [DATE] reads in part: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of the facility policy titled Labeling of Medication Containers revised [DATE] reads in part: Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. Labels shall include the date the medication was dispensed and the expiration date when applicable. UNLOCKED MEDICATION CARTS Observation on [DATE] at 11:54 AM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol, vitamins) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All of the drawers of the Medication Cart (#1) were unlocked and were easily accessible. Observation revealed the DON walked up to LVN D and told her to lock her cart. Surveyor over- heard LVN D respond to DON I am still passing meds. Observation on [DATE] at 12:23 PM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. No staff or residents were present in the area. Observation on [DATE] at 1:46 PM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 3:40 PM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 09:35 AM revealed unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 10:13 AM revealed unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 5:02 PM revealed unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Interview on [DATE] at 9:27 AM LVN D stated that she was nervous and has no excuse for leaving the Medication Cart (#1) unlocked while unattended. LVN D stated that she knows that medication cart should be locked, because someone could get in and get the medications. LVN D stated the medication cart has medications like insulin, vitamins, OTC medications, Tylenol and narcotics that could be dangerous. LVN D stated she is sorry for leaving the Medication Cart unlocked. Interview on [DATE] at 9:00 AM ADON stated that he told LVN D several times to lock her cart. ADON states that LVN D knows better than that and she has been working at the facility for a few years. ADON stated that he will do an in-service on locking Medication Carts. Review of the facility's policy, titled Security of Medication Cart, revised [DATE], reflected (in part): Medication carts must be locked at all times when out of nurses view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview and record review, the facility failed to ensure that menus were served per with adequate or appropriate nutritional items the menus reflected for the noon time meal (lunch) to meet the nutritional needs of residents. 1. [NAME] A did not serve residents on a regular or mechanical soft diet, the correct portion size of salad when served at (lunch or dinner meal). 2. [NAME] A failed to provide residents on a puree diet a starch food at lunch . These failures placed residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings included: Review of the residents food menu to be served on 01/10/23 revealed items to be served were: 1. Regular diet and mechanical soft diet: 2/3 cup of lasagna; 8 oz of salad, 1 garlic bread stick. 2. Puree Diet: 1/2 cup of puree lasagna; 4 oz of puree soft-cook vegetable; garlic bread stick . Observation of the noon meal preparation on 01/10/23 at 11:30 AM revealed [NAME] A plating the food. [NAME] A served lasagna and a bread stick to residents on the regular diet however, [NAME] A provided residents on the regular diet a (yellow handled scoop) equal to three tablespoons serving of salad instead of a full 8 oz of salad list on the menu. The residents on a puree diet did not receive a bread stick (a starch item) or equivalent with their meals. Interview on 01/10/23 at 12:19 PM the DM confirmed [NAME] A used a yellow-handled scoop (three tablespoons) when serving the salad to resident on the regular diet at meal preparation. Interview on 01/11/23 at 09:16 AM [NAME] A stated she had been the cook for six months. [NAME] A stated she was trained to use a grey scoop (1/2 cup) for all puree dishes. [NAME] A said the casserole on the regular trays the staff used a white scoop (2/3 cup). [NAME] A said she normally used a spoon with holes in it for vegetables and did not know how large that was. [NAME] A on the lunch meal for 1/10/23 she used the yellow scoop for the salad , and she thought the yellow scoop was three table spoons big. She said with the corporation switchover, the facility just got (received) new recipes , so she used the same serving sizes as she did under the old corporation. [NAME] A was shown the menu with serving sizes by diet. [NAME] A said she was unaware of the portion sizes. She said she normally would put bread in with the lasagna. She thought back and stated, she did not. Interview on 01/11/23 at 09:44 AM the DM stated she worked as the DM for 3 months. The DM said in hindsight the lunch meal preparation was a disaster. She said [NAME] A was nervous and the previous DM instructed the staff to use a grey scoop for everything. The DM looked at the menu for 1/10/23 with the serving size and said the residents should have received 8 oz of salad and did not. The DM explained the facility just returned to the corporation (Change of management) , so the menu was brand new to us. The DM was informed the residents on a puree diet did not receive a bread portion. She said she was informed not to use bread for puree because it turned back into dough but said there should be mashed potato or rice as a starch. Interview on 01/11/23 at 10:34 AM the Administrator was informed of the menu documenting 8 oz of salad for residents with regular diets and the residents on a puree diet not getting a bread or starch portion at the noon meal. She nodded her head and did not have any additional information. Interview on 01/11/23 at 1:19 PM the DM stated she could not find policies about dietary services.

Based on observation, interview and the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: 1.The facility failed to label and date food items. 2.The facility failed to discard expired food items. 3.The facility failed to ensure staff washed their hands in a manner that prevented cross contamination. These deficient practices could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings include: Observation on 01/09/23 at 10:24 AM revealed: Hand washing sink out of paper towel. DA B washed hands at sink at prep table turn off faucet with bare hands twice. Cook A rinsed hands at the prep table. She did not use soap and turned off the faucet with her bare hands. The preparation sink had a soap dispenser on the wall and a paper towel holder approximately 6 feet away on the next available wall space. Observation on 01/09/23 (at10:24 AM) of the refrigerator contained: - Tupperware container of Pasta dated 1/5/23 - Tupperware container of meat dated 1/5/23 - Zipper bag of ham dated 1/2/23 open to air. - Two bags of bacon dated 12/15/22 open to air. - Zipper bag of hotdogs that were undated. - handful of grilled jalapenos wrapped in plastic wrap and undated. Observation on 01/10/23 between 10:44 AM and 12:19 PM revealed the following: Cook A washed her hands in the food preparation sink and turned off the faucet with her bare hands five times. Cook A rinsed her hands at the preparation sink with no soap and turned off the faucet with her bare hands prior to fixing the puree desert. DA B rinsed her hands in the preparation sink with no soap and turned off the faucet with her bare hands three times. DA B washed her hands in the preparation sink and turned off the faucet with her bare hands twice. The DM washed her hands in the preparation sink and turned off the faucet with her bare hands. Cook A rinsed the measuring cup used to make the puree lunch in the preparation sink and not the dish washing sink immediately next to it. Cook A plated the food with her bare hands while touching the food eating surface. Interview on 01/11/23 at 09:16 AM [NAME] A said she was the cook at the facility for six months. She said she was trained how to wash her hands under the previous dietary manager and the manager trained them to turn on the water, soap hands, and turn off the water with a paper towel. [NAME] A said it needed to be turned off with a paper towel because the washer touched the faucet with dirty hands first. [NAME] A said since there was a soap dispenser and paper towels available that it was alright to wash hands in the preparation sink. [NAME] A said the previous DM trained her in serving the food and it was to wear glove if she was touching the food, she said she was told to grab the side of the plate. [NAME] A admitted she was nervous and in a rush because everyone was looking at her. She said left over food was supposed to be labeled. Interview on 01/11/23 at 09:44 AM the DM stated she worked as the DM for 3 months. The DM said in hindsight the lunch meal preparation on 1/10/23 was a disaster. The DM stated the expectation for hand washing was turn on the water as hot as tolerable, wash the entire hand with soap, rinse, dry hands with a paper towel, and turn off the faucet with a clean paper towel. She said this was done to prevent cross contamination. She said she was not sure if the staff were doing it that way. She was informed all dietary staff were observed washing their hands in the preparation sink and turning off the faucet with their bare hands. The DM said the paper towel dispenser by the handwashing sink was broken, The DM said it hat been acceptable so far to wash hands in the food preparation sink. The DM said the left-over storage depended on the dish stored, but usually the expectation was three days for leftovers. She stated she expected leftovers to be labeled, dated, and covered with the date to throw it away. The DM said the other cook was usually the cook that threw out leftovers and she was not on duty. The DM said leftovers dated 1/5/23 were not acceptable. The DM stated she was instructed by her managers to not wear gloves when serving. Surveyor took a plate and showed the DM how [NAME] A handled the plate. The DM stated touching the eating surface with hands gloved or not caused cross contamination. Surveyor requested policies and the DM stated she did not know where they would be but would look. Interview on 01/11/23 at 10:34 AM the Administrator was informed of the findings in the kitchen. She said her expectation for food in zipper bag was to the be sealed but if the person using it was in a rush sometimes it was hard to tell. The Administrator stated her expectation for hand washing was to be done between tasks, using the handwashing sink, and to use a paper towel to turn off the faucet. The Administrator stated she did not know why the staff were using the preparation sink instead of the handwashing sink. The Administrator stated she did sanitization rounds (checked the kitchen for cleanliness) and the kitchen had come a long way from last year. Interview on 01/11/23 at 1:19 PM the DM stated she had not done an in-service training on hand washing and the previous DM last had in-service training in the middle of last year. She said she could not find policies about dietary services.