**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records in that: The facility failed to document Resident #1's blood pressure before she was transported to dialysis on 08/13/25. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner.Findings included: Record review of Resident #1's face sheet, dated 09/17/25, reflected a [AGE] year-old female with an admission date of 01/24/23. Resident #1 had a diagnosis of Stage 5 Chronic Kidney Disease (the most advanced stage of kidney disease), Acute or Chronic Heart Failure (sudden life-threatening or worsening heart condition), Bacterial Infection (harmful bacteria enter the body and can cause damage), End Stage Renal Disease (kidneys have lost most of the function), Type 2 Diabetes Mellitus (body cannot regulate blood sugar levels), Fluid Overload (excessive amount of fluid in the body), Cardia Arrhythmia (abnormal heart rhythm), Presence of Heart Assist Device, Chest Pain, Unspecified Dementia (cognitive decline and memory loss), and Hypotension of Hemodialysis (a drop in blood pressure that occurs during dialysis). Record review of Resident #1's quarterly MDS assessment, dated 07/16/25, reflected she had a BIMS score of 11 in Section C, which indicated she was moderately impaired. Section N of the quarterly MDS assessment noted Resident #1 had anticoagulant, antibiotic, and hypoglycemic medications. Section O of the quarterly MDS assessment noted Resident #1 received dialysis while she was a resident. Record review of Resident #1's physician orders reflected the following orders: 04/21/25Dialysis MWF11:00 AM 04/21/25Vital Signs Every Shift Record review of Resident #1's Dialysis Communication Form, dated 08/13/25, reflected the following: Dialysis date: 08/13/25 Most Recent Blood Pressure Blood Pressure 102/65 Date 08/12/25 18:22 (6:22 PM) Record review of Resident #1's care plan with an initial date of 05/15/25 reflected the following: Resident #1 required hemodialysis 3 times per week due to ESRD Monitor vital signs. Notify MD of significant abnormalities Resident #1 has an implanted cardiac pacemaker Monitor vital signs. Notify MD of significant abnormalities Record review of the progress notes on Resident #1's electronic record reflected not vital listed for 08/13/25. Record review of the main page of the electronic record, dated 09/17/25, reflected the last blood pressure vital was taken on 08/12/25 at 18:22 (6:22 PM), and Resident #1's blood pressure was 102/65. Record review of the Vitals tab on Resident #1's electronic record reflected the last blood pressure recorded was on 08/12/25 at 18:22 (6:22 PM) by Nurse A. Record review of the August 2025 NAR reflected no blood pressure vitals documented on 08/13/25. Record review of the August 2025 MAR reflected no blood pressure vitals documented on 08/13/25. Record review of the August 2025 TAR reflected no blood pressure vitals documented on 08/13/25. During an interview on 09/17/25 at 11:10 AM, with the Director of Clinical Services, the DON, and the Administrator, Resident #1's Dialysis Binder was requested but not received prior to exit. In an interview on 09/17/25 at 11:40 AM, LVN B stated he prepped Resident #1 for dialysis on 08/13/25. He stated he took her to the transportation person and sent her dialysis folder with her. LVN B stated he checked all of her vitals before she left, and all were within the appropriate range. In an interview with the Director of Clinical Services and the ADON on 09/17/25 at 2:09 PM, The Director of Clinical Services stated he reviewed Resident #1's electronic record and did not locate documentation of Resident #1's blood pressure reading from 08/13/25. The ADON stated it could have been a coincidence that the blood pressure reading from 08/12/25 was the same reading for 08/13/25, and that LVN B probably just documented the wrong date for the blood pressure reading of 102/65. The Director of Clinical Services stated all staff were trained on quality of care, following physician's orders, and documentation. The Director of Clinical Services stated Resident #1's vitals would usually be checked before she left for dialysis. The Director of Clinical Services stated the risk of LVN B not possibly checking the blood pressure or recording the vitals of the patient could negatively affect the patient's care. In a follow-up interview on 09/17/25 at 2:26 PM, LVN B stated he recalled he manually checked Resident #1's blood pressure, but he could not remember what the reading was. LVN B stated he did remember that the blood pressure was within the normal range. LVN B stated vitals are checked on all dialysis residents before they leave for dialysis. He stated he must not have documented the blood pressure. He stated he thought he just wrote the wrong date on the dialysis communication form. LVN B stated the risk of not checking or not documenting the vital check was there could be a problem with the resident and staff would not be aware of before sending the resident to dialysis. In an interview on 09/17/25 at 2:59 PM, the Administrator stated the facility staff were trained on quality of care, documenting, and following physician's orders. The Administrator stated the risk of Resident #1's blood pressure not checked or documented as checked on 08/13/25 was a negative impact on the resident's care. Record review of the facility's in-service titled, Physician's orders, dated 08/20/25, reflected the following: Key Points Physician orders provide the medical plan of care for the patient. Nurses are responsible for carrying out those orders safely and documenting accurately. Following orders ensures continuity of care, patient safety, and compliance with regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored, in a plastic bag with the resident's name and date on it, when not in use on 08/13/2025.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 08/13/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included COPD (disease of the lungs and airway that affects breathing), diabetes (the body does not use insulin effectively), and chronic kidney disease (reduced kidney function). Record review of Resident #1's MDS (tool used to measure health status) Quarterly Assessment, dated 06/16/2025, reflected moderate impaired cognition with a BIMS (tool used to assess cognitive function) score of 12. Section I (active diagnoses) reflected Resident #1 was treated for COPD and asthma (lung disease that causes the airway to narrow and can make breathing difficult).Record review of Resident #1's Comprehensive Care Plan, dated 07/14/2025, reflected the resident had COPD and the approaches were to monitor for shortness of breath and administer medication as ordered.Record review of Resident #1's Physician's Order, dated 08/13/2025, reflected to administer Ipratropium Albuterol Solution 0.5-2.5 (3) mg/3ml - inhale 1 vial orally three times a day for shortness of breath. During an observation and interview on 08/13/2025 at 9:30 AM, Resident #1 was lying in bed. A nebulizer was on top of Resident #1's night stand next to the bed. A nebulizer mask and tubing was connected to the nebulizer. The nebulizer mask was in the top drawer of the night stand with Resident #1's personal items. The mask was not bagged. Resident #1 stated she had a breathing treatment earlier that day. In an interview on 08/13/2025 at 9:42 AM, the RN stated the nebulizer mask should have been in a bag. She stated nebulizer masks and tubing were changed weekly for all respiratory care items. She stated it was important to keep them covered to prevent contamination and infection. During an interview on 08/13/2025 10:05 AM, the CNA stated she also looked at nebulizer masks. She stated nebulizer masks should always be in a bag when the resident was not using it. She stated if a nebulizer mask were not in a bag, she reported it to the nurse so the nurse could get a new mask and put in a bag. She stated she had not noticed the nebulizer mask was not in a bag. She stated if it was not kept in a bag, it was exposed to whatever was in the air. She stated if the resident put the mask back on her face, the risk could be infection. During an interview on 08/13/2025 at 10:12 AM, the ADON stated staff members changed oxygen tubing and nebulizer masks weekly on Sunday night. She stated items should be dated and stored in bags when not being used by residents. She stated this was a risk for infection to residents.During an interview on 08/13/2025 at 1:25 PM, the facility's Regional Nurse Consultant stated in-service training for staff was in progress. He stated there were dust particles in the air and it was important to keep respiratory items in bag to prevent the risk of infection to residents. Record review of the facility's policy Administration Through a Small Volume (Handheld) Nebulizer, undated, reflected 29 . store in a plastic bag with the resident's name and the date on it.

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 the facility's only kitchen reviewed for food safety. 1. The facility failed on 05/01/2025 to ensure dented cans dated 04/28/2025 was placed in a separate storage area to keep from being used for residents' meals. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of dry storage on 4/29/2025 at 9:22am revealed the following: two 6lbs 9oz cans of marinara sauce dated 4/28/2025 was dented on the front. In an interview with [NAME] A on 05/01/2025 at 1:05pm she stated it was the cook's responsibility to store and inspect dry goods in the dry storage upon delivery. She stated if she observed a dented can, she would let the DM know, and placed the dented can in the separate area the kitchen had for dented cans. She stated the DM took a picture of the dented can and sent the photo to the vendor. [NAME] A stated the after the food was stored, labeled, and dated, the DM would go behind staff and inspect items. [NAME] A stated failure to keep dented cans separated could be used and cause sickness because dented cans could have bacteria. In an interview the DM on 05/01/2025 at 1:10pm who stated when the delivery truck delivered food to the facility, the kitchen cooks was responsible for dry storage food items to be properly labeled, stored, and inspected. He stated it was his responsibility to go behind the cooks and inspect all food items from the previous delivery. He stated if staff identified a dented can, he took a picture of the dented can and sent the picture to the vendor and was credited for the dented can. He stated dented cans was kept in separate area. He stated dented cans could cause botulism. The DM provided the facility's food storage policy and indicated the facility did not have a policy regarding dented cans. Record review of the U.S. FDA Food Code 2022 reflected: Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent incidents and accidents for one resident (Resident #1) of five residents reviewed for possible accident hazards and incidents. The facility failed to provide adequate supervision for Resident #1 on 07/23/2024 when he slid out of the sling during a mechanical lift transfer from wheelchair to bed. The noncompliance was identified as past noncompliance (PNC). The PNC began on 07/23/24 and ended on 07/28/24. The facility had corrected the noncompliance before the state's survey began. This failure could place residents at risk for possible injuries due to lack of adequate supervision. Findings included: Review of Resident #1's Face Sheet reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including dementia, hypertension (elevated blood pressure), diabetes mellitus (alteration in blood sugar), aphasia (communication disorder resulting from a brain injury and may include inability to speak well), and stroke. The MDS reflected Resident #1 required substantial/maximal assistance for transfers to and from the bed and wheelchair. Record review of Resident #1's Care Plan dated 03/15/2022 and effective at the time of the incident (07/23/2024) reflected Resident #1 was dependent with activities of daily living and required the use of a mechanical lift for transfers. Review of Provider Investigation Report reflected the facility reported to Health and Human Services on 07/24/2024 at 05:15 p.m. that on 07/23/35 at 07:45 p.m. an incident occurred in which Resident #1 fell out of a sling during a mechanical lift transfer as reported to the charge nurse on duty by CNA A and CNA B. Review of written witness statement obtained by the facility and signed by CNA B dated 07/23/24 were reviewed and stated, sling never detached from hoyer and As I along with another staff were preparing to transfer 405 we hooked and secured the sling to the hoyer lift. As he started to push the button to go up everything seem to be ok. Then patient slipped out legs first head cushioned by a pillow that was on the wheelchair. We checked on his wellbeing immediately and then transferred by hand to the bed.(unable to read) arranged and checked again verbalize to make sure patient was ok. No concern of pain. Nurse Notified. Review of written witness statement obtained by the facility, signed by CNA A, and dated 07/23/24 stated, As we were transferring the resident in room [ROOM NUMBER] with another CNA, the sling was properly hooked on the hoyer but along the line the patient slipped. We notified the nurse, picked him up and got him situated. The patient, when asked said he did not feel any pain. Review of records- Clinical Note dated 07/23/24 and entered by LVN H for Resident #1 stated, 1945 (07:45 p.m.) the CNAs reported to this nurse that during transfer the resident from the wheelchair to bed by use of the mechanical lift, the resident slipped out of the Sling and fell down. The sling never detached from the Hoyer. The clinical note reflected that the nurse completed a head-to-toe assessment of Resident #1, notified the nurse practitioner, the hospice company, the ADON, and the family. LVN H reported he received orders for x-rays, and initiated neuro checks. The clinical note did not indicate that Resident #1 experienced any injury or any pain. Review of records reflected that on 07/24/2024 that x-rays revealed compression fracture of the T11 vertebral body that was of indeterminate age. The physician was notified, and Resident #1 was sent to emergency room for follow up. Record review of hospital records reflected that Resident #1 had no acute injuries: Hospitalist Progress Note dated 07/24/24 and written by MD A was reviewed and revealed that Resident #1 cat scan of the brain and x-rays showed no acute bleed or fractures or dislocations and that T-spine showed chronic T3 and T11 compression fractures. In an interview and observation on 12/10/24 at 11:00 a.m. Resident #1 was observed laying in bed. The bed was in low position and the call light was in reach. He denied remembering any incident of falling from a lift. His answers to questions did not always correspond appropriately to the questions. A wheelchair was noted at the bedside and a sling was on the back of the chair. The sling was noted in good condition. In a telephone interview on 12/10/24 at 12:46 pm, LVN H reported he was the nurse for Resident #1 on 7/23/24 and that CNA A and CNA B reported to him in the evening that Resident #1 had slid out of the sling when they were transferring him from the wheelchair to the bed. He stated, I went to the room and the resident was on the floor. The CNAs reported they assisted the resident to the floor when he began to fall. They did not state that he hit his head or anything else. I looked and the Hoyer lift was okay, the sling was okay. LVN H reported he immediately went to Resident #1's room and noted Resident #1 lying on his back on the floor with his legs pulled up in a fashion typical for the resident, and that his hands were laying across his chest. LVN H stated the sling was under the resident but that he did not note the positioning of the sling. He reported that the resident was within one or two feet of the bed and was not contacting any object. He stated, I'm not sure what might have caused the slide, they did not mention anything. I assessed the resident, and he denied any pain. The facility policy to do neuro checks, we notified the hospice, management (unit manager), an x-ray was ordered, the family was contacted. The resident was not transferred on my shift, but I think maybe the next day. He also stated, A resident could slip out of a Hoyer lift if the resident was not properly positioned and that a resident who fell from a mechanical lift, could have a fracture or other injury. He reported that, Since the incident, the facility continues training on Hoyer lifts, but also nurses now monitor transfers with the Hoyer lift, when possible, to monitor for safe technique. In a telephone interview on 12/10/24 at 02:00 p.m., CNA A reported that on 7/23/24 he was working on evening shift when, the aide that was working that hall called me to help with Resident (Resident #1) to put him to bed. When we lifted him off of his chair, we noticed that his butt was almost off the sling, we lowered him to the floor with our arms and called the nurse to come and assess him. There was a pillow behind him on the neck area when he was in the chair and when we brought him down, we used the pillow as well to bring him down. He did not hit his head. He did not hit anything that we were aware of. When he was lifted from bed to chair, because of the way his legs are wide open, it may have created a wrinkle in the sling that made it not positioned well when we tried to transfer him. CNA A reported he received mechanical lift training about two weeks prior to the incident and again following the incident which including the need for two persons, locking the lift, manual controls, and the safe use of the lift. He stated he felt safe with the use of the mechanical lift at the time of the incident. He reported that the nurses are now more likely to check on the CNAs who are using mechanical lifts. In an interview on 12/10/24 at 12:50 p.m., the ADM reported that CNA B recently quit working at the facility, and they do not have an active contact number for her. The only phone number available for CNA B was noted as a non-working number. In a telephone interview on 12/10/24 at 04:04 p.m., NP A reported that Resident #1 did not have any injuries related to the fall from the mechanical lift in July. She denied any knowledge of any other residents at this facility having an injury related to a mechanical lift. She stated she has frequently seen Resident #1 and has had no concerns related to abuse or neglect in relation to this resident or the use of the mechanical lift by the facility staff. In an interview on 12/10/24 at 11:46 a.m., the ADM reported she had worked at this facility for 8 months. She reported she did the investigation related to the fall from the mechanical lift by Resident #1. She stated that based on the investigation at that time, When they were doing the transfer, the patient slipped out of the sling when going from wheelchair to the bed. They guided him as much as they could. He hit his back on the floor. They notified the charge nurse and the Hospice nurse and notified the family. X-rays were ordered and done 7/23/24 on the 2-10 shift. The x-ray came back negative through the hospice company, and we ordered a second x-ray through our company. The second x-ray done the next morning showed a possible compression fracture. The patient had no pain. The patient was sent out to the emergency room for a cat scan on 7/24/24. The cat scan showed the fractures were chronic and no new fractures were noted. The patient was kept for a urinary tract infection, but he returned to the facility after 4 days. ADM reported that the positioning of the patient on the sling was indicated as possible cause of the fall as CNA reported that the sling may have been mispositioned on the resident. She stated, If I remember correctly the patient wasn't up far enough on the sling. She reported there are 5 mechanical lifts at the facility. She reported that if a resident falls out of the mechanical lift, they could sustain a trauma or a fracture. In an interview on 12/10/24 at 12:00 p.m., LVN I stated she was here on 7/23/24 but that she was not here on the evening shift when the incident occurred. She reported that she was notified by CNA A and CNA B who were transferring resident #1 from the wheelchair to the bed, and they said he slid out of the sling, that basically Resident #1 was moving and that they guided him to the floor. The CNAs stated that the positioning of the resident on the sling may have and the resident moving, may have resulted in him sliding down, and they guided him down to the floor. LVN I reported the accident/injury assessment was done, the family and hospice were notified, the resident received an x-ray, and the facility did an x-ray as well. The resident was sent out to the hospital the next day for a cat scan which was negative. Review of Employee Coaching and Counseling Record dated 07/24/24 and signed by CNA B revealed, Employee in-service and re-evaluated on transferring and procedures when using lift with residents. The facility training records for CNA B were reviewed and noted to include signed Fall prevention competency testing dated 07-09-24 as well as a signed mechanical Lift Competency Skills Checklist dated 07/09/24 and a Transfer Skills Checklist signed and dated 07/09/24. Employee Coaching and Counseling Record dated 07/24/24 and signed by CNA A revealed, Employee inserviced and re-evaluated on transferring and procedures when using lift with residents. The facility training records for CNA A were reviewed and noted to include signed Fall prevention competency testing dated 07-09-24 as well as a signed mechanical Lift Competency Skills Checklist dated 07/09/24 and a Transfer Skills Checklist signed and dated 07/09/24. Review of Facility Accident/Incident Reports dated from 07/07/24 to 12/05/24 were reviewed with no incidents indicating the involvement of a mechanical lift. In an observation on 12/11/24 at 09:00 a.m., CNA C and CNA D were observed transferring Resident #1 from the bed to the chair using the mechanical lift. Proper technique including the proper positioning of the sling was utilized, and no safety concerns were identified. In an observation on 12/10/24 at 09:30 a.m., CNA E and CNA C were observed transferring Resident #2 from her electric wheelchair to her bed using the mechanical lift, providing incontinence care, and then transferring Resident #2 back to her wheelchair using the mechanical lift. The CNAs utilized the mechanical lift safely. The CNAs positioned the sling beneath the resident and attached it to the lift appropriately. The resident tolerated well, and no safety concerns identified. In an interview on 12/10/24 at 09:45, Resident #2 reported she has received assistance with mechanical lift transfers three to four times a day for months due to incontinence. She stated she has never been injured, fallen, or slipped during the use of the mechanical lift and that many different CNAs have assisted her. Review of facility Mechanical Lift Protocol (undated) reflected, 7. Complete return demonstration with all nursing staff with the Hoyer Lift transfer checklist. Review of the facility Full Mechanical Lift Competency Skills Checklist dated May 2024, reflected, 17. Ensure the patient is centered in the lift sling before raising the lift to transfer. The facility took the following actions to correct the noncompliance prior to the investigation: In an interview on 12/10/24 at 11:23 a.m., the DON reported he has worked at this facility for 9 months. He stated that he was not here and had been on leave during the time surrounding Resident #1's fall from the mechanical lift. He stated he was aware that post-incident training was completed with staff and that the unit manager for long-term, LVN I, was responsible for that. He stated that since the incident what the facility does differently is that he himself and LVN I often walk in to see if a resident being transferred is being transferred appropriately. He also stated that LVN I reinforces in-service trainings with the staff. He reported that staff receive mechanical lift training annually and prn and that mechanical lift training had been done within 8 months prior to the incident. The DON reported he did not know how Resident #1 might have fallen out of the sling. Review of facility Employee In-Service Training Report dated 07/24/2024 and titled, Abuse and Neglect in Skilled nursing Facilities: An Overview was reviewed and noted to include staff signatures. The Inservice Training Report dated 07/24/2024 and Titled Sling Care was reviewed and included the content, This sling must be inspected prior to each use for any rips, tears, frayed, or bleached areas which are unsafe and could result in injury. Do not exceed max. weight specified. Refer to Owner's manual for operation of your lift. The in-service training included staff signatures. In-service Training Report dated 07/24/2024 and titled, Mechanical Lift/Hoyer Training included topics of Hoyer lift storage, Battery Charging, and Procedure and Correct Use and was noted to include signatures of nurses and CNAs. Staff return demonstration checklists date 07/24/24 through 07/28/24 titled, Mechanical Lift Competency Skills Checklist were reviewed. Training record for CNA B revealed a Transfer Skills Checklist and a Mechanical Lift Competency Skills Checklist and Fall Prevention Competency Test were completed and signed by CNA B on 07/24/24. Fall Prevention Competency Test, Mechanical Lift Competency Skills Checklist, and Transfer Skills Checklist were completed and signed by CNA A on 07/06/22 and on 07/03/24, and these were repeated and signed post-incident on 7/24/24. In an interview on 12/10/24 at 12:00, LVN I reported she did one on one training with the two aides involved in the incident and all the nursing staff beginning the next day following the incident. She was assisted in training by the therapy department. She reported all staff have received training including the proper use of the mechanical lift and transferring, including the need for two people. She reported mechanical lift training will be done upon hire and quarterly and with annual training and that the staff will be required to do a return demonstration. She reported that in-services will be done as needed between the trainings. She reported that since the incident, the facility does more spot checking to go in and see that mechanical transfers are being done correctly. This is done by the unit managers, nurses, the DON, and staffing coordinator. The frequency of these checks can vary but are often done when it is noted a mechanical lift is being used. Mechanical lift training was reported as completed fully on 7/28/24 after the weekend staff received training. In an interview and review of records on 12/10/24 at 11:46 a.m., the ADM reported that retraining on mechanical lift transfers were done with the two CNAs involved as well as all nursing staff throughout facility beginning 07/24/24. The training completed on 07/28/24 in order to include the weekend staff. She reported that mechanical training continues to occur with all staff upon hire, quarterly and prn. The ADM reported that during the training staff were required to give return demonstration to assure competency and that nursing staff are conducting periodic random checks on mechanical lift transfers to monitor for proper technique. The ADM reported that an emergency QAPI meeting was called on 07/25/24. The QAPI cover sheet dated 07/25/24 titled, Emergency QAPI Plan. System Identified: Transfer Techniques was noted with Participants listed as the executive director, DON, Medical Director, Unit Managers, and Director of Rehab. In an interview on 12/10/24 at 03:34 p.m., DOR reported she began assisting with mechanical lift training for nursing staff including the safe use, safe procedures, including sling placement on 07/24/24. She reported that she required staff to provide a return demonstration of mechanical lift use. She stated she is aware that managers, RN's and LVN's are also checking in during mechanical lift transfers with residents. She reported she believed all staff were trained in mechanical lift transfers and that this was completed within a few days of the incident with Resident #1. A record review of the facility's Hoyer Transfer Audit revealed that Hoyer transfer audits were conducted on a weekly basis from 07/25/24 through 08/29/24 and then bi-weekly from 09/25/24 until 10/31/24. These audits included a sample of six residents each week and no concerns were identified. In an interview on 12/10/24 at 09:50 a.m., CNA E reported she has worked at this facility for about 3 years. She reported she last received mechanical lift training at this facility about 3 months ago and that this included the CNAs transferring each other from chair to bed using the mechanical lift. She denied having ever witnessed any resident falling out or sliding out of a mechanical lift sling. She stated that this would only occur if, the CNA did the transfer by themselves, or they positioned the sling wrong. In an interview on 12/10/34 at 09:55 a.m., CNA F reported she has worked at this facility about 6 years. She stated she received mechanical lift training about 3 weeks ago and that this involved demonstrating the transfer of a fellow CNA using the lift. She stated she has not witnessed or experienced a resident injured or fall during a mechanical lift. In an in an interview on 12/10/24 at 03:15 p.m., CNA G reported he has worked at this facility for about 7 months and that he last received mechanical lift training including the safe use of the mechanical lift including placement of the sling in July 2024. He stated that this occurred a day or two after an incident involving a resident in a mechanical lift. He stated that immediately following that training and since the nurses have been going around making sure we are doing Hoyer transfers right. In an interview on 12/10/24 at 03:18 p.m., RN I reported he has worked at this facility for five months (since August) and was not here at the time of the incident with Resident #1. He reported he last received mechanical lift training a few weeks ago. He stated that this included the safe use of the lift and sling placement as well as return demonstration. He reported that when he hired on, he was informed by his unit manager that nurses are expected to randomly pop in to monitor for the safety of residents receiving mechanical transfer. He stated that he assists and watches to ensure resident safety with mechanical transfers. In an interview on 12/10/24 at 03:20 p.m., LVN K reported he has worked at this facility for five months (since August) and was not here at the time of the incident with Resident #1. He reported he last received mechanical lift training a few weeks ago. He stated that this included the safe use of the life and sling placement as well as return demonstration. He reported that when he hired on, he was informed by his unit manager that nurses are expected to randomly pop in to monitor for the safety of residents receiving mechanical transfer. He stated that he assists and watches to ensure resident safety with mechanical lift transfers. In an interview on 12/10/24 at 03:45 p.m., LVN L reported he has worked at this facility for 6 or 7 years and that he received mechanical lift training in July. He reported the training included a return demonstration of the safe use of the mechanical lift including the positioning of the sling. He stated he was informed that nurses must always make sure that 2 CNAs are used when a resident is transferred and that he was told during training that nurses must check in on mechanical lift transfers periodically to ensure safety and he does this. In an interview on 12/10/24 at 09:00 a.m., CNA D (staffing coordinator) reported he often does random drop-ins to monitor mechanical lifts for proper techniques and safety, and that this began following the mechanical lift incident in July 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Resident #2 and Resident #4) reviewed for dignity and respect in that: 1) The facility failed to provide Resident #2 with help using the toilet and was told by staff to wear an adult brief after her preference to use the tiolet with help was voiced. 2) The facility failed to answer call lights in a timely manner for Resident #2 and Resident # 4's. These faillures could place residents at risk of diminished quality of life and loss of dignity and self-worth. The findings were: 1) Record review of Resident #2's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Right Arm Arthritis (swelling and tenderness causes joint pain or stiffness), Overactive Bladder (a problem with bladder function that causes the sudden need to urinate), Unspecified Osteoarthritis (a progressive joint disease that causes inflammation and pain in joints). Record review of Resident #2's admissions MDS dated [DATE] revealed a BIMS score of 15 which is cognitively intact. Record review of Resident #2's Care Plan revealed it was not completed. Interview on 5/22/24 at 11:23 a.m. Resident #2 stated she was admitted last Thursday evening, 5/16/24 after having surgery on her shoulder. Resident #2 said she fell when she got on a treadmill and the speed was too high. She dislocated her shoulder and had to have surgery. Resident #2 stated she has had a pretty bad experience at the facility. She stated the night shift is scary and they did not want to take her to the bathroom. They told her to pee in her diaper instead of helping her use the restroom. Resident #2 stated a female on the night shift told her she had over 30 residents to take care of by herself. She stated this is why they wanted her to wear a diaper. Resident #2 stated she could walk but needed assistance to use the restroom. She had told the facility staff she wanted help using the bathroom instead of wearing a diaper but stated they take so long to come when she used her call light. She stated she would almost wet herself or would wet herself. Resident #2 said it was better to wear the diaper than wet herself. She stated last night, 5/21/24, she needed two changes and used her call light but got no response. 2) Record review of Resident #4's face sheet revealed a [AGE] year-old man who was admitted on [DATE]. Diagnoses included: Acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), Cardiac arrhythmia (improper beating of the heart, whether irregular, too fast, or too slow), Hypertension/High Blood Pressure (a condition in which the force of the blood against the artery walls is too high), Long term use of anticoagulants (blood thinners which could increase the risk of bleeding, which can be fatal or affect critical organs), Pain, and Shortness of Breath. Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 09, which is moderately cognitively impaired. Resident #4's MDS revealed he needs partial/moderate assistance (helper does less than half) with eating. Also, Resident #4's MDS revealed he needed substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, dressing, and personal hygiene. Furthermore, Resident #4's MDS revealed he was dependent for chair/chair to bed transfer and uses a wheelchair and is incontinent. Record review of Resident #4's Care Plan revealed he was at risk for falls with interventions for staff to respond promptly to calls for assist to the toilet. Also, Resident #4's care plan stated he was always incontinent, and interventions were to check for incontinence; change if wet/soiled to keep skin intact. Furthermore, Resident #4's care plan stated he was at risk for pressure ulcer development with interventions for incontinent care provided every 2 hours and as needed. Interview and Observation on 5/22/24 at 11:56 a.m. with Resident #4 was in a wheelchair and was unable to speak but agreed to shake his head yes or no to questions. He shook his head yes and put his hands outstretched wide when asked if call lights took a long time to be answered. Resident #4 shook his head yes when asked if the night shift took longer to answer call lights. Interview on 5/22/24 at 12:01 p.m. with LVN B stated they do abuse/neglect training every week. He stated the call lights should be answered in 5 to 10 minutes. LVN B said residents should be checked on every two hours. Interview on 5/22/24 at 12:46 p.m. with CNA C stated they do abuse/neglect training weekly or bi-weekly at least. He stated call lights should be answered as soon as the call light went on. He said the call light beeps at the nurse's station also. CNA C stated resident should be checked on every 2 hours or more frequently if they are a fall risk or cannot use their call light. Interview on 5/22/24 at 12:59 p.m. with CNA D stated they do abuse/neglect training weekly and as needed. She stated they are supposed to answer call lights promptly. CNA D stated if you were with a resident, you went to the next resident when you were done. CNA D said all the nurses help each other out answering call lights. She stated residents were to be checked on every 2 hours and as needed. CNA D said she would check on fall risk residents more often. Interview on 5/22/24 at 1:17 p.m. with CNA E stated they do abuse/neglect training every week and as needed. He said call lights should be answered as soon as possible. CNA E said residents are to be checked every two hours or if their call light was on. Interview on 5/22/24 at 4:04 p.m. with DON stated calls lights were expected to be answered within 5 - 10 minutes. He stated residents were to be checked on rounds every 2 hours and as needed. The DON said it was not ok to tell a resident to wear a brief instead of getting help to use the bathroom. The DON stated they had a staff meeting every morning and the nurses would go to each resident's room and ask the resident if they were getting the proper care. Record Review of Resident Council minutes from 3/18/24 showed weekend and night shift take longer for call lights. Also, on 5/21/24, call light need answered timelier. Record Review of the facility's Resident Rights Guidelines for All Nursing Procedures, dated October 2010, stated under Preparation: a. Preventing, recognizing, and reporting resident abuse. b. Resident dignity and respect. Record Review of the facility's Abuse Prohibition Protocol policy dated April 2019, stated under 7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient Abuse: and l. l. Neglect is the failure of the facility, it is employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record Review of facility's Call Light policy, dated June 14, 2006, stated under Responsibility All Staff. Under Purpose To respond promptly to Patient's call for assistance and to ensure call system is in proper working order. Under Procedure Answer ALL call lights promptly whether or not you are assigned to the Patient. Answer all call lights in a prompt, calm, courteous manner. Never make the Patient feel you are too busy to give assistance; offer further assistance before you leave the room. Record Review of facility's Incontinent Care Protocol dated June 2013 stated under Goal: Maintain the Patient in a clean and dry state and prevent complications of incontinence by maintaining and providing incontinent care to the Patient at regular intervals. Under Procedure: Incontinent care will be provided after each incontinent episode. The incontinent product will be changed as indicated. Also, under Document/Review: Care plan and Daily Care Guide reflects every 2- hour checks, preventive skin care and turning/repositioning.

**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 unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 3 out of 8 residents (#2, #5, and #6) reviewed for ADL care. The facility failed to provide timely incontinence care for every two hours or as needed for Resident #2, # 5 and # 6 from 5/17/24 through 5/21/24. The facility failed to provide timely incontinence care on a regular basis for residents #2, #5, and #6. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity. Findings included: 1) Record review of Resident #2's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Right Arm Arthritis (swelling and tenderness causes joint pain or stiffness), Overactive Bladder (a problem with bladder function that causes the sudden need to urinate), Unspecified Osteoarthritis (a progressive joint disease that causes inflammation and pain in joints). Record review of Resident #2's admissions MDS dated [DATE] revealed a BIMS score of 15 which is cognitively intact. The MDS was not completed as Resident #2 was admitted on [DATE]. Record review of Resident #2's ADL care sheet showed incontinent care was documented on 5/17/24 at 1:10 p.m. and at 6:37 p.m., 5/18/24 at 1 a.m., 7:29 a.m. and at 5:42 p.m., 5/19/24 at 2:10 a.m., 6:59 a.m. and at 5:03 p.m., 5/20/24 at 7:44 a.m. and at 7:12 p.m., 5/21/24 at 12:28 a.m., 7:11 a.m., 7:44 p.m. and at 11:31 p.m., 5/22/24 at 9:19 a.m. Interview on 5/22/24 at 11:23 a.m. Resident #2 stated she was admitted last Thursday evening, 5/16/24 after having surgery on her shoulder. Resident #2 said she fell when she got on a treadmill and the speed was too high. She dislocated her shoulder and had to have surgery. Resident #2 stated she has had a pretty bad experience at the facility. She stated the night shift is scary and they did not want to take her to the bathroom. They told her to pee in her diaper instead. Resident #2 stated a female on the night shift told her she had over 30 residents to take care of by herself. She stated this is why they wanted her to wear a diaper. Resident #2 stated she could walk but needed assistance to use the restroom. She had told the facility staff she wanted help using the bathroom instead of wearing a diaper but said they take so long to come. She stated she would almost wet herself or would wet herself. Resident #2 said it was better to wear the diaper than wet herself. She stated last night, 5/21/24, she needed two changes and used her call light but got no response. 2) Record Review of Resident #5's face sheet revealed a [AGE] year-old female, who was admitted on [DATE]. Diagnoses included: Vascular Dementia (occurs when blood flow to brain is reduced which can lead to problems with memory, thinking and behavior), Presence of Right Arthritis (swelling and tenderness causes joint pain or stiffness), Insomnia (sleep disorder in which one has trouble falling asleep, staying asleep or getting quality sleep), Generalized Anxiety, Psychotic Disorder (a mental disorder characterized by a disconnection from reality), Depression and Shortness of Breath. Record Review of Resident #5's Quarterly MDS dated [DATE], revealed a BIMS score of 99 which revealed the resident was unable to complete interview. The MDS revealed Resident #5 was in a wheelchair and is dependent on ADL care provided by 2 or more staff. Furthermore, Resident #5's MDS revealed she was always incontinent. Record Review of Resident #5's Care Plan dated 4/18/24, revealed she required ADL care due to contracture and was incontinent of bowel and bladder. The care plan stated Resident #5 would remain clean, dry and odor free by being placed on a 2-hour toileting program. Resident #5 was also care planned as a fall risk, had dementia, and rejected care/medications at times. Record Review of Resident #5's ADL care sheet revealed incontinent care was documented as given on 5/17/24 at 3:27 a.m. and at 1:30 p.m., 5/18/24 at 1:15 a.m. and at 9:59 a.m., 5/19/24 at 12:58 p.m., 5/20/24 at 8:41 a.m., 9:58 p.m. and at 10:30 p.m., 5/21/24 at 9:58 p.m. 1:32 a.m. and at 11:16 a.m. Observation and attempted interview on 5/22/24 at 12:07 p.m. Resident #5 was watching television. Surveyor introduced herself, and asked if she could talk to her, but Resident #5 closed her eyes. Surveyor asked if she was all right, and she closed her eyes tighter. Surveyor left the room and less than a minute later, Resident #5 started moaning loudly. 3) Record Review of Resident #6's face sheet revealed an [AGE] year-old man who was admitted on [DATE]. Diagnoses Included: Unspecified Dementia (Dementia (loss of memory, language, problem solving and other thinking abilities that interfere with daily life) without a specific diagnoses), Unspecified Convulsions (fits or seizures), and Parkinsonism (disorder of central nervous system that affects movement, often including tremors). Record Review of Resident #6's admission MDS on 4/19/24 revealed a BIMS of 03; significantly cognitively impaired. The MDS for Resident #6 revealed he was in a wheelchair, and he was totally dependent on staff for ADL care including incontinent care with 2 or more people assisting. Record Review of Resident #6's Care Plan dated 4/19/24 showed he was a fall risk and had dementia. Record Review of Resident #6's ADL care sheet revealed incontinent care was documented as given on 5/17/24 at 12:45 a.m., 5/18/24 at 1:04 a.m. and 9:47 a.m., 5/19/24 at 12:14 p.m., 5/20/24 at 8:45 a.m., 5/21/24 at 9:57 p.m. and on 5/22/24 at 1:39 a.m. and 11:14 a.m. Interview on 5/22/24 at 12:01 p.m. LVN B stated they do abuse/neglect training every week. LVN B said residents should be checked on every two hours. Observation and attempted interview on 5/22/24 at 12:09 p.m. Resident #6 was sitting in his wheelchair in his room watching television. He was unable to answer any questions and just smiled and laughed when Surveyor told him she would let him go. Interview on 5/22/24 at 12:46 p.m. CNA C stated they do abuse/neglect training weekly or bi-weekly at least. CNA C stated resident should be checked on every 2 hours or more frequently if they are a fall risk or cannot use their call light. Interview on 5/22/24 at 12:59 p.m. CNA D stated they do abuse/neglect training weekly and as needed. She stated residents were to be checked on every 2 hours and as needed. CNA D said she would check on fall risk residents more often. Interview on 5/22/24 at 1:17 p.m. CNA E stated they do abuse/neglect training every week and as needed. CNA E said residents are to be checked every two hours or if their call light was on. Interview on 5/22/24 at 4:04 p.m. the DON stated residents were to be checked on rounds every 2 hours and as needed. The DON stated when incontinent care was done, the CNAs are to document it on the computer. The DON stated he would be concerned if an ADL dependent resident only had 2 documented incontinent care times documented in the computer in a day. The DON stated there were several risks to a resident such as a UTI, Neglect, and patient's rights as well if resident's ADL care was done in a timely manner. The DON stated it was not all right for staff to tell a resident to wear an adult brief instead of helping them use the restroom. The DON stated they had a staff meeting every morning and the nurses would go to each resident's room and ask the resident if they were getting the proper care. Record Review of the facility's Resident Rights Guidelines for All Nursing Procedures, dated October 2010, stated under Preparation: a. Preventing, recognizing, and reporting resident abuse. b. Resident dignity and respect. Record Review of the facility's Abuse Prohibition Protocol policy dated April 2019, stated under 7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient Abuse: and l. l. Neglect is the failure of the facility, it is employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record Review of facility's Incontinent Care Protocol dated June 2013 stated under Goal: Maintain the Patient in a clean and dry state and prevent complications of incontinence by maintaining and providing incontinent care to the Patient at regular intervals. Under Procedure: Incontinent care will be provided after each incontinent episode. The incontinent product will be changed as indicated. Also, under Document/Review: Care plan and Daily Care Guide reflects every 2- hour checks, preventive skin care and turning/repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #80) of 5 residents reviewed for clinical records. 1. The facility failed to ensure staff kept copies of Resident #80's shower sheets from February and March 2024. 2. The facility failed to provide nurses notes on Resident #80's refusals to shower from February and March 2024. These failures could affect residents and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #80's face sheet, dated 03/27/2024, reflected the resident was a [AGE] year-old woman who was admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included chronic obstructive pulmonary disease, unspecified infectious disease, unspecified fall, hemorrhage of left cerebrum without loss of consciousness, and urinary tract infection. Review of Resident 80's MDS assessment, dated 2/26/2024, reflected she had a BIMS score of a 3. Review of shower log provided by the facility for Resident #80 revealed there were no showers for the month of February 2024 and four showers the entire month of March 2024. Interview on 04/04/24 at 2:12 PM with CNA D revealed he cared for Resident #80 and provided her only four bed baths while she was at the facility. CNA D said Resident #80's shower days were Tuesdays, Thursdays, and Saturdays. CNA D said when a resident refused a shower he would notify LVN E and if Resident #80 continued to refuse he would fill out a shower sheet and give it to the LVN E. CNA D said he was not sure what happened to the shower sheets after that. Interview on 04/04/24 at 2:45 PM with the LVN E revealed he was not able to locate any shower sheets for Resident #80 or nurses notes documenting the refusal for February and March 2024. Interview on 04/04/24 at 3:08 PM with the DON revealed he was unable to locate any additional shower sheets for Resident #80 for the months of February and March 2024. The DON said the shower sheets were pulled and discarded at the end of each month. The DON said the CNA's were responsible for providing showers and filling out the shower sheet and then showing it to the Nurse and placing it in a specific place to be held until the end of the month. He revealed the purpose of keeping shower sheets was to prove that the resident was offered a shower on that date and if they refused it was annotated on the shower sheet. The DON revealed no nurse documented shower refusals of resident 80 and no notification to family. Review of the facility's policy, revised July 2017, and titled Charting and Documentation reflected: Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations; Treatment or services performed; changes in resident's condition. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident received reasonable accommodation of needs and preferences for one (Resident #2) of five residents reviewed for accommodations of needs. The facility failed to ensure Resident #2's call light was withing reach. This failure could place resident at risk for not being able to contact staff and their needs not being met. Findings included: Review of Resident #2's face sheet undated reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's primary diagnoses included dementia. Review of Resident #2's MDS undated reflected she had a BIMS score of 04 , which indicated she had severe cognitive impairment. She required assistance with activities of daily living (ADL) with two-person physical assist, including bed mobility, transfer, dressing, and toilet use. Review of Resident #2's care plan dated 05/21/22 revealed Problems Falls: at risk for falls R/t altered mental status, history of falls prior to admission. Interventions Place call bell/light within easy reach. Observation on 07/15/23 at 10:22 AM, revealed Resident #2 was alert and was lying in bed. When asked where her call light was, Resident #2 responded it's here somewhere. Resident #2 then attempted to roll from left to right in the bed. When asked if she could reach her water, Resident #2 attempted to pull herself up to reach the water cup located on the bedside table. Resident #2 was unable to reach the water cup. Call light was observed on the floor next to resident #2's bed. Interview with CNA C on 07/15/22 at 3:05 PM revealed that the call light was needed for residents to be able to indicate when they need help with something. If the call light was not within reach the resident could be at risk of falling. Review of the facility's call light policy dated 06/14/05 reflected, Purpose: to respond promptly to Patient's call for assistance wand to ensure call system is working order. When providing care to Patients, be sure to position the call light convenient for the Patient to use. Tell the Patient where the call light is and show him/her how to use the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to implement the developed care plan for Resident #1, which included an intervention for the use of fall mats, as it related to her being a fall risk due to her diagnosis of unspecified dementia. This failure could place residents at risk for not receiving necessary care and services. Findings included: Record Review of Resident #1's electronic Facesheet, dated 07/03/23, indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and muscle weakness. Record Review of Resident #1's Nursing Home Discharge MDS, dated [DATE], reflected Resident #1 had a BIMS of 4, which indicated her cognition was severely impaired. Additional review of the MDS reflected, Resident #1 required assistance for transfers and bed mobility and was always incontinent of bowel and bladder. Record Review of Resident #1's Care Plan , dated 06/23/23, reflected Resident #1 was at risk for falls due to unspecified dementia. The interventions included All staff: Place call bell/light within easy reach. Provide reminders to use ambulation and transfer assist devices. Remind [Resident] to call for assistance before moving from bed-to-chair and from chair-to-bed. Respond promptly to call for assist to the toilet. Monitor more frequently, frequent checks fall mats are in place. Record Review of Resident #1's Clinical Notes, dated 06/26/23, by the ADON, reflected Patient was observed on the floor laying on the left side, on assessment noted that patient had bruising to chin on left hand and left knee, Patient denies pain, Able to move BUE/BLE, Patient unable to state what happened, Patient assisted back to bed x(times) 2 person assist, MD notified, no new orders, RP notified. Will monitor Patient frequently. In an interview on 07/03/23 at 10:13 AM, CNA A stated she was walking pasts Resident #1's room and saw her on the floor. She stated she called CNA B, who was covering Resident #1's hall and she went to get LVN C. She stated LVN C assessed Resident #1 and then they got her off the floor. CNA A stated Resident #1's bed was at the lowest position, but there was not a fall mat in place. CNA A stated there should have been a fall mat and after Resident #1 fell, they immediately put the fall mats down. In an interview on 07/03/23 at 10:19 AM, CNA B stated CNA A called her to Resident #1's room because she fell. She stated she was the CNA assigned to Resident #1's hall. CNA B stated she let LVN C, who was the nurse responsible for Resident #1's hall, know that Resident #1 fell. CNA B stated Resident #1 did not have a fall mat in place. She stated LVN C assessed Resident #1 and they removed her from floor. CNA B stated they did put a fall mat in place after Resident #1 fell. She stated Resident #1 had bruising on her face, hand, and knee. In an interview on 07/03/23 at 10:23 AM, LVN C stated he was called to Resident #1's room by CNA B. He stated Resident #1 was on the floor. LVN C stated he took Resident #1's vitals and assessed her for injury and fractures. He stated she had a bruise on her face near her chin. LVN C stated he believed it was on the right side of her face. He stated she had bruising on her knee as well. LVN C stated he could not remember if there was fall mat in place before she fell, but he knew for sure one was there after Resident #1 fell because he was doing frequent checks on her. In an interview on 07/03/23 at 10:30 AM, the ADON stated she was called to Resident #1's room by LVN C. She stated Resident had fell on the floor from her bed and was laying she believed on her left side. The ADON stated LVN C took Resident #1's vitals and assessed her for fractures. She stated Resident #1 did not have any fractures or serious injuries. The ADON stated Resident #1 had bruising on her chin and knee. She stated Resident #1 was a fall risk and required a fall mat. The ADON stated she could not remember if a fall mat was in place prior to Resident 1 falling. In an interview on 07/03/23 at 2:50 PM, the Administrator stated she was on vacation when Resident #1 fell. The Administrator stated she believed Resident #1 entered the facility the day before she left for vacation, and she recalled putting a fall mat in her room. The Administrator stated she was not sure why the fall mat was not in place, prior to her fall, but there should have been one there. She stated Resident #1 was a fall risk and was care planned to have a fall mat. The Administrator stated she would complete an in-service with staff. Record Review of the facility's policy titled Patient Care Management System 12, dated November 2017, reflected Upon admission (including readmission) each Patient/Resident's diagnoses must be reviewed with the physician to develop individualized care plan interventions, including the touchscreen daily care guide. The facility will use Patient/Resident observation, communication, family input and clinical history as the primary source of information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to put fall mats in place for Resident #1, when she fell from her bed on 06/26/23, which could have potentially helped avoid Resident #1's bruising. This failure could place residents at risk of pain, injuries, and hospitalization. Findings included: Record Review of Resident #1's electronic Facesheet, dated 07/03/23, indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and muscle weakness. Record Review of Resident #1's Nursing Home Discharge MDS, dated [DATE], reflected Resident #1 had a BIMS of 4, which indicated her cognition was severely impaired. Additional review of the MDS reflected, Resident #1 required assistance for transfers and bed mobility and was always incontinent of bowel and bladder. Record Review of Resident #1's Care Plan , dated 06/23/23, reflected Resident #1 was at risk for falls due to unspecified dementia. The interventions included All staff: Place call bell/light within easy reach. Provide reminders to use ambulation and transfer assist devices. Remind [Resident] to call for assistance before moving from bed-to-chair and from chair-to-bed. Respond promptly to call for assist to the toilet. Monitor more frequently, frequent checks fall mats are in place. Record Review of Resident #1's Clinical Notes, dated 06/26/23, by the ADON, reflected Patient was observed on the floor laying on the left side, on assessment noted that patient had bruising to chin on left hand and left knee, Patient denies pain, Able to move BUE/BLE, Patient unable to state what happened, Patient assisted back to bed x(times) 2 person assist, MD notified, no new orders, RP notified. Will monitor Patient frequently. Record review of the facility's policy titled Fall Management Guidelines, dated November 2022, reflected 8. During daily Clinical Stand Up, any Patients who have had a recent fall and any patients admitted who are at risk fall will be discussed to ensure that fall prevention interventions have been implemented. 9. Staff assigned to the units will conduct rounds for residents at risk for falls or who have experienced a fall to ensure their fall prevention interventions are implemented. In an interview on 07/03/23 at 10:13 AM, CNA A stated she was walking pasts Resident #1's room and saw her on the floor. She stated she called CNA B, who was covering Resident #1's hall and she went to get LVN C. She stated LVN C assessed Resident #1 and then they got her off the floor. CNA A stated Resident #1's bed was at the lowest position, but there was not a fall mat in place. CNA A stated there should have been a fall mat and after Resident #1 fell, they immediately put the fall mats down. In an interview on 07/03/23 at 10:19 AM, CNA B stated CNA A called her to Resident #1's room because she fell. She stated she was the CNA assigned to Resident #1's hall. CNA B stated she let LVN C, who was the nurse responsible for Resident #1's hall, know that Resident #1 fell. CNA B stated Resident #1 did not have a fall mat in place. She stated LVN C assessed Resident #1 and they removed her from floor. CNA B stated they did put a fall mat in place after Resident #1 fell. She stated Resident #1 had bruising on her face, hand, and knee. In an interview on 07/03/23 at 10:23 AM, LVN C stated he was called to Resident #1's room by CNA B. He stated Resident #1 was on the floor. LVN C stated he took Resident #1's vitals and assessed her for injury and fractures. He stated she had a bruise on her face near her chin. LVN C stated he believed it was on the right side of her face. He stated she had bruising on her knee as well. LVN C stated he could not remember if there was fall mat in place before she fell, but he knew for sure one was there after Resident #1 fell because he was doing frequent checks on her. In an interview on 07/03/23 at 10:30 AM, the ADON stated she was called to Resident #1's room by LVN C. She stated Resident had fell on the floor from her bed and was laying she believed on her left side. The ADON stated LVN C took Resident #1's vitals and assessed her for fractures. She stated Resident #1 did not have any fractures or serious injuries. The ADON stated Resident #1 had bruising on her chin and knee. She stated Resident #1 was a fall risk and required a fall mat. The ADON stated she could not remember if a fall mat was in place prior to Resident 1 falling. In an interview on 07/03/23 at 2:50 PM, the Administrator stated she was on vacation when Resident #1 fell. The Administrator stated she believed Resident #1 entered the facility the day before she left for vacation, and she recalled putting a fall mat in her room. The Administrator stated she was not sure why the fall mat was not in place, prior to her fall, but there should have been one there. She stated Resident #1 was a fall risk and was care planned to have a fall mat. The Administrator stated she would complete an in-service with staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers from developing 1 (Resident #1) of 10 residents reviewed for pressure ulcers. The facility failed to use wedges and/or pillows under Resident #1's heels to reduce pressure. This failure could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers. Findings include: Record review of Resident #1's face sheet, dated 04/24/23, revealed a [AGE] year-old female, with an admission date of 01/10/23, and diagnosis of Metabolic Encephalopathy (brain issue caused by chemical imbalance), Cardiomegaly (enlarged heart), Hypertensive Heart Disease, Muscle Weakness, Dementia, Acute Embolism and Thrombosis of Unspecified Vein (blockage), Thyrotoxicosis(thyroid hormone condition), Hyperlipidemia (High Cholesterol), Insomnia, Nutritional Deficiency, Deficiency of other Vitamins, and Unspecified Open Wound. Record review of Resident #1's Care Plan dated 01/11/23 noted the following: Problems Ulcer Prevention Status: Active Goals: [Resident #1] will not develop new pressure ulcers. Status: Active C4.7- Use suspension devices, pillows, and/or wedges to reduce pressure on heels and boney prominences Status: Active In an observation on 04/21/23 at 1:00 PM, Resident #1 was observed, laying in bed, being fed her lunch. Resident #1 did not have a pillow or wedge under her feet. In an observation on 04/22/23 at 9:45 PM, Resident #1 was observed, laying in bed, watching television in her room. Resident #1 did not have a pillow or wedge under her feet. During an interview on 04/22/23 at 9:45 PM, Resident #1 was observed laying in bed. She stated she was just watching television. She stated she was tired and a little sore. Resident #1 did not say where the soreness was on her body. In an interview on 04/22/23 at 10:13 PM, CNA C stated he was familiar with Resident #1 and that he worked with Resident #1. He stated that if he looked at Resident #1's feet and her feet did not appear swollen or had fluid, he would not put the pillow under her feet. He stated that usually he would put the pillow under Resident #1's feet. In an interview on 04/22/23 at 10:36 PM, ADON stated that it was in Resident #1's care plan to place a pillow under her feet. She stated that Resident #1 should have had a pillow under her feet at all times. She stated the only time the pillow would not be placed under her feet was if she was being changed, bathed, or re-positioned in bed. ADON stated the pillow should have been replaced after any of those activities. She stated that she would complete an in-service to remind the staff. In a follow up interview on 04/24/23 at 12:20 PM, ADON stated that the staff knew to place the pillow under Resident #1's feet. ADON stated one risk of not placing the pillow under the resident's feet is the re-opening of a wound or Resident #1 having a new wound. In an interview on 04/24/23 at 2:26 PM, Assistant Administrator stated the care plans should be followed. He stated a risk of not putting the pillow under the resident's feet was diminished quality of life. Record review of the facility's policy titled Skin Treatment Protocol 1-A, dated November 2015, stated the following: This general skin protocol must be followed for all patients: 1. Use appropriate pressure-reducing devices to include but not limited to special care areas i.e. tracheostomy, O2, contractures, orthotic devices, etc. 3. Turn and reposition based on patient's individualized need and clinical condition.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one (medication cart #1) of 3 medication carts reviewed. The facility failed to ensure medication cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: An observation on 04/19/23 at 9:10 AM revealed Medication Cart #1 was unlocked and unattended. All drawers of the medication cart were unlocked, and medications were easily accessible. Surveyor was able to open all drawers of the cart, and prescription medication was accessible. Nurse Manager B walked over and locked the medication cart while Surveyor was standing by the cart. In an interview on 04/19/23 at 9:20 AM, Mediation Aide A stated the medication cart belonged to him. He stated he thought he locked it when he left to go do medications for a different hall. He stated he was trained that the medication cart should be locked at all times. He stated that one risk of leaving the medication cart unlocked was that any resident could get medications off the cart that was not theirs. In an interview on 04/19/23 at 10:15 AM, Nurse Manager B stated that all medication aides had been trained on not leaving their medication carts unlocked. He stated one risk of an unlocked medication cart was a resident or anyone could get medications off the medication cart. In an interview on 04/19/23 at 10:45 AM, Assistant Administrator stated all medication aides had been trained on locked medication carts, and that they had been trained on the risks, like missing medications. Record review of the facility's policy titled Storage of Medication, last revised April 2007, revealed the following: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure foods were properly sealed, labeled, dated, and stored. 2. The facility failed to dispose of expired or spoiled foods. These failures could place residents who received food from the kitchen at risk for food borne illness. Findings include: An observation of the pantry and refrigerator on 04/21/23 at 10:15 AM revealed the following: 1. A 6 LBS, 9 OZ can of California Diced Peaches, can dented at bottom, stored in the pantry 2. About 30 small cups of juice, not labeled or dated 3. About 120 cups of juice and tea on a black cart, label on black cart stated, Prep Date 04/18/23, use by 04/20/23 4. One-half large yellow onion, in an unsealed quart-size bag, not labeled or dated 5. One brown box of about 20 sweet potatoes, with white, green, and gray furry circular mold, with mold on the ends of the sweet potatoes, had a hand-written date on the box of 02/23. In an interview on 04/21/23 at 10:30 AM, Dietary Manager stated he was ultimately responsible for checking for spoiled and expired foods. Dietary Manager stated he checks weekly for expired and spoiled foods, and that he also would check when the delivery truck arrived. Dietary Manager stated that all kitchen staff were responsible for properly labeling and storing the food. He stated that if they received a dented can of food, they would place it near the office and not in the pantry, so they are not used. Dietary Manager stated that he was aware of the risks of it all and that would be residents getting sick. In an interview on 04/24/23 at 2:26 PM, Assistant Administrator stated that they completed an in-service with the dietary staff as a reminder to check for expired foods. He stated that the staff is aware of the risks, and the risks are a diminished quality of life and food-borne illness. Record review of the facility's undated policy titled Food Storage revealed the following: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 4. All containers must be legible and accurately labeled, including date the package was opened. 8. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. a. Old stock is always used first 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. 15. Refrigeration: e. All foods should be covered, labeled, and dated. Record review of the The U.S. Public Health Service, Food Code, dated 2017 revealed the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #1) of 5 residents reviewed for clinical records. The facility failed to ensure the nursing staff accurately documented Resident #1's skin condition and document treatment orders prior to the implementation of treatment. This failure could place residents at risk for inappropriate treatments and worsening of skin conditions due to incomplete and in accurate clinical records. Findings included: Review of Resident #1's face sheet, dated 3/1/2023, revealed the [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. Review of Resident #1's admission nursing assessment dated [DATE], described Resident #1's skin as being intact without wounds. Review of Resident #1's admission MDS assessment dated [DATE] revealed no cognitive impairment with a BIMS score of 15 (a score of 13 - 15 indicated no cognitive impairment). He had no behaviors and no rejection of care. He was extensive assistance of two staff for bed mobility, transfers, personal hygiene, bathing, and dressing. He was frequently incontinent of bowel. He was not at risk for pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. He had no skin and ulcer/injury treatments. Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 2/6/2023 revealed the resident was at mild risk for pressure sores. Review of Resident #1's undated care plan, reflected Resident #1 was at risk for pressure ulcers with approaches including: check for redness, skin tears, swelling or pressure areas. In an observation on 3/1/2023 at 11:30 AM, Resident #1 had a bandage on his sacrum dated 2/28/2023. Review of Resident #1's EMR on 3/1/2023, revealed the absence of documentation regarding a skin assessment, progress notes and treatment orders for a wound that was identified on 2/26/2023. Review of Resident #1's, progress note entered by LVN F dated 3/1/2023 at 1:46 PM revealed, notification to wound physician via telehealth. Reported findings on the right buttock and sacrum, new treatment orders obtained for Anisept Gel, calcium Alginate and dry dressing to both open areas, Offload and reposition per facility protocol. No documentation of a call or documentation of an open wound prior to this entry. Review of Resident #1 physician's orders reflected: as of 3/1/2023 telephone order cleanse wound to sacrum with Normal saline or skin cleanser. Pat dry. Apply Calcium Alginate (dressing used to promote healing) to wound bed. Cover with Dry dressing. As of 3/1/23 telephone order cleanse wound to right buttock with Normal Saline or skin cleanser. Pat dry. Apply Anisept Gel (used to prevent infection) to wound bed. Cover with dry dressing. No treatment orders found prior to 3/1/2023. In an interview on 3/1/2023 at 12:59 PM, LVN A stated on 2/25/2023 instructions were provided to RN D during weekend report, to provide the following treatment to the wounds on Resident #1's bottom clean the wound with saline or wound cleanser, apply calcium alginate and cover with a dry dressing. In an interview on 3/2/2023 at 08:54 AM, NOK stated on 2/26/2023 she saw 2 small open areas on Resident #1's bottom. NOK made the staff aware of the open sores on Resident #1's bottom. NOK reported that a dressing was applied to the open areas on 2/26/2023, 2/27/2023 and 2/28/2023. In an interview on 3/2/2023 at 09:36 AM Resident #1 stated, he had a sore on his bottom that they put medicine and a patch on over the weekend. In an interview on 3/2/2023 at 10:55 AM, the DON stated he was not aware that Resident #1 had an open wound on his bottom as of 2/26/2023. The DON was not able to locate documentation of the change in skin condition and was not able to locate treatment orders in the Resident #1's EHR. The DON stated a change in a resident's skin should be documented in a progress note. The DON expects that physician orders were entered into the EHR asap, to ensure treatments were provided as ordered. In an interview on 3/2/2023 at 1:30 PM, RN E stated that LVN A had fallen behind with the documentation. RN E did not find a progress note or physician order related to Resident #1's wounds prior to 3/1/2023. Nursing staff were expected to document a progress not when they observe changes in the skin of a resident. In an interview on 3/2/2023 at 2:08 PM, RN D stated that she received a verbal report from LVN A regarding wound care instructions for Resident #1. Instructions were as follows: after cleaning the wound, dress with calcium alginate and cover with a dry dressing. Review of the facility policy titled Patient Care Management System 1: Skin, revised July 2022 revealed, #4 any newly identified wounds will be addressed by the treatment nurse or Charge Nurse to include assessment and documentation of the skin site and initiate appropriate clinical interventions. Notify Patient's Representative and Medical Provider of any new or change in existing wound(s) and document in the EHR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interviews, and record reviews, the facility failed to develop a care plan with measurable goals, and interventions to address the care and treatment for a resident requiring pain management due to left hip replacement for 1 of 6 residents (Resident #87) reviewed for Care Plans. The facility failed to ensure Resident #87's pain management was care planned. This failure could place residents at risk of needs not being met. Findings include: Review of Resident #87's face sheet dated 02/24/2023 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included After care Following Joint Replacement Surgery, and Pain. Review of Resident #87's Minimum Data Set (MDS) dated [DATE], revealed the resident was assessed for pain management, and it indicated that the resident required a scheduled pain medication regimen. Review of Resident #87's Care Plan dated 02/24/2023, revealed the resident's Care plan was implemented on 01/17/2023; however, there was no care planning for Care Management. Record Review of Resident #87's Orders on 02/24/2023 revealed Physician orders for Aspirin 325 Miligram (mg) tablet, Tramadol 50 mg tablet, and Hydrocodone 5 mg, which are all pain medications. Interview with Resident #87 on 02/22/23 at 1:15 PM revealed she arrived from the hospital following hip surgery and she was at the facility for rehabilitation. She stated that sometimes she thinks she does not get her pain medication timely. Interview on 02/24/2023 at 09:45 AM with LVN B revealed that Resident #87 had arrived from the hospital post operation for her therapy. He stated they do practice pain management with the resident, and she does often complain of pain. He stated that they increased the resident's pain medication from every 6 hours to every 4 hours. He was asked if the resident's pain management should be care planned and he stated it should be. He stated that the resident was receiving her pain medication but if the resident's pain management is not care planned, the resident could miss out on receiving proper care. Interview on 02/24/2023 at 09:50 am with DON, Wound Nurse, Assistant Director of Nursing, and Regional Director of Clinical Services revealed the wound nurse reviewing Resident #87's Care Plan and she advised the resident's Care plan was updated on 02/23/2023 to include pain management. They were advised the resident was admitted to the facility originally on 01/17/2023 from post operation, but the resident's Care Plan only had one item of focus, which did not include pain management. They stated it is the responsibility of the MDS nurse to ensure that Care Plans are accurate and updated. They advised the risk of the resident not having pain management care planned is the resident could miss out on receiving the proper interventions. Interview on 02/24/2023 at 11:40 AM with MDS Nurse revealed she is responsible for inputting information for Care plans. She was asked about the Care Plans for Resident #87 and she acknowledged the resident had a diagnosis of Acute Pain and took medication to treat her pain. She stated the resident's pain diagnosis should have been care-planned for Pain Management. She stated she is the only MDS Nurse for the entire facility and she had gotten behind in doing Care plans. She stated she had updated residents' care plan to reflect a plan for Pain Management. She stated they are currently attempting to hire an additional MDS nurse, but in the meantime, she is getting some part-time assistance to help her get caught up. She stated the risk to the residents not having an accurate care plan could impact the care being provided to the residents. Interview with Administrator on 02/24/23 at 3:39 PM revealed she was made aware of Care Plan concerns, and she stated they were short an MDS nurse and although staff helps, they are still behind. She stated she expects the MDS Nurse or whomever is assisting, to ensure all major diagnosis areas are care planned appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe ,sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infection for one (Resident #46) of eight resdients reviewed for infection control . The facility failed to ensure Occupational Therapist Assistant (OTA A) properly donned her gloves and gown prior to providing therapy to Resident 1 of 3 residents (#46) placed in transmission-based isolation for Infection Control. This failure could place other residents at risk of contracting a transmission-based illness because of precautions not being taken. Finding Includes: Review of Resident #46's face sheet dated 02/24/2023 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Infections, Sepsis (bacteria Infections) and metabolic encephalopathy (Infections of the Brain). Observation on 02/22/23 at 1:13 PM revealed a sign on Resident #46's room door, which indicated Stop and a sign advising of appropriate PPE required when entering the room to provide care to the resident. The sign indicated a gown, gloves, and face mask being required. The door was open and OTA A was observed providing therapy to resident #46 and she was observed only wearing her face mask. OTA A noticed that she was being observed and she exited the room and began to put on a gown and she sanitized her hands before putting on gloves. Interview with Director of Rehabilitation on 02/24/23 at 10:00 am revealed she was made aware by OTA A that she was observed entering Resident #46's room to provide therapy without donning a gown and gloves. She stated she had just in-serviced her staff on proper donning and doffing of PPE when entering a resident's room who was placed in transmission-based isolations. She stated OTA A was placed on suspension because she knew the proper PPE to wear when caring for the resident. She stated the risk to OTA A not wearing the proper PPE could result in OTA A providing therapy to other residents and placing them at risk of an infection. Interview on 02/24/23 at 11:26 AM ADON revealed Resident #46 was in isolation because she was suspected of having bacteria virus, and they were still awaiting test results. She stated anyone entering the room to provide any care must wear the appropriate PPE. She stated staff must properly don their gown, face mask, and gloves after properly sanitizing their hands. She stated she was made aware of the Occupational Therapist Assistant entering a resident's room that was in isolation. She stated the risk to staff not donning the proper PPE when assisting a resident placed in transmission-based isolation could result in the staff spreading an infection to other residents. Interview on 02/24/2023 at 12:05 PM with OTA A revealed she was aware she needed to don gloves and gown before assisting resident #46, who is in isolation because of a suspected bacteria virus. She stated she had a lapse in judgement when providing care to the resident and she should have put on the proper PPE before caring for the resident. She stated she was in the resident's room to complete her occupational therapy. She stated the risk to the resident and other residents is that she could be exposed and she could expose other residents she provides care to. Interview with DON on 02/24/23 at 2:28 PM revealed he was made aware of OTA A entering the resident's room without donning the proper PPE when assisting this resident since she was suspected of having C-Diff. He advised staff had been made aware of the appropriate PPE when entering a resident's room who is in isolation because of an illness that could spread. He stated that staff are trained to ensure they wear the appropriate PPE based on the situation and in this case, the resident should have placed on the appropriate glove and gown before caring for the resident. He also stated that proper hand sanitization should also occur. The DON stated the risk to the staff member not donning the appropriate PPE was the staff member could spread an illness to others. Interview with Administrator on 02/24/23 at 2:00 PM revealed that she was made aware of staff not donning the appropriate PPE prior to providing therapy to Resident #46 and her expectation is for all staff to following proper guidelines for PPE when entering a room where transmission-based precautions are being taken. She stated the risk of anyone providing care to residents in transmission-based precautions is that they can infect other residents. Record review of the facility's policy on Contact Precautions, dated March 2019, revealed anyone entering a room suspected of a transmission-based illness, must wear full PPE (Gown, Gloves, and face mask).

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one of one kitchens reviewed for kitchen sanitation. 1.The facility failed to ensure food located in the facility only kitchen refrigerator, dry food pantry, and prep areas were labeled and dated. 2.The facility failed to ensure that staff covered their head and beard while conducting dietary duties. 3. The facility failed to cover the clean plates stacked and stored in the plate warmer. 4.The facility failed to ensure unserved resident trays were remained free of contamination from used resident rays on the hallway tray carts. These failures could place residents at risk for cross contamination and other bacteria illnesses. Findings include: During an observation of the facility's only kitchen on 02/22/2023 at 9:00 AM revealed the DA not wearing a beard restraint. DA's beard extended above his top lip, with sideburns from his earlobe to his chin. The hair covered the entire facial area, but it was short hair. DA' was walking through the kitchen, past the meal prep table (carrots and chicken), where uncovered plates were stored in the warmer, and to the dishwashing area. He was prewashing dishes, running the dishwasher with dishes, and emptying and stacking the dishes in their designated areas (plate warmers, carts, etc.) exposing a wide range of the kitchen area during food prepping and dish sanitation. An observation on 02/22/2023 at 9:28 AM revealed the following food in the facility refrigerator not being labeled or dated: -1 box of tomatoes, -1 pack of eggs, and -1 package of lettuce. An observation on 02/22/2023 at 9:33 AM revealed a large box of bacon on the bottom rack of the refrigerator, which was not dated and labeled. An observation on observation on 02/22/2023 at 9:33 AM revealed the following food in the facility dry storage that was not labeled or dated: -1 container of tac seasoning, -1 16 oz container of Nutmeg, and -1 box of dry gravy mix. An observation on 02/22/2023 at 9:35 AM, revealed the that [NAME] not wearing a beard covering or head covering with beard stubble hair exposed on the sides of his beard from the jaw line above the lips up to his earlobe. An interview with the DM on 02/22/2023 at 9:40 AM, revealed he does not date and label every box upon delivery from the manufacturer, because they have the manufactured delivery dates on each box to identify the date it was delivered. DM stated that he does physically date most of the delivered boxes. DM stated that it was his responsibility to receive, date, and store items upon delivery. DM stated that the plates in the warmer should be covered to keep warm and prevent cross contamination from food borne pathogens that could lead to illnesses. DM stated all food was dated to document the date of delivery, food condition, and expiration, to assure the food quality was good prior to storing. DM stated that dietary staff must wear beard and hair coverings while in the kitchen to contain hair and prevent hair from getting in the food. DM said all of these practices maintains the food integrity and prevents food contamination, possible illness, and exposure to environment and foodborne pathogens. An observation on 02/23/2023 from 12:40 PM- 12:50 PM, revealed 3 resident trays including Resident #4's tray was left in the hallway unsupervised and unattended on a cart with used trays. During an interview with Resident #1 on 02/23/2023 at 12:41 PM, revealed tray belonged to Resident #2, and that the tray had been sitting on the tray cart for approximately 2 minutes. Resident #1 requested that the roommate and family member for Resident #2 be given a fresh tray, because the food was cold and other residents had been putting used trays on the tray. An observation on 02/23/2023 at 12:43 PM, a resident was observed ambulating to the tray cart where the 3 un-served trays were on and placing his finished tray on the same cart. During an interview with DM on 2/23/2023 at 12:50 PM, revealed that staff were responsible for assessing the tray for right diet, distributing under sanitary conditions, and serving trays to residents when the tray entered the hall to prevent exposure, maintain appropriate temperature of the food, and to facilitate residents being fed timely to prevent weight loss. An interview with CNA M on 02/24/2023 at 8:50 AM, revealed that it was her responsibility to pass the trays upon being delivered to the hall from dietary staff. CNA M said that residents that need to be assisted with eating does not receive their trays until a staff was available to assist. CNA M said that residents should not be returning used trays to the carts. She stated that most of the time they have two carts, 1 for used tray and the other for unserved trays. She stated that she did not observe any residents returning food trays to carts. She stated that when she returned her resident's eaten tray to the cart, but she was not aware that the trays that were on the cart belonged to residents that had not been served. CNA M said that placing used trays on the same cart with unserved trays was an infection control as well as cross contamination. In an interview with on 12/24/2023 at 9:10 AM, with CNA J revealed she was instructed to pass all resident trays to residents that can eat independently first, leaving the trays on the carts until someone was available to serve and assist residents that need help. CNA J stated that if the temp had dropped, she would reheat food in the microwave. CNA J said she has sufficient staff to assist with feeding. CNA J said that used trays should not be stored on the same cart as unserved meal, as this could lead to cross contamination. In an interview with LVN H on 12/24/2023 at 10:10 AM, with LVN H revealed he was the charge nurse on the 200 hall, and he made does the serving assignments. LVN H said that it was his expectation for the assigned aid to serve the residents that could independently eat first, then available aides assist the residents with eating one by one. The residents awaiting assistance with meals were will not be given their tray until an aide was available LVN H said that the food would be reheated at the time of serving. LVN H denied a shortage of staff to assist with meals and support of dependent residents LVN H said that storing previously used trays on the same cart as unserved meals, exposed residents to infections and cross contamination. In an interview with the contracted RD on 02/24/2023 at 11:39 AM, revealed dietary staff were frequently in-serviced on kitchen sanitation, dating and labeling, food preparation guidelines, and causes of food born illness as well as cross contamination. The RD said staff that have visible hair on their head or face must use beard coverings (hair net/restraints) to prevent the food from being exposed to hair and other pathogens. In an interview on 02/24/2023 at 3:30 PM, with the administrator revealed it was her expectation for dietary staff to cover their beards and hair with hair nets to prevent hair being exposed to the food during preparation. She also expected food to be dated and labeled upon delivery to prevent the use of expired foods to the residents, as well as inspection of food delivered to the facility. A review of the facility policy dated November 2022 Titled Food Preparation and Service. Section: General Guidelines states Cross Contamination can occur when harmful substances i.e., chemical or disease causing disease-causing microorganism are transferred to food contact surfaces, or utensils that are not adequately cleaned. Section Titled Food Distribution and Service #8 Food and nutrition staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact the food.