**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 2 of 2 residents (Resident #22 and #272) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #22 who discharged on 03/01/25 and #272 who discharged on 05/14/25 within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings included: 1. A record review of Resident #22's admission record dated 06/06/24, revealed a [AGE] year-old male with an admission date of 12/16/24 and a discharge date of 03/01/25 with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs), acute respiratory failure with hypoxia (a condition where lungs are unable to adequately transfer oxygen into the bloodstream, leading to a dangerously low blood oxygen level), sepsis unspecified organism (a life-threatening complication of an infection), dysphagia (difficulty swallowing) and gastrostomy status (the presence of a gastrostomy tube going into the stomach to provide nutritional support). A record review of Resident #22's medical record revealed an entry MDS dated [DATE] and an admission MDS assessment dated [DATE] which revealed a BIMS score of 13 which indicated no impairment to his cognition. Further review of Resident #22's medical record revealed a 5-Day PPS MDS assessment dated [DATE]. A note on the MDS list in the medical record indicated Discharge - ARD 03/01/25 - 83 days overdue. 2. Record review of Resident #272's admission record, dated 06/03/25, reflected Resident #272 was an [AGE] year-old female admitted to the facility on [DATE] and discharged with home health services on 05/14/25, with diagnoses to include skin transplant. Record review of Resident #272's MDS assessment, dated 05/06/25 and no type selected, reflected Resident #272 had a BIMS score of 15 out of 15, indicating intact cognition. A note on the MDS list in the medical record indicated Discharge - ARD 05/14/25 - 9 days overdue and Discharge Return Not Anticipated MDS assessment, dated 05/14/25, was In Progress. An interview with the DON on 06/06/25 at 10:00 am, the DON was asked about 2 residents (Resident #22 and Resident #272) who did not have discharge MDS assessments. The DON stated he does not review the MDS assessments and that was done by someone at their corporate office. An interview with the two MDS Coordinators, LVN B and LVN C, on 06/06/25 at 10:22 am, revealed the 2 residents who did not have a discharge MDS were just missed and they will do a Discharge Return Anticipated for Resident #22 and Discharge Return Not Anticipated for Resident #272. The MDS Coordinators stated it was important to do Discharge MDS assessments so that CMS and insurance would be notified of changes. A facility policy titled Assessment Frequency/Timeliness dated 10/24/24 stated: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner according to the current RAI Manual. 6. An OBRA discharge assessment will be completed within 14 days of the discharge date . Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.19.1, dated October 2024, revealed 10. Discharge Assessment Return Anticipated [ .] Must be submitted within 14 days after the MDS completion date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #23 and 52) of 8 residents reviewed for care plans. The facility failed to update Resident #23's care plan, undated, included his need for set up and clean-up assistance with eating and Resident #52's care plan, undated, failed to include his ADL self-performance deficit for eating when Resident #52 needed extensive help and needed to be fed. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Record review of Resident #23's admission record, dated 06/03/25, reflected Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include type 2 diabetes. Record review of Resident #23's admission MDS assessment, dated 03/25/25, reflected Resident #23 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. It reflected Resident #23 needed set up or clean-up assistance with eating, where the helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Record review of Resident #23's comprehensive care plan did not reflect interventions for EATING (set up or clean-up assistance with eating), under the problem The resident has an ADL self-care performance deficit., which was initiated 03/24/25. Record review of Resident #52's admission record, dated 06/03/25, reflected Resident #52 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (weakness on half of body) follow cerebral infarction (ischemic stroke) affecting right dominant side. Record review of Resident #52's admission MDS assessment, dated 03/25/25, reflected Resident #52 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. It reflected Resident #52 needed substantial/maximal assistance with eating, where the Helper does MORE THAN HALF the effort Record review of Resident #52's comprehensive care plan did not reflect interventions for EATING (set up or clean-up assistance with eating or needing to be fed, under the problem The resident has an ADL self-care performance deficit., initiated 05/01/25. Interview and observation on 06/05/25 at 12:28 PM, Resident #23 was struggling to peel off the plastic covering over his soup. He stated he did not like when he had to take off the plastic covering over food products because it was too hard for him. Observation revealed his dessert also had plastic wrapping over it. Interview on 06/05/25 at 12:33 PM, CNA D and CNA E stated Resident #23 needed set up for eating, which would include taking the wrap off his food products. They stated Resident #52 needed extensive help with eating and needed to be fed. They revealed they knew this because it was spread by word of mouth. They relied on therapy to keep in contact with them. They stated their nurses and other CNAs would also let them know about this. Interview on 06/05/25 at 10:30 AM, MDS Coordinator B and MDS Coordinator C revealed to code MDS assessment for ADLs they speak with the therapy department and nursing staff. They revealed they would educate staff if there were any updates. They revealed the IDT oversaw the care plans to make sure the care plans were updated. They revealed it was important update the care plans as this updated the Kardex, which listed tasks for the CNAs to complete, that the CNAs access. They revealed this was important for resident care and resident safety. Record review of facility's policy Care Plan Revisions Upon Status Change, dated 10/24/22, reflected 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #28) out of 8 residents reviewed for environmental concerns. The facility failed on 06/03/2025 when Resident #28's window (1 of 2) would not close all the way in his room remaining open approximately 1-inch, which could have resulted in damage to the interior windowsill according to the Maintenance Director. The facility failed on 06/03/2025 when Resident #28's room refrigerator had not been functioning for an unknown amount of time resulting in Resident #28's RP not being able to bring in outside food for Resident #28. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe. The findings included: Record review of Resident #28's admission record, dated 06/03/25, reflected Resident #28 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include repeated falls, weakness, and dementia (decline in cognitive functioning, including memory, thinking, and reasoning, to the extent that it interferes with daily life and activities). Record review of Resident #28's admission MDS assessment, dated 05/05/25, reflected Resident #28 had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Observation and combined interview with Resident #28 and Resident #28's RP on 06/03/25 at 11:07 AM reflected, one of his windows (1 of 2) was slightly open. They stated they could not close it before today and demonstrated they could not close it by trying to close it again unsuccessfully. They stated they had put a towel to cover the crack so bugs and rain could not get in. They revealed this window had been cracked for at least last week. They stated when it rained last week water got in and this was when they told a staff member, who they were unable to identify. Observation of the interior windowsill revealed the top of the windowsill near the window was slightly warped. Observation and interview on 06/03/25 at 11:12 AM, reflected Resident #28's refrigerator was empty and was 58 degrees Fahrenheit. Resident #28's RP stated she had not used the refrigerator since Resident #28 was admitted to the facility and because the refrigerator had been broken so she could not store cold food properly in it. Resident #28's RP stated she had not told anyone about the broken refrigerator. Observation on 06/04/25 at 8:27 AM revealed that 1 of Resident #28's window (1 of 2) was slightly open approximately 1-inch. Interview and observation on 06/04/2025 at 2:58 PM revealed one of Resident #28's windows was cracked open approximately 1-inch. Observation revealed the vinyl material constructed on the windowsill to be warped along the window side of the windowsill. The Maintenance Director closed the window. The Maintenance Director confirmed damage to the windowsill. He stated he was not aware of the window being cracked open or the water damage to the windowsill. He stated he was not notified of Resident #28's room window was having issues closing, and he was not aware of how long the window had been cracked open. The Maintenance Director stated he was aware of the requirement to ensure walls are maintained, cleanable and in good repair. He further stated as the Maintenance Director it was his responsibility to maintain the building wall conditions. Maintenance Director understood and agreed not maintaining the walls could cause deterioration of the walls, leaving the walls uncleanable which could cause water penetration promoting mold growth, causing air-borne illnesses with the potential to expose the residents to unsanitary conditions, affecting the health and safety of the residents. Observation on 06/05/25 at 8:27 AM, reflected Resident #28's refrigerator was empty and was 60 degrees Fahrenheit. Interview on 06/05/25 at 4:21 PM, SW I, who was the ambassador for Resident #28's room, meaning he did morning rounds to make sure there weren't any concerns for Resident #28, to include anything that may need repair in his room. SW I stated the refrigerator this morning was 45 degrees Fahrenheit, so he let the Maintenance Director know and expected this to be fixed. He revealed he was not aware that Resident #28's window was unable to be closed. SW I stated anyone who went in Resident #28's room and noticed anything out of the ordinary, should report it to someone so they could find out who could fix any issue that came up. Interview on 06/05/25 at 4:44 PM, the ADM revealed the thermometer was broken in Resident #28's refrigerator which was why it was showing a wrong number. She was aware Resident #28's refrigerator was replaced earlier this week, but was not aware of why it was replaced. She stated the refrigerator felt cool when she assessed today and the thermometer had to be broken. The ADM revealed the facility placed 3 thermometers in the refrigerator to see if it was working. Interview and observation on 06/06/25 at 9:41 AM, Resident #28's RP stated Resident #28's refrigerator was replaced last night (06/05/2025) because it had not been working. It was observed that the refrigerator was functioning and maintaining proper temperature (less than 40 degrees Fahrenheit). Resident #28's RP stated Resident #28 had been progressing at this facility to include increased appetite, increased food consumption, and strength due to therapy. Resident #28's RP revealed they were satisfied with the nutritional interventions the facility implemented because it had helped Resident #28. Interview on 06/06/25 at 9:53 AM, the SW H stated she knew people wanted the windows open to get fresh air, but it was hard to close the windows sometimes. She stated it was important for windows to close so things like insects would not come in. She stated it was important for Residents' refrigerator to work so food would not get spoiled. She stated it was important to provide a homelike environment because it made the facility feel like home and helped with residents' dignity. SW H further stated the facility did not want the facility to be institutionalized looking, so the residents were not scared of staying in this facility and not being at home. Interview on 06/06/25 at 1:00 PM, the Maintenance Director revealed Monday 06/02/25 there was a work order for Resident #28's refrigerator. The Maintenance Director said the refrigerator was not at temperature because the temperature control was turned really low, but they decided to replace the refrigerator anyway. He revealed on Tuesday, 06/03/25, they found the refrigerator door was not closing all the way. They revealed they did not know how long Resident #28's refrigerator was broken before Monday. Maintenance Director stated ambassadors did morning rounds where they checked the refrigerator temperatures and this was one opportunity to catch if the refrigerator was broken, but anyone who visited resident rooms could have caught this. The Maintenance Director further stated Resident #28's window was slightly open, but he just had to push it down to close it. He revealed there was water damage on the windowsill, inside Resident #28's room and this could have happened last week. Interview on 06/06/25 at 1:30 PM, the Maintenance Director revealed the facility could not calibrate the thermometers, but they would compare it to a digital thermometer before they put it in the refrigerator. He stated the thermometers they used were not reliable and would break. He expected the facility staff to know if a thermometer was broken if the temperature read too high. He said if the thermometer read too high, this meant the thermometer was broken. He stated when they put a new refrigerator into a resident's room, they had to monitor it to ensure it was functioning correctly. Record review of work order created 06/02/25, reflected the refrigerator was not working even though it was plugged in, and they replaced the refrigerator on 06/02/25. Record review of work order created 06/05/25 at 8:04 AM by SW I for Resident #28's refrigerator reflected there was a refrigerator temperature issue, and he was continuing to monitor refrigerator temperature. Record review of Statement of Resident Rights, provided by the facility and undated, reflected You have a right to: . safe, decent and clean conditions. Facility did not have a policy for homelike environment or functioning equipment. Record review of facility's policy, Potluck Meals and Foods from Home, dated 10/01/18, reflected 2. The facility must ensure safe food handling techniques once the food is brought into the facility including . holding cold items <41 degrees . Record review of facility's policy, Food Safety for Residents, dated 2018, reflected Keep Food out of the Danger Zone . 2. Cold perishable food . should be kept at 40 degrees Fahrenheit or below. Discard any cold leftovers that have been left out for more than 2 hours at room temperature. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5°C (41°F) or less.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 17.24% based on 5 out of 29 opportunities, which involved 2 of 6 Residents (Resident #161 and Resident #171) reviewed for medication administration, in that: 1. The facility failed on 6/5/25 to ensure RN F observed if Resident #171 took her metoclopramide (used to treat various gastrointestinal conditions), pantoprazole (decreases the amount of acid produced in the stomach), and sucralfate (to treat an active duodenal ulcer. Sucralfate works mainly in the lining of the stomach and is not highly absorbed into the body.) medications. 2. The facility failed on 6/5/25 to ensure LVN G observed if Resident #161 took her docusate (stool softener used to treat constipation) and liquid protein (concentrated liquid protein supplement) medications. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #171's admission Record, dated 6/6/25, revealed an [AGE] year-old female admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, wheezing, cough, end stage renal disease, malignant neoplasm of pancreas (Pancreatic cancer), and diverticulitis of intestine (inflammation of irregular bulging pouches in the wall of the large intestine). Record review of Resident #171's admission MDS assessment, dated 5/31/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #171's care plan, revised on 6/5/25, revealed the resident had an ADL self-care performance deficit and required limited assistance x1 by staff with personal hygiene and oral care. Record review of Resident #171's physician order summary, dated 6/6/25, revealed orders for: - Metoclopramide HCl Oral Tablet 10 MG give 1 tablet by mouth before meals and at bedtime for GERD, with a start date of 5/28/25 and no end date. - Sucralfate Suspension 1 GM/10ML give 1 gram by mouth before meals for gastric protection, with a start date of 6/5/25, and no end date. - Pantoprazole Sodium Oral Tablet Delayed Release 40 MG give 1 tablet by mouth two times a day for acid reflux, with a start date of 5/28/25, and no end date. During an observation on 6/5/25 at 8:03 a.m. RN F planned to administer medications to Resident #171. Resident #171 was sitting up in a chair and stated she was not able to sleep all night due to her stomach bothering her. RN F handed Resident #171 a medicine cup with the metoclopramide and pantoprazole in it. The resident held the medication cup in her hands and continued speaking to the nurse. RN F placed a medication cup with the liquid sucralfate in it on the resident's bedside table. RN F then stated he was running behind. RN F then left the resident's room without observing if she took the medications or not. 2. Record review of Resident #161's admission Record, dated 6/6/25, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of gram negative sepsis (bacteria entering the blood stream), cellulitis of left limb (bacterial infection of the skin), and gout (a form of arthritis that causes sudden, sever pain and inflammation in one or more joints). Record review of Resident #161's BIMS assessment, dated 5/28/25, revealed her cognition was fully intact. Record review of Resident #161's care plan, initiated 5/28/25, revealed the resident had an ADL self-care performance deficit and required x2 staff for personal hygiene and oral care. Record review of Resident #161's Physician orders, dated 6/6/25, revealed orders for: - Protein Oral Liquid give 30 ml by mouth two times a day for supplement to promote wound healing, with a start date of 5/28/25, and no end date. - Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation, hold for loose stools, with a start date of 5/28/25, and no end date. During an observation on 6/5/25 at 9:07 a.m. LVN G planned to administer medications to Resident #161. LVN G handed Resident #161 a cup of pills. Resident #161 took the docusate pill out of the medicine cup and placed it on her bedside table. She stated she did not know if she wanted to take that one. Resident #161 then asked LVN G to split the other pills in half for her. LVN G split them in half and Resident #161 took them. LVN G mixed the protein liquid with water and left it on the resident's bedside table. It was unknown if the resident ever took the docusate or drank the liquid protein. During an interview on 6/5/25 at 3:25 p.m. the DON stated staff had to observe residents taking their medications for patient safety and to make sure they are getting the treatments as ordered. The DON stated they did not have any residents who could administer their own medications. Record review of the facility's document titled Medication Pass Competency Assessment revealed RN F completed assessments on 7/2/24 and LVN G completed assessments on 5/27/25. The competency stated .17. The resident is observed to ensure the medication is swallowed and not left at the bedside . Record review of the facility's policy titled Medication Administration, dated 10/01/19, stated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 3 medication cart (200 hall east and west carts) reviewed for labeling and storage of drugs. 1. The facility failed to ensure Resident #31's furosemide package directions matched the physician orders blood pressure parameters on the 200-hall east cart. 2. The facility failed to ensure 200-hall west medication cart was not left unlocked and out of sight from the nurse. 3. The facility failed to provide change direction labels for Resident #161's medication package of allopurinol which had medication order change from 100 mg (1 tablet) to 150 mg (1.5 tablets) on the 200-hall west cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: 1. During an observation on 6/5/25 at 8:18 a.m. the 200-hall east medication cart contained Resident #31's furosemide. The pharmacy label stated furosemide 20 tablet give 1 by mouth. Call for SBP less than 10 or DBP less than 60 before administration. Record review of Resident #31's physician orders, dated 6/5/25, revealed an order Furosemide Tablet 20 MG Give 1 tablet by mouth one time a day for CHF Contact MD for SBP<100 or DBP<60 before administering diuretic, with a start date of 5/23/25, and no end date. During an interview on 6/5/25 at 8:46 a.m. RN F stated the label should say less than 110 or 100. He stated he would call the pharmacy if he was unsure, but he thought it should say less than 100. RN F stated he would always call the provider if it was less than 100. 2. During an observation on 6/5/25 at 8:59 a.m. the 200-hall-west cart was unlocked and unattended. LVN G was in a resident room with his back turned away from the cart in the hallway. 3. During an observation on 6/5/25 at 9:07 a.m. revealed the 200-hall west medication cart contained Resident #161's allopurinol. The pharmacy label stated 100 mg of allopurinol give 1 tablet by mouth daily. Record review of Resident #161's physician orders, dated 6/6/25, revealed an order for Allopurinol Tablet 100 mg Give 1.5 tablet by mouth one time a day for Gout Give 1.5 tablet to equal 150mg, with a start date of 5/29/25, and no end date. During an interview on 6/5/25 at 9:41 a.m. LVN G stated they could add a change direction label on the resident's medication, but he was unsure if they had any. LVN G stated he should keep his cart lock for patient safety. During an interview on 6/5/25 at 3:27 p.m. the DON stated staff should lock carts when they walk away to prevent anyone from taking something from it or moving things around. The DON stated the facility had stickers to put on the medication packages if there was a correction for the label or a change in direction sticker. The DON stated they also could obtain a new label from the pharmacy or verify the parameters for the medication in the EMR. The DON stated the medication package label should match the current orders to ensure patient safety and to ensure the nurse is triggered to check parameters for safe medication administration. Record review of the facility's document titled Medication Pass Competency Assessment LVN G completed assessments on 5/27/25. The competency stated .10. The medication cart and medication room are free from any pre-poured medications . Record review of the facility's policy titled Medication Administration-Medication Cart and Supplies for Administering Meds, dated 10/01/2019, stated .Med CARTS: 3. Do not leave the medication cart unlocked or unattended in the resident care areas .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet resident choices for 2 of 8 residents (Resident #24 and #172) and 1 of 1 kitchen reviewed for dietary needs. The facility failed to ensure there was not a repetitive menu for the residents resulting in complaints about the lack of variety in food options. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their religious nutritional preferences met. Record review of Resident #24's admission record, dated 06/03/25, reflected Resident #24 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include constipation. Record review of Resident #24's admission MDS assessment, dated 04/20/25, reflected Resident #24 had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Record review of Resident #24's comprehensive care plan reflected problem The resident has nutritional problem or potential nutritional problem r/t refusal of meals . with goal The resident will maintain adequate nutritional status . Record review of Resident #172's admission record, dated 06/06/25, reflected Resident #172 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include major depressive disorder and dementia (decline in cognitive functioning, including memory, thinking, and reasoning, to the extent that it interferes with daily life and activities). Record review of Resident #172's admission MDS assessment, dated 05/19/25, reflected Resident #172 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Record review of Resident #172's comprehensive care plan did not reflect anything related to food intake or diet. Record review of facility's Week 1 through Week 5 Spring/Summer 2025 menu reflected every morning refried beans was on the menu. It further revealed the following meals also included beans, which would have the residents eating beans 2 times a day on these days: In Week 1, pinto beans were served in Thursday's lunch, red bean soup was served in Saturday's dinner, and refried beans were served in Sunday's dinner. This equated to 10 out of 21 meals in Week 1 including beans. In Week 2, pinto beans were served in Tuesday's dinner. This equated to 8 out of 21 meals in Week 2 including beans. In Week 3, refried beans were served in Wednesday's dinner, pinto beans were served in Saturday's lunch, and lentil soup was served in Sunday's dinner. This equated to 10 out of 21 meals in Week 3 including beans. In Week 4, black beans were served in Wednesday's dinner, and 3 bean salad was served in Saturday's dinner. This equated to 9 out of 21 meals in Week 4 including beans. In Week 5, pinto beans were served in Tuesday's lunch, pinto beans were served in Friday's dinner, and seasoned beans were served in Saturday's lunch. This equated to 10 out of 21 meals in Week 5 including beans. Record review of grievance for Resident #24, dated 05/30/25, reflected he complained about too many beans being served on menu with a final resolution of updating tray care to reflect no beans. Interview on 06/03/25 at 11:33 AM, Resident #24 revealed the facility served beans a lot and he had trouble with constipation and diarrhea, so he did not want to eat beans. Interview on 06/04/25 at 10:04 AM, Resident #172 revealed the facility served beans too much. Interview on 06/06/25 at 10:07 AM, the RD and CDM revealed there were some days where beans were served two times in a one day, because refried beans were served every morning. They revealed this was a new menu so they mentioned they would adjust the menu according to the feedback they had from the residents. They revealed if there were complaints, they would adjust the menu to not include certain items. The RD revealed she understood why someone would not want beans 2 times a day. Interview on 06/06/25 at 12:37 PM, the ADM revealed they reviewed the menu before they used it in the facility. She revealed she was not aware there were beans in the menu 2 times in one day. She revealed she would get with the RD to find better alternatives because it would help to have a variety of foods in the menu. Record review of facility's policy, Menu Planning, dated 06/01/19, reflected, The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious, and meets the preferences of the resident population. No other policy was provided in regard to menus.

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. The facility failed to label their food products with their respective discard dates. These failures could place residents at risk for food borne illness. The findings included: Interview and observation on 06/03/25 at 09:55 AM, all packaged foods in the fridge, located off the tray line, had dates: 06/02/25 and 06/03/25 with no discard dates. The CDM and RD revealed they did not have to put the discard dates on the labels, but the kitchen staff knew to discard food products after 3 days. Interview and observation on 06/04/25 at 11:10 AM, all packaged food in the fridge, located off the tray line, reflected prepared date and discard dates. The CDM and RD revealed they put discard dates on the labels just to be safe, but their policy did not tell them to put discard dates. They revealed they do follow the FDA Food Code. The RD revealed it could be helpful to put discard dates, so staff knew when to discard food products with a quick glance. The RD further revealed they did not have updated policies after the food code was updated in 2022. Interview on 06/06/25 at 02:25 PM, [NAME] A revealed he did not write discard dates on food products for food storage in the refrigerators because they knew to throw the food out after 72 hours. He revealed he was in-serviced this week and he knew to write discard dates on food products that were stored in the refrigerator. Record review of facility's policy Food Storage, revised June 1, 2019, reflected, 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 4 staff (RN F and LVN G) and 5 of 8 Residents (Resident #40, Resident #161, Resident #165, Resident #166, and Resident #217) reviewed for infection control: 1. The facility failed to ensure RN F sanitized the blood glucose monitor between use for Resident #166 and Resident #165. 2. The facility failed to ensure RN F did not touch pills with his bare hands and then administer the medication to Resident #40. 3. The facility failed to ensure RN F cleaned an insulin pen's rubber stopper with an alcohol swab prior to insulin administration for Resident #165. 4. The facility failed to ensure LVN G used a clean paper towel to turn of the sink after washing his hands during medication pass for Resident #161. 5. The facility failed to ensure Resident #217 was on EBP due to her surgical wound. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1. During an observation on 6/5/25 at 8:25 a.m. RN F checked Resident #166's blood glucose. RN F then returned to his medication cart and placed the monitor on top of the cart. RN F did not sanitize the monitor and continued passing medications to other residents. During an observation on 6/5/25 at 8:33 a.m. RN F used the same blood glucose monitor to check Resident #165's blood glucose. RN F did not sanitize the monitor before or after use. During an interview on 6/5/25 at 8:48 a.m. RN F stated he should sanitize the blood glucose monitor between residents to prevent the spread of potential pathogens from staff to residents or from residents to residents. 2. During an observation on 6/5/25 at 8:30 a.m. RN F used his keys to open the medication cart, opened his medication cart, looked for a medication, touched his keyboard to look for an order on the computer, and then RN F dispensed a medication from a blister package for Resident #40. RN F grabbed the pill from the back of the package with is bare hand and put in it in medication cup. Resident #40 then took the pill. During an interview on 6/5/25 at 8:50 RN F stated he was told he could touch pills with his fingers, and he did not need to wear gloves when handling medications. RN F stated on further thought he could have contaminated his hands prior and then touched the pill. 3. During an observation on 6/5/25 at 8:33 a.m. RN prepared an insulin glargine (a long action insulin) pen injection for Resident #165. RN F stated he needed to prime the pen with 5 units of insulin prior. RN F then placed the needle on the pen and did not clean the rubber stopper area with an alcohol pad prior. During an interview on 6/5/25 at 3:32 p.m. the DON stated staff should clean the glucose monitors with a wipe after each resident. The DON stated each cart had two monitors so they could clean one monitor, allow it to sit, meet the contact time with the cleaner, and use the other clean monitor in the meantime. The DON stated he thought the insulin pen should be cleaned prior to placing the needle on the end just like you would an insulin vial. The DON stated he did not think it specified in the insulin administration competency to clean the pen prior, but it would be important to ensure there is no cross contamination. The DON stated cleaning with an alcohol swab prior to placing the needle on the pen would ensure you remove any potential pathogens from the pen. 4. During an observation on 6/5/25 at 9:25 a.m. LVN G went into Resident #161's bathroom to wash his hands during medication administration. LVN G washed his hands at the sink and turned off the faucet with his barehand. LVN G then dried his hands with a paper towel. LVN G returned to his medication cart and split pills for Resident #161. LVN G then administered the medications to Resident #161. LVN G then returned to wash his hands at the sink and again turned off the faucet with his barehand. During an interview on 6/5/25 at 9:41 a.m. LVN G stated the paper towels were across the room and not easily accessible when washing his hands. LVN G stated he should use a clean paper towel to turn off the faucet because there could be bacteria on the handle when he turned it to begin with. During an interview on 6/5/25 at 3:36 p.m. the DON stated staff should use a clean paper towel to turn off the water to prevent infection. 5. Record review of Resident #217's Face Sheet, dated 6/6/25, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with diagnoses of aftercare following a joint replacement surgery, presence of right artificial hip joint, and type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood). Record review of Resident #217's BIMS Assessment, dated 6/2/25, reflected her cognition was fully intact for daily decision making. Record review of Resident #217's Comprehensive Person-Centered Care Plan, revised on 6/5/25, reflected the resident was at risk for impaired skin integrity related to impaired mobility and recent surgical procedure/hospitalization. The interventions included conduct skin inspections / examinations weekly and as needed and document findings. Record review of Resident #217's physician orders, dated 6/4/25, revealed orders for: - Wound care order: Right hip surgical site dressing with PICO drain (a device that provides negative pressure wound therapy to draw out excess fluid from a wound and protect the incision or wound.) is not to be removed until follow up is complete and or NPWT (negative pressure wound therapy) is complete. May change dressing if soiled and or dislodged. For treatment, refer to PRN order. If dressing change is provided, assess pain level pre and post treatment and every day shift, with an order date of 6/2/25, and no end date. - Wound care order: Right hip surgical site dressing with PICO drain is not to be removed until follow up is complete and or NPWT is complete. May change dressing if soiled and or dislodged. For treatment, refer to PRN order. If dressing change is provided, assess pain level pre and post treatment and as needed, with an order date of 6/2/25, and no end date. During an observation and interview on 6/3/25 at 9:52 a.m. Resident #217 stated she just had hip replacement surgery. She stated she had been assessed by therapy and had taken one shower since being admitted a few days prior. She stated a staff member helped her cover her surgical wound dressing with a waterproof dressing so she could shower. She stated no one had provided wound care since her admission because she had a wound vacuum device covering the surgical incision that was not supposed to get wet. She stated they would only do the wound care if it became dislodged. Resident #217's room did not have any signage for EBP. During an interview on 6/5/25 at 3:18 p.m. the DON stated EBP was used for any wounds and no wounds were excluded unless they were minor skin tears or stage 1 pressure wounds with no skin breaks. The DON stated Resident #217 should be on EBP due to the potential of infection to her wound. During a follow up interview on 6/6/25 at 9:51 a.m. the DON stated their policy for insulin administration stated the did not need to disinfect the insulin pen prior to placing the needle on the pen. The DON stated he thought the policy was acceptable. Record review of insulin glargine infection 100 units/mL manufacturer guidelines, dated 08/22, stated .Step 2 . Wipe the pen tip (rubber seal) with an alcohol swab. Remove the protective seal from the new needle, line the needle straight with the pen, and screw the needle on . Record review of the facility's policy titled Medication Administration Injectable Administration, dated 10/01/19, stated Procedure . Clean stopper with alcohol pad and allow to air dry (except on pen devices and pre-filled syringes) . Record review of the facility's policy titled Enhanced Barrier Precautions, dated 4/5/24, stated Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following:1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. c. Ensure access to alcohol-based hand rub . 4. High-contact resident care activities include: a. Dressing b. Bathing . h. Wound care: any skin opening requiring a dressing 5. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility . Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . Record review of the facility's policy titled Hand Hygiene, dated 10/24/22, stated Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . 5.Hand hygiene technique when using soap and water . d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f.Use clean towel to turn off the faucet .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure at the time each resident is admitted , the facility must have physician orders for the resident's immediate care for 1 (Resident #253) of 24 residents reviewed for admission physician orders. The facility failed to get oxygen orders from the physician for Resident #253, who was admitted on [DATE], and did not until 04/26/2024. This deficient practice affects residents admitted on oxygen therapy and could result in respiratory distress. The findings included: Record review of Resident #253's electronic face sheet dated 04/24/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: pneumonia (infection in your lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body tissues) and emphysema (type of lung disease that causes breathlessness). Record review of Resident #253's baseline care plan dated 04/24/2024 did not reflect she was on oxygen therapy. Record review of Resident #253's Active Orders as of: 04/24/2024 reflected no orders for oxygen therapy. Resident #253 was not at the facility long enough for an MDS assessment. Record review of Resident #253's hospital Discharge summary dated [DATE] reflected Plan: Oxygen supplementation as nasal cannula, titrate to keep saturation of oxygen above 90%. Record review of Resident #253's Daily Skilled Note dated 04/22/24, her admission notes, reflected Oxygen via Nasal Cannula. Record review of Resident #253's oxygen saturations dated 4/22/2024 and 04/23/2024 reflected she had saturations taken while she had oxygen therapy via nasal cannula. Observation on 04/23/2024 at 09:53 AM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula. Her oxygen concentrator delivered 2.5 l/min. Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy since admission. She stated oxygen was treated like a medication and required a physician's order. She stated the wrong rate could result in respiratory compromise. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. He stated he did not have a policy or procedure on oxygen administration. Record review of the National Library of Medicine, Chapter 11.1. at https://www.ncbi.nlm.nih.gov/ Oxygen Therapy Introduction reflected Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #3) of 24 residents reviewed for care plans. Resident #3's anticoagulant therapy was not address in her comprehensive care plan dated 04/24/2024. This deficient practice could affect residents who required specific care, services and interventions and could result in missed care or harm. The findings included: Record review of Resident #3's electronic face sheet dated 04/23/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: metabolic encephalopathy (a chemical imbalance in the blood which causes a problem in the brain), diabetes mellitus (the body's inability to produce or respond to the hormone insulin is impaired resulting in abnormal metabolism of carbohydrates and elevated levels of blood sugar), rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability, proteins and electrolytes are released into the blood by damaged muscle tissue) and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls, narrowing or blocking blood flow). Record review of Resident #3's admission MDS assessment dated [DATE] reflected she scored a 12/15 on her BIMS which signified she was cognitively intact. Record review of Resident #3's Active Orders as of: 04/23/2024 reflected Heparin Sodium Solution 5000 unit/ml, inject 5000 units subcutaneously every 12 hours for clotting prevention., active date 04/08/2024. Record review of Resident #3's comprehensive care plan revised dated 04/24/2024 did not reflect the resident was on heparin therapy which is an anticoagulant. Record review of Resident #3's MAR dated 04/23/2024 reflected she received Heparin Sodium Solution 5000 unit/ml every 12 hours. Interview on 04/24/2024 at 2:00 PM with Resident #3, she stated she received the Heparin shots twice a day, a week after she was admitted . Interview on 04/26/2024 at 2:40 PM with ADON A revealed she was part of the care planning team and stated Resident #3's Heparin should have been care planned after it was ordered on 04/08/2024. She stated it was a blood thinner or anticoagulant and needed monitoring. She stated a resident could bleed out if it was not managed correctly. Interview on 04/26/2024 at 2:50 PM with the DON revealed Resident #3's Heparin needed to be care planned because it was a blood thinner and could cause serious problems for a resident who required it such as bleeding and clotting if they needed the medication and did not get an accurate amount. Record review of the facility policy and procedure titled Comprehensive Care Plans, dated 10/24/2022 reflected It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 (Resident #253) of 4 residents reviewed for oxygen therapy. The facility failed to get oxygen orders from the physician for Resident #3, who was admitted on [DATE] and did not until 04/26/2024. This deficient practice affects residents admitted on oxygen therapy and could result in respiratory distress. The findings included: Record review of Resident #253's electronic face sheet dated 04/24/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: pneumonia (infection in your lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body tissues) and emphysema (type of lung disease that causes breathlessness). Record review of Resident #253's baseline care plan dated 04/24/2024 did not reflect she was on oxygen therapy. Record review of Resident #253's Active Orders as of: 04/24/2024 reflected no orders for oxygen therapy. Resident #253 was not at the facility long enough for an MDS assessment. Record review of Resident #253's hospital Discharge summary dated [DATE] reflected Plan: Oxygen supplementation as nasal cannula, titrate to keep saturation of oxygen above 90%. Record review of Resident #253's Daily Skilled Note dated 04/22/24, her admission notes, reflected Oxygen via Nasal Cannula. Record review of Resident #253's oxygen saturations dated 4/22/2024 and 04/23/2024 reflected she had saturations taken while she had oxygen therapy via nasal cannula. Observation on 04/23/2024 at 09:53 AM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula. Her oxygen concentrator delivered 2.5 l/min. Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy since admission. She stated oxygen was treated like a medication and required a physician's order. She stated the wrong rate could result in respiratory compromise. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. He stated he did not have a policy or procedure on oxygen administration. Record review of the National Library of Medicine, Chapter 11.1. at https://www.ncbi.nlm.nih.gov/ Oxygen Therapy Introduction reflected Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for 3 (Residents #25, #104 and #253) of 24 residents reviewed for baseline care plans. 1. Resident #25's baseline care plan dated 04/04/2024 did not reflect he received antibiotic therapy at dialysis. 2. Resident #104's baseline care plan dated 04/18/2024 did not reflect she received an antipsychotic medication. 3. Resident #253's baseline care plan dated 04/22/2024 did not reflect she was on oxygen therapy. This deficient practice could affect residents admitted to the facility and result in missed or inadequate care. The findings included: 1. Record review of Resident #25's face sheet dated 4/24/2024 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: septicemia (the body's extreme reaction to an untreated infection that causes the body to attack body organs that could lead to organ failure and then death); metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood); and ESRD (End Stage Renal Disease). Record review of Resident #25's MDS dated [DATE] revealed the resident had a BIMS score of 15. Under section O for Special Treatments, Procedures, and Programs, Group Other subgroup H1, revealed IV medications not checked, and subgroup H4, antibiotics was not checked. Record review of Resident #25's baseline care plan dated 4/5/2024 revealed dialysis with days was not care planned under medical conditions it was checked no and IV antibiotic Ceftazidime was not care planned which was to be administered at dialysis on scheduled dialysis days. Additional orders for dialysis days were to remove pressure dressing from shunt site 4 hours after dialysis was not care planned. During an interview on 2/26/2024 at 3:14 PM the DON stated it is important to assess a resident for accuracy of the care plan to establish point of care, and to ensure it is followed by staff. 2. Record review of Resident #104's face sheet dated 4/24/2024 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: pneumonia (an infection in your lungs caused by bacteria, viruses or fungi), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities. Record review of Resident #104's MDS dated [DATE] revealed it was incomplete due to the resident's recent admission and did not contain BIMS or medication information. In Section I - Active Diagnoses, Psychiatric/Mood Disorder, the diagnoses Anxiety Disorder and Depression (other than bipolar) were checked. Record review of Resident #104's Order Summary Report Active Orders as of 04/18/2024 revealed the resident had an order for: Sertraline HCL Oral Capsule 200 mg (Sertraline HCL), give one tablet by mouth one time a day for depression. The order date was 04/18/2024 with a start date of 04/19/2024. Record review of Resident #104's baseline care plan dated 04/18/2024 revealed under C. Orders, 2. Medications Ordered there was no check mark in the box next to 2b. Psychotropic Medications. During an interview on 04/24/2024 at 1:29 PM with the DON he stated the psychotropic medication Sertraline was not checked off on the resident's baseline care plan and should have been. The DON further stated they try to scrub the care plans as best as possible but sometimes things get missed, and it was important the baseline care plan indicated the medications the resident was receiving so all staff members will know to monitor for side effects. During an interview on 04/26/2024 at 2:55 PM with ADON A she stated one of the supervisors initiated Resident #104's Baseline care plan but she signed off on it, and they both missed indicating the resident was taking a psychotropic medication. 3. Record review of Resident #253's electronic face sheet dated 04/24/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: pneumonia (infection in your lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body tissues) and emphysema (type of lung disease that causes breathlessness). Record review of Resident #253's hospital Discharge summary dated [DATE] reflected Plan: Oxygen supplementation as nasal cannula, titrate to keep saturation of oxygen above 90%. Record review of Resident #253's baseline care plan dated 04/24/2024 did not reflect she was on oxygen therapy. Record review of Resident #253's Active Orders as of: 04/24/2024 reflected no orders for oxygen therapy. Resident #253 was not at the facility long enough for an MDS assessment. Record review of Resident #253's Daily Skilled Note dated 04/22/24, her admission notes, reflected Oxygen via Nasal Cannula. Record review of Resident #253's oxygen saturations dated 4/22/2024 and 04/23/2024 reflected she had saturations taken while she had oxygen therapy via nasal cannula. Observation on 04/23/2024 at 09:53 AM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula. Her oxygen concentrator delivered 2.5 l/min. Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy since admission. She said it was important to have the initial baseline care plan because it communicated the residents needs and without her oxygen she could be in respiratory distress. Interview on 04/26/2024 at 2:40 PM with ADON A revealed she reviewed the residents' baseline care plans and did not realize the oxygen therapy was missed. She stated it was important to have the resident's oxygen in her base line care plan to communicate her care needs. She stated Resident #253 could have respiratory issues without her oxygen. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed, and her baseline care plan needed to have her oxygen addressed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. Record review of the facility policy and procedure revised date 10/5/23 titled Baseline Care Plan reflected The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for one of one facility, in that: The Food Service Supervisor (FSS) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the staff roster provided by the facility, undated, revealed the hire date for the FSS was 09/01/2019. Record review of the FSS' certification documentation revealed a certificate stating the FSS successfully completed the Texas Food Safety Manager Certification Examination, effective 10/11/2023, expiration date 5 years from the effective date. Record review of facility employee files revealed the facility's RD was contracted and not a full-time employee of the facility. During an interview on 04/23/2024 at 10:50 AM, the FSS stated he was hired by the facility as a cook in 2019 and assumed the position of FSS in 09/2023. The FSS further stated upon assuming the FSS position, he completed a Texas Food Manager's Certification program, received a certificate, and believed this certification met the requirements for the position. During an interview on 04/23/2024 at 1:33 PM with the Administrator she stated she knew the Texas Food Manager's Certification was not a national certification and was not the appropriate certification for the position of FSS. The Administrator further stated she paid for the FSS to take the National Food Manager Certification exam; however, the FSS completed the Texas Food Manager Certification Exam in error. During an interview on 04/26/2024 at 11:45 AM the administrator stated the FSS demonstrated knowledge deficits and would benefit from additional training and possible mentoring from an existing FSS. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. There were two cases of vegetables and one case of beef patties open with their interior bags open in the walk-in freezer. 2. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 04/23/2024 at 10:52 AM in the walk-in freezer revealed three open cases of food: One 30-lb. case of mixed vegetables, one 30-lb. case of cut green beans, and one 10 lb. case of beef fritters. All three open cases had interior plastic bags that were also open, exposing the food to the ambient air in the freezer and subjecting the food to potential contaminants, freezer burn and a decrease in quality. During an interview on 04/23/2024 at 10:55 AM with the FSS he stated the three cases of food were open and their interior bags were open and should not have been. The FSS further stated the cooks storing the cases in the freezer are responsible for ensuring the food was properly sealed to maintain freshness. 2. Observation on 04/25/2024 at 10:39 AM in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade, the plastic insert inside the base, and also surrounded the part of the base that was affixed to the table with screws. During an interview on 04/25/2024 at 10:40 AM with the FSS he stated that the can opener blade and entire base was covered in grime and in need of cleaning and sanitizing. The FSS stated the cooks were responsible for keeping the can opener clean and free of debris and failing to do so could result in cross contamination and foodborne illness. The FSS further stated he trained the dietary staff on a monthly basis. Record review of the facility policy, Food Storage, 03.003, revised 06/01/2019, revealed: Procedure: 3. Freezers: e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility policy Can Opener, 04.009, approved 10/01/2018, revealed: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers will be cleaned after each use. Procedure: 1. Hand held or table top: a. Remove can opener shank from base. b. Wash shank in sink with warm water and detergent or in the dishwasher. c. Give close attention to the blade and moving parts. d. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. f. Air dry. g. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. h. Rinse with clean cloth soaked in clear hot water. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302 Preventing food and ingredient contamination. 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #3) reviewed for infection control, in that: The facility failed to ensure Resident #3 received wound care to the sacrum (triangular shaped area over a bone in the lower back just above the intergluteal cleft) and left arm utilizing appropriate hand hygiene and infection control principles. Treatment Nurse B did not perform both hand hygiene and glove changes and did not sanitize the work surface prior to use. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings were: Record review of Resident #3's face sheet dated 2/09/2024 revealed an admission date of 1/30/2024 with diagnoses which included: urinary tract infection, heart failure and malignant neoplasm of unspecified kidney (cancer of the kidney). Record review of Resident #3's admission MDS assessment dated [DATE] revealed unhealed stage II pressure ulcers requiring the application of ointments/medications that were present upon admission. Record review of Resident #3's care plan dated 1/31/2024 revealed a plan of care to address the residents impaired skin integrity included: monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration , etc. to MD and wound care orders. Record review of Resident #3's physician order summary for February 2024 revealed: 1. Wound care to sacrum and buttocks, cleanse with normal saline, pat dry, apply zinc and cover with optifoam dressing with every brief change and PRN. 2. Wound care to left upper extremity for drainage, apply abdominal pads, then wrap with kerlix, then wrap with ace wrap, change Monday, Wednesday, Friday, and PRN. During an observation of wound care on 2/08/2024 at 3:04 p.m., Resident #3 was observed seated in a wheelchair in his room. Treatment Nurse B prepared supplies in the hallway with gloves on and then entered the resident room. She placed the supplies on the edge of the sink in the resident room which was not on a sanitized or prepared surface. The supplies were kept in their original wrappers. Treatment Nurse B washed her hands in the bathroom sink, donned (put on) new gloves and then proceeded to assist the resident to standing, handling both the resident and the rollator (walker with wheels). Treatment Nurse B pulled down Resident #3's pants, removed the side of his brief to expose his buttocks and provided wound care to the sacrum all without changing gloves. Treatment Nurse B did not remove her gloves during from start until finish until after she pulled up Resident #3's pants after the treatment was completed. During an observation of wound care on 2/08/2024 at 3:19 p.m., Treatment Nurse B entered Resident #3's room and placed wound care supplies, still in their original packaging on the nightstand which was cluttered with personal items without sanitizing or preparing the surface. The Treatment Nurse did not wash or sanitize her hands upon entry to the room. After donning gloves, she unwrapped Resident #3's arm and removed the old dressing. Treatment Nurse B doffed (took off) the gloves after removing the old dressing but did not wash or sanitize her hands before placing on new gloves. Treatment Nurse B cleaned the wound and applied a new dressing before doffing gloves. Treatment Nurse B again did not wash or sanitize her hands before once again donning gloves and re-wrapping Resident #3's arm in kerlix and an ace bandage. During an interview on 2/08/2024 at 3:37 p.m., Treatment Nurse B stated she did not wash or sanitize her hands during either of Resident #3's separate wound care observations. Treatment Nurse B stated she did wash her hands at the beginning and at the end and did change her gloves several times. She stated she did not change her gloves during the first wound care observation because Resident #3 was standing, and she did not want to leave him alone to go wash her hands. She stated if Resident #3 had been in bed for the wound care or if the wound had been more serious, she would have washed her hands. The Treatment Nurse stated a more serious wound was a larger open area and she did not consider the small opening of Resident #3's sacral wound to be serious because the opening was very small, and the wound was almost healed. Treatment Nurse B stated with the arm wound care she did change her gloves more often but did not wash or sanitize her hands. She stated she did not perform hand hygiene because there was no hand sanitizer in the room. Treatment Nurse B stated she could have gone outside of the room to sanitize her hands. She stated she should have but did not because at the last place she worked the hand sanitizer had been in the resident room and that was what she was used to. Treatment Nurse B stated she did have hand sanitizer on the treatment cart but she did not think she was supposed to bring it into the residents room. The Treatment Nurse stated she did not wash her hands because she was nervous. The Treatment Nurse stated she typically just washes her hands before wound care and after wound care and then if she has to leave the room for any reason, she will use hand sanitizer before re-entering the room. Treatment Nurse B stated she had been trained to keep the supplies in their original wrapper which could be placed on any surface. She stated she was trained to sanitize her hands between glove changes and when going from dirty to clean, when working on different wounds or different body parts. During an interview on 2/09/2024 at 10:57 a.m., the Infection Preventionist stated wound care should be completed with the following steps: .knock on door, wash hands, make sure surface where supplies will be used was clean by using a sanitizing wipe on the surface and then allowing it to dry, put a napkin or tray down on the clean surface, place supplies in small amounts in medication cups and ensuring applicators available for application of medication, place on the cleaned area, wash hands again, don gloves, place patient close, expose area needed with gloves on, remove old dressing and throw in trash, wash hands, put on clean gloves, clean the wound from dirty to clean, pat dry and apply medication with applicator, cover with dry dressing .discard all trash, take gloves off, wash hands .The Infection Preventionist stated she expected the Treatment Nurse to wash her hands after doffing gloves and before donning new gloves. She stated she expected the Treatment Nurse to sanitizer her hands with alcohol-based sanitizer if she was not able to leave the resident but if no hand sanitizer was available the Treatment nurse should wash her hands with soap and water. The Infection Preventionist stated infection prevention during wound care was important to prevent the spread of infection, to protect oneself and to protect the patient (resident) from pathogens. Record review of Treatment Nurse B's annual wound care competencies dated 11/18/2023 revealed the Treatment Nurse had met the competencies for application of wound dressing with the following critical element steps: 2. Gather supplies 3. Uses personal protective equipment as indicated. 4. Cleans over-bed table. 5. Places clean barrier on the over the bed table and places supplies on barrier 11. Cleans hands 12. If patient has multiple wounds; b. in separate locations: treats each as a separate procedure 13. If breaks aseptic technique (a method of procedures used by healthcare professional to prevent cross contamination) , removes gloves, cleanses hands, and applies clean gloves 14. Opens supplies without contaminating. Keeps the dressing/gauze within the open packet and places it directly on top of barrier 15. Prepared medications/ointments, if indicated by placing on inner sterile package 16. Exposes area to be treated. Applies clean gloves and removes soiled dressing 17. Discards dressing and gloves according to infection control policy 18. Cleans hands 19. Applies gloves 20. Cleanses/irrigates the wound as ordered 21. Wipes an excess fluid from the surrounding skin using a dry, gauze wipe 22. if gloves become contaminated, removes gloves, cleanses hands and applies clean gloves 24. Applies and secures clean dressing 25. Removes gloves and discards according to infection control procedures. 27. Cleanses hands. Record review of a facility policy, titled Hand Hygiene dated 10/24/2022 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. During an interview on 2/09/2024 at 11:22 a.m., the Administrator stated the facility did not have a policy that specifically addressed application of wound care or wound care technique.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident, for 3 of 8 Residents (Resident #58, #49 and #113) reviewed for medication administration in that: 1. LVN D administered Humalog (insulin) to Resident #58 without priming the insulin pen (removing air bubbles from the needle) prior to administering. 2. a. LVN E dropped 1 medication prescribed to Resident #49 on the medication cart counter and dispensed it to the resident. b. LVN E dropped 2 medications prescribed to Resident #113 on the medication cart counter and dispensed them to the resident. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings were: 1. Record review of Resident #58's face sheet, dated 3/10/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the nervous system, spinal stenosis (narrowing of the spinal canal cause by age-related wear and tear resulting in pressure on the spinal cord and the nerves within the spin), heart failure, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should), morbid obesity and hypertension (high blood pressure). Record review of Resident #58's most recent admission MDS assessment, dated 2/28/23 revealed the resident was cognitively intact for daily decision-making skills, was diagnosed with diabetes and was treated with insulin. Record review of Resident #58's comprehensive care plan, initiated on 2/27/23 revealed the resident had altered endocrine status related to diabetes. Record review of Resident #58's Order Summary Report, dated 3/10/23 revealed an order for Humalog solution Pen-injector 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime for diabetes, with order date 2/25/23 and no end date. Observation on 3/8/23 at 4:14 p.m. during the medication pass revealed, LVN D placed an injection needle on the Humalog Pen-Injector, set the dial on the insulin pen at 2 units and administered the insulin to Resident #58 without priming the Humalog Pen-Injector first. During an interview on 3/8/23 at 4:26 p.m., LVN D stated, I don't even know what prime means; I've never done that. LVN D stated, she had not had an in-service on administering insulin since she had been in school. LVN D stated she had worked for the facility for the past 3 years. During an interview on 3/9/23 at 5:06 p.m., the DON stated, the insulin pen should have been primed to make sure there was no air in the pen and that would ensure the insulin dose dispensed was correct. The DON stated insulin not administered as prescribed could make the glucose level not come down to the expected level you would hope for and the negative outcome potentially could be the blood sugar would be under corrected. The DON stated nursing staff were provided competencies upon hire during orientation. Record review of the annual Clinical Competency Validation, Medication Administration - Licensed Nurse document for LVN D, dated 9/13/22 revealed she had satisfied the requirement for proper technique when storing, preparing and administering injectable (IM, sub-q) medications. Record review of the prescribing manufacturer's insert titled, Instructions for use Humalog KwikPen, revision date 4/2020 revealed in part, .Priming your pen .Prime before each injection .Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly .If you do not prime before each injection, you may get too much or too little insulin . 2. a. Record review of Resident #49's face sheet, dated 3/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of left femur (bone of the thigh or upper hind limb), orthopedic aftercare, osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), difficulty in walking, abnormalities of gait and mobility and lack of coordination. Record review of Resident #49's most recent admission MDS assessment revealed the resident was cognitively intact for daily decision-making skills, required 2-person physical assist with bed mobility and transfers and was treated with pain medication as needed. Record review of Resident #49's comprehensive care plan, initiated on 2/8/23 revealed the resident received pain medication therapy with interventions that included to administer analgesic pain medications as ordered by the physician. Record review of Resident #49's Order Summary Report, dated 3/10/23 revealed an order for Acetaminophen-Codeine tablet 300-30 mg, give 1 tablet by mouth every 6 hours as needed for severe pain, with order dated 2/7/23 and no end date. Observation on 3/9/23 at 7:45 a.m., during the medication pass revealed, LVN E dispensed 8 prescribed medications for Resident #49 into a medication cup and then took the Acetaminophen-Codeine 300-30 mg tablet from the medication bottle and dropped it on the medication cart counter. LVN E then took a plastic spoon and scooped the Acetaminophen-Codeine 300-30 mg tablet into the medication cup with the other 8 pills. LVN E then administered the medications to Resident #49. 2. b. Record review of Resident #113's face sheet, dated 3/10/23 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included spontaneous bacterial peritonitis (infection of abdominal fluid within the abdomen such as a hole in the intestines or a collection of pus), sepsis (the body's extreme response to an infection), cirrhosis of liver (scarring of the liver caused by long-term liver damage), hepatic failure (liver failure), Cushing's syndrome (disorder caused by excessive production or administration of glucocorticoid hormones), cholelithiasis (gallstones, a hardened deposit within the fluid in the gallbladder), asthma and hypertension (high blood pressure). Record review of Resident #113's comprehensive care plan, initiated on 3/9/23 revealed the resident was treated with pain medication with interventions that included to administer analgesic medications as ordered by the physician. Record review of Resident #113's Order Summary Report, dated 3/10/23 revealed an order for Potassium Chloride ER (extended release) tablet, 10 meq (milliequivalent) one time a day for supplement, give 2 tablets to equal 20 meq, with order date 3/9/23 and no end date and an order for acetaminophen 325 mg tablet, give 2 tablets every 6 hours as needed for pain/fever with order dated 3/7/23 and no end date. Observation on 3/9/23 at 8:16 a.m., during the medication pass revealed, LVN E took Resident #113's Potassium Chloride ER tablet from the blister package, dropped it on the medication cart counter and scooped up the Potassium Chloride ER tablet with a plastic spoon and placed it in the medication cup. LVN E then dispensed 7 more pills into the same medication cup and administered them to Resident #113. Resident #113 then requested pain medication. LVN E returned to the medication cart, dispensed two acetaminophen 325 mg tablets, dropped one tablet on the floor and the other tablet fell on the medication cart counter. LVN E used the medication cup to scoop the acetaminophen 325 mg tablet from the medication cart counter and dispensed another tablet from the medication bottle. LVN E picked up the tablet from the floor and disposed it. LVN E then returned to Resident #113's bedside and administered the acetaminophen 325 mg tablets to the resident. During an interview on 3/9/23 at 8:41 a.m., LVN E stated she began her shift at 6:00 a.m. and had been using the same medication cart during the medication pass. LVN E stated she had sanitized the medication cart counter at the beginning of the shift, so dropping medications on the medication cart counter was ok. LVN E then stated the medication cart had been used and other objects had been placed on the medication cart counter so dropping a pill on the counter should have been discarded because it would be considered cross contamination. During an interview on 3/9/23 at 5:09 p.m., the DON stated, Best practice would be to discard the medications if the pill fell on the counter and get new pills. The DON stated the expectation was for LVN E to discard the pills and start over. The DON stated, dropping the pills on the medication cart counter could result in the resident being exposed to a contaminant and was considered cross contamination. Record review of the Clinical Competency Validation Medication Administration - Licensed Nurse form, dated 12/21/22 revealed LVN E had satisfied the requirements for preparing the medication cart for medication pass, including the following, Uses proper technique when storing, preparing, & administering oral medications .b. Pours medication into medication cup. Record review of the facility policy and procedure, titled Medication Administration, dated 10/24/22 revealed in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .

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 2 ice makers reviewed for food handling sanitation. 1. The facility failed to ensure the nutritional room ice machine was clean. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings include: Observation on 03/08/23 at 11:14 AM revealed a large black mass along the side of the condenser unit above the ice inside of the ice machine. The condenser unit was observed to be located directly above the ice with recently produced ice dropped directly from above. Interview on 03/08/23 at 10:16 AM, the DM stated the nutritional room is entirely the responsibility of the nursing department except for the refrigerator in that room. Interview on 03/08/23 at 11:46 AM, LVN G stated she provided ice to the residents upstairs from the ice maker in the nutrition room. LVN G stated if there was a concern with the ice maker, she would submit a work order which could be done anywhere. LVN G stated it was the responsibility of any nurse or CNA who got ice in the nourishment room to report a concern to the Maintenance Supervisor. Interview on 03/08/23 at 11:50 AM, the DON stated he could not identify the black substance on the side of condenser and that the MS regularly evaluated the ice maker. The DON stated to identify the black sustenance he would like for it be viewed and evaluated by maintenance and stated he would contact the MS immediately. The DON stated the MS confirmed the responsibility for evaluating the ice maker for needed service was the responsibility of the dietary department. Interview on 03/08/23 at 11:58 AM, the MS stated he checks the nutrition room's ice maker monthly and evaluates it for cleanliness. The MS stated the last cleaning was about 2 weeks ago and he normally does the cleaning in the middle of the month. The MS stated the ice maker will produce more buildup depending on the run time and humidity. The MS stated the concern was something that needs a full cleanout. The MS stated a full cleanout was one where all the ice was melted, and then all items are cleaned inside. The MS stated a full cleanout was the only service needed. The MS stated he did not remember the last time the ice maker received a full cleanout. The MS stated full cleanouts are not documented, only the regular cleanings. The MS stated he did not have any recollection of a work order request for the ice maker and that nursing can submit that digitally. The MS stated the risk associated with having a dirty or unclean ice maker would be a potential for contaminated water and thus cause contaminated ice for resident use. Interview on 03/08/23 at 1:22 PM, the ADM stated they have cleaned the ice maker after removing the ice and stated there was a breakdown of communication in that the dietary was not aware the ice maker was their responsibility. The ADM stated she was not aware of the ice maker's condition or cleanliness and stated she expects staff to report concerns with essential equipment to the MS to be serviced immediately. Record review of the facility's, undated, policy titled Logbook Documentation reflected Clean Interior: Sanitize interior of ice maker per manufacturer's instructions; Clean out and sanitize ice bin. It further reflected the last indicated date the service was completed was on 02/27/23. A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. Record review of the US Food Code, dated 2017, reflected (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 15 residents (Resident #4) reviewed for accuracy of medical records in that: 1. Resident #4 did not have a physician's order for code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings were: Record review of Resident #4's face sheet, dated [DATE] revealed an [AGE] year-old-female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acute gastric ulcer with hemorrhage (bleeding, open ulcers in the digestive tract), paroxysmal atrial fibrillation (irregular heart beat that returns to normal within 7 days, on its own or with treatment), chronic iron deficiency anemia secondary to blood loss (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), pure hypercholesterolemia (genetic condition that causes the development of high LDL cholesterol levels), hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), cirrhosis of liver (scarring of the liver caused by long-term liver damage), heart disease, chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems) and hypertension (high blood pressure). Record review of Resident #4's most recent admission MDS assessment, dated [DATE] revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #4's comprehensive care plan, dated [DATE] revealed the resident was a full code with interventions that included to initiate CPR and call 911. Record review of Resident #4's Directive to Physicians and Family or Surrogates form, signed and dated by Resident #4 on [DATE] revealed, under Terminal Condition, Resident #4 requested all treatments other than those to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. The Directive to Physicians and Family or Surrogates form, under Irreversible Condition, revealed Resident #4 requested all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. Further review of Resident #4's Directive to Physicians and Family or Surrogates form, under Additional Requests revealed Resident #4 requested the following, I do not want cardiac resuscitation, I do not want mechanical respiration, I do not want tube feeding, I do not want antibiotics and I do not want to be maintained in a condition or approaching a condition of what is known as a vegetative stated, and I want a treating physician and my agent designated in my Medical Power of Attorney of even date herewith to do all that is possible to avoid the administration of procedures which will only prolong the moment of death. Record review of Resident #4's Social Services Initial Evaluation and Social History document, dated [DATE] revealed the resident requested full code status. Record review of Resident #4's Order Summary Report for active orders as of [DATE] revealed there was no order for code status. During an interview on [DATE] at 1:21 p.m., Resident #4's family member, who was visiting Resident #4 stated, Resident #4 was in DNR status and the family was looking into palliative care and hospice services. Resident #4's family member stated the resident had the DNR status for about a year and Resident #4 had been in and out of the hospital since [DATE]. Resident #4's family member stated the facility should have had a DNR document on file. During an interview on [DATE] at 1:22 p.m., Resident #4 stated she did not know about her code status, indicating she did not know if she was full code status or DNR status. During an interview on [DATE] at 1:37 p.m., LVN Charge Nurse A stated, a resident who was identified as DNR status would have a sign posted above the resident's bed. LVN Charge Nurse A stated, residents on her unit, including Resident #4, did not have a DNR status. LVN Charge Nurse A stated, a resident's code status could be found on the resident's physician's orders. LVN Charge Nurse A, after checking in the medical electronic record revealed, Resident #4 did not have an active order for code status. LVN Charge Nurse A stated, a physician's order for code status was necessary to confirm code status and in case something should happen then staff would know how to take care of the resident. LVN Charge Nurse A stated the admissions nurse was responsible for obtaining a code status order. LVN Charge Nurse A stated she had never done an admission. During an interview on [DATE] at 1:50 p.m., SW B stated, code status documentation, such as for a DNR, was provided at the time of admission. SW B stated the social worker would ask the resident directly if they had an advanced directive at the time of admission. During an interview on [DATE] at 1:50 p.m., SW C stated, the Directive to Physicians and Family or Surrogates form for Resident #4 did not constitute a DNR status and therefore did not make Resident #4 a DNR. SW C stated, the DNR would dictate how Resident #4 would be treated should the resident require CPR. SW C stated, it was negligence on their part because the resident's wishes needed to be respected. During an interview on [DATE] at 2:04 p.m., the Administrator stated, a code status for Resident #4 could be found under the physician's orders and any DNR documentation could be found under the miscellaneous tab in the electronic record. The Administrator stated, a resident's code status would not be on a sign on the wall in a resident's room. The Administrator stated LVN A made her aware Resident #4 did not have an order for code status after surveyor intervention and had given LVN A the directive to put an order in the resident's medical electronic record for a full code. The Administrator stated it was the SW's responsibility to have the code status discussion with the resident and/or the family about an advanced directive and if Resident #4 and/or family wanted the resident to become a DNR, the SW would help initiate that. The Administrator stated the nurse should be able to check if the resident had a DNR code status immediately on the face sheet and under the miscellaneous tab in the electronic record. The Administrator stated it was important to have an order for code status and a plan of care to abide by the resident's wishes. The Administrator stated an order for DNR or full code status could not be bypassed because it infringed on the resident's rights. During a follow up interview on [DATE] at 3:08 p.m., SW B stated, only nursing could input orders, so if Resident #4 was determined a DNR status, the information would have been provided to nursing during report and then the SW would have helped to initiate the documents needed for an advanced directive. SW B stated, if the information or paperwork was not provided, Resident #4 would automatically become a full code status. SW B stated it was the Social Worker's responsibility to help initiate the paperwork for the DNR. A request for the policy and procedure for clinical records was made on [DATE] at 3:25 p.m. but was not provided by the Administrator. The Administrator stated, the facility used best practice to establish code status and attain an order from the physician for code status upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #216, #49 and #56) observed for infection control in that: 1. During the medication pass, LVN E did not sanitize the wrist blood pressure cuff used between Resident #216 and Resident #49. 2. LVN Treatment Nurse F placed several gloves in his pant pocket and used them during wound care for Resident #56. These deficient practices could place residents at risk of infection. The findings were: 1. a. Record review of Resident #216's face sheet, dated 3/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hepatic failure (liver failure), hepatic encephalopathy (loss of brain function when a damaged liver doesn't remove toxins from the blood), cirrhosis of liver (scarring of the liver caused by long-term liver damage), liver cell carcinoma (a form of liver cancer), hyperlipidemia (high cholesterol) and hypertension (high blood pressure). b. Record review of Resident #49's face sheet, dated 3/10/23 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included fracture of left femur (bone of the thigh or upper hind limb), orthopedic aftercare, osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), difficulty in walking, abnormalities of gait and mobility and lack of coordination and hypertension (high blood pressure) Observation on 3/9/23 at 7:45 a.m. during the medication pass revealed LVN E exited Resident #216's room with the wrist blood pressure cuff and placed it on top of the medication cart counter. LVN E then prepared Resident #49's medications, took the same wrist blood pressure cuff used on Resident #216 and placed it on her own wrist. LVN E then went into Resident #49's room, removed the wrist blood pressure cuff from her own wrist and placed it on Resident #49's right wrist without sanitizing it. LVN E obtained Resident #49's blood pressure, removed the wrist blood pressure cuff and placed it back onto her own wrist. LVN E then returned to the medication cart, removed the wrist blood pressure cuff from her wrist and stored it in a drawer in the medication cart without sanitizing it. During an interview on 3/9/23 at 8:41 a.m., LVN E stated she had started her shift at 6:00 a.m. and had borrowed the wrist blood pressure cuff from the Treatment Nurse. LVN E stated she had initially used the wrist blood pressure cuff on Resident #216 and did not sanitize the wrist blood pressure cuff before using it to obtain Resident #216's blood pressure or prior to obtaining Resident #49's blood pressure. LVN E stated she had forgotten to sanitize the wrist blood pressure cuff between Resident #216 and Resident #49 and should have because it was considered cross contamination and the residents could be affected in that illness could be transferred from resident to resident. During an interview on 3/9/23 at 5:09 p.m., the DON stated it was the expectation for nursing staff to disinfect any equipment used between patient use and between patients to prevent cross contamination. The DON stated, If we don't do that, we could potentially cross contaminate and the resident may come in contact with something like any sort of other patient's organisms. 2. Record review of Resident #56's face sheet, dated 3/5/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included urinary tract infection, HIV disease (human immunodeficiency virus, a virus that attacks the body's immune system), acute respiratory failure (develops when the lungs can't get enough oxygen into the blood), and kidney failure. Record review of Resident #56's Order Summary Report, dated 3/9/23 revealed an order for wound care to the buttock/rear BLE every day shift and as needed with order date 3/7/23 and no end date. Record review of Resident #56's comprehensive care plan, dated 3/8/23 revealed the resident had pressure ulcer development related to lack of mobility with interventions that included to administer treatments as ordered and monitor for effectiveness and wound care to the buttock/rear to bilateral lower extremities. Observation on 3/9/23 at 9:33 a.m., during wound care revealed, LVN Treatment Nurse F took several disposable gloves from a box mounted outside of Resident #56's room, placed the disposable gloves into the right leg pocket of his pants and then went into Resident #56's room to wash his hands. LVN Treatment Nurse F returned to Resident #56's bedside, took the disposable gloves out of his right leg pocket and placed them on the resident's bedside table with other wound care supplies. LVN Treatment Nurse F used all of the disposable gloves he had put into his right leg pocket during the wound care to Resident #56. During an interview on 3/9/23 at 10:11 a.m., LVN Treatment Nurse F stated he realized he should not have placed the disposable gloves into his pant leg pocket because it could be considered cross contamination. LVN Treatment Nurse F stated, I put other items in the same pocket and in doing so the resident could get a bacterial infection. During an interview on 3/9/23 at 5:18 p.m., the DON stated, LVN Treatment Nurse F should not have put the disposable gloves into his pocket because the gloves in the box were clean but when they come out of the box and placed in any other container they were no longer assumed clean. The DON stated, it was not considered to be in line with standard practice of care and the resident could potentially come in contact with some sort of potential contaminant inside of LVN Treatment Nurse F's pocket, or even on the table where he placed his gloves. Record review of the facility policy and procedure titled, Infection Prevention and Control Measure for Common Infections in LTC (Long Term Care) Facilities, undated, revealed in part, .Standard precautions are used for all resident care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment that protect staff from infection and prevent the spread of infection among residents and staff .Standard precautions included .Practicing Hand Hygiene .Implementing correct Disinfection and Sterilization of instruments and devices .Hand hygiene refers to cleaning your hands by using hand washing techniques .Prior to direct contact with residents .After removing gloves .