Every finding on record at Avir at Waco

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 development and transmission of communicable diseases and infections for one (Resident #1) of four residents reviewed for infection control. The facility failed to ensure staff practiced hand hygiene when performing perineal care (Incontinence care). The failure put residents at risk for infection, hospitalization, and decreased quality of life.Findings included: During the record review on 04/05/2026, the medical electronic record of Resident #1 revealed the residents the admission date was 02/03/2026 and the initial admission date was 06/13/2026. Resident #1 had a history of TYPE 2 DIABETES MELLITUS (Blood sugar becomes too high) WITHOUT COMPLICATIONS, SEPSIS (Serious infection), EPILEPSY (Sudden changes in movement or awareness), HYPERLIPIDEMIA (Fat-cholesterol level is high), HYPERTENSION (High blood pressure), POLYNEUROPATHY (Many nerve damage), and ANEMIA (Not enough oxygen in the blood). Resident #1 code status was DNR. During an observation of the Resident #1's perineal care on 04/05/2026 at 11:15 AM, CNA-A performed perineal care by cleansing the resident's anterior area and subsequently repositioned the Resident #1's to provide posterior care without performing hand hygiene during glove change. CNA-A put on a new pair of gloves without hand hygiene, then put on the socks and shoes for Resident #1. During an interview on 04/05/2026 at 11:28 AM, CNA-A stated she changed the gloves three times during care. CNA-A stated that she did not change gloves between the front and back cleaning, but did change gloves after cleaning the back side. CNA-A applied the moisture barrier cream with the second pair of gloves, then CNA-A put the clothes back on the resident and transferred Resident #1 from bed to the wheelchair with the same gloves. CNA-A stated she changed the gloves for the second time, which was the third pair without hand hygiene, and put the socks and shoes back on the resident. CNA-A stated that after putting on her socks and shoes, CNA-A brushed the resident's hair, then washed her hands in the restroom. CNA-A stated she did not perform hand hygiene after changing the gloves.CNA-A stated that if she does not follow proper hand hygiene techniques, she could pass germs to the resident and to herself. During an interview on 04/05/2026 at 3:18 PM, RN-B stated that you wash your hands as soon as you change your gloves. During record review on 04/05/2026 of the facility policy titled Perineal Care, revision date February 2018 stated discard soiled gloves, sanitize hands, and re-glove prior to touching other clean areas like clean linens/adult briefs. The facility policy titled Personal Protective Equipment, revision date February 2018, stated under Applying and Removing Gloves:1. Perform hand hygiene before applying non-sterile gloves.2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff.3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove.5. Perform hand hygiene. The policy stated that supplies necessary for hand hygiene include alcohol-based hand rub containing at least 60% alcohol for most clinical situations.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards.The facility failed to label a large plastic bottle of purified water, which was kept in Resident #1's room, as hummingbird water, which RN A poured into Resident #1's CPAP water reservoir on 03/09/2026. This failure could place residents at risk of infection or exposure to fungus.Findings included:Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, and cognitive communication deficit. Resident #1 had a BIMS score of 07-indicating severe cognitive impairment.Review of Resident #1's comprehensive care plan dated 03/11/2026 reflected the resident required use of a CPAP machine at bedtime for diagnosis of obstructive sleep apnea as evidenced by a sleep study conducted on 12/10/2025. The interventions included: 3/11/25-Obtain vital signs every 4 hours for 7 days. Licensed nurse to perform and document respiratory assessment assessing for signs of infection every 4 hours for 7 days; Respiratory Therapist to visit and assess resident every day for 7 days. Fill CPAP reservoir with distilled water only every night. Clean [CPAP] mask and tubing with antibacterial soap, rinse with water until clearand hang to dry weekly on Monday mornings and as needed.Review of Resident #1's sleep study report dated 12/10/2025 revealed a respiratory analysis of a total of 139 obstructive events of which 111 were obstructive apneas (partial or complete blockage of the upper airway), 28 were hypopneas (shallow breaths). The respiratory arousal index was 44.4/hr (44.4 times per hour that the brain is aroused due to respiratory events). Her baseline oxygen saturation (percentage of hemoglobin in the blood that carries oxygen) was 92% while awake. The lowest de-saturation (decrease in the oxygen saturation of the blood) was 73%. A new diagnosis was reported on this date of Obstructive sleep apnea with an order for nightly use of CPAP.Review of Resident #1's physician orders active as of 03/12/2026 revealed an order for '[CPAP] to be worn at night. On at HS, off in AM Settings: 7cmH20 at bedtime.' Ordered on 01/07/2026.Review of facility self-report undated, revealed, Resident's [family member] notified the respiratory therapist that the night nurse had filled the resident's CPAP reservoir with hummingbird water. This bottle of sugar water was contained in a disposable plastic water bottle with the label purified water. The water was light yellow in color. Upon report of this occurring the respiratory therapist immediately performed a respiratory assessment with no deviations from baseline noted. On 03/11/26, the resident attended a pulmonology appointment, accompanied by her RP. Upon return, her RP reported to the respiratory therapist that the pulmonologist had stated the occurrence was very, very dangerous and the resident would need to be monitored closely for a bacterial infection and that the CPAP would need to be replaced or sterilized.In an interview on 03/12/2026 at 10:30 AM with Resident #1's RP, she stated that the bottle of water used to refill the CPAP machine on 03/09/2026 by RN A was a jug of hummingbird water, which was a mixture of tap water and granulated sugar, that was filled around July 2025 by the family, and the jug was kept sitting underneath the residents refrigerator near the bird seed in her room.Observation of an AEM video timestamped 03/09/2026 at 6:05:56 PM, revealed RN A looking near Resident #1's bed and saying where is your water at? She handed Resident #1 her CPAP mask to apply to her face and continued looking for distilled water. RN A then turned around and could be heard saying, oh there it is, and was seen bending down and picking up a bottle of water that had a blue label from an area beneath where the AEM was located. She took the bottle over to Resident #1's nightstand and poured the water into the CPAP machine, returned the bottle of water to the place she found it, and left the room. Observation of an AEM video timestamped 03/09/2026 at 6:25:49 PM, LVN B was observed entering Resident #1's room, removed the CPAP mask off Resident #1, and began looking at the CPAP machine.In an interview on 03/12/2026 at 12:12 PM with RN A, she stated she had been working at the facility for 2 years and worked night shift. She stated that when she went into Resident #1's room on 03/09/2026, she noticed the resident was asleep in bed. She woke up the resident, had her put her CPAP mask on and noticed the water reservoir on the CPAP was empty. She stated she did not see the distilled water bottle that was normally on Resident #1's nightstand or floor next to it. She stated she found a labeled bottle of purified water under the resident's refrigerator, and used it because the water looked clear and that the restroom light was on in the room and she could see adequately. She stated she was then told by the nurse at the nurses station that the water she had used was hummingbird food, and that there were bottles of distilled water in the medication room. She stated she had tried to clean out the water reservoir with water and tissues. She stated that normally the distilled water was kept in the resident's room, and if there was not any in the room, it would be in the medication room, and last time she went into the medication room there was no distilled water. She stated that purified water was not the same as distilled water, and that she thought it was okay to use because at least it was not tap water. She stated that she did not recall receiving specific training at this facility on CPAP use. She stated that she was supposed to clean the mask, the hose, and the reservoir after every use. She stated she could not detach the reservoir from Resident #1's machine in order to clean it. She stated the expectations were that the mask and hoses were to be cleaned after every use and to be air dried when the resident was awake. She stated that the machine was to be cleaned with soap and water and rinsed thoroughly. She stated that she cleaned Resident #1's with a tissue and water, because she was just doing what she could until she was told not to take care of the Resident #1 anymore. She stated that she would not do anything to put Resident #1 harms way. She stated she was very emotional after this incident, and she was suspended pending a facility investigation . She stated that a negative outcome could be that the resident could get sick.In an observation and interview on 03/12/2026 at 12:38 PM, Resident #1 was lying in bed in her room. She stated that she did not wear her CPAP often, and she did not recall the incident with RN A from the other night.In an interview on 03/12/2026 at 2:08 PM with LVN B, she stated that she normally did not work Resident #1's hall, so she was not aware the hummingbird water was kept in her room. She stated that she knew Resident #1 had recently started using the CPAP machine. She stated that she got a phone call from Resident #1's RP at the nurse's desk, and the RP told LVN B that RN A had poured hummingbird water into Resident #1's CPAP. LVN B stated she then went into Resident #1's room and took the CPAP off the resident, and took the hummingbird water to the medication room. She stated the room was a little dark, and you would have had to turn on a light to see better, but the water did look discolored to her. She stated that the jug of water RN A used was not the type of jug they usually used for CPAP machines, but that they used a milk jug type. She stated that she believed this incident was just a mistake and was not a pattern for RN A. She didn't know of any negative outcome that could happen.In an interview on 03/12/2026 at 2:23 PM with the RT, she stated she was familiar with Resident #1 because she had hooked up the CPAP machine when it first arrived for Resident #1. She stated that a CPAP machine was for oxygenation, it would help a patient that had, from mild to severe (Resident #1 had severe she stated), sleep apnea, and the humidified water would be going into one's lungs. She stated the water to be used in the humidifier was sterile or distilled. She stated that she did not know what a mixture of tap water and granulated sugar would do to the lungs by inhaling it, but it was dangerous to have in the machine, because it could coat the machine. It could, over time, also cause bacteria to build up in the machine, which could potentially cause a bacterial infection in the lungs, if breathed in over a long period of time. She stated that breathing complications would only occur if bacteria were breathed in for a long period of time, like a whole night. The RT stated that she personally cleaned Resident #1's CPAP machine on 03/09/2026, with soap and water. She stated that Resident #1's pulmonary doctor told the facility to take the CPAP out of service. She stated that it was her understanding Resident #1 had been without her CPAP for 2 nights. She stated that negative outcomes could be that Resident #1's oxygen could have dropped, she could have had long pauses of not breathing during her sleep, potentially be very drowsy during the day. She stated that normally the vitals were done by the nurses, but she would be doing them until next week for Resident #1. She stated that she would be responsible for doing respiratory assessments daily, for the next 7 days, which were to include: checking Resident #1's heartrate, breath sounds (respirations), and an oxygen check, and all of the assessments she had conducted so far had no abnormal findings. She stated that she last would have done CPAP/BIPAP training in December at this facility. In an interview on 03/12/2026 at 3:37 PM with the MD, he stated that Resident #1 went to a pulmonary appointment 2 days after the incident. He stated that the facility did an x-ray and it came back normal. He stated that the facility informed him of how the incident happened. He stated that if Resident #1 would not have gone to the pulmonary doctor, and if the facility had continuously administered that water mixture it could build up in the machine, and the biggest risk would be that the residue would be getting stuck in the chamber. He stated that he thought Resident #1 being administered that mixture of water 1 or 2 times was not dangerous, but that the facility would need to monitor the resident for fever, and signs or symptoms of infection, he stated he would be worried if the machine got colonized and not cleaned out. In an interview on 03/12/2026 at 3:48 PM with the FNP, who saw Resident #1 in her clinic on 03/11/2026, stated she had not read any scholarly articles on this matter. She stated the concern she had was how long this water mixture had been used, or if this was the first time. She stated that she told the family to look out for any signs of infection (cough, fever). She stated she supposed there could be potential for infection or risk for fungus if continued use over a period of time. She stated that when she saw Resident #1, she did not see anything out of the resident's normal baseline, there were no signs of distress, or coughing, and if she had heard anything abnormal on her lungs, an x-ray that would have been the first thing she obtained. She told the family that Resident #1 needed to be monitored.In an interview on 03/13/2026 at 10:43 AM with the DON, she stated that the facility's investigation into the incident with Resident #1 had not been completed yet, but that that they had gotten the statement from RN A, and RN A was suspended pending completion of the investigation. She stated the incident was not intentional, the hummingbird water bottle was not clearly labeled, and from her observation, the water was cloudy but not necessarily a color. She stated that she did not think it was malicious. She stated that the facility did use that same bottle when they obtained them from the supplier, the milk jugs were from the grocery store, when they ran out of supplier water. She stated that she was not aware of how long the bottle of hummingbird water had been in Resident #1's room. She stated that they would start focusing on potential room hazards during angel rounding. She stated that this was such an off thing that she was unsure what negative outcomes could occur, unless this substance had bee administered to Resident #1 for an extended period of time. She stated that because of the type of substance it was, she felt that it would have messed up the machine before it would have hurt the resident. She stated to the best of her knowledge RN A had not used that bottle of hummingbird water before this incident. She stated that the resident went 1 night without the CPAP after it was taken out of service on 03/11/2026. The new machine was delivered to the facility on [DATE], and Resident #1 used it that night.Review of the facility's policy titled CPAP/BiPAP Support, undated, reflected, Humidifier water- Empty the humidifier chamber in the morning, rinse it, and leave it empty during the day. Refill it with fresh distilled water in the evening before using it.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care.RN A knowingly used a bottle of water labeled purified water instead of using distilled water, as she was trained to use by the facility to fill Resident #1's CPAP reservoir on 03/09/2026.RN A failed to follow the care plan and training to use only distilled water resulting in Resident #1's CPAP air being humidified with sugar water and Resident #1 being without the use of her CPAP on 03/11/2026.These failures could place residents at risk of receiving incorrect or inadequate treatment and could result in exposure to fungus and/or infection. Findings included:Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, and cognitive communication deficit. Resident #1 had a BIMS score of 07-indicating severe cognitive impairment.Review of Resident #1's comprehensive care plan dated 03/11/2026 reflected the resident required use of a CPAP machine at bedtime for diagnosis of obstructive sleep apnea as evidenced by a sleep study conducted on 12/10/2025. The interventions included: 3/11/25-Obtain vital signs every 4 hours for 7 days. Licensed nurse to perform and document respiratory assessment assessing for signs of infection every 4 hours for 7 days; Respiratory Therapist to visit and assess resident every day for 7 days. Fill CPAP reservoir with distilled water only every night. Clean [CPAP] mask and tubing with antibacterial soap, rinse with water until clearand hang to dry weekly on Monday mornings and as needed.Review of Resident #1's sleep study report dated 12/10/2025 revealed a respiratory analysis of a total of 139 obstructive events of which 111 were obstructive apneas (partial or complete blockage of the upper airway), 28 were hypopneas (shallow breaths). The respiratory arousal index was 44.4/hr (44.4 times per hour that the brain is aroused due to respiratory events). Her baseline oxygen saturation (percentage of hemoglobin in the blood that carries oxygen) was 92% while awake. The lowest de-saturation (decrease in the oxygen saturation of the blood) was 73%. A new diagnosis was reported on this date of Obstructive sleep apnea with an order for nightly use of CPAP.Review of Resident #1's physician orders active as of 03/12/2026 revealed an order for '[CPAP] to be worn at night. On at HS, off in AM Settings: 7cmH20 at bedtime.' Ordered on 01/07/2026.Review of facility self-report undated, revealed, Resident's [family member] notified the respiratory therapist that the night nurse had filled the resident's CPAP reservoir with hummingbird water. This bottle of sugar water was contained in a disposable plastic water bottle with the label purified water. The water was light yellow in color. Upon report of this occurring the respiratory therapist immediately performed a respiratory assessment with no deviations from baseline noted. On 03/11/26, the resident attended a pulmonology appointment, accompanied by her RP. Upon return, her RP reported to the respiratory therapist that the pulmonologist had stated the occurrence was very, very dangerous and the resident would need to be monitored closely for a bacterial infection and that the CPAP would need to be replaced or sterilized.In an interview on 03/12/2026 at 10:30 AM with Resident #1's RP, she stated that the bottle of water used to refill the CPAP machine on 03/09/2026 by RN A was a jug of hummingbird water, which was a mixture of tap water and granulated sugar, that was filled around July 2025 by the family, and the jug was kept sitting underneath the residents refrigerator near the bird seed in her room.Observation of an AEM video timestamped 03/09/2026 at 6:05:56 PM, revealed RN A looking near Resident #1's bed and saying where is your water at? She handed Resident #1 her CPAP mask to apply to her face and continued looking for distilled water. RN A then turned around and could be heard saying, oh there it is, and was seen bending down and picking up a bottle of water that had a blue label from an area beneath where the AEM was located. She took the bottle over to Resident #1's nightstand and poured the water into the CPAP machine, returned the bottle of water to the place she found it, and left the room. Observation of an AEM video timestamped 03/09/2026 at 6:25:49 PM, LVN B was observed entering Resident #1's room, removed the CPAP mask off Resident #1, and began looking at the CPAP machine.In an interview on 03/12/2026 at 12:12 PM with RN A, she stated she had been working at the facility for 2 years and worked night shift. She stated that when she went into Resident #1's room on 03/09/2026, she noticed the resident was asleep in bed. She woke up the resident, had her put her CPAP mask on and noticed the water reservoir on the CPAP was empty. She stated she did not see the distilled water bottle that was normally on Resident #1's nightstand or floor next to it. She stated she found a labeled bottle of purified water under the resident's refrigerator, and used it because the water looked clear and that the restroom light was on in the room and she could see adequately. She stated she was then told by the nurse at the nurses station that the water she had used was hummingbird food, and that there were bottles of distilled water in the medication room. She stated she had tried to clean out the water reservoir with water and tissues. She stated that normally the distilled water was kept in the resident's room, and if there was not any in the room, it would be in the medication room, and last time she went into the medication room there was no distilled water. She stated that purified water was not the same as distilled water, and that she thought it was okay to use because at least it was not tap water. She stated that she did not recall receiving specific training at this facility on CPAP use. She stated that she was supposed to clean the mask, the hose, and the reservoir after every use. She stated she could not detach the reservoir from Resident #1's machine in order to clean it. She stated the expectations were that the mask and hoses were to be cleaned after every use and to be air dried when the resident was awake. She stated that the machine was to be cleaned with soap and water and rinsed thoroughly. She stated that she cleaned Resident #1's with a tissue and water, because she was just doing what she could until she was told not to take care of the Resident #1 anymore. She stated that she would not do anything to put Resident #1 harms way. She stated she was very emotional after this incident, and she was suspended pending a facility investigation . She stated that a negative outcome could be that the resident could get sick.In an observation and interview on 03/12/2026 at 12:38 PM, Resident #1 was lying in bed in her room. She stated that she did not wear her CPAP often, and she did not recall the incident with RN A from the other night.In an interview on 03/12/2026 at 2:08 PM with LVN B, she stated that she normally did not work Resident #1's hall, so she was not aware the hummingbird water was kept in her room. She stated that she knew Resident #1 had recently started using the CPAP machine. She stated that she got a phone call from Resident #1's RP at the nurse's desk, and the RP told LVN B that RN A had poured hummingbird water into Resident #1's CPAP. LVN B stated she then went into Resident #1's room and took the CPAP off the resident, and took the hummingbird water to the medication room. She stated the room was a little dark, and you would have had to turn on a light to see better, but the water did look discolored to her. She stated that the jug of water RN A used was not the type of jug they usually used for CPAP machines, but that they used a milk jug type. She stated that she believed this incident was just a mistake and was not a pattern for RN A. She didn't know of any negative outcome that could happen.In an interview on 03/12/2026 at 2:23 PM with the RT, she stated she was familiar with Resident #1 because she had hooked up the CPAP machine when it first arrived for Resident #1. She stated that a CPAP machine was for oxygenation, it would help a patient that had, from mild to severe (Resident #1 had severe she stated), sleep apnea, and the humidified water would be going into one's lungs. She stated the water to be used in the humidifier was sterile or distilled. She stated that she did not know what a mixture of tap water and granulated sugar would do to the lungs by inhaling it, but it was dangerous to have in the machine, because it could coat the machine. It could, over time, also cause bacteria to build up in the machine, which could potentially cause a bacterial infection in the lungs, if breathed in over a long period of time. She stated that breathing complications would only occur if bacteria were breathed in for a long period of time, like a whole night. The RT stated that she personally cleaned Resident #1's CPAP machine on 03/09/2026, with soap and water. She stated that Resident #1's pulmonary doctor told the facility to take the CPAP out of service. She stated that it was her understanding Resident #1 had been without her CPAP for 2 nights. She stated that negative outcomes could be that Resident #1's oxygen could have dropped, she could have had long pauses of not breathing during her sleep, potentially be very drowsy during the day. She stated that normally the vitals were done by the nurses, but she would be doing them until next week for Resident #1. She stated that she would be responsible for doing respiratory assessments daily, for the next 7 days, which were to include: checking Resident #1's heartrate, breath sounds (respirations), and an oxygen check, and all of the assessments she had conducted so far had no abnormal findings. She stated that she last would have done CPAP/BIPAP training in December at this facility. In an interview on 03/12/2026 at 3:37 PM with the MD, he stated that Resident #1 went to a pulmonary appointment 2 days after the incident. He stated that the facility did an x-ray and it came back normal. He stated that the facility informed him of how the incident happened. He stated that if Resident #1 would not have gone to the pulmonary doctor, and if the facility had continuously administered that water mixture it could build up in the machine, and the biggest risk would be that the residue would be getting stuck in the chamber. He stated that he thought Resident #1 being administered that mixture of water 1 or 2 times was not dangerous, but that the facility would need to monitor the resident for fever, and signs or symptoms of infection, he stated he would be worried if the machine got colonized and not cleaned out. In an interview on 03/12/2026 at 3:48 PM with the FNP, who saw Resident #1 in her clinic on 03/11/2026, stated she had not read any scholarly articles on this matter. She stated the concern she had was how long this water mixture had been used, or if this was the first time. She stated that she told the family to look out for any signs of infection (cough, fever). She stated she supposed there could be potential for infection or risk for fungus if continued use over a period of time. She stated that when she saw Resident #1, she did not see anything out of the resident's normal baseline, there were no signs of distress, or coughing, and if she had heard anything abnormal on her lungs, an x-ray that would have been the first thing she obtained. She told the family that Resident #1 needed to be monitored.In an interview on 03/13/2026 at 10:43 AM with the DON, she stated that the facility's investigation into the incident with Resident #1 had not been completed yet, but that that they had gotten the statement from RN A, and RN A was suspended pending completion of the investigation. She stated the incident was not intentional, the hummingbird water bottle was not clearly labeled, and from her observation, the water was cloudy but not necessarily a color. She stated that she did not think it was malicious. She stated that the facility did use that same bottle when they obtained them from the supplier, the milk jugs were from the grocery store, when they ran out of supplier water. She stated that she was not aware of how long the bottle of hummingbird water had been in Resident #1's room. She stated that they would start focusing on potential room hazards during angel rounding. She stated that this was such an off thing that she was unsure what negative outcomes could occur, unless this substance had bee administered to Resident #1 for an extended period of time. She stated that because of the type of substance it was, she felt that it would have messed up the machine before it would have hurt the resident. She stated to the best of her knowledge RN A had not used that bottle of hummingbird water before this incident. She stated that the resident went 1 night without the CPAP after it was taken out of service on 03/11/2026. The new machine was delivered to the facility on [DATE], and Resident #1 used it that night.Review of the facility's policy titled CPAP/BiPAP Support, undated, reflected, Humidifier water- Empty the humidifier chamber in the morning, rinse it, and leave it empty during the day. Refill it with fresh distilled water in the evening before using it.

Based on interview and record review, the facility failed to provide pharmaceutical services, (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of (Resident #30. Resident #62 & Resident #83) of 5 residents reviewed for pharmacy services.The facility failed to administer Resident #30's antipsychotic medication Risperidone 1mg two times a day for schizophrenia as prescribed from 02/01/2026-02/03/2026 during the standard time frame.The facility failed to administer Resident #62's antipsychotic medication Risperidone 0.5mg two times a day for schizophrenia as prescribed from 02/01/2026-02/05/2026 during the standard time frame.The facility failed to administer Resident #83's antiseizure medication Valproic Acid 15ml two times a day and Venlafaxine 75 MG 1 capsule a day for depression as prescribed from 02/01/2026-02/05/2026 during the standard time frame.This failure could place residents at risk for serious complications such as increased behaviors, seizures, and/or increased depressive episodes. The findings included: Review of Resident #30's annual MDS assessment dated [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: acute kidney failure, schizophrenia (a mental disorder characterized by a disruption in thought process), and moderate intellectual disabilities. He had a BIMS score of 1, indicating severe cognitive impairment. Review of Resident #30's comprehensive care plan dated 05/28/2022 and revised 12/19/2025 reflected he was care planned for diagnosis of anxiety. Exhibits signs and symptoms of anxiety/behaviors. A risk for side effects to medications. Interventions included Monitor for side effects to medications to include but not limited to dizziness, drowsiness, nausea, headache, fatigue, diarrhea, insomnia, and notify medical doctor of abnormal findings, provide medications as ordered. Review of Resident #30's active doctor's orders as of 2/05/2026 reflected an order for Risperidone 1mg two times a day for schizophrenia. Review of Resident #30's medication administration audit report dated 02/01/2026-02/05/2026 filtered by late administrations greater than 1 hour revealed the following: An order for Risperidone 1mg two times a day for schizophrenia was scheduled to be administered on 02/01/2026 at 9:00 a.m. but was administered at 10:20 a.m.An order for Risperidone 1mg two times a day for schizophrenia was scheduled to be administered on 02/02/2026 at 9:00 a.m. but was administered at 11:36 a.m.An order for Risperidone 1mg two times a day for schizophrenia was scheduled to be administered on 02/03/2026 at 9:00 a.m. but was administered at 10:16 a.m. In an observation on 02/05/2026 at 9:15 a.m. of Resident #30 revealed he was clean and up in his wheelchair sitting in the day area. Resident #30 was not interview able. MA D administered Resident # 30 his medications. Review of Resident #62's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: muscle weakness, schizophrenia (a mental disorder characterized by a disruption in thought process), and major depression. She had a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #62's comprehensive care plan dated 08/29/2025 reflected he was care planned for Resident has a diagnosis of schizophrenia. At risk for side effects to medications Interventions included Observe for side effects, adverse reaction from medication to include but not limited to agitation, sedation, headache, sleep disturbance, and notify medical doctor of abnormal findings, provide medications as ordered. Review of Resident #62's active doctor's orders as of 2/05/2026 reflected an order for Risperidone 0.5mg two times a day for schizophrenia. Review of Resident #62's medication administration audit report dated 02/01/2026-02/05/2026 filtered by late administrations greater than 1 hour reflected the following: An order for Risperidone 0.5mg two times a day for schizophrenia was scheduled to be administered on 02/01/2026 at 8:00 a.m. but was administered at 09:59 a.m., scheduled for 4:00 p.m. but was administered at 5:13 p.m.An order for Risperidone 0.5mg two times a day for schizophrenia was scheduled to be administered on 02/02/2026 at 8:00 a.m. but was administered at 11:41 a.m.An order for Risperidone 0.5mg two times a day for schizophrenia was scheduled to be administered on 02/03/2026 at 8:00 A.M. but was administered at 10:59 a.m., scheduled for 4:00 p.m. but was administered at 5:30 p.m.An order for Risperidone 0.5mg two times a day for schizophrenia was scheduled to be administered on 02/04/2026 at 8:00 a.m. but was administered at 9:54 a.m., scheduled for 4:00 p.m. but was administered at 5:13 p.m.An order for Risperidone 0.5mg two times a day for schizophrenia was scheduled to be administered on 02/05/2026 at 8:00 a.m. but was administered at 9:06 a.m. In an observation and interview on 02/05/2026 at 9:06 a.m. Resident #62 was clean in her bed, alert and dressed in her pajamas. She stated she was not feeling well and wished to remain in bed. MA D administered Resident #62 her medications. Review of Resident #83's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: high blood pressure, hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone), lumbago with sciatica (a condition that causes pain in the lower back and legs due to nerve compression), anxiety (feelings of worry, nervousness, or unease), and depression (persistent feelings of sadness, loss of interest). She had a BIMS score of 14, indicating intact cognition. Review of Resident #83's comprehensive care plan revealed she was care planned for being at risk of alteration in comfort, at risk for pain presence r/t sacroiliitis, lumbago with sciatica and the goals were to have pain alleviated with both pharmacological interventions and nonpharmacological interventions.She was care planned for having episodes of anxiety and at risk for fluctuation in moods and the goal was to maintain the anxiety at a tolerable level demonstrated by reduced anxiety from proper medication. The interventions included administering medications as ordered, monitor and document s/sx of adverse effects of medications given.She was care planned for potential complications r/t hypothyroidism and the interventions included to administer prescriptions as ordered by the MD. She was care planned for having hypertension and the interventions included to give anti-hypertensive medications as ordered. Review of Resident #83's active doctor's orders as of 2/05/2026 reflected an order for Valproic Acid 15ml two times a day for seizures. An order for Venlafaxine 75 MG 1 capsule a day for depression. Review of Resident #83's medication administration audit report dated 02/01/2026-02/05/2026 filtered by late administrations greater than 1 hour revealed the following:An order for Valproic Acid 15ml two times a day for seizures was scheduled to be administered on 02/01/2026 at 7:00 A.M. but was administered at 09:12 A.M., scheduled for 7:00 PM but was administered at 8:58 PM.An order for Valproic Acid 15ml two times a day for seizures was scheduled to be administered on 02/02/2026 at 7:00 A.M. but was administered at 09:17 A.M., scheduled for 7:00 PM but was administered at 9:50 PM.An order for Valproic Acid 15ml two times a day for seizures was scheduled to be administered on 02/03/2026 at 7:00 A.M. but was administered at 09:51, scheduled for 7:00 PM but was administered at 8:50 PM.An order for Valproic Acid 15ml two times a day for seizures was scheduled to be administered on 02/04/2026 at 7:00 A.M. but was administered at 08:46 A.M.An order for Valproic Acid 15ml two times a day for seizures was scheduled to be administered on 02/05/2026 at 7:00 A.M. but was administered at 11:31 A.M. An order for Venlafaxine 75 MG one time a day for depression was scheduled to be administered on 02/05/2025 at 9:00 A.M. but was administered at 11:31 A.M. In an interview on 02/04/2026 at 1:47 PM with Resident #83, she stated that she had a seizure this past Monday (2/02/2026), but did not require hospitalization, and that she took medication for her seizure disorder twice a day. She stated that sometimes they receive their medications after breakfast, and that she was supposed to receive her seizure medication at 7 A.M., but that she never missed her doses. She stated that with her medication, she still occasionally had seizures, but they were controlled and did not require hospitalization. She stated that since her admittance to the facility she had not been admitted to the hospital. In an interview on 02/05/2026 at 9:50 a.m. MA D stated if she sees medications were going to be late, she would notify the nurse. The Nurse will notify the doctor to ensure it was safe to give the medication to the resident. The Medication aides were responsible for making sure residents got their medications on time. She stated on time means a 2-hour window. She said the negative effects for not giving residents medications within a time limit could include overall health such as blood pressure could lead to unregulated blood pressure. In an interview on 2/5/26 at 2:11 p.m. the DON stated all nurses and medications aides were responsible for ensuring medications were given in a timely manner. Administration does not run a late medication report daily, so they had not monitored late medications. Medications should be given within an hour before or an hour after designated time on the order. If staff were late administering medications, nurse managers need to be notified so they can assist and get them caught up if needed. She stated the medication aides were checked off on medication pass annually and as we identify any issue. Pharmacy does medication pass [NAME] with the medication aides. The potential risk for residents receiving medications later than allotted time could include pain or blood pressure could be too high. Record review of facility policy titled Administering Medications dated April 2019 reflected: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.1. The facility failed to ensure sanitation practices (cleaning the dishwasher from buildup).2. The facility failed to ensure all items were covered and stored properly in the pantry and freezer.3. The facility failed to label and date all food items in the kitchen.This failure could place residents at risk of foodborne illness. Findings included:In an initial observation on 02/04/2026 at 9:05 AM the kitchen pantry revealed opened bags of cereal placed inside plastic labeled and dated bags that were not properly sealed to limit exposure to outside air. An opened package of cornstarch was observed in the dry pantry and the contents were exposed to the air. In an initial observation on 02/04/2026 at 9:10 AM in the facility's only kitchen revealed 2 bags of chopped yellow squash with no label or use by date in the freezer, and an opened box of frozen biscuits exposed to freezer air.In a follow up observation on 02/05/2026 at 8:48 AM in the facility's only kitchen revealed the top of the low temperature dish washing machine that was at about eye level of a 5 foot 5 inch person, was covered in food particle build up at the door that opened to insert dirty dishes, and the door that opened to remove clean dishes. In an interview on 02/04/2026 at 9:30 AM, the DM stated that normally after serving a meal the kitchen staff would individually label and date food items in the pantry or freezer. She stated that the cornstarch in the pantry was supposed to be placed inside a clear plastic bag and labeled and dated, not just folded up, and that the cereal had been used for the breakfast meal and was not properly sealed shut afterwards. She stated a negative outcome if foods were exposed, would be contamination or losing their nutritional value. In an interview on 02/06/2026 at 2:30 PM with the DON, she stated that she did not oversee the kitchen, but that the ADM did. She stated that she thought their expectation concerning labeling and dating of food products was that the kitchen dated all food items and stored all food items in order to prevent debris from getting in the food. Additionally, that they were to not give expired or contaminated foods to residents, which could cause food borne illness. In an interview on 02/06/2026 at 2:40 PM with the ADM, stated their expectations concerning labeling and dating of food items was that the kitchen staff labeled and dated food items when they were delivered by the vendor, and/or by the facility policy. He stated that if a food item was not properly sealed bugs could get in the packaging. The ADM stated if labeling and dating practices were not followed that could negatively affect residents by diminished taste, spoiled food, and diminished health status. The ADM stated their expectation concerning kitchen cleaning and general sanitation was that the kitchen followed company policies for cleaning and general sanitation. He stated that the top of the dishwasher should probably be cleaned after each meal. He stated that cross contamination could occur if clean dishes were going through a dirty machine. Review of the facility's policy titled Food Receiving and Storage dated November 2022 reflected, Foods shall be received and stored in a manner that complies with safe food handling practice. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated foods are stored in such a way that promotes adequate air circulation around food storagecontainers. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging untilthey are ready to use.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident # 68) of six residents reviewed for infection control. IP A failed to wear enhanced barrier precautions (a protective layer over clothing to prevent the spread of germs) during an observation of wound care on 2/05/2026.This failure could place residents at risk of cross contamination which could result in infections or illness. Findings included:Review of Resident #68's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: heart failure, hypertension (elevated blood pressure), Diabetes Mellitus (elevated blood sugars), and depression. He had a BIMS score of 15, indicating intact cognition.Review of Resident #68's comprehensive care plan reflected he had a chronic non-healing wound or indwelling medical device. This places them at an increased risk of transmission of MDROs. Interventions included change personal protection equipment before caring for other residents. Face protection may be needed if performing activity with risk for splash or spray. Personal protection equipment will be used for the following situations during resident care: dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, or assisting with toileting. Date Initiated: 07/07/2025In an interview on 02/04/2026 at 3:01 PM Resident #68 denied any abuse or neglect. He stated he does have wounds, and the facility nurse does care for them. He stated the wound doctor sees him weekly in the facility.In an observation on 02/05/2026 at 10:11a.m., IP A performed wound care to Resident #68s right leg. Wound care to right lower extremity, posterior: Cleanse with wound cleanser, pat dry, apply Calcium Alginate (a type of dressing to promote healing) and cover with dry dressing. Resident #68 denied any pain prior to and during care. The IPN did not use enhanced barrier precautions during wound care. Signage was posted for enhanced barrier precautions at the residents' door.In an interview on 02/05/2026 at 10:35 a.m. IP A stated she should have used enhanced barrier precautions while performing wound care. She stated it just slipped her mind. She stated she has been instructed on using EBC and educated on infection control. She said not using enhanced barrier precautions could spread infection. In an interview on 02/05/2026 at 2:11 p.m. the DON stated all nurse management ADON and DON educate staff on enhanced barrier precautions. The DON said the DON and ADON were responsible for monitoring infection control and use of enhanced barrier precautions. She stated all nurses should use enhanced barrier precautions when performing wound care. The negative effects of not using enhanced barrier precautions could be the spread of infection. Record review of facility policy titled Enhanced Barrier Precautions dated March 2024 reflected 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include wound care (any skin opening requiring a dressing).

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #14) reviewed for care plans. The facility failed to include that Resident #14 was on droplet precautions in her comprehensive care plan. The facility failed to provide interventions for the care plan problem of Resident #14 having a UTI. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.Findings included: Record review of Resident #14's face sheet dated 02/05/26 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had a diagnoses of Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), osteoporosis (a common silent bone disease occurring when bone density decreases, causing bones to become weak, brittle, and highly prone to fractures, particularly in the hip, spine, and wrist), influenza (the flu) (is a highly contagious viral infection of the respiratory system, causing fever, cough, fatigue, sore throat, and muscle aches, typically lasting 7 to 14 days), and urinary tract infection (UTI) (is an infection caused by bacteria-most commonly Escherichia coli-that enters and multiplies within any part of the urinary system, including the kidneys, ureters, bladder, and urethra). Record review of Resident #14's Quarterly MDS assessment dated [DATE], reflected that Resident #14 had a BIMS score of 00 which reflected the resident was severely cognitively impaired. Resident #14's Quarterly MDS assessment reflected that the resident required supervision or touching assistance with eating, was dependent on staff for toileting, and required substantial/maximum assistance with showering and personal hygiene. Resident #14's Quarterly MDS reflected that the resident was always incontinent of bowel and bladder. Record review of Resident #14's Physician's Orders, dated 02/05/26, reflected the resident had an order initiated on 01/30/26 for: Resident is on antibiotic therapy for (UTI/FLU). every shift for 10 days. Physicians Orders dated 01/30/26 reflected Resident #14 was taking levofloxacin Oral Tablet 750 MG(Levofloxacin) with an end date of 02/06/26. Physician orders dated 01/30/26 reflected Resident #14 was on Droplet isolation - gown, gloves, mask or respirator where applicable, and eye protection. Document if resident is compliant and if resident is in a single room. Disposable equipment preferred but if unavoidable, clean and disinfect such equipment immediately after use. Record review of care plan dated 01/31/26 reflected Resident #14 had not been care planned for being placed on droplet precautions. Resident #14's care plan dated 01/31/26 reflected Resident #14 has Influenza A with a goal of resident will be free from s/sx of dehydration as evidenced by good skin turgor with interventions that included Encourage good fluid intake and offer residents favorite beverages. Give antipyretics and analgesics as ordered for fever and pain. Monitor/document side effects and effectiveness. Monitor/document/report PRN for signs of dehydration: poor skin turgor, dry mucous membranes, slowed capillary refill, increased heart rate (Tachycardia), cool dry skin, sunken eyeballs, decreased urinary output, difficulty breathing (Dyspnea), hypotension. Resident #14's care plan dated 02/04/26 reflected Resident #14 has a Urinary Tract Infection with a goal of resident's urinary tract infection will resolve without complications by the review date. Resident #14's UTI care plan reflected no interventions. In an observation on 02/04/26 at 12:40 PM, Resident #14's door had signage on the door for droplet precautions with a cart of PPE placed outside of Resident #14's room beside the door. In an observation on 02/04/26 at 12:42 PM, Resident #14 was sitting up in her wheel chair in her room with her call light in reach. Resident #14 appeared pleasantly confused. Resident #14 was awake and alert but not responsive to surveyors questions. Resident was dressed appropriately for the weather and appeared clean and groomed. Resident showed no signs of pain or distress. In an interview on 02/06/26 at 12:22 PM, the MDS nurse stated she was responsible for the care plans. She stated she had been trained on completing care plans correctly. She stated it was a group effort and all of the IDT (herself, DON, Social Worker, and Wound Care Nurse) team did their part. She stated she or the ADON or DON would put in a care plan about droplet precautions if a resident was on those precautions. She stated she was not aware that Resident #14 did not have a care plan for droplet precautions. She stated she thought she had care planned Resident #14 for the droplet precautions because resident had the FLU. She stated droplet precautions was absolutely something that should be care planned. She stated she was not aware that Resident #14's care plan did not include interventions for resident's UTI, but the UTI should have most definitely been on there. She stated there could have been a potential spread of infection to other residents if droplet precautions were not care planned and the staff did not know to take those precautions. In an interview on 02/06/26 at 1:14 PM, MA C, stated she had worked in the facility for about 2 years. She stated she was in-serviced on following residents care plans. She stated she knew where to find the residents care plans and she followed the care plans to provide care to the residents. In an interview on 01/27/26 at 1:31 PM, CNA E stated she had worked in the facility for about 2 years. She stated she was in-serviced on following residents care plans. She stated she knew where to find the residents care plans and they were in their electronic records. She stated she followed the care plans to provide care to the residents. In an interview on 01/27/26 at 1:41 PM, LVN A stated she had worked in the facility for about 7 months. She stated she was in-serviced on following residents care plans. She stated she knew where to find the residents care plans and she followed the care plans to provide care to the residents. In an interview on 01/27/26 at 2:05 PM, LVN B stated she had worked in the facility for about 6 months. She stated she was in-serviced on following residents care plans. She stated she knew where to find the residents care plans and she followed the care plans to provide care to the residents. In an interview on 01/27/26 at 2:11 PM, the DON stated she was in-servicing staff regularly on following residents care plans. She stated all nurses knew where to find the residents care plans and the CNA's knew where to find the tasks that rolled over from the care plans which shows the transfer requirements and assistance needed. She stated the staff should follow the care plans to provide care to the residents. She stated if they were unsure or there was a change in the amount of assistance the resident needed, the staff would come to her so the resident could be evaluated by therapy and the care plan could be changed. She stated she, the MDS nurse, the ADON, and the Care Plan Nurse were responsible for completing the care plans and they all did different parts. She stated with an acute change she or the MDS would do that. She stated she also initiated the initial care plans. She stated those staff and herself have been trained on completing the care plans correctly and if they had questions they would come to her. She stated if a resident was on droplet precautions it should be a part of the residents care plan. She stated Resident #14 had the FLU and she was on droplet precautions. She stated she was not aware that Resident #14's care plan did not include droplet precautions. She stated she was the one that care planned Resident #14 for the FLU but she failed to care plan resident for being on droplet precautions. She stated if a resident was on droplet precautions and it was not care planned it could cause a potential spread of infection to other residents. She stated interventions should have been in place for residents UTI and she was not aware there were not interventions added until recently. She stated she put the care plan in for the UTI but must have forgotten to add the interventions. In an interview on 02/06/26 at 3:06 PM, CNA F stated she had worked in the facility for about a year. She stated she was in-serviced on following residents care plans. She stated she knew where to find the residents care plans. She stated she follows the care plans to provide care to the residents. Record review of facility policy dated 2001 and revised March 2022 titled reflected Care Plans, Comprehensive Person-Centered: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

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 [DATE] 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 [DATE] 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 [DATE] at 9:28 AM of kitchen juice dispenser machine revealed orange and red sticky buildup on underside of dispenser near dispenser nozzles. Observation on [DATE] at 9:32 AM of kitchen table mounted can opener revealed black and brown buildup on inside of can opener. Observation on [DATE] at 9:32 AM of back kitchen prep area of 2 55-gallon trash cans without lids secured and trash debris inside. Observation on [DATE] 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 [DATE] 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 [DATE] at 9: 38 AM of kitchen equipment temperature logs revealed temperature logs were not completed on refrigerators and freezers for ([DATE],28,29,30,31 [DATE],29,30 [DATE],28). Observation on [DATE] 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 [DATE] at 9:46 AM of kitchen dry storage area revealed a dented can of mandarin oranges dated ,d+[DATE] 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 [DATE] at 9:52 AM of kitchen cooktop range drip pans revealed drip pans to have spilled dried food debris on them. Observation on [DATE] 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 [DATE] 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 [DATE] 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 [DATE] at 1:50 PM of [NAME] C with beard guard down under chin with exposed facial hair while running dish machine. Observation on [DATE] 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 [DATE] 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 [DATE] 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 [DATE] at 10:20 AM of [NAME] C with beard guard down below mustache while in kitchen. Observation on [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] at 10:02 AM of back kitchen prep area revealed a 55-gallon trash can without lid secured with trash debris inside. Observation on [DATE] at 10:20 AM of [NAME] C with beard guard down below mustache while in kitchen. Observation on [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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.

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 1/4 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 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.

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.

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 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 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 admitted [DATE] and readmitted [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.

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 1/2 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 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 Don 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.

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 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.

Based on observation, interview, the facility failed to post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides and Resident Census at the beginning of each shift in a prominent place readily accessible to residents and visitors. The facility did not post the required staffing information on 10-31-2023, 11-1-2023, and 11-2-2023. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per each shift daily. Findings include: Based on observation throughout the facility on 10-31-2023 from 8:00 AM till 3:30 PM, 11-1-2023 from 8:00 AM till 4:00 PM, and 11-2-2023 from 8:00 AM till 3:45 PM, the facility did not post the required nurse staffing information in a visible location and in a readable format. Interview and observation on 11-2-23 at 3:45 PM with the ADM revealed that the postings were placed near the front of the lobby. The ADM walked to the front of the lobby to point out the nurse staffing postings, but they were not there. Interview on 11-2-2023 at 5:00 PM with the DON revealed that they were new at the DON position and was not aware of the posting requirement and that it would be investigated. Interview on 11-2-2023 at 5:05 PM with the ADM revealed that the facility had posted the required nurse staffing in the past and was unsure why the nurse staffing was not posted during the times of recertification survey. Interview and observation 11-2-2023 at 5:10 PM with the DON revealed that the nurse staffing information was in a five-inch-thick black binder located at the nursing station. The DON stated that LVN A was responsible for creating the document and posing it in a visible location in a readable format. Interview on 11-2-2023 at 5:11 PM with LVN A revealed that the nurse staffing information was created each day. LVN A stated that she usually posted the information at the nurse's station, but had not for 10-31-2023, 11-1-2023, and 11-2-2023 because they had been working on the floor providing care. The facility did not present a policy, requested on 11-2-2023 from the ADM at 3:45 PM, governing the requirement to prominently display the nurse staffing information in a visible location and in a readable format.