**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 is fed by enteral means receives the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #32) reviewed for medication administration via a gastric tube. The facility failed to ensure Resident #32's gastric tube was flushed according to the physician's order and the facility's policy during resident's medication administration. This failure could place residents at risk of gastric tube clogging, which could have required the resident to repeat an unnecessary invasive procedure (gastric tube replacement). Findings include: Record review of Resident #32's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of stroke, dysfunction of bladder, dysphagia (swallowing difficulties), gastrostomy (stomach tube), and heart failure. Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident #32's Care Plan, reflected a Focus area was initiated on 5/14/20 and revised on 11/15/24 for risk for malnutrition related to dysphagia and receives nutrition and hydration by PEG tube with interventions including: Provide liquids as ordered. Provide medications per tube as ordered. Flush tube with 30 cc of water before and after medications. Record review of Resident #32's Orders, reflected the following: 12/08/23 order NPO diet Tube Feeding texture, for meals. 1/3/24 order Flush G tube with 30 cc before and after medications. 7/13/23 order for Free water 150 cc QID per peg Record review of Resident #32's December Medication Administration Record reflected the following: 1/4/24 order for Flush G tube with 30 cc before and after medications signed off (indicating done) by RN-A on 12/30/24 night shift when medication observations were done at 10:11 PM. 3/28/24 order allowing medications to be crushed and combined into a cocktail was also signed off on 12/30/24 night shift by RN-A Observation on 12/30/24 at 10:11 PM revealed RN-A at bedside of Resident #32 after she had crushed and dissolved the resident's medications according to orders. RN-A checked the residual and only 1-2 cc was found. Placement was verified with air according to orders. No water flush was observed at this step prior to medications. Medications previously crushed and dissolved were placed in gastric tube and gravity flow was good and medications completely emptied from the tube. 150 cc of water flush was run through the feeding pump after the medications were completed to flush the tube. Medication administration completed at 10:17 PM. Observed electronic monitoring device (camera) in place on resident. In an interview on 12/30/24 at 9:18 AM with Resident #32's family member he stated, RN-A did not do pre-flushes when giving medications into the gastric tube per their electronic monitoring in September and they complained to the DON. He stated the DON said she addressed the concern with the nurse. In an interview on 12/30/24 at 10:17 PM RN-A stated, she used the feeding pump to flush 150 cc of water into the G tube after the medications. In an interview on 12/31/24 with LVN -A at 11:40 AM he stated, prior to each medication administration he flushes the Gtube with water then also flushes it after the medications are completed. He stated this was done to prevent the tube from becoming clogged which could result in a tube replacement if clogged. He also checked residual and verified placement as ordered and said medications are mixed as a cocktail. In an interview on 12/31/24 at 11:45 AM with DON she stated, the orders to flush the G-tube prior to each medication and after applies to each medication pass and not just per shift. She stated that prior to each medication cocktail administration they should flush the G tube with water then also flush it after the medications are complete. She stated this was done to prevent the tube from becoming clogged which could result in a tube replacement if clogged. She also stated the family requested the medications be mixed as a cocktail instead of done one medication at a time. In an interview on 12/31/24 at 4:15 PM with LVN-B she stated, when giving medications in a G tube the process is to check residual and verify placement by auscultation (air and listening), flush 30 cc of water before and after medications if order allows a medication cocktail. She stated the flush was important to prevent the tube from clogging and to make sure hydration clears the tube. LVN-B stated if flushing was not done the resident could need the G tube replaced. She stated this could cause the resident to miss food, hydration, and medications. In a second interview on 12/31/24 at 4:37 PM with DON she stated, when giving medications in a G tube it was important to follow the amount of water ordered for the flush before and after medications. She stated the flush is important to prevent clogging of the G tube. DON stated a clogged G tube could have to be replaced. A record review of Facility September 2024 Grievance Log reflected a grievance filed and resolved on 9/9/24 that a nurse did not flush the gastric tube with medication administration. A record review on 12/31/24 of the undated facility policy titled, -Administering Medications-Enteral Tube reflected the following: 10. Insert the feeding syringe in the enteral tube and flush tube with 15 cc air bolus . 11. Pull plunger back to check for residual. If less than 100 cc return content to stomach. Flush tube with 30 cc of water. 12. Administer medication 13. Flush enteral tube with 30 cc of water after all medications are administered.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's, to meet the needs of each resident for 1 of 1 medication storage rooms. The facility failed to ensure that expired medication administration supplies were removed from 1 of 1 medication storage rooms. This failure could place residents at risk for ineffective treatments and unnecessary invasive procedures. Use of these expired supplies and medications would not meet acceptable standards of medical practice and could cause a Central Line Catheter to need replacement due to dislodgement or infection. Findings included: Observation on 12/30/24 at 4:49 PM of the Medication Storage Room located by the nurse's station revealed the following: 3 IMED Dressing Change Kits (Item number IM46023) expired 1-17-2024. In an interview on 12/31/24 at 4:15 PM with LVN-B she stated, the policy on expired medical supplies was to destroy them or give them to the DON and everyone who goes in the room was responsible for checking the medication room. She stated the negative outcome to residents if expired items are used is that residents can have a reaction, or the supplies could begin to breakdown. In an interview on 12/31/24 at 4:22 PM with ADM he stated, the policy on expired sterile medical supplies was they should be pulled and disposed of. He stated the nurses are responsible for checking the medication room and the negative outcome to residents if expired items are used was that medications can lose efficacy. In an interview on 12/31/24 at 4:37 PM with DON she stated, the policy on expired medical supplies is they should be thrown away and that the nurses are responsible for checking the medication room. DON stated the negative outcome to residents if expired items are used was that residents could potentially get sick or an infection. She stated the supplies would not be as effective. Record review of the facility undated policy titled -Proper Storage of Discontinued or Expired Medications reflected, when a medication is changed or expires, the medication was to be removed (no specific policy on expired supplies.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 1 laundry. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings included: Observation on 12/31/24 at 01:22 PM of the laundry revealed a well separated clean side and dirty side of the laundry. Two shelves of clean linens were located on the right side designated to be the dirty side. The first was a covered shelf located near the door used to bring dirty laundry inside. The shelf had clean blankets and linens. Multiple used house cleaning carts were located next to the shelf in the same room. The second shelf with neatly folded and stacked clean linens, gowns, and sheets was also located on the designated dirty side of the laundry room within a few feet of the housekeeping carts. The 2nd shelf was completely open with no cover. In an interview on 12/31/24 at 13:22 PM with LA, he stated they had extra clean linen stock, so they organized it on the shelves. He stated that he did not know it should not be located on the dirty side, but they could move the shelves. In an interview on 12/31/24 at 4:00 PM with LS he stated, the policy for storing clean and dirty laundry in the laundry room is to stack and cover clean laundry. If too much linen, then store on the left, dryer side of the laundry (clean side). He stated it is important to keep clean and dirty laundry separated because it can become cross-contaminated if together. If it is together then the clean must be rewashed. He also stated the negative outcome to residents if the clean is not kept separated is that the laundry may have a smell or have something on it. It would not be clean then, so that is not good, and it can make residents sick if they get other patients' sicknesses. In an interview on 12/31/24 at 4:15 PM with LVN-B she stated, clean and dirty laundry is kept separated to prevent cross-contamination. She stated the negative outcome to residents if linen is contaminated is that it could spread contamination/germs to patients and expose them to infections. In an interview on 12/31/24 at 4:22 PM with ADM he stated, the policy on storing clean and dirty laundry is store dirty on one side and then after washed it goes to the clean side and is distributed. He said it is important to keep separated to prevent cross-contamination. He further stated the negative outcome to residents if laundry is not kept separated is it could spread contamination to other residents. He said viruses, like Covid for example, can live and spread like that. ADM stated that they already started moving the clean linen out of the dirty side of the laundry. In an interview on 12/31/24 at 4:37 PM with DON she stated clean and dirty laundry is kept separated and that it is important to separate to prevent cross-contamination. She stated the negative outcome to residents if it is contaminated is that it could potentially spread infections. On 12/31/24 a Record review of the facility's undated policy titled Linens reflected the following: All clean linen will be stored in a secured area. The linen cart will be covered. Clean and soiled linens will be stored in separate areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure menus were followed for all residents for 2 of 3 meals observed. The facility failed to follow the posted cycle menus for two lunch services served at the facility on Sunday, 12/29/24 and Tuesday, 12/31/24. These failures could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss. The findings included: Record review of Resident # 34's admission face sheet undated reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of neurocognitive disorder with Lewy bodies (a progressive disease that causes a decline in thinking abilities). Record review of Resident # 34's quarterly MDS dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. Record review of Resident # 34's care plan dated 05/24/2019 and revised on 06/11/2024 reflected problem of nutrition: at risk for/HX of weight changes and malnutrition: resident has a lipoprotein metabolism disorder (a disorder of lipoprotein overproduction or deficiency that results in elevation of total cholesterol); resident is at risk for metabolic acidosis (accumulation of too much acid in the body). Interventions include observe meal intake, record, and offer alternative if eats less than 50% of meal. Offer preferences when available. Provide regular diet with regular texture as ordered with thin liquids. Record review of Resident # 122's admission face sheet undated reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of 4-part fracture of the surgical neck of the right humerus (upper portion of the leg bone by the hip joint), subsequent encounter for fracture with routine healing. Record review of Resident # 122's comprehensive MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident # 122's care plan dated 12/16/2024 and revised on 12/27/2024 reflected problem of nutrition: resident at risk for/HX of weight changes, dehydration, and malnutrition related to poor dentation/chewing problems. Interventions include observe meal intake, record, and offer alternative if eats less than 50% of meal. Provide regular diet with food cut in bite size pieces as ordered with regular thin liquids. Record review of Resident # 220's admission face sheet undated reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of encounter for surgical aftercare following surgery on the digestive system. Record review of Resident # 220's nursing home and swing bed tracking MDS dated [DATE] reflected a BIMS score was not documented as a comprehensive MDS had not been completed and uploaded. Record review of Resident # 220's care plan dated 12/11/2024 and revised on 12/27/2024 reflected problem of nutrition: resident at risk for/ HX of weight changes, dehydration, and malnutrition related to dysphagia (problem swallowing foods or liquids). Interventions include observe meal intake, record, and offer alternative if eats less than 50% of meal. Provide regular pureed texture diet as ordered with thin liquids. Offer preferences when available. Observation on 12/29/24 at 9:23 AM revealed a 4-week cycle menu posted in the dining room with week 2 Sunday lunch meal consisting of roast turkey, cheesy squash casserole, crumb topped brussels sprouts, fruit cobbler, and beverage. The week 2 Tuesday lunch meal consisted of smothered pork, corn casserole, country green beans with bacon and onion, pineapple upside down cake, and beverage. Observation on 12/29/24 at 12:06 PM of dining room lunch meal trays being served consisting of roast turkey, cubed butternut squash, steamed plain brussels sprouts, fruit cobbler, and beverage. Observation on 12/29/24 at 12:40 PM of dining room lunch meal service revealed multiple meal trays left on tables with butternut squash still on tray and hearing multiple residents discuss amongst themselves how the squash was too hard to eat. Observation/Interview on 12/29/2024 at 1:06 PM revealed Resident # 34 finishing her lunch tray stated lunch was ok, but the squash was not cooked to be soft enough to eat. Observation on 12/31/24 at 10:30 AM of kitchen staff preparing lunch meal items consisting of BBQ pork ribs, creamed corn, black-eyed peas, cornbread, pound cake, and beverage. Observation on 12/31/24 at 10:32 AM of kitchen posting of 4-week cycle menu with week 2 Sunday lunch meal consisting of roast turkey, cheesy squash casserole, crumb topped brussels sprouts, fruit cobbler, and beverage. The week 2 Tuesday lunch meal consisted of smothered pork, corn casserole, country green beans with bacon and onion, pineapple upside down cake, and beverage. Observation on 12/31/24 at 12:30 PM of dining room lunch meal trays being served consisting of BBQ pork ribs, creamed corn, black-eyed peas, cornbread, plain pound cake, and beverage. Observation on 12/31/24 at 12:45 PM of dining room lunch meal service with residents eating the BBQ pork ribs. Observation on 12/31/24 at 4:55 PM of posted menus revealed sitting in a dining room chair 3 feet away from menus the menus are not large enough print to be able to read. Standing in the dining room [ROOM NUMBER] feet away from menus the menus are not large enough print to be able to read. In an interview on 12/29/2024 at 2:30 PM revealed Resident # 122 In an interview on 12/31/2024 at 12:48 PM with Resident # 220 In an interview with DM on 12/31/24 at 4:00 PM revealed the DM stated when menu substitutions are made it is noted on the QAPI meeting minutes. DM stated the exact items substituted are not documented just the number of times the menus were changed in the past month. DM stated the facility sometimes must make menu changes due to not receiving a product in or if it is resident preference with not liking a certain food that is on the cycle menus. DM stated the cycle menus posted will not always match the daily menu posted if she has had to make any substitutions and that is why she posts the daily menu. DM stated as for why the cheesy squash posted on the daily menu for Sunday week 2 was not the item served that the residents were still served squash just a different type. DM stated as for why the smothered pork posted on the daily menu for Tuesday week 2 was not the item served that the residents received smothered BBQ pork ribs, so the item was in fact smothered pork. DM stated the facility does not use a substitution log to document any menu substitutions. In an interview with DON on 12/31/24 at 5:16 PM revealed the DON stated their expectation concerning the kitchen staff following the menus would be that the kitchen staff would follow the menus and let staff and residents know if menu changes were required and to offer the residents an alternate of the same nutritive value. DON stated they expected the cycle menus and the daily menus to match therefore there would not be any resident confusion. DON stated by not following menus this could negatively affect residents by them not eating and maintaining good health status. In an interview with ADM on 12/31/24 at 5:21 PM revealed the ADM stated their expectation concerning the kitchen staff following menus would be that kitchen staff would follow the menus and follow the company policies and procedures pertaining to menus. ADM stated by not following menus this could negatively affect the resident's nutritional status by being compromised. ADM stated the DM is responsible for ensuring menus are followed. Record review of Menus policy undated reflected under heading purpose: Menus will be prepared in advance, be nourishing, palatable, well-balanced, and will meet the daily nutritional and special dietary needs of the residents. Under heading procedures: 1. The dietitian will approve all menus. 2. The resident council will be included in menu planning. 3. If any meal served varies from the planned menu, the change and the reason for the change will be noted on the posted menu in the kitchen and/or in the record used solely for recording such changes. 4. Menus will provide a variety of foods and indicate standard portions at each meal. Menus will be varied for the same day of consecutive weeks. When a cycle menu is used, the cycle will be of no less than three (3) weeks duration and revised quarterly. Menus will be adjusted to include seasonal foods. 5. Menus will be prepared in advance. 6. Menus will be reasonably planned with consideration of the religious, cultural, and ethnic background and food habits/preferences of residents and resident groups. 7. A copy of the menu (as served) will be kept on file for at least 180 days. 8. A copy of menus will be posted in at least one (l) resident area and will be posted low enough and in print large enough for residents to read them. 9. Menus will reflect the religious, cultural, and ethnic needs of the current resident population as determined via the resident's preferences and resident group input. Record review of Food Substitutions policy undated reflected under heading purpose: Food substitutions will be made as appropriate or necessary. Under heading procedure: 1. The dietary manager may make food substitutions as appropriate or necessary. 2. An exchange list identifying the seven (7) exchanges of food groups is posted in the dietary manager's office. 3. The dietary manager will consult the dietitian as necessary prior to making a substitution. 4. Residents' likes and dislikes are considered when making substitutions. 5. All substitutions are noted on the menu and filed in accordance with established dietary policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The kitchen test tray of the lunch meal foods was unappealing and lacked flavor. The kitchen test tray lacked condiments and the dessert of pound cake was unappealing and very dry. There was no garnishment on any foods or meal tray. 2. The lunch meal tray on 12/31/24 for Resident # 220 who has an order for a pureed diet consisted of a packaged plastic ware utensils with one salt and one pepper packet, a glass full of ice and ¼ full of water as the beverage, a scoop of pureed BBQ brisket, a scoop of pureed creamed corn, a scoop of pureed black-eyed peas, and a container of packaged applesauce. There was no gravy or sauce present on any of the food items and no garnishment present on the meal tray. 3. The lunch meal served on Sunday 12/29/2024 consisting of cubed butternut squash was complained of by 2 residents (Resident # 34 and Resident # 122) of being not cooked properly and too hard to be able to eat. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Record review of Resident # 34's admission face sheet undated reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of neurocognitive disorder with Lewy bodies (a progressive disease that causes a decline in thinking abilities). Record review of Resident # 34's quarterly MDS dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. Record review of Resident # 34's care plan dated 05/24/2019 and revised on 06/11/2024 reflected problem of nutrition: at risk for/HX of weight changes and malnutrition: resident has a lipoprotein metabolism disorder (a disorder of lipoprotein overproduction or deficiency that results in elevation of total cholesterol); resident is at risk for metabolic acidosis (accumulation of too much acid in the body). Interventions include observe meal intake, record, and offer alternative if eats less than 50% of meal. Offer preferences when available. Provide regular diet with regular texture as ordered with thin liquids. Record review of Resident # 122's admission face sheet undated reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of 4-part fracture of the surgical neck of the right humerus (upper portion of the leg bone by the hip joint), subsequent encounter for fracture with routine healing. Record review of Resident # 122's comprehensive MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident # 122's care plan dated 12/16/2024 and revised on 12/27/2024 reflected problem of nutrition: resident at risk for/HX of weight changes, dehydration, and malnutrition related to poor dentation/chewing problems. Interventions include observe meal intake, record, and offer alternative if eats less than 50% of meal. Provide regular diet with food cut in bite size pieces as ordered with regular thin liquids. Record review of Resident # 220's admission face sheet undated reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of encounter for surgical aftercare following surgery on the digestive system. Record review of Resident # 220's nursing home and swing bed tracking MDS dated [DATE] reflected a BIMS score was not documented as a comprehensive MDS had not been completed and uploaded. Record review of Resident # 220's care plan dated 12/11/2024 and revised on 12/27/2024 reflected problem of nutrition: resident at risk for/ HX of weight changes, dehydration, and malnutrition related to dysphagia (difficulty swallowing food and drinks). Interventions include observe meal intake, record, and offer alternative if eats less than 50% of meal. Provide regular pureed texture diet as ordered with thin liquids. Offer preferences when available. Observation /Interview on 12/31/2024 at 12:48 PM with Resident # 220 revealed observation of resident lunch meal tray had scoop of pureed BBQ brisket, scoop of pureed creamed corn, scoop of pureed black-eyed peas, container of applesauce, packaged plastic ware utensils, 1 packet of salt and pepper, and glass of ice water filled with ice and 1/4 full of water. Further observation revealed no gravy or sauce on any of the food items and no garnishment on the meal tray. Interview with resident revealed resident stated the food is not good it does not taste good and is normally cold and therefore I don't eat much. Resident stated they are still on a pureed diet, but the food in general is just unappealing. Resident stated breakfast is the best meal, but the portion sizes have been cut down. Resident stated this morning's breakfast consisted of oatmeal, sausage, and orange juice and that is it. Resident stated the trays never have condiments and you always must request to get any condiments. Resident stated the food is always cold but is slowly improving now that her meals are served with a heated tray that the plate sits on. Resident stated the lunch meal is lukewarm. Resident stated the dinner meal on 12/30/24 was very cold and the heated tray was not under her plate. Observation on 12/31/2024 at 1:00 PM of the lunch meal test tray revealed the tray consisted of smothered pork ribs, black eyed peas, creamed corn, pound cake, and grape Kool-Aid, with no condiments present on the tray, and no garnishment on tray. Temperatures were adequate. The test tray lacked flavor, and the pound cake very dry and unappealing. It needed sauce or whipped topping for palatability. Interview on 12/29/2024 at 1:06 PM revealed Resident # 34 stated lunch was ok, but the squash was not cooked to be soft enough to eat. Interview on 12/29/2024 at 2:30 PM revealed Resident # 122 said the food is ok. Resident # 122 stated the food is frequently served cold and that the squash served at lunch today was too hard to eat. Interview on 12/31/2024 at 4:00 PM with DM revealed DM stated all food items are to be prepared and presented to the residents in an appealing and appetizing manner. DM stated if a resident complains of food being served cold then the resident is given a hot warmer plate with all their meals to ensure the proper temperatures are maintained for the meal to be appealing. DM states paper goods and plastic ware are only used when the dish machine is down or if there are issues like a power outage. DM stated the facility has a variety of condiments available and that the appropriate condiments are put on the meal trays for each meal service such as salad dressings when a dinner salad is served or mustard and mayonnaise for a sandwich or burger and that if resident is requesting a different condiment, they are always available. DM stated they were unaware of residents complaining that the squash was too hard to eat and that they would be speaking with the cook about cooking that type of squash longer in the future. DM states the cooks taste test the food prior to serving the meal. Record review of Food Service policy undated reflected under heading purpose: Meet the nutritional needs of each resident. Provide a well-balanced, flavorful, visually appealing, and varied food service program. Under heading procedure: 5. Meals will be prepared in a way that is visually appealing and should include a garnishment. Record review of grievance report form dated 12/29/2024 reflected Resident # 220 had completed a grievance form in reference to meals being served cold when they are delivered. The resolution was for the resident to receive a hot warmer plate moving forward with all three meals. The complaint was resolved by the DM on 12/30/2024.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the ice machine in the nourishment room, cleaning the juice machine dispenser, cleaning the can opener from buildup, cleaning the inside of the microwave, leaving dirty mop water in the mop bucket in the chemical storage closet, ensuring the dish machine sanitizer levels are within the required range, storing the ice scoop in the nourishment room in an ice scoop receptacle that was free from standing water accumulation, ensuring staff utilize hair restraints while in the kitchen, ensuring trash receptacles in the kitchen had lids secured covering contents, ensuring food items are not being stored on the floor, cleaning the range cook top drip pans of food debris, ensuring hand wash sinks have paper towels available and are only being used for handwashing) 2. The facility failed to ensure equipment temperature logs were being completed. 3. The facility failed to ensure all items were covered and stored properly. 4. The facility failed to label and date all food items in the kitchen. 5. Dented can of mandarin oranges in the dry storage area stored with all the other cans of fruit. These failures could place residents at risk of foodborne illness. Findings included: Observation on 12/29/2024 at 9:24 AM of kitchen hand wash sink near kitchen entrance door from dining room revealed to be out of paper towels to dry hands as hand hygiene. Observation on 12/29/2024 at 9:26 AM of front stand-alone refrigerator near kitchen entrance door from dining room revealed 2 sandwiches saran wrapped unlabeled and undated, a tub of drinks including what appeared to be apple juice, orange juice, and milk uncovered, unlabeled, and undated, a gallon pitcher of what appeared to be tea unlabeled and undated. Observation on 12/29/2024 at 9:28 AM of kitchen juice dispenser machine revealed orange and red sticky buildup on underside of dispenser near dispenser nozzles. Observation on 12/29/2024 at 9:32 AM of kitchen table mounted can opener revealed black and brown buildup on inside of can opener. Observation on 12/29/2024 at 9:32 AM of back kitchen prep area of 2 55-gallon trash cans without lids secured and trash debris inside. Observation on 12/29/2024 at 9:33 AM of kitchen microwave revealed inside of microwave to be dirty on all surfaces and inside wall to be rusty with paint peeling off. Observation on 12/29/2024 at 9:34 AM of kitchen chemical storage closet revealed a rolling mop bucket of dirty mop water with the mop stored inside of the bucket. Observation on 12/29/2024 at 9: 38 AM of kitchen equipment temperature logs revealed temperature logs were not completed on refrigerators and freezers for (October 26,27,28,29,30,31 November 27,28,29,30 December 26, 27,28). Observation on 12/29/2024 at 9:43 AM of kitchen back stand-alone refrigerator revealed a package of processed American cheese slices wrapped in saran wrap unlabeled and undated, a half of a red onion wrapped in saran wrap unlabeled and undated. Observation on 12/29/2024 at 9:46 AM of kitchen dry storage area revealed a dented can of mandarin oranges dated 12/13 stored stacked on a shelf with all the other canned fruit products, a gallon bag of fruit rings cereal unlabeled and undated, a gallon bag of cheerios cereal unlabeled and undated, a gallon bag of raisin bran cereal unlabeled and undated, a gallon bag of puffed rice cereal unlabeled and undated, a gallon bag of frosted flakes cereal unlabeled and undated, a storage tote of brown sugar with lid unsecured unlabeled and undated, an opened bag of gravy mix wrapped with saran wrap unlabeled and undated, and a box of orange juice base stored on the floor. Observation on 12/29/2024 at 9:52 AM of kitchen cooktop range drip pans revealed drip pans to have spilled dried food debris on them. Observation on 12/29/2024 at 9:52 AM of shelving in front of kitchen with dishes stored on it and on top shelf a tray of individual cereal bowls prepared with different types of dry cereal with each bowl individually wrapped with saran wrap unlabeled and undated. Observation of box of white assorted plastic cutlery on floor underneath shelving. Observation on 12/29/2024 at 10:00 AM of dish machine cycle revealed dish machine not to have proper sanitizer levels running in machine. Sanitizer levels undetectable during dish machine cycle. Observation on 12/29/2024 at 1:49 PM of back of kitchen hand wash sink revealed dried brown liquid staining appearing to be tea in bottom of sink. Hand wash sink is located near beverage preparation area. Observation on 12/29/2024 at 1:50 PM of [NAME] C with beard guard down under chin with exposed facial hair while running dish machine. Observation on 12/30/2024 at 9:00 AM of [NAME] D with beard guard down under chin with exposed facial hair while wiping down prep table. When [NAME] D saw surveyor [NAME] D put beard guard on correctly to cover all facial hair. Observation on 12/30/2024 at 9:06 Am of [NAME] C with beard guard down under chin with exposed facial hair putting up delivery of grocery items in refrigerators located in back part of kitchen. Observation on 12/30/2024 at 9:12 AM of DA washing emptying meal carts of dirty dishes with beard guard down under chin with exposed facial hair. When DA saw surveyor DA put beard guard on correctly. Observation on 12/30/2024 at 10:20 AM of [NAME] C with beard guard down below mustache while in kitchen. Observation on 12/30/2024 at 11:18 AM of [NAME] D making pureed lunch items with beard guard underneath chin with exposed facial hair. When [NAME] D saw surveyor watching [NAME] D stop applied beard guard correctly and performed hand hygiene before going back to finish the pureed meal items. Observation on 12/30/2024 at 9:08 AM of kitchen prep area near dish machine and 3 compartment sink revealed 55-gallon trash can without lid secured with trash debris inside. Observation on 12/30/2024 at 10:24 AM of kitchen prep area near dish machine and 3 compartment sink revealed 55-gallon trash can without lid secured with trash debris inside with trash can lid propped against wall beside 3 compartment sinks. Observation on 12/30/2024 at 7:44 PM of nourishment room ice scoop receptacle with standing water in bottom of ice scoop holder. Observation of nourishment room ice machine revealed inside lid of ice machine to have black and brown mold appearing substance coating inside of door and around door seals. Observation on 12/31/2024 at 10:02 AM of back kitchen prep area revealed a 55-gallon trash can without lid secured with trash debris inside. Observation on 12/31/2024 at 10:20 AM of [NAME] C with beard guard down below mustache while in kitchen. Observation on 12/31/2024 at 12:20 PM of DA in kitchen passing completed lunch meal trays to nursing staff for residents with beard guard down under chin exposing facial hair. Interview on 12/29/2024 at 10:05 AM with DM revealed DM stated they would be contacting the dish machine chemical provider to come out and service the dish machine and address the sanitizer level problem. DM stated until the sanitizer problem could be fixed the facility would be using their dish machine for washing and then using their 3-compartment sink for running all dishes thru the sanitizer. Interview on 12/31/2024 at 10:15 AM with [NAME] D revealed [NAME] D stated the facility hair restraint policy is to keep all hair and beards covered while in the kitchen. [NAME] D stated sometimes he forgot to pull his beard guard up to cover his facial hair. Interview on 12/31/2024 at 10:20 AM with DA revealed DA stated the facility hair restraint policy is for all hair to be covered with a hair net and all facial hair to be covered with a beard guard. Interview on 12/31/2024 at 4:00 PM with DM revealed DM stated their expectations concerning hair restraints was that they expected all hair to be covered including facial hair. DM stated everyone entering the kitchen including delivery staff are asked to wear a hair net and beard guard if they have facial hair. DM stated beard guards are to be worn above the lip directly under the nose and extend down under the chin to provide full facial hair coverage. DM stated if hair restraints are not properly worn then it could negatively affect residents by cross contamination. DM stated their expectations concerning labeling and dating of food items was very high and that all products will be dated upon receipt when opened or prepared with a preparation date and a discard date. DM stated if proper labeling and dating practices were not occurring this could negatively affect the residents by residents receiving expired or spoiled food products or food products, they have allergies to. DM stated concerning equipment temperature logs being completed they had high expectations of these logs being completed twice daily. DM stated if equipment temperature logs are not completed it could negatively affect residents by residents receiving spoiled food and possibly food borne illness. Interview on 12/31/2024 at 4:34 PM with [NAME] C revealed [NAME] C stated the hair restraint policy for the facility is that all hair is to be covered while in the kitchen and dining room with a hairnet and a beard guard for staff who have facial hair. Interview on 12/31/2024 at 5:16 PM with DON revealed DON stated their expectation concerning hair restraint for the kitchen is that they expect all staff entering the kitchen to wear hair restraints and beard guards if they have facial hair. DON stated if hair restraints are not worn this could negatively affect residents by having hair in their food. DON stated their expectation concerning labeling and dating of food products is that the kitchen follows the facility policies and if food labeling and dating policies are not followed this could negatively affect residents by residents receiving expired food or food borne illness. Interview on 12/31/2024 at 5:21 PM with ADM revealed ADM stated their expectations concerning hair restraint is that they expect all staff to follow the facility policy and have their hair restrained including facial hair. ADM stated if hair is not restrained this could negatively affect residents by cross contamination and infection control. ADM stated their expectation concerning labeling and dating of food items is that the kitchen staff follow the facility policies concerning labeling and dating. ADM stated if labeling and dating practices are not followed this could negatively affect residents by diminished taste, spoiled food, and diminished health status. ADM stated their expectation concerning kitchen cleaning and general sanitation is that the kitchen follow company policies for cleaning and general sanitation. ADM stated if the policy for cleaning and general kitchen sanitation is not followed this could negatively affect residents by diminished health status and possible food borne illness. Record review of Dry Storage and Supplies policy undated reflected under heading policy: All facility storage areas will be maintained in an orderly manner that preserves the condition of food supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Under heading procedure: 1.b. All food and supplies are to be stored six (6) inches above the floor on surfaces which facilitate thorough cleaning. 3. Dry bulk foods (flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Scoops should not be left in food containers or bins. Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record review of Storage of Food in Refrigeration policy undated reflected under heading procedure: 6. All containers must be labeled with the contents and date food item was placed in storage. Record review of Hair Net policy undated reflected under heading procedure: It is MANDATORY that all dietary staff wear hairnets while on duty in any food preparation area while in facility. Any person with a beard must wear a beard net. Bald persons are excluded from wearing hairnets and clean-shaven persons are excluded from wearing beard guards. Record review of Cleaning policy undated reflected under heading procedure: 2. Surfaces must be cleaned with a sanitizing agent/solution. Chlorine, iodine or quaternary ammonium compounds are approved sanitizing agents. 3. All food surfaces will be cleaned at the end of each food preparation session.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect one (Residents #1) of one of one reviewed, from verbal abuse, in that: The facility failed to ensure Resident #1 was not verbally abused by CNA A. This failure could place residents at risk of fear, depression, intimidation, and a diminished quality of life due to verbal abuse. Findings included: Review of the face sheet, undated, for Resident #1 reflected a [AGE] year-old female initial admission date of [DATE] and readmission date of [DATE] with diagnoses of hepatic encephalopathy (liver does not filter toxins as it should) cirrhosis of liver (severe scarring of the liver) end stage renal disease, and diabetes. Resident #1 discharged from the facility on [DATE] to an acute care facility and is deceased . Review of the quarterly minimum data set (MDS) for Resident #1 dated [DATE] reflected a brief interview for mental status (BIMS) was not conducted. Review of Section I Active Diagnoses revealed medically complex condition. Review of the care plan dated [DATE] reflected Resident #1 was at risk for decreased socialization and altered mood related to diagnosis of depression, disinterest in current activity, impaired cognition, signs and symptoms of depression with interventions to approach Resident #1 in calm manner, introduce self and explain procedure/care to be provided, provide positive interaction with resident, and provide validation of feelings by restating concerns and feelings and encourage Resident #1 to focus on the positive, and encourage and allow resident to verbalize needs and concerns. In an Interview with the a family member of Resident #1 on [DATE] at 2:55 pm she revealed, Resident #1 called her after the incident on [DATE] and was crying. Resident #1 told the family member she was crying because people did not want to help her. The family member had an audio and video recorder in Resident #1's room. The family member did not provide the recording . The family member revealed she could not see CNA A in the bathroom with her mother (CNA A was on the camera when her mother came out of the bathroom). The family member revealed she heard CNA A tell her mother, in an ugly tone, can you not do anything for yourself? Come on, shit. The family member said CNA A could have been more kind and CNA A upset Resident #1 enough for Resident #1 to call her crying. The family member revealed CNA A did not respect Resident #1's rights when she spoke to her in a discouraging manner. In an interview with CNA A on [DATE] at 11:00 am she revealed she did not know that Resident #1 had declined so much since the last time she assisted Resident #1. She revealed she answered Resident #1's call light on [DATE] and when Resident #1 said she needed help getting on the toilet she said to Resident #1, you are going to have to do more for yourself. She revealed she was trying to encourage Resident #1 but said she could have used different words and did not mean to upset Resident #1. She apologized to Resident #1. In an interview with the DON on [DATE] at 2:55 pm she revealed she listened to the recording that was provided to the facility by Resident #1's family member . The DON revealed CNA A said can you not do anything for yourself (use of Resident #1's first name), come on. The DON felt what CNA A said to Resident #1 was not encouraging and she should have used a more encouraging tone. The DON revealed when she spoke to Resident #1, she should have thought about how Resident #1 would have felt to hear those words. The DON revealed CNA A was suspended from work and was in-serviced on abuse and neglect and how to speak to Residents. The DON said she spoke to Resident #1 about the incident, but Resident did not recall it occurred. Review of a statement, undated, from CNA A revealed she responded to Resident #1's call light and found Resident #1 on her wheelchair asleep by the toilet. The statement revealed CNA A asked Resident #1 what she needed, and Resident #1 said she needed help getting on the toilet. The statement from CNA A revealed she said to Resident #1, are you not able to anything on your own now? CNA A revealed in her statement that she wanted Resident #1 to have the independence like she had previously. CNA A revealed in the statement that she knew she spoke in an assertive manner and realized she should have said things in a different manner. Review of CNA A's personnel file reflected a statement signed on [DATE] that reflected she had been trained in and received education on the definition of abuse and the different kinds of abuse. Review of facility abuse and neglect policy, undated, reflected the purpose of the policy was to protect the residents in the facility from abuse and neglect. Verbal abuse is defined as oral, written, or gestured language that includes disparaging and derogatory terms to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident #54) of 8 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #54's skin concerns. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: Record Review of Resident #54's face sheet, dated on 11/02/23, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #54 with diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations), type 2 diabetes (characterized by high blood sugar, insulin resistance, and relative lack of insulin), quadriplegia (paralysis of all four limbs), and chronic pain syndrome (when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives). Record review of Resident #54's quarterly MDS assessment, dated 09/08/23, section C 0500 reflected Resident #54's cognition was intact with a BIMS score of 15, and section GG 0130 revealed he required supervision or touching assistance with eating, partial/moderate assistance for oral and personal hygiene, and substantial/maximum assistance for toileting, showering/bathing, upper and lower body dressing, and putting on and taking off footwear. MDS section H 0300 reflected Resident #54 was incontinent of bowel and bladder. Section M 0210 revealed Resident #54 had one or more unhealed pressure ulcer/injuries. Section M 0300 revealed Resident #54 had one stage 2 pressure ulcer. Section M 1200 revealed Resident #54 received treatment of applications of ointments/medication. Record review of the physician orders tab in Resident #54's EHR reflected the following order: Place pillow between legs/knees when laying on side every shift. Right medial knee wound cleanse with saline or wound cleaner. Apply collagen to wound bed and cover with dry dressing. PRN. Right medial knee wound cleanse with saline or wound cleanser. Apply collagen to wound bed and cover with dry dressing. Resident may have wound care per facility wound protocol. Record review of Resident #54's Care Plan, initiated 10/17/19 with last revision on 09/28/2023, reflected the care plan did not address the resident's stage 2 pressure area to right medial knee. Record review of facility wound care sheet dated 10/29/23 reflected Resident #54 had an old wound to right knee, treatment in place, resident refuses to place pillow or blanket in between knees to relieve pressure as ordered at times. In an interview on 10/31/23 at 10:19 AM Resident #54 stated he was doing ok, and things were fine. He stated he got his showers and medications as scheduled. He stated he had a sore on his knee and the staff took care of it and treated it for him when they were supposed to. He stated he used the call light to call for help and he felt safe in the facility. He stated he had no concerns about anything. In an interview on 11/02/23 at 03:40 PM with the MDS, she stated she was responsible for completing care plans. She stated all wounds and skin concerns should be care planned as long as they are a stage 2 or greater. She stated she had been trained on how to complete care plans and what should be included in the care plan . She stated if a residents care plan was not completed correctly the resident may not get the proper care. he stated she was not sure if there was a policy that informed her of what to care plan. In an interview on 11/02/23 at 03:50 PM with the DON, she stated the MDS nurse was responsible for completing care plans. She stated she initiated initial care plans and then the MDS nurse did the rest of the care plans. She stated she expected all wounds and skin concerns to be care planned. She stated the staff responsible for completing care plans had been trained on how to complete a care plan and what should be included in care plans. In an interview on 11/02/23 at 04:01 PM with the ADM, he stated the MDS nurse was responsible for completing care plans. He stated he expected all wounds and skin concerns to be care planned. He stated he was not sure about what level of training the MDS nurse had been given but he knew that the Cooperate MDS nurse came to the facility the past week and had done some trainings with the MDS nurse. In an interview on 11/02/23 at 04:08 PM with MDS, she stated there was not a policy on what to care plan and she was told previously that she was only to care plan stage 2 and higher skin concerns. She stated she clarified what should have been care planned with the cooperate nurse and she was to care plan everything including all wounds no matter the stage and all skin concerns. She stated she would care plan every skin concern from now on. Record review of the undated facility's policy titled FourCooks Senior Care, LLC - Section 18 - Minimum Data Set (MDS) - Policy: Comprehensive Care Plans - Procedures 1. The facility will develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a residents' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. 4. The services provided or arranged by the facility must: a. Meet professional quality standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation for three of eight residents (Resident # 28, Resident # 42, and Resident # 44) who were reviewed for reasonable accommodations. The facility failed to ensure that call lights were within arm's reach of the resident # 28, # 42, and # 44, This failure placed residents at risk of harm by not being able to call for help when needed. Findings include: Record review of Resident # 28's Facility admission Record, dated 11-2-2023, indicated that Resident # 28 was a [AGE] year-old female admitted to the facility on [DATE]. Resident # 28 was diagnosed with Difficulty in walking, muscle weakness, unsteadiness on feet, other lack of coordination, and unspecified abnormalities of gait and mobility. Record review of Resident # 28's Facility Care Plan, dated 1-16-2023, indicated that an intervention for Resident # 28's conditions for anxiety, depression, unsteady gait, decision making, and skin breakdown called for Resident # 28's call light to be placed within arm's reach. The Facility Care Plan indicated that Resident # 28 was legally blind and unable to care for self. Record review of Resident # 28's BIM indicated a score of 15. Record review of Resident # 42's Facility admission Record, dated 11-2-2023 indicated that Resident # 42 was a [AGE] year-old female admitted to the facility on [DATE]. Resident # 42 was diagnosed with depression, partial paralysis of the body, and residual effects of a previous stroke. Record review of Resident # 42's Facility Care Plan, dated 6-23-2023, indicated that an intervention for Resident # 42's pain, skin breakdown, falls, and cognition called for Resident # 42's call light to be placed within arm's reach. Record review of Resident # 42's BIM indicated a score of 15. Record review of Resident # 44's Facility admission Record, dated 11-2-2023, indicated that Resident # 42 was admitted to the facility on [DATE]. Resident # 44 was diagnosed with blockage of a pulmonary artery, underactive thyroid, kidney disease, pain in left hip, and muscle weakness. Record review of Resident # 44's Facility Care Plan, dated 9-2-2023, indicated that an intervention for Resident # 42's skin breakdown, pain, falls, cognition, and ADL self-care called for Resident # 42's call light to be placed within arm's reach. Record review of Resident # 44's BIM indicated a score of 4. Observation on 10-31-2023 at 11:06 AM reflected Resident # 28's call light out of arm's reach. The call light was four feet away from the resident on the right side of the bed on the floor between the resident's room furnished chair and Resident # 28's oxygen machine. The metal clip on the call light cord was bent and inoperable. Observation and interview on 10-31-2023 at 11:07 AM with Resident # 28 revealed that Resident # 28 was in bed and could not reach the Call Light, when asked, to locate it. Resident # 28 was observed having reached along the left side of the mattress and the wall. Resident # 28 stated the Call Light was usually placed on the left side of the bed between her and the wall. The call light was observed four feet away on the right side of the bed. Resident # 28 stated that she could not reach the Call Light. Interview on 10-31-2023 at 11:10 AM with CNA A revealed that the correct placement of the Call Light was supposed to be within arm's reach of the resident. CNA A looked at the clip and confirmed that the clip was broken. CNA A stated that broken clips were reported to maintenance for repair. CNA A placed the call light on the right side of Resident # 28's bed and reported the broken clip to maintenance. Observations on 10-31-2023 at 1:18 PM reflected Resident # 42's call light out was out of arm's reach of the resident. The call light was three feet away from the resident behind her draped over some folded bedding on the resident's room furnished chair. The clip was operable. Interview and observation on 10-31-2023 at 1:19 PM with Resident # 42 revealed that Resident # 42 was seated in the middle of the living area in a wheelchair watching TV and could not reach the Call Light, when asked, to locate it. Resident # 43 was observed having turned her wheelchair with one wheel and propelled herself close enough to secure it. Resident # 42 stated she did not like it when the Call Light was placed too far from reach by the staff. Observations on 11-2-2023 at 9:33 AM reflected Resident # 44's call light out was out of arm's reach of the resident. The call light was two feet away from the resident behind her draped over some folded bedding on the resident's room furnished bed and tucked in a drawer. The clip was operable. Interview and observation on 11-2-2023 at 9:34 AM with Resident # 44 revealed that Resident # 44 was seated in the middle of the living area in a wheelchair watching TV and could not reach the Call Light, when asked, to locate it. Resident # 44 was observed having turned her wheelchair with one wheel and leaned close enough to secure it. Resident # 44 stated that her bedding was just changed, and the caregiver left the Call Light where it was. Interview on 11-2-2023 at 1:57 PM with CNA B revealed that CNAs were trained to answer Call Lights right away. CNA B stated that CNAs are instructed to make sure the Call Light was placed within arm's reach of the resident, regardless is that resident can move to reach it. Interview on 11-2-2023 at 2:24 PM with CNA C revealed that CNAs were trained to answer the Call Lights right away. CNA C stated that CNAs were trained to make sure the Call Lights were always in arms' reach of the resident, regardless if they can move to reach it. CNA C stated that clips have broken before, and those repairs were reported to maintenance. Interview on 11-2-2023 at 4:32 with the DON revealed that Call Lights were placed in the room for the resident to use if they needed assistance with anything. The DON stated that it was everybody's responsibility to make sure the Call Lights were within arm's reach. The DON stated that the Call Light should have been placed next to the resident and that the resident was not supposed to have to move to the Call Light's location. The [NAME] stated that staff was trained to contact maintenance for broken clips on the Call Lights right away, or document it in the book, so maintenance could fix it the next morning. The DON stated that dangers associated with Call Lights out of reach were falls, accidents, and skin breakdown without the ability to call for help. Interview on 11-2-2023 at 4:56 PM with the ADM revealed that the Call Light system was in place for residents to call for help when needed. The ADM stated that it was everybody's responsibility to make sure that the Call Lights were within arm's reach. The ADM stated that the Call Light should be within arm's reach when the resident was in bed; The ADM stated that the Call Light should have been placed within arm's reach of residents in wheelchairs, but a resident's movement away from the Call Light would be out of the staff's control. The ADM stated that staff was instructed to tell maintenance for any damaged parts of the Call Light. The ADM stated that negative outcomes of Call Lights out of reach were skin breakdowns, falls, ad unintended accidents. Record review of the facility Call Light Policy, undated, stated to (8) endure to position the call light conveniently for the resident to use; tell the resident where the call light is and show him/her [NAME] to use the call light; (10) notify the maintenance department and enter defective call light locations in the maintenance log; and (11) be sure all call lights are placed on the bed at all times, never on the floor or bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 1 (Resident #27) of 2 resident's reviewed for PASARR coordination, by failing to ensure: 1. Resident # 27's PASARR Level I was completed accurately for Resident #27 who had active mental health diagnosis. This failure could place residents at risk for inappropriate placement in the nursing facility for long term care and at risk of not receiving appropriate care and services from the local authority, which could result in a possible decline in mental health The findings were: 1. Record review of Resident # 27's face sheet, dated 11/02/23, reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included unspecified psychosis (certain types of schizophrenia, paranoid, and other psychotic disorders), psychotic disorder (a condition of the mind that results in difficulties determining what is real and what is not real), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and major depressive disorder (a mental condition characterized by a persistently depressed mood and long term loss of pleasure or interest in life often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). Record review of Resident # 27's Quarterly MDS dated [DATE] reflected a BIMS score of 00, indicating Resident #27 was cognitively impaired. Further review reflected in section D, 0100 that Resident #27 should have a mood interview conducted, section D 0200 reflected had symptoms of feeling down, depressed, or hopeless for 2-6 days (several days). Section G reflected Resident #27 required extensive one person assist with bed mobility, transfers, locomotion on and off unit, dressing and personal hygiene, supervision with one person assist for eating, and total one person assist for toilet use. Section I, 5900 - Bipolar Disorder, I, 5950 reflected Resident #27 had active diagnosis of - Psychotic Disorder (other than Schizophrenia). Record review of Resident # 27's client progress notes titled Psych notes dated 09/06/23 reflected that Resident #27 had been seen for a psychiatric visit for depression, psychosis, and psychotic disorder. Record review of Resident # 27's PASARR Level I screening dated 09/30/19 reflected Resident # 27 did not have a mental illness. Record review of Resident # 27's PASARR Level I screening dated 01/29/22 reflected Resident #27 did not have a mental illness. Record review of Resident # 27's PASARR Level I screening dated 03/03/22 reflected Resident #27 did not have a mental illness. Record review of Resident # 27's PASARR Level I screening dated 04/13/22 reflected Resident #27 did not have a mental illness. Record review of Resident # 27's clinical record reflected there was no PASRR Level II Screening found. Record review of Resident # 27's care plan, dated 10/17/19, last revised on 09/28/23, reflected a care plan for Resident #27 residents ability for decision making needs to be anticipated by staff due to psychosis, and psychotic disorders with delusions. Goal: Resident needs will be anticipated and met by staff as evidenced by being clean, appropriately dressed daily through next review date. Interventions: If resident becomes agitated, provide for safety, remove for common area if affecting others, back away, reproach when calm, and seek help as needed. Record review of Resident # 27's care plan, dated 11/16/19, last revised on 09/28/23, reflected Resident #27 had a communication problem related to his CVA, psychosis, and psychotic disorders with delusions. Resident said minimal 2-3 words at a time and only when he wants to speak. Speech is unclear most of the time. Goal: The resident would maintain current level of communication function through the review date. Interventions: Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or use of sign language as alternate communication to speech. Use effective strategies touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1:1, quiet setting for communicating with resident. Record review of Resident # 27's care plan, dated 11/24/19, last revised on 09/28/23, reflected Resident #27 had a diagnosis of depression. Goal: The resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Interventions: Monitor/record/report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. In an observation on 11/01/23 at 09:28 AM Resident # 27 was sitting up in wheelchair. Resident #27 appeared clean, groomed, and dressed appropriately for the weather and temperatures. Resident #27 did not reveal any signs of pain or distress. In an interview on 11/02/23 at 09:32 AM with the MDS, she stated the documents she had given surveyor were the only documents that were available regarding any PASARR screenings for Resident #27. She stated there were multiple level 1 PASARR screenings for Resident #27, but no level 2 PASARR evaluations because resident did not have a positive level 1 PASARR screening. She stated she called her local authority, and they told her they did not have anything related to PASARR's for Resident #27. She stated the local authority had come out to the facility the following day to evaluate Resident #27 for PASARR services. In an interview on 11/02/23 at 03:40 PM with the MDS, she stated she was responsible for completing and ensuring the accuracy of resident's PASARR screenings and evaluations. She stated she was not aware Resident #27's PASARR screening was not completed accurately or that he had not been referred to the local authority to possibly receive services. She stated that Resident #27's PASARR was done prior to her taking the position as MDS nurse. She stated if a PASARR was completed incorrectly, it could cause a resident to not receive the services they may want or need. She stated she had been trained on PASARR completion and accuracy and making sure resident information was sent over to the local authority. In an interview on 11/02/23 at 03:50 PM with the DON, she stated the MDS nurse was responsible for completing and ensuring accuracy of resident's PASARR screenings and evaluations. She stated she was not aware Resident #27's PASARR screening was not completed accurately or that he had not been referred to the local authority to possibly receive services. She stated if a PASARR was not completed correctly, a resident may not get the services and benefits that they needed. She stated the staff responsible for completing and ensuring accuracy of PASARR screenings and evaluations had been trained on PASARR's. In an interview on 11/02/23 at 04:01 PM with the ADM, he stated the MDS nurse was responsible for completing and ensuring accuracy of resident's PASARR screenings and evaluations. He stated he was not aware that Resident #27's PASARR screening was not completed correctly or that he had not been referred to the local authority to possibly receive services. He stated if a PASARR was completed incorrectly, residents may not get all of the services they are funded or are eligible for. He stated was not sure if the staff responsible for completing and ensuring accuracy of PASARR screenings and evaluations had been trained on PASARR's. Record Review of undated facility policy FourCooks Senior Care, LLC - Section 18 - Minimum Data Set (MDS) - Policy: Preadmission Screening and Resident Review (PASRR ) - It is the policy of this facility to ensure that all residents are screen and appropriately addressed via the PASRR process as outlines by the regulations. The result of this process will be used to develop, review and revise the residents care plan. The facility will not admit any new resident with: 1. A mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, a. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and b. If the individual requires such level of services, rather the individual requires specialized services. Procedure: 1. The facilities designated staff will review all potential admission for possible positive PASSR conditions and ensure that CMS Preadmission guidelines are followed.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals were stored in locked compartments for treatment cart 1 (Treatment Cart #1). 1. Treatment cart # 1 located in hallway B in the facility, outside of room B20, was observed to be unlocked and left unattended by LVN. This failure could place residents at risk of drug diversion and access to medications. Findings included: An observation on 10/31/23 at 9:49 AM reflected a medication/treatment cart parked on Hall B in the hallway in the facility outside of room B20 was unlocked and unattended. LVN, which was responsible for cart was in room B20 with door closed halfway and privacy curtain pulled. Medication/treatment care was not in visible range of nurse. No residents were present in hallway. In an interview on 10/31/23 at 9:53 AM LVN stated she was aware the medication/treatment cart was unlocked because she was then seeing it. She stated she did not realize she left the cart unlocked or left the keys in the cart. She stated she was receiving training at that time and that was the first day she had worked mornings in the facility. She stated she knew the medication cart was supposed to be locked and she had just made a horrible mistake. She stated there was wound care supplies and creams, medications, insulins, and supplies on the cart and that if a resident were to get into the cart, they could have taken some of the medications and harm could have been caused . She stated she would learn from this experience, and she would never do that again. An observation on 10/31/23 at 9:58 AM revealed inside the medication/treatment cart, there was insulin, medications, supplies, and treatment medications such as creams on unlocked medication/treatment cart. In an interview on 10/31/23 at 11:39 AM the MA stated all medication and treatment carts should be locked when not in use. She stated she was trained on keeping the medication carts locked. She stated if a resident got on an unlocked cart, they could get poisoned. She stated they had a few residents that could possible get into the cart in the facility. In an interview on 11/02/23 at 03:40 PM the MDS, stated if a medication or treatment cart was not in use or was left unattended, it should be locked. She stated she had been in-serviced on keeping medication and treatment carts locked when not in use or unattended. She stated if a medication cart was left unlocked or unattended, a resident could get into the cart and take medications that did not belong to them and that could possibly cause harm to the resident. In an interview on 11/02/23 at 03:50 PM the DON, she stated it was her expectation that any medication or treatment cart that was not in use or was left unattended, should be locked. She stated staff were in-serviced on locking medication and treatment carts when not in use or if unattended. She stated if a medication cart was left unlocked and unattended, a resident could possibly get into the cart and take medications that were not theirs, and it could possibly cause them serious adverse side effects or harm. She stated herself and the ADON would make rounds at anonymous times and anytime they found a medication or treatment cart unlocked or unattended, they would take the entire cart, and the staff that was responsible for the cart would have to see them and be educated on locking unattended medication or treatment carts prior to getting their carts back. In an interview on 11/02/23 at 04:01 PM with the ADM, he stated it was his expectation that if a medication or treatment cart was not in use or was left unattended, it should be locked. He stated he was not aware if staff were in-serviced on keeping medication and treatment carts locked when not in use or unattended because he has only worked here for about 1 month. He stated a resident could get medications that did not belong to them out of an unlocked, unattended cart which could possibly cause harm to the resident. Record review of undated FourCooks Senior Care, LLC Section 6 - Medication Policy : Storage of Medication reflected: 6. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). Record review of undated FourCooks Senior Care, LLC Section 16 - Nursing - Policy: Securing Medication and Treatment Carts - Procedure: It is expected that medication carts and treatment carts are to be remain locked at all times when not in use by the assigned personnel.

Based on observations, interviews, and record reviews, the facility failed to store foods properly and maintain a sanitized food preparation area for the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to safely store food containers in the facility's only pantry, walk-in cooler, and freezer. 2. The facility failed to maintain clean kitchen surfaces/appliances. These failures placed residents at risk of exposure to food borne pathogens. Findings include: Observations on 10-31-2023 beginning at 8:10 PM in the facility's dry storage area reflected six small individual open bags of unsealed biscuit gravy mix placed inside a unsealed plastic bag WLD; one open bag of tricolor pasta stored in a plastic bag maintained past its labeled use by date; one bag of opened corkscrew pasta stored on a plastic bag WLD; one large dented can of blackeye peas; one bag of powdered sugar maintained past is labeled use by date; one opened green gallon sized bottle of real lemon juice WLD; one small box of cream of wheat stored in an unsealed plastic bag WLD; one five gallon plastic bucket of cornmeal maintained past its labeled use by date; one five gallon plastic container of brown sugar WLD; and one unsealed 25 pound bag of flower WLD. Observations on 10-31-2023 beginning at 8:20 AM of the facility's refrigeration system (two refrigerators side by side) reflected: Refrigerator one contained one large bag of cheddar cheese cubes WLD; one large bag of shredded cheddar cheese WLD; one four-inch by four-inch stack of sliced American cheese partially wrapped in aluminum foil WLD; and one 8-inch by four-inch stack of sliced American cheese wrapped in plastic wrap WLD. Refrigerator two contained two 6-inch summer sausages WLD; one open package of bacon stored in a plastic bag WLD; and one open package of sliced turkey breast stored in a plastic bag WLD. Observations on 10-31-2023 beginning at 8:30 AM of the facility's freezer system (2 freezers side by side) reflected: Freezer one contained 19 frozen food boxes WLD. The freezer did not contain sufficient racks to allow for foods to be spaced apart to allow proper circulation. Other observations in the freezer revealed a ½ inch of ice on the bottom of the freezer with three boxes of food frozen to the bottom. One package of hot dogs was unsealed and open to the air with an accumulation of ice and freezer burn. Freezer two contained 13 frozen boxed of food WLD. The freezer did not contain sufficient racks to allow for foods to be spaced apart to allow proper circulation. Other observations in the freezer revealed a large spill of a red substance on the bottom of the freezer. Observations on 10-31-2023 beginning at 8:45 AM of the facility's dish, utensil, pots, and pan storage drying area reflected 17 glasses stacked on a rectangular grey tray with debris, stains, and a collection of an oily substance on the bottom of the tray; 11 red small bowls stacked on a grey rectangular tray with food particles on the bottom of the tray; two plastic storage containers at the bottom shelf of the drying racks that stored large spoons, scoopers, and knives that had debris collected at the bottom of each container; a large silver colander with food particles collected in the straining holes; and two fry baskets with food particles stuck in the mesh wiring. Observations on 10-31-2023 beginning at 9:00 AM of the facility's kitchen appliances reflected a coating of grease and food particles collected on the top of the facility's oven; one industrial can opener with collected particles of food and debris in its internal working parts; and collected rust and discoloration inside the venting hood on top of the facility's only dishwasher. Observations on 11-1-2023 at 1:35 PM reflected the facility's manual three-sink washing system not set up with functioning sink stoppers. The facility used two fabricated sink stoppers made of plastic wrap and a kitchen towel. Cleaning solution was observed leaking from the drain and cleaning solutions were not maintained at the at the proper level for sanitization. Interview on 11-2-2023 at 3:38 PM with the DM revealed that food should be stored in sealed containers and labeled with an 'open date' and 'use by date' to ensure food stays fresh, prevents food-borne ill nesses, prevents cross contamination, and prevents bacteria growth. The DM stated that kitchen appliances and equipment should be sanitized regularly to prevent food-borne ill nesses, prevent cross contamination, and prevent bacteria growth. The DM stated that common food-borne illnesses are norovirus, salmonella, e-coli, botulism, and listeria. The DM stated that negative results of food-borne illnesses could result in vomiting, diarrhea, nausea, and untended weight loss. Interview on 11-2-2023 at 4:25 PM with the DON revealed that food safety and proper sanitization of kitchen equipment is important to reduce food- borne pathogens. The DON stated that food-borne illnesses could cause vomiting, diarrhea, food poisoning, and weight loss. Interview on 11-2-2023 at 4:53 PM with the ADM revealed that food safety and proper sanitization of kitchen equipment is important to reduce food-borne pathogens. The ADM stated that cross-contamination and food-borne pathogens can turn out bad for everyone. The ADM stated that negative outcomes from a food-borne pathogen could result in vomiting, diarrhea, dehydration, and UTIs. Record review of the facility's policy for Storage of Food In Refrigerators, undated, indicated all containers must be labeled with the contents and date the food item was placed in storage. Record review of the facility's policy for Dry Storage and Supplies, undated, indicated open packages of food are stored in closed containers with tight covers, and dated as to when opened. Record review of the facility's policy for Storage Refrigerators, undated, indicated food must be covered when stored, with a date label identifying what is in the container. Record review of the facility's policy for Dented Cans, undated, indicated any can presented for delivery that is dented, bulging, or leaking is to be sent back. The policy indicated that any can that has been damaged while in the facility was to be thrown out or placed in the designated area for dented cans. Record review of the facility's policy for Cleaning, undated, indicated all (1d) equipment, food contact services, and utensils shall be cleaned whenever contamination has occurred, and (9) refrigerators and freezers must be cleaned quarterly or more often if needed. Record review of the facility's policy for Prevention of Cross-Contamination, undated, indicated cross-contamination can occur when using unclean equipment, such as slicers, can openers, and utensils to prepare food. Directions on how to prevent cross-contamination when storing food indicated that food needed to be covered or wrapped before storing.

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to a dignified existence and treated with dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #50 and Resident #55) observed for privacy. Residents # 50 and #55 did not have a catheter bag and tubing covered. This deficient practice could have affected residents with catheters and placed them at risk for diminished quality of life and increase risk for isolation. Findings Included: Resident #50 In an observation and interview on 8/16/22 at 0808 (8:08 AM), Resident # 50 had an uncovered catheter bag attached to her bed that was visible from the hallway. She stated she tried to keep her blanket over the catheter bag, so people do not see it. In an observation on 8/17/22at 0919 (9:19AM), Resident # 50 had an uncovered catheter bag attached to her bed that was visible from the hallway. Resident #55 In an observation on 8/16/22 at 0830, Resident # 55's catheter bag was visible from the hallway hanging from his recliner without a cover bag. During observations of Resident #55 on 8/17/22 the following times noted the placement of his catheter bag: - At 0921, the catheter bag was visible from the hallway hanging from the inside wall of a trash can. - At 1102, the catheter bag was visible from the hallway hanging from the inside wall of a trash can. - At 1402, the catheter bag was visible from the hallway hanging from the inside wall of a trash can. In an observation on 8/18/22 at 0858, Resident #55's catheter bag was visible from the hallway hanging from his recliner without a cover bag. In an interview on 8/18/22 at 0858 with LVN C, she stated catheter bags should be covered or positioned to where it could not be seen. In an interview on 8/18/22 at 0902 with LVN D, she stated catheter bags should be covered or positioned to where it could not be seen. In an interview on 8/18/22 at 1114 with Administrator, he stated a resident's catheter bag should be covered or positioned to where it could not be seen. He said he had not noticed or thought of this as a concern but does understand how this could impact a resident's dignity or privacy. In an interview on 8/18/22 at 1134 with ADON, she stated a resident's catheter bag should be covered or positioned to where it could not be seen. She stated an uncovered catheter bag could impact a resident's dignity. In an interview on 8/18/22 at 1143 with DON, she stated the resident's catheter bag should be covered or positioned to where it could not be seen. She stated an uncovered catheter bag could impact a resident's dignity.

**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 needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences, and for 1 of 1 residents (Resident #55) reviewed for oxygen therapy in that: Resident #55's nebulizer mask and tubing were not bagged while not in use and stored in a drawer filled with trash. This deficient practice could affect residents on respiratory therapy care and placed them at risk of infection. Findings Included: Record review of Resident #50's face sheet revealed a 77- year-old male who was admitted on [DATE]. Record review of Resident #55's MDS dated 7/14,2022 revealed a diagnosis of Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease. MDS Section J1100: Shortness of Breath is indicated Z. None of the above. MDS Section O0100: Special Treatments, Procedures, and Programs is indicated for C. Oxygen therapy while a resident. During observation of Resident #55's nebulizer mask/ tubbing dated 8/13/22 was seen inside the bedside table drawer uncovered, surrounded by empty plastic food wrappers on the following dates and times: -8/16/22 at 8:30 AM -8/16/22 at 9:06 AM -8/17/22 at 9:21 AM -8/17/22 at 11:02 AM -8/17/22 at 2:02 PM In an interview on 8/18/22 at 8:58 AM , LVN C stated Resident #55's nebulizer mask was inside the bedside table uncovered and surrounded by empty plastic food wrappers. She further stated the nebulizer mask should be placed in a dated plastic bag when not in use, to reduce the resident's risk for infection. In an interview on 8/18/22 at 9:02 AM , LVN D, stated Resident #55's nebulizer mask left inside a bedside table without being contained in a dated plastic bag could increase the resident's risk for infection. In an interview on 8/18/22 at 11:14 AM, the Administrator stated a nebulizer mask being left uncovered in a drawer filled with trash could increase the risk of infection for a resident. The Administrator stated the facility did not have a policy regarding oxygen/equipment. In an interview on 8/18/22 at 11:34 AM the ADON, stated a nebulizer mask left inside a bedside table without being contained in a dated plastic bag could increase a resident's risk for infection. In an interview on 8/18/22 at 11:43 AM, the DON stated a nebulizer mask left inside a bedside table without being contained in a dated plastic bag could increase a resident's risk for infection.

Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were not expired and were disposed of according to facility policy for one of one medication storage rooms and two of two (Hall 3 and Hall 4) nurses' medication carts reviewed in that: The medication storage room refrigerator had three expired drugs/biologicals, one prescribed for Resident #17, one prescribed for Resident #33 and one stock medication. The nurse's medication cart on Hall 3 had nine expired drugs/biologicals, one prescribed for Resident #40, one prescribed for Resident #63, one prescribed for Resident #33 and six stock medications. The medication cart on Hall 4 had four stock expired drugs/biologicals. These failures could place residents at risk of not receiving the intended therapeutic benefit of their medications. Findings include: Observation of the medication storage room refrigerator and interview on 08/16/2022 at 11:37 AM with CMA C revealed the following expired medications: - Omeprazole suspension 2 mg/ml per peg tube do not use after 08/04/2022 for Resident #17 - Stock Omeprazole Powder do not use after 8/4/2022, and - Keflex 250mg/5 ml Do not use after 08/08/22 for Resident #33. CMA C stated, The Pharmacy technician will come once a month or so and say we need to go through the carts. She'll tell us what we need to do. Observation of the medication cart at the nurse's station for Hall 300 and an interview on 08/16/2022 at 9:09 AM with LVN B revealed the following expired stocked medications: -Hibiclens, Chlorhexidine Gluconate 4% expiration 06/2022, -Lactulose Solution 10 gm/15 ml expiration 05/03/2022, -Assure C clear lubricant expiration 9/22/2020, -Geri-Tussin (Guaifenesin), expiration 04/2022, -Saline enemas expiration 01/2021, Mupirocin 2% 04/2021, - Ketoconazole shampoo 2% for Resident #40, expiration 05/2021. -Acyclovir 5% cream TID for Resident #63, expiration 10/2021, and -Nystatin 100,000 Units per gram for Resident #33, expiration 06/2022. LVN B stated, The (expired) medication is not going to work like it should or be as potent. She had no explanation for why expired medications were on the cart. Observation of medication cart on Hall 400 and an interview on 08/16/2022 at 8:45 AM with LVN A revealed the following expired stock medications: -Cetirizine expiration 06/2022, -Miralax mix in packet 10 daily doses expiration 05/2022, -Dynagel 2 tubes, wound hydrogel, expiration 04/2022, and -Skin repair cream Dimethicone 1.5 % expiration 09/2021. LVN A stated, Personally, I check the cart for expired medications. This is my first day back here. I work here prn. I'm not aware of any policy for checking expiration dates. The potential risk of expired meds is if the medication is past its expiration dates, the therapeutic potency wouldn't be where it should be. Interview on 08/16/2022 at 11:55 AM, the ADON stated, Medicine would not do its job if it's outdated. We have our pharmacy consultant here one time a month I usually count the expired meds and destroy them one time a week. I check the carts, one time a week but I just got back from 19 days of sick time. In my absence, the DON should be checking the carts and the med storage room for expired meds. Interview on 08/18/22 at 11:18 AM, the PharmD consultant stated her monthly responsibilities are to watch a med pass and look for expired meds. I was at the facility about a month ago. I check the refrigerator in the medication storage room for expired medications. I expect the facility to follow-up on what I comment on. I don't know who is responsible at the facility for removing expired meds. The potential risk of expired meds (medications) is they could lose their potency. Interview on 08/18/2022 at 11:30 AM, the DON stated, The aides and nurses are supposed to check their carts at least once a week for expired meds at a minimum. I hold whoever works that cart responsible for ensuring that it is completed. Me (the DON) and the ADON are responsible for ensuring this is completed. I was developing a system for that (checking for expired medication) but haven't had luck completing it due to other problems. The potential risk of giving an expired medication is it will not have the intended effect; it could lose potency. There is an increased risk of adverse effects. Interview on 08/18/2022 at 11:37 AM, the Administrator stated, The medication aides and nurses are supposed to be doing periodic checks of the medication carts. I'm not sure what their schedule is, but it should be weekly. They have a rotation of checking the carts for expired meds. Ultimately the DON and me (the administrator) are responsible. They (carts and medication storage room) get audited by the PharmD, once a month or so. She does a surprise audit to see how we're doing. The potential risk of expired meds is a potential adverse effect, and they will not work. Review of the facility's policy for Storage of Medications undated reflected No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications will be destroyed.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for all 21 residents residing on hall B, 2 of 2 residents receiving wound care, and 1 of 6 residents with indwelling catheters. 1.The drinks delivered with hallway B's meal trays were uncovered on top of delivery cart sitting in the hallway. 2.The wound care nurse failed to maintain proper hand hygiene during wound care provided to Resident #50 and Resident #55. 3.Resident #55's catheter was inside of a trash can next to his recliner. These deficient practices could put residents at an increased risk of infection. Findings Included: 1.During an observation of hallway B's meal chart revealed the drinks on the top trays were uncovered on the following date and times: -8/16/22 at :830 AM, -8/17/22 at 9:21 AM -8/18/22 at 8:58 AM In an interview on 8/18/22 at 8:58 AM with LVN C, she acknowledged and confirmed the drinks being uncovered is an infection control risk. She stated the residents could be exposed to airborne illnesses or other bacteria with drinks being uncovered in the hallway. In an interview on 8/18/22 at 9:02 AM with LVN D, she acknowledged and confirmed the drinks being uncovered is an infection control risk. She stated the residents could be exposed to bacteria with drinks being uncovered in the hallway. In an interview on 8/18/22 at 9:05 AM with CNA A, she stated the drinks being uncovered is an infection control risk. She stated the residents could be exposed to airborne illnesses or other bacteria with drinks being uncovered in the hallway.In an interview on 8/18/22 at 11:14 AM with Administrator, he stated drinks being uncovered is an infection control risk. He stated the residents could be exposed to bacteria with drinks being uncovered in the hallway. It also makes it more of a homelike environment with the drink being freshly covered and helps keep desired temperature. In an interview on 8/18/22 at 11:34 AM with ADON, she stated drinks being uncovered is an infection control risk. She stated the residents could be exposed to infection control risk with drinks being uncovered in the hallway. In an interview on 8/18/22 at 11:43 AM with DON, she stated drinks being uncovered is an infection control risk. She stated the residents could be exposed to infection control risk with drinks being uncovered in the hallway. 2.In an observation on 8/17/22 at 2:15 PM the wound care nurse/ LVN C provided non-sterile wound care to Resident # 50's left gluteal fold. She wore the same pair of gloves and did not wash hands throughout the cleansing of wound, applying medication, packing wound, and applying the bandage. In an observation on 8/18/22 at 8:47 AM LVN C, provided wound care to Resident # 55's bilateral lower extremity toes. She washed her hands, put on a pair of gloves, then cleansed, medicated, and bandaged both resident's feet without washing hands and changing gloves between cleansing, medicating or between each wound care site. In an interview on 8/18/22 at 8:58 AM with LVN C, she stated during the wound care she provided she did not wash her hands or change her gloves in between wound sites or between the wound being cleansed or bandaged. In an interview on 8/18/22 at 11:14 AM with Administrator, he stated it is an infection control concern that puts residents at risk for infection when not washing hands or changing gloves in between wound sites or between wound being cleansed or bandaged. In an interview on 8/18/22 at 11:34 AM with ADON, she acknowledged this is an infection control concern that puts residents at risk for infection when not washing hands or changing gloves in between wound sites or between wound being cleansed or bandaged. In an interview on 8/18/22 at 11:43 AM with the DON, she acknowledged this is an infection control concern that puts residents at risk for infection when not washing hands or changing gloves in between wound sites or between wound being cleansed or bandaged. 3.During an observation with Resident # 55, his catheter bag was visible from the hallway hanging from the inside wall of a trash can next to his recliner on the following date and times: 8/17/22 at 9:21 AM 8/17/22 at 11:02 AM 8/17/22 at 2:02 PM In an interview on 8/18/22 at 8:58 AM LVN C, she stated a catheter bag should never be hung on a trash can. She said a catheter bag that is attached to a resident, hung inside a trash can could increase the resident's risk for infection. In an interview on 8/18/22 at 9:02 AM LVN D, stated a catheter bag should never be hung on a trash can. She stated a catheter bag that is attached to a resident, hung inside a trash can could increase the resident's risk for infection. In an interview on 8/18/22 at 11:14 AM with Administrator, he acknowledged and confirmed a catheter bag should not be placed inside of the trash can. He confirmed this is an infection control concern that puts residents at risk for infection. In an interview on 8/18/22 at 11:34 AM with ADON, acknowledged and confirmed a catheter bag should not be placed inside of the trash can. She confirmed this is an infection control concern that puts residents at risk for infection. Record review of the Key Contact Information from[Healogics],that provided the wound care training, indicated *the wound care supervisor/overseer comes every week to the facility. Record review of LVN C's , Certificate of Completion for Skin Care In-Service, undated Indicated *she had received training to provide skin care. Record review of LVN C's In-Service: 43 Skin Care Test dated 6/9/20, revealed the Score on test was left blank did not indicate training for proper handwashing during wound care treatments. Record review of LVN C's , NPIAP training material was signed by LVN C and dated 6/9/20 indicated training was received on preventing unavoidable pressure injury during Covid-19. Record review of LVN C's AMT Education Division article titled Frequently Asked Questions undated was signed by LVN C and did not indicate training for proper handwashing during wound care treatments Record review of the facility's Infection Control Plan: Overview revised 12/08/2021, to include Standard Precautions, indicated a policy to wash gloves as if they were hands when moving from one task to another in resident's dwelling unit. Record review of the facility's Hand Washing Policy indicated hands should be washed twenty seconds under the following conditions: Before handling clean or soiled dressings, gauze pads, etc., after handling used dressings, contaminated equipment, etc., after contact with blood, body fluids, excretions, secretions, mucous membranes, or nonintact skin, after handling items potentially contaminated with blood, body fluids, excretions, or secretions, after removing gloves, and whenever in doubt. Record review of the facility's wound Care Guidelines (Procedure 686), indicated *the facility has a policy in place specifying gloves are required equipment for wound care. Included in policy is a step-by-step process for wound care to Stage I, Stage II, Stage III-IV or eschar-covered pressure wounds, and skin tears, but does not specify when to wash hands or change gloves. Policy does state to follow steps for dressing change (Procedure 330) but this document could not be provided by facility.