**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a therapeutic diet when ordered by the physician to maintain adequate nutritional status, to the extent possible to maintain acceptable parameters of nutritional status for 1 of 18 residents (Resident #227) reviewed for nutrition: The facility did not ensure Resident #227's diet was consistent with physician's order on 5/8/25 for Diabetic Diet. This failure could place the resident at risk for weight loss and further decline in health. Findings included: Review of Resident #227 admission Minimum Data Set (MDS) Assessment, dated 5/13/25, reflected she was a [AGE] year-old female with an admission date of 5/6/25. Resident #227 had no impairment to her cognition and had a BIMS score of 15. The resident was to have a therapeutic diet while a resident at the facility. She had the following diagnoses: Diabetes (a group of diseases that result in too much sugar in the blood), Malnutrition, Anemia (a condition marked by a deficiency of red blood cells or hemoglobin in the blood), Gastroesophageal Reflux Disease (a condition in which stomach contents flow back up into the esophagus, causing irritation and discomfort), and muscle weakness. Review of the active physician's order dated 5/8/25 for Resident #227 reflected Diet - NSOT diet, Diabetic, Regular texture, Thin Liquids, 1500ml fluid restriction. Lactose intolerant. Review of Resident #227's Summit Baseline Careplan dated 5/7/25 reflected the diet type was NSOT. Review of Resident #227's Care Plan dated 5/8/25 reflected .Problem Start Date: 06/03/2025 Category: Dietary Resident is at nutritional/weight variance risk r/t therapeutic diet, lymphedema, diuretic therapy, kidney disease and diabetes .Approach Start Date: 06/03/2025 Diet as ordered Created: 06/03/2025 . Review of Resident #227's Medical Nutrition Therapy Assessment dated 6/2/25 reflected .Diet (Type, texture, fluids) NSOT diabetic diet, regular texture, thin liquids. 1500 ml fluid restriction . Review of Resident #227's lunch meal ticket on 6/3/25 reflected .Diet: Regular, Texture: Regular, Diet Other NSOT .Allergies: Milk . Interview with Resident #227 on 6/3/25 at 10:13am revealed she was lactose intolerant, was diabetic, had gout and the food she was receiving was not matching her medical needs , she had gotten a lot of carbs on her trays. Resident #227 stated she had spoken to the Dietician the day before and was hopeful that her meals would be corrected. Observation of Resident #227's lunch tray on 6/3/25 at 1:06pm reflected broccoli, a dinner roll, 1 piece of fried chicken, lettuce and tomato salad, Italian dressing, pineapples in juice, tea, water, butter and packets of sugar. Interview with Dietician J on 6/4/25 at 11:25am revealed the Dietary Manager would initially meet with the residents during admission to obtain information about resident's food preferences. The Dietary Manager would then meet with residents as needed or quarterly to update preferences. She stated the facility did not have a diabetic diet, they had a therapeutic LCS diet. She stated there was no such thing as a diabetic diet at the facility. She stated the facility did not have a specific diet for lactose intolerance, but a restriction on a food or intolerances would be documented in a progress note in the EMR and on their tray ticket. Not all residents who were diabetic were on an LCS diet, unless it was indicated by a doctor, or the resident was experiencing negative effects from having had a regular diet. While reviewing Resident #227's EMR she reviewed the doctor's order on 5/8/25 where it indicated a diabetic diet and she stated that was not the proper verbiage for a restricted diet for someone with diabetes. If the doctor deemed it appropriate, then it would have been an LCS diet. She reviewed Resident #227's lunch ticket from 6/4/25 and stated in her opinion it was consistent with the physician order on 5/8/25 due to the facility not having a diabetic diet. She was not assigned to this facility and had not met with Resident #227. She stated a colleague of hers had met with that resident. Dieticians typically met with residents when there was a complaint or if there was a concern for weight loss. New admits were reviewed the next time the Dietician came to the facility. Dieticians could make a recommendation for diet change when they reviewed the new admits, but the doctor had to modify the order and accept the change. Interview with the DON on 6/4/25 at 12:00pm revealed the facility did not have a diabetic diet and called the doctor on behalf of Resident #227's since the order was incorrect and corrected the order to LCS diet. She clarified the resident had a milk and lactose allergy and had that corrected as well on her ticket and EMR. The DON stated she would also go speak to Resident #227 regarding her food preferences. Interview with the Manger for Nutritious Lifestyle on 6/4/25 at 2:09pm revealed she was the supervisor of the dieticians that go to the facility. She stated that the dieticians spent 16 to 24 hours per month at each facility, which was equivalent to 2-3 onsite visits per month. Dietician K was the dietician that visited the facility regularly. He was last at the facility on 6/2/25 at which time he assessed Resident #227 but did not assess her dietary needs in May 2025 . The facility had a 30-day window for dieticians to meet with new residents after they were admitted to the facility. The facility had the option to reach out to the Dietician at any time if they needed assistance with a resident. Dieticians did not have to approve a diet change and were not required to update dietary staff on diet changes. Most of the time, changes to diets happened internally without the dietician and the dietician would review the change at the next visit. Doctors had the final say on residents' diets. Interview with the Dietary Manager on 6/4/25 at1:35pm revealed she had met with Resident #227 when she first arrived at the facility to discusses food preferences. Resident #227 told her that she was allergic to milk. She was just notified earlier that morning about Resident #227's need for diabetic food. She was not notified prior to today of the resident's need for an LCS diet. She stated Resident #227 now had a LCS diet and lactose allergy listed on her ticket and in their system. She stated typically nursing notified her when there was a new order for a diet for a resident. Nursing would give her a copy of the order and she would enter it in the system. The risk to the resident of not having had the correct order was it could cause illness. Interview with the DON on 6/5/25 at 10:56am revealed their process for new admits was the nurse filled out a dietary form with the prescribed diet and it would be handed to the Dietary Manager. If nursing got an order to change a diet, they were supposed to print it and hand it to dietary. The person who received Resident #227's order should have clarified with the doctor what therapeutic diet he wanted because the facility did not have a Diabetic Diet. The dietician would review diet orders when they came to the facility and made recommendations of change if necessary. The Dietician was at the facility 3 times in May 2025 but had not met with Resident #227. The Dietician should be looking at orders and making recommendations and therefore should have caught the error on Resident #227's dietary order. She had the Dietary Manager speak to Resident #227 yesterday and it was corrected. The risk to the resident of not having had the correct diet was that that her blood sugar could have been elevated and could have affected her need for medications. Review of the facility's policy Diets Offered by the Facility dated 4/26/19 reflected .The following diets are available: Regular, No added Salt, LCS, Liberal Renal (kidney), Puree, mechanical soft. Procedure: 1. All diets must be ordered by the attending physician and recorded in the resident's medical record. 2. Nursing services will complete a Diet Order Form for all new admissions and diet changes and forward to Nutrition and Food service Department .3. Any order for diets other than those above or diet orders for as tolerated will be clarified by nursing prior to forwarding the Diet Order from to the Dietary Department .If a physician orders a special diet, nursing will consult with the physician to determine if one of the diets above can be substituted . Review of the Facility's policy Liberalized Diets dated 4/26/29 reflected .1. Nursing will clarify any diet that does not match the diets offered at the facility prior to forwarding the diet order form to the dietary Department. 2. Nursing will use the following to clarity the liberalized diet with the physician: If these diets are ordered .Diabetic .Obtain order for: Low Concentrated Sweets (LCS) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for one (Residents #177) of one resident reviewed for dialysis. The facility nursing staff failed to document and assess Resident #177's returning vital signs, access site, and mental status after Resident #177 returned from dialysis treatment on 05/27/25, 05/31/25, and 06/03/25. This failure places residents in the facility who received dialysis at risk of not receiving proper care and coordination of care. Findings included: Record review of Resident #177's Comprehensive MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility admitted on [DATE] with the diagnoses of anemia (low iron), kidney disease, heart failure, and diabetes (high blood sugar) with a BIMS score of 15 (intact cognition). Resident #177 required dialysis services. Record review of Resident #177's care plan, dated 06/03/25 reflected The resident is on dialysis due to Acute kidney failure . on Tuesdays and Saturdays at 9:30 AM. In an interview on 06/03/25 at 1:43 PM with Resident #177 she stated she just got back from dialysis. She stated there was an issue with transportation to dialysis once, when she first admitted to the facility, and there had been no problems since then. She stated she had no concerns regarding her dialysis. She stated she planned to discharge home soon. Review of Resident #177's Dialysis Communication Record Binder reflected the following: Dialysis Communication Record Form dated 05/27/25 revealed Resident #177's facility pre-dialysis and post-dialysis section was not completed by the facility nurse for vital signs, access site, dressing, and if there was any change of condition; the dialysis nurse completed their section. Dialysis Communication Record Form dated 05/31/25 revealed Resident #177's facility pre-dialysis vital signs were taken, the access site was assessed, and the medication list by LVN R; the dialysis nurse completed their section, and the post-dialysis section was not completed by the facility nurse for vital signs, access site, dressing, and if there were new orders. Dialysis Communication Record Form dated 06/03/25 revealed Resident #177's facility pre-dialysis vital signs were taken, the access site assessed, and the medication list and was not signed by a facility nurse; the dialysis nurse completed their section, and the post-dialysis section was not completed by the facility nurse for vital signs, access site, dressing, and if there were new orders. Record review of Resident #177's vitals from 05/22/25-06/03/25 reflected the following on dialysis days: -vitals dated 05/27/25 at 7:27 AM: blood pressure 108/71; pulse 98 bpm by MA D -vitals dated 06/03/25 at 7 PM: pulse 78 bpm by LVN U Record review of Resident #177's Medication Administration History from 05/05/25 to 06/05/25 reflected the following order: metoprolol tartrate 25 mg tablet for hypertension twice a day with special instructions of per order from dialysis please hold metoprolol before dialysis ., and monitoring of pulse and blood pressure at 7 AM and 7 PM, start dated 01/27/25 and discontinue date of 06/03/25. Review of blood pressure and pulse on the following dialysis days reflected the following: 05/27/25: Scheduled time 7 AM: Not Administered: On Hold .Comment: dialysis charted at 7:28 AM by MA D Scheduled time 7 PM: Not Administered: Other . Comment: dialysis charted at 11:51 AM by MA D 05/31/25: Scheduled time 7 AM: Not Administered: Refused charted at 7:27 AM by MA X Scheduled time 7 PM: Not Administered: Refused charted at 6:26 PM by MA X 06/03/25: Scheduled time 7 AM: Not Administered: Other .Comment: dialysis charted at 6:15 AM by MA D Scheduled time 7 PM: Late Administration: Charted late .Comment: adm on time .Pulse: 78 .Blood Pressure: 121/58 charted at 8:52 PM by LVN U. There were no Progress Notes about assessment of Resident #177's dialysis pre or post assessment by nursing for the date range of 05/22/25-06/03/25. In an interview on 06/04/25 at 1:26 PM with MA D, she stated that Resident #177 was on dialysis services and she completed vital signs before she left for dialysis. She stated that nurses assessed the resident when she returned. In an interview on 06/05/25 at 10:55 AM with the DON she stated that LVNs should be completing the vitals section of the Dialysis Communication Sheets before and upon return of the resident to dialysis and did not know they were not completed upon Resident #177's return from dialysis. She stated she was going to in-service staff immediately. She stated that it was important for the nurses to complete the return section of the dialysis communication record form to ensure the resident was doing well post-dialysis. In an interview on 06/05/25 at 12:45 PM with LVN B she stated she worked on 06/03/25 during the 6 AM -2 PM shift and completed the dialysis communication record top portion for Resident #177. She stated she checked Resident #177 vitals and filled out the top portion of the form before Resident #177 left to dialysis and then when Resident #177 returned she checked the sheet for any new orders or changes, but she did not know if she was supposed to check Resident #177's vitals when she returned from dialysis. In an interview on 06/05/25 at 1:21 PM with the Administrator he stated he expected staff to follow their policy regarding the dialysis communication record sheets and the DON was going to in-service staff on the policy and procedures. Record review of the facility's policy and procedure titled Dialysis-General Guidelines and Management, dated December 2018, reflected: It is the policy of this home that dialysis residents will receive dialysis service as per physician orders and will be monitored accordingly . Potential Complications After Hemodialysis :( a treatment that cleans the blood) Disequilibrium phenomenon (loss of balance) results when excess solutes (urea) are cleared from the blood more rapidly than they can diffuse from the body's cells into the vascular compartment . Nursing Implications: 1. Monitor blood pressure and pulse . Potential Complications After Hemodialysis: Blood Loss/Hemorrhage . Nursing Implications: 1. Check access site immediately when resident returns. 2. Check vitals (B/P in arm opposite of access site) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one of two (Resident #43) reviewed for behavioral health services. The facility failed to ensure Resident #43 received his ongoing psychiatric services. Resident #43's last psychiatric appointment provided was on 01/29/25. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings Included: Record review of Resident #43 quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male with an admission date of 12/01/19. Resident #43 had a BIMS of 15 which indicated he was cognitively intact. There were no behaviors, signs of delusions or rejection of care noted on the assessment. Resident #43 had active diagnoses which included anxiety, depression, schizophrenia which included schizoaffective disorder and post-traumatic stress disorder. Record review of Resident #43's MD's progress note dated 01/03/24 reflected, .Has multiple psychiatric problems including anxiety, depression, schizoaffective disorder, post traumatic disorder, is on Latuda 10 daily. Has stable mood and behaviors, denies suicidal/homicidal ideation. Needs to see psych to optimize meds . Record Review of Resident #43's Physician's order report dated 05/04/25 to 06/04/25 reflected the resident was taking Latuda 10 mg once a day (antipsychotic), Trazadone 150 mg at bedtime (antidepressant), Prozac 60 mg daily (antidepressant), and buspirone 15 mg twice a day (used to treat anxiety). Record review of Resident #43's care plan with a problem start date of 04/03/25 reflected, .Behavioral Symptoms-Resident at risk for heightened emotions related to traumatic experiences related to witnessing a man shoot several people .Interventions .allow resident time to discuss emotions/trauma in a calm and safe environment as needed .consult mental health as needed .no triggers identified . Additional problems with a start date of 05/21/24 reflected, Resident has diagnosis of Post traumatic Stress disorder, at risk for anxiety, hallucinations, irritability, difficulty sleeping, lack of interest in activities, easily startled,/triggered, and loss of memory .approach .monitor/document behaviors per facility policy .administer medications per MD orders . Record Review of Resident #43's Behavioral health note dated 01/29/25 reflected an increase in buspirone to 15 mg twice a day for anxiety, continue Prozac 60 mg daily and Trazadone 150 mg at bedtime. Record review of Resident #43's Behavior Monitoring log from 04/01/25 through 06/04/25 reflected the facility was monitoring for hallucinations, anxiety/fearfulness, sleepiness, and mood swings. No behaviors were reported for the monitoring period. In an interview with Resident #43 on 06/04/25 at 01:30 p.m. the resident stated he had been the witness to a shooting when he was [AGE] years old. He stated he and his wife were both present and thought they were also going to be shot. He stated it had messed with him for years. He stated the man was sent to prison. He stated the only thing that really triggered him was firecrackers or someone knocking loudly on the door. He stated he had been going to psychiatric services outside of the facility but stated he had not been in a while and was not sure why. He stated the visits did help him and he wanted to continue to receive those services. In an interview with the behavioral health Clinic Representative on 06/04/25 at 02:40 p.m. revealed Resident #43 was last seen at the clinic on 01/29/25 and was scheduled for every 2 months. The Representative stated he never returned to the clinic and there were no notes indicating why he had not returned. In an interview with the DON on 06/05/25 at 09:45 a.m. she stated she knew Resident #43 was going to an outside behavioral health service instead of their contracted psychiatric services. She stated she was not sure why Resident #43 had not been to see them since January 2025. She stated she would reach out to his MD and see if something had changed. In an interview with Resident #43's MD on 06/05/25 at 11:01 a.m. she stated she was not aware Resident #43 was not receiving his psychiatric services until today. She stated due to his numerous psychiatric issues and his medications he needed to be seen on a routine basis so that they could manage his medications effectively. She stated she gave the facility a referral today to set him up with the in-house psychiatric services. In an interview with the Social Worker on 06/05/25 at 11:30 a.m. she stated she had made a referral to the facility's psychiatric services today for Resident #43. She stated she started at the facility mid-April 2025 and was not familiar with Resident #43's outside psychiatric services. She stated she made the referrals for any of the psychiatric services requested by nursing staff, or if she identifies a need she would ask for a referral. She stated the in-house psychiatric services followed up with her while they were in house. She stated she would follow up to make sure Resident #43 was seen. In an interview with the ADON on 06/05/25 at 02:10 p.m. she stated she was the floor nurse who took care of Resident #43 in January 2025. She stated she could not remember why Resident #43's MD wanted him seen by an outside psychiatric service. She stated they would send a card with him after each of his appointments to let them know when his next appointment was, and the nurse would be responsible for placing it in the scheduling book. She stated she was not sure how the follow up appointment was missed. In a follow up interview with the DON 06/05/25 at 02:45 p.m. she stated the Social Worker would be responsible for making the referral to the psychiatric provider and following up to ensure the services had been provided. She stated failing to ensure residents received their psychiatric services could cause a delay in the resident receiving necessary services and a possible mental decline. She stated it also helped determine if the resident was on the proper medications. Record review of the facility's policy titled, Behavior Management- Plan of Care, dated December 2018, reflected, It is the policy of this home to document behavioral symptoms, interventions, and goals. The Plan of Care is completed and updated, in the clinical software, for a resident assess as requiring behavior intervention. It is updated per the resident's clinical status .

**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 and administering of all medications to meet the needs of each resident for one of five residents (Resident #70) reviewed for pharmacy services. The facility failed to ensure LVN A followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #70. These failures placed residents at risk of not receiving full dosage of medication. Findings included: Record review of Resident #70's, Face sheet, dated 06/05/25 reflected a [AGE] year-old female with a readmission date of 05/08/25. Resident #70 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) Record review of Resident #70's Physician's Order report dated 05/05/25 to 06/05/2025, reflected, Humalog Kwikpen Insulin (Insulin lispro) insulin pen: 100 unit/ml; amt: Per Sliding Scale; If blood sugar is . 321to 350, give 7 units . with a start date of 02/25/25. An observation on 06/04/25 at 11:35 a.m. revealed LVN A performed hand hygiene and put on gloves and entered Resident #70's room to obtain a fingerstick blood sugar. The blood sugar reading was 340. LVN A checked the computer to determine the amount of insulin per sliding scale was 7 units of Lispro insulin. LVN A retrieved the insulin pen from the medication cart. LVN A dialed in 8 units and then pushed one unit out to obtain the 7 units. LVN A then entered the resident's room and administered the insulin. In an interview with LVN A on 06/04/25 at 11:45 a.m. he stated he was not aware the pen was supposed to be primed with 2 units before each dose. He stated he had always drawn up an extra unit of what was needed and pushed out 1 unit to make sure the insulin was to the end of the needle. He stated he was not aware he was supposed to prime with 2 units and push and hold the button to clear the chamber and then dial in the amount of insulin. In an interview with the DON on 06/05/25 at 09:45 a.m. she stated the insulin pen was to be primed before each injection. She stated failure to do so could result in the resident not receiving the prescribed amount of insulin. She stated dialing in extra insulin and trying to waste 1 unit was risky and not the proper way to prime the pen. She stated they could waste 2 much or not waste enough and give the wrong amount of insulin. She stated she would in-service the nursing staff to ensure they were all aware of the proper procedure. Record review of the facility's policy, Medication Administration, dated December 2018, revealed it did not list the procedure for use of Insulin pens. In a follow up interview with the DON on 06/05/25 at 12:05 p.m. she stated they followed the manufacture recommendation on the use of Insulin pens. Review of the manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 06/06/25 reflected, .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. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 residents (Resident #71) reviewed for medication storage. The facility failed to ensure Resident #71 did not have a medication named BioFreeze (a topical analgesic) at Resident #71's bedside table on 06/03/25. This failure could place residents at risk of having access to medications, resulting in harm, misuse of medication, drug diversions, and adverse reactions to medications due to improper storage. Findings included: Record review of Resident #71's Quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), dementia (loss of cognition), and cervical disc myelopathy disorder (compressed spinal cord in the neck), with a BIMS score of 14 (intact cognition). Record review of Resident #71's care plan revealed no indication regarding her ability to self-administer her medications. Observation and interview on 06/03/25 at 11:49 AM of Resident #71's room with CNA Q revealed a tube of BioFreeze on Resident #71's nightstand. She stated that Resident #71 had not asked for her to apply it and she had seen it in her room and thought nursing was aware. In an interview on 06/03/25 at 12:18 PM with the ADON she stated that she became aware that the resident had BioFreeze at her bedside recently and had told a CNA to remove it and did not know it was still at her bedside. She stated that the risk to a resident to have BioFreeze at the bedside would be nursing would not know if the resident had applied it or it could be used by another resident. She stated over the counter medications are supposed to be stored in the medication carts and residents needed to have a physician order for the medication. In an interview on 06/04/25 at 1:34 PM with CNA P she stated that the BioFreeze had been at Resident #71's bedside since she admitted to the facility and thought it was for the resident's legs. She stated Resident #71 never asked her to apply it on her. In an interview on 06/04/25 at 2:06 PM with Resident #71 revealed the BioFreeze came with her from another facility, it's used to help her legs, and was not sure when the last time it was applied to her legs. She stated she thought LVN R might have applied it to her legs once but was not sure. Observation of Resident #71's hands revealed she had difficulty using her hands due to contractures. In an interview on 06/04/25 at 7:04 PM with LVN R revealed she was not aware that Resident #71 had BioFreeze at her bedside and stated that it was not one of the resident's prescribed medications and Resident #71 was not able to apply it herself due to her hand contractures . She stated it was important to ensure medications were stored, even over the counter medications, because they needed to know how often the medication was administered, ensure it was administered properly, and to prevent accidents like another resident getting a hold of the medication or Resident #71 rubbing their eyes after using the medication after using the BioFreeze. In an interview on 06/05/25 at 10:55 AM with the DON she stated all medications, even over the counter medications, needed a physician order and should be locked in a nurse's cart because it insured resident safety and prevented accidents. She stated over the when staff round on residents they can see if an over the counter was in open view. She stated that she expected CNA's to inform nursing if they saw an over the counter medication at a resident's bedside and nursing would remove it and educate the resident on why they cannot have over the counters at the bedside and verify if there was an physician order if the resident needed or requested the medication. She stated that staff are trained on the process for medication administration that includes ensuring medications, even over the counters, are stored in a secure location. She stated it was possible Resident #71's family brought it to Resident #71 . Record review of the facility's medication policy, titled Medication- Administration, dated December 2018, reflected: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations . PROCEDURE 1. Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides, medical, pharmacy, or other personnel authorized by state laws and regulations. to administer medications. 2. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with guidelines for self -administration of medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for two of five shower rooms (shower rooms on 100 and 200 halls), 4 of 4 linen storage areas (3 blue carts (100, 200, and 300 halls) and 1 linens closet) reviewed for environment and 16 of 18 residents (Resident #14, Resident #19, Resident #58, and Resident #65) and 12 confidential residents reviewed for clean linens which included towels, and sheets. 1. The facility failed to ensure the shower rooms were cleaned throughout the day, kept orderly, and maintained in a sanitary and comfortable condition for resident use. 2. The facility failed to ensure there were clean washcloths for Residents #19, #58, and #65 on 06/04/25 and 06/05/25 for bathing. 3. The facility failed to provide clean bed linens for Resident #14's bed on 6/3/25 and 6/4/25. The failures could place residents at risk of exposure to infectious diseases and other unsanitary health hazards. Findings include: 1. While in an observation and interview for laundry on 06/04/2025 at 01:25 PM with Housekeeping Supervisor the shower rooms were observed. It was revealed that the 100 and 200 hall shower rooms had orange and pink residue along the grout lines of the bottom perimeter of the tiled shower, on areas of the tile wall and floor of the shower. Hall 100 shower room also had a brown residue on left side of the upper wall of shower. Hall 200 shower room also had light black areas of grout where the floor and wall met. When observed, Housekeeping Supervisor stated that the expectations were for the shower rooms to be cleaned daily. She stated that when she did competency checks of housekeepers work, she did not look down in the shower at the walls and floors. She stated that she had not noticed the orange, pink, black residue in the shower until it was pointed out. She stated that the showers were not cleaned to the standard that she wanted. In an observation and interview of hall 200 shower room on 06/04/2025 at 01:45 PM with the Administrator, he observed the orange, pink, and black residue on the left and back side of the shower wall and floor. He stated that the cleaning was not up to his standards and that the shower needed to be power washed. In an observation and interview on 06/05/2025 at 09:18 AM with Housekeeper L revealed she was responsible for cleaning on the 200 hall and odd rooms on the 300 hall, and the dining room after breakfast and lunch. She stated that she had cleaned the hall 200 shower on 06/04/2025. She observed the 200 hall shower which revealed an orange and pink residue. She stated that when she sprayed the Micro-kill all the residue usually came off without her having to scrub the walls. She stated that she did know why the orange and pink residue observed in the shower did not come out. She stated that the cleaning solution she used was called Medline Micro-kill. She observed the shower room on the 200 hall and stated residue came off once she sprayed it. Housekeeper L demonstrated and explained how she cleaned the shower room. She stated that she sprayed everything in the shower room which included the faucet, entire toilet, shower handrails, shower knobs, all shower walls and the shower floor with Micro-kill. After she sprayed the Micro-kill, she would let it sit and while sitting she would mop from inside the shower room on her way out to the 200 hall. She stated after she mopped, she went back in the shower room and sprayed the shower with water and wiped everywhere she sprayed with a rag. Housekeeper L stated that she wiped the shower wall from top to bottom. She stated she was out of green pads to scrub the showers. Observation of a bottle of Medline Micro-Kill R2 that Housekeeper L stated that she used. Housekeeper L stated that the risk of not properly cleaning was that residents could get sick. In an observation and interview on 06/05/2025 at 09:37 AM with Housekeeper M revealed she was responsible for cleaning all areas. She observed the 100 shower room which revealed a circular 2 to 4 inch brown stain on the back of the shower wall. She stated that the shower room had already been cleaned and stated that the brown stain appeared to be poop. She stated that she worked the days that each housekeeper had off. She stated that she worked opposite of the normal housekeepers. She stated that she would take the Micro-kill to spray handles and everything in the shower room. She stated after she sprayed, she swept then wiped down everywhere she sprayed with her towel. She stated that on the current week she cleaned the 200 hall on 06/01/2025 and 100 hall on 06/04/2025 and today. She stated that there had not ever been scrubbers at the facility to clean the shower rooms since she started working. She stated that she was not accustomed to cleaning a shower room with just a rag. She stated when she asked supervisor about scrubbers, she was told that the facility did not use scrubbers. Housekeeper M stated that the risk to residents for not properly cleaning could mess with the residents breathing. In an interview on 06/05/2025 at 10:15 AM with CNA E revealed that the housekeepers did not clean the shower rooms. She stated that it was the aides that cleaned the shower room. She stated that they were only cleaning because State was in the building. She stated that the housekeepers were acting because they did not usually do all that cleaning that they were doing. 2. Record review of Resident #19's Quarterly MDS dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #19 had intact cognition and a BIMS score of 15. She used a motorized wheelchair to get around in the facility. Resident #19 had the following diagnoses which included Dementia (lose of cognition), Parkinson's disease (movement affected), and Other specified arthritis (pain, stiffness, and inflammation in the joints). In an interview with Resident #19 on 06/04/2025 at 09:05 AM, she stated that she was bathed regularly. She stated that most times the facility had towels but when they did not, she used her pillowcase to bathe. She stated that she was told that laundry was backed up. Record review of Resident #58's Quarterly MDS dated [DATE], reflected a [AGE] year-old who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #58 had intact cognition and a BIMS score of 15. She used a wheelchair to get around in the facility. Resident #58 had diagnoses which included Vascular dementia (disruption of blood flow to the brain), Need for assistance with personal care, Polymyalgia rheumatica (pain and stiffness in shoulders, neck, and hips), Unspecified inflammatory spondylopathy (inflammation that affect spine and joints causing pain and stiffness), Other recurrent depressive disorders (high-function depression (persistent sadness and loss of interest). In an interview with Resident #58 on 06/03/2025 at 11:53 AM, it was revealed that the facility was always out of washcloth towels. She stated that she had to use a big towel for her washcloths on numerous occasions. She stated that when she asked about it, she was told by staff that the towels just disappeared. Record review of Resident #65's Quarterly MDS dated [DATE], reflected an [AGE] year-old who was admitted to the facility on [DATE]. Resident #65 had intact cognition and a BIMS score of 13. She used a wheelchair to get around in the facility. Resident #65 had diagnoses of the which included the following, Unspecified dementia (loss of memory, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) (undetermined dementia with lack of behavior disturbance), Other abnormalities of gait (walking or running) and mobility (ability to move freely and easily), Unspecified lack of coordination (inability to coordinate voluntary muscle movements), Other intervertebral disc degeneration (discs that cushion the backbone in the spine begin to breakdown). In an interview with Resident #65 on 06/03/2025 at 11:50AM, it was revealed that the facility did not always have washcloths for her when it was time for showers. Resident #65 stated that when she did not have a washcloth for a shower, she would use a large towel. In a confidential group interview on 06/04/2025 at 11:03 AM with 12 residents, the 12 residents had concerns with availability and cleanliness of washcloths. Interview revealed in the confidential group stated there are not always available washcloths when it was time for showers. Residents stated that they would use one of the big towels or pillowcases to bathe. It was also revealed that bed linens were not being changed with clean sheets after showers. In an interview and observation on 06/04/2025 at 12:27 PM with Laundry Aide S, she revealed that she was told and made aware by residents that there were not towels for everyone. She stated that on 06/04/25 she had not folded many washcloths. She stated that any towels that were not in the laundry room were on a blue cart in the hallways which was not many. She stated that she had almost completed all laundry and she had not washed or folded many washcloths. She stated that there had been issues with not enough towels for a little while. She also stated that there was a time when the towels were replenished then the towels started dwindling away. She also stated that any extra laundry that the facility had was in the laundry/housekeeping supervisor's office. The laundry room was observed with no washcloths on the table with the clean linen. There were approximately 7 large bath towels observed on the folding table in the laundry room. In an interview with the Housekeeping Supervisor on 06/04/2025 at 01:17 PM, she stated that there were not many of the washcloth towels because the washcloths were being thrown away by the residents. She stated that there had not been a shortage with towels. She also stated that she could have had washcloth and big towels completely stocked and towards the end of the day there would not be any towels left. She stated that she kept the overstock supply of linens in her office. She stated once the linens in her office ran short, she gave the list of supplies that needed to be ordered to the Medical Records department to order what was needed. She stated that she pulled the last of the towels out of her office on 05/30/2025. She also stated that an order was completed on 06/04/2025. She stated that she ordered towels at least every two weeks. She stated that she tried to keep her office stocked and did not have problems with having towels and linens ordered. In an interview and observation on 06/04/2025 at 01:24 PM with the Housekeeping Supervisor there were no clean washcloths and 2 clean large towels on the 200 hall laundry cart, no clean washcloths and no clean large dry towels on the 100 hall laundry cart, approximately 9 clean big towels and approximately 6 clean washcloths in the laundry storage room, and approximately 7 clean big towels on the 300 hall laundry cart. She stated that she did not know where the washcloth towels were during the observation of linens. She stated that during the walk around observation that there were not may washcloths in the areas observed. Record review on 06/05/25 of supplies order titled, Medline Packing List, revealed an order date of 05/07/2025 with a quantity of 10 packs with 12 washcloths each. The order on 05/07/2025 was the last order of washcloths. 3. Review of Resident #14's MDS reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #14 had little to no cognitive deficit and had a BIMS score of 13. She used a wheelchair to get around in the facility. She required partial to moderate assistance with most ADLs. Resident #14 had the following active diagnoses: Non-Alzheimer's Dementia (a progressive and irreversible neurodegenerative disease), Depression (a serious mood disorder characterized by persistent feeling of sadness, loss of interest or pleasure in activities and changes in thinking, sleeping, and acting), Vascular Dementia (memory loss in older adults) and chronic kidney disease(longstanding disease of the kidneys leading to renal failure). Observation of Resident #14's bedroom on 06/03/25 at 10:30 AM revealed the fitted sheet on her bed had a circular 3 to 4 inch grayish black with little black specks stain close to her footboard. Resident #14 was not in her room at the time of the observation. Observation of Resident #14's bedroom on 06/04/25 at 08:58 revealed the fitted sheet on her bed had the same stain from the day before and did not appear to have been changed. Interview with CNA E on 6/3/25 at 9:17am revealed she was working Resident #14's hall this morning and had not changed her sheets. She acknowledged she typically changed sheets when they were dirty like Resident #14's sheets. She stated sheets needed to be changed every shift if they were dirty like the sheets on Resident #14's bed. She had no idea when they last changed Resident #14's sheets, but they should have been changed on her last shower day. Resident #14's showers were on Tuesdays, Thursdays, and Saturdays on the 6am to 2pm shifts. She stated she had not worked Resident #14's hall yesterday and did not know if she had gotten a shower yesterday. Interview with CNA O on 6/3/25 at 9:23am revealed Resident #14's sheets should have been changed yesterday regardless of if she had a shower or not. She did not work the hall yesterday and did not know why Resident #14's sheets were not changed. She stated sheets were changed every shower day regardless of if they were soiled or not. If she would have seen them dirty, then she would have changed them. She was not working Resident #14's portion of that hall today. The risk to the resident of not changing her dirty sheet would be infection, sore breakdown, and rashes. Interview and observation with Resident #14 on 06/04/25 at 01:55 PM revealed she had not had a shower this week and her sheets were usually changed on shower days. She stated her shower day was yesterday and she did not get a shower, or her sheets changed. She stated they told her they would shower her yesterday, but no one ever came to shower her. She stated she did not enjoy sleeping on dirty sheets. She states she did not remember how dirty her sheets were but was appreciative they changed them. It was observed the resident's sheets on her bed had been changed. Interview with LVN A on 6/4/25 2:47pm revealed he made sure residents got showers and their sheets changed on every shift when they were due. He had not heard about Resident #14 rejecting her shower or sheet changes. He assessed sheets every two hours during his shift and ensured CNAs changed dirty sheets. He defined dirty sheets as wet or having stains. He had not observed Resident #14's sheets dirty. Interview with CNA P on 6/5/25 at 8:27am revealed she did not know the resident, but CNAs typically change sheets on shower days, which would be 3 times per week or if the bed was soiled. Most of the time they would have enough towels and linens but there were times, about twice a month, they didn't have enough linens and towels. The risk to the resident was they may not be able to shower them. She stated the worst shortage was towels and wash cloths. Interview with CNA Q on 6/5/25 at 8:35am revealed she changed sheets for residents on bath days and if they were incontinent, specifically if there was a stain or spot on the sheets. Most of the time they would have enough linen to change beds unless the washer was down. Sometimes they have had to borrow towels from other halls because they could not find any. If she could not find any towels, she would find the Housekeeping Supervisor and request more towels, as she had some in her office. The Housekeeping Supervisor had never told them there were no more towels. The risk to the resident if there were not enough linens and towels would be they could not get changed and would be lying in a dirty bed. Interview with LVN B on 6/5/25 at 8:55am revealed when sheets were soiled, she would make sure they would change them during her shift. If the sheets were wet, stained or if there was food on them, she would request staff to change the sheets. She stated ideally sheets should be changed every shift in her opinion. Sometimes there had been issues with not having enough towels or linens and it happened a couple times per month. The risk to the resident of not getting sheets changed were skin breakdown and possible infection if they had any wounds. If her resident had sheets with a circle of dirt, she would request for them to be changed. Observation on 6/5/25 at 9:01am of Resident 14's bed was stripped and had no sheets. The mattress was exposed to the air without any linen. Interview with LVN I on 6/5/25 at 9:15am revealed she was working Resident #14's hall for the past two days. She stated Resident #14 should have had her sheets changed on her bath days. If she declines a bath, her sheets should still have gotten changed. She stated she did not know when Resident #14's sheets had been last changed and had not known she had dirty sheets. She stated she would talk to the CNAs about changing Resident #14's sheets more frequently. The risk to the resident of not changing sheets would be possible infection. The sheets needed to be changed regardless of if they had a stain or dirt on them. She stated at times they run out of linens and must go to the laundry room to get them and it's usually once or twice per week. Interview with the DON on 6/5/25 at 10:56am revealed bed sheets were supposed to be changed on shower days but if they were soiled, they need to be changed sooner. Soiled was described as wet or dirty. She acknowledged Resident #14 tended to have dirty sheets because she refused to wear socks or shoes while in her wheelchair amd her feet would get dirty. She stated Resident #14's sheets should have been changed daily. The risk to the resident of having had dirty sheets was skin breakdown. Interview with the Administrator on 6/5/25 at 12:42pm revealed his expectation was sheets be changed as much as needed. He noted staff should have made rounds every 2 hours and should have checked to see whether sheets needed to be changed. Moreover, sheets should have been changed on the shower days, unless residents did not want them changed. He had heard on occasion the facility did not have linens, but they always find linens. When he heard they didn't have linens he would do a sweep of the facility to locate them, wash them if needed and would put more out if needed. He had never denied an order for linens. Record review of facility's policy titled Statement of Resident Rights, revision date of 12/1/2018, reflected the following: 3. Safe, decent, and clean conditions. A safe, clean, homelike environment policy was requested via email on 06/05/25 at 9:32 AM, but the policy was not received by exit of survey on 06/05/25 at 3:15pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Residents #227, #46, #32) of 18 residents reviewed for comprehensive care plans. 1. The facility failed to create a care plan that reflected Resident #227's preference for only female staff to provide her personal care. 2. The facility failed to create a care plan that reflected Resident #46's preference for only female staff except for CNA T (a male CNA) to care for her. 3. The facility failed to create a care plan that reflected Resident #32's highly impaired hearing, vision, and aphasia. These failures 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 well-being. Findings Include: 1.Review of Resident #227 admission Minimum Data Set (MDS) Assessment, dated 5/13/25, reflected she was a [AGE] year-old female with an admission date of 5/6/25. Resident #227 had no impairment to her cognition and had a BIMS score of 15. Resident #227 needed substantial assistance with transfers, toileting, and showering. Resident #227 was frequently incontinent from bowel and bladder. She had the following diagnosis: Diabetes (a group of diseases that result in too much sugar in the blood), Malnutrition, Depression (a persistent mood disorder characterized by loss of interest or pleasure in activities and prolonged sad moods), Metabolic Encephalopathy ( a brain disorder characterized by changes in mental status or consciousness due to an underlying metabolic imbalance) and muscle weakness. Interview with Resident #227 on 06/03/25 at 10:13am revealed she had told staff several times she did not want male caretakers providing her incontinent care, but she was getting pressured the weekend of 5/31/25 to get changed by a male staff. Resident #227 stated she had told multiple staff of her preference. Review of Resident #227's care plan dated 5/8/25 did not reveal the resident's preference for female caretakers during incontinent care, showers and baths. Interview with LVN A on 6/4/25 at 2:47pm revealed he was informed by Resident #227 she preferred a female caretaker to change her for incontinent care. He stated he got a female CNA to provide her incontinent care that day. He stated he was told by Resident #227 about 2 weeks ago about her preference for female caretakers. He stated he never told the ADON or DON about her preference because it occurred during the weekend when they were not there. The risk to the resident of everyone not knowing her preference for caretakers was delayed incontinent care. Interview with MA C on 6/5/25 at 9:03am revealed she worked Resident #227's hall frequently and she was not aware Resident #227 did not want male aides providing her personal care likes baths and incontinent care. Interview with LVN I on 6/5/25 at 10:00 am revealed she was familiar with Resident #227 but was not aware of Resident #227's preference for female caretakers. 2. Record review of Resident #46's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE], with the diagnoses of dementia (loss of cognition), depression (persistent feelings of sadness) with a BIMS score of 6 (severely impaired cognition). In an interview on 06/03/25 at 9:58 AM with Resident #46 and her family member, Resident #46 stated that she did not feel comfortable with male aides, with the exception of CNA T, and was not sure if it was care planned. Her family member stated that on Saturday (05/31/25) and Sunday (06/01/25) there were male aides assigned to her and the family member and Resident #46 had to tell them that Resident #46 preferred female aides only. They stated that the male aides found a female from another hall to perform incontinent care but it was frustrating that it happened two days in a row where they had to explain Resident #46 did not feel comfortable with men in her room and preferred to have females provide incontinent care, with the exception of CNA T. Resident #46 stated that CNA T was the only male aide she felt comfortable with and would prefer either CNA T or females only in her room. In an interview on 06/04/25 at 2:39 PM with CNA E, she stated that Resident #46 preferred females to take care of her. She stated that Resident #46 told her she didn't want any men in her room. She stated that she informed the nurse, and it was well known by staff. In an interview on 06/04/25 at 7:04 PM with LVN R, she stated that Resident #46 had told her in the past that she did not want any male caregivers to take care of her except for one male aide, CNA T. LVN R stated at the start of her shift, she informed Resident #46 who was working on that shift; and if there was a male assigned to her, LVN R told Resident #46 which female aide would be taking care of her instead to accommodate her preference and ensure she felt comfortable. She stated that the MDS Nurse was responsible for updating care plans and was not aware that Resident #46's preference for female caregivers was not care planned. LVN R stated it was important to care plan a resident's preference for male or female caregivers so that staff knew the resident's wishes. In an interview on 06/04/25 at 7:36 PM with LVN S, he stated that Resident #46 did seem to have anxiety but he was not aware of any preferences she had for CNA T or female caregivers or if it was care planned. He stated Resident #46 seemed to be comfortable with him because when he went in to check on her and let her know he was taking care of her during the evening shifts, she said things like thank god you are here or thank god [CNA T] is here. He stated it would be important to care plan a resident's preferences for female aides because it ensured staff knew what a resident needed and preferred. In an interview on 06/05/25 at 9:35 AM with the Social Worker, she stated she was not sure if Resident #46 had a preference for male or female caregivers and it was important to care plan if she preferred female aides only and if there were exceptions to that preference because residents had a right to have their preferences honored, especially with incontinent care. 3. Record review of Resident #32's Comprehensive MDS, dated [DATE], reflected he was an [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of aphasia (loss of ability to understand or express speech) due to stoke, highly impaired hearing, moderately impaired vision, and unclear speech with a BIMS score of 00 (severely impaired cognition). In an observation on 06/03/25 at 10:17 PM of Resident #32 revealed he was seated in a wheelchair taking out hearing aids and was not responsive to attempt at interview. Observation of sign above Resident #32's bed revealed take resident hearing aides out before showers. Record review of Resident #32's care plan, dated last revised 06/03/25, revealed no indication regarding his hearing or speech (related to aphasia), or vision. In an interview on 06/04/2025 at 8:58 AM with Resident #32's Responsible Party she stated that Resident #32 was blind in one eye and had extreme hearing difficulty and aphasia due to a stroke. She stated she was not able to recall if there had been care plan meetings that discussed his aphasia, hearing, and vision status, and he admitted to the facility for rehabilitation services following the stroke, with a goal to discharge home. In an interview on 06/04/25 at 2:39 PM with CNA E, she stated that Resident #32 was very hard of hearing and she had to get up to his left ear and speak loudly for him to hear and he did not like to wear his hearing aid. She stated she did not think he had much difficulty seeing. In an interview on 06/04/25 at 1:26 PM with MA D she stated that Resident #32 had difficulty hearing and was not sure if he had vision issues. In an interview on 06/04/25 at 7:36 PM with LVN S, he stated Resident #32 had highly impaired hearing and had aphasia and was not sure if it was care planned. He stated he thought Resident #32 might have a vision impairment, but he was not sure. He stated that it was important to care plan hearing, vision, or communication difficulties to ensure staff were able communicate with the resident and meet their needs. In an interview on 06/05/25 at 9:35 AM with the Social Worker revealed Resident #32 had a stroke and admitted to the facility to rehabilitate and eventually discharge back home. She stated he had a severe hearing issue and had headphones that had amplifiers and a hearing aid. She stated the resident's hearing and vision issues should be care planned because caregivers needed to know how to be able to communicate with Resident #32. In an interview on 06/05/25 at 10:08 AM with the Regional Reimbursement Consultant, she stated other regional personnel and the nursing team were responsible for updating the care plans. She stated the facility hired a full time MDS Nurse about 2 weeks ago and she was in-training. She stated she was on-site several days a week and was responsible for annual and quarterly care plans and updated care plans when she was offsite; and the DON helped with acute care plans and any of the clinical team had the ability to update care plans, but they usually reached out to her to update the care plans. She stated she received updates by any of the clinical nursing or clinical regional team or the Administrator via email, phone, or when she was on-site when updates to resident care plans were needed or if there were questions on how to care plan something. She stated she was not sure if Resident #32 had hearing issues. She reviewed his progress notes and his Comprehensive MDS and stated he had highly impaired hearing, moderately impaired vision, and aphasia due to a stroke. She stated that his hearing, vision, and aphasia was not care planned and it was important to care plan those issues to ensure staff could communicate effectively with the resident. She stated she was not familiar with Resident #46 and was not aware she preferred female care givers for incontinent care. She stated she was not aware that Resident #227's preference for female care givers and it was not care planned. She stated if a resident preferred a specific gender of caretaker it should be care planned. She stated it was important to care plan a resident's preference for female caregivers and if there were exceptions to that preference because knowing a resident's preferences ensured staff were aware and the resident's rights were honored. In an interview on 06/05/25 at 10:55 AM with the DON, she stated that nurses had the ability to update the care plan and it generally was updated by the Reimbursement Consultant who was in the process of training a newly hired full time MDS Coordinator for the facility. She stated she did not know Resident #32's hearing, vision, and aphasia difficulties were not care planned and it was important because it ensured staff knew he was hard of hearing and guided their plan of care. The DON stated that she was aware that Resident #227 preferred female caregivers only and Resident #46 preferred female aides except for CNA T and she ensured staff were aware by word of mouth and during shift change. She stated a resident's preference for female caregivers should be care planned so that staff were aware and had a place to look and see what the resident preferences were. She stated it was her and the MDS Nurse Coordinator, which had been covered by the Regional Reimbursement Consultant, to ensure care plans were updated. Interview with the Administrator on 6/5/25 at 12:42pm revealed he was not aware Resident #227 only wanted female caretakers. He stated request like those were usually put in the resident's care plan or the Nursing Book at the nursing station. He was unsure if Resident #227's preference was listed on her care plan or in the Nursing Book. He stated it was important to honor the resident's wishes by providing her care based on her preference. Review of the Facility's policy Care Plan - Resident effective date 12/2018 reflected .12. Resident Care Plan Documentation and use of the Plan, a. The resident care plan is used to plan and assign care for all disciplines .c. The resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 7.89 %, based on 3 errors of 38 opportunities, which involved two of five residents (Residents #19 and #26) and two of five staff (MA C and MA D) reviewed for medication errors, in that: 1. MA C administered Vitamin B-12 1000 mcg instead of Vitamin B-12 100 mcg and failed to administer duloxetine 60 mg to Resident #19's on 06/04/25 as ordered by the physician. 2. MA D failed to administer Resident #26's folic acid 1 mg on 06/04/25 as ordered by the physician. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. A record review of Resident #19's Quarterly MDS assessment, dated 04/04/25, reflected a [AGE] year-old female with an admission date of 07/19/22. She had a BIMS score of 15, which indicated she was cognitively intact. Diagnosis included coronary artery disease (damage or disease in the heart's major blood vessels), heart failure, depression, and muscle weakness. A record review of Resident #19's Physician's order report dated 05/05/25 to 06/05/25 reflected Resident #19 was to receive the following medications: Cyanocobalamin (vitamin b-12) tablet (mineral); 100 mcg once a day at 08:00 a.m. Duloxetine capsule 60 mg (antidepressant) twice a day at 09:00 a.m. and 09:00 p.m. During a medication pass observation on 06/04/25 at 07:25 a.m. revealed MA C administered the following medications to Resident #19: Vitamin B-12 1000 mcg 1 tablet Acidophilus 1 capsule Allergy eye drops (Naphozoline-[NAME]) 0.025-0.3 % 1 drop each eye. Glipizide 5 mg 1 tablet Metoprolol 50 mg tablet Gabapentin 100 mg 1 capsule Buspirone 10 mg 1 tablet Docusate 100 mg 1 tablet Flonase allergy relief spay 50 mcg 1 spray each nostril. Lidocaine patch 4% to left shoulder. Lidocaine patch 4% to lower back Miralax powder 17 grams mixed with 8 ounces of water. Ranolazine 500 mg 1 tablet Singular 10 mg 1 tablet Tramadol 50 mg 1 tablet Venlafaxine 75 mg 1 tablet Mucinex 600 mg 1 tablet Pantoprazole 40 mg 1 tablet Lasix 40 mg 1 tablet Hydrocodone-acetaminophen 7.5-325 mg 1 tablet Loratadine 10 mg 1 tablet Potassium Chloride 20 meq 1 tablet She did not administer Duloxetine 60 mg 1 capsule. Record Review of Resident #19's medication administration record on 06/04/25 at 03:00 p.m. reflected cyanocobalamin (vitamin-b12) tablet; 100 mcg at 08:00 (8 a.m.) and duloxetine capsule 60 mg 09:00 a.m. The medication was signed out as given by MA C on 06/04/25. A late administration note at 11:23 a.m. reflected: Charted late: Comment: administered on time. In an interview and observation with MA C on 06/05/25 at 04:45 a.m. MA C searched the med cart to reveal there was no B-12 100 mcg on her cart. She stated she misread the dosage and gave the 1000 mcg instead. MA C pulled all of Resident #19's morning medications and verified Duloxetine should had been given with the morning med pass. She stated she was not sure how she missed it. Stated she just got nervous. 2. A record review of Resident #26's Quarterly MDS assessment, dated 04/07/25, reflected a [AGE] year-old female with an admission date of 03/03/21. She had a BIMS score of 15, which indicated she was cognitively intact. Diagnosis included heart failure and anemia (condition in which the blood doesn't' have enough health red blood cells to carry oxygen all through the body). A record review of Resident #26's Physician's order report dated 05/05/25 to 06/05/25, reflected Resident #26 was to receive the following medications: Folic acid tablet 1 mg once a day at 07:00 a.m. During a medication pass observation on 06/04/25 at 08:05 a.m. revealed MA D administered the following medications to Resident #26: Eliquis 2.5 mg 1 tablet Multiple-Vitamin-Minerals 1 tablet Levothyroxine 100 mcg 1 tablet Fenofibrate 48 mg 1 tablet Metoprolol 25 mg ½ tablet Omeprazole 20 mg 1 capsule Allegra Allergy 180 mg (resident refused) Potassium chloride 10 meq 1 capsule Colace 100 mg 1 capsule (resident refused) Vitamin E 180 mg 1 capsule Allopurinol 300 mg 1 tablet Vitamin B-12 500 mg 2 tablets Vitamin D-c 50,000 units 1 capsule She did not administer Folic acid 1 mg 1 tablet. Record Review of Resident #26's medication administration record on 06/04/25 at 03:10 p.m. reflected Folic Acid 1 mg 1 tablet once a day at 07:00 a.m. The medication was signed out as given by MA D on 06/04/25. In an interview with MA D on 06/05/24 08:47 a.m. verified what medications were administered to Resident # 26 on 06/04/25 and stated she missed the folic acid. She stated she was not sure how she missed it. In an interview with the DON on 06/05/25 at 09:45 a.m., she stated she expected the staff to follow the 5 rights of medication administration which are right drug, right dose, right route, right patient, and right time. She stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to drug interactions if the correct medication or dosage was not given. She stated the MAs should always go to the Charge nurse, the ADON or herself if there were any question about a medication and they should clarify with the physician if they did not have a prescribed over the counter medication in stock. Record review of the facility policy titled Medications-Administration, dated December 2018, reflected, .medications will be administered and documented as ordered by the physician and in accordance with state regulations .The residents MAR is initialed by the person administering a medication .Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the mediation label. If the label and are different and container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide food and drink that was palatable for one meal (Lunch 6/3/25) observed for 3 out of 18 residents (Resident #227, Resident #56 and Resident #177) for food palatability and food form. The facility failed to provide palatable lunch meal on 6/3/25 for 3 residents. This failure could place residents at risk of decline in nutrition status, loss of appetite, and decreased intake placing them at risk for unplanned weight loss. Findings included: 1. Review of Resident #227 admission Minimum Data Set (MDS) Assessment, dated 5/13/25, reflected she was a [AGE] year-old female with an admission date of 5/6/25. Resident #227 had no impairment to her cognition and had a BIMS score of 15. Resident was to have a therapeutic diet while a resident at the facility. She had the following diagnoses: Diabetes (a group of diseases that result in too much sugar in the blood), Malnutrition, Anemia (a condition marked by a deficiency of red blood cells or hemoglobin in the blood), Gastroesophageal Reflux Disease (a condition in which stomach contents flow back up into the esophagus, causing irritation and discomfort), and muscle weakness. Review of active physician order dated 5/8/25 for Resident #227 reflected Diet - NSOT diet, Diabetic, Regular texture, Thin Liquids, 1500ml fluid restriction. Lactose intolerant. Review of Resident #227's Care Plan dated 5/8/25 reflected .Problem Start Date: 06/03/2025 Category: Dietary Resident is at nutritional/weight variance risk r/t therapeutic diet, lymphedema, diuretic therapy, kidney disease and diabetes .Approach Start Date: 06/03/2025 Diet as ordered Created: 06/03/2025 . Interview with Resident #227 on 6/3/25 at 10:13am revealed the food at the facility was not great, it was cold and bland most of the time. Resident stated she had told multiple staff of her concerns with the food. In an interview with Resident #227 on 6/4/25 at 9:00am revealed she had not eaten the fried chicken lunch the day before, as her friend had brought her lunch. She frequently had her friend bring her food because the food was so awful. 2. Record review of Resident #56's Comprehensive MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure and diabetes (high blood sugar) with a BIMS score of 15 (intact cognition). Record review of Resident #56's care plan reflected she had congested heart failure and interventions included to monitor and document food preferences, dated 05/06/25. In an interview and observation on 06/03/25 at 1:37 PM with Resident #56 revealed she was seated in her room with her a plate of fried chicken with strips of meat pulled apart on her plate and mashed potatoes with gravy and stated that the food was not good. She stated she was able to get an alternative meal if she were to ask and she had not spoken with a CNA yet. She stated she was not able to eat the fried chicken because it was too tough. 3. Record review of Resident #177's Comprehensive MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of anemia (low iron), kidney disease, heart failure, and diabetes (high blood sugar) with a BIMS score of 15 (intact cognition). Record review of Resident #177's care plan reflected she was at risk for pressure ulcers due to diabetes and incontinence, interventions included monitor nutritional status, serve diet as ordered and monitor intake, dated 01/08/25. Record review of Resident #177's physician order's reflected an order with a start date of 06/02/25 for a Renal diet, Regular texture, thin liquids. In an interview and observation on 06/03/25 at 1:43 PM with Resident #177 she was seated in front of her bedside table with a plate of fried chicken with mashed potatoes and gravy and stated that the food was not good. Resident #177 stated the fried chicken was too tough and dry and the mashed potatoes were not edible. She stated she had not yet told a staff member that she did not like the meal. In an interview on 06/04/25 at 1:34 PM with CNA P she stated that she had heard residents complain about food at the facility- either it was too cold, or not what they ordered, or it had not flavor. She stated that they always have available a alternative meal for residents who wanted something other than what was served. Record review of Week At a Glance menu for 6/3/25 Lunch reflected .Meal of the Month, fried chicken, mashed potatoes, broccoli w/ cheese sauce, dinner roll, chocolate pie . Record review of Resident Council Minutes on 3/10/25 reflected .Dietary: Hall trays are cold . Record review of Resident Council Response Sheet dated 3/10/25 reflected .we have ordered more dome lids and bases to help keep the food hot. If you food is cold, please let someone know so they can get you hot food. We don't want anyone to eat cold food . Record review of Resident Council Minutes on 5/12/25 reflected .Dietary: .Lunch and dinner late sometimes . Record review of Resident Council Response Sheet dated 5/12/25 reflected .I will work with the nursing department on getting staff in the dining room on time so meal service can start on time. Record review of the Facility mealtimes reflected Main Dining Room Breakfast 7:00 - 8:30, Lunch 11:30 - 1:00, Dinner 5:00 - 6:30. Hall Delivery Schedule Breakfast 100, 200, 300 Lunch 200, 300, 100, Dinner 300, 100, 200. Hall trays are delivered after the dining room is served. The hall trays follow the above schedule once the dining room service is complete. Residents residing on the above halls can expect their trays within the listed mealtime. Record review of Dining Manager Fried Chicken Recipe reflected .Preheat oven to 425 F - Convection oven 1. place the chicken and milk in a container with lid .pour melted margarine on sheet pan. 4. Remove chicken from milk and dredge each piece in flour .6. Bake 12 minutes. Carefully remove pan from oven and turn the chicken pieces over bake another 12 minutes until chicken reaches desired temperature . maintain 165F or above . Observation of fried chicken being cooked on 6/3/25 at 11:26am revealed chicken piece soaking in a bowl of milk, dipped in a flour mixture and tossed in the fryer. Chicken was observed to be tempted after removal from fryer. Fried Chicken was tempted at the holding table at 170 degrees. Observation and interview of residents in the Main Dining room on 06/03/25 at 11:59am revealed 4 residents stated the food was horrible. They hate the food in general. They complained the chicken served today was overcooked and hard to chew. Residents stated the meal being service was the residents' choice for meal of the month. Observation of lunch tray delivery in the 100 hall on 6/3/25 revealed the last resident received her tray at 1:05pm. The test tray was delivered to the conference room at 1:06pm and was tested by 3 surveyors. The test tray arrived with the following items: 1 piece of fried chicken, broccoli w/ cheese, mashed potatoes and gravy, chocolate pie and a dinner roll. The food on the tray was lukewarm. The fried chicken was dry with little to no taste, and it was difficult to chew. The broccoli was bland and mushy, the cheese sauce on top of the broccoli had no salt and did not taste like cheese. The mashed potatoes and gravy were good consistency with some salt. The chocolate pie was cool, sweet, and moist with whip cream. The following condiments were provided, salt, sugar, and butter. A glass of unsweetened tea and water were provided with a few pieces of ice in each cup. In a confidential group interview on 6/4/25 at 11:02am residents stated food at the facility was mostly served cold and on occasion warm. When food was late it tasted terrible. They stated the trays of food sit in the halls for long periods of time for those who were eating in their room. Residents in the dining hall were usually finished eating by the time residents in the hallways got their food. The resident in their rooms may eat an hour after the residents in the dining room. Residents complained about overcooked vegetables and undercooked beans. They stated temperature of food had not gotten any better even after the changes the facility had made. Residents also stated the food had no flavor and had to add their own seasoning. Interview with the Administrator on 6/5/25 at 10:00am revealed the facility does not have a policy on food palatability. He stated they go by common standards. He stated they had bought warming trays for the trays in the hallway to help ensure the food was warm and had purchased a warming tray. He was informed the test tray food was lukewarm, the chicken was hard to chew, and the food was bland. He stated the taste of food was dependent on personal choice and they cannot accommodate everyone's taste. He stated they have been providing alternate foods from available all the time meals to residents who did not want the regular menu food. He stated all menus were based on recipes provided by Nutritious Lifestyle. He stated it was a resident choice meal, as it was requested from Resident Council. He stated the risk to the residents of not having palatable food was it could affect their eating and weight. Review of the facility's policy Menu Planning revised on June 1, 2019 reflected .The facility believes that nutrition is an important part of maintaining the wellbeing and health of its residents and is committed to providing a menu that is well balanced, nutritious and [NAME] the preferences of the resident population .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility freezer were dated or labeled. 2. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 6/3/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: Observation of freezer in the kitchen and interview with Dietary Manager on 06/03/25 beginning at 9:16 am: -clear opened to the air plastic bag with about 25 corn dogs, in an unsecured box labeled corn dogs. Dietary Manager stated the bag should be closed and proceeded to close it by making a knot on top. -clear opened to the air, plastic bag with about 30 1.5-inch circular disc inside an unsecured box. The Dietary Manager stated they were biscuits and took the box out and knotted the plastic bag and labeled it. -clear opened to the air, plastic bag in a broken box with about 20 dinner rolls. The Dietary Manger took the bag out of the box and removed the box. She then sealed the bag, labelled it, and put the bag back into the freezer. She stated the bag should have been properly sealed. Interview with Dietary Manager on 6/3/25 at 9:25am revealed the expectation was all food should be dated in the refrigerator and freezer when received and when opened it should be dated with date opened. Every item should be labeled of what it was if not in original box or bag. Once something was opened it needed to be sealed with a knot or tied in original packaging if possible. The risk to the residents was freezer burn and cross contamination if the food was consumed. She stated she would be providing a refresher training and in-service to kitchen staff to remind them of her expectations. Observation of Dietary Aide N on 6/3/25 at 11:46am revealed he was carrying a tray of water and tea during lunch service and the trays were being held with two hands, but several cups were touching his shirt. He put the trays down on the metal serving table and wiped shirt and pants with bare hands, left the area toward the dishwashing area and grabbed gloves, returned, and put gloves on, he then proceeded to put plastic tops on each glass of water and tea. He did not wash his hands before putting the gloves on. Dietary Aide N then took the dirty gloves off and threw them on the serving table, where food was being held and left to the back of the kitchen. He returned with new gloves and put them on. He then touched his pants, dug in his pockets with the gloves on and proceeded to put drinks on the food trays. He also put his gloved hands on his pants while looking at the hall trays on the bottom shelf of the cart and proceeded to grab cups of tea and water and put them on those trays. Interview with the Dietary Manager on 6/3/25 at 12:50pm revealed hand hygiene requires kitchen staff to wash their hands between task, when they wear gloves, they were supposed to wash hands before putting gloves on. When cooks or aides go to the back to get something they should wash hands and put new gloves on. Kitchen staff should not touch clothing or other surfaces that could contaminate food. The risk to the residents was cross contamination and issues with infection control. Interview with Dietary Aide N on 6/3/25 at 1:23pm revealed he should have washed his hands when he passed the threshold of the serving area. He stated he did not know he could not put the serving trays on his clothing while carrying them but realized he could cross contaminate food and bacteria on his clothing could get on the food served to the residents. He stated he was supposed to throw away dirty gloves in the trash and should not touch clothes when he had gloves on. He stated he should wash his hands with soap and water in between glove changes and when touching his clothes or personal items. Review of the Facility's policy Hand Washing effective 12/2018 reflected .1. They use of gloves does not replace proper hand washing .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .before and after eating or handling food (handwashing with soap and water) .after removing gloves or aprons . Review of the Facility's policy Food Storage date approved 4/26/19 reflected .Freezers .e. store frozen foods in moisture-proof [NAME] or containers that are labeled and dated . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

**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 four (Resident #70, Resident #66, Resident #19, and Resident #61) of seven residents observed for infection control. 1. The facility failed to ensure LVN A used the required PPE for Resident #70, who was on enhanced barrier precautions due to her venous access device, while administering resident IV antibiotics on 06/04/25. 2. The facility failed to ensure LVN A and LVN B decontaminate the glucometers which were used to obtain a fingerstick blood sugar on Resident's #70 and Resident # 66 when they failed to allow the glucometer that was sanitized with a germicidal wipe to air dry before returning the glucometer to the medication cart and laying it on top other supplies inside the medication cart. 3. The Facility failed to ensure MA C did not cross contaminate Resident #19's eye drops and nose spray when she carried the items into the resident's room on 06/04/25 and did not perform hand hygiene before administering resident eye drops. 4.The facility failed to ensure CNA E performed hand hygiene before and after transferring Resident #61 to her wheelchair and before leaving the residents' room. Theses failure placed residents at risk for infection and cross contamination. Findings included: 1. Record review of Resident #70's admission MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident had a BIMS score of 13 which indicated she was cognitively intact. Diagnoses included type 2 diabetes mellitus and Osteomyelitis (infection in the bone). Record review of Resident #70's comprehensive care plan initiated on 02/24/25, reflected, Resident requires Enhanced Barrier Precautions (infection control strategy used to reduce the transmission of Multiple drug resistant organisms) during contact care related to central lines .Interventions .Staff to provide/utilize appropriate PPE along with standard precautions while providing resident care. (i.e. wound care, care to .IV sites .) An observation of the medication pass on 06/04/25 at 08:30 a.m. revealed LVN A at the medication cart preparing Resident #70's intravenous antibiotic. LVN A performed hand hygiene and put on gloves, but no gown. Signage was observed on the door indicating Resident #70 was in EBP. LVN A entered Resident #70's room and cleaned the PICC line (a long, flexible tube that is inserted into a vein in the arm and used to deliver medications) lumen (access device) with an alcohol wipe and flushed the PICC line with 10 cc of Normal Saline. LVN A then connected the IV line to the PICC line for the medication administration. LVN F returned to the medication cart and removed his gloves and performed hand hygiene. A second observation on 06/04/25 at 09:50 a.m. revealed LVN A perform hand hygiene and put on glove, but no gown. He entered Resident #70's room to disconnect the IV infusion. LVN A disconnected the IV line from the resident's PICC line and flushed the PICC line with 10 cc of normal saline. LVN A removed his gloves and performed hand hygiene. In an interview with LVN A on 06/04/25 at 09:55 a.m. he stated Resident #70 was on Enhanced Barrier Precautions because of her surgical wound on her back. He stated the resident was on EBP because of her wound. When asked what other times enhanced barrier precautions were required, he stated anyone with an access device and then stated he should have worn a gown when providing her IV medications. He stated he had been in serviced on the use of Enhanced Barrier Precautions and what PPE was required but still gets confused at times of what is required for what. In an interview with the DON on 06/04/25 at 10:05 a.m. she stated any resident with an indwelling device, such as a PICC line, required the use of Enhanced Barrier precautions. She stated signs are posted on the door to make sure staff is aware of what type of precautions are required. She stated she will re-Inservice staff again. She stated the purpose of the enhanced barrier precautions is to prevent the potential spread of MDRO's to other residents in the facility. 2. Record review of Resident #70's admission MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident had a BIMS score of 13 which indicated she was cognitively intact. Diagnoses included type 2 diabetes mellitus and Osteomyelitis (infection in the bone). A record review of Resident #66's undated face sheet reflected a [AGE] year-old female with an admission date of 06/30/24. Diagnosis included diabetes. An observation on 06/04/25 at 11:35 a.m. revealed LVN A at the medication cart preparing to perform Resident #70's fingers stick blood sugar (FSBS). LVN A put on gloves, removed the glucometer from the medication cart, wiped the glucometer down with a germicidal wipe and placed it on a tissue on top of the medication cart. LVN A removed his gloves, performed hand hygiene, and put on clean gloves. LVN A entered the resident's room to perform the FSBS, pricked Resident #70's finger and obtained a blood sample for FSBS. LVN A returned to the medication cart, removed the test strip, and disposed of it and the lancet. LVN A removed his gloves and performed hand hygiene. LVN A re-gloved and retrieved a germicidal wipe (with a kill time of 1 minute) and wiped the glucometer with the germicidal wipe and immediately placed the glucometer back into the cart on top of other supplies in the medication cart, without letting the glucometer air dry. In an interview with LVN A on 06/04/25 at 11:45 a.m. he stated he was not sure how long the contact time was for the germicidal wipe he used to clean the glucometer. LVN A reviewed the contact time on the EPA approved germicidal wipe and determined it was for 1 minute. He stated by not letting the glucometer air dry there was the potential for cross contamination and could potentially expose residents to blood borne pathogens. He stated he should have let it dry before placing it back in the cart. An observation on 06/04/25 at 12:05 p.m. revealed LVN B at the medication cart preparing to perform Resident #66's fingers stick blood sugar (FSBS). LVN B put on gloves, removed the glucometer from the medication cart, wiped the glucometer down with a germicidal wipe and placed it on a tissue on top of the medication cart. LVN B removed her gloves, performed hand hygiene, and put on clean gloves. LVN A entered the resident's room to perform the FSBS, pricked Resident #66's finger and obtained a blood sample for FSBS. LVN B returned to the medication cart, removed the test strip, and disposed of it and the lancet. LVN B removed her gloves and performed hand hygiene. LVN B re-gloved and retrieved a germicidal wipe (with a kill time of 1 minute) and wiped the glucometer with the germicidal wipe and immediately placed the glucometer back into the cart on top of other supplies in the medication cart, without letting the glucometer air dry. In an interview with LVN B on 06/04/25 at 12:05 p.m. she stated she was not aware she had to allow the surface of the glucometer to dry before placing it back in the cart. She stated she knew she had to disinfect between each resident to prevent the spread of blood borne pathogen. She stated no one had reviewed with her about contact time for proper disinfecting. In an interview with the DON on 06/05/25 at 12:00 p.m. she stated staff needed to make sure all equipment was cleaned with appropriate germicidal wipes between patient use especially glucometers. She stated the glucometers had to remain visibly wet for the appropriate contact time for the glucometer to be considered sanitized. She stated they should always let them air dry and should not place them back into the cart until they are dry. She stated this failure placed residents at risk of the spread of germs and cross contamination. She stated the facility does not have a policy specific to glucometer disinfection so they would follow the manufactures recommendation. She stated she would be in servicing the staff on proper protocol for sanitizing the glucometer. 3. A record review of Resident #19's Quarterly MDS assessment, dated 04/04/25, reflected a [AGE] year-old female with an admission date of 07/19/22. She had a BIMS score of 15, which indicated she was cognitively intact. Diagnosis included coronary artery disease (damage or disease in the heart's major blood vessels), heart failure, depression, and muscle weakness. During a medication pass observation on 06/04/25 at 07:10 a.m. MA C was observed at the medication cart. MA C sanitized her hands and pulled Resident #19's oral medications. MA C then retrieved a box containing the resident's allergy eye drops and a box containing the resident's Flonase (allergy spray). MA C entered the resident's room and placed the box of eye drops and nose spray on top of the resident bedcovers. MA C then removed the blood pressure cuff from the resident's arm and administered her oral medications. MA C then opened the eye drops box and removed the bottle of eye drops. MA C put on gloves without performing hand hygiene and applied one drop in each eye and then removed the nose spray from the box and sprayed one spray to each of the resident's nostrils. MA C then placed the nose spray and eye drops back into their box and placed them on the resident's wheelchair. MA C called for assistance to reposition the resident in the bed. MA C and another staff member lifted the resident up in the bed. MA C then removed her gloves, gathered up the box of eye drops and nose spray and went to leave the room. The bottle of eye drops fell out of the box and hit the floor. MA C picked up the bottle of eye drops and returned it to the medication cart. When reaching to place the eye drop bottle, the box for the eye drops and the box of nose spray onto the cart, MA dropped the box for eye drops onto the floor. MA C picked up the box and then placed the bottle of eye drops back in the box that had just been on the floor. MA C then placed both the box of eye drops and the box of nose spray back into the top of the medication cart. In an interview with MA C on 06/04/25 at 08:00 a.m. she stated she should not have taken in the boxes for the eye drops and Flonase and should not have placed them on the bed or resident's chair due to cross contamination risk. She stated she should have performed hand hygiene before putting on her gloves to do the eye drops. She stated she should have disposed of the eye drops when she dropped them on the floor. In an interview with the DON on 06/05/25 at 09:45 a.m. she stated the MAs were trained not to carry in the boxes for any medication into the resident's room and if they had to set a bottle of drops or nose spray down, they had to place it on a barrier. She stated it should never by placed on the resident's bedcovers or chairs. She stated any medication dropped on the floor was to be discarded. She stated hand hygiene was to be performed every time before putting on gloves and especially before administering eye drops. She stated they would in-service MA C on infection control. 4. Record review of Resident #61's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included reduced mobility and hemiplegia (partial paralysis on one side of the body) following unspecified cerebrovascular (blood vessels that supply the brain) disease. An observation on 06/03/25 at 10:30 a.m. revealed CNAs E and F entered Resident # 61's room to perform a mechanical lift transfer. Both staff performed hand hygiene. CNA F put on gloves, but CNA E did not. Both staff attached the mechanical sling to the lift and then transferred the resident to her wheelchair. CNA F removed her gloves and performed hand hygiene. CNA E straightened up the resident's bed linens and then pushed the resident down the hall to the dining room area without performing hand hygiene. In an interview on 06/03/25 at 10:38 a.m. with CNA E, she stated she only had to wear gloves to do incontinence care. She stated since Resident #61 was dressed and there was no contact with body fluids, she did not have to wear gloves. She stated she was supposed to do hand hygiene before she started anything but was not aware she had to do hand hygiene after just contacting a resident or items in their rooms. She stated she had worked for 10 years and was not aware that was a requirement. In an interview with the DON on 06/05/25 at 12:05 p.m. she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any resident, or items in the resident's room and before leaving the resident's room. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. She stated she had only been in this role since the end of March and was conducting in-services as areas of concern came up. She stated they would be doing another Inservice on infection control. Record review of the facility's policy, Infection control-Precautions-Categories and Notices, revised on March 2024, reflected, .In addition to Standard Precautions, Contact precautions must be implemented for resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident .Gloves and hand washing .remove gloves before leaving the room .Gown- In addition wearing a gown .when entering the room if you anticipate that your clothing will have substantial contact with the infectious material .For residents for whom EBP are indicated, EBP is employe when performing the following high-contact care activities .Device care or use: central line .Wound care: any skin opening requiring a dressing Record review of the facility's policy, Infection Control-Cleaning and Disinfecting Resident Care items and equipment, dated December 2018, It is the policy of this home to clean and disinfect resident-care equipment, including reusable items and durable medical equipment per current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Reusable resident care equipment will be decontaminated and/or sterilized between residents per manufactures' instructions . Record review of the manufacturers guidelines searched on 06/10/25 at https://www.medline.com/media/catalog/Docs/MKT/LIT302_MAN_EvenCare, reflected, .To clean the meter, clean with one of the validated disinfecting wipes .Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe meter dry or allow to air dry Review of the facility's policy titled, Hand Washing, dated December 2017, reflected, .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .Before and after contact direct resident contact; Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident) .after handling soiled equipment . After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#3) of 7 residents reviewed for ADLs. The facility failed to ensure Resident #3's nails were cleaned and trimmed on 04/16/2025. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #3's Face Sheet dated, 04/16/25, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of myocardial infarction (heart attack), contracture ( the abnormal shortening of muscles, tendon, skin or ligaments leading to a fixed tightening that restricts normal movement), of left hand and left shoulder, and hemiplegia and hemiparesis (paralysis and weakness on one side of the body). Record review of Resident #3's MDS assessment 04/02/25, reflected Resident #3 had a BIMS 13 indicated Resident #3's cognition was intact. Resident #3 was dependent for showering/bathing and toileting hygiene. Record review of Resident #3's Comprehensive Care Plan, revised date 1/24/25, reflected the following: Problem [Resident#3] had impaired visual functioning and is at risk for a decreased in ADL's and injuries . [Resident #3] was a x1 person assist with dressing, eating, toileting, personal hygiene, and bathing. Observation and interview on 04/16/25 at 09:49 AM revealed Resident #3's fingernails on both hands were approximately 0. 5 inches in length extending from the tip of his fingers with dark substance underneath the nails. Resident #3 stated his nails were too long and that he did not like it. In an interview on 04/16/25 at 09:54 AM, CNA B stated she did not notice Resident #3's fingernails were long and dirty. CNA B stated nails are supposed to be cut during their shower's days. She stated if a resident has diabetes, only nurses were allowed to provide nailcare. CNA B stated Resident #3's fingernails needed to be trimmed and cleaned. CNA B stated the risk to Resident #3 would be infection. In an interview on 04/16/25 at 10:15 AM, LVN L stated that both nurses and CNAs were responsible for grooming and doing nail care for the residents. She stated if a resident has diabetes, only nurses were allowed to provide nailcare. LVN L stated Resident #3's nails were long and needed to be cleaned and trimmed. LVN L stated the risk of Resident #3's nails not cut and cleaned could lead to infection. Review of the facility's policy titled Nail/Hand and Foot Care, dated December 2017, reflected It is the policy of this home to ensure residents receive nail care (hand and foot) in a safe manner Under procedure, .Trimming fingernails, the following procedure will be followed: 1. b. Be sure the nails have been soaked for at least 5 minutes before trimming Cut nails soon after soaking while they are still soft .d. Using clean nail clipper cut fingernails straight across and slightly above the end of the fingers .e. Do not cut the skin or trim nail below skin line.

**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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #1 and Resident #2) of 4 residents reviewed for infection control. 1. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and #2 on 04/16/2025. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 1/1/2025, reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included coronary artery disease (Damage or disease in the heart's major blood vessel), Hypertension, and Diabetes. Resident #1 had a BIMS of 12 which indicated Resident #1 cognition was moderately impaired. Record review of Resident #2's Quarterly MDS assessment, dated 01/7/2025, reflected Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Stroke (sudden interruption of blood flow to the brain leading to tissue damage), Heart Failure, Hypertension and Non-Alzheimer's Dementia (a group of neurological conditions that cause memory loss and other cognitive declines). Resident #2 had a BIMS of 6 which indicated severely impaired cognition. Observation on 4/16/2025 at 9:40 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressure on Resident #1. LVN A did not sanitize the blood pressure cuff before and after using it on Resident #1 and continued to the next resident without sanitizing the blood pressure cuff. LVN A then checked Resident #2's blood pressure. LVN A did not sanitize the blood pressure cuff before using it on Resident #2. Interview with LVN A on 4/16/2025 at 10:01 AM, LVN A stated that reusable medical equipment, like blood pressure cuffs, should be sanitized before and after use on each resident to prevent cross contamination. She stated she forgot to sanitize the blood pressure cuff between residents use because she is still a new nurse and is learning. Interview with the DON on 4/16/2025 at 2:21 PM stated that she was made aware of LVN A's mistake and stated the expectation is that all medical equipment used with residents be sanitized before and after each use. She stated LVN A was a new nurse and new to the facility and she would work with LVN A closely to ensure she understood the expectation. The risk of not appropriately sanitizing the equipment was cross contamination and illness. Record review of the facility's policy titled, Infection Control - Cleaning and Disinfection Resident Care Items and Equipment dated 10-2020, reflected, . non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers .reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) .3. Reusable resident care equipment will be decontaminated and/or sterilized between resident per manufacturers' instructions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (200 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure the 200 Hall medication cart had: 1- 1 insulin pen for Resident #175 with an expired opened date. 2- 1 insulin pen for Resident #17 with an expired opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Record review of Resident #175's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus and hyperlipidemia (too many lipids and fats in the blood). She had a BIMS score of 11 indicating her cognition was cognitively moderately impaired. Record review of Resident #175's Medication Administration Records dated [DATE] to [DATE] revealed an order for Novolin insulin pen 100 unit/ml. Novolin 10 units subcutaneous. Administer only if blood sugar is greater than 300. Observation on [DATE] at 11:29 AM revealed the 200-hall nurse's medication cart had a pen of Novolin insulin pen 100 unit/ml for Resident #175, had an opened date of [DATE]. The label revealed discard after 28 days. 2- Record review of Resident #17's Comprehensive MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia (too many lipids and fats in the blood). He had a BIMS score of 12 indicating his cognition was cognitively moderately impaired. Record review of Resident #17's physician's orders dated [DATE] revealed an order for Humalog U - 100 Insulin (insulin lispro) solution; 100 unit/ml; administer per sliding scale. If blood sugar is 180-200=3 units, 201-230=4 units, 231-260=5 units, 261-290=7 units, 291-320=9 units, 321-350=11 units Observation on [DATE] at 11:29 AM revealed the 200-hall nurse's medication cart had a pen of Humalog U-100 insulin 100 unit/ml, for Resident #17, had an opened date of [DATE]. The label revealed discard after 28 days. Interview on [DATE] at 11:41 AM, LVN F stated the 2 pens of insulin belong to Resident #175 and Resident #17 had an expired open date. LVN F stated she did not use any of the insulin pens in the morning. She stated she did not check the pens for expiration dates. LVN F stated the purpose of open dates was for expiration purposes because the insulin was only good for 28 days. She stated expired insulin would be ineffective. Interview on [DATE] at 1:15 PM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a 28 or 30 days shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the Assistant DON and the DON were supposed to do random check of the medication carts for monitoring. Record review of the facility's policy titled Medication Storage, dated [DATE], revealed in part .12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedures for medications destruction, and reordered from the pharmacy, if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #24) observed for infection control. Facility failed to ensure CNA D performed hand hygiene while providing incontinence care to Resident # 24. This failure could place the residents at risk for infection. Findings include: A record review of Resident #24's Quarterly MDS assessment, dated 04/30/2024, reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, need for assistance with personal care, and dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Resident #24 had a BIMS of 07 which indicated Resident #24's cognition was severely impaired. Resident#24 required extensive assistance of two-person physical assistance with toilet use and personal hygiene. In an observation on 05/22/24 at 9:58 AM revealed CNA D and CNA E entered Resident #24's room to provide incontinence care. Both CNAs washed hands and put the gloves on their hands hands, CNA D cleaned the front pubic area. The resident was assisted onto her side revealing she had a medium bowel movement. CNA D discarded the dirty gloves, without hand hygiene she donned clean gloves. CNA E held resident and CNA D cleaned the resident's buttocks area using several wipes. CNA D, without changing gloves, she placed a clean brief under resident. Both CNAs repositioned the resident back on her back. Both CNAs gathered the dirty clothes and trash, removed their gloves, and washed hands. In an interview on 05/22/24 at 10:14 AM, CNA D stated she was to wash hands before and after care. CNA D also stated she was supposed to change gloves and complete hand hygiene after removing the dirty gloves. CNA D stated she did not complete hand hygiene or change gloves after cleaning the resident because she was nervous. CNA D stated she was supposed to change gloves and complete hand hygiene to prevent the spread of infection. In an interview on 05/22/24 at 01:15 PM with the DON she stated during incontinent care the staff were to complete hand hygiene before and after care. The DON also stated in between care CNA was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection. Record review of the facility policy dated 12/1/2018, titled Hand Washing reflected, . it is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Procedures: . Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #13, Resident #40) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #13 had her fingernails cleaned and trimmed. 2- Resident #40 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Resident #13 Review of Resident #13's Annual MDS assessment dated [DATE]/2023 reflected Resident #13 was a [AGE] year-old female with initial admission date to the facility on [DATE]. Her diagnoses included coronary artery disease (chronic condition of plaque buildup in heart), hypertension (high blood pressure), heart failure (heart doesn't pump enough blood for body needs), Renal insufficiency (poor functioning of kidneys), Diabetes Mellitus (high blood glucose levels), hyperlipidemia (high blood lipid levels), Cerebral Vascular Accident (stroke), Parkinson disease (chronic and progressive neurological disorder). Resident #13 had a BIMS of 10 which indicated she had moderate cognitive impairment. Resident #13 was always incontinent of bowel and bladder and required assistance with personal hygiene. Review of Resident #13's Comprehensive Care Plan, revised 03/25/24, reflected the following: Problem: [Resident #13] had ADL self-care deficit related to limited physical mobility. Goal: [Resident #13] will maintain current level of function in personal hygiene. Approach: Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. An observation and Interview on 05/21/24 at 11:22 AM revealed Resident#13 resident's nail on both hands were long and dirty. The fingernails on both hands were 0.75 inches long and dirt under the nail bed. Interview with Resident#13 revealed she would like her fingernails to be trimmed and cleaned. She stated usually the nails were trimmed and cleaned by a Nurse, but the nails have not been cut for more than a month. In an interview with CNA B on 05/21/24 at 11:26 AM revealed she has been in the facility for about a month and both CNAs and LVNs were responsible for nail care. She stated if a resident has diabetes, only nurses were allowed to provide nailcare. She stated the risk for not performing nailcare was increased risk of infection. In an interview with LVN C on 05/21/24 at 11:30 AM revealed Resident #13 was very vocal of her needs and Nurses trim her nails since Resident #13 had diagnosis of diabetes. She stated that she had not offered nailcare to the Resident#13 recently. She stated that nailcare should be provided every Sunday or as needed. She stated Resident #13's fingernails were long and dirty and offered to clean them after the interview. She stated the risk of not providing adequate nail care was increased infections. 2- A record review of Resident #40's Quarterly MDS assessment dated [DATE] reflected Resident #40 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebrovascular accident (a loss of blood flow to part of the brain, which damages brain tissue), hemiplegia (paralysis of one side of the body, contracture of left hand and left shoulder, and speech and language deficit. Resident #40 had a BIMS of 12 which indicated Resident #40's cognition was moderately impaired. He required extensive assistance of two-person physical assistance with personal hygiene. A record review of Resident #40's Comprehensive Care Plan, revised 05/17/24, reflected the following: problem: ADLs Functional status . Personal Hygiene: Assist.: x 1. Goal: Resident will maintain a sense of dignity by being clean, dry, odor free and well groomed. Interventions: Assist with ADLs. An observation and interview on 05/21/24 at 10:56 AM revealed Resident #40 was laying in his bed. The nails on the right hand were approximately 0.3 centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. The nails on the left hand were approximately 0.5 centimeter in length extending from the tip of his fingers. Resident #40 was unable to answer questions. Interview on 05/17/23 at 11:02 AM with CNA D revealed CNAs were allowed to cut the residents' nails if they were not diabetic. CNA D stated she would clean and trim Resident #40's nails right then. CNA D stated the risk for not performing nailcare was increased risk of infection. In an interview with the DON on 05/22/24 3:35 PM revealed her expectation was that nail care should be provided every Sunday or as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had diagnosis of diabetes. She stated that they utilized agency staffing on weekends and her expectation was weekend supervisor should follow through with nail care. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated residents having long and dirty fingernails could be an infection control issue. Record Review of the facility policy titled Activities of Daily Living dated 1, 2023 reflected, . It is the policy of this home to assure residents have their activities of daily living needs met

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen: 1. The facility failed to ensure food items in the facility refrigerator, freezer and dry storage were covered and dated. 2. The facility failed to ensure [NAME] A used appropriate hair restraint in the kitchen. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observation in facility's walk-in refrigerator on 05/21/24 at 9:31 AM revealed a packet of hot dog did not had an expiration date on them. Observation in facility's dry storage on 5/21/24 at 9:36 AM revealed a packet of tortilla in plastic bag did not had used-by date and a packet of cornflakes that was left open without an use-by date marked on it. Observation in facility's freezer on 5/21/24 at 9:32 AM revealed a packet of bread did not had an expiration date. Observation of lunch meal service on 5/22/24 at 12:11 PM revealed that [NAME] A did not wore his hair restraint properly. [NAME] A had half of his hair tied in a bun which was tucked in the hair restraint while the other half of the hair was not restrained under the hair restraint and left loose. Observed [NAME] A perform tasks in the kitchen prep area that included handling washed utensils with improper hair restraint. In an interview with Dietary Manager on 5/22/24 at 12:21 PM revealed all the cooks and dietary aide , including herself , were responsible for dating and covering food items in the kitchen. The food items should be dated with expiration date for all unopened items and use by date for opened items. She stated it was important to date all food items in the kitchen; so that older items can be used first and decrease the risk of any food borne illness. She stated that per facility policy, they need to follow all state, federal and US Food code guidelines for dating and storing food items in the kitchen. She stated it was her expectation that all staff entering the kitchen prep area including cooking, serving, and handling food item should always wear appropriate hair restraint such that all hair were covered. She stated that hair restraints were a part of the uniform in the kitchen. She stated failure to wear appropriate hair or beard restraint may lead to food safety issues including food borne illness. In an interview with [NAME] A on 05/22/24 at 12:44 PM revealed he has been working in the facility for about 8 months. [NAME] A stated he had long , frizzy hair and some hair could be left out while wearing hair restraint. He stated he knew all hair needed to be secured appropriately to prevent any hair from getting into resident's food and the possibility of contacting food borne illness. He stated that cooks and dietary aide were responsible for dating and covering food items. He stated that all foods should be marked with an expiry date in the facility kithcen. He stated if the facility failed to label or date food items, they would not know how long the food items had been in the kitchen and can lead to compromised food safety for the residents. Record Review of the Facility's policy titled Food storage, revised June 2019, reflected To ensure that all foods served by the facility is of good quality for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry Storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage . Record Review of the Facility's policy titled Employee sanitation, dated October 2018, reflected .b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 4 out of 5 residents (#1, #3, #4, and #5) reviewed for ADL care. The facility failed to provide timely incontinence care every two hours or as needed for Resident #1 on 4/22/24. The facility failed to provide timely incontinence care on a regular basis for residents #1, #3, #4, and #5. This failure could place residents at risk of skin breakdown, urinary tract infections, and loss of dignity. Findings included: 1) Record review of Resident #1's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Blindness of right eye category 3, blindness of left eye category 5, ankylosing spondylitis (autoimmune disease that includes pain and stiffness in the spine and may affect other joints), atrophic disorder of skin (a reduction in epidermal and dermal thickness of skin), mild cognitive impairment, abnormalities of gait and mobility, rash and other skin disruption, stiffness of right hand, anxiety disorder, type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy), sepsis due to Escherichia (strain of e. coli which can make you very sick), epilepsy (neurological disorder in the brain, causing seizures), muscle weakness, age related osteoporosis (deterioration in bone mass, with increasing risk to fragility fractures), and chronic kidney disease (long standing disease leading to renal failure). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated she was cognitively intact. Record review of Resident #1's Care Plan dated 2/27/24, showed resident has made allegations that staff do not change her in a timely manner. Also, .is at risk for pressure ulcer due to incontinence, bedfast. Furthermore, Resident is at risk for falls due to visual impairment. Record review of Resident #1's ADL care sheet revealed incontinent care was completed on 4/21/24 at 3 a.m., 12:12 p.m. and at 4:10 p.m. On 4/22/24, incontinent care was completed at 2:06 a.m., 12:05 p.m. and 9 p.m. On 4/23/24, incontinent care was completed at 4:25 a.m., 9:11 a.m. and unanswered for unknown time. Interview and observation on 4/23/24 at 10:19 a.m. with Resident #1 said she was changed at 9 p.m. on 4/21/24 and was not changed again until the CNA on the 6-2 shift came in at 6:15 a.m. on 4/22/24. Resident #1 said the CNA had her lift her arms and she had feces in her armpits. She was usually a two person move for ADL care. Resident #1 said being left wet overnight before, during the night shift. She said she had to wait her turn and staff were very slow to respond, if you could get someone to come in at all on the night shift. Resident #1 stated there were too many times to remember when she has not gotten a response on the night shift. She was considered a heavy wetter and was supposed to be changed every two hours. Resident #1 said she had paper thin skin and had to keep the urine off her skin so she would not get skin wounds. 2) Record Review of Resident #3 face sheet revealed a [AGE] year-old woman, was admitted on [DATE]. Diagnoses included: Chronic pain syndrome, low back pain, tachycardia (fast heart rate), muscle weakness, chronic respiratory failure with hypoxia (low blood oxygen levels cause respiratory failure), major depressive disorder, anxiety disorder, unsteadiness on feet, unspecified lack of coordination, unspecified fracture on left pubis, fracture of other parts of pelvis, and urinary tract infection. Record Review of Resident #3's MDS dated [DATE], revealed a BIMS score of 14 which indicated she was cognitively intact. Record Review of Resident #3's ADL care sheet revealed on 4/23/24, she was checked for incontinent care at 4:28 a.m. and 9:22 a.m. Interview and Observation on 4/23/24 at 11:00 a.m. of Resident #3, she said when she used her call light, sometimes nobody would come. She said the nursing staff do not take care of her roommate as they should as they will not change her brief every two hours as they are supposed to. 3) Record Review of Resident #4' face sheet revealed an [AGE] year-old female, admitted on [DATE]. Diagnoses included: Alzheimer's Disease (progressive mental deterioration due to degeneration of the brain), Chronic Obstructive Pulmonary Disease (Group of lung diseases that block airflow and make it difficult to breath), Osteoarthritis, Chronic Pain, Muscle Weakness, Depressive Disorders, Abnormalities of Gait and Mobility, Heart Failure, Neuromuscular Dysfunction of Bladder (lacks bladder control due to brain, spinal cord, or nerve problems), Type 1 Diabetes Mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), Unsteadiness on feet, Anxiety Disorder, and Lack of Coordination. Record Review of Resident #4's MDS dated [DATE] revealed a BIMS score of 13 which indicated she was cognitively intact. Record Review of Resident #4's Care Plan dated 3/12/24 revealed she was at risk for decreased cardiac output, has urinary incontinence, and bowel incontinence. Record Review of Resident #4's ADL care sheet revealed on 4/23/24, she was checked for incontinent care at 4:18 a.m. and 9:11 a.m. Interview and observation on 4/23/24 at 11:12 a.m. with Resident #4 said the staff were not good at answering call lights. She said sometimes staff never come or come and turn off the call light without helping her with her needs. Resident #4 said today she had put on her call light, went to the bathroom and waited for help, but nobody came so she changed herself. 4) Record Review of Resident #5's face sheet was a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Alzheimer's disease, muscle weakness, unsteadiness on feet, need for assistance with personal care, type 1 diabetes mellitus with nephropathy (deterioration of kidney function), and myocardial infarction (a blockage of blood flow to heart muscle/heart attack is a medical emergency). Record Review of Resident #5's MDS dated [DATE], revealed a BIMS score of 15 which indicated she was cognitively intact. Record Review of Resident #5's Care Plan dated 4/18/24 revealed resident was on diuretic (promotes increased production of urine) therapy (alleviates signs of congestion). Record Review of Resident #5's ADL care sheet revealed she was checked for incontinent care on 4/21/24 at 12:53 a.m. and 12:13 p.m. On 4/22/24, incontinent care was completed at 12:38 a.m., 7:44 a.m. and 6:07 p.m. On 4/23/24, incontinent care was completed at 12:17 a.m. and at 8:34 a.m. In an interview on 4/23/24 at 11:38 a.m. with Resident #5 she said there was not enough staff on the floor during mealtime to help change if she was incontinent. Resident #5 said it usually took 20 - 30 minutes for her call light to be answered but she had waited longer (an hour or more) before. Resident #5 was concerned if an emergency happened, and she had to wait that long. In an interview on 4/23/24 at 12 p.m. with CNA A, she said call lights were supposed to be answered as soon as done with a resident, when you were helping someone. In an interview on 4/23/24 at 12:08 p.m. with CNA B, she said call lights were to be answered within 5 - 10 minutes. She said if the resident was incontinent, they would be checked every two hours to see if they needed to be changed. In an interview on 4/23/24 at 12:13 p.m. with LVN D, she said call lights were to be answered as soon as a nurse sees it. She stated she had gone down the hall to answer the call light if the CNA's were busy. LVN D said it was important to answer call lights quickly because it could have been an emergency. LVN D said incontinent residents get checked every two hours or as needed. In an interview on 4/23/24 at 12:35 p.m. with CNA C, she said staff should answer call lights as quick as possible. She said incontinent residents were checked every two hours or as needed. In an interview on 4/23/24 at 2:44 p.m. with RN E, she said she expected her staff to answer call lights in 2 - 5 minutes. RN E said it was important to answer call lights quickly as the resident could have fallen, could be aspirating, could be wet/dirty, and to make sure needs were met. In an interview on 4/23/24 at 2:47 p.m. with RN F, she said she was not sure of a specific time the call lights were to be answered but said most residents called the nurses station with their cell phone. RN F said it was important to answer call lights because one did not know if the resident fell, needed to be cleaned, or needed assistance. Record Review of Call Light Procedures showed: 1) all nursing personnel must be aware of call lights at all times, 2) answer call lights promptly whether or not you are assigned to the resident .6) Answer call lights in a prompt, calm, courteous manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative of the discharge with the reasons for the discharge in writing, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and failed to record the reasons for the discharge in the resident's medical record for 1 (Residents #1) of 3 residents reviewed for transfer and discharge requirements. 1. The facility failed to initiate a 30-day discharge notice to Resident #1 and ombudsman on 08/28/23 when facility made decision based on inability to meet resident's needs not to readmit Resident #1 to the facility from the hospital. 2. The facility failed to have written documentation of facility's decision to not readmit Resident #1 from the hospital in resident's medical record. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care. Findings included: Review of Resident #1's face sheet printed 09/20/23 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cirrhosis of liver (permanent scarring that damages liver), diabetes, arthritis, uropathy (blockage in urinary tract), and kidney failure. Resident #1 was his own responsible party and had been discharged from the facility. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. He was extensive assistance with most ADLs. Review of Resident #1's discharge MDS assessment dated [DATE] reflected Resident #1 was discharged on 08/25/23 from facility to a hospital with return anticipated. Review of Resident #1's Progress notes reflected the following: - 08/25/23 9:25 AM by RN A: Resident called this nurse to his room to discuss intense bladder pain with pain being 10/10. Resident stated the pain is coming approximately 5 times per hour and was unable to sleep even with AZO being administered. Resident requested to be sent to [local hospital] ER for further evaluation. - 08/25/23 9:27 AM by RN A: Nurse Practitioner notified of resident wanting to be sent to [local hospital] ER for bladder pain 10/10. New order received to send resident to [local hospital] ER. - 08/25/23 9:55 AM by RN A: EMS here in facility to transport resident to [local hospital] ER - 08/25/23 10:03 AM by RN A: Resident left facility via stretcher with 2 EMT's. - 08/25/23 10:05 AM by RN A: Resident #1's emergency contact notified that [Resident #1] left facility to be taken to [local hospital] ER. - 08/28/23 9:32 AM by SW: SW called the resident's emergency contact .and told her that he (Resident #1 would not be coming back to the building. Review of Resident #1's closed clinical chart reflected Resident #1 was given a discharge notice on 03/03/23 for inability to meet resident's health care needs. Resident #1 did not have a written discharge notice on 08/28/23. Review of Resident #1's clinical records did not reflect any documentation of facility's reasoning of not accepting Resident #1 back from the hospital on [DATE]. Review of hospital records dated 09/21/23 reflected Resident #1 was admitted to the hospital on [DATE]. - Hospital Physician progress note dated 09/21/23 reflected under Discharge Planning Return to previous agency/facility/nursing home when accepted. Social service working on it. [Facility] has not accepted the patient in transfer back yet Pt is appealing to judge---hearing is pending Discharge planning once placement available. - Review of Case Management Forms on 09/18/23 by Hospital Case Manager reflected Per ombudsman she received notification from the court that she 'will receive hearing date within the next 14 days'. Patient continues to state he 'wants to only return back to [facility]'. Notified physician. - Review of Case Management Forms on 09/08/23 by Hospital Case Manager reflected Ombudsman and CM (case manager) visited with patient, ombudsman entering an appeal with the state on Monday which will allow a court hearing with judge for judgement to be able to return .Notified physician and CM director of plan. - Review of Case Management Forms on 09/01/23 by Hospital Case Manger reflected .corporate office, refusal to accept patient is accurate, knows the patient has not recd [received] an eviction notice in several months and has not had a recent appeal. The last eviction notice and won appeal was 4 months ago which is outside current timeframe of last 30 days to be able to not allow patient to return. Ombudsman contacted and will need patient consent to visit .patient reports he will contact her then to arrange. CM provided SNF (skilled nursing facility) options, patient still adamantly refuses to transfer to a new .facility however willingly accepted list to review quality ratings of each . - Review of Case Management Forms on 08/29/23 by Hospital Case Manager reflected Discharge order placed by [physician], upon contacting [facility] per administrator states 'corporate has made the decision to refuse to accept back, patient is not able to return, eviction notice provided twice with the last on being up to 4 months ago but has refused to leave'; no other information provided. CM notified hospitalist and charge nurse, contacted ombudsman who stated she had been informed of previous incidences at facility with this patient and insists patient is allowed to return to facility and they must accept him back otherwise they are in violation of patient rights and laws. Notified the administrator of ombudsman statements, administrator stated again corporate decision not to allow back. An interview with the local Ombudsman on 09/20/23 at 11:09 AM revealed the facility had not issued a 30 day discharge notice to Resident #1 and had not informed ombudsman of issuing a 30 day discharge notice. She stated hospital informed of facility refusing to readmit Resident #1 due to being unable to meet his needs at the facility. She stated Resident #1 wished to return to the facility and Resident #1 had requested an appeal on 09/12/23 to be able to return to the facility. She stated Resident #1 was ready to be discharged from hospital but was still at hospital due to wanting to return to the facility. She had not received a hearing date for Resident #1's appeal. An interview on 09/21/23 at 3:12 PM with Hospital Case Manager revealed the hospital contacted the facility about discharge for Resident #1 back to the facility but was told corporate would not allow him to return. She stated the facility had not been specific about reasoning of not accepting Resident #1 back. She stated on 08/29/23 the hospital sent a formal request through online portal request for discharge from hospital to their facility and the resident was denied readmission to the facility. She stated Resident #1 was still in the hospital as of today but was ready for discharge back to the facility. She stated Resident #1 wanted to return to the facility where he told her the facility was his home. An interview on 09/21/23 at 10:18 AM with Administrator revealed the facility did not accept Resident #1 back into the facility due to being unable to meet the resident needs and corporate was involved in the decision making. He stated in the past Resident #1 was issued a 30 day discharge notice in March 2023 for failure to meet resident's needs at the facility. The Administrator stated Resident #1 discharged to the hospital per request for him to be sent to hospital on [DATE] and on 08/28/23 is when decision was made after discussing with corporate. He stated Resident #1 did have behaviors of refusing care and not allowing staff to take care of him at times. He stated the social worker informed Resident #1's emergency contact of their decision not to accept Resident #1 for readmission. He stated a 30 day discharge notice was not initiated due to Resident #1 being sent to the hospital per resident request. He stated he was aware Resident #1 wanted to return to the facility from the hospital. An interview on 09/21/23 at 10:30 AM with Social Worker revealed he was informed by Administrator on 08/28/23 to inform Resident #1's emergency contact of facility's decision not to accept Resident #1 back for readmission. He stated he did not give specific reasoning to emergency contact on 08/28/23 when he contacted them . He stated he was not involved in facility or corporate's decision to accept or not accept new resident admissions or readmissions. He stated he could not recall if he had spoken to hospital about not accepting Resident #1 for readmission but if he had it would have been in his social worker notes. He stated a 30 day discharge notice was not needed since Resident #1 discharged to hospital. An interview on 09/21/23 at 10:35 AM with DON revealed on 08/25/23 Resident #1 was sent to hospital per resident request and physician agreed for Resident #1 to be sent to hospital for further evaluation due to discomfort and pain in his bladder. She stated Resident #1 was not issued a 30 day discharge notice since he was sent to hospital for change of condition. She stated admissions coordinator informed the hospital of facility's decision not to accept Resident #1's readmission back to the facility. She stated the facility's reasoning was unable to provide for his needs. She stated he had behaviors of refusal of ADL care, wound care and catheter care. She stated the staff provided for his needs as much as Resident #1 would allow them and varied depending on the day. She stated facility was not aware a 30 day discharge notice was required since he went to the hospital. DON stated she was not aware of Resident #1's condition from the hospital for discharge. An interview on 09/21/23 at 10:44 AM with Admissions Coordinator revealed when a hospital requested admission or readmission to the facility, they have to determine if they can meet his financial and medical needs by reviewing discharge paperwork. She stated corporate and facility both included in decision about resident admissions to the facility. She stated she was not aware of any formal request by the hospital for Resident #1 to be readmitted to the facility. She stated Resident #1 discharged to the hospital on [DATE] (Friday). She stated she informed Hospital Case Manager about facility's decision not to readmit Resident #1 to the facility but did not give a specific reason. She stated Hospital Case Manager told her they spoke to Ombudsman and were told the facility had to take him back. She stated the Hospital Case Manger did not mention specifically about Resident #1's ready to be discharged when she spoke with them. Interview on 09/21/23 at 1:55 PM with Administrator and DON revealed the facility did not have any written documentation to include a 30 day notice to Resident #1, family or ombudsman of facility decision to not readmit Resident #1 back to the facility. Administrator stated he was only given verbal to not accept Resident #1 for admission to the facility and stated it was due to facility unable to meet resident's needs. They both were not aware they needed to have treated the discharge as a facility initiated discharged when decision was made for Resident #1 not to return to the facility from the hospital. Follow-up Interview on 09/21/23 at 2:25 PM with Administrator revealed they did not have a policy on readmission from hospital and was not aware the facility should have a policy addressing readmissions to the facility. Review of the facility's policy titled, Discharge - Transfer of the Resident revised December 2017 reflected residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software. The policy did not reflect about readmission or facility-initiated discharge. Review of the facility's policy titled, Admissions to the Facility revised December 2006 reflected the facility would admit only those residents whose medical and nursing care needs can be met .5. The Administrator, through the Admissions Department, shall assure that the resident and the facility follow applicable admission policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 (Resident #1) of 3 residents reviewed for transfer/discharge requirements. The facility failed to establish and follow a policy to address Resident #1's request to return to the facility after a hospitalization when facility initiated discharge on [DATE]. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care. Findings included: Review of Resident #1's face sheet printed 09/20/23 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cirrhosis of liver (permanent scarring that damages liver), diabetes, arthritis, uropathy (blockage in urinary tract), and kidney failure. Resident #1 was his own responsible party and had been discharged from the facility. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. He was extensive assistance with most ADLs. Review of Resident #1's discharge MDS assessment dated [DATE] reflected Resident #1 was discharged on 08/25/23 from facility to a hospital with return anticipated. Review of Resident #1's Progress notes reflected the following: - 08/25/23 9:25 AM by RN A: Resident called this nurse to his room to discuss intense bladder pain with pain being 10/10. Resident stated the pain is coming approximately 5 times per hour and was unable to sleep even with AZO being administered. Resident requested to be sent to [local hospital] ER for further evaluation. - 08/25/23 9:27 AM by RN A: Nurse Practitioner notified of resident wanting to be sent to [local hospital] ER for bladder pain 10/10. New order received to send resident to [local hospital] ER. - 08/25/23 9:55 AM by RN A: EMS here in facility to transport resident to [local hospital] ER - 08/25/23 10:03 AM by RN A: Resident left facility via stretcher with 2 EMT's. - 08/25/23 10:05 AM by RN A: Resident #1's emergency contact notified that [Resident #1] left facility to be taken to [local hospital] ER. - 08/28/23 9:32 AM by SW: SW called the resident's emergency contact .and told her that he (Resident #1 would not be coming back to the building. Review of Resident #1's closed clinical chart reflected Resident #1 was given a discharge notice on 03/03/23 for inability to meet resident's health care needs. Resident #1 did not have a written discharge notice on 08/28/23. Review of Resident #1's clinical records did not reflect any documentation of facility's reasoning of not accepting Resident #1 back from the hospital on [DATE]. Review of hospital records dated 09/21/23 reflected Resident #1 was admitted to the hospital on [DATE]. - Hospital Physician progress note dated 09/21/23 reflected under Discharge Planning Return to previous agency/facility/nursing home when accepted. Social service working on it. [Facility] has not accepted the patient in transfer back yet Pt is appealing to judge---hearing is pending Discharge planning once placement available. - Review of Case Management Forms on 09/18/23 by Hospital Case Manager reflected Per ombudsman she received notification from the court that she 'will receive hearing date within the next 14 days'. Patient continues to state he 'wants to only return back to [facility]'. Notified physician. - Review of Case Management Forms on 09/08/23 by Hospital Case Manager reflected Ombudsman and CM (case manager) visited with patient, ombudsman entering an appeal with the state on Monday which will allow a court hearing with judge for judgement to be able to return .Notified physician and CM director of plan. - Review of Case Management Forms on 09/01/23 by Hospital Case Manger reflected .corporate office, refusal to accept patient is accurate, knows the patient has not recd [received] an eviction notice in several months and has not had a recent appeal. The last eviction notice and won appeal was 4 months ago which is outside current timeframe of last 30 days to be able to not allow patient to return. Ombudsman contacted and will need patient consent to visit .patient reports he will contact her then to arrange. CM provided SNF (skilled nursing facility) options, patient still adamantly refuses to transfer to a new .facility however willingly accepted list to review quality ratings of each . - Review of Case Management Forms on 08/29/23 by Hospital Case Manager reflected Discharge order placed by [physician], upon contacting [facility] per administrator states 'corporate has made the decision to refuse to accept back, patient is not able to return, eviction notice provided twice with the last on being up to 4 months ago but has refused to leave'; no other information provided. CM notified hospitalist and charge nurse, contacted ombudsman who stated she had been informed of previous incidences at facility with this patient and insists patient is allowed to return to facility and they must accept him back otherwise they are in violation of patient rights and laws. Notified the administrator of ombudsman statements, administrator stated again corporate decision not to allow back. An interview with the local Ombudsman on 09/20/23 at 11:09 AM revealed the facility had not issued a 30 day discharge notice to Resident #1 and had not informed ombudsman of issuing a 30 day discharge notice. She stated hospital informed of facility refusing to readmit Resident #1 due to being unable to meet his needs at the facility. She stated Resident #1 wished to return to the facility and Resident #1 had requested an appeal on 09/12/23 to be able to return to the facility. She stated Resident #1 was ready to be discharged from hospital but was still at hospital due to wanting to return to the facility. She had not received a hearing date for Resident #1's appeal. An interview on 09/21/23 at 3:12 PM with Hospital Case Manager revealed the hospital contacted the facility about discharge for Resident #1 back to the facility but was told corporate would not allow him to return. She stated the facility had not been specific about reasoning of not accepting Resident #1 back. She stated on 08/29/23 the hospital sent a formal request through online portal request for discharge from hospital to their facility and the resident was denied readmission to the facility. She stated Resident #1 was still in the hospital as of today but was ready for discharge back to the facility. She stated Resident #1 wanted to return to the facility where he told her the facility was his home. An interview on 09/21/23 at 10:18 AM with Administrator revealed the facility did not accept Resident #1 back into the facility due to being unable to meet the resident needs and corporate was involved in the decision making. He stated in the past Resident #1 was issued a 30 day discharge notice in March 2023 for failure to meet resident's needs at the facility. The Administrator stated Resident #1 discharged to the hospital per request for him to be sent to hospital on [DATE] and on 08/28/23 is when decision was made after discussing with corporate. He stated Resident #1 did have behaviors of refusing care and not allowing staff to take care of him at times. He stated the social worker informed Resident #1's emergency contact of their decision not to accept Resident #1 for readmission. He stated a 30 day discharge notice was not initiated due to Resident #1 being sent to the hospital per resident request. He stated he was aware Resident #1 wanted to return to the facility from the hospital. An interview on 09/21/23 at 10:30 AM with Social Worker revealed he was informed by Administrator on 08/28/23 to inform Resident #1's emergency contact of facility's decision not to accept Resident #1 back for readmission. He stated he did not give specific reasoning to emergency contact on 08/28/23 when he contacted them . He stated he was not involved in facility or corporate's decision to accept or not accept new resident admissions or readmissions. He stated he could not recall if he had spoken to hospital about not accepting Resident #1 for readmission but if he had it would have been in his social worker notes. He stated a 30 day discharge notice was not needed since Resident #1 discharged to hospital. An interview on 09/21/23 at 10:35 AM with DON revealed on 08/25/23 Resident #1 was sent to hospital per resident request and physician agreed for Resident #1 to be sent to hospital for further evaluation due to discomfort and pain in his bladder. She stated Resident #1 was not issued a 30 day discharge notice since he was sent to hospital for change of condition. She stated admissions coordinator informed the hospital of facility's decision not to accept Resident #1's readmission back to the facility. She stated the facility's reasoning was unable to provide for his needs. She stated he had behaviors of refusal of ADL care, wound care and catheter care. She stated the staff provided for his needs as much as Resident #1 would allow them and varied depending on the day. She stated facility was not aware a 30 day discharge notice was required since he went to the hospital. DON stated she was not aware of Resident #1's condition from the hospital for discharge. An interview on 09/21/23 at 10:44 AM with Admissions Coordinator revealed when a hospital requested admission or readmission to the facility, they have to determine if they can meet his financial and medical needs by reviewing discharge paperwork. She stated corporate and facility both included in decision about resident admissions to the facility. She stated she was not aware of any formal request by the hospital for Resident #1 to be readmitted to the facility. She stated Resident #1 discharged to the hospital on [DATE] (Friday). She stated she informed Hospital Case Manager about facility's decision not to readmit Resident #1 to the facility but did not give a specific reason. She stated Hospital Case Manager told her they spoke to Ombudsman and were told the facility had to take him back. She stated the Hospital Case Manger did not mention specifically about Resident #1's ready to be discharged when she spoke with them. Interview on 09/21/23 at 1:55 PM with Administrator and DON revealed the facility did not have any written documentation to include a 30 day notice to Resident #1, family or ombudsman of facility decision to not readmit Resident #1 back to the facility. Administrator stated he was only given verbal to not accept Resident #1 for admission to the facility and stated it was due to facility unable to meet resident's needs. They both were not aware they needed to have treated the discharge as a facility initiated discharged when decision was made for Resident #1 not to return to the facility from the hospital. Follow-up Interview on 09/21/23 at 2:25 PM with Administrator revealed they did not have a policy on readmission from hospital and was not aware the facility should have a policy addressing readmissions to the facility. Review of the facility's policy titled, Discharge - Transfer of the Resident revised December 2017 reflected residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software. The policy did not reflect about readmission or facility-initiated discharge. Review of the facility's policy titled, Admissions to the Facility revised December 2006 reflected the facility would admit only those residents whose medical and nursing care needs can be met .5. The Administrator, through the Admissions Department, shall assure that the resident and the facility follow applicable admission policies.

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 biologicals) to meet the needs of one (Resident #2) of one resident reviewed for pharmacy services. 1. MA C did not remove a Fentanyl Transdermal Patch (a controlled substance used to treat severe pain) from Resident #2's right upper back prior to applying a new patch to right shoulder. This failure could place residents at risk for not receiving their medications as ordered, inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: A record review of Resident #2's digital chart revealed a 75 y.o. female admitted to the SNF on 02/24/21. Resident #2 was admitted to Hospice on 06/04/23. Resident #2 had diagnoses of encephalopathy (a decrease in blood flow or oxygen to the brain); unspecified dementia without behavioral disturbance; pain in unspecified joint; COPD (a group of diseases that cause airflow blockage and breathing-related problems); HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); and pressure ulcer of right buttock, stage 2 (history of). Resident #2 was cognitively impaired per staff assessment. Resident #2 returned to the SNF on 06/14/23 after an inpatient acute care hospital stay (06/11/23 - 06/14/23). During a phone interview on 06/14/23 at 12:08 PM, Resident #2's family member indicated during visitation on 06/11/23, Resident #2 was not coherent, seemed drugged . was trying to talk but would start snoring after a said one - two words. The family member said that they discovered a Fentanyl patch on Resident #2's right shoulder and took it off. The family member said that they called for the nurse to come to the room to assess Resident #2. When the nurse [LVN H] arrived, the family member told the nurse their thoughts that Resident #2 may had a narcotic overdose and requested to send Resident #3 to the ED. The family member said that LVN H verbalized understanding and left the room. The family member said that LVN H returned to the room after 20 mins and stated that she wanted to check Resident #2 for other patches. The family member said that LVN H found another Fentanyl patch on Resident #2's right shoulder blade. Resident #2 was transferred to the ED to be assessed and evaluated. A review of the emergency department clinical report dated 06/11/23 indicated Resident #2 presented to the ED from SNF and [family member] reported checking on Resident #2 and noticed that she was obtunded (A dulled or reduced level of alertness or consciousness). Patient is disoriented x 4 though alert now. The emergency department clinical report revealed a primary admitting diagnosis: Acute cystitis without hematuria and secondary diagnosis: Altered mental status, unspecified. Vital Signs on admission to the ED reflected: HR 84; RR 16; BP 121/95; O2 sat 100% RA. Further review of the emergency department clinical report did not reflect medications administered to Resident #2 for signs of opioid overdose or if opioid overdose was suspected. A review of Resident #2's clinical physician orders reflected: - Start date 06/03/23: Admit resident to Hospice. - Start date 06/04/23: Fentanyl - schedule II patch 72 hour; 25 mcg/hr; one patch; transdermal. Every 72 hours. 7:00 AM A review of Resident #2's MAR for June 2023 revealed an order for Fentanyl - schedule II patch 72 hour; 25 mcg/hr; one patch; transdermal. Every 72 hours. 7:00 AM with the User Initials CC43 [MA B] under the column that represented Wednesday, 06/07/23 and the User Initials RM49 [MA C] under the column that represented Saturday, 06/10/23. A review of Resident #2's nursing progress note dated 06/04/23 at 10:40 PM, entered by RN G reflected, Received new order from [HMD] to start Fentanyl 25 mcg patches, same arrived at [9:00 PM]. Fentanyl patch initial dosed. Placed on right upper back. Record review of a Medication Error Event Report dated 06/11/23 at 6:00 PM indicated the medication error was discovered by family, [Resident #2] had two Fentanyl 25 mcg patches on. One was dated 06/07/23 and the other was dated 06/10/23. MA C was identified as the person responsible for error. The type of error, Failed to remove old patch prior to administering new one. There were no adverse drug reactions documented. Interventions included: MD notified, [Fentanyl] patches removed, and Resident #2 was sent to ED per family request. LVN H signed and dated the report. MA C was not available for interview on 06/14/23 or 06/14/23. The investigator was unable to speak to MA C by phone. During an interview on 06/16/23 at 10:32 AM, the DON said she was notified about the medication error and conducted a chart audit. The DON said that an entry on the MAR to remove the old patch before applying the new patch could have prevented the error. The DON said that updating the MARs to reflect the removal of patches before a new patch has been discussed and will be implemented. The DON said that she expected staff to follow facility policy and procedure when giving medications as ordered by the doctor and follow the Medication Rights (A medication safety, best practice standard). The DON stated that she oversees the nurse's and medication aide's adherence to safe medication administration. The DON indicated the following interventions to reduce the risk of medication errors: - Monthly in-services - Annual skills checkoffs - Educate staff on appropriate administration of medication During a phone interview on 06/16/2023 at 11:24 AM, the HMD stated was informed about the medication error and agreed to send Resident #2 to ED per family request. The HMD said that the reported VS were within [Resident #2] baseline and did not have any concerns. The HMD stated that she did not feel the error of not removing the previous [Fentanyl] patch before the new patch was applied and left in place for more than 24-hours was at a great enough dose to cause an overdose. A review of the Medication Administration Policy and Procedure dated 01/2023 indicated the purpose of the policy is that . medications will be administered and documented as ordered by the physician and in accordance with state regulations. The procedures reflected: Medications are administered at the time they are prepared Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label

Based on observation, interview, and record review the facility failed to ensure that it is free of medication error rates of five percent or greater. The facility had a medication error rate of 5.4%, based on 2 errors out of 37 opportunities, which involved one (Resident #1) of six residents reviewed for medication administration. 1. MA A failed to check Resident #1's blood pressure before administering blood pressure medications (Amlodipine and Metoprolol) 2. MA A failed to administer Dorzolamide-Timolol (eye) Drops (used to treat increased pressure in the eye caused by open-angle glaucoma or a condition called hypertension of the eye) to Resident #1 as ordered by physician These failures could place residents at risk for not receiving their medications as ordered, inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: During medication preparation and administration observation on 06/16/23 at 8:05 AM, observation of the label/OTC bottle and identification of the medication indicated MA A dispensed the following medications for Resident #1: - Cyanocobalamin (Vitamin B-12) 1,000 mcg; two tablets - Cyanocobalamin (Vitamin B-12) 500 mcg; one tablet - Aspirin [OTC] 81 mg; one tablet, chewable - Brilinta 90 mg; one tablet - Atorvastatin 10 mg; one tablet - Tamsulosin 0.4 mg; one capsule - Gemfibrozil 600 mg; one tablet - Glipizide 2.5 mg; one ER tablet - Amlodipine 5 mg; one tablet - Omeprazole 20 mg; one DR tablet - Metoprolol 25 mg; half tablet (already split) During medication preparation and administration observation on 06/16/23 at 8:26 AM, MA A located Resident #1 in the therapy gym after preparing the medications and discovered Resident #1 was not in his room. MA A did not check Resident #1's blood pressure before administering two blood pressure medications (Amlodipine 5 mg, 1 tab and Metoprolol 25 mg, 0.5 tab). Medication administration observation revealed MA A did not administer Dorzolamide-Timolol (eye) Drops (used to treat increased pressure in the eye caused by open-angle glaucoma or a condition called hypertension of the eye), one drop, to Resident #1's right eye as ordered. Record review to reconcile the record of observation with Resident #1's active physician orders indicated: - Start date 05/25/23: Amlodipine tablet; 5 mg; one tablet; oral. Special Instructions - Hold SBP (first/top number of blood pressure measurement) less than 100. Once A Day 7:00 AM - Start date 05/25/23: Aspirin [OTC] tablet, chewable; 81 mg; one tablet; oral. Once A Day 9:00 AM - Start date 05/25/23: Atorvastatin tablet; 10 mg; one tablet; oral. Once A Day 7:00 AM - Start date 05/25/23: Brilinta (ticagrelor) tablet; 90 mg; one tablet; oral. Twice A Day 7:00 AM; 700 PM - Start date 05/26/23: Cyanocobalamin (Vitamin B-12) tablet, sublingual; 2,500 mcg; one tablet; oral. Once A Day 9:00 AM - Start date 05/29/23: Dorzolamide-Timolol drops; 22.3-6.8 mg/mL; one drop into right eye; ophthalmic (eye). Twice A Day 7:00 AM; 700 PM - Start date 05/25/23: Gemfibrozil tablet; 600 mg; one tablet; oral. Once A Day 9:00 AM - Start date 05/25/23: Glipizide tablet extended release 24hr; 2.5 mg; one tablet; oral. Twice A Day 7:00 AM; 700 PM - Start date 05/26/23: Metoprolol Tartrate tablet; 25 mg; 0.5 tablet; oral. Special Instructions - Hold SBP (first/top number of blood pressure measurement) less than 100. Hold HR less than 60. Twice A Day 7:00 AM; 700 PM - Start date 05/26/23: Omeprazole capsule, delayed release; 20 mg; one capsule; oral. Once A Day 9:00 AM - Start date 05/26/23: Tamsulosin capsule; 0.4 mg; one capsule; oral. Once A Day 9:00 AM A review of Resident #1's MAR for June 2023 revealed an order for Dorzolamide-Timolol drops; 22.3-6.8 mg/mL; one drop into right eye; ophthalmic (eye). Twice A Day 7:00 AM; 700 PM with the User Initials NC9 [MA A] under the column that represented Friday, 06/16/23 and in the row that represented 7:00 AM. The User Initials had an asterisk (*) next to it. Per the Information Key on the MAR, the asterisk indicated there was a comment in the Reasons/Comments section. The MAR reflected the following: Scheduled date, 06/16/23; Scheduled time, 7:00 AM: Charted Date - Time: 06/16/23 - 8:05 AM; Late Administration: Other. Comment: given on time; Created by: [MA A]. During an interview on 06/16/23 at 9:00 AM, MA A said that she should always check the residents blood pressure before giving blood pressure medications because there are special instructions to not give the medication if the blood pressure measurement is outside the parameters. MA A said that the nurse [LVN D] checked Resident #1's blood pressure before she [LVN D] administered a diuretic early in the morning [06/16/23] around 7:00 AM - Resident #1's BP was 134/76. MA A said that risks to the resident giving a medication when it should be held can worsening the blood pressure or heart rate levels. MA A said that she checked off the medications on the MAR after she prepared the medications and forgot to take the eye drops to administer to Resident #1. MA A stated that she knows that she should not initial the MAR until after the medication is administered. During an interview on 06/16/23 at 10:32 AM, the DON said that she expected staff to follow facility policy and procedure when giving medications as ordered by the doctor and follow the Medication Rights (A medication safety, best practice standard). The DON stated that she oversees the nurse's and medication aide's adherence to safe medication administration. The DON indicated the following interventions to reduce the risk of medication errors: - Monthly in-services - Annual skills checkoffs - Educate staff on appropriate administration of medication A review of the Medication Administration Policy and Procedure dated 01/2023 indicated the purpose of the policy is that . medications will be administered and documented as ordered by the physician and in accordance with state regulations. The procedures reflected: Medications are administered at the time they are prepared Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication carts (300 hall medication aide cart) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 03/28/2023 at 11:45 AM of the Medication Aide Cart Hall 300 revealed the blister pack for Resident #12's clorazepate 15 mg tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill was still inside the broken blister and taped over. In an observation and interview on 03/28/23 at 11:45 AM, MA C stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk of a damaged blister would be a potential for drug diversion. She stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blister during the count. At this time the surveyor checked the medication; the count was compared to the blister pack and the count was correct. Interview on 03/30/23 at 2:04 PM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the pharmacy consultant checks the medication room and the medication cart monthly. Review of the facility's policy Medications Storage - in the Home, revised December 2017, reflected the following: . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedures for medications destruction, and reordered from the pharmacy, if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #17) observed for infection control. Facility failed to ensure CNA E perform hand hygiene while providing incontinence care to Resident # 17. This failure could place the residents at risk for infection. Findings include: A record review of Resident #17's Comprehensive MDS assessment dated [DATE], revealed Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, dementia, and depression. Resident #17 had a BIMS of 14 which indicated Resident #17 was cognitively intact. Resident #17 was incontinent of bowel and bladder. Observation on 03/29/23 at 9:58 AM revealed CNA E providing incontinent care to Resident #17. CNA E was observed completing hand hygiene before care, then she informed the resident she was providing incontinent care. CNA E donned clean gloves. CNA E with the help of CNA A positioned the resident and unfastened the brief and proceeded to clean Resident #17's front area with wipes. CNA E discarded the dirty gloves, she sanitized her hand and donned clean gloves. CNA E with the help of CNA A positioned the resident on the side and cleaned the resident's bottom area. After cleaning the resident CNA E took off and discarded the dirty brief and without any form of change of gloves or hand hygiene, CNA E applied the clean brief, she put the bed in low position, she pulled the bed side table closer to resident #17 bed, she positioned a cup of thickened liquid on the table, and then she doffed and discarded the dirty gloves and completed hand hygiene. In an interview on 03/29/23 at 10:13 AM with CNA E she stated she was to wash hands before and after care. CNA E also stated she was supposed to change gloves and complete hand hygiene after taking the resident's dirty brief off. CNA E stated she did not complete hand hygiene or change gloves after cleaning the resident because she forgot. CNA E stated she was supposed to change gloves and complete hand hygiene to prevent the spread of infection. CNA E stated she had an in-service on infection control about two weeks ago. In an interview on 03/30/23 at 02:04 PM with the DON she stated during incontinent care the staff were to complete hand hygiene before and after care. DON also stated in between care CNA E was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection. Review of the facility policy revised December 2017, titled Incontinent Care reflected, It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensure no cross contamination. Female . a. after completing perineal care, cover resident, discard soiled gloves, sanitize hands, re-glove.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation (Resident #47, and #56). The facility did not implement their abuse/neglect policy related to reporting and investigating allegations within time frames required by federal requirements when 2 residents were involved in altercations with other residents (Residents #47 and #56). This failure could place residents in the facility at risk for abuse and neglect. The findings included: Resident #47 Review of an undated face sheet revealed that Resident #47 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, high cholesterol, left-sided paralysis, contracture of left hand and shoulder, generalized muscle weakness, lack of coordination, vascular dementia (reduced blood flow to brain causing impaired memory and thinking), major depressive disorder, non-pressure ulcers of left lower leg and buttock, stage 2 pressure ulcer (unspecified site), difficulty swallowing, speech and language deficits after stroke, difficulty urinating, high blood pressure, hallucinations, and gastric reflux. Review of MDS assessment (dated 3/15/23) indicated that the resident had a BIMS score of 11 (indicating moderate cognitive impairment) and needed extensive assistance with ADLs. The resident required extensive assistance with all ADLS, had limited mobility of lower extremities and paralysis on one side. Resident #47 used a geri-chair for ambulation and was totally dependent for transfer and mobility. Review of Progress Note dated 2/20/23 written by SW G revealed that on 2/19/23 another resident (since transferred to a memory care unit) had accused Resident #47 of touching her on the breast inappropriately. Interview with the resident on 03/30/23 revealed he denied the allegation of inappropriate behavior. He stated that he would not do that. In an interview on 03/30/23 at 03:59 PM SW G revealed the other resident was discharged to another facility prior to entry. The SW stated the other resident had cognition issues and behavior issues. The SW stated the two residents lived in two different halls. Interviewed revealed I can't find a report. I thought someone else had done the grievance report. Interview with the Social Worker revealed he could not recall if he reported the allegation to the Administrator or if the Administrator asked him to do interviews for the investigation. Review of grievance log on 3/29/23 revealed no evidence that this incident had been reported. Review of TULIP on 3/29/23 revealed no report related to this incident. In an interview on 03/30/23 at 04:59 PM the DON admitted that this incident had not been investigated nor reported to HHSC. The DON stated she contacted the Administrator but he could not recall the incident and could not recall if he reported or investigated the incident. Resident #56 Review of an undated face sheet revealed that Resident #56 was a [AGE] year-old male diagnosed with infection of left lower limb, Type 2 diabetes, cirrhosis of the liver, psoriatic arthritis (autoimmune arthritis), urinary retention, acute kidney failure, unspecified arthritis, generalized muscle weakness, contracture of the left hand, cognitive communication deficit, psoriasis (autoimmune skin condition), hypothyroidism, major depressive disorder, anxiety disorder, peripheral neuropathy (nerve disease of limbs), gastric reflux, obesity, and deep vein thrombosis. Review of MDS assessment (dated 3/06/23) revealed that Resident #56 had a BIMS score of 15 (indicating resident was cognitively intact),and needed extensive assistance with ADLs. In an interview on 3/28/23 at 10:18 AM, Resident #56 said, [LVN H] took pictures of my privates without my permission. The DON tried to cover it up. Review of grievance log on 3/29/23 revealed no evidence that this incident had been reported. Review of TULIP on 3/29/23 revealed no report related to this incident. In an interview on 03/30/23 at 04:59 PM the DON admitted that this incident had not been investigated nor reported to HHSC. Interview with the DON revealed she talked to LVN H when she learned about the incident. The DON stated Resident #56 asked the LVN to take a picture of his genital area so he could see what was going on. Interview with the DON revealed the LVN followed the resident request, took the picture, showed the resident and then deleted the picture. The DON stated Resident # 56 then alleged that LVN H took picture of his genitals without his permission. The DON could not recall if she had reported the incident to the Administrator. An attempt was made to interview LVN H. In an interview on 03/30/23 at 05:29 PM, the Interim ADM stated, Per our policy, the expectation is that all allegations of abuse that occur at the facility will be investigated and reported per the facility policy. Review of facility policy (dated 1/10/23) titled, Abuse/Reportable Events read in part, Reporting: Facility employees must report all allegations of: abuse, neglect . to facility administrator. The facility administrator will report the allegation to HHSC. Review of facility policy (dated 1/10/23) titled, Abuse/Reportable Events read in part, Investigation: Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect . will be investigated . The administrator will be responsible for investigating and reporting cases to the HHSC. At time of exit 3/30/23 at 5:45 PM the facility had not self-reported the incidents, nor had they investigated the incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 24 hours after the allegation was made for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation (Residents #47, and #56). The facility failed to timely report an allegation of resident abuse after the allegation was made to the administrator. This failure could affect all residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered. The findings included: Resident #47 Review of an undated face sheet revealed that Resident #47 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, high cholesterol, left-sided paralysis, contracture of left hand and shoulder, generalized muscle weakness, lack of coordination, vascular dementia (reduced blood flow to brain causing impaired memory and thinking), major depressive disorder, non-pressure ulcers of left lower leg and buttock, stage 2 pressure ulcer (unspecified site), difficulty swallowing, speech and language deficits after stroke, difficulty urinating, high blood pressure, hallucinations, and gastric reflux. Review of MDS assessment (dated 3/15/23) indicated that the resident had a BIMS score of 11 (indicating moderate cognitive impairment) and needed extensive assistance with ADLs. The resident required extensive assistance with all ADLS, had limited mobility of lower extremities and paralysis on one side. Resident #47 used a geri-chair for ambulation and was totally dependent for transfer and mobility. Review of Progress Note dated 2/20/23 written by SW G revealed that on 2/19/23 another resident (since transferred to a memory care unit) had accused Resident #47 of touching her on the breast inappropriately. Interview with Resident # 47 revealed he denied the allegation of inappropriate behavior. He stated he would not do that. In an interview on 03/30/23 at 03:59 PM SW G revealed the other resident was discharged to another facility prior to entry. The SW stated the other resident had cognition issues and behavior issues. The SW stated the two residents lived in two different halls. Interviewed revealed I can't find a report. I thought someone else had done the grievance report. Interview with the Social Worker revealed he could not recall if he reported the allegation to the Administrator or if the Administrator asked him to do interviews for the investigation. Review of grievance log on 3/29/23 revealed no evidence that this incident had been reported. Review of TULIP on 3/29/23 revealed no report related to this incident. In an interview on 03/30/23 at 04:59 PM the DON admitted that this incident had not been investigated nor reported to IHS. The DON stated she contacted the Administrator but he could not recall the incident and could not recall if he reported or investigated the incident. Resident #56 Review of an undated face sheet revealed that Resident #56 was a [AGE] year-old male diagnosed with infection of left lower limb, Type 2 diabetes, cirrhosis of the liver, psoriatic arthritis (autoimmune arthritis), urinary retention, acute kidney failure, unspecified arthritis, generalized muscle weakness, contracture of the left hand, cognitive communication deficit, psoriasis (autoimmune skin condition), hypothyroidism, major depressive disorder, anxiety disorder, peripheral neuropathy (nerve disease of limbs), gastric reflux, obesity, and deep vein thrombosis. Review of MDS assessment (dated 3/06/23) revealed that Resident #56 had a BIMS score of 15 (indicating resident was cognitively intact),and needed extensive assistance with ADLs. In an interview on 3/28/23 at 10:18 AM, Resident #56 said, [LVN H] took pictures of my privates without my permission. The DON tried to cover it up. Review of grievance log on 3/29/23 revealed no evidence that this incident had been reported. Review of TULIP on 3/29/23 revealed no report related to this incident. In an interview on 03/30/23 at 04:59 PM the DON admitted that this incident had not been investigated nor reported to HHSC. Interview with the DON revealed she talked to LVN H when she learned about the incident. The DON stated Resident #56 asked the LVN to take a picture of his genital area so he could see what was going on. Interview with the DON revealed the LVN followed the resident request, took the picture, showed the resident and then deleted the picture. The DON stated Resident # 56 then alleged that LVN H took picture of his genitals without his permission. The DON could not recall if she had reported the incident to the Administrator. An attempt was made to interview LVN H. In an interview on 03/30/23 at 05:29 PM, the Interim ADM stated, Per our policy, the expectation is that all allegations of abuse that occur at the facility will be investigated and reported per the facility policy. Review of facility policy (dated 1/10/23) titled, Abuse/Reportable Events read in part, Reporting: Facility employees must report all allegations of: abuse, neglect . to facility administrator. The facility administrator will report the allegation to HHSC. At time of exit 3/30/23 at 5:45 PM the facility had not self-reported the incidents, nor had they investigated the incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all alleged violations involving abuse and neglect were thoroughly investigated, and failed to report the results of all investigations to HHSC within 5 working days of the incident for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation Residents #47, and #56). The facility failed to properly investigate allegations of abuse or neglect for Residents #47, and #56. This failure could place residents at risk of allegations not being investigated. The findings included: Resident #47 Review of an undated face sheet revealed that Resident #47 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, high cholesterol, left-sided paralysis, contracture of left hand and shoulder, generalized muscle weakness, lack of coordination, vascular dementia (reduced blood flow to brain causing impaired memory and thinking), major depressive disorder, non-pressure ulcers of left lower leg and buttock, stage 2 pressure ulcer (unspecified site), difficulty swallowing, speech and language deficits after stroke, difficulty urinating, high blood pressure, hallucinations, and gastric reflux. Review of MDS assessment (dated 3/15/23) indicated that the resident had a BIMS score of 11 (indicating moderate cognitive impairment) and needed extensive assistance with ADLs. The resident required extensive assistance with all ADLS, had limited mobility of lower extremities and paralysis on one side. Resident #47 used a geri-chair for ambulation and was totally dependent for transfer and mobility. Review of Progress Note dated 2/20/23 written by SW G revealed that on 2/19/23 another resident (since transferred to a memory care unit) had accused Resident #47 of touching her on the breast inappropriately. In an interview on 03/30/23 at 03:59 PM SW G revealed the other resident was discharged to another facility prior to entry. The SW stated the other resident had cognition issues and behavior issues. The SW stated the two residents lived in two different halls. Interviewed revealed I can't find a report. I thought someone else had done the grievance report. Interview with the Social Worker revealed he could not recall if he reported the allegation to the Administrator or if the Administrator asked him to do interviews for the investigation. Review of grievance log on 3/29/23 revealed no evidence that this incident had been reported. Review of TULIP on 3/29/23 revealed no report related to this incident. In an interview on 03/30/23 at 04:59 PM the DON admitted that this incident had not been investigated nor reported to HHSC. The DON stated she contacted the Administrator but he could not recall the incident and could not recall if he reported or investigated the incident. Resident #56 Review of an undated face sheet revealed that Resident #56 was a [AGE] year-old male diagnosed with infection of left lower limb, Type 2 diabetes, cirrhosis of the liver, psoriatic arthritis (autoimmune arthritis), urinary retention, acute kidney failure, unspecified arthritis, generalized muscle weakness, contracture of the left hand, cognitive communication deficit, psoriasis (autoimmune skin condition), hypothyroidism, major depressive disorder, anxiety disorder, peripheral neuropathy (nerve disease of limbs), gastric reflux, obesity, and deep vein thrombosis. Review of MDS assessment (dated 3/06/23) revealed that Resident #56 had a BIMS score of 15 (indicating resident was cognitively intact),and needed extensive assistance with ADLs. In an interview on 3/28/23 at 10:18 AM, Resident #56 said, [LVN H] took pictures of my privates without my permission. The DON tried to cover it up. Review of grievance log on 3/29/23 revealed no evidence that this incident had been reported. Review of TULIP on 3/29/23 revealed no report related to this incident. In an interview on 03/30/23 at 04:59 PM the DON admitted that this incident had not been investigated nor reported to HHSC. Interview with the DON revealed she talked to LVN H when she learned about the incident. The DON stated Resident #56 asked the LVN to take a picture of his genital area so he could see what was going on. Interview with the DON revealed the LVN followed the resident request, took the picture, showed the resident and then deleted the picture. The DON stated Resident # 56 then alleged that LVN H took picture of his genitals without his permission. The DON could not recall if she had reported the incident to the Administrator. An attempt was made to interview LVN H. In an interview on 03/30/23 at 05:29 PM, the Interim ADM stated, Per our policy, the expectation is that all allegations of abuse that occur at the facility will be investigated and reported per the facility policy. Review of facility policy (dated 1/10/23) titled, Abuse/Reportable Events read in part, Reporting: Facility employees must report all allegations of: abuse, neglect . to facility administrator. The facility administrator will report the allegation to HHSC. Review of facility policy (dated 1/10/23) titled, Abuse/Reportable Events read in part, Investigation: Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect . will be investigated . The administrator will be responsible for investigating and reporting cases to the HHSC. At time of exit 3/30/23 at 5:45 PM the facility had not self-reported the incidents, nor had they investigated the incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Residents #26, #44 and #52) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #26's contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) in her legs and preference to stay in bed were care planned for Resident #26. 2. The facility failed to ensure Resident #44's lower extremities impairment was care planned for Resident #44. 3. The facility failed to ensure Resident #52's right side limited range of motion was care planned for Resident #52. These failures could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of Resident #26's face sheet dated 03/30/23 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Idiopathic normal pressure hydrocephalus (progressive neurologic condition), dysphagia (swallowing disorder), Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), contractures in left hip, right hip and right knee. Review of Resident #26's Annual MDS assessment dated [DATE] reflected Resident #26 had a BIMS of 15 indicating she was cognitively intact. Resident #26 required extensive assistance with ADLs of bed mobility and total dependence with transfers. Resident #26 had upper extremity on one side and lower extremity impairment on both sides. Review of Resident #26's quarterly MDS assessment dated [DATE] reflected Resident #26 had a BIMS of 15 indicating she was cognitively intact. Resident #26 required extensive assistance with ADLs of bed mobility. Resident #26 had upper extremity on one side and lower extremity impairment on both sides. Review of Resident #26's comprehensive care plan last revised on 02/28/23 reflected Resident #26 had an ADL self-care performance deficit related to weakness and limited mobility (Parkinson's). It did not reflect Resident #26's contractures and specific areas of limited range of motion. Observation and Interview on 03/30/23 at 12:43 PM with Resident # 26 revealed Resident #26 was lying in bed with both legs contractured. She stated she needed staff assistance in repositioning. Interview on 03/30/23 at 11:35 AM with PT K revealed Resident #26 had contractures in both legs. She stated Resident #26 was not able to move her left leg by self and needs assistance in moving her right leg. PT K stated Resident #26 prefered to stay in bed. Interview on 03/30/23 at 2:10 PM with LVN I revealed Resident #26 had contractures in both her legs and was dependent on staff for ADLs. She stated Resident #26 preferred to stay in bed. Interview on 03/30/23 at 2:57 PM with the MDS Coordinator revealed Resident #26 should have a care plan for the contractures and limited range of motion in both of her legs. She stated Resident #26's care plan about ADLs did not address her contractures. She stated Resident #26's care plan should address Resident #26's preference to stay in bed. 2. Review of Resident #44's face sheet dated 03/30/23 reflected Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinson's disease, heart failure, respiratory failure and fibromyalgia (disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues). Review of Resident #44's quarterly MDS assessment dated [DATE] reflected Resident #44 had a BIMS of 11 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs of bed mobility and transfers did not occur. Review of Resident #44's comprehensive care plan last revised 03/29/23 reflected Resident #44 had an ADL self care performance deficit related to mobid obesity. The care plan did not reflect Resident #44's limited range of motion in her legs. Observation on 03/28/23 at 10:34 AM revealed Resident #44 lying in bed on left side. Observation and Interview on 03/30/23 at 12:55 PM revealed Resident #44 lying in bed on left side. Resident #44 stated she did have limited range of motion in her legs. She stated she preferred lying on her left side and it was more comfortable for her. Interview on 03/30/23 at 11:25 AM with OT J revealed Resident #44 therapy assessed her quarterly but she declined therapy services. OT J stated Resident #44 preferred to stay in bed and liked to lie on her left side. Interview on 03/30/23 at 2:10 PM with LVN I revealed Resident #44 preferred to lay on her left side even when staff try to reposition her. She stated Resident #44 had limited range of motion in her legs. Interview on 03/30/23 at 3:10 PM with the MDS Coordinator revealed Resident #44 should have a care plan for her limited range of motion in her lower extremities. 3. Review of Resident #52's face sheet dated 03/30/23 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a nervous system disease that affects your brain and spinal cord), stroke, stiffness of right hand, elbow and shoulder. Review of Resident #52's quarterly MDS assessment dated [DATE] reflected Resident #52 had a BIMS of 14 indicating she was cognitively intact. Resident #52 required extensive assistance with ADLS of bed mobility. She had upper and lower extremities impairment on both sides in functional limitation of range of motion. Review of Resident #52's Comprehensive Care plan last revised 02/16/23 reflected Resident #52 had an ADL self care performance deficit and limited physical mobility related to multiple sclerosis. It did not specify the areas of limited range of motion and interventions to address limited range of motion. Review of Resident # 52's OT evaluation dated 03/16/23 reflected Resident #52 had diagnoses of pain in right elbow and shoulder, stiffness of right shoulder and right elbow and generalized muscle weakness. Observation and Interview on 03/28/23 at 10:57 AM with Resident # 52 revealed she was able to use her left hand but stated her right side including her right arm and hand she could not use due to having a stroke. Interview on 03/30/23 at 11:18 AM with OT J revealed Resident # 52 was currently on OT services. She stated she was working with Resident #52 with her limited range of motion in her left hand. She stated Resident #52 could not use her right hand or arm. Interview on 03/30/23 at 2:53 PM with the MDS Coordinator revealed Resident #52 should have a more specific care plan about her limited range of motion. She stated the ADL deficit addressed ADL care but did not address Resident #52's limited range of motion and interventions to address it. She stated she had been working at the facility about 5 weeks as the MDS coordinator. Interview on 03/30/23 at 4:44 PM with the DON revealed she expected resident compressive care plans to address residents' limited range of motion and contractures. Review of facility's policy Care Plan - Resident revised December 2017 reflected staff must develop a comprehensive care plan to meet the needs of the resident .4. Concerns and Problems a. Review CAA (Care Area Assessment) triggers on the MDS. If the interdisciplinary team decides to proceed with care planning, list the problem .b. Sources are, but are not limited to: .6. Rehabilitation problems 7. Behavior control problems .6. Approach/Plan .c. Individualize care to ensure the care plan is person centered for the unique needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #13, Resident #45, Resident #54) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #13 had his fingernails trimmed. 2- Resident #45 had his fingernails trimmed and cleaned. 3- Resident #54 had his fingernails cleaned This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #13's Quarterly MDS assessment dated [DATE] reflected Resident #13 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), muscle weakness, and lack of coordination. Resident #13 had a BIMS of 04 which indicated Resident #13 was severely impaired cognitively. He required extensive assistance of two-persons physical assistance with toilet use, and personal hygiene. Review of Resident #13's Comprehensive Care Plan, revised 11/23/22, reflected the following: Focus: Resident has an ADL self-care performance deficit. Goal: Resident will maintain current level of function through the review date. Interventions: Totally dependent on (1) staff. An observation and interview on 03/28/23 at 09:25 AM revealed Resident #13 was sitting in his wheelchair. The nails on both hands were approximately 0.5centimeter in length extending from the tip of his fingers. The middle fingernail, on both hands, were chipped. Resident #13 stated when they get very long, I break them. 2- Review of Resident #45's 5 days MDS assessment, dated 02/26/2023, reflected Resident #45 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included lack of coordination, type 2 diabetes mellitus, and muscle weakness. Resident #45 had a BIMS of 11 which indicated Resident #45 was moderately impaired cognitively. Resident#45 required limited assistance of one-person physical assistance with transfers, and personal hygiene. Review of Resident #45's Comprehensive Care Plan dated 02/21/23 reflected the following: Focus: resident#45 has an ADL self-care performance deficit related to blindness. Goal: the resident will maintain current level of function in ADLs through the review date. Interventions: Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation and interview on 03/28/23 at 10:51 AM revealed Resident #45 was laying in his bed. The nails on both hands were approximately 0.5cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #45 stated he did not know that his nails were dirty. 3- Review of Resident #54's Comprehensive MDS assessment, dated 03/08/2023, reflected Resident #54 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, rash, muscle weakness, and lack of coordination. Resident #54 had a BIMS of 06 which indicated Resident #54 was cognitively severely impaired. Resident#54 required limited assistance of one-person physical assistance with bed mobility, transfers, and personal hygiene. Review of Resident #54's Comprehensive Care Plan revised 03/29/23 reflected the following: Focus: resident#54 has an ADL self-care performance deficit r/t age, disease and debility. Goal: Resident #54 will maintain current level of function in ADLs through the review date. Interventions: the resident requires staff participation with ADLs. Observation and interview on 03/28/23 at 10:13 AM revealed Resident #54 was laying in his bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue, and the bed of the nails had dark brown colored residue. Resident #54 stated he scratched sometimes his bottom. Interview on 03/29/23 at 9:40 AM, CNA A stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA A stated she would clean and trim Resident #13's nails right then. CNA A stated she would talk to the nurse about Resident #45 and Resident #54 because they were diabetics. Interview on 03/29/23 at 9:45 AM, LVN B stated CNAs were responsible to clean and trim residents' nails during the showers. LVN B stated only nurses cut residents' nails if they were diabetic. LVN B stated no one notified her Resident #45 and Resident #54's nails were long and dirty, and she had not noticed the nails herself. LVN B stated Resident#45 and Resident#54 were diabetic she would clean and trim their nails. Interview on 03/30/23 at 2:04 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. DON stated she was responsible to do routine rounds for monitoring. Record review of the facility's policy titled Nail/Hand and Foot Care, dated December 2017, reflected It is the policy of this home to ensure residents receive nail care (hand and foot) in a safe manner. Precautions- 1. Nursing assistants will provide nail care to those residents requiring assistance . Procedure . 3. Hand and /or foot care: a. Perform hand and foot care after bath when possible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for t of six Residents (Resident #60 and #62) reviewed for medication administration errors. Facility failed to ensure the medications were administered per the physician orders for Resident #60 and #62. 28 medications were administered, two of the medications administered were late. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #60's Quarterly MDS assessment dated [DATE], revealed Resident #60 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including elevated blood pressure, muscle weakness, and dementia. Resident #60 had a BIMS of 12 which indicated Resident #60 was cognitively moderately impaired. A record review of Resident #60's physician's orders dated 3/29/23 revealed Resident #60 was to receive metoprolol tartrate tablet; 25 mg; oral Special Instructions: Give 0.5 tablet by mouth one time a day for hypertension Hold for SBP<105 or DBP<50 at 7:00 AM. A record review of Resident #60's medication administration record dated 3/29/23 revealed Resident #60 was to receive metoprolol tartrate tablet; 25 mg; oral Special Instructions: Give 0.5 tablet by mouth one time a day for hypertension Hold for SBP<105 or DBP<50 or HR<50 at 7:00 AM. During an observation on 3/29/23 at 8:09 AM revealed MA C checked blood pressure of Resident #60, the systolic blood pressure was 109, and the diastolic blood pressure was 70. MA C administered the following medications: loratadine 10 mg, cranberry 250 mg, famotidine 20 mg, vitamin B-1 100 mg, folic acid 1 mg, buspirone 10 mg, potassium 10 mg, tamsulosin 0.4 mg. MA C did not administer metoprolol tartrate tablet; 25 mg. A record review of Resident #62's Quarterly MDS assessment dated [DATE], revealed Resident #62 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, muscle weakness, and type 2 diabetes with diabetic neuropathy (numbness and pain from nerve damage, in the hands and feet). Resident #62 had a BIMS of 10 which indicated Resident #62 was cognitively moderately impaired. A record review of Resident #62's physician's orders dated 3/29/23 revealed Resident #62 was to receive gabapentin capsule; 300 mg; amt: 1 cap twice daily; oral Twice A Day 07:00 AM, 04:00 A record review of Resident #62's medication administration record dated 3/29/23 revealed Resident #62 was to receive gabapentin capsule; 300 mg; amt: 1 cap twice daily; oral Twice A Day 07:00, 16:00 (7:00 AM, 04:00 PM) During an observation on 3/29/23 at 8:18 AM revealed MA C administered the following medications to resident#62: Aspirin 81 mg, vitamin B-1 100 mg, citalopram 40 mg, esomeprazole 20 mg, topiramate 100 mg, fenofibrate 160 mg, metformin 1000 mg, and folic acid 1 mg. MA C did not administer gabapentin capsule; 300 mg. In an interview on 3/29/23 at 12:30 PM with MA C she stated she forgot to administer the metoprolol tartrate to resident #60 and gabapentin to resident # 62. MA C stated she would call the physician about the incident. MA C stated she was to follow the five rights of medications: right patient, right order, right time, right dose, and right route. MA C stated delay of medication could lead to the medication not being effective and if administered too close could cause negative side effects to residents. In an interview on 3/30/23 at 02:04 PM with the DON, she stated she expected the medications to be administered per the physician orders and for the staff to follow the five rights of medication administration. She stated medications were to be administered timely to prevent adverse effects like increased blood pressure and overdosing if the medications were administered to close. The DON stated MA C and MA D were to complete in-service and talk with the MA C regarding lateness in medication administration. 3/30/23 at 02:30 PM attempted to call the physician, a message was left. Record review of the facility policy revised December 2017, titled Medications Administering reflected, 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. 13. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to inform residents, their representatives, and families of those residing in the facility by 5 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 for one (Resident #1) of five residents reviewed for COVID-19 reporting. The facility failed to notify Resident #1's representative/family until 12/11/22 following a confirmed infection of COVID-19 on 12/09/22. This could place residents, their representatives, and families at risk of not being aware of the COVID-19 cases in the facility. Findings included: Record review of Resident #1's electronic medical record revealed an [AGE] year-old female with an admission date of 09/30/22. Resident #1 had a diagnosis of COVID-19. Record review of Resident #1 COVID-19 test result dated 12/09/22 revealed a positive result. Record review of Resident #1 late entry progress note dated 12/09/22 written by (Staff ID)revealed Resident #1 tested positive for COVID-19 via PCR test. Room change for contact isolation due to droplet precautions. Record review of Resident #1 progress note dated 12/11/22 written by (Staff ID) revealed Resident #1 family member visited and was notified on 12/11/22 of the residents COVID-19 infection which began on 12/09/22. Interview with Resident #1's family member on 12/20/22 at 10:40 AM, she stated she went to visit Resident #1 on 12/11/22 and was informed by a nurse (name unknown) that Resident #1 tested positive for COVID-19 on 12/09/22 and was moved into isolation. Interview on 12/21/22 at 8:20 AM with the Administrator revealed the Social Worker was responsible for contacting the resident's responsible party of a positive COVID-19 test result if the result was obtained during normal business hours however after hours it was the nurse assigned to the resident who was responsible to contact that resident's responsible party. Interview on 12/21/22 at 8:41 AM with the DON revealed the facility was experiencing a COVID-19 outbreak which started 11/28/22 when one staff member tested positive for COVID-19. On 12/04/22 the facility had residents who tested positive for COVID-19. As of 12/21/22 there were five residents who had tested positive for COVID-19. She stated everyone knew they had to notify the families by the next day of any initial COVID-19 infection in the building. The DON stated that LVN B was the nurse assigned to Resident #1 on 12/09/22 and was responsible for contacting Resident #1's responsible party of the COVID-19 positive result since the results were obtain after hours. Interview on 12/21/22 at 9:28 AM via telephone with LVN B revealed she was assigned to Resident #1 on 12/09/22 when the resident was identified as positive for COVID-19. LVN B stated it was her responsibility to contact a resident's family for a change in condition including a positive COVID-19 result. LVN B stated she could not remember if she had contacted Resident's #1's family member regarding the COVID-19 test result. LVN B stated the risk of not informing a resident's family member of change in condition could result in not keeping them informed appropriately. Record review of the facility's policy, titled Managing COVID-19 in your facility , dated May 2020, reflected .Caring for a resident with suspected/confirmed COVID-19 .Notify the .resident representative of suspected case .