Every finding on record at Bethel Lutheran Home

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for 49 of 49 sampled residents when: 1. Licensed Vocational Nurse (LVN) 4 went into Resident 1's room, who was on contact precautions (requiring staff and visitors to wear gloves and gowns when entering the room, wash hands thoroughly, and use special equipment to prevent touching the patient or their stuff to stop germs from spreading from a sick person to others), and performed patient care without wearing personal protective equipment (PPE) such as a gown and gloves. This failure placed all residents LVN 4 came in contact with at risk for cross contamination (when harmful bacteria move from one item to another), of bacteria that could result in resident infections and illness. 2. The dietary cook (DC) 1 was observed cooking with his side beard exposed and did not have a hair net covering that area. This failure had the potential to put residents at risk of cross contamination that could result in the transmission of infections and pathogens (germs that invade the body and cause illness) which could lead to infection, hospitalization, or death. 1. During a review of Resident 1's admission Record (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/5/25, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (the paralysis or severe weakness affecting one entire side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke where a blood clot blocks a blood vessel in the brain, cutting off oxygen and nutrients, causing brain cells to die) affecting right dominant side and methicillin staphylococcus aureus infection (MRSA- a dangerous, contagious bacterial infection resistant to many common antibiotics, often starting as skin issues like red, swollen, pus-filled sores resembling boils or spider bites, but can spread to cause severe infections in blood, lungs, or bones. Spread through skin-to-skin contact or contaminated surfaces, it's treated with specific antibiotics and by draining abscesses, with prevention focusing on hygiene like frequent handwashing and covering wounds). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 10/16/25, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 7 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was severely impaired. During a review of Resident 1's Order Summary Report (OSR), dated 12/5/25, the OSR indicated .Order Summary: . Contact Precautions due to wound with MRSA as per Centers for Disease Control and Prevention/. facility policy. Active: 10/10/25. During an observation on 12/3/25 at 2:20 p.m., in Resident 1's room, Resident 1's door when entering her room has a sign labeled .CONTACT PRECAUTIONS. STOP. Perform hand hygiene before entering and before leaving room. Wear gloves when entering room and when touching patients intact skin, surfaces, or articles in close proximity. Wear gown when entering room and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. Resident 1 also had a cart with gown and gloves outside of her room that was not accessed. LVN 4 walked into her room without personal protective equipment (PPE -staff use things like gloves, masks, and gowns to create a barrier that prevents the spread of invisible germs (viruses, bacteria) going between sick people and the healthcare workers) and turned the resident's body while adjusting her pillows underneath her right side. LVN 4 made contact with the resident, her bed and her pillows. During an interview on 12/3/25 at 4:15 p.m., with LVN 4, LVN 4 stated Resident 1 was on contact precautions for a MRSA infection. LVN 4 stated the expectation for a resident on contact precautions is to wear the proper PPE, which would be a gown and gloves before she interacted with the resident. LVN 4 stated she did not put any PPE on before having given Resident 1 care and she should have. LVN 4 stated she could have cross contaminated other residents that she interacted with after she left Resident 1's room. LVN 4 stated by not having worn PPE, other Residents could potentially get sick from her error. During an interview on 12/5/25 at 2:33 p.m., with Charge LVN 1, LVN 1 stated Resident 1 was on contact precautions and PPE needed to be put on before any staff member enters her room. LVN 1 stated if PPE was not worn when providing care for Resident 1, her MRSA infection could spread to other residents. During an interview on 12/5/25 at 2:33 p.m., with the Infection Preventionist (IP), the IP stated the expectation for all staff was to gown and glove up when caring for Resident 1. The IP stated Resident 1 had MRSA diagnosis and this was a highly contagious infection. The IP stated PPE should be put on before entering Resident 1's room and it was not. The IP stated staff should take off the PPE before leaving the room and there was a sign on Resident 1's door that said what should be done. The IP stated LVN 4 did not meet the facility expectation and could have cross-contaminated the infection to herself, co-workers, family members, or other residents. The IP stated that facility's policy and procedure Isolation- Categories of Transmission Based Precautions was not followed. During an interview on 12/5/25 at 3:12 p.m., with the Director of Nursing (DON), the DON stated the PPE expectation when entering Resident 1's room was not met. The DON stated there was a contact precautions sign on Resident 1's door that explicitly said what to do in order to care for her. The DON stated all of the supplies (gown, gloves) were right outside her room in the hallway. The DON stated cross contamination to other residents could occur and they could become ill. The DON stated the facility policy and procedure Isolation- Categories of Transmission Based Precautions was not followed. During review of the facility's policy and procedure (P&P) Isolation- Categories of Transmission Based Precautions, dated September 2022, indicated, .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact Precautions. Contact precautions are implemented for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care [BB1] [LP2] items in the residents environment. Staff and visitors wear gloves (clean, non-sterile) when entering the room. hand hygiene performed before leaving the room. staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. During a review of National Library of Medicine.org professional reference titled, Precautions, Bloodborne, Contact, and Droplet, dated 9/4/23 (found at https://www.ncbi.nlm.nih.gov/books/NBK551555/) the reference indicated, . Contact Precautions. Defined as direct or indirect contact with a patient and/or his or her environment including person's room or objects in contact with the person, that has an infection with. such as methicillin-resistant Staphylococcus aureus (MRSA). PPE defined by the CDC required before entering a contact precaution designated room is always gloves and a gown. Health-care team members, including physicians, nurses, and nursing assistants, should pay close attention to proper PPE use and isolation precautions for the personal safety and safety of the patients. It is also crucial for team members to enforce isolation precautions on visitors and other members not complying with standard protocols to reduce infection transmission within the workplace. 2. During an observation on 12/3/25 at 11:18 a.m. in the kitchen, DC 1 wore a hair restraint (a hairnet that keeps a person's beard completely covered) while he cooked. DC1's hair restraint did not cover his entire beard and left his side beard exposed with no hair restraint covering the area.During a concurrent observation and interview on 12/3/25 at 11:19 a.m. with the Dietary Supervisor (DS) in the kitchen, DC1 was observed cooking with side beard exposed and no hair restraint covering the area. The DS stated all hair including facial hair must always be covered with a hair restraint. The DS stated she spoke to DC1, DC1 adjusted his hair restraint to cover his side beard and washed his hands. The DS stated that it was important to have all hair covered so that hair did not get on the food and contaminate it. The DS stated that if a resident found hair on their food it could lead to the resident refusing to eat it.During an interview on 12/5/25 at 7:52 a.m. with the Director of Staff Development (DSD)/ Infection Preventionist (IP), DSD/IP stated she audits the kitchen once a week for infection control practices (set of practices and procedure used to stop germs from spreading and causing illness) and checks the staff for hair restraints, hand hygiene, and cleanliness. The DSD/IP stated that her expectation in the kitchen was that all hair be covered at all times to avoid hair falling on the food and contaminating it. The DSD/IP stated hair has bacteria on it and could lead to foodborne illness (a sickness caused by eating or drinking contaminated food, water, or beverages) and cross contamination. The DSD/IP stated if a resident were to find hair on their food, it could lead to the resident's loss of appetite and refusal of food. DSD/IP stated the facility had a vulnerable population and refusing to eat the food could lead to weight loss and cause serious health problems for the resident. DSD/IP stated the facility's policy was to have hair covered at all times while in the kitchen.During an interview on 12/5/25 at 2:13 p.m. with the Director of Nursing (DON), the DON stated her expectation in the kitchen was that all hair needed to be covered the entire time staff was in the kitchen to minimize the chance of hair falling into the food. The DON stated if hair were to fall into the food, it would cause cross contamination that could lead to foodborne illness. The DON stated the facility's policy was not followed for infection control in the kitchen when DC 1's beard was not covered completely.During a review of the facility's Diet Type Report, dated 12/4/25, the Diet Type Report indicated, 49 out of 49 residents at the facility received food from the kitchen.During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, (undated) the P&P indicated, .General Guidelines.2.Cross-Contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms [bacteria, viruses, etc. not seen with the naked eye] are transferred. 3.Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.Food Distribution and Service.8.Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.During a review of the Food and Drug Administration (FDA) Food Code 2022, Hair restraints section 2-402.11, indicated, .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review, the facility failed to ensure food and beverages were stored, distributed, and served safely in accordance with professional standards of food service safety for 49 out of 49 residents eating at the facility when: 1. Three packages of bread were expired in the dry good pantry.2. Two opened cereal containers were not labeled with received, opened and expiration dates in the dry good pantry.3. One opened crushed rosemary seasoning was expired in the kitchen preparation area.4. One lemon juice bottle was stored below meat and had a wet, yellow spotted sticky substance on the bottle in the serving preparation fridge.These failures had the potential to result in the serving of expired or contaminated food and beverage items which could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).1. 1. During a concurrent observation and interview on 12/2/25 at 10:17 a.m. with the Dietary Supervisor (DS), in the dry good pantry, three packages of bread were observed with an expiration date of 11/30/25. The DS stated the three packages of bread were expired and expected to have been removed from the dry good pantry on 11/30/25.2. During a concurrent observation and interview on 12/2/25 at 10:35 a.m. with the DS, in the dry good pantry, one opened cereal container was labeled with initials and a date of 10/24/25. The label did not indicate if 10/24/25 was a received, open or expiration date. The second opened cereal container was observed with initials and a date of 11/11/25. The label did not indicate if 11/11/25 was a received, open or expiration date. The DS stated when cereal bags were opened, it was transferred into a cereal container and labeled with a received (R ), opened (O), and expiration (EXP) date followed by the corresponding date. The DS stated the two opened cereal containers were not labeled correctly. The DS could not state if the dates on the two open cereal container labels were received, opened, or expiration dates. The DS stated all opened and transferred food items placed into containers required a R,O, EXP label with the corresponding date and staff initials. 3. During a concurrent observation and interview on 12/2/25 at 10:53 a.m. with the DS, in the kitchen preparation area, one opened bottle of crushed rosemary seasoning was observed with an expiration date of 8/15/24. The DS stated the crushed rosemary seasoning was expired and should not be in the kitchen preparation area for use. The DS stated every evening the night shift dietary cook was responsible to check food items in the kitchen for accurate labeling, dating and expiration. The DS stated she performed weekly audits to check food for accurate labeling, dating and expiration. The DS stated the Registered Dietician (RD) performed monthly audits to check food for accurate labeling, dating and expiration. The DS stated expired food items were not fresh and could affect the taste of food which could result in residents not eating or enjoying their meal. The DS stated expired food items could spoil and result in food borne illness or have decreased nutrition if consumed.4. During a concurrent observation and interview on 12/2/25 at 11:13 a.m. with DC 3, in the serving preparation fridge, a bottle of lemon juice was observed on the bottom shelf under turkey lunch meat and hot dogs. The bottle of lemon juice was observed with a wet, yellow spotted sticky substance on the top and sides of the bottle. DC 3 stated the bottle of lemon juice was expected to be clean, free from debris and residue. DC 3 stated the bottle of lemon juice should not have been placed under the turkey meat or hotdogs because it could leak on the lemon juice bottle and cause cross contamination. DC 3 stated the contamination could lead to food borne illness or illicit a food allergy if the lemon juice was served to a resident with allergies to the substance on the bottle.During an interview on 12/5/25 at 9:36 a.m. with the Registered Dietician (RD), the RD stated expired food items were to be removed from the kitchen on their expiration date. The RD stated all kitchen staff were responsible to identify and remove expired food items. The RD stated all food items were to be labeled with received, open and expiration dates to prevent expired food items from being stored or served. The RD stated there was a risk for expired food items being served to residents if they were left in the kitchen past their expiration date. The RD stated expired food items could spoil, lose their taste, quality and nutrients. The RD stated it was important to remove expired food items from the kitchen to prevent food borne illness which could make residents sick. The RD stated all food items were expected to be stored clean and free from debris. The RD stated lemon juice was a ready to serve food item and should not be stored under food items like turkey meat or hotdogs that could potentially cross contaminate the juice served to residents. The RD stated cross contamination could cause food borne illness or illicit food allergies which could result in serios medical condition. During an interview on 12/5/25 at 2:13 p.m. with the Director of Nursing (DON), the DON stated expired food items were to be removed from the kitchen on their expiration date to prevent serving expired food items. The DON stated all food items in the kitchen were to be labeled with received, opened and expiration dates to prevent serving expired food items. The DON stated all food items were expected to be served in a safe and sanitary environment free from cross contamination. The DON stated facility policy had not been followed when three bags of expired bread were kept in the dry good pantry, two cereal containers were not properly labeled, one bottle of expired crushed rosemary was kept in the kitchen preparation area and one lemon juice bottle was stored under meats with an unknown substance on the bottle. The DON stated residents receiving food from the kitchen were at risk of foodborne illness and cross contamination which could result in serious medical condition.During a review of the facility's in -service titled, Labeling and Dating, dated 11/16/25, the in-service indicated it was important to label food items to prevent food spoilage, cross contamination and food illness. The in-service indicated if a food item was missing a label the food item was to be discarded. The in-service indicated a food label required product name, preparation date, use by date and initials.During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated 11/2022, the P&P indicated, . all food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is open.supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.refrigerators and freezers are kept clean, free of debris, and disinfected.During a review of the facility's P&P titled, Food Preparation and Service, undated, the P&P indicated, .cross contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross- contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods.food preparation staff adhere to proper hand hygiene and sanitary practices to prevent the spread of foodborne illness.During a review of the facility's P&P titled, Food Receiving and Storage, dated 11/2022, the P&P indicated, .dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in-first out system .all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) .refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded .

Based on interview and record review, the facility failed to ensure pharmaceutical services kept accurate records for 23 out of 23 residents when 37 controlled substance medication (medication with a high potential for physical and mental dependence) entries, from 6/26/25-11/18/25, did not have a Registered Nurse witness signature for destruction on 11/20/25 in the controlled drug disposition log. This failure resulted in inadequate record keeping of controlled substance medication which had the potential to lead to inaccurate controlled medication inventory, diversion (when healthcare providers obtain or use prescription medicines illegally) of controlled medications and delayed identification of controlled medication diversion. During a concurrent interview and record review on 12/4/25 at 3:25 p.m. with the Director of Nursing (DON) the facility's Controlled Drug Disposition Log (CDL), dated 6/26/25-11/18/25, was reviewed. The DON stated the CDL required all entries to be filled out on the form to be considered complete and accurate. The DON stated the DON and the Consultant Pharmacist (CP) destroyed controlled medications together and both signed the CDL to ensure controlled substance medications were accounted for and disposed of. The DON stated on 11/20/25 she destroyed 37 controlled substance medications, which had been held from 6/26/25-11/18/25, for 23 residents with the CP. The DON stated she did not sign the 37 controlled substance medication entries for destruction on 11/20/25. The DON stated her destruction signature as the witnessing Registered Nurse was required to ensure the CP destroyed the correct medication in the correct quantity. The DON stated it was important the CDL was correctly and accurately completed to prevent drug diversion and ensure all controlled substance medications were accounted for and destroyed accurately with the CP. During an interview with the Consultant Pharmacist (CP) on 12/5/25 at 11:44 a.m., the CP stated he visited the facility monthly and destroyed controlled substance medication as needed. The CP stated controlled substance medication destruction timeframes varied depending on the controlled substance medication lock box capacity. The CP stated he destroyed controlled substance medication with the DON when the controlled substance medication lock box reached capacity. The CP stated before medication destruction a verification of medication and quantity was confirmed, and both the CP and the DON signed the CDL. The CP stated all entries on the CDL were required to be filled out and completed to ensure accurate tracking and destruction of controlled substance medication. The CP stated the DON's signature was required on the CDL to ensure a verification of controlled substance medication destruction occurred. During an interview on 12/5/25 at 2:13 p.m. with the DON, the DON stated her signature was required on the CDL for each resident's controlled substance medication disposal date. The DON stated her signature ensured the CP had a witness when destroying controlled substance medications and all medications were accounted for at the time of destruction. The DON stated facility policy and procedure was not followed on 11/20/25 when 37 controlled substance medications for 23 residents, held from 6/26/25-11/18/25, were destroyed with the CP and she did not sign the CDL as the destruction witness. The DON stated there was a risk for inaccurate controlled medication inventory, diversion of controlled medications and delayed identification of controlled medication diversion. During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 11/2022, the P&P indicated, .medications that cannot be returned to the dispensing pharmacy (e.g., non unit-dose medications, medications refused by the resident, and/or medications left by the residents upon discharge) are disposed of in accordance with federal, state and local regulations.individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that : the receiving pharmacist and a registered nurse employed by the facility sign a separate log.the medication disposition record contains, as a minimum, the following information.signature of witness.

Based on observation, interview, and record review, the facility failed to accurately label and store medications in one of two medication carts and one of two medication rooms when:1. Medication cart, referred to as, medication cart B, contained one prescription medication with no expiration date for one resident (Resident 30)2. Medication room, referred to as, medication room C, contained one expired prescription medication for one resident (Resident 6). This failure had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications.During a concurrent observation and interview on 12/2/25 at 2:29 p.m. with Licensed Vocational Nurse (LVN) 3, medication cart B was observed behind nursing station B. Resident 30's morphine sulfate (controlled substance medication used to treat pain) 15 milligram (mg-a unit of measurement) prescription medication was observed with no use by or expiration date on the pharmaceutical label. LVN 3 stated Resident 30 had not been administered morphine sulfate 15 mg since it had been ordered. LVN 3 stated she could not locate a use by or expiration date on Resident 30's morphine sulfate 15 mg prescription medication. LVN 3 stated all prescription medication from the pharmacy should be delivered with an expiration or use by date on the pharmaceutical label. LVN 3 stated when Resident 30's medication was delivered to the facility the receiving nurse should have identified the lack of a use by or expiration date and reported it to the pharmacy. LVN 3 stated it was important all medication had an expiration date or use by date label to ensure expired medication was not administered. LVN 3 stated if expired medication was administered it could lose its potency and not have the intended desired effect or cause adverse reactions. During a review of Resident 30's Order Summary (OSR), dated 12/4/25, the OSR indicated Resident 30 was ordered morphine sulfate oral tablet 15 mg every 2 hours as needed for pain on 10/17/25. 2. During a concurrent observation and interview on 12/2/25 at 3:30 p.m. with LVN 4, medication room C was observed locked behind nursing station C. Resident 6's triamcinolone acetonide injection kit 40 mg/ml (milliliters- a unit of measurement) was observed with an expiration date of 11/29/25. LVN 4 stated Resident 6's triamcinolone acetonide injection kit 40 mg/ml was expired and should not be in the medication refrigerator. LVN 4 stated night shift nurses perform medication room audits and remove discontinued and expired medications nightly. LVN 4 stated expired medication should not be in the medication room because there was a chance it could be administered. LVN 4 stated expired medication could cause adverse side effects or be less effective if administered. During a review of Resident 6's OSR, dated 12/4/25, the OSR indicated Resident 6 no longer had an active order for triamcinolone acetonide injection kit 40 mg/ml. The OSR indicated Resident 6's triamcinolone acetonide injection kit 40 mg/ml medication was discontinued on 6/4/25. During an interview on 12/5/25 at 11:44 a.m. with the Consultant Pharmacist (CP), the CP stated he performed monthly medication cart and medication room audits to assess and remove expired medications, discontinued medications and ensure medications were labeled accurately. The CP stated nursing was expected to review expiration dates before administration of medication and at routine intervals. The CP stated all prescription medications from the pharmacy were required to have an expiration date on the label before they were delivered to the facility. The CP stated nursing was expected to identify an incomplete pharmacy label on prescription medications when they were delivered and alert pharmacy for a replacement. The CP stated a complete and accurate pharmacy label was important to ensure expired medication was removed promptly and not administered. The CP stated there was a risk for administration if expired or discontinued medication remained in medication carts or medication rooms which could result in adverse side effects or decreased medication efficiency.During an interview on 12/5/25 at 2:13 p.m. with the Director of Nursing (DON), the DON stated she reviewed Resident 30's morphine sulfate 15 mg prescription medication and it did not have an expiration date on the pharmacy label. The DON stated all medication from pharmacy required an expiration date before arriving at the facility. The DON stated the nurse who received Resident 30's medication was responsible to ensure the pharmacy label had an expiration date. The DON stated it was facility policy to ensure pharmaceutical medication labels were complete and accurate to ensure expired medication was not administered to residents. The DON stated facility policy was not followed when Resident 30's morphine sulfate 15 mg prescription medication did not have an expiration date on the label. The DON stated she reviewed Resident 6's triamcinolone acetonide injection kit 40 mg/ml prescription medication and it was expired. The DON stated Resident 6's medication was discontinued on 6/4/25 and should have been removed from the medication room refrigerator when it was discontinued, before it expired. The DON stated facility policy was not followed when Resident 6's triamcinolone acetonide injection kit 40 mg/ml prescription medication was left in the medication refrigerator after it was discontinued and after it expired. The DON stated it was important to remove improperly labeled prescription medication and expired medication to ensure expired medications were not administered to residents. The DON stated expired medications could become less effective and not work as intended or cause adverse side effects.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, .the nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner.if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.the medication label includes, at minimum: expiration date.if medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying the items.

Based on observation, interview and record review the facility failed to ensure 19 of 49 residents receiving meals from the kitchen were served the correct serving for lunch on 12/3/25 when 19 residents on regular texture and portion diets were served sea greens with an incorrect serving size of #10 scoop (3/8 cup) instead of a #8 scoop (1/2 cup) serving. This failure resulted in 19 residents receiving the wrong caloric intake which could result in inadequate nutrition, weight gain or weight loss, and lead to serious medical conditions. During a review of the facility's document titled, Diet Type Report, dated 12/4/25, the document indicated 49 residents received meals from the kitchen. The document indicated 19 of 49 residents received regular texture diets with regular portions from the kitchen. During a review of the facility's recipe document titled, Sea Greens #2, undated, the document indicated, .suggested portion: #8.serve with a #8 scoop. During a concurrent observation and interview on 12/3/25 at 11:52 a.m. with Dietary [NAME] (DC) 1, in the kitchen during lunch tray line, DC 1 stated residents were being served meat and beans, potatoes, spinach (also known as sea greens), and cornbread for lunch. DC 1 was observed placing a #10 scoop on the tray line in the sea greens container. DC 1 was observed reviewing meal tickets and using a #10 scoop to serve sea greens onto the trays of residents with regular diet textures. DC 1 stated as the cook he reviewed recipes, made and served the food item per recipe during tray line. DC 1 stated he used sea greens #2 recipe to make and serve the sea greens. DC 1 stated serving scoop portion sizes were on each recipe and expected to be followed. DC 1 stated he was using a #10 scoop size to serve sea greens onto resident trays with regular diet textures and portions. During a concurrent observation and interview on 12/3/25 at 11:55 a.m. with DC 2, in the kitchen during lunch tray line, DC 2 was observed assisting DC 1 with tray line. DC 2 was observed reviewing meal tickets and using a #10 scoop size to serve sea greens onto the trays of residents with regular diet textures and portions. DC 2 stated he was using a #10 scoop size to serve sea greens onto resident trays with regular diet textures and portions. During a concurrent observation and interview on 12/3/25 at 12:09 with the Dietary Supervisor (DS), in the kitchen during lunch tray line, the DS stated residents were being served meat and beans, potatoes, spinach, and cornbread for lunch. The DS stated the Sea Greens #2 recipe was utilized for lunch. The DS stated the Sea Greens #2 recipe called for a #8 scoop size for serving. The DS stated DC 1 and DC 2 were using the incorrect serving scoop size, #10 scoop, to serve sea greens to residents on a regular texture diet with regular portions. The DS stated DC 1 and DC 2 should have used a #8 serving scoop size to serve sea greens to residents on a regular texture diet with regular portions. The DS stated DC 1 and DC 2 were responsible to prepare, make, and serve scheduled menu items per the recipe. The DS stated it was important to follow recipe guidelines to ensure residents received the correct nutrition ordered for their diet. The DS stated using the incorrect scoop size could lead to altered caloric intake, weight gain, weight loss, and altered nutrition.During an interview on 12/5/25 at 9:36 a.m. with the Registered Dietician (RD), the RD stated recipes were expected to be followed by dietary cooks when food items were prepared, made and served. The RD stated the DS was responsible to oversee the kitchen and ensure dietary cooks followed recipes and served correct portion sizes per diet orders. The RD stated it was important dietary cooks followed recipes and resident diet orders to ensure residents received the correct amount of nutrition to maintain their well-being. The RD stated the correct serving scoop size was important to ensure adequate nutrition was provided to each resident. The RD stated using the incorrect scoop size could lead to altered caloric, nutrient, vitamin and mineral intake which could result in weight gain, weight loss or altered nutrition. During an interview on 12/5/25 at 2:13 p.m. with the Director of Nursing (DON), the DON stated per facility policy she expected kitchen staff to follow recipes, menus and diet orders. The DON stated dietary cooks were responsible to ensure food items were prepared, made, and served per recipes, menus, and diet orders. The DON stated the DS and RD were responsible for ensuring kitchen staff competencies. The DON stated facility policy was not followed when residents on a regular texture diet with regular portion sizes were served sea greens with a #10 scoop. The DON stated it was important to serve the correct portion size to ensure residents received adequate nutrition. The DON stated residents were at risk for weight variances, elevated or decreased blood sugar, and inaccurate nutrition monitoring when the incorrect serving scoop size was used to serve sea greens. During a review of the facility's document titled, Food Preparation, dated 2011, the document indicated, .portion control assures correct quantities are served to resident/patients to meet the nutritional specifications as determined by the menu. Standard portions are necessary to control food costs, quality, attractiveness and appeal of food. Resident/patient satisfaction is highest when expectations about the amount of food received are the same for all resident/patients.portions served are those listed on the menu for each food item.standard tools are utilized to assure portion control, i.e. scoops.standardized recipes.scoops are sized according to the number of scoops needed to equal one quart. The smaller the number, the larger the size.amount in cups 3/8 [cups] scoop size 10.amount in cups 1/2 [cups] scoop size 8.the dietary service supervisor (DSS) should routinely check portion control of all food/beverages. During a review of the facility's policy and procedure (P&P) titled, Menus, dated 10/2017, the P&P indicated, .menus meet the nutritional needs of residents in accordance with the recommend dietary allowances of the Food and Nutrition Board. menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal.

Based on interview and record review, the facility failed to have record of abuse in-service training for the year 2025 for one of three certified nursing assistants (CNA 4) reviewed. This failure had the potential to put all 49 residents at risk of experiencing abuse by staff. During a concurrent interview and record review on 12/4/25 at 10 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP) and Director of Nursing (DON), the abuse in-service training sign-in sheet (AIS) for employed certified nursing assistants (CNA) for 2025 was reviewed. The AIS indicated CNA 4 was not accounted for in having completed her abuse in-service for 2025. The DON stated CNA 4 was a full-time employee. During an interview on 12/5/25 at 2:51 p.m., with the DSD/IP she stated she was responsible for the abuse trainings but was not the DSD at the time of these trainings. The DSD/IP stated the expectation was that all CNA's received the required training, but CNA 4 was missing. The DSD/IP stated abuse training was important to educate staff on how to report and recognize abuse with residents at the facility. The DSD/IP stated missing these trainings would affect resident safety and staff might not know how to deal with abuse scenarios and care for them properly.During an interview 12/5/25 at 3:12 p.m., with the DON, the DON stated CNA's need to attend all of the required trainings and be proficient with the information they learned. The DON stated CNA 4 not getting the required abuse training would affect residents' quality of care negatively and it was a safety concern. The DON stated the facility's policy and procedure (P&P) In-Service Training, All Staff was not followed. During a review of the facility's Policy and Procedure (P&P) In-Service Training, All Staff, not dated, the P&P indicated, .All nurse aide personnel participate in regular in-service education. All personnel are required to participate in regular in-service education.Annual in-services: ensure the continuing competence of nurse aides. address the special needs of the residents. include training in . resident abuse prevention. all training supports current scope and standards of practice. required training for all staff include: . abuse, neglect and exploitation of residents. Nurse aid participation in training is documented by the staff development coordinator. and includes: the date and time of the training. B. The topic of the training; c. The method used for training; d. Summary of the competency assessment; e. The hours of training completed.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 15 residents (Resident 9), when Resident 9's care plan indicated she needed one on one (1:1- one dedicated caregiver gives their full, undivided attention to just that person) supervision and a bolster (a long pillow or cushion) mattress on her bed and neither of those interventions were being implemented. This failure of not implementing an individualized care plan for Resident 9 had the potential to place Resident 9's safety at risk and her specific needs not being met.During a review of Resident 9's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the admission Record indicated, Resident 9 was admitted to the facility on [DATE] with a diagnosis of unspecified disorder of Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to carry out simple daily tasks, and is the most common type of dementia, causing problems with memory, thinking, and behavior that worsen over time) muscle weakness, difficulty in walking and unspecified dementia (a general decline in mental abilities, primarily affecting memory, thinking, and behavior, that interferes with daily life and worsens over time).During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated [DATE], the MDS assessment indicated Resident 9's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 00 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS assessment indicated Resident 9 was severely impaired. During a review of Resident 9's Care Plan Report (CPR), dated [DATE], the CPR indicated, .Resident is at risk for falls and/or repeated falls due to: Diagnosis: Alzheimer's, anxiety, dementia. difficulty in walking, generalized muscle weakness. history of falling. Goal: Minimize risks for fall and fall related. Date initiated: [DATE]. Interventions: . 1:1 supervision while awake. Date initiated: [DATE]. Bolster mattress. Date initiated: [DATE]. During an observation on [DATE] at 10:56 a.m., in Resident 9's room, Resident 9 was sitting in a wheelchair, awake, next to her bed without any staff present. Resident 9 had a hospital bed without bolsters or any other additions. During an interview on [DATE] at 1:39 p.m., with certified nursing assistant (CNA) 2, CNA 2 stated Resident 9 was not to be supervised with 1:1 care. CNA 2 stated if the care plan was not correct then ,staff could have given the wrong care for Resident 9. CNA 4 stated that care plans should be known by all staff and they tell staff, how to give care on a daily basis for the resident. During a concurrent observation and interview on [DATE] at 1:56 p.m., in Resident 9's room, with licensed vocational nurse (LVN) 1, Resident 9 was sitting next to her bed in a wheelchair and did not have 1:1 supervision by staff nor a bolster mattress on her bed. LVN 1 stated that she was Resident 9's nurse for the day. LVN 1 stated Resident 9 did not have 1:1 supervision by staff nor a bolster mattress on her bed. LVN 1 stated care plans were there to tell staff how to care for the resident on a daily basis. LVN 1 stated Resident 9's care plan was not individualized, comprehensive or person centered because she did not have 1:1 care nor a bolster mattress on her bed. LVN 1 stated the care plan was wrong and the care being provided was not accurate. LVN 1 stated Resident 9 was at risk for a fall because of the lack of a bolster mattress. During an interview on [DATE] at 2:40 p.m., with the Infection Preventionist (IP), the IP stated Resident 9's care plan was not person centered nor comprehensive. The IP stated the care plan needed to be updated to her individual needs and it was not. The IP stated care plans were important because they state what kind of care staff needs to provide the resident on a daily basis. The IP stated because the care plan was not accurate the resident had the potential to get hurt because staff do not know what type of care the resident actually needs. During an interview on [DATE] at 3:17 p.m., with the Director of Nursing (DON), the DON stated the resident did need 1:1 staff support and bolsters on her bed at one point, but that was not the level of care she needed now. The DON stated Resident 9's care plan was not up-to-date, person centered nor comprehensive. The DON stated care plans are used by all staff to know what to do for the resident in order to keep them safe. The DON stated because the care plan was incorrect, Resident 9 could potentially get hurt because staff aren't doing the appropriate interventions for her current condition. The DON stated ultimately this was a patient safety issue. The DON stated staff did not follow the facility's policy and procedure Care Plans, Comprehensive Person-Centered. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical. functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: . reflects currently recognized standards of practice for problem areas and conditions. care plan interventions are chosen only after data gathering. careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making. assessments of residents are ongoing, and care plans are revised as information about the residents and the residents conditions change. During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated [DATE], (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making. Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation.During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated [DATE], (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice for one of thirteen sampled residents during medication administration (Resident 6) when Resident 6's Tylenol (pain medication used to treat mild pain) medication lacked an appropriate indication and an associated pain rating scale to guide administration.This failure resulted in Resident 6's Tylenol medication order not having complete and appropriate administration instructions which resulted in the administration of Tylenol with no prior pain assessment which could lead to uncontrolled or mismanaged pain management. During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/4/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of diverticulitis (an acute or chronic condition causing inflammation or infection of the large intestine lining), osteoarthritis (chronic condition causing breakdown of cartilage) and age-related osteoporosis (chronic condition causing breakdown of bone).During a review of Resident 6's Order Summary Report, (OSR) dated12/4/25, the Order Summary Report indicated, .Tylenol oral tablet 325 mg (milligram-a unit of measurement) give 2 tablet by mouth every 6 hours for mild pain.start date 6/8/25.During a medication pass observation on 12/4/25 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 was observed administering 2 tablets of Tylenol 325 mg to Resident 6. LVN 5 was not observed performing a pain assessment on Resident 6. Resident 6 was observed taking 2 tablets of Tylenol 325 mg.During a concurrent interview and record review on 12/4/25 at 2:28 p.m. with LVN 5, Resident 6's OSR, dated 12/4/25 was reviewed. LVN 5 stated Resident 6 had an active order for Tylenol 325 mg every 6 hours for mild pain. LVN 5 could not state if Resident 6 received Tylenol for acute or chronic pain from the order administration instructions. LVN 5 stated Resident 6's Tylenol administration instructions did not include an indication for use or an associated pain scale to guide administration. LVN 5 stated it was important administration instructions included the indication for use to ensure the medication was administered as prescribed by the provider. LVN 5 stated she did not complete a pain assessment prior to administration of Tylenol to confirm Resident 6 had mild pain. LVN 5 stated mild pain was a pain rating of 1-3. LVN 5 stated routine pain medication required a pain assessment prior to administration to ensure the appropriate medication was administered to appropriately treat a resident's level of pain. LVN 5 stated pain assessments tracked resident pain management progress and ensured pain management follow up occurred. LVN 5 stated Resident 6 was at risk for uncontrolled pain management with no pain assessment prior to administration, indication for pain medication use or associated pain scale.During an interview on 12/5/25 at 11:44 a.m. with the Consultant Pharmacist (CP), the CP stated administration instructions on all medications required indication for use. The CP stated licensed nursing staff were expected to complete pain assessments prior to pain medication administration. The CP stated licensed nursing staff were responsible for ensuring administration instructions were complete and to contact the provider if they were not. The CP stated pain assessments were important to ensure the proper pain medication was administered to treat the residents pain.During a concurrent interview and record review on 12/5/25 at 2:13 p.m. with the Director of Nursing (DON), Resident 6's OSR, dated 12/5/25 was reviewed. The DON stated Resident 6's order for Tylenol 325 mg every 6 hours for mild pain did not have an indication for use. The DON stated Resident 6's order for Tylenol 325 mg every 6 hours for mild pain should indicate the targeted condition, disease or rationale for use within the administration instructions. The DON stated it was important orders included indication for use to determine why and how long medication was intended for use to ensure appropriate monitoring was in place. The DON stated Resident 6's order for Tylenol 325 mg every 6 hours for mild pain did not have an associated pain scale to guide administration. The DON stated it was important orders included an associated pain scale, such as a numeric pain rating scale, to ensure resident pain was assessed consistently and accurately by licensed nursing staff.The DON stated licensed nursing staff were expected to perform pain assessments prior to all scheduled, routine and as needed pain medication. The DON stated facility policy was not followed when Resident 6 did not receive a pain assessment prior to the administration of Tylenol. The DON stated facility policy was not followed when Resident 6 did not have an appropriate indication or an associated pain rating scale to guide administration on her Tylenol order. The DON stated Resident 6 was at risk for uncontrolled or mismanaged pain management, over-medication, under-medication or overdose when her medication, Tylenol 325 mg every 6 hours for mild pain, lacked an appropriate indication and an associated pain rating scale to guide administration.During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, dated 7/2016, the P&P indicated, .orders for medications must include.clinical condition or symptoms for which the medication is prescribed.During a review of the facility's P&P titled, Pain Assessment and Management, dated 10/2022, the P&P indicated, .acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. For chronic stable pain the resident's pain and consequences of pain are assessed at least weekly.assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.if pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper analgesic medications to the extent possible.document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program.During a review of the facility's P&P titled, Pain-Clinical Protocol, dated 10/2022, the P&P indicated, .the staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity.staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.if pain is stable and the underlying cause is resolved or it is unclear whether a source of pain remains, the physician will consider a trial reduction or elimination of analgesic medication .and see if there is any change in pain-related symptoms or use of PRN analgesics.based on results of attempted dose reductions, the physician should document a clinically significant rationale for not attempting further analgesic reduction. It should not just be assumed that the absence of pain symptoms implies the need for indefinite analgesic administration. Sometimes a trial tapering or discontinuation of analgesic is indicated to determine if current medications or doses are still needed.During a professional reference review retrieved from https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications titled, Recommendations to Enhance Accuracy of Administration of Medications, dated 3/30/23, the professional reference review from the National Coordinating Council for Medication Error Reporting and Prevention indicated, . one aspect of the overall medication use system, the following goals of the medication administration process should be included in the organizations processes and policies to ensure that systems are appropriately designed and functional for humans to safely administer medications.the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason.

Based on interview and record review, the facility failed to ensure that medical records were complete for one of seven sampled residents (Resident 64) when Resident 64's Inventory of Personal Effects form (An Inventory sheet of resident's personal belongings completed upon admission to the facility) was incompletely filled out. This failure had the potential to result in Resident 64's poor continuity of care due to miscommunication among caregivers, inconsistent care delivery or loss or theft of personal belongings.During an interview on 12/4/25 at 11:29 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated an Inventory of Personal Effects form is filled out on admission by the CNA, signed by the CNA, and the form given to the nurse. CNA 1 stated the Inventory form should be filled out accurately and completely so that everyone knows what resident belongings were brought into the facility, resident items don't go missing, and to keep track of the resident's items. CNA 1 stated if the residents belongings were to go missing, it was important to have an accurately filled out inventory list so the responsible party (RP-the person designated in the admission agreement to manage the resident's affairs) and staff are aware of what items are missing.During a concurrent interview and record review on 12/4/25 at 3:09 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 64's Inventory of Personal Effects form, dated 11/19/25 was reviewed. The Inventory of Personal Effects form indicated, no documentation of resident or resident representative signature and date, witness signature, title of witness and date, Attending Physician name, Record Number, and Room/Bed. LVN 2 stated the Inventory of Personal Effects form was not complete and was missing several items of information such as attending physician name, resident room number, witness signature, and responsible party (RP) signature. LVN 2 stated Resident 64 had episodes of confusion and could not sign his own inventory form. LVN 2 stated Resident 64's RP should have signed the form. LVN 2 stated it was important to have all signatures on the Inventory of Personal Effects form because it ensured accuracy and that all personal items are accounted for. LVN 2 stated that an accurate form would provide staff with knowledge of what items were brought into the facility and would help in the event any items went missing or were misplaced. LVN2 stated when the form was not signed by the resident or the resident's RP, it could lead to miscommunication if items were lost. LVN 2 stated if a resident's form was not filled out completely and accurately and items were lost; there was a potential that items would not be verified. During a concurrent interview and record review on 12/4/25 at 4:02 p.m. with Medical Records (MR), Resident 64's Inventory of Personal Effects form, dated 11/19/25 was reviewed. MR stated she was responsible for auditing resident records the following day after a resident's admission. MR stated she checks that the Inventory of Personal Effects form has been completed by the CNA. MR stated she remembered giving the Inventory of Personal Effects form to the CNA on Resident 64's date of admission with only the resident's name written on it. MR stated she remembered it was a hectic day with two new admissions near the end of day, and she needed to clock out. MR stated the Inventory of Personal Effects form was not complete and was missing several items such as Physician name, medical record number, and RP signature. MR stated it was important to have accurate and complete Inventory of Personal Effects forms for the residents in case there were missing items, for reimbursement purposes, and for accuracy of items brought to the facility. MR stated she knew that it was important to have the medical record number on residents' paperwork because people could have the same name and the medical record number is specific to only one person and serves as the identifier for that resident. During a concurrent interview and record review on 12/5/25 at 2:26 p.m. with Director of Nursing (DON), Resident 64's Inventory of Personal Effects form, dated 11/19/25 was reviewed. DON stated Inventory Forms were completed by the CNA or Nurse on admission and as needed when items were brought in and out of the facility. DON stated her expectation was that medical records be complete and accurate with all information completed on the form. DON stated medical records was responsible for auditing the chart after an admission to check completion of forms. DON stated Resident 64's Inventory of Personal Effects form was not a complete form because there was no RP or resident signature, no physician name, no medical record number, and no room number. DON stated the form could have been signed by a witness if the resident was unable to sign. DON stated the medical record number was important in order to refer back to a resident. DON stated a patient could have the same name and the medical record is used to track each individual patient. DON stated it was important to have accurate and complete medical records and inventory forms to track resident belongings if items were to go missing. DON stated it was important for the RP to sign the inventory form to acknowledge the items that the resident came in with. DON stated her expectation was the inventory form be signed no later than 24-48 hours. DON stated the facility's policy states that medical records should be complete and accurate with all information on the form. DON stated that the facility's policy regarding complete and accurate medical records was not followed.During a review of Resident 64's admission Record, dated 12/5/25, the admission Record indicated Resident 64's admit date was 11/19/25.During a review of the facilities policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

Based on observation and staff interview during the survey period from 12/2/25 through 12/5/25, the facility failed to ensure each bedroom had 80 square feet of usable living space for residents in 22 of 29 rooms (Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60). This failure to provide the residents in rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60 with 80 square feet (sq ft- unit of measurement) of space had the potential for the residents to not have enough space to accommodate their personal needs and belongings. During an interview on 12/2/25 at 10 a.m., with the Administrator (ADM), the ADM stated he was aware rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60 did not meet the minimum space requirement for two residents. The ADM provided the room measurements for rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60. The room measurements were as follows: Room Number: Number of Beds/Residents: Square Footage per Resident:27 2 154 square feet (77 sq ft per resident)28 2 154 square feet (77 sq ft per resident)29 2 154 square feet (77 sq ft per resident)30 2 154 square feet (77 sq ft per resident)31 2 154 square feet (77 sq ft per resident)32 2 154 square feet (77 sq ft per resident)33 2 154 square feet (77 sq ft per resident)34 2 154 square feet (77 sq ft per resident)35 2 154 square feet (77 sq ft per resident)36 2 154 square feet (77 sq ft per resident)47 2 154 square feet (77 sq ft per resident)48 2 154 square feet (77 sq ft per resident)50 2 154 square feet (77 sq ft per resident)51 2 154 square feet (77 sq ft per resident)52 2 154 square feet (77 sq ft per resident)53 2 154 square feet (77 sq ft per resident)54 2 154 square feet (77 sq ft per resident)55 2 154 square feet (77 sq ft per resident)56 2 154 square feet (77 sq ft per resident)57 2 154 square feet (77 sq ft per resident)58 2 154 square feet (77 sq ft per resident)59 2 154 square feet (77 sq ft per resident)60 2 154 square feet (77 sq ft per resident) During an observation throughout the survey period from 12/2/25 through 12/5/25 twenty-two resident bedrooms (Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60) had two residents per room and had less than 80 square feet of space for each resident. Although the bedrooms accommodated less than 80 square feet for each resident, each room met the required needs of the residents. The residents had a reasonable amount of privacy, and closet and storage space was adequate. Bedside stands were available. There was sufficient room for nursing care and for the mobility of the residents. Wheelchairs, devices, and toilet facilities were accessible. The health and safety of the residents will not be adversely affected by the continuance of this waiver. Recommend waiver to continue in effect. _______________________________________Beth [NAME], HFES Health Facilities Evaluator Supervisor Date 12/10/25

Based on observation, interview, and record review the facility failed to provide care in a manner that maintained dignity and respect for one of three sampled residents (Resident 1), when Resident 1 was awoken at 2:00 a.m. and subjected to two attempted straight catheterizations (invasive thin flexible tube used to drain urine from the bladder) without a physician order or consent. This failure violated the resident's rights to receive care in a dignified and respectful manner.During a review of Resident 1's admission Record (AR) dated 8/22/25, the AR indicated, Resident 1 was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (the loss of the ability to move one side of the body), Metabolic encephalopathy (brain dysfunction, which disrupts normal brain function) and malignant neoplasm of brain ( a cancerous growth in the brain or central nervous system).During a review of Resident 1's Order Summary Report (OSR) dated 8/8/25, at 1307 the OSR indicated, .May have UA (urinalysis medical test that examines urine to help diagnose medical conditions). One time only for foul order for 3 days.During a review of Resident 1's OSR dated 8/10/25 at 0305 the OSR indicated .May have UA with C&S (culture and sensitivity a more detailed test of the urinalysis indicates a possible infection) if indicated one time only for foul odor for 3 days. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/24/25, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 1 was cognitively intact. During an interview on 8/22/25 at 8:50 a.m. with Resident 1's sister who is also the Responsible Party (RP) for Resident 1, the RP stated on 8/8/25 the facility informed her of Resident 1 having foul smelling urine and suspected UTI (infection of the urinary tract). The facility also informed her a urine sample was needed for a UA. The RP stated Resident 1's urine sample was obtained by a hat (a common term for a medical device that fits over the toilet bowl to collect urine). The RP stated on 8/11/25, RP made a daily visit to see Resident 1 and Resident 1 became visibly upset when explaining in detail about a nurse coming into Resident 1's room in the middle of the night and inserting a straight catheter into her urethra (a short tube in females that connects the bladder to the external genitals, serving as the pathway for urine to exit the body). During an interview on 8/22/25 at 10:23 a.m. at nurses' station on C wing, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated a physician order was needed to obtain a UA. LVN 2 stated UA collection methods included urinating into a hat that was placed over the toilet or by straight catheterization. LVN 2 stated once the UA is collected a label is placed on the specimen then the specimen is placed within the fridge and laboratory was notified. LVN 2 stated if an additional UA specimen was required a new physician order would be required with method for collection. During a concurrent observation and interview on 8/22/25 at 11:39 a.m. with Resident 1, Resident 1 was observed coming from her restroom. Resident 1 stated she had used the restroom. Resident 1 recalled the nurse who had entered her room on 8/10/25 at 2:00 a.m. and stated another urine sample was needed. Resident 1 mentioned she was very confused and too nervous to ask questions, when the nurse began preparing the items for catheterization, especially since she had been able to use the hat for the first urine sample that was collected.During a phone interview on 8/27/25 at 3:44 p.m. with LVN 1, LVN 1 indicated on 8/10/25 she had entered Resident 1's room around 2:00 a.m. and woke Resident 1 up to collect a urine sample from Resident 1. LVN 1 stated around 2:00 a.m. was the normal time for brief checks and changing of residents, LVN 1 stated she felt it was a good time to collect the sample. LVN 1 used a straight catheter for the urine sample collection of Resident 1. LVN 1 stated she went into Resident 1's room alone and did not ask for help going into the room, because LVN 1 was able to perform a straight catheterization on residents who are alert such as Resident 1. LVN 1 stated she performed two attempts at inserting the catheter into Resident 1's urethra with failed attempts. LVN 1 stated after the failed attempts she had Resident 1 urinate into a bedpan, and the sample was collected. LVN 1 stated she did not contact the physician to obtain an order and there was no order for the straight catheter.During a phone interview on 8/26/25 at 1:05 p.m. with the DON, the DON acknowledged LVN 1 had attempted to perform a straight catheterization on Resident 1 without a physician's order and without obtaining consent from Resident 1's RP. The DON stated straight catheterization is considered an invasive procedure, and it was not the facility's expectation for staff to perform such a procedure without following physician orders and policy requirements. The DON further stated the physician should have been notified to obtain an order prior to the procedure being attempted.During an interview on 8/22/25 at 12:01 pm with the Administrator (Admin), the Admin acknowledged LVN 1 was wrong to attempt a straight catheterization on Resident 1 without a physician order. The Admin stated it was the facility's expectation all staff follow physician orders, adhere to facility policy, and document all interactions and communications. During a review of the facility's policy and procedure (P&P) titled, Cultures, Specimen Collection, dated 10/11, the P&P indicated, .Procedure guidelines.Explain the procedure completely to the resident.Urine culture from indwelling catheter 1. Validate the physician's order.During a review of the facility's P&P titled, Indwelling (foley) Catheter Insertion, Female Resident, dated 8/22, the P&P indicated .2. Verify that there is a physician's order for this procedure.Documentation.The indication.how the resident tolerated the procedure.During a review of the facility's P&P titled, Clean Catch Urine Specimen, dated 10/10, the P&P indicated .Verify that there is a physician's order for this procedure.Equipment and Supplies.Bedpan/urinal (if resident is unable to leave bed) .During a review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedures, dated 10/10, the P&P indicated .If the resident is sleeping, and the procedure is not urgent or scheduled, return when the resident is awake.

Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (Resident 1). When the Licensed Vocational Nurse (LVN) 1 obtained a urine specimen by straight catheterization (invasive thin flexible tube used to drain urine from the bladder) without a physician order for catheter.This failure had the potential to place the resident at risk for unnecessary pain, infection, and psychosocial harm.During a review of Resident 1's Order Summary Report (OSR) dated 8/8/25, at 1307 the OSR indicated, .May have UA (urinalysis medical test that examines urine to help diagnose medical conditions). One time only for foul order for 3 days.During a review of Resident 1's OSR dated 8/10/25 at 0305 the OSR indicated .May have UA with C&S (culture and sensitivity a more detailed test of the urinalysis indicates a possible infection) if indicated one time only for foul odor for 3 days.During a review of Resident 1's admission Record (AR) dated 8/22/25, the AR indicated, Resident 1 was initially admitted to the facility on [DATE] with diagnoses of, hemiplegia (the loss of the ability to move one side of the body), Metabolic encephalopathy (brain dysfunction, which disrupts normal brain function) and malignant neoplasm of brain ( a cancerous growth in the brain or central nervous system).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/24/25, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 1 was cognitively intact.During a concurrent observation and interview on 8/22/25 at 11:39 a.m. with Resident 1, Resident 1 recalled the nurse who had entered her room on 8/10/25 at 2:00 a.m. and informed her another urine specimen was needed. Resident 1 stated she was very confused and too nervous to ask questions, when the nurse began preparing the items for catheterization, since she had previously been able to provide a urine specimen using a hat.During a phone interview on 8/27/25 at 3:44 p.m. with LVN 1, LVN 1 indicated on 8/10/25 she had entered Resident 1's room around 2:00 a.m. and attempted to insert a straight catheter two times without success. LVN 1 stated after two failed attempts she obtained a urine specimen by having Resident 1 void into a bedpan. LVN 1 stated she did not notify the physician for an order and did not notify the responsible party before attempting the straight catheterization. LVN 1 Further indicated she was unaware this practice was unacceptable because it was the standard procedure for obtaining a urine sample at her previous place of employment, for residents who are incontinent (lack of voluntary control over urination) .During a phone interview on 8/26/25 at 1:05 p.m. with the Director of Nursing (DON), the DON stated LVN 1 had attempted to perform a straight catheterization on Resident 1 without a physician's order. The DON stated straight catheterization is considered an invasive procedure, and it was not the facility's expectation for staff to obtain a physician order prior to performing such procedure.During an interview on 8/22/25 at 12:01 pm with the Administrator, the Administrator acknowledged LVN 1 was wrong to attempt a straight catheterization on Resident 1 without a physician order, and it was facility's expectation all staff follow physician orders, adhere to facility policy, and document all interactions and communications.During a review of the facility's policy and procedure (P&P) titled, Cultures, Specimen Collection, dated 10/11, the P&P indicated, .Procedure guidelines.Explain the procedure completely to the resident.Urine culture from indwelling catheter 1. Validate the physician's order.During a review of the facility's P&P titled, Indwelling (foley) Catheter Insertion, Female Resident, dated 8/22, the P&P indicated .2. Verify that there is a physician's order for this procedure.Documentation.The indication.how the resident tolerated the procedure.During a review of the facility's P&P titled, Clean Catch Urine Specimen, dated 10/10, the P&P indicated .Verify that there is a physician's order for this procedure.Equipment and Supplies.Bedpan/urinal (if resident is unable to leave bed) .During a review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedures, dated 10/10, the P&P indicated .If the resident is sleeping, and the procedure is not urgent or scheduled, return when the resident is awake.During a review of the facility's P&P titled, Medication and Treatment Orders, dated 7/16, the P&P indicated .orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and time of the order.

Based on interview and record review, the facility failed to ensure the rights of two of three sampled residents (Resident 1 and Resident 2) right to a dignified private and personal space was respected when one facility male employee laid down on the bed with Resident 1 and had taken a nap with her for several minutes; and when Resident 1's roommate, Resident 2, observed this. This failure resulted in the potential for psychosocial harm such as emotional distress for Resident 1 and Resident 2. Findings: During a review of the facility document titled SOC 341/5 Day Report (Report) , dated 11/18/24, the Report indicated, On 11/13/24, [at approximately 4 p.m.] Administrator was notified by [Resident 2] that a male CNA [Certified Nursing Assistant 1] had taken a nap in [Resident 1's] bed with her. An investigation was started immediately by the management team. Resident [1] was interviewed by [Licensed Nurse] and [Social Services Director]. Watched video footage of B-Wing Hall [hall where Resident 1 and 2 resided]. Staff member from B-wing hall interviewed. Confirmed incident was found to be true. [CNA 1] was notified that he is suspended until further notice. The two [other CNAs, CNA 2 and CNA 3] seen going in the room [from video footage] at [2:06 p.m.] were interviewed. One out of two confirmed that [CNA 1] was lying in bed with [Resident 1]. [CNA 1] was interviewed and confirmed the incident did happen. Facility terminated [CNA 1] effective 11/14/24. [Resident 1] is currently on alert charting for psychosocial distress. During a review of a facility letter (Letter ) dated 11/14/24, to CNA 1, the Letter indicated, We regret to inform you that we have come to the decision to terminate your employment with [the facility] effective November 14, 2024. This decision was reached after careful consideration of your violation of resident rights and its impact on [the facility]. As a responsible employer we believe it has become evident that your behavior does not meet the standards and expectations set forth by [the facility]. The letter was written by the Administrator and signed by CNA 1. During a review of a signed, written statement (Statement 1 ) from CNA 2, dated 11/15/24, Statement 1 indicated she was getting report from the morning shift CNA when, . [CNA 1] followed us into [Resident 1 and 2's shared room] and greeted the resident then we noticed him sitting/laying next to [Resident 1] and I remember saying Ew, [CNA 1] get out leave her alone but he just laughed it off. That is when [CNA 4] and I came out of her room and moved on to the next. [CNA 4] and I were both in the other room for about 10+ minutes.After that time . I then went into [Resident 1's] room again to ask her if she was ready for her shower that's what [sic] I noticed that [CNA 1] was still in there standing by her door, that's when I was like you're still here and he said ' yes but I'm leaving already. Then he walked off and I just asked [Resident 1] if she was ready and she said yes. During a review of a signed, written statement (Statement 2 ) from CNA 3, dated 11/15/24, Statement 2 indicated, On November 13 [2024], around 2:06 [p.m.], I was doing water pass and got to [Resident 1 and Resident 2's shared room] and noticed [CNA 1] sitting on [Resident 1's] bed moving her blanket then laid on [Resident 1] right side. I had said ew [CNA 1] why are you laying there, then proceeded to do the waters and get out of the room. I did not think anything of it at the time. I had thought as soon as I got out he would've as well. During a concurrent record review and interview on 11/15/24, at 8:55 a.m., with the Administrator and the Director of Nursing (DON), recorded facility video surveillance was reviewed. The Administrator stated the recorded video footage was of the B-Wing hallway, from a ceiling-mounted video camera, that recorded activities in the hallway outside Resident 1 and Resident 2's shared room. The Administrator stated there are no video cameras located inside the residents' room. The video footage indicated time and date information; the Administrator stated the date and times were accurate. The video footage dated 11/13/24, at 2:06 p.m., indicated three uniformed staff persons enter Resident 1 and Resident 2's shared room (the room ). The Administrator identified the staff persons as CNA 1, CNA 2, and CNA 4. The video footage dated 11/13/24, at 2:07 p.m., indicated CNA 2 and CNA 4 leaving the room. The video footage dated 11/13/24, at 2:15 p.m., indicated a staff person working with a cart of water pitchers near the room. The Administrator identified the staff person as CNA 3, and at 2:15 p.m., CNA 3 entered the room. The video footage dated 11/13/24, at 2:16 p.m., indicated CNA 1 coming to the room's doorway, and scratched his head. CNA 3 left the room. CNA 1 then went back into the room. The video footage dated 11/13/24, at 2:23 p.m., indicated CNA 2 entering the room, and walked out about a half a minute later. CNA 1 then walked out of the room. The video footage indicated CNA 1 was the only staff in the room for approximately 16 non-consecutive minutes, from 2:07 p.m. to 2:23 p.m. During an interview on 11/15/24, at 9:29 a.m., with the Administrator, the Administrator stated she learned of the incident involving Resident 1 and CNA 1 on 11/13/24 at 4 p.m. The Administrator stated first learned of the incident when Resident 2 had called her on her phone, as Resident 2 had her phone number. The Administrator stated Resident 2 is alert and oriented, and was Resident 1's roommate. The Administrator stated she then went to Resident 2 and spoke with her about the incident. The Administrator stated Resident 2 saw CNA 1 in Resident 1's bed and had asked CNA 1 ' what are you doing in bed with [Resident 1]?' and CNA 1 responded ' napping. During an interview on 11/15/24, at 9:48 a.m., with the Administrator, the Administrator stated she interviewed CNA 1 regarding the incident between him and Resident 1. The Administrator stated CNA 1 told her he was tired and put his head down. The Administrator stated she also interviewed Resident 1 who gestured to the side of her bed and indicated that was where CNA 1 had laid down. The Administrator stated Resident 1 said this made her uncomfortable. During an interview on 11/15/24, at 11:22 a.m., with Resident 2, in her shared room with Resident 1, Resident 2 stated she had been a resident of the facility since 2017. Resident 2 stated she recalled the event occurring on 11/13/24, with CNA 1. Resident 2 knew and recalled the involved staff by their names. Resident 2 stated, There were females putting water in my room. It was [CNA 2 and CNA 4] and [CNA 1] was in here. I saw that [CNA 1] was in [Resident 1's] bed and was under the blankets with her. I don't know if [Resident 1] was asleep but he was asleep. I could see [Resident 1 and CNA 1] in bed. Our divider curtain [separating Resident 1 and Resident 2's beds for privacy] was halfway open so I could see [Resident 1's] bed. I asked [CNA 1] what he was doing in here but he didn't say anything. No staff came in the room while [CNA 1] was lying in the bed. Staff didn't come in until CNA 2 came in at 2:25 p.m. and told him ' are you still here' and he woke up and got out of bed and left. I saw that [Resident 1] was awake but she didn't say anything about [CNA 1] being in the bed. I didn't like that he was in the bed. I've never seen him do that before. I reported this. I called [the Administrator by phone] and I feel she was responsive. During a review of Resident 2's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 10/28/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 2 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). During a concurrent observation and interview on 11/15/24, at 11:32 a.m., with Resident 1, in her shared room with Resident 2, Resident 1 was noted have difficulties with speech. Resident 1 had a picture board with commonly used words and a device that indicated ' yes' or ' no' but did not use them during the interview. During the interview, Resident 1 nodded her head up and down to indicate ' yes', and shook her head and/or hand back and forth to indicate ' no'. Resident 1 was asked if she recalled CNA 1 being in her bed, and Resident 1 pointed to her right side of her bed and indicated ' yes'. Resident 1 was asked if CNA 1 was just under the covers with her and sleeping, Resident 1 indicated ' yes'. Resident 1 was asked if CNA 1 touched her inappropriately, Resident 1 indicated ' no.' During a review of Resident 1's MDS , dated 9/20/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact. During a review of Resident 1's Progress Notes (PN) , dated 11/13/24, at 4:27 p.m., the PN indicated, .notified by [Resident 2, Resident 1's roommate] that a male CNA [CNA 1] had taken a nap with her roommate [Resident 1]. [Resident 2] noted that [CNA 1] was sleeping on top of bedding. The PN indicated this event made Resident 2 uncomfortable , and Will continue to monitor and offer emotional support. The PN dated 11/13/24, at 4:27 p.m., indicated, LATE ENTRY . asked resident if a male CNA had taken a nap with resident. In which resident responded YES.Did the CNA touch you in a personal way? In which resident was able to say No . and shock [sic] her head no. During a review of Resident 1's PN dated 11/13/24, at 4:30 p.m., the PN indicated, Resident will be monitored for psychosocial and emotional distress x72 [hours]. During a review of Resident 1's PN dated 11/14/24, at 8:41 a.m., the PN indicated, Resident [1] is currently on alert charity [sic] for psychosocial distress. Resident did not display any post-distress Resident slept well through the night. Resident has followed her normal routine. Writer and staff will continue to offer emotional support. During an interview on 11/15/24, at 12:13 p.m., with CNA 2, CNA 2 stated she recalled the incident occurring on 11/13/24 with Resident 1 and CNA 1. CNA 2 stated while in Resident 1's room, she saw CNA 1 enter the room, then CNA 2 left the room. CNA 2 stated about 10 minutes later, she re-entered the room and saw CNA 1 sitting on Resident 1's bed with part of her blanket covering him. CNA 2 stated, I honestly don't know what he was doing in there. I told him: ' Hey, what are you doing? Leave her alone. CNA 2 stated he then left the room. CNA 2 stated, I should have told the nurse about this after he didn't leave during my first visit, but I didn't I should have told the nurse because I thought he was violating her personal space. If I was in [Resident 1's] position, I wouldn't want someone on my bed like that. During an interview on 11/15/24, at 12:30 p.m., with CNA 3, CNA 3 stated she recalled the incident occurring on 11/13/24 with Resident 1 and CNA 1. CNA 3 stated she entered Resident 1's room and saw CNA 1 sitting on Resident 1's bed, holding a blanket. CNA 3 stated, I asked him: ' What are you doing?' He didn't answer. I didn't think much of it. It's not normal behavior. CNA 3 stated seeing CNA 1 on Resident 1's bed wasn't a normal chit-chat, it was different from a normal chit-chat. I don't know how it was different. I should have told someone. During a review of the facility document titled, Resident Rights , dated 1/24, the Resident Rights indicated, Residents of [the facility] are entitled to certain rights and protections designed to ensure their dignity, safety, and well-being. Here are some of the core rights residents have: 1.Right to Dignity and Respect [:] Residents have the right to be treated with respect and dignity at all times. They should receive care that promotes their independence, privacy, and personal preferences. 4. Right to Freedom from Abuse and Neglect [:] [the facility] is prohibited from subjecting residents to physical, emotional, or verbal abuse, neglect or exploitation. This includes. mistreatment by staff, visitors, or other residents.

Based on interview and record review, the facility failed to ensure two of three employees' (CNA 1 and CNA 3) orientation to the facility and education documentation was thorough and completed by the Director of Staff Development (DSD). This failure had the potential for staff education requirements to not be verified by the DSD, enabling poorly trained staff to work in the facility with residents. Findings: During a review of the facility document titled, Job Description - Director of Staff Development (DSD) , dated 1/24, the Job Description indicated, The Director of Staff Development (DSD) plays a key role in creating a positive learning culture within [the facility], overseeing training and continuing education to support the growth and professional development of nursing and support staff. This role ensures that all personnel maintain the required licensure and certifications, comply with facility policies and are well-equipped with the knowledge and skills necessary for providing high-quality resident care. The DSD coordinates with all mandatory training programs, evaluates staff competencies, and implements educational initiatives in line with federal, state, and facility regulations. Education and Training: Develop, implement, and manage comprehensive training programs, including orientation for new hires, ongoing education, and skills enhancement for staff. Compliance and Regulatory Oversight: Maintain accurate records of all training activities, staff competencies, and compliance documentation. During a concurrent record review and interview on 11/15/24, at 10:18 a.m., with the DSD and the Administrator, Certified Nursing Assistant (CNA) 1's education records were reviewed. Among the documents was a single untitled page indicating, Training was provided for the following substance, processes, or procedures: Harassment Video Abuse Prevention Video/Your Legal Duty Post-Test Blood-borne pathogens & PPE Video and Post-Test Choking? What to do? Dementia Training Video (2hrs) Falling Star Program Unusual Occurrences Fire and Disaster Disaster Prep The single untitled page contained areas for name of instructor and date; these areas were blank. The DSD stated, That's because I didn't sign it. The DSD then left the interview and record review. During a review of CNA 1's education records, a four-page document titled, Employee Orientation , contained numerous items, including Job Description, Confidentiality of Resident Information, Fire and Safety Regulations and Procedures, Disaster Plan, a CNA's skill check list, and many others. The Employee Orientation contained areas for the employee and a licensed nurse to sign, name of employee, and Date of Orientation Completed. All these areas were blank on all four pages. During a review of CNA 1's education records, a single page document titled, Orientation , indicated, Please initial on each line that applies to your individual orientation. The Orientation document was blank with no employee name, signature, initials indicating completion, or date. During a review of CNA 1's education records, a single, undated document titled, Harassment: Sex, Religion and Beyond Employee Version , indicated, We are committed to providing a workplace free from unlawful discrimination, harassment and retaliation. The harassment training you received today is part of that effort. Please initial by each number and sign it and turn it in at the end of the training. The document was otherwise blank and contained no employee name, no initials, no signature indication completion, and no date. During a concurrent record review and interview on 11/15/24, at 10:24 a.m., with the Administrator, CNA 3's education records were reviewed. Among the documents was a single untitled page, dated 6/30/23, indicating Training was provided for the following substances, processes, or procedures: Harassment Video Abuse Prevention Video/Your Legal Duty Post-Test Blood-borne pathogens & PPE Video and Post-Test Choking? What to do? Dementia Training Video (2hrs) Falling Star Program Unusual Occurrences Fire and Disaster Disaster Prep The single untitled page contained an area for name of instructor , which was blank. During a review of CNA 3's education records, a two-page document titled, Employee Orientation , was reviewed. Page two indicated areas for the employee and a licensed nurse to indicate orientation items such as Facility Organization, Job Description, Daily Routine, Shift Responsibilities, Daily Assignment Sheets, CNA skill checklist and several other items. All were unsigned, with the Date of Orientation Completed left blank. The Administrator verified the findings for CNA 1 and CNA 3. During an interview on 11/15/24, at 11:55 a.m., with the Administrator, the Administrator stated, It is my expectation that in-service [education] for new hires be proctored [supervised by someone, referred to as a proctor, who verifies the identity of the test taker and maintains test integrity] and precepted [a preceptor is an experienced practitioner who provides supervision during clinical practice and facilitates the application of theory to practice] by the DSD.

Based on interview and record review, the facility failed to ensure one of three employees ' (Certified Nursing Assistant, or CNA 1) education on Resident ' s Rights was thorough and completed by the Director of Staff Development (DSD). This failure resulted in staff education on Resident Rights to not be completed and verified by the DSD for CNA 1, enabling CNA 1 to be untrained on Resident Rights while working with residents, including Resident 1 [cross-reference with F550]. Findings: During a review of the facility document titled, Job Description - Director of Staff Development (DSD), dated 1/24, the Job Description indicated, The Director of Staff Development (DSD) plays a key role in creating a positive learning culture within [the facility], overseeing training and continuing education to support the growth and professional development of nursing and support staff. This role ensures that all personnel maintain the required licensure and certifications, comply with facility policies and are well-equipped with the knowledge and skills necessary for providing high-quality resident care. The DSD coordinates with all mandatory training programs, evaluates staff competencies, and implements educational initiatives in line with federal, state, and facility regulations. Education and Training: Develop, implement, and manage comprehensive training programs, including orientation for new hires, ongoing education, and skills enhancement for staff. Compliance and Regulatory Oversight: Maintain accurate records of all training activities, staff competencies, and compliance documentation. During a concurrent record review and interview on 11/15/24, at 10:18 a.m., with the DSD and the Administrator, Certified Nursing Assistant (CNA) 1 ' s education records were reviewed. The education records indicated CNA 1 was hired at the facility in 2023. During a review of CNA 1 ' s education records, a four-page document titled, Employee Orientation, indicated numerous items, including I have been instructed in and understand Resident Rights. This item contained an area for CNA 1 to sign the item; it was blank with no signature. The Employee Orientation document indicated other areas for the employee and a licensed nurse to sign, name of employee, and Date of Orientation Completed. All these areas were blank on all four pages. The DSD stated, That ' s because I didn ' t sign it. The DSD then left the interview and record review. During a review of a facility letter (Letter) dated 11/14/24, to CNA 1, the Letter indicated, We regret to inform you that we have come to the decision to terminate your employment with [the facility] effective November 14, 2024. This decision was reached after careful consideration of your violation of resident rights and its impact on [the facility]. As a responsible employer we believe it has become evident that your behavior does not meet the standards and expectations set forth by [the facility]. The letter was written by the Administrator and signed by CNA 1. During an interview on 11/15/24, at 11:55 a.m., with the Administrator, the Administrator stated, It is my expectation that in-service [education] for new hires be proctored [supervised by someone, referred to as a proctor, who verifies the identity of the test taker and maintains test integrity] and precepted [a preceptor is an experienced practitioner who provides supervision during clinical practice and facilitates the application of theory to practice] by the DSD. During a review of the facility Policy & Procedure, title Resident Rights Guidelines for All Nursing Procedures (P&P), date 10/10, the P&P indicated, Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: . Resident dignity and respect[.]

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1. A walk- in freezer had beef stew meat with ice crystals inside the bag labeled [DATE]. 2. A foam cup containing food with staff name undated labeled was stored on shelf in walk-in refrigerator. 3. An open yogurt container with no opened date was found in the walk-in refrigerator 4. A white bin containing oats was not labeled with open and received date in the storage room. 5. Cookies, snacks and 2-liter sodas brought from family members, were found with no label of date opened, date received, or initials, in two of six sampled residents' (Resident 2 and 24) room. These failures had the potential to transmit food-borne illnesses to residents. 1. During a concurrent observation and interview on [DATE] at 8:23 a.m. in the walk- in freezer with the Dietary Service Supervisor (DSS) a bag containing stew meat dated [DATE] had ice crystals inside. The DSS stated, she was going to throw the stew meat away. During an interview on [DATE] at 9:33 a.m. with the DSS, the DSS stated, frozen meat was good up to 6 months and the stew meat was not right. The DSS stated, the stew meat had freezer burn (condition that occurs when frozen food loss moisture and dried out due to exposure to air) and it should have been thrown away. The DSS stated, the stew meat was used on an old menu and the old menu was discontinued. The DSS stated, We go through our meat every seven days. The DSS stated, the stew meat should have been thrown away when menu was discontinued. The DSS stated, expired stew meat lowered taste and quality and residents would not eat it. During an interview on [DATE] at 11:38 a.m. with the Registered Dietitian (RD), the RD stated the stew meat with freezer burn should have been thrown away. The RD stated, stew meat had compromised quality and taste. The RD stated, Residents would not eat it. The RD stated the stew meat had potential to contain bacteria. The RD stated freezer burned stew meat could have caused food poisoning and had potential to get residents sick. The RD stated staff should have noticed stew meat and should have thrown it out. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control dated 2011, the P&P indicated, Subject: Freezer Storage .4. New items should be placed behind older items .5. All foods should be stored in an airtight moisture-resistance wrapper such as a plastic bag or freezer paper to prevent freezer burn . During a review of the professional reference titled, What is Freezer burn? dated [DATE], retrieved from, https://ask.usda.gov/s/article/What-is-freezer-burn, the article indicated, Freezer burn appears as grayish-brown leathery spots on food and is caused by air reaching the surface of the food .Heavily freezer-burned foods may have to be discarded for quality reasons . 2. During a concurrent observation and interview on [DATE] at 8:40 a.m. in the walk-in refrigerator with the DSS, a foam cup containing food had staff name without no labeled dated next to resident food on a shelf. The DSS stated the foam cup should not be mixed with resident food and it should be labeled with date. During an interview on [DATE] on 9:33 a.m. with the DSS, the DSS stated the foam cup should have been stored in staff bin (a container where staff stored all personal items). The DSS stated the foam cup had potential to be mixed with resident's food and served to residents. The DSS stated staff should have thrown it away. During an interview on [DATE] on 11:43 a.m. with the RD, the RD stated staff should have a designated area for their items. The RD stated, the foam cup should have been stored inside staff bin. The RD stated all staff items should be stored inside staff bin. The RD stated items stored in staff bin prevented cross contamination. The RD stated, staff items stored outside staff bin caused confusion for staff. The RD stated residents could have been served food meant for staff. The RD stated, Residents could have potentially gotten food that belong to the staff members and we do not know if resident might eat it. The RD stated, cross contamination could have resulted when residents were served food eaten by staff. The RD stated, residents could have an allergic reaction from the ingredients inside the foam cup. The RD stated, staff should have dated the foam cup to prevent serving food past expiration. The RD stated, following storing practices could have prevented confusion. During a review of the facility's policy and procedure (P&P) titled, Dietary Staff Food Storage dated ,d+[DATE], the P&P indicated, .Dietary Saff may keep their refrigerated items in a separate bin within the walk-in-refrigerator. This must be labeled and dated. The items will not be stored on the shelf outside of the bin with the resident's food items. It is the responsibility of the Dietary staff to keep their items dated and clean bin weekly by a designated staff member . 3. During a concurrent observation and interview on [DATE] at 8:40 a.m. in the walk -in refrigerator with the DSS, an open yogurt container was labeled with received dated [DATE] and no open date. The DSS stated, open yogurt container should have an open date labeled. During an interview on [DATE] at 9:45 a.m. with the DSS, the DSS stated, open yogurt container needed to have an open date when it was opened. The DSS stated, open yogurt containers without date should have been thrown out. The DSS stated, undated opened yogurt could have been served to Residents. The DSS stated, resident can get sick from eating expired yogurt. During an interview on [DATE] at 11:43 a.m. with the RD the RD stated, yogurt containers should date when opened. The RD stated the open date was important to know when to throw it away. The RD stated, undated yogurt containers could have been served past expiration dates. The RD stated, undated open yogurt could have mold and bacteria and it could have been served to residents and could have gotten them sick. The RD stated, staff should have thrown it out. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control dated 2011, the P&P indicated, .9. Leftover food or unused portion of packaged foods should be covered, labeled, and dated to assure they will be used first . 4. During a concurrent observation and interview on [DATE] at 9:50 a.m. in the storage pantry in the kitchen, a plastic storage bin containing oats was not labeled with an opened and received date. The DSS stated, storage bins should have been labeled with both and opened and received dates. During an interview on [DATE] at 9:33 a.m. with the DSS, the DSS stated, staff should have labeled the oat bin with opened and received dates. The DSS stated, it was important to have both dates on the bin to prevent mixing old items with new items. The DSS stated, the staff did not follow the policy when the oat bin was not labeled with an opened and received date. During an interview on [DATE] at 11:43 a.m. with the RD, the RD stated, the bin for oats should have been labeled with a received and opened date. The RD stated, When in doubt throw it out The RD stated, it was important to label the bin with an opened and received date to prevent residents from consuming expired oats. The RD stated residents could have gotten sick if they ate the expired oats. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control dated 2011, the P&P indicated, Subject: canned and Dry Goods Storage .15. Bins holding dry goods such as flour, sugar, etc, must be clearly labeled on the lid and front of the container and dated when produces were put into bin . 5. During a review of Resident 2 s Admission Record (document containing resident demographic information and medical diagnosis) dated [DATE], the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 's diagnosis included hypertension (high blood pressure), Alzheimer's disease ( a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform basic tasks), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and depression. During an observation on [DATE] at 10:30 a.m. in Resident 2's room, two bottles of tamarind soda with no received date and no initials were on the nightstand. During an interview on [DATE] at 3:45 p.m. in Resident 2's room, Certified Nurse Assistant (CNA) 4 verified there were two unlabeled bottles of tamarind soda in Resident 2's room. CNA 4 verified one bottle was opened. CNA 4 stated, opened two-liter soda should be labeled with an open date and Resident 2's initials. CNA 4 stated, the opened two-liter soda should have been refrigerated. CNA 4 stated, it was important to label the two-liter soda to prevent Resident 2 from consuming it past expiration date. CNA 4 stated Resident 2 could have gotten sick when he consumed expired soda. During a concurrent observation and interview on [DATE] at 10:42 a.m. in Resident 2's room with Licensed Vocational Nurse (LVN) 2, LVN 2 verified two tamarind soda bottles were on the table with no date and no initial. LVN 2 stated, two-liter sodas needed to be labeled with date, time, and resident initials. During a review of Resident 27s Admission Record (document containing resident demographic information and medical diagnosis) dated [DATE], the admission record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27 's diagnosis included Parkinsons disease (chronic, progressive brain disorder that causes movement problems and other symptoms), protein-caloric malnutrition (the state of inadequate intake of food (as a source of protein, calories, and other essential nutrients) and pain. During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE] the MDS, indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of ,d+[DATE] ) score of 15 (a score of ,d+[DATE] suggests severe cognitive impairment, ,d+[DATE] suggests moderately impaired, ,d+[DATE] suggests cognitively intact) indicating Resident 27 was cognitively intact. During an observation on [DATE] at 11:35 a.m. in Resident 27's room one plastic container contained cookies, one plastic container contained crackers and one plastic container was empty. During an interview on [DATE] at 3:30 p.m. with Resident 27, Resident 27 stated, his family member brought cookies to the facility last week. During an interview on [DATE] at 3:23 p.m. with LVN 4, LVN 4 stated, Resident 27's family brought cookies and snacks from home. LVN 4 stated, there should be a date on the cookie container. LVN 4 stated she was not sure how long the cookies were kept in the container. During an interview on [DATE] at 3:35 p.m. in the hallway with CNA 5, CNA 5 stated she worked for the facility for [AGE] years. CNA 5 stated plastic containers with cookies and crackers should have a label with received and open date. CNA 5 stated cookies received from family member were good for three days. CNA 5 stated snacks were kept in resident utility room or refrigerator. CNA 5 stated, it was important to labeled items with received and open date to ensure food was not expired. During an interview on [DATE] at 3:53 p.m. with CNA 6, CNA 6 stated, she had worked for the facility for seven years. CNA 6 stated Resident 27 had cookies in clear plastic containers with no date or initials. CNA 6 stated cookies should have been labeled with received date and Resident 27's name. CNA 6 stated it was important to label received date on cookies and snacks so Resident 27 would not be given expired items. CNA 6 stated, expired cookies or crackers could have caused Resident 27 to be sick. CNA 6 stated cookies brought in by Resident 27's family member should be thrown away after three days. CNA 6 stated, CNAs were responsible to clean resident tables and to label cookies. CNA 6 stated she did not remember the last time she cleaned Resident 27's table. During an interview on [DATE] at 10:27 a.m. with LVN 2, LVN 2 stated, Resident 27's family member brought cookies and snacks. LVN 2 stated, staff should have labeled cookies and snacks when it was opened. LVN 2 stated all staff were responsible to check the cookies and snacks for residents. LVN 2 stated cookies and snacks brought in by family member were kept in the refrigerator for seventy-two hours. LVN 2 stated, we should have labeled the cookies with open date to prevent Resident 27 from consuming expired cookies. LVN 2 stated, cookies with open date prevented food borne illness. LVN 2 stated, expired food caused health issues. During an interview on [DATE] at 1:40 p.m. with the Director of Staff Development (DSD), the DSD stated staff were trained in labeling food and sodas brought in by family members. The DSD stated new hires were trained to label food and sodas brought in by family members during orientation. The DSD stated dating food was important to prevent residents from consuming expired food. The DSD stated all staff members were educated about the safety of expired food. During an interview on [DATE] at 2:19 p.m. with the Director of Nursing (DON), the DON stated food brought in by family members should have an open date label. The DON stated food that was left over for more than three days should have been tossed or thrown away. The DON stated food items should have been labeled with received date and resident name. The DON stated, food brought in by family members was sensitive and could have effect on the residents. The DON stated anytime family members bring food, the CNA should notify the charge nurse. The DON stated the policy is to date the food when it arrives. The DON stated it was important to date it for resident safety. During a review of the facility's policy and procedure (P&P) titled, Food brought by Family/Visitors revised date ,d+[DATE], the P&P indicated, .Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food .containers are labeled with the resident's name, the items and the 'used' by date .

During observation, interview, and record review the facility failed to ensure privacy and confidentiality for two out of four residents (Resident 10 and Resident 15) during medication administration and medical treatment when: 1. Resident 10's curtains were not pulled during blood glucose testing (a measurement of the amount of sugar in a person's blood. It involves a finger prick or blood draw from the vein) and administration of insulin (a medication that lowers the amount of sugar in the blood). 2. Resident 15's curtains were not pulled during the administration of eye drops. These failures had the potential to place Resident 10 and Resident 15 at risk of losing their privacy and confidentiality during their medical treatments, and not attaining, or maintaining physical, mental, and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 10/23/24 at 11:16 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 10's room, Resident 10 was observed dressed, sitting in his wheelchair in the middle of his room, in view of the open doorway. LVN 2 was observed performing a finger stick to check Resident 10's blood glucose. LVN 2 proceeded to lift Resident 10's shirt, exposing his abdomen and administered Resident 10's medication by injection into his abdomen. LVN 2 did not close the door to Resident 10's room or draw Resident 10's curtains for privacy during Resident 10's treatment. LVN 2 stated Resident 10's curtain should have been drawn when administering medications and treatment. LVN 2 stated Resident 10 should have been given privacy during his treatment. LVN 2 stated someone could have walked by and seen Resident 10 getting his finger stick and injection. During a review of Resident 10's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/24/24, the AR indicated, Resident 10 was admitted on [DATE] with diagnoses of heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), personal history of transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), Type 2 Diabetes Mellitus (a condition where the blood sugar levels in the body are too high), difficulty in walking and polyneuropathy (damage to the nerves that can cause decreased ability to move and feel [sensation]). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 8/14/24, the MDS section C indicated Resident 10 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 10 was cognitively intact. 2. During a concurrent observation and interview on 10/23/24 at 7:32 a.m. with LVN 2, in Resident 15's room, Resident 15 was observed dressed, sitting in her wheelchair in the hallway. LVN 2 was observed moving Resident 15 into her room, with Resident 15's roommate. LVN 2 was observed administering Resident 15's eye drops into both eyes of Resident 15. LVN 2 did not pull Resident 15's curtain. Resident 15's roommate was observed sitting in her wheelchair watching the administration of Resident 15's eye drops. LVN 2 stated Resident 15's curtain should have been drawn to provide privacy during Resident 15's medication administration. During a review of Resident 15's AR, dated 10/24/24, the AR indicated , Resident 15 was admitted on [DATE] with diagnoses of heart failure, epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 15's MDS dated [DATE], the MDS section C indicated Resident 15 had a BIMS score of three, which suggested Resident 15 had severe cognitive impairment. During an interview on 10/24/24 at 3:04 p.m. with LVN 3, LVN 3 stated nurses should pull resident's curtain for medication administration. LVN 3 stated pulling the resident's curtain was important to provide resident privacy, HIPPA (Health, Insurance, Portability and Accountability act - a federal law to protect health information) protection, and resident dignity. LVN 3 stated the curtain should have been pulled when residents received medication or care. During an interview on 10/25/24 at 3:32 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated it was important to pull resident's curtains when providing patient care to give the residents privacy. CNA 4 stated the facility provided training on patient privacy, resident rights, and neglect approximately every three months. During an interview on 10/28/24 at 1:49 p.m. with the Director of Nursing (DON), the DON stated resident privacy was very important during resident care. The DON stated all residents deserved privacy. The DON stated if residents did not receive privacy during care, it could harm residents emotionally. The DON stated it didn't matter which resident, or if the resident had dementia, all residents deserved privacy during their care and treatments. During a review of the facility's job description document titled, Licensed Vocational Nurse (LVN), dated 3/2024, indicated, . key responsibilities . adhere to all state regulations, facility policies, and industry standards related to resident care . compassionate and patient-centered approach to resident care . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2/2021, indicated, . employees shall treat all residents with kindness, respect, and dignity . federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to . privacy and confidentiality .

Based on observation interview and record review the facility failed to provide services that met professional standards of quality of care for one of six sampled residents (Resident 3) when Resident 3's Hoyer lift sling (a mobile device which helps caregivers safely transfer patients) was used incorrectly during a transfer from his wheelchair to the bed. This failure caused Resident 3 to experience pain and discomfort and had the potential to result in injury as a result of using the lift improperly. Findings: During a review of Resident 3's Admission Record (AR- a document which provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 10/25/2024, the AR indicated Resident 3 was admitted with the following conditions: contracture of muscles (stiffness or tightening of the muscles which causes inability to move), generalized weakness (overall lack of strength), and generalized abdominal pain (pain in the stomach area). During an observation on 10/23/24 at 11:46 a.m. in Resident 3's room, Certified Nursing Assistants (CNA) 1 and 2 used a Hoyer lift to transfer Resident 3 out of his wheelchair and into his bed. CNAs 1 and 2 positioned the Hoyer lift sling with the shortest hooks attached near Resident 3's shoulders and the longest hooks attached near his legs causing him to be lifted in a sitting position. Resident 3 told CNAs 1 and 2 he was uncomfortable and felt pain during the lift. During an interview on 10/23/24 at 11:58 a.m. with Resident 3, Resident 3 stated he felt uncomfortable when CNAs 1 and 2 were lifting him with the Hoyer lift. Resident 3 stated the way they lifted him put pressure on his lower back and caused pain and discomfort. Resident 3 stated he had had back surgery in the past which made sitting for a prolonged period of time uncomfortable. Resident 3 stated he felt a lot of pressure on his lower back as they were lifting him and placing him on the bed because he was transferred sitting up instead of reclined. During an interview on 10/23/24 at 12:08 p.m. with CNA 1, CNA 1 stated Resident 3 had complained of discomfort during lifts in the past. CNA 1 stated she attached the sling with the longer hooks towards his legs and the shorter hooks towards his shoulders in order to have him sitting upright when transferring from his chair to the bed. CNA 1 stated staff had routinely used this technique and she was unsure if this method was incorrect, as other staff had not provided any correction. During an interview on 10/25/24 at 11:10 a.m. with the director of staff development (DSD), the DSD stated CNAs got trained on how to properly attach the Hoyer lift sling using educational videos. The DSD stated if staff were transferring a resident from a chair to bed, they should have had him in a more reclined position because if they transferred him using a sitting up position, they would need to support his back, so he did not fall. During an interview on 10/25/24 at 2:46 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated staff were supposed to hook the Hoyer lift sling on properly. LVN 6 stated if a transfer from bed to chair was occurring the resident needed to be sitting upright in the sitting position and if a transfer from chair to bed was occurring then the sling needed to be in a more reclined position. LVN 6 stated it was important to use the Hoyer lift and sling properly because improper use could result in injury to Resident 3. During a concurrent interview and record review on 10/28/24 at 10:06 a.m. with LVN 2, the Hoyer lift's, Owner's Manual and Instruction Guide, undated, was reviewed. The Owner's Manual and Instruction Guide indicated when lifting a resident from bed to chair the sling should be positioned so the resident is lifted in a sitting up position, when transferring from chair to bed the position should be reversed in order to have the resident in a reclined position. LVN 2 stated the Owner's Manual and Instruction Guide were not followed for proper use of the Hoyer lift and sling. LVN 2 stated when transferring a resident from the bed to chair the Hoyer lift slings hooks should have been attached with the longer hooks on the bottom part towards the legs and the shortest hooks on the top towards the shoulders and the set up should have been reversed when transferring from chair to bed. LVN 2 stated improper use of the Hoyer lift when transferring a resident could have caused Resident 3 to feel unsafe, sustain an injury, and feel pain. During an interview on 10/28/24 at 11:27 a.m. with the Director of Nursing (DON) the DON stated Resident 3 should not have experienced discomfort during a Hoyer lift transfer. The DON stated staff should have followed the manufacturer guidelines for use of the Hoyer lift in order to use it properly. During a professional reference review, retrieved from https://www.hlshealthcare.com.au/patient-lifting-slings-which-loop-is-which/ titled, Patient Lifting Slings: which loop is which?, undated, indicated, .If a client is returning to bed . the best option would be the longer loops at the back that will lead them to leaning back in the sling. This ensures a smooth transition as the hoist strap is lowered, as the client only has a short journey down to their final position on the pillow. If the carer incorrectly chose the shorter loops, the client would be sitting fully upright in the bed and would then recline down onto the pillow. some clients have described this as a 'free falling' feeling so it makes for a much smoother transfer if the begin the process leaning back . 49949 DO NOT CITE

During observation, interview, and record review, the facility failed to ensure accurate labeling of resident medications, and storage of resident medications at proper temperatures to preserve their integrity in accordance with accepted professional standards of practice when: 1. One of two medication carts had two out of 199 pill packets with no visible expiration dates. 2. Seven out of seven boxed medications did not have the inside medication container labeled with resident information. 3. One of two medication refrigerators was below the facility required temperature range of 36 degrees Fahrenheit (F) and 46 degrees F. These failures put residents at risk for unsafe administration of medications. Findings: 1. During a concurrent observation and interview on 10/24/24 at 12:00 p.m. with Licensed Vocational Nurse (LVN) 2, in the B-wing nurse's station, the B-wing medication cart was observed to have two of 199 resident pill cards (a packet containing a set number of prefilled prescription medications) without visible expiration dates. LVN 2 stated the residents' medication pill cards should have had a visible expiration date. LVN 2 stated if nurses were unable to read the expiration date, the medication should not be given. LVN 2 stated the pharmacy should be called to advise if a new label would be sent, or if the nurse was to dispose of the medication and get a new medication card sent from the pharmacy. During an interview on 10/28/24 at 1:49 p.m. with the Director of Nursing (DON), the DON stated labeling residents' medications correctly was a facility policy. The DON stated her expectation was for the resident's correct name and the medication expiration date to be visible on the resident's medication. The DON stated if the medication was not labeled correctly, staff could harm the resident who received the medication. The DON stated the medication expiration date should have always been visible. The DON stated staff should have contacted the pharmacy if the medication expiration date was not visible. The DON stated it was important to see the medication expiration date because the medication could have expired. The DON stated expired medications could have lost their potency and not helped the resident who received the medication. During a review of the facility's job description (JD) document titled, Licensed Vocational Nurse, dated 3/2024, the JD indicated, . key responsibilities . dispense prescribed medications accurately . according to established protocols . maintain accurate medication records and documentation . During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, indicated, . medications are administered in a safe and timely manner . the expiration/beyond use date on the medication label is checked prior to administering . During a review of the facility's P&P titled, Medication Labeling and Storage, dated 2/2023, indicated, . labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . the medication label includes, at a minimum . expiration date . if medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items . only the dispensing pharmacy may label or alter the label on a medication container or package . 2. During a concurrent observation and interview on 10/23/24 at 7:32 a.m. with LVN 2, outside of Resident 15's room, LVN 2 was observed removing an unlabeled bottle from a labeled box of eye drops. The box was observed to have Resident 15's name, the box opened date, and the use by date for the eye drops written on the inside of the box flap. LVN 2 stated over-the-counter medications did not have the resident's name written on the bottle, only the box was labeled. LVN 2 stated if the bottle came out of the labeled box in the medication cart, staff should throw the bottle away and get a new box. LVN 2 stated staff would not know who the bottle belonged to if the box was not labeled. During a concurrent observation and interview on 10/24/24 at 2:28 p.m. with LVN 3, in the nurse's station, the B-wing medication cart was observed to contain six boxes of eye drops and one inhaler with resident names on each box. The eye drop bottles inside each box were observed to have no labels on the medication bottles, and the inhaler inside the box had no label on the medication. LVN 3 stated the medication containers inside of the box should be labeled with the resident's name. LVN 3 stated if the medication came out of the unlabeled box, the medication could be given to the wrong person. LVN 3 stated an unlabeled eye drop bottle or inhaler could cause a medication error. During an interview on 10/28/24 at 1:49 p.m. with the DON, the DON stated labeling resident's medication bottles correctly was in the facility's medication policy. The DON stated it was important that the resident's medication was labeled with the correct resident's name and was readable. The DON stated if the medication was not labeled with the resident's name, staff could harm the resident. The DON stated the medication containers in boxes should be labeled. The DON stated the medication container could fall out of the box and staff would not know who it belonged to. During a review of the facility P&P titled, Medication Labeling and Storage, dated 2/2023, indicated, . labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . the medication label includes, at a minimum . resident's name . 3. During a concurrent observation and interview on 10/24/24 at 11:18 a.m. with the Minimum Data Set Nurse (MDSN) in the B-wing medication room, the medication refrigerator temperature was observed at 32 degrees Fahrenheit (F). The MDSN stated the refrigerator temperature of 32 degrees F was too cold to hold medications. The MDSN stated having the refrigerator temperature below the accepted temperature range of 36 degrees F could damage the medications and make them unsafe for resident use. During a concurrent interview and record review on 10/24/24 at 11:20 a.m. with the MDSN, the Temperature Log for Refrigerator (TL), dated [DATE] was reviewed. The TL indicated, . Danger! Temperatures below 36 degrees F are too cold! Write any out-of-range temps and room temp on the lines below . The MDSN stated if the refrigerator temperature was below the accepted temperature range, the medications in the refrigerator could be damaged. During an interview on 10/24/24 at 11:21 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the Infection Prevention (IP) Nurse kept track of the medication refrigerator temperatures. The ADON stated if the medication refrigerator temperature was out of range, the nurse should notify maintenance and call the pharmacist for guidance. During an interview on 10/24/24 at 2:20 p.m. with the MDSN, the MDSN stated the protocol for medication questions was to call the pharmacist for guidance. The MDSN stated the pharmacist informed her if the medications were not out of acceptable ranges for over 6 hours, the medications should be okay. The MDSN stated the pharmacist recommended staff to check the affected medications for crystallization (the process in which solids form in a liquid substance) prior to use on residents. During an interview on 10/28/24 at 1:49 p.m. with the Director of Nursing (DON), the DON stated her expectation was the medication refrigerator to be kept within the appropriate temperature range for holding resident medications. The DON stated if the medication refrigerator was not within the appropriate range, it could affect the resident's medication potency. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, indicated, . the facility stores all medications and biologicals . under proper temperature, humidity and light controls . During a review of the facility's policy and procedure titled, Pharmacy Services Overview, dated 4/2019, indicated, . medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice . the consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to) . receipt, labeling and storage of medications . facility staff roles and responsibilities during the receipt and storage of medication . During a review of the facility's policy and procedure titled, Pharmacy Services - Role of the Consultant Pharmacist, dated 4/2019, indicated . the consultant pharmacist will provide specific activities related to medication regimen review including . review of medication storage areas at least monthly, and medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and expired medications .

Based on observation, interview and record review, the facility failed to ensure 56 of 56 sampled residents received safe and appetizing temperature food when Dietary [NAME] (DC) did not check temperature of food on steam table on 10/23/24 before serving. This failure had the potential for all 56 residents to be served cold food and for all 56 residents to contract food borne illnesses. Findings: During an observation on 10/23/24 at 10:19 a.m. in the kitchen with the DC, the DC removed tray #1 lasagna from oven and placed the lasagna on steam table. During an observation on 10/23/24 at 11:33 a.m. the DC removed tray #2 lasagna from oven and placed the lasagna on steam table. During an observation on 10/23/24 at 11:39 a.m. in the kitchen during tray line (food service assembly line system where workers add components to a tray as it moves along a line),the following items were observed on the steam table: tray #1 lasagna stacked on top of tray #2 lasagna, a silver tray of boiled vegetables, six foam containers (three pureed lasagna and three pureed vegetables) were on the steam table. DC did not check temperatures prior to putting food on the plate. During an interview on 10/23/24 at 12:15 p.m. with the DC, the DC stated, he did not check temperature of food on steam table. The DC stated, We don't have temperature logs for items on steam table. The DC stated he should have checked temperature of food prior to serving. The DC stated he was trained by the Dietary Services Supervisor (DSS) for four days. During an interview on 10/24/24 at 9:33 a.m. with the DSS, the DSS stated, the DC should have checked the temperature of the items on the steam table prior to serving. The DSS stated, checking the temperature of the items on the steam table ensures the food is warm and appropriate temperature prior to serving. The DSS stated, we want to make sure the food is warm for the Residents. The DSS stated, Residents do not like cold food and would not eat it. The DSS stated, residents lost weight when they refused to eat. The DSS stated, food should have been checked to make sure it was acceptable temperature and to prevent bacterial growth. The DSS stated, residents could get sick when consuming food below 165-degree Fahrenheit. During an interview on 10/24/25 at 11:43 a.m. with the Registered Dietitian, the RD stated, Prior to serving, food temperature should have been checked. The RD stated it was important to check food on steam table to ensure accurate temperature prior to serving. The RD stated checking temperature prior to serving was for food safety. The RD stated checking temperature will prevent bacterial growth that cause foodborne illness. The RD stated food was appetizing when served hot. The RD stated, food served cold resulted in residents eating less and had the potential to cause weight loss. During a review of the facility's policy and procedure titled, Proper Temperatures for meal preparation and service dated 2011, the P7P indicated, .[box] Food items [box] Casseroles .[box] hold temperature (minimum acceptable) [box] 140 [degree Fahrenheit] .[box] vegetables .[box]140 [degree Fahrenheit] .