Based on the facility's abuse investigation forms, State Survey Agency incident database review, policy and procedure review, and staff interview, the facility failed to implement policies and procedures for ensuring the reporting of 3 of 3 resident-to-resident altercations reviewed for allegations of abuse which involved resident #2, #3, #4, and #5. The findings were: 1. Review of the facility's policy Abuse, Neglect, and Exploitation, implemented on 4/1/24, showed .Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The following concerns were identified: a. Review of a nurse progress note, dated 12/21/24 and timed 5:18 PM, showed resident #4 and #5 were involved in an altercation which resulted in a minor injury to resident #4. Review of the state survey agency incident database showed the allegation occurred on 12/21/24 at 4:30 PM and was reported to facility administration at 5 PM; however, the allegation was not reported to the agency until 12/23/24 at 4:59 PM. b. Review of the state agency incident report form showed a resident-to-resident altercation occurred on 11/26/24 at 6 PM between resident #2 and #3 and was reported to the facility administration on 11/27/24 at 10 PM. The allegation of abuse was not reported to the agency until 11/30/24 at 9:42 PM. c. Review of a nurse progress note, dated 11/28/24 and timed 6:20 PM, showed resident #2 and #3 were involved in a resident-to-resident altercation which resulted in minor injury to resident #3. Review of the state survey agency incident database showed the allegation occurred on 11/28/24 at 6 PM and was reported to the facility administration on 11/28/24 at 7 PM; however, the allegation was not reported to the agency until 11/30/24 at 9:42 PM. 2. Interview with the administrator on 1/15/25 at 10:13 AM confirmed the allegations of abuse were not reported within the required timeframe. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure acceptable parameters of nutritional status for 2 of 5 sample residents (#5, #6) reviewed for nutrition. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #5 had short-term and long-term memory problems and diagnoses which included chronic kidney disease stage 3, non-Alzheimer's dementia, anxiety disorder, depression, muscle wasting and atrophy, and dysphagia. Further review showed the resident had weight loss greater than 5 percent and required supervision or touching assistance with eating. The following concerns were identified: a. Review of the resident's weight history showed s/he weighed 148 pounds on 5/22/24 and 120.3 pounds on 11/6/24, a weight loss of 18.71 percent. b. Review of the meal intake record from 10/9/24 through 11/7/24 showed the resident did not have a recorded meal intake for 16 out of 88 meals, was marked response not required was marked for 15 out of 88 meals, ate 0 to 25 percent for 5 out of 88 meals, and ate 26 percent to 50 percent for 10 of 88 meals. Further review showed on 10/24 there was no record of dinner, on 10/25 there were no recorded meals, and on 10/26 there was no record for breakfast and lunch was recorded as 0 to 25 percent. c. Interview with the dietitian on 11/7/24 at 9:46 AM revealed the resident will sleep through meals and the facility has to work with staff to encourage residents to get up. She revealed if the resident was up more often, his/her nutrition would improve. Further interview revealed the resident body mass index was below where she would like him/her to be. 2. Review of the annual MDS assessment dated [DATE] showed resident #6 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, depression, and muscle wasting and atrophy. Further review showed the resident had weight loss greater than 5 percent and required partial/moderate assistance with eating. The following concerns were identified: a. Review of the resident's weight history showed s/he weighed 103 pounds on 5/6/24 and 91 pounds on 10/1/24, a weight loss of 11.65 percent. b. Review of the meal intake record from 10/8/24 through 11/6/24 showed the resident did not have a recorded meal intake for 12 out of 87 meals, was marked response not required for 13 out 87 meals, ate 0 to 25 percent for 3 out of 87 meals, and ate 26 percent to 50 percent for 5 out of 87 meals. c. Interview with the dietitian on 11/7/24 at 9:46 AM confirmed the resident had a decline and revealed staff needed to ensure s/he was assisted up to the dining room. Further interview confirmed the resident's body mass index was below where she would like it to be. 3. Interview with staff member #1 on 11/6/24 at 12:52 PM revealed a lack of staff had resulted in weight loss for residents. The staff member indicated staff were not able to assist residents to the dining room or provide assistance with meals. 4. Interview with the DON, administrator, and regional nurse on 11/7/24 at 12:08 PM revealed they were unsure why the residents were marked response not required and revealed the system should trigger an alarm if they did not receive a meal. Further interview revealed if a resident refused meals or did not eat their meal, staff should offer an alternative and snacks. 5. Review of the policy titled Meal Supervision and Assistance provided by the facility on 11/7/24 showed .15. If the resident refuses to eat offer alternative items/meal choice, inform the supervisor of continued refusal .17. Encourage the resident to participate with his or her meal as much as possible. When indicated, provide special devices (i.e., two-handed and/or covered cups, hand holder utensils, dishes secured with suction cups, etc.) which will increase independence and participation with meals. 18. Continue feeding until the resident has had enough food or until the meal is finished .20. If the resident wishes to eat later, or cannot eat now, communicate the resident's wishes to your supervisor and other staff members caring for the resident and set a more appropriate time for the resident to receive the meal .

Based on medical record review, and staff interviews, and review of the staff schedule,the facility failed to ensure sufficient nursing staff was provided on 1 of 4 units (Courtyard) reviewed for medication administration. The findings were: 1. Review of resident #7's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of finasteride 5 milligrams (mg) related to benign prostatic hyperplasia with lower urinary tract symptoms, fluoxetine 10 mg related to depression, tamsulosin 0.4 mg related to benign prostatic hyperplasia with lower urinary tract symptoms, and protonix 40 mg related to gastrointestinal hemorrhage, at 6 AM. Further review showed the resident had a hold order on 10/10/24, which was signed off by the administrator, for losartan 100 mg, apply moisturizing lotion, and triamcinolone acetonide external cream 0.1% at 6 AM. 2. Review of resident #8's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of cyanocobalamin 1000 micrograms (mcg) related to supplementation, metformin 1000 mg related to type II diabetes mellitus, multiple vitamins tablet related to supplementation, vitamin D3 capsule 25 mcg related to supplementation, acetaminophen 650 mg related to pain and pacing, losartan 50 mg related to hypertension (hold for blood pressure less than 100/60), and Risperdal 1 mg related to dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance at 6 am. 3. Review of resident #9's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of dexlansoprazole 60 mg related to gastro-esophageal reflux disease, Zoloft 50 mg related to major depression, divalproex sodium 250 mg related to unspecified dementia, unspecified severity, with other behavioral disturbance, midodrine 5 mg related to orthostatic hypotension, and Seroquel 100 mg related to degeneration of the brain, at 6 AM. Further review showed the resident had a hold order on 10/10/24, which was signed off by the administrator, for acidophilus probiotic related to cellulitis of the left lower limb, aloe vera capsule related to urinary health, aspirin 81 mg related to prophylaxis, d-mannose 500 mg related to urinary health, MiraLAX 17 grams (gm) related to fecal impaction/constipation at 6 AM, nutritional snacks at 10 AM and 3 PM, Seroquel 100 mg at 11 AM, and midodrine 5 mg at 12 PM. 4. Review of resident #10's medication administration record for October 2024 showed the resident had a hold order on 10/10/24, which was signed off by the administrator, for glycolax powder 17 gm related to constipation, meloxicam 15 mg related to bilateral primary osteoarthritis of the knee, multivitamin-minerals related to supplementation, levetiracetam 500 mg related to seizures, sennosides 8.6 mg related to constipation, Tylenol 650 mg related to pain, at 6 AM, Tylenol 650 mg at 11 AM, haloperidol 2 mg related to schizophrenia at 6 AM and 11 AM, and nutritional supplements at 9 AM and 2 PM. 5. Review of resident #11's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of amlodipine 10 mg related to hypertension, donepezil 5 mg related to unspecified dementia without behavioral disturbance, lisinopril 5 mg related to hypertension (hold if blood pressure less than 100/60), meloxicam 7.5 mg related to low back pain, MiraLAX powder 17 gm related to constipation management, and Tylenol 1000 mg related to low back pain, at 6 AM. 6. Review of resident #12's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of calcium-vitamin d 600 mg-220 mg related to vitamin D deficiency and docusate sodium 100 mg related to constipation, at 6 AM. Further review showed the resident had a hold order on 10/10/24, which was signed off by the administrator, for urea external cream 40% related to keratosis at 6 AM and oral nutritional supplement at 2 PM. 7. Review of resident #13's medication administration record for October 2024 showed the resident had a hold order on 10/10/24, which was signed off by the administrator, metoprolol 25 mg related to chronic diastolic heart failure (hold if blood pressure is less than 100/60), polyethylene glycol 17 gm related to bowel health, quetiapine 50 mg related to vascular dementia with behavioral disturbance, sertraline 100 mg related to anxiety disorder, and acetaminophen 1000 mg related to pain, at 6 AM, sennoside-docusate 8.8 mg-50 mg related to bowel management and spironolactone 25 mg related to edema at 8 AM, acetaminophen 1000 mg at 11 AM, and trazadone 50 mg related to unspecified vascular dementia, unspecified severity, with other behavioral disturbance, at 12 PM. 8. Review resident #14's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of folic acid 1 mg related to supplementation, levothyroxine 75 mcg related to drug-induced thyroiditis, potassium chloride 20 milliequivalent (mEq) related to hypokalemia, tamsulosin 0.4 mg related to benign prostatic hyperplasia, thiamine 100 mg related to supplementation, and pantoprazole 40 mg related to gastro-esophageal reflux disease, at 6 AM. Further review showed the resident had a hold order on 10/10/24, which was signed off by the administrator, for Tums 500 mg related to heartburn, probiotic, at 6 AM, and the 9 AM and 11 AM snacks. 9. Review of the staff schedule dated 10/10/24 showed no nurse or MA-C was scheduled for the 6 AM to 6:30 PM shift in the courtyard unit. 10. Interview with CNA #1 on 11/6/24 at 2 PM revealed the staff member was moved to the courtyard unit on 10/10/24 due to someone being ill and not being available to work. The CNA revealed there was not a staff member passing medications to residents that day and another CNA came to the unit at 8 AM. 11. Interview with CNA #2 on 11/6/24 at 2:16 PM revealed she replaced CNA #1 on 10/10/24 because they did not have anyone to work Courtyard. 12. Interview with MA-C #1 on 11/6/24 at 2:23 PM revealed when she left on 10/10/24 she was told to give the keys to the Courtyard medication cart to MA-C #1 until the former DON came in. MA-C #2 was assigned to the Rock Creek unit and the only staff member on the Courtyard unit was a CNA. When MA-C #1 returned later that day for her next shift, there continued to be only a CNA on the Courtyard unit. The MA-C revealed the CNA told her no medications had been administered to the residents on the unit and MA-C #1 would need to administer the missed medications. At that time, MA-C #1 notified the administrator and regional operations director, the medications had not been administered. The MA-C revealed she was told it was a serious medication error and they would need to notify the regional clinical director. The MA-C revealed the residents in the Courtyard unit were pacing and some had elevated blood pressures and she attempted to keep them calm. Further interview revealed that when she reviewed the residents' notes they indicated medications had been held due to provider orders. 13. Interview with the former DON on 11/6/24 at 2:35 PM revealed on 10/10/24 he was the only nurse in the building. He stated if he remembered right, he did the morning medications. He revealed he tried to help out but was probably caught up somewhere else or probably kept getting pulled away. 14. Interview with MA-C #2 on 11/7/24 at 12:10 PM revealed she was asked to work on the Rock Creek unit on 10/10/24 and when she learned there was nobody scheduled for the Courtyard unit, she said she could not do both units. The MA-C revealed she gave the Courtyard unit medication cart keys to the former DON at 8 AM. She revealed she told the former DON she had not administered any medications to residents on the unit. At 11 AM, she was notified by the CNA on the Courtyard unit, of resident behaviors and the CNA needed help. The MA-C went to the unit to try and calm residents. The MA-C revealed the residents were yelling and screaming, threatening others, seemed unsettled, and were getting worked up. The MA-C revealed the behaviors seemed normal for the residents when they had not received their medications. At that time, the CNA reported the residents had not received any medications that day and the former DON had not been on the unit. 15. Interview with the administrator on 11/6/24 at 2:43 PM revealed on 10/10/24, MA-C #1 reported none of the medications were administered to residents on the Courtyard unit. The administrator revealed the former DON was assigned to administer the medications and said he forgot. The administrator revealed the former DON said he had not administered any medications to residents on the Courtyard unit that day. She revealed the scheduling that day was supposed to be a CNA in Courtyard and the former DON was to be available. 16. Interview with nurse practitioner #1 and the administrator on 11/7/24 at 8:56 AM confirmed the staff members scheduled on Courtyard between 6 AM and 6:30 PM were not able to administer medications.

Based on medical record review and staff interview, the facility failed to ensure medical records were accurately documented for 6 of 8 sample residents (#7, #8, #9, #11, #12, #14) reviewed for significant medication errors. The findings were: 1. Review of resident #7's medication administration record for October 2024 showed 10/10/24 the former DON signed off administration of finasteride 5 milligrams (mg) related to benign prostatic hyperplasia with lower urinary tract symptoms, fluoxetine 10 mg related to depression, tamsulosin 0.4 mg related to benign prostatic hyperplasia with lower urinary tract symptoms, and protonix 40 mg related to gastrointestinal hemorrhage, at 6 AM. 2. Review of resident #8's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of cyanocobalamin 1000 micrograms (mcg) related to supplementation, metformin 1000 mg related to type II diabetes mellitus, multiple vitamins tablet related to supplementation, vitamin D3 capsule 25 mcg related to supplementation, acetaminophen 650 mg related to pain and pacing, losartan 50 mg related to hypertension (hold for blood pressure less than 100/60), and Risperdal 1 mg related to dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance at 6 AM. 3. Review of resident #9's medication administration record for October 2024 showed 10/10/24 the former DON signed off administration of dexlansoprazole 60 mg related to gastro-esophageal reflux disease, Zoloft 50 mg related to major depression, divalproex sodium 250 mg related to unspecified dementia, unspecified severity, with other behavioral disturbance, midodrine 5 mg related to orthostatic hypotension, and Seroquel 100 mg related to degeneration of the brain, at 6 AM. 4. Review of resident #11's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of amlodipine 10 mg related to hypertension, donepezil 5 mg related to unspecified dementia without behavioral disturbance, lisinopril 5 mg related to hypertension (hold if blood pressure less than 100/60), meloxicam 7.5 mg related to low back pain, MiraLAX powder 17 gm related to constipation management, and Tylenol 1000 mg related to low back pain, at 6 AM. 5. Review of resident #12's medication administration record for October 2024 showed the former DON signed off administration of calcium-vitamin d 600 mg-220 mg related to vitamin D deficiency and docusate sodium 100 mg related to constipation, at 6 AM. 6. Review resident #14's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of folic acid 1 mg related to supplementation, levothyroxine 75 mcg related to drug-induced thyroiditis, potassium chloride 20 milliequivalent (mEq) related to hypokalemia, tamsulosin 0.4 mg related to benign prostatic hyperplasia, thiamine 100 mg related to supplementation, and pantoprazole 40 mg related to gastro-esophageal reflux disease, at 6 AM 7. Interview with CNA #1 on 11/6/24 at 2 PM revealed on 10/10/24 there was not a staff member passing medications to residents that day. 8. Interview with MA-C #1 on 11/6/24 at 2:23 PM revealed when she left on 10/10/24 she was told to give the keys to courtyard medication cart to MA-C #2 until the former DON came in. MA-C #2 was assigned to the rock creek unit and the only staff member on the courtyard unit was a CNA. When MA-C #1 returned later that day, there continued to be only a CNA on the Courtyard unit. The MA-C revealed the CNA told her no medications had been administered to the residents on the unit and MA-C #1 would need to administer the missed medications. At that time, MA-C #1 notified the administrator and regional operations director the medications had not been administered. The MA-C revealed she was told it was a serious medication error and they would need to notify the regional clinical director. The MA-C revealed the residents in the courtyard unit were pacing and some had elevated blood pressures and she attempted to keep them calm. Further interview revealed when she reviewed the residents' notes they indicated medications had been held due to provider orders. 9. Interview with the former DON on 11/6/24 at 2:35 PM revealed on 10/10/24 he was the only nurse in the building. He stated if he remembered right, he did the morning medications. He revealed he tried to help out but was probably caught up somewhere else or probably kept getting pulled away. 10. Interview with MA-C #2 on 11/7/24 at 12:10 PM revealed on she was asked to work on the Rock Creek unit on 10/10/24 and when she learned there was nobody scheduled for the Courtyard unit, she said she could not do both units. The MA-C revealed she gave the Courtyard unit medication cart keys to the former DON at 8 AM. She revealed she told the former DON she had not administered any medications to residents on the unit. At 11 AM, she was notified by the CNA on the Courtyard unit, of resident behaviors and the CNA needed help. The MA-C went to the unit to try and calm residents. The MA-C revealed the residents were yelling and screaming, threatening others, seemed unsettled, and were getting worked up. The MA-C revealed the behaviors seemed normal for the residents when they had not received their medications. At that time, the CNA reported the residents had not received any medications that day and the former DON had not been on the unit. 11. Interview with the administrator on 11/6/24 at 2:43 PM revealed on 10/10/24, MA-C #1 reported none of the medications were administered to residents on the Courtyard unit. The administrator revealed the former DON was assigned to administer the medications and said he forgot. The administrator revealed the former DON said he had not administered any medications to residents on the courtyard unit that day and she was unsure why the medications were signed off. 12. Interview with nurse practitioner #1 and the administrator on 11/7/24 at 8:56 AM revealed when the administrator spoke to the former DON following the incident on 10/10/24, he was unable to explain why the medications were not administered. They confirmed the other staff members scheduled on Courtyard between 6 AM and 6:30 PM were not able to administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents choice for advance directive for 1 of 18 sample residents (#50). The findings were: 1. Review of the electronic medical record (EHR) Clinical Resident Profile for resident #50 on [DATE] at 8:02 AM showed Code Status: (Advance Directives) ADC: Full Code. 2. Review of a physician's note for resident #50 dated [DATE] and timed 7:16 AM showed .Code Status: ADC FULL CODE . 3. Review of the physician orders for resident #50 showed an order for ADC: Full Code which was active with a start date of [DATE]. 4. Review of the [DATE] WyoPOLST-Providers Orders for Life Sustaining Treatment signed by resident #50 showed Cardiopulmonary Resuscitation (CPR) was marked DNR/Do Not Attempt Resuscitation (Allow Natural Death). 5. Interview with the DON on [DATE] at 9 AM confirmed resident #50 had elected a code status of DNR and the EHR indicated Full code. Further interview revealed the facility should follow the resident's code status election.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure preadmission screening was performed and was accurate for 2 of 18 sample residents (#8, #59) with qualifying diagnoses. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had diagnoses which included depression and bipolar disease. Review of the resident's active diagnosis report showed the resident had diagnoses which included mood disorder due to known physiological condition with mixed features and did not have a primary diagnosis of dementia. The following concerns were identified: a. Review of the PASARR Level I assessment completed on 3/8/23 showed the resident had a qualifying diagnosis of mood disorder due to known physiological condition with mixed features and was marked no for all mental illness screening questions. Further review showed the PASARR Level I screening summary indicated no evidence of mental illness or intellectual disability. A PASARR level II was not triggered or performed. 2. Review of the admission MDS assessment dated [DATE] showed resident #59 had diagnoses which included depression and bipolar disease. The following concerns were identified: a. Review of a PASARR level I completed on 5/23/24 showed the resident had diagnoses which included bipolar disorder and depression and the mental illness screening indicated the resident had a major mental illness. Further review showed the PASARR level I screening summary indicated a categorical 6 determination and the resident was appropriate for convalescent care after acute hospital stay, not to exceed 120 days. Additional information showed .An individualized level II determination will be required on the 120th day if client stay will be extended, please plan accordingly. b. Review of a PASARR Level I completed on 7/3/24 showed the resident had diagnoses which included bipolar disorder and depression and was marked no for all mental illness screening questions. Further review showed the PASARR Level I screening Summary showed No evidence of Mental Illness or Intellectual disability. 3. Interview with the administrator on 9/12/24 at 9:02 AM revealed the facility identified issues with duties performed by social services and the social services director was terminated. Further interview revealed PASARR completion was one of the duties assigned to the social services director. 4. Interview with the administrator on 9/12/24 at 10:58 AM revealed a plan to correct issues with PASARR completion was created; however, she confirmed it had not been implemented at that time. Further interview confirmed the most recent PASARR level I for resident #8 and resident #59 was not completed accurately.

Based on observation and resident and staff interview, the facility failed to ensure mail was delivered and unopened, including on Saturday. The census was 78. The findings were: 1. Interview with 5 residents during a group interview on 9/11/24 at 2 PM revealed the mail was locked up and the facility did not deliver mail on Saturdays. Further, the residents revealed mail was sometimes opened by the business office prior to delivery. 2. Interview with the activities director on 9/13/24 at 9:02 AM revealed she sorted through the mail and if it was not postcards or junk mail, she took it to the business office to open. Further, she revealed that mail was not delivered on Saturdays as the business office was closed. 3. Interview with business office manager on 9/13/24 at 10:20 AM revealed she was new to the facility and still learning what to do with the mail. She revealed she opened the mail to decide where it should go as some would be scanned into the computer for the resident's file and bills for the residents were paid out of their account. She revealed If it's personal mail it's opened here. Sometimes they get stressed over bills and they don't know what to do with them so we do that here. 4. Observation on 9/13/24 at 10:20 AM showed a stack of residents' mail on the desk in the business office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, resident representative, and staff interview, and medical record review, the facility failed to ensure residents received services to maintain good personal hygiene for 3 of 5 sample residents (#8, #25, #53) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had a brief interview for mental status score of 15 out of 15, which indicated no cognitive impairment, and diagnoses which included polyneuropathy, cervicalgia or neck pain, osteoarthritis, and muscle wasting and atrophy. Further review showed the resident required substantial/maximal assistance with bathing. Review of the ADL (activities of daily living) care plan last revised on 4/8/24 showed I have told staff I prefer to have my showers, but I often may refuse my showers and only get 1 a week. If staff if [sic] making up my shower it may not be on the day or time I originally chose, but I am ok with that .BATHING/SHOWERING: I need 1 staff to provide weight-bearing assistance for my shower activities. Encourage me to perform any part of showering I am able . The following concerns were identified: a. Interview with the resident on 9/11/24 at 11:07 AM revealed s/he did not receive showers routinely and s/he felt it was due to the facility not having enough staff. b. Review of the resident's bathing record from 6/29/24 through 9/12/24 showed the resident went without bathing for 6 days between 7/1/24 and 7/9/24, 14 days (including 3 documented refusals) between 7/9/24 and 7/24/24, 9 days between 7/29/24 and 8/8/24, 6 days between 8/12/24 and 8/19/24, 7 days between 8/23/24 and 8/29/24, and 14 days between 8/29/24 and 9/12/24. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #25 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of the care plan last revised on 6/22/24 showed the resident preferred to shower once a week in the morning. The following concerns were identified: a. Interview with the resident on 9/11/24 at 8:55 AM revealed I'm supposed to get showers once a week. Yesterday was my two weeks and I didn't get any. b. Review of the 30-day look-back for the showers tasks showed the resident went 21 days without a shower from 8/6/24 to 8/27/24, and 15 days without a shower from 8/27/24 through 9/11/24. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #53 had a BIMS score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Review of the care plan last revised on 7/31/24 showed the resident preferred to take a shower two times a week during the day. The following concerns were identified: a. Interview with the resident on 9/10/24 at 3:36 PM revealed s/he was supposed to get two showers a week and almost never did. I hear lots of excuses. b. Observation of the resident on 9/10/24 at 3:36 PM showed the resident was wheelchair bound and dependent on others for bathing. The resident's hair was greasy and nails were long. c. Review of the 30-day look back for the showers task showed the resident went 6 days without a shower from 9/5/24 to 9/11/24. 4. Interview with the resident representative for resident #47 on 9/11/24 at 4:15 PM revealed she had concerns about the amount of care residents received and stated the facility was short-handed. 5. Interview with CNA #1 on 9/12/24 at 2:04 PM revealed the staffing levels were not sufficient enough to get resident care done. The CNA revealed she was expected to get showers done; however, she was unable to perform the showers. The CNA revealed showers were completed for residents when staff identified the residents had body odor and really need a shower. Further interview revealed staff had voiced concerns to the leadership team and they were told we are trying; however, felt it was impossible to get all tasks done daily. 6. Interview with CNA #2 on 9/12/24 at 2:07 PM revealed getting normal care done was possible; however, she was not able to get showers completed. Further interview revealed sometimes they had a shower aide; however, she wasn't at the facility daily and only worked 4 hours per day. 7. Interview with CNA #3 on 9/12/24 at 2:19 PM revealed there were not enough CNAs to ensure resident care was performed and CNAs were expected to provide ADL care including showers and making beds, taking meal orders, and picking up and passing room trays for meals. The CNA revealed showers were not completed often, beds are were not made, and linens were not changed as expected. 8. Interview with the DON and director of clinical operations on 9/12/24 at 1:17 PM revealed the facility identified concerns related to bathing and completed an ad hoc meeting on 9/3/24. The leadership team was to audit showers daily on the night shift, discuss the audit results in stand up, and clinical management was to follow up the next day. Further interview confirmed there were residents, including resident #8, who had not received showers prior to or following the ad hoc meeting.

Based on observation, resident, resident representative, and staff interviews, facility staff posting review, and facility assessment review, the facility failed to ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3 of 4 resident care units (Deer, Chapel, Courtyard). The census was 78. The findings were: 1. Observation on the Courtyard Hall (secure unit) on 9/10/24 at 5:10 PM showed MA-C #1 assisted resident #68 who stood up from a recliner and walked across the room. The MA-C attempted to get the resident to sit in his/her wheelchair; however, she was only able to sit the resident sideways in the seat and was unable to reposition the resident safely in the wheelchair. The MA-C required assistance from a second person, and attempted to call 5 people for assistance, which were not answered. Interview with the MA-C revealed this is how it always is. Continued observation showed at 5:16 PM an unidentified non-clinical staff member opened the secure unit door and the MA-C asked them to get some help now! At 5:17 PM (seven minutes later) a CNA arrived to assist and the staff member repositioned the resident in the wheelchair. 2. Observation of the Deer Hall on 9/12/24 at 8:54 AM showed resident #50 yelled from the bathroom No one's coming in here! I've been waiting half an hour! Review of the MDS assessment showed the resident's brief interview for mental status score was 15 out of 15 which indicated no cognitive impairment. 3. Interview with resident #8, who resided on the Chapel Hall, on 9/11/24 at 11:07 AM revealed s/he did not receive showers routinely and s/he felt it was due to the facility not having enough staff. Review of the resident's bathing record from 6/29/24 through 9/12/24 showed the resident went without bathing for 6 days between 7/1/24 and 7/9/24, 14 days (including 3 documented refusals) between 7/9/24 and 7/24/24, 9 days between 7/29/24 and 8/8/24, 6 days between 8/12/24 and 8/19/24, 7 days between 8/23/24 and 8/29/24, and 14 days between 8/29/24 and 9/12/24. 4. Interview with resident #25, who resided on the Deer Hall, on 9/11/24 at 8:55 AM revealed s/he was supposed to get showers once a week, and yesterday was my two weeks and I didn't get any. Review of the 30-day look-back for the showers tasks showed the resident went 21 days without a shower from 8/6/24 through 8/27/24, and 15 days without a shower from 8/27/24 through 9/11/24. 5. Interview with resident #53, who resided on the Deer Hall, on 9/10/24 at 3:36 PM revealed s/he did not receive two showers per week because of staffing. Observation of the resident at that time showed the resident's hair was greasy and his/her nails were long. Review of the 30-day look back for the showers task showed the resident went 6 days without a shower from 9/5/24 through 9/11/24. 6. Interview with the resident representative for resident #10, who resided on the Deer Hall, on 9/11/24 at 11:55 AM revealed when the representative was there to visit there were not a lot of staff to help and the representative had assisted the resident with meals. The representative reported it could be several hours before the resident received assistance. 7. Interview with resident #23, who resided on the Deer Hall, on 9/11/24 at 2 PM revealed that the facility had lost a lot of staff recently. Further interview revealed nothing is getting done after losing administrative staff. The resident also reported to have waited 30 minutes for call lights to be answered, and s/he missed a doctor's appointment as there was no van driver available. 8. Interview with the resident representative for resident #47, who resided on the Chapel Hall, on 9/11/24 at 4:15 PM revealed she had concerns about the amount of care residents received and stated the facility was short-handed. 9. Interview with CNA #4, who worked on the Rock Creek Hall, on 9/12/24 at 1:57 PM revealed the facility continued admitting residents even though they didn't have sufficient staff to take care of the residents already in the facility. The CNA revealed if there were more staff, they could better watch over residents who need closer observation. 10. Interview with CNA #1, who worked on the Deer Hall, on 9/12/24 at 2:04 PM revealed the staffing levels were not sufficient enough to get resident care done. The CNA revealed she was expected to get showers done; however, she was unable to perform the showers. The CNA revealed showers were completed for residents when staff identified the residents had body odor and really need a shower. Further interview revealed staff had voiced concerns to the leadership team and they were told we are trying; however, felt it was impossible to get all tasks done daily. 11. Interview with CNA #2, who worked on the Deer Hall, on 9/12/24 at 2:07 PM revealed getting normal care done was possible; however, she was not able to get showers completed. Further interview revealed sometimes they had a shower aide; however, she wasn't at the facility daily and only worked 4 hours per day. 12. Interview with CNA #3, who worked on the Chapel Hall, on 9/12/24 at 2:19 PM revealed there were not enough CNAs to ensure resident care was performed and CNAs were expected to provide ADL care including showers and making beds, taking meal orders, and picking up and passing room trays for meals. The CNA revealed showers were not completed often, beds are were not made, and linens were not changed as expected. 13. Review of facility staff posting on 9/12/24 at 11 AM showed resident assistant (RA) hours were included in daily staffing hours. Review of the RA job description dated 1/20/23 showed .the resident assistant/CNA trainee provides basic personal service to residents/patients under the direction and supervision of RN, LPN or LVN. Interview with staff scheduler on 9/13/24 at 9:39 AM revealed she was not sure if RA hours could be included in the daily staff hours, but she had included them. 14. Review of the revised facility assessment tool dated 8/6/24 showed the minimum hours per resident days (HPRD) for RN's/LPN's was 0.6 for both day and night shifts, CNAs on day shift was 1.0 and night shift was 0.9. HPRD for a total 2.0 HPRD. 15. Review of the July 2024 nursing schedule showed the facility failed to ensure the minimum staffing requirement identified on the facility assessment was met on 3 days, 7/22, 7/23, and 7/28. 16. Review of the August 2024 nursing schedule showed the facility failed to ensure the minimum staffing requirement identified on the facility assessment on 15 days, 8/1, 8/2, 8/3, 8/9, 8/10, 8/11, 8/12, 8/20, 8/21, 8/22, 8/23, 8/28, 8/29, 8/30, and 8/31. 17. Review of the September 2024 nursing schedule, from 9/1/24 through 9/12/24, showed the facility failed to ensure the minimum staffing requirement identified on the facility assessment was met on 5 days, 9/1, 9/2, 9/5, 9/8, and 9/9. 18. Interview with the administrator, DON, and staff scheduler on 9/13/24 at 9:39 AM confirmed the facility was aware of staffing concerns and revealed they recently had a lot of staff return to school or leave during a recent leadership turnover. The staff scheduler revealed she usually attempted to stick to 2.75 and 2.92 combined HPRD total CNA's and RN/LPN's. They revealed they attempted to staff 24 hours per day for nurses and between 75 and 80 hours on day shift and 34 and 46 hours on night shift for CNAs. They revealed the current open positions included 2 full time day shift and 2 full time night shift nurses and 2 full time day shift and 4 or 5 full time night shift CNAs. Further interview revealed a lot of nurse positions were being covered by MA-Cs who help CNAs; however, they were not assigned to resident care and the MA-C hours were counted in the CNA hours on staff postings.

Based on observation, staff interview, and policy review, the facility failed to ensure medications available for resident use were labeled appropriately in 2 of 5 medication storage areas (Rock Creek Hall medication cart, Deer Hall medication cart). The findings were: 1. Observation of Rock Creek Hall medication administration cart on 9/10/24 at 4:16 PM showed a Novolog insulin pen which was opened and undated. In the top-drawer of the cart, yellow stickers were available for medication labeling. 2. Observation of the Rock Creek Hall medication cart on 9/11/24 at 10 AM showed a Lantus SoloStar insulin pen and Toujeo SoloStar multidose insulin pen which were opened and undated. In the top-drawer of the cart, yellow stickers were available for medication labeling. 3. Observation of the Deer hall medication cart on 9/11/24 at 09:55 AM showed a Basaglar insulin pen which was opened and undated. In the top-drawer of the cart, yellow stickers were available for medication labeling. 4. Interview with the LPN #1 on 9/10/24 at 4:16 PM revealed she did not open the insulin pen and a yellow sticker should have been placed to indicate when the medication was opened, when it would expire, and who opened it. 5. Interview with LPN #2 on 9/11/24 at 10 AM revealed all insulin pens should be labeled with a yellow sticker, dated with an open date and expiration date, and initialed. Further she revealed all insulin pens should be discarded after 28 days from the open date. 6. Interview with the DON on 9/13/24 at 8:23 AM revealed all nurses were responsible for labeling and dating multidose vials of medication upon opening. Further he revealed the nurses were also responsible for indicating the 28-day expiration date on the yellow labels, along with their initials. 7. Review of the policy titled Labeling of Medications and Biologicals dated 4/16/24 showed .Labels for multidose vials must include: the date the vial was initially opened or accessed (needle-punctured) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and MDS 3.0 Resident Assessment Instrument (RAI) manual review, the facility failed to ensure MDS assessments were accurate for 2 of 4 sample residents (#37, #41) reviewed for MDS discrepancies. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #37 was coded as taking anticoagulant and antiplatelet medications. Review of the physician orders showed the resident received Plavix (antiplatelet medication) 25 mg (milligrams) by mouth, one time daily for unspecified sequelae of unspecified cerevrovascular disease; however, there was no indication the resident received an anticoagulant medication. 2. Review of the admission MDS assessment dated [DATE] showed resident #41 was coded as not taking an anticoagulant; however, review of physician orders showed the resident received Rivaroxaban [anticoagulant] 20 mg once per day for a diagnosis of atherosclerotic heart disease of native coronary artery. 3. Interview with the MDS coordinator on 4/4/24 at 11:18 AM confirmed the assessments for both residents were not coded correctly. 4. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual version 1.18.11 last revised October 2023 showed .code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Column 1: Check if the resident is taking any medication by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days). Column 2: If Column 1 is checked, check if there is an indication noted for all medications in the drug class .N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) .N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident and family interviews, and review of facility policies, the facility failed to ensure residents and their representative(s) participated in the development of the care plan for 2 of 2 sample residents (#8, #41) reviewed for care planning. The findings were: 1. Review of the 2/14/24 initial MDS assessment showed resident #8 was admitted on [DATE] and had a BIMS score of 15 out of 15, indicating intact cognition. Review of a progress noted dated 2/12/24 showed Resident recently discharged return not anticipated and it was a failed discharge. Resident readmitted within 72 hours of discharge. Care plan reviewed from previous stay prior to discharge and updated to reflect any changes to resident's care plan. The following concerns were identified: a. During an interview on 4/2/24 at 10:47 AM the resident stated s/he had not been invited to a care conference to participate in the development of a care plan. b. Review of the medical record showed a care conference note from 12/18/23, but no care conference note since the resident's re-admission to the facility on 2/7/24. c. During an interview on 4/4/24 at 10:33 AM the social services designee stated he was unable to find evidence a care conference was completed for the resident after re-admission. 2. Review of the 1/30/24 initial MDS assessment showed resident #41 was admitted on [DATE], had a diagnosis of dementia, and had a BIMS score of 7 out of 15, indicating severe cognitive impairment. Review of guardianship papers dated 4/21/23 showed the resident met the definition of an incompetent person and the resident's daughter was appointed as guardian and conservator. The following concerns were identified: a. During an interview on 4/2/24 at 4:07 PM the daughter stated there had not been a care conference yet. She stated she had left messages with the case manager, but had not received a call back. b. Review of a progress note dated 1/26/24 showed a care conference was held with staff and the resident. The note did not indicate if the daughter, who was the legal guardian, was invited. c. Review of a nursing note dated 4/3/24 showed the daughter was called to provide an update on the resident. The note read .[daughter] stated she has requested a care plan but has not received a call. Care plan scheduled for Tuesday at 1 PM. d. During an interview on 4/4/24 at 10:33 AM the social services designee and the social services assistant stated family members were usually invited for care conferences. They stated they would leave a note if the family was invited but did not participate. 3. Review of the facility's policy Care planning-Resident Participation, revised 1/1/24, showed .The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes .If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications available for resident use were not expired in 1 of 3 medication storage areas (medication storage room). The findings were: 1. Observation of the medication storage room on [DATE] at 5:12 PM showed 2 bottles of Geri-mox (liquid antacid) on the shelf with an expiration date of 3/2024. 2. Interview with the DON on [DATE] at 5:19 PM confirmed the medications were available for resident consumption and had expired. They were immediately removed by the DON at that time. 3. Review of the facility policy Medication Storage revised [DATE] showed It is the policy of this facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consult pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents received timely care in accordance with professional standards for 1 of 24 sample residents (#15). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #15 had severe cognitive impairment and diagnoses which included non-Alzheimer's dementia, anxiety, history of falls, muscle wasting and atrophy, and a history of traumatic brain injury. The resident required extensive physical assistance for bed mobility, locomotion, and dressing and total physical assistance for transfers, eating, toileting, hygiene, and bathing. Further review showed the resident had no falls since admission or the prior assessment. Review of the Behavior care plan last revised on 7/19/23 showed interventions which included .Floor mat or spare mattress will be placed on floor next to [resident's name] bed to ensure s/he is able to safely roll and reposition out of [his/her] bed. [Resident name] at times prefes (sic) to roll off of his/her bed . Review of the Falls care plan last revised on 9/22/23 showed the resident had a fall on 9/22/23 and interventions which included anticipate and meet the resident's needs, be sure the call light is within reach, and encourage the resident to use the call light for assistance as needed. Further review showed .due to my behaviors with movement while in bed, I need my staff to place me in the center of the bed or by the wall to aid in prevention of rolling/falling to the floor . Review of the progress notes from 9/1/23 through 10/2/23 showed the resident had falls on 10/2/23, 9/30/23, 9/24/23, and 9/22/23. The following concerns were identified: a. Observation on 10/2/23 at 5:10 PM showed resident #15 was in his/her room calling out for help. At that time, no staff were observed on the resident's hallway. The resident was lying on the fall mat next to the bed, with his/her legs on the floor and his/her torso positioned between the night stand and the head of the bed. During the observation the call light location was unable to be found and the surveyor attempted to get staff assistance by turning on the emergency call light. At 5:24 PM a social services staff member was observed in the hallway and notified of the resident's position, as no staff members had responded to the emergency call light. The DON, administrator, and a nurse arrived to the resident's room at 5:25 PM, 15 minutes after the resident's initial calls for help. b. Interview with the administrator on 10/2/23 at 5:25 PM revealed the staff member assigned to the 500 hall was expected to answer the call lights, as most the staff members were in the dining areas assisting with resident meal service. Further interview revealed the social services staff member should have checked on the emergency call light to identify what the resident's needs were. c. Interview with the administrator on 10/2/23 at 5:25 PM revealed the staff member assigned to the 500 hall was expected to answer the call lights, as most the staff members were in the dining areas assisting with resident meal service. Further interview revealed the social services staff member should have checked on the resident upon notification of a need for assistance. 2. Interview with the administrator on 10/4/23 at 2 PM revealed he expected staff to answer call lights within 8 minutes, barring certain circumstances. 3. Review of policy Call Lights: Accessibility and Timely Response last revised 8/1/23 showed .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on employee record review and staff interview, the facility failed to follow up to ensure CNA registration on the state nurse aide abuse registry for 1 of 1 CNA (#1) who was recently certified at the time of hire. The findings were: Review of the employee records for CNA #1 showed the hire date was on 3/13/23 and there was no evidence the state nurse aide abuse registry was checked prior to resident contact. Interview with the DON on 10/4/23 at 4:14 PM revealed CNA #1 was hired and certified on 3/13/23. Further interview confirmed the facility attempted to register the CNA on 10/4/23. Interview with the administrator on 10/4/23 at 4:34 PM confirmed the facility did not have evidence the CNA was on the state nurse aide abuse registry.

Based on observation, staff interview, and policy review the facility failed to provide call light accessibility for 1 of 24 initial pool residents (#15). The findings were: 1. Observation on 10/2/23 at 5:10 PM showed resident #15 was observed on the floor calling out for help. Further observation showed the call light location could not be found. 2. Interview with CNA #3 and #4 on 10/4/23 at 3:10 PM revealed the resident had a pull type call light; however, they were unsure if the resident was able to use it. 3. Observation on 10/4/23 at 3:12 PM showed the resident was lying in bed, awake. A full sized mattress was against the wall and a fall mat was on the floor beside bed. Further observation showed the call light was clipped to itself and placed above the mattress on the wall, out of the resident's reach. 4. Observation with the DON on 10/4/23 at 4:15 PM showed the resident was lying in bed and the call light was on top of a full sized mattress which was leaning against the wall. The call light was clipped to itself and positioned just below the call light switch, out of reach of the resident. Interview with the DON at that time revealed the resident should have the call light beside him/her and confirmed the resident was able to pull the call light cord for help. Further interview confirmed the resident could not reach the call light from where s/he was lying. 5. Interview with the administrator on 10/4/23 at 2 PM revealed he expected staff to answer call lights within 8 minutes, barring certain circumstances. 6. Review of policy Call Lights: Accessibility and Timely Response last revised 8/1/23 showed .1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.5. Staff will ensure the call light is with reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations with the resident's room. 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor

Based on observation, staff interview, review of policy and procedures, and 2022 FDA Food Code review, the facility failed to ensure a sanitary environment in 1 of 1 food preparation area. The census was 77. The findings were: 1. Observation on 10/4/23 at 9:13 AM showed cook #1 was starting the food preparation tasks for the noon meal. The cook was wearing a beard restraint around his neck; however, he had not placed the restraint so it covered his beard. At 9:39 AM the dietary manager entered the kitchen and assisted cook #1 by trimming fat off of the raw chicken pieces. The dietary manager was not wearing a beard restraint. Interview with the dietary manager at 10:08 AM revealed beard restraints were only required while serving food. 2. Observation in the kitchen on 10/4/23 starting at 9:13 AM until 10:10 AM and again from 11:02 AM until 12:27 PM showed cook #1 and dietary aide #1 failed to ensure hand hygiene was performed as required. The following concerns were identified: a. Observation at 9:24 AM showed cook #1 used a hand antiseptic; opened the steam oven door; prepared a baking sheet; and opened a box of pre-made frozen rolls. Without performing hand hygiene the cook donned gloves and placed the rolls onto the pan using his gloved hands. At 9:29 AM cook #1 doffed his gloves and without performing hand hygiene, placed the pan of rolls on the steam table; packaged the unused rolls in the box; and returned the box to the freezer. b. Observation at 9:53 AM showed cook #1 used a hand antiseptic and retrieved a plastic storage bag; donned gloves and placed the discarded raw chicken pieces into the plastic bag. The cook doffed his gloves and used hand antiseptic; however, he did not wash his hands with soap and water. c. Observation at 11:35 AM showed cook #1 used a hand antiseptic; donned gloves, and transferred the baked rolls to a serving pan with his gloved hands, doffed his gloves, and covered the rolls with plastic wrap. Without performing hand hygiene, the cook donned a glove on his right hand and retrieved a hamburger patty from the walk-in refrigerator, and placed it on the grill. The cook doffed the glove and without performing hand hygiene, obtained a second serving pan; donned new gloves, and transferred the remaining rolls into the pan. d. Observation at 11:47 AM showed dietary aide #1 used a hand antiseptic; retrieved supplies to make peanut butter and jelly sandwiches; donned gloves, and proceeded to prepare the sandwiches, touching the bread with her gloved hands. e. Observation of the kitchen's supply of hand antiseptic showed 3 bottles of a promotional hand antiseptic with an expiration date of 5/2023; 1 bottle of a scent therapy antiseptic, and one bottle of Epi Clenz hand antiseptic. None of the hand antiseptic bottles indicated they had been FDA approved for use in a kitchen. f. Interview with the dietary manager on 10/4/23 at 4:46 PM confirmed hand antiseptic should not be used in the kitchen area and only on the service line. The dietary manager discarded the hand antiseptic bottles at that time. 3. Review of the policy Food Safety Requirements, last revised 8/1/23, showed .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. e. Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad . 4. Review of the 2022 FDA Food Code showed 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 5. According to the 2022 FDA Food Code showed 2-301.16 Hand Antiseptics. In the 2005 Food Code, the use of the term hand sanitizer was replaced by the term hand antiseptic to eliminate confusion with the term sanitizer, a defined term in the Food Code, and to more closely reflect the terminology used in the FDA Tentative Final Monograph for Health-Care Antiseptic Drug Products for OTC Human Use, Federal Register: June 17, 1994. In addition, 2-301.16 Hand Antiseptics (A) A hand antiseptic used as a topical application, a hand antiseptic solution used as a hand dip, or a hand antiseptic soap shall: (1) Comply with one of the following: (a) Be an APPROVED drug that is listed in the FDA publication Approved Drug Products with Therapeutic Equivalence Evaluations as an APPROVED drug based on safety and effectiveness; (b) Have active antimicrobial ingredients that are listed in the FDA monograph for OTC Health-Care Antiseptic Drug Products as an antiseptic handwash, . 6. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ¶ 2-403.11(B); (D) Except as specified in ¶ 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.