Every finding on record at Creekside Center

Based on interview and record review, the facility failed to ensure quality of care was provided according to professional standards of practice for one of three sampled residents (Resident 1) when, 1. Resident 1's Continuous Positive Airway Pressure (CPAP- a medical device attached to a facemask and then placed over the resident's mouth or nose and used to deliver pressurized air into the airway to keep it open) order was not transcribed from the [ACUTE CARE HOSPITAL NAME]'s discharge orders on 5/24/26 to Resident 1's active orders at the facility upon admission on [DATE]. 2. Resident 1 was given Resident 2's medications by mistake on 6/6/26. These joint failures put Resident 1's health and safety at risk when Resident 1 developed an altered level of consciousness (a state of confusion) due to impaired gas exchange (a condition where the lungs struggle to transfer oxygen into the bloodstream and remove carbon dioxide) after she had not received CPAP treatment for 14 days (delayed care), which resulted in her being admitted to [ACUTE CARE HOSPITAL NAME] on 6/7/26 for three days to receive further evaluation and treatment; and additionally, Resident 1 was at risk for health complications related to med to med interactions (occurs when another medication alters how another medication works in the body) related to the medication error. Findings: 1.During a review of Resident 1's hospital clinical record titled, [ACUTE CARE HOSPITAL NAME] .Discharge summary, dated [DATE], indicated, . Continue supportive care and use of CPAP if available.Discharge Order Details: 05/24/06 . Today- Skilled Nursing Facility . During a review of a facility provided document titled, INVENTORY OF PERSONAL EFFECTS [RESIDENT 1'S NAME AND ROOM NUMBER] ., admit date [DATE], signed by FM 2 and the facility, indicated Resident 1's inventory list included, . Breathing Machine. During a review of Resident 1 ' s facility clinical record titled, admission Record, (a document that contained Resident 1's demographic information) dated 5/24/26, indicated Resident 1 ' s diagnoses included Obstructed Sleep Apnea (a condition where the throat muscles relax too much during sleep, blocking the airway), morbid obesity (the accumulation of excess fat that increases the body's effort of breathing) with alveolar hypoventilation, (a breathing pattern that is too slow or shallow to meet the body's needs) Asthma (a long term disease that makes the airways narrow), and anemia (low red blood cells that leads to low oxygen in the blood). A review of Resident 1's clinical record from the [ACUTE CARE HOSPITAL NAME], titled, Discharge Summary, admission date of 6/7/26 and discharge date of 6/10/26, indicated on 6/7/26, Resident 1 was admitted from the facility to [ACUTE CARE HOSPITAL NAME] with an altered level of consciousness (confusion) and was further evaluated for dehydration (lacking adequate water in the body). Upon admission, Resident 1 appeared to be experiencing, shortness of breath. The hospital admission labs revealed a partial pressure of carbon dioxide (pC02- measures how much carbon dioxide is in the blood and an indicator of how well the lungs are removing carbon dioxide) level of 59 (high, normal range for pCo2 = 35 to 45), and bicarbonate (HC03-a natural compound in the body that balances the acid levels) level of 34.9 (high, normal range 22-26). The record indicated Resident 1's acute metabolic encephalopathy (a medical emergency characterized by a rapid, decline in brain function) was likely due to a combination of dehydration and hypoventilation (breathing at an abnormally slow rate, resulting in an increased amount of pCO2 in the blood), and mixed medications. The record further indicated, .It was unclear if the patient uses her CPAP each night.Patient was started on Bilevel Positive Airway Pressure [BiPAP- uses two types of pressures to treat apnea]/CPAP.per nursing staff, patient started to become more oriented overnight after being started on the BiPAP. During a phone interview on 6/12/26 at 11:45 AM with Family Member (FM) 1, FM 1 stated she was in Resident 1's room on 6/6/26 and observed Resident 1 sleeping in bed without the CPAP in place. FM 1 stated she informed the nurse. FM 1 stated there were multiple times when Resident 1 was seen without the CPAP machine since her admission to the facility on 5/24/26. FM 1 stated Resident 1 began to show signs of excessive tiredness and a change in mentation three day before the hospitalization. FM 1 stated the family expressed their concern about the CPAP not being placed on Resident 1 with the Director of Nursing (DON) and various nursing staff with no corrective action. During a follow up interview on 6/26/26 at 10:09 AM with FM 1, FM 1 stated the CPAP machine was provided by the family to the facility on the day Resident 1 was admitted to the facility (5/24/26). FM1 stated when during the multiple times she visited Resident 1 she would notice the compartment on the machine that stored the water was empty. Resident 1 stated the family supplied the facility with the water for the machine and the water was not being used by the facility. FM1 stated the water had to be refilled after each use. FM1 further stated this prompted her to inform the facility and request the usage of the CPAP. FM 1 stated when Resident 1 went to the hospital on 6/7/2026 a discussion with the DON was conducted prior to Resident 1's return to the facility from [ACUTE CARE HOSPITAL NAME] about the importance of the CPAP order being followed. FM 1 stated that she informed the DON that Resident 1' was hospitalized for high levels of carbon dioxide in the blood and it was caused by Resident 1 not being placed on CPAP at night. FM 1 stated the DON apologized and offered to do weekly blood levels on Resident 1 when she returned to the facility to ensure her carbon dioxide levels remained within the normal range. During an interview on 6/12/26 at 11:04 AM with Licensed Nurse (LN) 1, LN 1 stated she was one of the regular nurses that took care of Resident 1. LN 1 stated on 6/7/26 (the day Resident 1 went to the hospital) she was lethargic (extremely sluggish and drowsy), confused, and her body was making jerky movements. LN 1 stated this presentation was not Resident 1's baseline and LN 1 stated Resident 1's baseline was alert and oriented to person, place, time, and sometimes the situation. During a follow up interview on 6/26/26 at 10:48 AM with LN 1, LN 1 stated prior to sending Resident 1 to the hospital on 6/7/26 she took care of Resident 1 approximately five to six times. LN 1 stated she was not aware Resident 1 needed to be on a CPAP machine and had not placed or removed a CPAP mask on Resident 1 during her shifts on or prior to 6/7/26. LN 1 stated if Resident 1 needed a CPAP machine for assistance with breathing and was not given as ordered by the doctor, Resident 1 was at risk to stop breathing. During a telephone interview on 6/26/29 at 8:31AM with Licensed Nurse (LN) 2, LN 2 stated on 6/6/26 (the day prior to Resident 1 becoming hospitalized ) she took care of Resident 1 and did not place a CPAP mask on Resident 1. LN 2 stated the nurse from the prior shift did not mention the CPAP machine and LN 2 did not recall a CPAP order. LN 2 stated she did not provide CPAP care to Resident 1. During a concurrent interview and record review on 6/25/26 at 3:01 PM with Licensed Nurse (LN) 3, Resident 1's Medication Administration Record (MAR- a document to record medication orders and treatments orders) for the month of May 2026 and June 2026 were reviewed. LN 3 stated she had taken care of Resident 1, two to three times prior to her hospitalization on 6/7/26. LN 3 stated Resident 1 was not on a CPAP machine prior to returning from the hospital on 6/11/26. LN 3 verified the MAR for May 2026, and the MAR for June 2026 did not have an order for CPAP machine. LN 3 stated when an order had been placed for a resident to use CPAP, the evening shift nurse put the CPAP mask on the resident and the morning shift nurses to take it off. LN 3 stated she did not remove the mask from Resident 1 during any of the morning shifts she worked with the resident. During a concurrent interview and record review on 6/25/26 at 2:30 PM with the DON, a review of Resident 1's documents titled, [ACUTE CARE HOSPITAL NAME.Discharge Summary., dated 5/24/26; MAR, dated 5/24/26 through 6/7/26; Progress Notes, [filtered by all progress notes] dated 5/24/26 through 6/11/26; and Resident 1's active care plan, were reviewed. [ACUTE CARE HOSPITAL NAME] .Discharge Summary, indicated, .Continue supportive care and use of CPAP if available. The DON verified this order was supposed to be carried out by the nursing staff at the facility and was an oversight on the facility's behalf. The DON stated the orders should be inputted by a nurse supervisor in the electronic medical record (EMR) and a meeting held to review the orders. The DON stated somehow the CPAP order was overlooked. Resident 1's MAR from 5/24/26 through 6/7/26 was reviewed with the DON and she stated although there was no order in the MAR for a CPAP machine, the staff were still applying the CPAP. Resident 1's Progress Notes from 5/24/26 through 6/7/26 were reviewed with the DON and the DON verified there was no documentation of the CPAP being applied or any treatment related to the CPAP given. The DON was unable to provide documentation to support that Resident 1 received the CPAP during 5/24/26 through 6/7/26. Resident 1's Progress Notes, [late entry] dated 6/11/26, written by the DON for the events on 6/10/26, indicated, .Daughter expressed concerns regarding a previously reported medication error, CPAP use and monitoring.respiratory care and safety measures. The DON confirmed the facility had not started Resident 1 on a respiratory care plan from the admit date of 5/24/26 through 6/7/26 when Resident 1 was transferred to the hospital. The DON stated the risk of Resident 1 not having been administered the benefits of CPCP could have affected Resident 1's oxygen perfusion (the delivery of oxygen to the blood), which could have affected Resident 1's mental status. The DON stated this error created a safety risk to Resident 1. The DON stated if the nurses didn't document the placement of the CPAP, there was no way to verify it was done. The DON further stated if a resident was dependent on CPAP at night and it was not used, the resident may not breathe for a long period of time which could affect the resident's cognitive function, wound healing, and other respiratory conditions. During an interview on 5/26/26 at 2:59 PM, with the Medical Doctor (MD), the MD stated his expectation was for the staff to transcribe and follow the CPAP orders given from hospital that would've come from a sleep study (an overnight test used to calibrate the air pressure of the CPAP machine). The MD stated when Resident 1 did not use the CPAP for 14 nights while at the facility, that may have contributed to Resident 1's elevated PCO2 blood levels and need to a higher level of care at the hospital. The MD stated when staff noticed there was no active facility order for the CPAP machine, the nurse should've called him and got an order. During a concurrent interview and record review on 6/25/26 at 3:43 PM with the DON, the facility's policy and procedure (P&P) titled, .CPAP. dated 4/7/27 and the P&P titled, Physician Orders, dated 3/22/26, were reviewed. The P&P titled, .CPCP . indicated, This policy is to ensure the correct and safe use of PAP [positive airway pressure] equipment and ensure proper fitness and function of the equipment.Residents with Obstructive upper airways. While they sleep, their throat closes in and prevents air from getting into their lungs. This causes their oxygen saturation to drop and their carbon dioxide to rise.Without proper ventilation.result in sleepiness during the day and other medical problems. Verify physician order. The order should state the CPAP pressure [the amount of air pressure used to keep the airway open] . The DON was unable to provide documentation that verified the staff followed the P&P as indicated. The DON stated Resident 1's was at risk for shortness of breath that could lead to respiratory failure (a critical condition when the lungs cannot exchange oxygen properly). The DON stated when the CPAP order was missed by nursing staff during the admission process, it had not met her expectations. The P&P titled, Physician Orders, indicated, .This will ensure that all physician orders are complete and accurate.The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. The DON stated her staff had not followed the policy because the order was not written or verified. The DON stated this did not meet her expectations, and this action posed a risk of delayed care for Resident 1. 2. During an interview on 6/11/26 at 11:45 with FM 1, FM 1 stated while picking Resident 1 up for an outing with family on 6/6/26 the nurse gave Resident 1 her morning medications in the hallway. After the nurse administered Resident 1's medications, FM 1 stated the LN 2 stated she was going to give Resident 1 her nicotine patch (a patch placed on the skin with medication that curbs the need for nicotine), and she'll be ready to go on the outing with the family. FM 1 stated she told LN 2 that Resident 1 never smoked and wasn't prescribed a nicotine patch. FM 1 stated at that time LN 2 realized she administered Resident 1, Resident 2's medication. FM 1 stated LN 2 checked the paperwork and informed them that Resident 1 was only given vitamins. During an interview on 6/11/26 at 12:44 PM with LN 2, LN 2 stated on 6/6/26 while working day shift, she gave Resident 1, Resident 2's medications in the morning. LN 2 stated she administered Resident 1 Thiamine (also known as vitamin B1, a vitamin that assists with increasing energy), Folic Acid (a vitamin that helps repair the body), and a multivitamin (a daily supplement) tablet when she realized she had given the wrong medications to the wrong person. LN 2 stated after the mistake was realized, she verified that only vitamins that was given to Resident 1. LN 2 stated she did not notify the Director of Nursing (DON) or Medical Doctor (MD) until three days later when she was contacted by the Assistant of Director of Nursing (ADON). LN 2 stated she didn't notify anyone right away because she had a busy day. LN 2 stated the ADON asked her to come in and document about the error and to notify the MD. LN 2 stated when administering Resident 1 her medications she did not check the five rights (patient name, medication name and dose, correct route, and correct time). LN 2 confirmed the patient identifiers were available, and she did not use them. LN stated she did not think it was that big of a deal because the medications were vitamins. During a follow up interview on 6/26/26 at 8:31 with LN 2. LN 2 stated the risk of administering the wrong medication to the wrong person was that it could have caused harm to the patient such as dizziness, a change in the blood pressure, an allergic reaction, possible shortness of breath, and/or a skin rash. During a concurrent interview and record review on 6/11/26 with the DON, Resident 1's Progress Notes were reviewed. The DON confirmed there was not documentation about the medication error and the MD being notified until 6/9/26. The DON confirmed the only documentation in Resident 1's medical record about the medication error was written on 6/9/26 at 6:12 AM as a late entry for 6/6/26 by LN 2 and indicated, Pt. [patient] went out on pass with daughter via [with] wheelchair in stable condition. No acute distress noted. The DON stated she expected a more descriptive assessment of the resident's condition and more detailed notes regarding the med error event. The DON Stated the risk of not doing the five medication (right person, right medication, right time, right dose, right route) and not informing the MD timely of the medication error, placed Resident 1 at risk for worsening of her medical condition and possible adverse effects to the medication. During a concurrent interview and record review on 6/12/26 at 1:45 PM with the Pharmacist Consultant (PC), Resident 1 Medication Administration Record, (MAR) dated 5/2026 through 6/2026 and Resident 2's MAR, dated 5/2026 through 6/2026, were reviewed. The PC stated that she was unaware of this medication error. The PC stated after reviewing and comparing both Resident 1 and Resident 2's MAR, Resident 1 was given Folic Acid 1 milligram (mg, a unit of measurement), Multivitamin with minerals, and Thiamine 100MG, and cholecalciferol Tablet 1000 units (also known as Vitamin D3), in addition to her prescribed morning medications. The PC stated she did not see any interaction with the medications, however when an error like this occurred the PC stated the MD should be notified. During a concurrent interview and record review of the facility's policy and procedures (P&P) on 6/25/26 at 3:50 PM, with the DON, the P&P titled, Adverse Consequences and Medication Errors., dated 6/25, indicated, .Document the following information in an incident report and in the residents clinical record.Resident name age.medication, route, dose, date, and time of administration.factual description of the error or adverse consequences.name of provider and time notified.providers orders.Resident's condition for 24 to 72 hours or as directed.when a suspected ADR (adverse drug reaction) is encountered, the following protocol should be followed: The pharmacist and facility nurse review the reaction or untoward event. A plan of action is formulated and implemented. The provider contacted.Each incident is forwarded to.director of nursing.medical director.consultant pharmacist.Medication errors are managed according to facility policy. The DON verified the facility did not follow most of the aspects policy regarding documentation. The DON verified the facility did not monitor the patient's status following the medication error and stated she expected more documentation from the nursing staff related to this incident. During a concurrent interview and record review on 6/25/26 at 3:55 PM, with the DON, the facility's P&P titled, Change in Condition., dated 8/25/25, indicated, Purpose To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition.A facility must immediately inform the Resident.Residents physician.where there is an accident involving the Resident. The DON verified the facility did not follow this policy. The DON confirmed the facility did not do a change of condition nor notify the MD until three days later.

Based on interview and record review, the facility failed to complete an accurate assessment in a timely manner for one of two sampled residents (Resident 1) when Resident 1's stage 2 pressure ulcers (localized skin and tissue injuries caused by prolonged pressure, friction, or shear, primarily develop over bony prominences like the tailbone, heels, and hips, stage 2 is a partial-thickness skin loss) at right buttocks and left buttocks merged and worsened to stage 3 pressure ulcer (a severe wound featuring full-thickness skin loss where subcutaneous fat is visible, but muscle, tendon) at coccyx and a Significant Change in Status Assessment (SCSA- an assessment which captures a major decline or improvement in a resident's condition) was not completed .This failure placed Resident 1 at risk for not receiving the necessary services indicated for Resident 1's current condition upon change in status and had the potential to worsen Resident 1's wound and health condition.Findings:During a concurrent interview and record review with the MDSC (A Minimum Data Set Coordinator is a specialized nurse in nursing facilities who oversee the standardized resident assessment process required for federal funding, tracking patient health status, compliance, and care planning) on 5/7/26, at 3:12 PM, The MDSC stated they would complete a SCSA if a resident had a decline, or started on new therapy. During a concurrent interview and record review with the MDSC, on 5/8/26, at 1:31 PM, Resident 1's MDS (a standardized, federally mandated clinical assessment tool used in nursing homes to evaluate a resident's overall health, functional capabilities, and care needs) assessments were reviewed. The MDSC stated he was not sure if stage 2 pressure ulcer would prompt a SCSA assessment. The MDSC stated stage 3 or stage 4 pressure ulcer development would prompt to complete a SCSA. The MDSC stated they checked residents' change of condition notes, wound notes, progress notes to assess for any significant changes. The MDSC added they also reviewed the evaluations and new doctor's orders. The MDSC stated that if a resident's pressure ulcer went from stage 2 to stage 3, then there should be an SCSA conducted by the following business day. The MDSC stated that without proper assessment, a resident would be at risk for wound development and/or worsening of wounds and sepsis (the body's extreme, life-threatening response to an infection). The MDSC further stated that resident's plan of care could differ if not accurately assessed. During a concurrent interview and record review with the DON, on 6/4/26, at 3:53 PM, Resident 1's wound progress notes dated 6/6/24 and 6/20/24 were reviewed. The DON confirmed Resident 1's stage 2 pressure ulcer on the left and right buttocks merged and became stage 3 pressure ulcer at coccyx on 6/20/24. The DON stated Resident 1's stage 2 pressure ulcer worsened to stage 3 pressure ulcer. The DON stated worsening of the wound from stage 2 to stage 3 was a very significant change of condition (COC) and there should have been an MDS assessment. The DON confirmed that an SCSA was not conducted when Resident 1's stage 2 pressure ulcer worsened to stage 3 on 6/20/24. The DON stated the purpose of MDS assessment was to conduct accurate assessment, that would trigger the interventions, and if not done, then there would not be accurate interventions and the wound could worsen.A review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, dated October 2023, indicated in Chapter 2: Assessments, An SCSA is appropriate when: -There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and - The resident's condition is not expected to return to baseline within two weeks . emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status.Must be completed .within 14 days after the determination that the criteria are met for a Significant Change in Status assessment . SECTION M: SKIN CONDITIONS.A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program.

Based on interview, and record review, the facility failed to ensure assessments were completed accurately for one of two sampled residents (Resident 1) when:1. Resident 1's admission Minimum Data Set (MDS- a standardized, federally mandated clinical assessment tool used in nursing homes to evaluate a resident's overall health, functional capabilities, and care needs) assessment inaccurately reflected Resident 1 without pressure ulcer (localized skin and tissue injuries caused by prolonged pressure, friction, or shear, primarily develop over bony prominences like the tailbone, heels, and hips) upon admission to the facility,2. Resident 1's admission nursing assessment did not accurately reflect Resident 1's skin integrity, and3. Resident 1's weekly nursing assessments did not reflect Resident 1's skin condition accurately.These failures resulted in delayed wound care treatment and worsening of Resident 1's pressure ulcers.Findings:1. Review of Resident 1's MDS assessment dated [DATE], Section I - Active Diagnoses, indicated Resident 1 had multiple diagnoses including but not limited to generalized muscle weakness, type 2 diabetes mellitus (a medical condition that causes high blood sugar levels), and cerebrovascular accident (CVA or stroke).During a concurrent interview and record review with the Director of Nursing (DON) on 5/8/26, at 8:19 AM, the DON confirmed that Resident 1's Care Plan dated 5/26/24 indicated, .Resident at risk for skin breakdown related to: admitted with Scattered Discoloration to L [left] and R [right] upper extremities [NAME] [in hospital acquired]: Stage 2 to R/L [right and left] buttock.During a concurrent interview and record review with the MDSC, on 5/8/26, at 1:31 PM, the MDSC stated they checked hospital records to make sure all orders were correct and captured. The MDSC confirmed Resident 1's hospital record titled, PROBLEM LIST & PLAN, dated 5/16/24, indicated Resident 1 had back wound and was seen by wound care, discharge planning included anticipate discharge within 3 days and wound care was ordered. The MDSC confirmed Resident 1's care plan dated 5/26/24, indicated, .Resident [Resident 1] at risk for skin breakdown related to: admitted with Scattered Discoloration to L [left] and R [right] upper extremities [NAME] [in hospital acquired]: Stage 2 to R/L [right and left] buttock. The MDSC confirmed Resident 1's admission MDS assessment dated [DATE], in Section M did not reflect Resident 1's stage 2 pressure ulcers upon admission. The MDSC stated they should have accurate assessment for resident care to contribute to accurate interventions for the resident.During an interview with the DON on 5/8/26, at 4:40 PM, the DON stated that an accurate treatment would always be based on an accurate assessment. The DON stated there was a note in the referral from the hospital that Resident 1 had wound care. The DON stated care plan dated 5/26/24 specified that Resident 1's stage 2 pressure ulcers at right and left buttock were hospital acquired. The DON stated there was contradicting MDS assessment. The DON stated that the purpose of accurate assessment was to address the resident's medical problems accurately, and to provide proper interventions. The DON further stated that if the interventions were not accurate then it would not address the problem and it would affect resident's goal of care. 2. During a concurrent interview and record review with the Director of Nursing (DON), on 6/4/26, at 3:17 PM, the DON stated that during a resident's admission at the facility, the nurses must do a head-to-toe assessment and document the skin assessment in the admission nursing evaluation. The DON stated if a resident had skin issues, the nurses should describe the wound condition, notify the doctor immediately, get treatment orders and get a wound consult. The DON stated Resident 1's care plan dated 5/26/24, indicated Resident 1 was admitted with scattered discoloration to left and right upper extremities and hospital acquired stage 2 pressure ulcer at left and right buttock. The DON confirmed Resident 1's admission nursing assessment titled Nursing Documentation Evaluation dated 5/25/24, indicated Resident 1 had no skin issues. The DON stated it was an inaccurate assessment. The DON stated nurse should have completed an accurate assessment. The DON confirmed a there were no treatment orders for Resident 1's stage 2 pressure ulcers until 6/5/24. The DON confirmed Resident 1's wound progress notes dated 6/6/24 and 6/20/24 indicated Resident 1's right and left buttock stage 2 (a partial-thickness skin loss) pressure ulcers merged into stage 3 (a severe wound featuring full-thickness skin loss where subcutaneous fat is visible) pressure ulcer at coccyx on 6/20/24. The DON stated Resident 1's pressure ulcers got worsened from stage 2 to stage 3.3. During a concurrent interview and record review with the DON, on 6/4/26, at 4:18 PM, the DON stated Resident 1's care plan dated 5/26/24, indicated Resident 1 was admitted with scattered discoloration to left and right upper extremities and hospital acquired stage 2 pressure ulcer at left and right buttock. The DON confirmed Resident 1's weekly summaries dates 5/30/24 and 6/2/24, indicated Resident 1 had no skin issues. The DON confirmed Resident 1's nurses note titled Daily Documentation dated 6/5/24, indicated that Resident 1 had no skin issues. The DON stated nursing assessments dated 5/30/24, 6/2/24 and 6/5/24 were not accurate. The DON stated that the purpose of skin assessment was to address the skin issue, and if they missed seeing or documenting it, they could not provide an accurate treatment. The DON further stated that if the wounds were not treated, it might get worse and the resident could get an infection. The DON stated the nursing assessments should be accurate and the nurses should develop a care plan right away. The DON stated that the care plan should be updated every time there was a change in condition.Review of the facility's policy and procedure titled, Comprehensive Assessments and the Care Delivery Process, revised December 2016, indicated, .Comprehensive assessments will be conducted to assist in developing person-centered care plans.Assessment and information collection includes (WHAT, WHERE and WHEN?). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient.Assess the individual.Observation.Physical Assessment. Complete the Minimum Data Set within 14 days after admission, within14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually.Review of the facility's policy and procedure titled, Skin Integrity Management, dated 5/26/21, indicated, .PURPOSE To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds.Staff continually observes and monitors patients for changes and implements revision to the plan of care as needed.Complete comprehensive evaluation of the patient upon admission/re-admission to the Center.Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information.

Based on interview, and record review, the facility failed to provide necessary care and services to prevent and/or heal pressure injuries (areas of damaged skin caused by staying in one position for too long) for one of two sampled residents (Resident 1) when:1a. Resident 1 did not have any treatment orders for his stage 2 pressure ulcers on his left and right buttock for 10 days from 5/25/24 to 6/4/24,b. Low air loss (or LAL, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) mattress was not ordered timely for Resident 1, c. Resident 1's care plan interventions of turning and repositioning and wound care treatments for pressure ulcer healing were not implemented consistently,d. Resident 1 was not seen by a wound specialist for 13 days from 6/6/24 till 6/20/24, e. IDT meetings (Interdisciplinary Team meeting: a collaborative gathering of professionals from different specialties such as doctors, nurses, social workers, and therapists who meet to coordinate holistic, personalized care plans for a patient) regarding Resident 1's pressure ulcers were not done for 5 months from 5/25/24 till 10/3/24 and care plans were not updated consistently, and2. Resident 2 was not repositioned every 2 hours as ordered.These failures resulted in worsening and delayed healing of Resident 1's pressure ulcers and had potential of developing new pressure ulcers for Resident 1 and Resident 2 and risk of reopening old pressure ulcers for Resident 2. Findings:1a. Review of Resident 1's Hospital Discharge summary dated [DATE] indicated Resident 1 had multiple diagnoses including but not limited to upper GI bleed (blood loss from the esophagus, stomach, or upper small intestine) , scattered acute to subacute infarctions (small, patchy areas of tissue death in the brain that happened at slightly different times suggesting an ongoing process rather than single large stroke), ventilator acquired pneumonia (a severe lung infection that develops in a person on mechanical ventilation), dysphagia (difficulty swallowing), anemia (lack of red blood cells), ERSD (End-Stage Renal Disease - the final, permanent stage of chronic kidney disease, where the kidneys can no longer filter waste and excess fluids from the body). Further review of the discharge summary indicated Resident 1 had back wound, was seen by the wound care and to apply triple antibiotic wound cream to open areas.During a concurrent interview and record review with the DON, on 5/8/26, at 8:19 AM, Resident 1's Care plan dated 5/26/24 was reviewed with the DON. The DON confirmed the care plan indicated Resident 1 was admitted with stage 2 pressure ulcer (a partial-thickness skin loss) on right and left buttocks and interventions included to provide wound treatment as ordered. The DON confirmed that Resident 1's order summary report from May 2024 to October 2024 indicated there were no treatment orders for Resident 1's pressure ulcers upon admission for 10 days from 5/25/24 to 6/4/24. During a concurrent interview and record review with the Infection Preventionist (IP), on 5/8/26, at 2:15 PM, Resident 1's physician orders dated 6/4/24 were reviewed with the IP. The IP confirmed that the first wound treatment order for Resident 1, .Open areas to bilateral Medi honey [a medical-grade, sterilized honey used to treat wounds, burns, and ulcer] for bilateral inner buttocks. was ordered on 6/4/26, 10 days after Resident 1 was admitted to the facility. The IP stated that a delay in wound treatment could contribute to worsening or developing more wounds. The IP further stated that if a resident was not properly assessed, it could affect the interventions. 1b. During a concurrent interview and record review with the Infection Preventionist (IP) on 5/8/26, at 2:15 PM, Resident 1's order summary report was reviewed. The IP stated that the LAL mattress was part of their wound prevention, and treatment if a resident had pressure ulcers. The IP confirmed that Resident 1 was diagnosed with Stage 2 pressure ulcer on left and right buttocks on 6/6/26. The IP confirmed the LAL mattress for Resident 1 was not ordered until 6/12/24. The IP stated she did not know why the order was delayed. The IP stated that the LAL mattress should have been ordered at the same day they found Resident 1's pressure ulcers to prevent it from getting worse. The IP stated that the risk of the delayed intervention would be worsening of the wounds. During a concurrent interview and record review with the DON, on 5/8/26, at 8:19 AM, Resident 1's initial wound evaluation & management summary report dated 6/6/24 was reviewed. The DON confirmed the report indicated Resident 1 had stage 2 pressure ulcer of the right and left buttock with recommendations of using a moisture barrier cream three times daily for 30 days, off load (keeping pressure off) wound, and reposition. Resident 1's wound evaluation & management summary report dated 6/27/24 was reviewed with the DON. The DON confirmed the report indicated Resident 1 had stage 3 pressure wound on coccyx (tailbone) exacerbated due to generalized decline of Resident 1. The DON stated Resident 1 was hospitalized on [DATE] and was readmitted to the facility on [DATE] with admitting diagnosis of cellulitis (bacterial skin infection), sepsis (life-threatening reaction to an infection that causes immune system to harm healthy tissues and organs)/decubitus ulcer (pressure sore or bedsore) of coccyx and sacrum.During an interview with the DON, on 5/8/26, at 5:17 PM, the DON stated she expected LAL mattress to be ordered at the same time when a resident was diagnosed with a pressure ulcer. The DON stated that the purpose of LAL mattress was to maintain the skin intact, to distribute the weight and help with preventing or worsening of wound. The DON stated that she expected the nurses to notify the doctor to obtain a LAL mattress order when Resident 1 was diagnosed with pressure ulcer. The DON stated that ideally the LAL mattress should be ordered together with the other wound treatments. The DON stated that the nurses were responsible to implement the LAL mattress nursing intervention in collaboration with the maintenance staff.During concurrent interview and record review with the DON on 6/4/24 at 3:39 PM, the DON confirmed Resident 1's wound report dated 6/6/24 indicated the physician recommendations included offload wound and reposition. The DON stated offload wound meant to keep pressure off of the wound which was implemented by turning, repositioning the resident to their sides and using LAL mattress. The DON confirmed their policy indicated to determine the need for offloading devices to implement the pressure ulcer prevention interventions. The DON stated offloading devices meant LAL mattress. The DON stated they had LAL mattress available in the facility and were used for residents who were at risk of developing pressure ulcers or had pressure ulcers. The DON stated LAL mattress should have used for Resident 1 the day he was noted with the wound on 6/4/24 and as doctor recommended offloading on 6/6/24. The DON stated if LAL mattress was not used timely then pressure ulcer would not be offloaded, which could worsen the pressure ulcer and increased the risk of infection and decline in resident health condition. 1c. During a concurrent interview and record review with the DON, on 5/8/26, at 8:19 AM, Resident 1's Care plan dated 5/26/24 was reviewed with the DON, indicated, .[Resident 1 was] at risk for skin breakdown related to: admitted with Scattered Discoloration to L [left] and R [right] upper extremities [NAME] [in hospital acquired]: Stage 2 to R/L [right and left] buttock.Interventions.Lal mattress Supplements as ordered Date Initiated: 06/12/2024.Provide wound treatment as ordered Date Initiated: 05/26/2024. During a concurrent interview and record review with the Infection Preventionist (IP), on 5/8/26, at 2:15 PM, the IP stated that the interventions on the care plan should be implemented by any health care staff caring for the resident. During a concurrent interview and record review with the DON, on 5/8/26, at 4:40 PM, Resident 1's Treatment Administration Record (TAR) from June 2024 to October 2024 was reviewed. The DON verified that TAR indicated Resident 1 did not receive wound treatment for his right buttock pressure ulcer on 6/16/24, coccyx pressure ulcer on 8/22/24, and 9/27/24. The DON confirmed TAR dated October 2024 indicated a LAL mattress setting and function check every shift were not done on the day shift of October 9, 10 and 14. The DON stated she expected the nursing staff to document all nursing interventions that were done for Resident 1. The DON stated that the purpose of turning and repositioning a resident was to prevent skin breakdown and enhance resident mobility. The DON stated that the purpose of wound treatments was to resolve and treat any wound concerns and skin alterations. The DON stated if the wound treatments or interventions were not done consistently, the resident would be at high risk for skin alterations, and it would be a cycle, and the wound could possibly not heal. Resident 1's turning and repositioning record for May 2024 to October 2024 was reviewed with the DON. The DON confirmed the record indicated to turn and reposition Resident 1 every 2 hours every shift. The DON confirmed that there was no record that Resident 1 was turned and repositioned on the day shift on 6/14/24, 6/16/24, 6/19/24, 7/15/24, 7/16/24, 7/19/24, 7/23/24, 8/23/24, 8/26/24, on the evening shift on 5/26/24, 6/10/24, 10/10/24, 10/21/24, and on the night shift on 5/31/24, 6/22/24, 6/30/24, 8/31/24, , 918/24, 9/27/24, 9/30/24, 10/6/24, 10/9/24, 10/10/24, 10/16/24, 10/17/24. The DON stated when it was not documented she could not say if Resident 1 was turned and repositioned on those days. The DON stated that the purpose of turning and repositioning was to prevent skin breakdown and enhance resident mobility. The DON further stated that the risk if turning and repositioning was not done would be skin alterations, risk of wound reopening.1d. During a concurrent interview and record review with the DON, on 6/4/26, at 3:39 PM, the DON stated a resident with pressure ulcer should be seen every week by a wound doctor. The DON confirmed Resident 1's Wound Progress Note dated 6/13/24, indicated, .Patient [Resident 1] not seen due to a non-wound-related hospitalization. Resident 1's Census List (Resident's history of admission, readmission, bed change and transfer to hospital) was reviewed with the DON. The DON confirmed Resident 1 was in the facility and was not at the hospital on 6/13/24. The DON confirmed Resident 1's progress notes dated 6/12/24, indicated Resident 1 was moved to another room on 6/12/24. The DON confirmed Resident 1's wound progress note dated 6/6/24, indicated, .FOLLOW-UP Evaluation by wound care specialist within 7 Day(s) with further intervention . The DON confirmed that Resident 1 was not seen by the wound doctor for 13 days from 6/6/24 till 6/20/24. The DON stated besides wound nurse, a resident should be seen by a medical professional, wound doctor every week to evaluate resident's wounds because it was a higher level of profession, they would be able to further the treatment. The DON stated that when Resident 1 was not seen by the wound specialist for 13 days, there was a risk for infection, the wounds could worsen if not seen by a wound specialist/professional.During a concurrent interview and record review with the DON, on 6/4/26, at 3:53 PM, Resident 1's wound progress notes dated 6/20/24 was reviewed. The DON stated the wound report indicated Resident 1's left and right buttocks stage 2 pressure ulcers merged and became one pressure ulcer - stage 3 (a severe wound featuring full-thickness skin loss where subcutaneous fat is visible) at coccyx. The DON stated that Resident 1's pressure ulcer got worsened.1e. During a concurrent interview and record review with the DON, on 6/4/26, at 3:53 PM, the DON stated a wound meeting should be done weekly with IDT, including Registered Dietician for resident's nutritional supplements for wound healing, Infection Preventionist for any wound related infections, MDS coordinator for proper coding, Activity Director for bedbound resident to encourage turning and repositioning, Physical Therapist for the mobility of residents with wounds. The DON confirmed the care plan dated 5/26/24, indicated Resident 1 was admitted with stage 2 pressure ulcer on right and left buttocks. The DON confirmed Resident 1's wound report dated 6/20/24, indicated Resident 1's stage 2 pressure ulcers on right and left buttocks were merged and became stage 3 coccyx pressure ulcer on 6/20/24. The DON confirmed there were no IDT meetings held until 10/3/24 when Resident 1's wound had progressed to stage 4 (the most severe form of pressure injury, involving full-thickness tissue loss with exposed fascia, muscle, tendon, or bone). The DON stated there was risk of worsened wound and infection when weekly wound IDT meetings were not conducted. The DON stated resident's pressure ulcer care plan should be updated to reflect the wound condition, stage, size, site, treatment and interventions. The DON stated the care plan should be updated on the same day there was a change in wound condition, size, treatment. Resident 1's care plans were reviewed with the DON. The DON confirmed Resident 1's care plan was not updated to reflect Resident 1's pressure ulcer and treatment changes on 6/20/24. The DON stated the care plan should have been updated because it was a change in condition (COC). The DON stated care plan was their guide in caring for the residents, addressing the health concerns of the residents, addressing the wound. The DON stated when care plan was not updated, then there was a risk not to implement the expected interventions, treatment, worsened wound and Resident 1's condition could have deteriorated. 2. Review of Resident 2's admission RECORD, indicated Resident 2 had a diagnosis of dislocation of internal right hip prosthesis, periprosthetic fracture around prosthetic right hip joint, presence of right artificial hip joint, and generalized muscle weakness.Review of Resident 2's Care Plan, dated 1/21/26, indicated Resident 2 was at risk for impaired skin integrity related to urinary and bowel incontinence, fragile skin, limited mobility, and history of pressure injuries. Care Plan Interventions included reposition at least every 2 hours and utilize pressure-relieving devices as ordered.During a concurrent observation and interview with certified nursing assistant (CNA) 1, on 5/7/26, at 3:03 PM, Resident 2 was observed sleeping on his bed while lying on his back. CNA 1 stated she usually turned and repositioned Resident 2 every 2 hours. CNA 1 stated that not all residents were scheduled to be turned every 2 hours, but they would reposition all of them as much as possible. CNA 1 stated they documented the turning and repositioning in the electronic health record (EHR). CNA 1 stated the nurses would tell them which resident needed to be turned and repositioned. CNA 1 stated that sometimes they would know which residents needed to be turned and repositioned such as if they had surgery, in pain or had wounds.During a concurrent interview and record review with the Director of Nursing (DON), on 5/7/26, at 4:07 PM, Resident 2's turning and repositioning record from February 2026 -April 2026 was reviewed. The DON confirmed that there was no documentation of turning and repositioning on the day shift of 4/10/26, 5/5/26, evening shift of 2/14/26, 4/4/26, night shift of 2/26/26 and 2/28/26, 3/28/26, 3/31/26 and 4/30/26.During a concurrent observation and interview on 6/4/26, at 1:47 PM, Resident 2 was observed lying in bed in a supine position (lying flat on the back with face and torso facing upward). Resident 2 stated he was not sure if he could turn by himself. Resident 2 was then observed trying to turn himself but could not do it all the way. Resident 2 stated he no longer had wounds on his back. Resident 2 stated that staff did not tell him that he needed to reposition himself.During an observation on 6/4/26, at 2:58 PM, Resident 2 was observed lying flat on his back.During a concurrent observation and interview with CNA 2, on 6/4/26, at 3:59 PM, Resident 2 was lying on his back. CNA 2 stated that Resident 2 could not turn by himself. CNA 2 further stated that Resident 2 needed extensive assistance to turn in his bed. CNA 2 confirmed that Resident 2 could not push himself to turn to his side. During a concurrent observation and interview with CNA 2, on 6/4/26, at 5:08 PM, Resident 2 was observed in a semi-Fowler's position (a posture where a person lies on their back with the head and upper body elevated at a 30 to 45-degree angle). CNA 2 stated they were supposed to turn and reposition Resident 2 every 2 hours. CNA 2 stated Resident 2 was forgetful and could not remember that he was supposed to reposition every 2 hours. CNA 2 stated they needed to remind him and assist him with repositioning. CNA 2 stated it was part of their job to turn and reposition residents and document it in their record. CNA 2 stated her shift started at 2:30 PM but she didn't start working on the floor until around 4pm and repositioned him around 4pm. CNA 2 stated she did not know when the last time Resident 2 was repositioned. CNA 2 stated she did not get the report from the previous shift about Resident 2's repositioning. CNA 2 stated she usually checked residents' vital signs (clinical measurements that indicate the state of a body's essential functions such as body temperature, heart rate (pulse), respiratory rate, and blood pressure) in the beginning of her shift and then repositioned the resident or tell them to reposition.During an interview on 6/4/26, at 5:19 PM, with Licensed Nurse (LN) 2, LN 2 stated Resident 2 was at risk for skin breakdown. LN 2 stated residents should be repositioned every 2 hours. LN 2 stated that Resident 2 could not remember that he needed to reposition and staff needed to remind him. LN 2 stated turning and repositioning was important to offload the pressure, to prevent skin breakdown. LN 2 stated that repositioning meant offloading one side, lying on a side. LN 2 stated changing a resident's position from supine to semi-Fowlers would not be considered repositioning since pressure would remain on resident's back, bony prominences buttocks, sacrum and coccyx.During an interview with the DON, on 5/8/26, at 4:40 PM, the DON stated if a care was not documented then could not say it was not done. The DON stated she expected the nurses and CNAs to document all the nursing interventions those was done for the resident. The DON stated that the purpose of turning and repositioning was to prevent skin breakdown and enhance resident mobility. The DON further stated that the risk if turning and repositioning was not done would be skin alterations, risk of wound reopening.A review of the facility's policy and procedure titled, Wound Care, dated 2001, indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Apply treatments as indicated .Use supportive devices as instructed .Documentation.The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data.9. If the resident refused the treatment and the reason(s) why.A review of the facility's policy and procedure titled, Skin Integrity Management, dated 5/26/21, indicated, .PURPOSE To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds.Staff continually observes and monitors patients for changes and implements revision to the plan of care as needed.Complete comprehensive evaluation of the patient upon admission/re-admission to the Center.Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information.Document on Treatment Administration Record (TAR) or in [Electronic Health Record].Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated.Implement pressure ulcer prevention for identified risk factors.Determine the need for support surface for bed and chair.Determine the need for offloading devices .Turning and repositioning based on resident care needs.A review of the facility's policy and procedure titled, CARE PLAN COMPREHENSIVE dated 8/25/21, indicated, .PURPOSE An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.Each resident's comprehensive care plan is designed to.Aid in preventing or reducing declines in the resident's functional status and/or functional levels.A review of the facility's undated policy and procedure titled, Activities of Daily Living (ADLs), Supporting indicated, Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.b. Unavoidable decline may occur is he or she:.Refuses care and treatment to restore or maintain functional abilities and.the refusal and information are documented in the resident's clinical records.

Based on interview, and record review, the facility failed to provide appropriate care and services for G-tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) for one of two sampled residents (Resident 1) when Resident 1's G-tube (gastrostomy tube - a medical device inserted directly through the abdomen into the stomach) dressing was not changed for more than a month.This failure had the potential for Resident 1's G-tube site to develop an infection and/or sepsis (life-threatening reaction to an infection that causes immune system to harm healthy tissues and organs).Findings:A review of Resident 1's admission RECORD, indicated Resident 1 had multiple diagnoses including but not limited to, gastrostomy status (presence of a surgical opening in the abdomen that leads directly into the stomach).During a concurrent interview and record review, on 5/8/26, at 8:19 AM, Resident 1's progress note dated 10/28/24 was reviewed with the Director of Nursing (DON). The progress note indicated Resident 1 had large amount of blood coming from wound and the doctor was notified and sent Resident 1 to the emergency department. On a separate progress notes dated 10/28/24, indicated, . CALLED [hospital name] ED [emergency department] FOR F/U [follow up], NURSE STATED PT [patient/Resident 1] admitted for SEPSIS/ GT [G-tube] WOUND INFECTION. Treatment Administration Record (TAR) was reviewed from September 2024- October 2024 with the DON. The DON confirmed that there was no TAR or order for G-Tube site cleaning and dressing when Resident 1 was readmitted in September 2024.During a concurrent interview and record review with the Infection Preventionist (IP), on 5/8/26, at 2:15 PM, the IP stated she expected the nurses caring for residents with G-tube to clean the G-tube site daily with normal saline and change the dressing daily and as needed. The IP confirmed that the order for G-tube cleaning and dressing change was never placed back or reordered when Resident 1 was readmitted in September 2024 to the facility. The IP stated that it was important to clean and change the G-tube dressing because it would be a risk for infection, the site could get infected, and it could lead to sepsis. The IP stated she would know that the dressing had been change if the dressing had a date or the TAR had been signed, unless there was no order. The IP stated that the only way to know if it was done was to check the actual dressing and the TAR. The IP stated that physician's order was important to guide the nurses for the proper care of the residents. The IP confirmed that Resident 1 had not had G-tube dressing change for 41 days from 9/17/24 to 10/28/24. The IP stated that the incident was preventable if the nurses were doing the dressing change. During an interview with Licensed Nurse (LN) 1, on 4/8/26, at 4:22 PM, LN 1 stated she would know if a resident's G-tube dressing was changed if there was a date on the dressing and it should also be documented in the TAR. LN 1 stated if there was no order for the G-tube cleaning and dressing change, she would call the doctor.During an interview with the DON, on 5/8/26, at 4:40 PM, the DON confirmed that there was no G-tube dressing change and cleaning order for Resident 1 for 41 days from 9/17/24 to 10/28/24. The DON stated she expected the nurses to assess Resident 1's G-tube site, check patency, check the dressing, check for signs and symptoms of infection and do the dressing daily and as needed. The DON stated that if there was no order for G-tube dressing change and cleaning, the nurses should have followed up with the doctor to obtain a treatment order for dressing change. The DON further stated that the bedside nurse had the responsibility to obtain the order and implement it.A review of the facility's policy and procedure titled, Enteral Nutrition dated November 2018, indicated, .Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of feeding tube, such as.Skin breakdown around insertion site.

Based on observation, interview, and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 73 residents who ate facility prepared meals when: 1. Dishware not kept according to standard; 2. Food preparation equipment not kept clean per food safety standards; 3. Food items not properly labeled and/or stored and; 4. Staff unfamiliar with correct sanitizing process. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:20 a.m., with the CDM (Certified Dietary Manager) in the kitchen, four (4) out of twelve (12) coffee mugs were found scratched on the inside surface. The CDM confirmed this finding and stated the mugs should have been replaced. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 9:37 a.m., with the CDM in the kitchen, two (2) frying pans were found with signs of over usage, such as scratched, discolored and coating worn off cooking surface. The CDM confirmed the frying pans should have been replaced. During an interview on 3/19/26 at 4:05 p.m., the CDM stated scratched mugs and scratched frying pans could lead to cross-contamination (bacteria that transfers from one surface to another) and should be replaced. A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 4-202.11, titled, Food Contact Services, indicated, .Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. During an interview on 3/18/26 at 8:30 a.m., Resident 49 stated she often received large spoons with the meal tray, and it was impossible to eat without spilling food all over her chest. During a concurrent observation and interview on 3/18/26 at 9:20 a.m. with the CDM in the kitchen, the spoon storage area was observed. There were two containers of stored spoons, one contained standard size spoons, and one contained large serving spoons. The spoons were approximately 20 in count. The CDM could not explain when the large serving spoons were given to a resident. During an interview on 3/18/26 at 11:32 p.m., DA 1 (Dietary Aide 1) stated the facility didn't have enough regular sized spoons, so serving spoons and soup spoons were being used in place of regular spoons. During an interview on 3/18/26 at 3:26 p.m., the SLP (Speech Language Pathologist) stated there was no reason for ordering such an overly large sized spoon for rehabilitation purposes. During an interview on 3/18/26 at 4:12 p.m., the Occupational Therapist (OT) stated she had not ordered any large size spoons for any residents. The OT concurred that it would be difficult to eat with such a large serving spoon and could cause food spillage. 2. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:46 a.m., with the CDM in the kitchen, one (1) serving spoon ladle and three (3) steamtable pans were found stored wet. The CDM confirmed that these should have been dried before storing. A review of the facility's policy and procedure (P&P) titled, Manual Warewashing (3-Compartment Sink [manual warewashing, ensuring dishes are cleaned, rinsed, and sanitized to prevent infection]), revised 2024, indicated, .All silverware and cookware will be air dried prior to storage.) During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:48 a.m., with the CDM in the kitchen, a stored blender was noted wet and with light brown food residue on the blade. The CDM confirmed this finding and took the blender to be washed again. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:52 a.m., with the CDM in the kitchen, a can opener was found with light brown residue on the blade. A drawer was opened and found with food debris next to the clean scoops. The CDM confirmed these items were not up to the facility's standards. During multiple observations on 3/17/26, 3/18/26 and 3/19/26 at various times, the stove was found with greasy buildup on burners, and the oven was found with an old spill inside. During a review of the cleaning log on 3/17/26 at 9:40 a.m., the stove and oven was listed as being deep cleaned every Wednesday. During an observation on 3/19/26 at 11:46 a.m., the steam table (a food warming table) ledge was found with food crumbs and old spills on the surface. This ledge was holding the clean steam table pan lids. During an interview on 3/19/26 at 4:05 p.m., the CDM stated dirty items, old spills and food debris, were not acceptable and should have been cleaned properly as they could lead to cross contamination. A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. A review of the facility's P&P titled, Environment, revised 2025, indicated, .All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.All food contact surfaces will be cleaned and sanitized after each use. 3. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:33 a.m., with the CDM in the kitchen, fish fillets and carrots were found not closed properly in the freezer. The CDM said they should have been closed tightly. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:46 a.m., with the CDM in the kitchen, a white powdery substance was found in a large measuring cup, inside a plastic bag, which was unlabeled and undated. The CDM stated that the powdery substance was thickener (substances used to increase the thickness of liquids and foods) but was unable to state when it was opened or when it should be discarded. A plastic container of garlic powder and one (1) container of beef broth base were found unlabeled. The CDM confirmed that these should have been labeled. During an interview on 3/19/26 at 4:05 p.m., the CDM stated the food items needed to be labeled and dated to ensure food safety. The CDM also stated that food products needed to be closed properly to prevent cross contamination. A review of the facility's P&P titled, Food Storage: Cold Foods, revised 2023, indicated, .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the facility's P&P titled, Food Storage: Dry Goods, revised 2023, indicated, .All dry goods will be appropriately stored in accordance with the FDA Food Code. A review of the US FDA 2022 Food Code, section 3-602.11, titled, Food Labels, indicated, .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients. A review of the US FDA 2022 Food Code, section 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container, 1/18/23 version, indicated, The possibility of product contamination increases whenever food is exposed .Once the original seal is broken, the food is vulnerable to contamination. A review of the US FDA 2022 Food Code, section 3-302.11, titled Packaged and Unpackaged Food -Separation, Packaging, and Segregation, 1/18/23 version, indicated, (A) FOOD shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings . 4. During a concurrent observation and interview on 3/17/26, during the initial kitchen tour at 8:49 a.m., with the CDM in the kitchen, Dietary Aide (DA 2) discussed the process of manual 3 compartment dishwashing (used in commercial kitchens for the manual washing, rinsing, and sanitizing of dishes and utensils). DA 2 stated that dishes were placed in the sanitizer and then quickly removed from the sanitizer. DA 2 read aloud the sanitizing directions that were placed over the sink and stated that the dishes/utensils were supposed to be held in the sanitizer for 60 seconds. During a concurrent observation and interview on 3/17/26, within the initial kitchen tour at 8:57 a.m., DA 3 demonstrated the process of checking the concentration of the red bucket (sanitizing bucket). DA 3 put the concentration test strip (a rapid, single-use diagnostic tools that determine the strength of chemical solutions) into the green bucket of sudsy water for 4 seconds. The strip did not show the correct sanitation level. DA 3 read the bottle instructions, put a new strip in the solution for 10 seconds, with the result of inadequate sanitation level. DA 3 stated the bucket appeared to be cleaning solution and not sanitation solution. During a concurrent observation and interview on 3/17/26 at 3:01 p.m., the [NAME] (Ck 2) showed the department surveyors the manual dishwashing area. Ck 2 verbalized that the washing process included putting the dishes in the sanitizer solution but did not know how long to keep the dishes in this solution. Ck 2 stated the dishes need to be kept in the sanitizer solution for 60 seconds. During a concurrent observation and interview on 3/17/26 at 3:17 p.m., DA 4 demonstrated how to check the sanitizer solution in the red bucket. DA 4 put the test strip in the solution for 4 seconds and removed the test strip. DA 4 stated the color was good even though it was very faint and did not reach the correct concentration level. DA 4 then read the instructions and retested for 11 seconds, bringing the color to the correct level. During an interview on 3/19/26 at 4:05 p.m., the CDM stated the staff should be following the correct sanitization procedures. The CDM further stated that not following the correct procedures could lead to cross contamination of food and utensils. A review of the facility's P&P titled, Manual Warewashing (3-Compartment Sink), revised 2024, indicated, .Sanitize in the third sink: Chemical sanitizer testing and concentrations used according to manufacturer guidelines.) A review of the facility's P&P titled, Environment, revised 2025, indicated, .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control measures for a census of 73, when:1. Resident 47's suprapubic catheter (a thin, flexible tube surgically inserted through the lower abdomen directly into the bladder to drain urine. Potential complications include infections such as urinary tract infection [UTI, a common infection caused by bacteria entering the bladder, or kidneys]) drainage bag was observed positioned on the floor; 2. Staff failed to perform proper hand hygiene during medication administration for Resident 4, Resident 23, Resident 42, Resident 58, and Resident 77; and,3. Staff failed to follow infection control protocols when nutritional drinks were transferred from one resident's room to another.These failures in infection prevention and control practices had the potential to contribute to the spread of infection among residents and staff within the facility.Findings: 1.During a review of Resident 47's admission Record, the record indicated Resident 47's diagnosis included Neuromuscular dysfunction of bladder (a neurogenic bladder where nervous system damage disrupts signals between the brain, spinal cord [a long, thin, tubular bundle of nervous tissue and cells, serving as the main pathway for information connecting the brain and the rest of body], and bladder muscles, causing loss of control, incontinence, or retention [inability to empty the bladder]), and presence of urogenital implants (indicates the existence of a permanent artificial devices supporting urinary function). During a review of Resident 47's medical record, titled Order Summary Report, reflected to active orders as of 3/18/26, indicated, Perform Suprapubic Catheter [a thin, flexible tube surgically inserted through the lower abdomen directly into the bladder to drain urine. Potential complications include infections such as urinary tract infection; a common infection caused by bacteria entering the bladder, or kidneys] Care every shift ., with a start date of 4/30/24. This order reflected an ongoing intervention, and its continued presence on the active orders list indicated it remained in effect without documented discontinuation. During a concurrent observation and interview conducted on 3/17/26 at 12:27 PM, Resident 47 was observed in a sitting position in bed with a suprapubic catheter in place. The catheter drainage bag was noted to be inside the privacy bag that was placed directly on the floor to the left side of the resident. Resident 47 further stated that he had the suprapubic catheter for several months due to an inability to urinate. During a concurrent observation and interview conducted on 3/17/26 at 12:38 PM in Resident 47's room, Licensed Nurse (LN) 3 confirmed that Resident 47's suprapubic catheter drainage bag was found on the floor. LN 3 stated that the catheter drainage bag should have been hung from Resident 47's bed frame and not placed on the floor. LN 3 further explained that Resident 47 was at increased risk for infection due to the presence of an indwelling suprapubic catheter. LN 3 acknowledged that the observed placement of the drainage bag on the floor posed an infection control and prevention concern. During an interview on 3/18/26 at 9:55 AM, LN 2 stated that indwelling catheter drainage bags were required to be off the floor at all times to prevent contamination and reduce the risk of UTI. During an interview on 3/19/26 at 11:47 AM, the Infection Preventionist (IP) stated her expectation from nursing staff was to ensure that Resident 47's suprapubic catheter drainage bag was not placed on the floor, was hung from the bed frame, and remained below bladder level while in bed. The IP further stated that Resident 47 was prone to infection due to having an indwelling catheter, which could be a potential site for organism entry into the body. During an interview on 3/19/26 at 4:47 PM, the Director of Nursing (DON) stated her expectation was that nursing staff ensured Resident 47's suprapubic catheter drainage bag was properly secured to the bed frame while the resident was in bed, not positioned on the floor, and hung above the floor. The DON further stated that her expectation was not being met. During a review of Resident 47's care plan dated 10/29/25, in the section Goal, indicated, Resident will have no signs and symptoms of urinary tract infection., and in the section Focus, indicated, Resident requires indwelling suprapubic catheter. In the section, Interventions, indicated, Keep catheter off floor. During a review of the facility provided policy and procedure (P&P) titled Suprapubic Catheter Care, revised in 10/2010, indicated, . The purpose of this procedure is. to prevent infection of the resident's urinary tract. Preparation 1. Review the resident's care plan. 2. During a medication administration observation on 3/18/26 at 4:40 p.m. at Unit 2, LN 6 wheeled Resident 23 to her room to administer her medication. LN 6 prepared Resident 23's medication and when it was done, she entered Resident 23's room and handed the pills to her. LN 6 went back to her medication cart and prepared the medication for Resident 42 who was in the same room in bed A. LN 6 handed the pills to Resident 42. LN 6 went back to her medication cart and went to the next room. LN 6 did not perform hand hygiene after giving medication to Resident 23 and did not perform hand hygiene before and after medication administration for Resident 42. During a medication administration observation on 3/18/26, at 5:11 p.m. at Unit 2, LN 6 prepared Resident 77's medication and when it was done, she entered Resident 77's room and handed the pills and inhaler (medication in spray or powder form that you breath in) to him. LN 6 went back to her medication cart and made her way to Resident 58's room without performing hand hygiene after giving resident 77's medication. LN 6 then prepared Resident 58's medication, entered the room and handed Resident 58's pills. LN 6 went back to her medication cart and prepared Resident 4's medication who was in the same room in bed A. LN 6 then entered the room and gave the medication to Resident 4. LN 6 did not perform hand hygiene before and after medication administration for Resident 58 and Resident 4. LN 6 was not available for interview after her medication administration in Unit 2. During an interview on 3/19/26 at 12:03 p.m. with the IP, the IP stated hand hygiene should be performed when entering and exiting the room, before and after medication administration, and going from bed A to bed B in the same room. The IP also stated cross contamination would be the biggest risk for bacterial and viral infections (microorganisms that can cause diseases) among the residents without proper hand hygiene practices. During an interview on 3/19/26 at 3:16 p.m. with the DON, the DON stated she would expect the nursing staff to perform hand hygiene either to wash hands or use hand sanitizer before and after medication administration. The DON also stated this practice would prevent the risk for cross-contamination among residents and the spread of infection. During a review of the facility's policy titled, Administering Medications, revised 4/2019, the policy indicated, .Staff follows established facility infection control procedures (e.g., handwashing.) for the administration of medications. During a review of the facility's policy titled, Handwashing/Hand Hygiene, dated 9/18/23, the policy indicated, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Wash hands with soap.and water.When hands are visibly soiled.Use an alcohol-based hand rub containing at least 62% alcohol.Before and after contact with the resident. During a review of the facility's job descriptions titled, Licensed Practical (Vocational) Nurse (LPN)(LVN), revised May 2022, the job description indicated, .Adhere to the facility infection prevention and control practices. During a review of the facility's job descriptions titled, Registered Nurse (RN), revised 7/2024, the job description indicated, .Adhere to the facility infection prevention and control practices. 3. During a review of Resident 1's admission RECORD, dated 3/19/26, the record indicated, Resident 1 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing) and encounter for attention to gastrostomy (a surgical procedure that creates an opening (stoma) through the abdominal wall directly into the stomach, usually to insert a feeding tube (G-tube) to allow nutrition, medication, and fluids to be delivered directly to the stomach). During a review of Resident 1's Minimum Data Set, (a resident assessment tool) dated 2/13/26, the MDS under the swallowing/nutrition Status revealed, Resident 1 had a feeding tube on admission and while a resident in the facility. During a review of Resident 1's Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 2/11/26, the care plan indicated, .Resident has an enteral feeding tube [a method of delivering liquid nutrition directly into the stomach via a tube] to meet nutritional needs. During a review of Resident 1's Order Summary Report, active physician's orders as of 3/19/26, the order indicated, .Enteral Feed Order two times a day.use [feeding formula] 1.5 CAL if 1.2 CAL [CAL-the caloric density of the formula in calories per milliliter/ml, unit of measurement] is not available [feeding formula] 1.2 CAL Administer continuous via Pump. During a medication administration observation and interview on 3/17/26 at 3:02 p.m. at Unit 2 with LN 6, LN 6 was in Resident 1's room preparing for Resident 1's enteral feeding. The bag for the enteral formula was full, and tube passed through the pump ready for feeding. There were also 4 unopened cartoons of feeding formula 1.5 CAL of 230 ml each cartoon and an unopened package of feeding tube that were on Resident 1's bedside table. After LN 6 finished preparing Resident 1's enteral feeding, she took the 4 cartoons of feeding formula and the feeding tube and brought the items to another resident's room. LN 6 stated she was preparing Resident 1's enteral feeding to be ready for her scheduled feeding time. LN 6 also stated the 4 cartoons of feeding formula and the new feeding tube that were on Resident 1's bedside table that she took and brought to another resident was for the resident who was also on enteral feeding. LN 6 stated she should not have done that to transfer items from one resident to another. LN 6 further stated she did not observe infection control practices and increased the risk for cross contamination and infection from one resident to another. During an interview on 3/19/26 at 12:03 p.m. with the IP, the IP stated cross contamination would be the biggest risk for bacterial and viral infections (microorganisms that can cause diseases) among the residents without proper infection control practices. During an interview on 3/19/26 at 3:16 p.m. with DON, the DON stated once an item or items were in one resident's room, it should not have been transferred to another resident's room. The DON also stated this practice would increase the risk for cross contamination and potentially could spread infection to residents, staff, and visitors. During a review of facility's policy titled, Infection Prevention and Control Program, dated 9/18/23, the policy indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's job descriptions titled, Licensed Practical (Vocational) Nurse (LPN)(LVN), revised 5/2022, the job description indicated, .Adhere to the facility infection prevention and control practices. During a review of the facility's job descriptions titled, Registered Nurse (RN), revised 7/2024, the job description indicated, .Adhere to the facility infection prevention and control practices.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) for 2 out of 20 sampled residents when:1. A care plan for the use of psychotropic medication (mind altering medication) was not developed for Resident 8.2. The care plan interventions for an indwelling suprapubic catheter were not followed for Resident 47.These failures had the potential to place Resident 8 for not receiving effective and person-centered care, and Resident 47 at increased risk for infection. Overall, these could negatively impact the health, safety, and well-being of Residents 8 and 47. Findings: 1.During a review of Resident 8's admission Record, the record indicated Resident 8's diagnosis included depression (mental depression with feeling of sadness), anxiety disorder (persistent or excessive worrying that interferes with daily life), post-traumatic stress disorder (or PTSD a mental condition triggered by experiencing or witnessing a traumatic events with flashbacks and nightmares), and Lewy bodies dementia (a type of memory loss with hallucinations and fluctuating alertness). The record additionally indicated that Resident 8 was a responsible party (being fully accountable for own health care decisions). During a concurrent interview and record review on 3/19/26 at 2:29 PM with Licensed Nurse 3 (LN 3), Resident 8's medical record titled, MEDICATION ADMINISTRATION RECORD [MAR, a list of the resident's ordered medications and times they were given or held], dated 3/1/26 to 3/31/26 and Resident 8's care plans were reviewed. LN 3 confirmed that following order: . diazepam Oral Tablet 10 MG [ MG, milligram - a unit of measurement] . Give 1 tablet by mouth every morning and at the bedtime for Anxiety. was started on 3/11/26. During a review of Resident 8's care plans, the care plan indicated a care plan for the medication diazepam 10 MG oral tablet had not been developed. LN 3 acknowledged the findings and stated that care plans served as a framework for the care provided by nursing staff. LN 3 explained that nurses were responsible for developing care plans and implementing interventions as guiding tools, as well as following those interventions to evaluate their effectiveness. LN 3 further stated that without a developed care plan, nurses were unable to assess the effectiveness of the medication or monitor improvement in the resident's health status. LN 3 further added that when a care plan was not developed, it appeared that no interventions were implemented and that there was a lack of coordination of care. During an interview on 3/20/26 at 7:44 AM with LN 5, LN 5 stated that nurses were required to develop a care plan for psychotropic medications when a medication was initiated to monitor its effectiveness in managing the resident's behaviors during the treatment period. LN 5 explained that care plans should have been individualized based on the resident's current health and psychological condition and served as a tool to guide nursing staff in providing care. LN 5 further stated in the absence of a developed care plan for the psychotropic medication, nurses were unable to effectively evaluate the medication's effectiveness. During an interview on 3/20/26 at 11:19 AM with the DON, the DON stated that care plans should have been individualized and included person-centered goals and interventions to improve residents' health conditions. The DON added that care plans served as guidelines to direct nursing staff in providing appropriate care. The DON further stated that her expectation of the nursing staff was to develop a care plan for Resident 8's psychotropic medication, diazepam, implement appropriate interventions, evaluate the effectiveness of the medication in managing the resident's behaviors, and notify the Medical Director (MD) regarding its effectiveness. The DON further added that this expectation was not met. 2.During a review of Resident 47's admission Record, the record indicated Resident 47's diagnosis included Neuromuscular dysfunction of bladder (a neurogenic bladder where nervous system damage disrupts signals between the brain, spinal cord [a long, thin, tubular bundle of nervous tissue and cells, serving as the main pathway for information connecting the brain and the rest of body], and bladder muscles, causing loss of control, incontinence, or retention [inability to empty the bladder]), and the presence of urogenital implants (indicates the existence of a permanent artificial devices supporting urinary function). During a concurrent observation and interview on 3/17/26 at 12:27 PM with Resident 47, Resident 47 was observed in a sitting position in bed with a suprapubic catheter (a thin, flexible tube surgically inserted through the lower abdomen directly into the bladder to drain urine. Potential complications include infections such as urinary tract infection [UTI, a common infection caused by bacteria entering the bladder, or kidneys]) in place. The catheter drainage bag was noted to be inside the privacy bag that was placed directly on the floor to the left side of the resident. Resident 47 further stated that he had the suprapubic catheter for several months due to an inability to urinate. During a review of Resident 47's medical record titled, Order Summary Report, indicated there was an order to perform suprapubic catheter care every shift that was initiated on 8/23/25. The order reflected it was an ongoing intervention, and its continued presence on the active orders list suggested it remained in effect without documented discontinuation. During a review of Resident 47's care plan initiated on 10/29/25, in the section titled, Focus, indicated, . [Resident 47] Requires indwelling suprapubic catheter due to: other: BPH [benign prostatic hyperplasia- a condition characterized by an enlarged prostate gland and causes frequent urination, weak stream, or difficulty starting urination] . In the section titled, Interventions, indicated, .Keep catheter off floor. During an interview on 3/19/26 at 11:06 AM, LN 4 stated nurses were responsible for developing care plans and initiating person-centered interventions for each resident based on their individual needs. LN 4 explained that interventions should be regularly reviewed and followed, as they served as guidelines for proving care to residents. LN 4 further stated according to the care plan goal for a suprapubic catheter, the drainage bag should be kept off the floor and should not come into contact with the floor for infection control and prevention purposes. LN 4 further added that placing the suprapubic catheter drainage bag on the floor increased the risk of infection when the care plan intervention was not followed. During a concurrent interview and record review on 3/19/2026 at 11:47 AM with the IP, Resident 47's care plan for indwelling suprapubic catheter, created on 10/29/25 was reviewed. The review indicated the suprapubic catheter should have been kept off the floor. The IP stated that Resident 47 was at risk for infection due to the indwelling suprapubic catheter. The IP explained that the drainage bag should be positioned below the bladder level and kept off the floor at all times as per care plan interventions. The IP further stated that her expectation of the nursing staff was to monitor Resident 47 to ensure the catheter bag was not in contact with the floor and that care plan interventions were followed to reduce the risk of infection and further complications. The IP further added that her expectation was not met by the nursing staff. During an interview on 3/19/26 at 4:27 PM with the DON, the DON stated that the suprapubic catheter drainage bag should not have touched the floor at any time and should be hung slightly above the floor. The DON further stated that her expectation was for the nursing staff to follow the care plan interventions; however, the expectation was not met. During a review of the facility provided policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE, dated 8/25/21, the review indicated, . PURPOSE. individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. PROCEDURE.1. h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 4. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.

Based on observations, interviews, and record review, the facility failed to prepare meals adequately when; 1.Meals prepared were bland and lacked flavor for 4 out of 73 residents (Resident 18, Resident 49, Resident 55 and Resident 64), and 2. Pureed foods (a smooth, thick, pudding-like consistency created by blending, mashing, or straining food, requiring no chewing) were not prepared by methods that conserve nutritive value, flavor, and appearance when recipes were not followed, and water was used to thin the prepared foods. These failures had the potential for malnutrition, weight loss, impaired wound healing, and increased susceptibility to disease. Findings: 1. During an interview on 3/17/26 at 2:22 p.m. with Resident 55, Resident 55 stated the food tasted bad. Resident 55 was noted to have multiple outside food items and beverages on the bedside table. Resident 55 stated that his family brought in food because the facility food was not appetizing. During an interview on 3/18/26 at 8:30 a.m. with Resident 49, Resident 49 stated the food was not up to her expectations, especially at breakfast. Resident 49 gave the example of food being cold, lacking flavor, and that the oatmeal was too runny and was able to be eaten through a straw. During an interview on 3/19/26 at 12:45 p.m. with Resident 64, Resident 64 stated the food was bland and needed more seasoning and garnishing. During an interview on 3/19/26 at 12:55 p.m. with Resident 18, Resident 18 stated, the food was nasty and very bland. Resident 18 also stated that the food was not visually appealing and lacked taste and seasoning. During the tasting of a test meal on 3/18/26 at 12:58 p.m., the two department surveyors found both the regular and pureed foods tasted bland and lacked seasoning. The stir fry entree lacked Asian flavorings such as ginger and soy sauce. The green beans and rice had no seasoning added and tasted uninteresting. During an interview on 3/19/26 at 11:38 p.m. with the Regional Dietary Manager (RDM), the RDM concurred that the food lacked seasoning and stated that he had been talking to the management about it for some time, hoping to make some flavor enhancements. A review of www.Mayoclinic.org article titled, Loss of taste and smell: Natural with aging?, indicated, Some loss of taste and smell is natural with aging. Loss of taste and smell can have a significant effect on quality of life. It often leads to decreased appetite and poor nutrition. It can sometimes contribute to depression. A review of www.osufacts.okstate.edu article titled, Nutrition for Older Adults: Taste, Smell and Nutrition, indicated in the tips section, . to use herbs, spices and lemon juice . to increase the flavor of foods. 2. During a return visit to the kitchen on 3/19/26 at 11:01 a.m., the [NAME] 1 (Ck1) was preparing the lunch meal. The menu for the lunch meal indicated Lasagna, Italian Vegetables, and a Roll. Review of the lunch menu for the vegetarian diet for 3/19/26 indicated vegetarian meatballs, marinara sauce, and pasta. After making various textured versions of the lunch meal, the Ck 1 took out a 19-ounce tub of tofu and cut it into quarters. The Ck 1 took two (2) of the quarters (approximately 9 1/2 ounces) and placed them in the food processor bowl. The Ck 1 next added an unmeasured amount of canned tomato sauce and blended the mixture. No recipe was followed, and no other seasonings were added. Once blended, the Ck 1 found the mixture too thin and added an unmeasured amount of thickener twice. The Ck 1 decided the mixture was too thick and added hot water to the mixture to thin it three times, before being content with the texture. The Ck 1 then poured the mixture into a steam table pan and placed it in the warmer in preparation for the lunch meal. No taste testing of product was observed. Review of puree instructions found at website idaho.gov, https://publicdocuments.dhw.idaho.gov, indicated Do not serve a pureed meal to one of your clients if you would not be willing to eat it yourself! It further indicated in the directions for making pureed foods to: Start with just the food (drained, no extra liquid) Add small amounts of liquid to reach desired consistency Never puree with water. Review of website www.GInutrition.virginia.edu indicated when pureeing food: Liquids to try are milk, broth, fruit or vegetable juice, liquid nutritional supplements (such as Ensure , Boost , or the store brand equivalent), Lactaid milk, kefir, etc. Choose whichever liquid will taste best (e.g., use chicken broth with chicken, milk with sweets).

Based on interview, and record review, the facility failed to ensure timely medication processing and administration when there was a delay in both processing and administration of a prescribed mental health medication for one of 20 sampled residents (Resident 8). This failure had the potential to negatively impact Resident 8's health and place him at increased risk for a decline in psychological status.Findings: During a review of Resident 8's admission Record, the record indicated Resident 8's diagnosis included depression (mental depression with feeling of sadness), anxiety disorder (persistent or excessive worrying that interferes with daily life), post-traumatic stress disorder (or PTSD a mental condition triggered by experiencing or witnessing a traumatic events with flashbacks and nightmares), and Lewy bodies dementia (a type of memory loss with hallucinations and fluctuating alertness). The record additionally indicated that Resident 8 was a responsible party (being fully accountable for own health care decisions). During a concurrent interview and record review on 3/19/26 at 2:29 PM with Licensed Nurse 3 (LN 3), Resident 8's medical record titled, AFTER VISIT SUMMARY [when residents see a specialist outside the facility], dated 3/5/26 was reviewed. The review indicated,. Today's medication changes. diazepam (VALIUM)-medication strength, how much to take, how to take this, when to take this, reasons to take this, additional instructions. diazepam 10mg ( mg is milligram, a unit of strength). generalized anxiety disorder. take one tablet in the morning and one tablet at bedtime scheduled What changed. medication strength. how much to take. how to take this. when to take this. reasons to take this. Further review of Resident 8's medical record titled MEDICATION ADMINISTRATION RECORD [MAR], dated 3/1/26 to 3/31/26, LN 3 confirmed that following orders: . diazepam Oral Tablet 5 MG (milligram, a unit of strength) . Give 1 tablet by mouth every 8 hours as needed for Anxiety. Start Date- 01/22/2026 . D/C Date (D/C Date, discontinue date) 03/11/2026.; and, . diazepam Oral Tablet 10 MG. Give 1 tablet by mouth every morning and at the bedtime for Anxiety. Start Date-03/11/2026. LN 3 acknowledged that prescribed medication was initiated with a six-day delay. LN 3 explained that when there was an increase in dosage or a new psychotropic medication was ordered by an outside provider, she first would notify the facility's Medical Director (MD), and if the MD agreed with the new order, she would proceed with implementation. LN 3 further stated that delays in both processing and administering prescribed mental health medications could lead to a worsening of Resident 8's mental health condition rather than improvement. During an interview on 3/20/26 at 7:44 AM with LN 5, LN 5 stated physician's orders, particularly those involving psychotropic medications, should be carried out without delay. LN 5 emphasized that delays in processing and administering those medications could result in worsening resident behaviors and a decline in psychological health status. During a concurrent phone interview and record review on 3/20/26 at 8:23 AM with the Medical Director (MD), Resident 8's medication orders were reviewed. The MD confirmed that the order for diazepam 10 MG was initiated on 3/11/26. The MD also verified that there was a prescription from an outside physician, dated 3/5/26, which reflected an increased dosage of the medication. The MD further stated that whenever there was a change in an existing medication prescribed by an outside physician, the facility's MD should have reviewed the order as soon as the notification was received from nursing staff, and if the MD agreed with the updated order, the nurse was expected to implement it in a timely manner. During a review of the facility provided policy and procedure (P&P) titled, Administering Medications, revised on 4/2019, the P&P indicated, . Policy. Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 4. Medications are administered in accordance with prescriber orders, including any required time frame. During a review of the facility provided P&P titled, Physician Orders, dated 3/22/2022, the review indicated, . PURPOSE This will ensure that all physician orders are complete and accurate. II. Physician orders will include the following. The date and time the order was received .

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for one of 20 sampled residents (Resident 3), when Resident 3's low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not correctly calibrated according to her current weight.This deficient practice had the potential to delay wound healing and place Resident 3 at increased risk for developing pressure injury and/or skin breakdown.Findings: During a review of Resident 3's admission Record, the record indicated Resident 3 was admitted to the facility with multiple diagnoses including morbid obesity (a serious, chronic disease defined as significant excess weight that could increase the risk, or cause of serious illness), and muscle weakness. During a concurrent observation and interview on 3/17/26 at 9:53 AM with Resident 3, Resident 3's LAL mattress was on the bedframe, and the setting was calibrated to 110 pounds (LBS-a unit of measurement). Resident 3 stated the mattress was in use due to multiple pressure injuries to her buttocks area (consists of two rounded muscles which are essential for walking, running, standing up from a chair, and a primary support for the body while in a seated position), with the purpose of promoting wound healing and preventing further skin breakdown. During a concurrent observation, interview, and record review conducted on 3/17/26 at 2:55 PM with Licensed Nurse (LN 1), Resident 3's medical record titled, Weights and Vitals Summary, dated 3/16/26 was reviewed. The record indicated Resident 3's most recent weight documented on 3/16/26, was 249.78 LBS. During a follow-up observation and interview with LN 1 at 2:57 PM, in Resident 3's room, LN 1 confirmed that the LAL mattress was not adjusted to reflect Resident 3's current weight because the mattress pump was set for 110 LBS, which did not correspond to Resident 3's actual weight. LN 1 stated that the purpose of the LAL mattress was to promote healing of existing wounds and prevent further skin breakdown. LN 1 further explained that Resident 3 had multiple skin injuries on the buttocks and stated that failure to properly set the LAL mattress pump could lead to worsening of those wounds' conditions. During a review of Resident 3's medical record titled Order Summary Report, with active orders as of 3/18/26, the following orders were noted: Low air loss mattress: Monitor setting based on residents Weight/ Functioning. initiated on 3/1/26; Right buttocks unstageable. initiated on 3/13/26; Left upper thigh posterior/buttock. initiated on 3/13/26; and, TX [treatment]- to Groin and bilat [bilateral] buttocks. initiated on 2/18/26. During an interview on 3/18/26 at 9:55 AM with LN 2, LN 2 explained that the purpose of LAL mattress was to relieve pressure on wound sites to promote the wound healing process. LN 2 stated that nurses were responsible for adjusting the pump setting based on the resident's current weight. LN 2 added that those settings should have been checked and adjusted every shift to ensure accuracy. LN 2 further stated that if the LAL mattress pressure was not properly adjusted according to the resident's current weight, the underlying metal bed frame could exert additional pressure on the wounds, potentially worsening the resident's condition. During an interview on 3/19/26 at 11:06 AM with LN 4, LN 4 stated that LAL mattress was used for preventative care and to promote wound healing. LN 4 explained that the pressure of mattress should have been adjusted according to the resident's current weight. LN 4 further stated improper adjustment of Resident 3's LAL mattress in relation to her current weight could result in inadequate support, allowing pressure from the metal bed frame to impact the wound areas and potentially contribute to further deterioration. During an interview on 3/19/26 at 4:27 PM with the Director of Nursing (DON), the DON stated that the purpose of LAL mattress for Resident 3 was to maintain skin integrity and prevent wound deterioration. The DON explained that nurses were expected to reference Resident 3's current weight and adjust the mattress pressure accordingly each shift. The DON further stated that nurses were instructed to calibrate and adjust the mattress settings based on Resident 3's weight. The DON concluded that failure to adjust the LAL mattress pressure properly could negatively affect Resident 3's skin integrity.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to one of six residents (Resident 1) who receive nutrition, fluids, and medications through a gastrostomy tube (GT- also referred to as an enteral feeding/tube feeding- a tube inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications when swallowing is not possible or safe) when Resident 1's percutaneous endoscopic gastrostomy tube (PEG tube-a tube inserted through the skin and abdominal wall directly into the stomach for the delivery of nutrition, fluids, and medications) placement was not checked before medication administration.This failure had the potential to result in Resident 1 developing infection and even death.Findings:During a review of Resident 1's admission RECORD, dated 3/19/26, the record indicated Resident 1 was admitted to the facility with a diagnosis which included dysphagia (difficulty swallowing), quadriplegia (paralysis of all four limbs, arms and legs, and the torso), cerebral palsy (a brain disorder that appears in infancy or early childhood that affects body movement, muscle coordination, and posture), and an encounter for attention to gastrostomy.During a Review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), under the cognitive Patterns, dated 2/13/26, the MDS revealed Resident 1's Brief Interview for Mental Status (BIMS-a tool to assess mental functioning) score was entered as 0 indicating, .resident is rarely/never understood. The MDS also revealed under the Swallowing/Nutrition Status, Resident 1 had a feeding tube on admission, while not a resident, and while a resident in the facility.During a review of Resident 1's Order Summary Report, the report indicated an active physician's orders as of 3/19/26, the order report indicated, .Enteral feed: Check tube placement prior to each feeding, flush [the process of delivering water through the tube with a syringe to prevent from clogging], or Medication Administration every shift.During a review of Resident 1's Care Plan Report, (a form where you can summarize a person's health conditions, specific care needs, and current treatments) dated 3/17/26, the report indicated, .Risk for complications r/t [related to] enteral feeding via PEG tube.Verify tube placement prior to feeding/medication.During a medication administration observation on 3/19/26 at 8:09 a.m. in Resident 1's room, Licensed Nurse (LN) 4 prepared three medications for Resident 1 to be administered via the PEG tube. LN 4 gathered all her equipment and together with the crushed medications and a half-filled cup of water, entered Resident 1's room and placed the medication and supplies on the bedside table after putting on her disposable gown and gloves. LN 4 did not bring her stethoscope (a medical instrument used for listening to internal body sounds such as the heart, lungs, and intestines) with her to the bedside.During a subsequent medication administration observation on 3/19/26 at 8:09 a.m. with LN 4, LN 4 disconnected the tube from the feeding formula and attached the syringe into the tube. She then poured approximately 1/4 full of the syringe with water to flush the tube then followed by the crushed medications dissolved with small amount of water. She then flushed another 1/4 full of water into the syringe to clear the tube from the remaining medicines that were still in the tube to prevent from clogging. LN 4 did not verify the placement of the gastrostomy tube by drawing 5 to 10 ml (ml-milliliters, a unit of measurement) of air into the syringe and push the air in while listening with a stethoscope for a growl or swoosh sound over the abdomen before flushing with water for medication administration.During a concurrent interview and record review on 3/19/26 at 1:07 p.m. with LN 4, Resident 1's Order Summary Report, active order as of 3/19/26 was reviewed. LN 4 stated that she had verified the placement of the PEG tube before medication administration 30 minutes earlier at 7:30 a.m. and there was no need to check the placement again 30 minutes after. LN 4 acknowledged the physician's order report clearly indicated to check placement prior to each feeding, flush, or medication administration and stated she had not followed the physician's order to check the tube placement prior to each flushing and medication administration. LN 4 stated she should have checked the placement. LN 4 also stated the tube could have been dislodged, and if dislodged the tube would not be in the proper place and there could be a potential for aspiration.During a concurrent interview and record review on 3/19/26 at 3:16 p.m. with the Director of Nursing (DON), Resident 1's Order Summary Report, active orders as of 3/19/26 was reviewed. The DON stated she would expect the nursing staff to follow the physician's order and check the PEG tube placement as ordered. The DON also stated the risk for aspiration could potentially lead to complications. The DON confirmed the order report indicated, .ASPIRATION PRECAUTIONS: Implement aspiration precautions at all times.Verify PEG tube placement prior to feedings, flushes, or medication administration.During a review of the facility's Policy titled, Enteral Nutrition, revised 11/2018, the policy indicated, .Risk of aspiration may be affected by.Failure to confirm placement of the feeding tube prior to initiating the feeding.During a review of the facility's Policy and Procedures (P&P) titled, ENTERAL TUBE MEDICATION ADMINISTRATION, dated 8/2014, the (P&P) indicated, .The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes.During a review of the facility's job descriptions titled, Licensed Practical (Vocational) Nurse (LPN)(LVN), revised 5/2022, the job description indicated, .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care.During a review of the facility's job descriptions titled, Registered Nurse (RN), revised 7/2024, the job description indicated, .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care.

Based on interview and record review, the facility failed to inform and document an informed consent (a signed document requires healthcare providers to disclose risks, benefits, alternatives to ensure patients make educated decisions about their care or medication use) for increasing the diazepam (a mental health drug used to treat anxiety) dosage in one out of 5 sampled residents (Resident 8) that were reviewed for unnecessary drug use based on facility's policy on resident's rights.This failure had the potential to violate Resident 8's right to be aware of the consequences (risks versus benefits) of higher drug dosage usage that could contribute to adverse effects including dizziness, excessive sedation, fall risk and bone fracture.Findings: During a review of Resident 8's admission Record, the record indicated Resident 8's diagnosis included depression (mental depression with feeling of sadness), anxiety disorder (persistent or excessive worrying that interferes with daily life), post-traumatic stress disorder (or PTSD a mental condition triggered by experiencing or witnessing a traumatic events with flashbacks and nightmares), and Lewy bodies dementia (a type of memory loss with hallucinations and fluctuating alertness). The record additionally indicated that Resident 8 was self-responsible party (being fully accountable for own health care decisions). During a concurrent interview and record review on 3/19/26 at 2:29 PM with Licensed Nurse 3, (LN 3) Resident 8's medical record titled, AFTER VISIT SUMMARY [when residents see a specialist outside the facility], dated 3/5/26 and MEDICATION ADMINISTRATION RECORD [MAR, a document used by healthcare professionals to track, document, and verify the medications administered to a patient], dated 3/1/26 to 3/31/26 were reviewed. The AFTER VISIT SUMMARY indicated,. Today's medication changes. diazepam [VALIUM]-medication strength, how much to take, how to take this, when to take this, reasons to take this, additional instructions. diazepam 10mg [mg is milligram, a unit of strength]. generalized anxiety disorder. take one tablet in the morning and one tablet at bedtime scheduled What changed. medication strength. how much to take. how to take this. when to take this. reasons to take this. Resident 8's clinical record titled, MEDICATION ADMINISTRATION RECORD [MAR], dated 3/1/26 to 3/31/26, contained the following order that started on 3/11/26: . diazepam Oral Tablet 10 MG. Give 1 tablet by mouth every morning and at the bedtime for Anxiety. The review indicated the updated order with dosage increase was approved by the primary medical doctor (MD) in the facility and initiated on 3/11/26. The medical record did not show documentation that the MD recorded a discussion with Resident 8 on diazepam dosage increase and its risks or benefits. LN 3 acknowledged there was a lack of informed consent documentation for the diazepam dose increase. LN 3 stated, except in emergency situations where a physician might override the requirement, informed consent should have been obtained prior to initiating or increasing psychotropic medications. LN 3 stated that the physician was responsible for discussing the medication's purpose, necessity, potential side effects, and risks and benefits with the resident and/or the resident's representative. LN 3 further stated the physician should have documented the informed consent prior to administration of diazepam. During an interview on 3/20/26 at 7:44 AM with LN 5, LN 5 was asked to explain the workflow on processing residents' after-visit summary orders (a document provided to residents after a medical appointment, summarizing the visit, diagnosis, treatments plans, and necessary follow-ups). LN 5 stated she reviewed all documents, including after-visit summary instructions, whenever residents returned from outside provider visits and identified any changes in medication orders. LN 5 indicated that she followed the instructions outlined in the after-visit summaries. LN 5 stated that when there was an increase in medication dosage, or a new psychotropic (mental health/mind altering drugs) medication order, she notified the Medical Director (MD). LN 5 added if the MD agreed with the new order or changes, informed consent was obtained from the resident or the resident's representative by the MD. LN 5 stated signed consents were documented in the resident's medical record prior to implementation of new medication orders. LN 5 further stated nurses should not have administered psychotropic medications without a documented informed consent. During a concurrent phone interview and review of Resident 8's electronic medical record for informed consents, on 3/20/26 at 8:23 AM with the MD, the MD stated that Resident 8 had multiple chronic medical and psychiatric conditions. The MD stated Resident 8 had been evaluated and followed by a psychiatrist (mental health specialist doctor) for mental health conditions. The MD stated he reviewed Resident 8's electronic medical record and confirmed that informed consent was not obtained with medication dosage increase. The MD further stated that informed consent was required prior to the administration of psychotropic medications, including when there was a new order or an increased dosage, and that consent should have been obtained from the resident and, or the resident's representative and it was not. The MD stated that he was unsure how the requirement had been missed for Resident 8. During a concurrent interview and record review on 3/20/26 at 11:19 AM with the Director of Nursing (DON), Resident 8's medical record was reviewed for informed consent. The DON acknowledged informed consent had not been obtained or documented in Resident 8's medical record for diazepam dosage increase. The DON stated it was her expectation and best practice to obtain informed consent for new, or dose increases for psychotropic medications in accordance with regulatory requirements. The DON further stated that this expectation was not met in this instance. During a review of an undated facility provided document titled, Informed Consent for Psychotropic Drugs Pharmacy Services, The review indicated, . Purpose. It outlines responsibilities for obtaining, verifying, and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications for residents with behavioral or psychotic symptoms, such as those associated with dementia. Facilities must also comply with any additional state-specific requirements. Scope. This policy applies to all residents Medicare- and/or Medicaid-certified skilled nursing facilities (SNFs) prescribed psychotropic drugs, including new initiations, dose increases. Definitions. Informed Consent. Consent must be obtained prior to initiation or increase.

Based on interview, and record review, the facility failed to identify and report to the Department, an allegation of financial abuse for one of three sampled residents (Resident 1) when Resident 1 reported that his money was missing from his wallet after seeing a staff member holding his wallet.This failure resulted in a delay of the Department's investigation into Resident 1's allegation of theft and had the potential to affect other residents of the facility.Findings:A review of Resident 1's admission RECORD, indicated that he was admitted in the Summer of 2022.A review of Resident 1's MDS [Minimum Data Set, a comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status], dated 10/31/25, indicated Resident 1 had a Brief Interview for Mental Status Score of 15 (BIMS, a standardized 0-15 point cognitive assessment used primarily upon admission to long-term care facilities to gauge mental acuity, with higher scores indicating better cognition) which indicated Resident 1's cognition (the mental process of knowing and understanding) was intact.A review of Resident 1's Progress Notes, dated 1/20/26, indicated, .On 01/19/26 @ [at] 0500H [5 AM], resident [Resident 1] reported missing approximately $120-$140 [dollars] from his wallet. Resident stated he witnessed laundry staff [LS 1] holding his wallet while resident was asleep. Resident reassessed at time of report and noted to be cognitively intact (BIMS 15), calm, and able to verbalize concern clearly. Writer and SSD [Social Service Director] met with resident to discuss resident concern, resident rights, reporting options ([Department]/State/PD [police department]/Ombudsman [long term care resident advocate]), facility grievance [formal complaint] process, and investigation steps. Resident stated he does NOT want to file a formal grievance/complaint and just wants staff to know. Resident was offered option to report concern externally and resident declined at this time. Laundry staff [LS 1] interviewed regarding allegation and vehemently [strongly] denied holding resident's wallet or taking any money. Investigation completed with no additional evidence identified to confirm theft at this time. Resident educated on valuables safety options (secure storage/avoid keeping cash). Facility offered secured valuables storage and lockbox to be provided once available. Resident informed of facility process for lost personal property and agreed to reimbursement per facility policy; resident advised reimbursement does not affect his rights to file a grievance or report to [Department]/State/Ombudsman at any time. Resident updated on findings, verbalized understanding, and case closed at this time .A review of a facility provided document titled, Theft/Loss Report, dated, 1/19/26, indicated that Resident 1 had a $120-$140 dollars in twenty dollar bills missing. Further review of the document, under the section titled, Facility Action Taken to Find Missing Item, indicated, .Cash was not located, DON [Director of Nursing] and SSD met with resident regarding concern, resident rights and reporting options. Resident declined to file a formal grievance and just wanting money replaced . During an interview on 1/23/26, at 12:28 PM, with the SSD, the SSD stated that Resident 1 reported to her and to the DON that he lost his money (on 1/19/26). The SSD further stated that Resident 1 filled out a theft and lost form regarding his lost money. The SSD stated that Resident 1 had reported that he saw LS 1 holding his wallet in his room. The SSD stated that Resident 1 was offered to report the incident to the Department, police and Ombudsman. The SSD further stated that Resident 1 declined to report the incident and just wanted his money to be reimbursed. The SSD stated that she and the DON interviewed LS 1 and LS 1 denied holding Resident 1's wallet. The SSD further stated that LS 1 told them that he went to Resident 1's room to place the clothes in the closet while Resident 1 was sleeping. The SSD stated that Resident 1 told them that he did not witness LS 1 taking the money and did not confront LS 1. The SSD confirmed that Resident 1's money was not found.During an interview on 1/23/26, at 1:39 PM, with Resident 1, Resident 1 stated he woke up because he felt someone was in his room. Resident 1 further stated that when he looked up, he saw LS 1 putting clothes in the closet at 5 in the morning. Resident 1 stated he just saw LS 1 holding the wallet but did not see if LS 1 took out any cash. Resident 1 further stated he did not say anything but as soon as LS 1 left the room, he checked his wallet and noticed his $140 was missing from his wallet. Resident 1 stated that the money was still there before he slept the night before. Resident 1 further stated that seven $20 bills were gone. Resident 1 stated that when the CNA came in his room, he reported it to the CNA and to the head nurse. Resident 1 further stated he signed some paperwork for the lost money. Resident 1 stated that he reported it to the SSD and the DON. Resident 1 confirmed that the facility offered to report the incident to the Department, the police and the Ombudsman, but he declined because he did not want the trouble of reporting and he just wanted his money back.During an interview on 1/23/26, at 3:15 PM, with the DON, the DON stated that when a resident reported a missing item or cash, the SSD would initiate an investigation. The DON further stated that after a thorough investigation, they would involve the Administrator (ADM) and see if it would be a case of abuse and if it would be reportable. The DON stated that they would involve Human Resources (HR) if a staff member had stolen something. The DON further stated that if it was an abuse case, they would trigger the abuse protocol which was to contact the Department, Ombudsman, and Police Department. The DON stated that the potential outcome for a resident if a resident's items were stolen or missing would be degrading the resident rights because this was the resident's home. The DON further stated that the facility investigated Resident 1's allegation on the same day that he reported it. The DON stated the investigation was a laundry staff member (LS 1) allegedly was holding the wallet of Resident 1 but Resident 1 did not see LS 1 removing the money from his wallet. The DON further stated that Resident 1 claimed he counted his money in the wallet the night before and noticed $120-$140 was missing when he woke up. The DON stated if the amount of money or the value of the item missing was above $100, they would report it to the police and the Department, but if the resident wanted it to be reported then the amount did not matter. The DON stated reporting was always offered to the residents and the residents were educated about reporting to the Department. The DON confirmed Resident 1's allegation was not reported to the Department because Resident 1 declined to report the incident when he was given the option to report.During a concurrent interview and record review on 1/23/26, at 4:36 PM, with the ADM, Resident 1's progress notes was reviewed. The ADM confirmed that the facility did not report the incident to the Department. The ADM stated that he was not aware that the incident was an alleged incident of abuse and usually the facility would act on behalf of the resident. The ADM stated that Resident 1 was given a choice to report the incident to the police and not the Department. The ADM further stated that he was under the impression that this was not an abuse because he was not aware that Resident 1 accused a staff member of stealing his money. The ADM stated that in the progress notes it was not stated that Resident 1 was accusing the staff of stealing his money. The ADM further stated that his understanding was that Resident 1 had some money missing from his wallet. The ADM stated that both the facility and the residents had reserved the right to have a choice in reporting. The ADM further stated that there was no alleged abuse going on and no misappropriation of funds that happened. The ADM stated it was 100% not a potential for financial abuse because Resident 1 did not see LS 1 take the money and Resident 1 did not want to file a grievance. The ADM further stated that when they reported something there was an alleged abuse but in this case, there was no malicious intent. The ADM stated that Resident 1 reported that some of his money was missing, and that the LS 1 was present. The ADM further stated that their abuse policy did not apply to this scenario because there was not enough evidence to deem that it was a misappropriation of the resident's funds.During an interview on 1/23/26, at 4:59 PM, with Resident 1, Resident 1 stated he did not ask a staff member to report the incident to the Department and police department, but he did report it to the CNA, the nurse, the SSD and the DON. Resident 1 stated when the incident happened, he felt ripped off, stolen, and upset. Resident 1 further stated that the incident made him think that this could potentially happen again. Resident 1 stated that he saw LS 1 putting the wallet back on the table, but LS 1 did not notice that he was awake. Resident 1 further stated when LS 1 left, he immediately checked his wallet, and the money was gone, and he said to himself that he (LS 1) stole his money. Resident 1 stated that LS 1 should have not held his wallet in the first place.During an interview on 1/23/26, at 5:05 PM, with the ADM and the DON, both the ADM and the DON stated that there was nothing to be reported because there was no theft incident, Resident 1 just lost his money, and it was not proven that LS took his money. The ADM and the DON stated that LS 1 did not have any records, and he had been working at the facility for 19 years. During a phone interview on 1/29/26, at 2:02 PM, with the DON, the DON confirmed that Resident 1's cash was not included in the inventory sheet. The DON stated that the incident was not reported to the police department and Ombudsman. A review of Resident 1's INVENTORY OF PERSONAL EFFECTS, dated 7/4/22, the document did not include any monetary cash.A review of the facility's policy and procedure titled, Resident's Personal Property, dated 8/25/21, indicated, .Any loss or breakage of a Resident's personal item will be properly documented on the Theft/Loss form and/or Grievance form by the person receiving the report, and then referred to the Administrator.A review of the facility's policy and procedure titled, Investigating Incidents of Theft and Loss, revised April 2017, indicated, .All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated.Residents have the right to be free from theft and Loss.Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: a. State Licensing and Certification Agency; b. Ombudsman; c. Resident Representative; d. Adult Protective Services; e. Law Enforcement Officials.The administrator will report the results of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident.A review of the facility's policy and procedure titled, Resident Rights, revised October 2025, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be free from abuse, neglect, misappropriation of property, and exploitation.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, indicated, .Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman. c. The resident's representative. d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials.

Based on interviews and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards for one of four sampled residents (Resident 4) when Resident 4's Visual Checks (a document detailing staff observations of Resident 4's activity in timed increments), dated 10/06/25 indicated that Resident 4 was in the facility during the time that he had eloped from the facility.This failure resulted in inaccurate documentation in Resident 4's medical record for twenty minutes, with staff documenting safety observations that they did not perform.Findings:A review of Resident 4's admission RECORD, indicated that Resident 4 was admitted to the facility in 2025 with diagnoses which included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).A review of Resident 4's SBAR [Situation, Background, Assessment and Recommendation, a healthcare communication tool] Communication Form and Progress Note, dated 10/6/25 indicated, .the resident was noted with wandering behavior and had actual elopement incident.Code [NAME] (facility emergency response) was activated, room and facility ground physical check was done per protocol. At 1350H (hours), he was found walking in [sp] the sidewalk along the traffic light.he then came willingly with DON [Director of Nursing] and facility driver.During an interview on 10/24/25 at 1:04 p.m. with Licensed Nurse (LN) 1, LN 1 stated that she remembered Resident 4. LN 1 stated that she was not assigned to care for Resident 4 but was on duty the day of the incident. LN 1 stated that she saw the resident earlier in the day sitting in a wheelchair. LN 1 stated that later, a coworker told her that Resident 4 was missing. LN 1 stated that the staff looked for the resident but could not find him. LN 1 stated that she notified the Administrator (ADM) and the DON that the resident was missing. LN 1 stated that the staff announced the Code Green indicated that everyone was needed to find the resident as instructed by the ADM. LN 1 stated that staff looked both inside the facility and outside in the parking lot and surrounding areas but could not find the resident. LN 1 stated that the DON and another staff member got in the facility van and drove around to look for the resident. LN 1 stated that they found Resident 4 down the block at the stop light and brought him back to the facility. LN 1 stated that frequent visual checks were done on residents after elopement by the staff. LN 1 stated that the frequent visual checks on residents after elopement were documented on paper forms. A review of Resident 4's Visual Checks, form dated 10/6/25 indicated that Resident 4 was observed in location L2 which indicated Bedroom Awake every fifteen minutes from 1300 (1 PM) to 1345 (1:45 PM) on 10/6/25. During an interview and concurrent review of Resident 4's Visual Checks form and Electronic Medical Record [EMR], on 11/14/25 at 9:45 a.m. with the DON, the DON stated that her expectation was that staff documented accurately in the residents' medical records. The DON acknowledged that the entries on Resident 4's Visual Checks form dated 10/6/25 indicated that Resident 4 was in his room at 1:30 PM and at 1:45 PM on 10/6/25, and Resident 4's SBAR Communication Form and Progress Note, dated 10/6/25 indicated that Resident 4 was located down the street from the facility at a stop light at 1:50 PM on 10/6/25. The DON confirmed that the documentation on the Visual Checks form and the SBAR Communication Form and Progress Note were inconsistent, as staff noticed that Resident 4 was missing at 1:30 PM on 10/6/25. The DON stated that the documentation on Resident 4's Visual Checks form dated 10/6/25 should have been accurate. The DON acknowledged that the facility policy was not followed. A review of a facility policy and procedure (P&P) titled, Nursing Documentation, effective date 6/27/22, the P&P indicated, .Purpose.To communicate patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided.Policy.Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's (hereinafter patient) condition, situation, and complexity.Nursing documentation will follow.policy and procedure and federal and state regulations.Procedure.b. Timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion.c. The patient's record specifies what nursing interventions were performed by whom, when, and where.d. All patient information will be documented, scanned, or entered in the appropriate section of the clinical record following established guidelines.

Based on interview and record review, the facility failed to ensure an environment free of accidents or hazards for two of four sampled residents (Resident 3 and Resident 4) when:Resident 3 did not have Wander Gard device (a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area) placement and functioning checks documented every shift daily per physician order after an elopement (when a resident leaves a healthcare facility against medical advice when doing so poses an imminent threat to the resident's health or safety) episode; andResident 4 did not have a Wander Gard device placed upon admission to the facility despite a recent history of elopement and according to facility policy.These failures put Resident 3 at increased risk of elopement and resulted in Resident 4 eloping (leaving the facility without staff knowledge) on 10/6/25, with the potential to lead to severe harm like falls, a serious injury, and/or deathFindings:1. A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the facility with diagnoses which included Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).A review of Resident 3's Elopement Evaluation, dated 4/13/25, the evaluation indicated, .Does the resident have a history of elopement or an attempted elopement while at home: Yes.Does the resident have a history of attempting to leave the facility without informing staff: Yes.Has the resident expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes.Does the resident wander: Yes.During a review of Resident 3's SBAR [Situation, Background, Assessment and Recommendation, a healthcare communication tool] Communication Form and Progress Note, dated 4/13/25, the document indicated, .Summarize your observations and evaluation: .Resident [Resident 3] exited the main door of the building. Able to get redirected inside. No c/o [complaint of] pain or discomfort noted.Asked where she is going. Resident didn't say anything.Ensured all exits are secured with alarms. Whereabouts monitored.Primary Care Clinician Notified: Yes Date: 04/13/2025 Time: 11:00 AM.Recommendations of Primary Clinicians.Wander guard.During an interview on 10/24/25 at 3:30 p.m. with a Certified Nursing Assistant (CNA), the CNA stated that the Licensed Nurses checked the functioning of the Wander Guard devices, and the CNAs checked to make sure the devices were on the residents. During an interview on 10/24/25 at 3:30 p.m. with Licensed Nurse (LN) 2, LN 2 stated that the LNs checked the function of the Wander Gard devices every shift. LN 2 stated that the functioning of the Wander Guard devices was documented in the residents' EMR (Electronic Medical Record) either in the MAR (Medication Administration Record, a document listing medications and monitoring parameters) or the TAR (Treatment Administration Record, a list of prescribed treatments) each shift. During an observation and concurrent interview on 10/24/25 at 3:32 p.m. with Resident 3 in her room, Resident 3 sat in a wheelchair near her door with a Wander Guard device on her wrist. Resident 3 stated that she did not remember going outside of the facility in April of 2025. A review of Resident 3's TAR, dated 12/25, indicated that Resident 3's Wander Guard device placement and function was not checked every shift daily on 8/5/25, 8/27/25 and 8/30/25.A review of Resident 3's TAR, dated 9/25, indicated that Resident 3's Wander Guard device placement and function was not checked every shift daily on 9/1/25, 9/5/25, 9/11/25, 9/28/25, and 9/29/25.A review of Resident 3's TAR, dated 10/25, indicated that Resident 3's Wander Guard device placement and function was not checked every shift daily on 10/11/25. A review of Resident 3's Care Plan Report, indicated, .Focus.Wander gard [sp] Elopement Device Due to poor safety awareness.Date Initiated: 04/14/2025.Goal.The resident will remain safe from any harm.Target Date: 12/08/2025.Interventions.Check for proper fitting.The nurse will monitor resident's whereabouts.ensure wander gard [sp] is functioning properly. During a concurrent interview and record review of Resident 3's TARs, with the DON on 11/14/25 at 9:45 a.m., the DON stated that her expectation was that residents deemed at risk for wandering would have a Wander Guard device placed and would be monitored frequently. The DON stated that the staff checked the placement and function of the Wander Guard device every shift each day and documented the placement and function of the Wander Guard device in the residents' medical record. The DON confirmed that Resident 3 had a Wander Guard device. The DON stated that Resident 3 had a prior history of elopement in April of 2025. The DON confirmed that Resident 3 had a Wander Guard placed in April of 2025 after the elopement. The DON confirmed that Resident 3's Wander Guard placement and function were not documented in her TARs every day each shift on 8/5/25, 8/27/25, 8/30/25, 9/1/25, 9/5/25, 9/11/25, 9/28/25, 9/29/25 and 10/11/25. The DON stated that the risk was elopement. The DON confirmed that the facility policy was not followed.2. A review of Resident 4's admission RECORD, indicated that Resident 4 was admitted to the facility with diagnoses which included but not limited to, dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness, unsteadiness on feet, and history of falling.A review of Resident 4's Physician Narrative H&P [history and physical], dated 10/3/25, the document indicated, .LATE ENTRY.was recently hospitalized after being found wandering by police from his previous facility.during hospitalization, CT [computed tomography, a diagnostic imaging test that combines x-rays with computer processing to create detailed pictures of the inside of the body] was negative for trauma [injury]. [Resident 4] has now been discharged to skilled nursing facility for close monitoring. A conservator [when a judge appoints another person to act or make decisions for the person who needs help] has been appointed following psychiatric evaluation due to [Resident 4's] incapacity [lacking the physical, mental, or legal ability to manage personal affairs, make decisions, or perform functions] to make independent decisions.Since admission to the facility, [Resident 4] has had ongoing issues with elopement, most recently being found wandering on the street after leaving his room, though no falls or injury occurred.Assessment/Plan.now requiring close monitoring due to ongoing elopement risk and safety concerns.Implement close monitoring and safety measures to prevent elopement.A review of Resident 4's Elopement Evaluation, dated 10/3/25, the evaluation indicated, .1. Does the resident have a history of elopement.No.Does the resident wander.Yes.A review of Resident 4's SBAR Communication Form and Progress Note, dated 10/6/25 indicated, .the resident was noted with wandering behavior and had actual elopement incident.Code [NAME] (facility emergency response) was activated, room and facility ground physical check was done per protocol. At 1350H [1:30 PM], he was found walking in [sp] the sidewalk along the traffic light.he then came willingly with DON [Director of Nursing] and facility driver.Full head to toe assessment done.Primary Care Clinician Notified: Yes.Date: 10/06/2025.Time: 1:55 PM.ordered to put wander guard [sp].continuously monitor the resident.A review of Resident 4's Progress Note, dated 10/6/25, the documents indicated, .was seen wandering.teaching given on risk of wandering and elopement given to pt [patient; Resident 4], pt has history of dementia.wander guard explained to pt and pt verbalized agreement of device.md [medical doctor] notified of behaviors and order was given for device.During an interview on 10/24/25 at 1:04 p.m. with Licensed Nurse (LN) 1, LN 1 stated that she remembered Resident 4. LN 1 stated that she was not assigned to care for Resident 4 but was on duty the day of the incident (elopement). LN 1 stated that she saw Resident 4 earlier in the day sitting in a wheelchair. LN 1 stated that later, a coworker told her that Resident 4 was missing. LN 1 stated that the staff looked for Resident 4 but could not find him. LN 1 stated that she notified the Administrator (ADM) and the DON that Resident 4 was missing. LN 1 stated that the staff announced the Code Green which indicated that everyone was needed to find the resident as instructed by the ADM. LN 1 stated that staff looked both inside the facility and outside in the parking lot and surrounding areas but could not find Resident 4. LN 1 stated that the DON and another staff member got in the facility van and drove around to look for Resident 4. LN 1 stated that they found Resident 4 down the block at the stop light. LN 1 stated that Resident 4 was brought back to the facility by the DON and another staff member. LN 1 stated that Resident 4 was assessed from head to toe and was not harmed. LN 1 stated that the staff helped each other to complete paperwork regarding the incident. LN 1 stated that she did the Change in Condition form (CIC) and the SBAR Progress Note to help. LN 1 confirmed that Resident 4 was not wearing a Wander Guard device prior to the elopement. LN 1 stated that a Wander Guard device was placed on Resident 4 when he returned to the facility. LN 1 stated that staff checked the Wander Guard devices every shift and documented the checks in the electronic medical record (EMR). LN 1 stated that if a resident with a Wander Guard device got too close to the exit doors an alarm would sound. LN 1 stated that the frequent visual checks on residents after elopement were documented on paper forms. LN 1 stated that staff received in-service education on dementia, elopement and exit-seeking behaviors every time an incident occurred and periodically during the year. During an interview and concurrent record review of Resident 4's EMR with the DON on 11/14/25 at 9:45 a.m., the DON stated that her expectation was that residents deemed at risk for wandering would have a Wander Guard placed and would be monitored frequently. The DON acknowledged that Resident 4's Elopement Evaluation, dated 10/3/25, indicated that Resident 4 did not have a history of elopement. The DON confirmed that Resident 4's Physician Narrative H&P, dated 10/3/25, indicated that Resident 4 had a prior history of wandering and elopement. The DON confirmed that Resident 4's Physician Narrative H&P further indicated that Resident 4 required close monitoring and safety measures to prevent elopement. The DON confirmed that Resident 4 eloped from the facility on 10/6/25. The DON confirmed that Resident 4 did not have a Wander Guard device prior to his elopement from the facility. The DON acknowledged that Resident 4 should have had a Wander Guard device placed when he was admitted to the facility. The DON stated that the risk for Resident 4 not having a Wander Guard device was elopement and that he fortunately was not injured when he eloped on 10/6/25. The DON acknowledged that the facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Tab Alarms, Bed Alarms, Wanderguard System, revised 12/12/24, the P&P indicated, .Policy Statement.The Wanderguard would be used for residents at risk for elopement.Procedure.1. Nursing Assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for.elopement.5. The Wanderguard bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed.7. The Wanderguard bracelets are checked daily.A review of an undated facility P&P titled, Wandering and Elopements, the P&P indicated, .Policy statement.The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.A review of a facility P&P titled, Safety and Supervision of Residents, revised 7/17, the P&P indicated, .Policy Statement.Our facility strives to make the environment as free from accident hazards as possible.Policy Interpretation and Implementation.Individualized, Resident-Centered Approach to Safety.4. Implementing interventions to reduce accident risks and hazards shall include the following.d. Ensuring that interventions are implemented.e. Documenting interventions.Resident Risks and Environmental Hazards.e. Unsafe wandering.

These findings represent past non compliance with this regulatory requirement. There was significant evidence the facility corrected the non compliance as of 08/15/25 and there were no other occurrences of the same deficient practice at the time of the survey. The facility was in substantial compliance with this regulatory requirement and there for doesn't not require a plan of correction. Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella Disease (a type of pneumonia (lung infection) caused by the bacteria Legionella pneumophila) and other opportunistic waterborne pathogens (a microorganism (bacteria) that exists in water sources or plumbing (pipes required for the water supply, heating, and sanitation in a building) systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 71 when:a. The facility did not implement adequate water safety control measures; b. The facility did not establish sufficient water safety monitoring protocols; andc. The facility did not create an intervention plan for when control limits were not met.These failures put the residents and staff at risk of potential Legionella and other opportunistic waterborne pathogen exposure, threatening their health and well-being.Findings:During an interview on 8/14/25 at 9 AM, the local Public Health Officer (PHO) confirmed she discussed with the facility about improving their water management plan. The PHO stated the facility's plan and policy in place did not align with nationally accepted standards to minimize the risk of Legionella contamination. The PHO further stated when she reviewed the Water Safety Management Program (Legionella) policy and procedures, and stated the facility was missing important components such as the roles of each member of the water management program must be assigned and listed. The PHO further explained these roles once they were assigned, the staff should be aware and knowledgeable when they were needed. The PHO explained, during a meeting with the facility on 8/6/25, the facility was provided with the information needed to have a complete and compliant water management program. The PHO stated the information needed to be mapped out with an action plan, including who they would contact and work with to chlorinate and flush lines in case of a Legionella outbreak.During an interview with Licensed Nurse 1 (LN1) on 8/14/25 at 1:31 PM, LN1 stated since being employed at the facility for a little over a year she did not receive any training on water management during her employment at this facility. LN1 stated, on 7/22/25 staff received their first notification via text indicating the water would be off for some time for maintenance.During an interview with the Maintenance Director (MTD) on 8/14/25 at 3 PM, the MTD stated upon recommendation of his regional headquarters due to the recent legionella alert he recently completed replacing the showerheads and placing filters on all areas where water was used for consumption by the residents. A walk through in the kitchen and visualization of the specialized filters confirmed placement. The MTD stated preventative maintenance was important to prevent the residents from getting sick. The MTD explained the special filters on the showerheads and eye washing station help filter diseases like Legionella from the water. The MTD further stated it was important to test the water to prevent sicknesses which could harm the residents and cause death. The MTD could not explain the facilities process for decontaminating the facilities water systems if necessary. The MTD confirmed they did not have an outside source contracted to decontaminate the water system, prior to the notification of a positive Legionella resident and a company was scheduled to come on 8/15/25. The MTD stated it was important to have a contracted company to be aware if there were harmful things in the water.During an interview on 8/14/25 at 4:10 PM with the Administrator (ADM), the ADM stated the facility was notified by the Public Health Department (PHD) on 7/22/25 that a resident who was sent to the hospital from the facility tested positive for Legionella pneumophila (a severe form of pneumonia -a lung infection caused by Legionella bacteria). The ADM further stated the facility contacted the local Public Health Department after they initially contacted the facility to schedule a meeting to develop a better understanding of how to address this issue. This meeting was conducted on 8/6/25 for detailed guidance on how to handle the results. The ADM explained the PHD asked that the water samples be collected by a company certified to do so. The ADM explained the PHD also wanted the facility to be contracted with a company to provide certified testing and facility water maintenance in case of a positive result. The ADM stated they did not have a contracted provider at the time and requested a list of certified companies from the PHD. The ADM explained the facility contracted with a company who will be coming out to the facility on 8/15/25 to collect six samples to test the water. The ADM confirmed the facility did not have records of baseline testing for legionella or any comparative results that would inform the facility of the need for immediate corrective action.During an interview with the Director of Nursing and the Infection Preventionist (IP) on 8/14/25 at 4:30 PM, the DON explained the PHD told them to test the residents with respiratory symptoms (signs like runny nose, cough, and difficulty breathing that indicate a problem with your breathing or lungs) and to test their water for Legionella by a certified company. The DON stated they tested all the residents in the facility with respiratory symptoms and all results were negative. The DON and the IP confirm the facility did not have a risk management program (program is a proactive plan to find and fix any problems in a building's water system that could allow dangerous Legionella bacteria to grow and spread) in place and documentation of utilization of the program nor a protocol for testing the residents. The DON stated the staff have not had any water management training prior to the notification from the PHD about the positive legionella case.During a follow up interview and record review of the policy and procedures with the ADM, on 8/15/25 at 5 PM while reviewing the facilities water management program, the ADM confirm the facility did not have assigned duties to each member of the water management program team.During a follow-up interview on 8/15/25 at 3:46 PM, the DON stated the water management plan prior to the incident did not meet her expectations. The DON further stated although the facility did have water management in place all the components and requirements were not utilized to the standards of the PHD. The DON explained legionella can grow and spread in stagnant water and plumbing. The DON further explained it was important to have a detailed water safety management program and plan in place to prevent the residents from getting Legionella pneumonia. The DON stated the risk to the residents was respiratory distress and illness.A review of the facilities Policy and Procedures (P&P) titled, Water Safety Management Program (Legionella) dated, 7/21, the P&P indicated, .1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] recommendations for developing a Legionella water management program . A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program.A review of the Centers for Disease Control's online guide titled Overview of Water Management Programs, published 3/15/24, the guide indicated, .Key Points.Many buildings need a water management program (WMP) for their building water system.WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens.Developing and maintaining a WMP is a multi-step process that requires continuous review.Seven steps of a Legionella WMP are to: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Ensure the program runs as designed and is effective 7. Document and communicate all activities.the principle of effective water management includes Ensuring adequate disinfection.Maintaining devices to prevent.Sediment, Scale, Corrosion, Biofilm.Maintaining water temperatures to limit Legionella growth, preventing water stagnation.Once established, WMPs require regular monitoring of key areas for potentially hazardous conditions. The programs use predetermined responses to respond when control measures aren't met.Each program has to be tailored for each building at a particular point in time.In some settings, the entire building needs a WMP: Hospitals and long-term care facilities.(https://www.cdc.gov/control-legionella/php/wmp/index.html)

Based on interview, and record review, the facility failed to provide an environment to ensure residents' needs related to nursing services were met for a census of 72 when only one scheduled nurse worked the entire night shift on 5/4/25. This failure had the potential for residents' care services not being met by nursing staff and could affect the health and well-being of all residents in the facility. Findings: During an interview on 5/8/25, at 2:58 p.m., Licensed Nurse (LN) 1 stated that in emergency situations such as a code blue (a medical emergency requiring urgent medical help) a nursing shortage could lead to placing residents' safety and well-being at risk. During a phone interview on 5/8/25, at 3:54 p.m., LN 2 confirmed there was one nurse for the entire night shift on 5/4/25. LN 2 stated that it was not a safe practice to have one nurse for the entire facility if a resident had a medical emergency. LN 2 further stated that this unsafe practice could possibly affect residents' safety. During an interview on 5/9/25, at 6:15 a.m., Certified Nursing Assistant (CNA) 1 stated there was a possibility of placing all residents' safety at risk when there was one licensed nurse working on the floor for the whole night shift. CNA 1 further stated medical emergencies could happen anytime during the shift and it would be difficult for one licensed nurse to handle the emergency. During an interview on 5/9/25, at 6:32 a.m., CNA 2 stated shortages in nursing would impact residents' health and safety. CNA 2 further stated there was a possibility for residents to not to receive medications as they were scheduled by the physician which could lead to a decline in health and suffer in emergency situations. During a concurrent interview and record review on 5/9/25, at 9:35 a.m., with the Staffing Coordinator (SC), the facility document titled, [facility name] DAILY STAFFING, dated 5/4/25 was reviewed. The SC confirmed that on 5/4/25, during the 10:30 p.m.-7 a.m. night shift, only one LN worked for the entire shift, and the second LN clocked out at 12:25 a.m. on 5/4/25. The SC further stated that one of the nurses tried calling staff to fill in the shortage. During a concurrent interview and record review on 5/9/25, at 10:52 a.m., with the Director of Nursing (DON) the facility document titled, [facility name] Daily Census, and [facility name] DAILY STAFFING, dated 5/4/25 were reviewed. The DON confirmed that they were short of one licensed nurse from 12:25 a.m.-7 a.m. for a census of 72 and stated that it might result in placing a census of 72 at risk for not receiving medications in a timely manner, increased risk for falls, and unable to meet resident needs in a medical emergency that would affect residents' safety and well-being. The DON further stated her expectation from the licensed staff was to leave a voicemail message when a licensed nurse called her on 5/4/25 at 11:32 p.m. The DON stated her expectation was not met by the licensed staff. A review of an undated facility provided document titled, Facility Assessment Tool, indicated, .Guidelines for Conducting the Assessment .4. The Facility Assessment will be used to .c. Consider the specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to the resident population .3. Facility resources .staffing plan 3.2. Based on the facility's resident population and their needs for care and support, describe the facility's general approach to staffing to ensure that it has sufficient staff members with the appropriate competencies and skill sets to meet the needs of the residents, as identified through resident assessments and care plans at any given time . A review of the facility provided job description titled, Director of Nursing, revised on October 2020, indicated, .The primary purpose of this position is to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times .Duties and Responsibilities .Provide direct nursing care and resident assessments .Ensure the facility has sufficient nursing staff .Working Conditions .Works beyond normal working hours and on weekends and holidays when necessary .

Based on interview and record review, the facility failed to ensure adequate treatment and services were provided for one of three sampled residents (Resident 1) when, Resident 1 was not transferred to an acute care hospital (provides short-term treatment for illnesses, injuries, or surgeries that require immediate medical attention) in a timely manner for further evaluation after Resident 1 had an unwitnessed fall with a head injury on 2/17/25 and Resident 1 had a fall again on 2/28/25 with noted pain to Resident 1 ' s left hip. This failure placed Resident 1 at risk for delayed treatment and services that could possibly result in a decline in health and well-being. Findings: On 2/24/25, the Department received a complaint report that Resident 1 was not transferred after a fall on 2/17/25 to the acute care hospital for further evaluation till the following day. On 3/4/25, the Department received an additional complaint report that Resident 1 was not transferred after a fall on 2/28/25 to the acute care hospital for further evaluation until the following day. Review of Resident 1 ' s admission RECORD, indicated Resident 1 was admitted to the facility in early 2025 with diagnoses which included dementia (a decline in memory or other thinking skills severed enough to reduce a person ' s ability to perform everyday activities), difficulty in walking, muscle weakness, and repeated falls. Review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool), dated 1/25/25, the cognitive patterns section of the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) Summary Score of 3 out of 15 indicating a severely impaired mental functioning (a significant decline in cognitive abilities that substantially interferes with daily life and activities). Review of Resident 1 ' s HISTORY AND PHYSICAL EXAMINATION, dated 1/25/25, indicated Resident 1 had fluctuating capacity to understand and make decisions due to cognitive impairment. A. Review of Resident 1 ' s eInteract SBAR [Situation Background Assessment Recommendation; verbal or written communication tool that helps provide essential, concise information] Summary, dated 2/17/25, indicated Resident 1 had a fall on 2/17/25 at 3:30 a.m. This summary also revealed Resident 1 had indicated she hit her head and a small hematoma (bruise or swelling caused by bleeding under the skin or into a tissue) was noted to the right posterior lobe (back area of the brain) of the head and she was in pain. Review of Resident 1 ' s Fall Care Plan, dated 2/17/25, indicated, .The resident has had an actual fall with hematoma to back of head . Review of Resident 1 ' s eInteract SBAR Summary, dated 2/18/25, at 8:35 a.m., indicated, .Resident noted to have two episodes of nausea with vomiting. S/p [status post] unwitnessed fall resulting in head injury on 2/17. Resident now present with increased confusion and unable to tell what time of the day it is, her age, and states she does not remember yesterday which is abnormal from baseline . Review of Resident 1 ' s Progress Note, dated 2/18/25, at 9:56 a.m., indicated, .resident was sent out to the hospital for further evaluation . During an interview on 3/6/25, at 10:19 a.m. with Licensed Nurse (LN) 1, LN 1 stated she would call the attending physician and would request to send the resident to the acute care hospital for further evaluation when a head injury was involved, and it was an unwitnessed fall. LN 1 also stated the resident would be better assessed when transferred to the acute care hospital. During a phone interview on 3/27/25, at 2:55 p.m. with LN 2, LN 2 stated she would also notify the Director of Nursing (DON) for a fall involving a head injury for further instructions especially if the attending physician did not respond immediately. Further review of Resident 1 ' s eInteract SBAR Summary, dated 2/17/25, there was no documented evidence the DON was notified immediately after the fall. During an interview on 3/6/25, at 12:45 p.m. with the DON, the DON stated she would have expected to be called regarding an unwitnessed fall with a head injury to ensure proper implementation of interventions. B. Review of Resident 1 ' s eInteract SBAR Summary, dated 2/28/25, indicated Resident 1 had a fall on 2/28/25, at 11:49 p.m. Resident 1 ' s SBAR summary also indicated, .legs bent and soles of feet on the floor .Nodule noted to left hip . This summary also revealed Resident 1 was in pain. Review of Resident 1 ' s eInteract Change in Condition Evaluation, dated 2/28/25, under section Functional Status Evaluation indicated, .Is the fall: 1. Associated with any suspected serious injury (e.g. fracture) any hip pain, or more than minor pain elsewhere [was marked] . Under the section Provider Notification and Feedback indicated, .2. Date and time of clinician notification: 3/1/25 [at] 6 a.m . Under the section Pain Status Evaluation indicated, .7a. Does the resident/patient have pain? 1. Yes [was marked] .Describe musculoskeletal pain: 1. Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall [was marked] .7e. Specify exact location of pain .Left trochanter (hip) .Small nodule noted with pain to touch . Under section Resident Representative Notification, indicated, .2. Date and time of family/resident representative notification: 3/1/25 [at] 6:07 a.m . Review of Resident 1 ' s Nurses Progress Note, dated 3/1/25 at 8:10 a.m., indicated, .he [family member] preferred her [Resident 1] be sent out [transfer to acute hospital] for further evaluation and treatment . Review of Resident 1 ' s eInteract Transfer Form, dated 3/1/25, at 2:12 p.m., indicated Resident 1 was transferred to the acute care hospital. Review of Resident 1 ' s General Progress Note, dated 3/1/25, at 6:25 p.m., indicated, .pt [patient/Resident 1] admitted .due to sustaining a left hip fracture . Review of Resident 1 ' s Interdisciplinary Care Conference, dated 3/3/25, indicated, .Concern/Issue: Fall with major injury significant event occurring on 3/1/25 regarding the resident where she had sustained a fall on the night of 2.28.2025, resulting in the transfer and admission to the acute [care hospital] with a left hip fracture . Review of Resident 1 ' s Discharge Summary from the acute care hospital, dated 3/1/25, indicated, .Left greater trochanter fracture and inferior pubic ramus fracture [broken bone to left hip and lower part of the pelvis] . During an interview on 3/6/25, at 10:53 a.m. with the Primary Care Physician (PCP), the PCP stated he knew about the Resident 1 ' s fall and had ordered for an x-ray based on the reported assessment and information received from the facility nurse. The PCP further stated family had requested to transfer Resident 1 to the acute care hospital and had the x-ray done at the hospital. The PCP explained if a resident ' s fall did not involve a head injury, was not on any blood thinner, and could move all extremities, he would order an x-ray. The PCP stated had he would have known the resident to have signs of fracture, he would had ordered to transfer the resident to the acute care hospital. The PCP further explained he did not receive a report from the facility nurse regarding Resident 1 ' s signs of a fracture. During an interview on 3/6/25, at 12:45 p.m., with the DON, the DON stated she would have expected to be called of an unwitnessed fall with an injury or with pain involved to ensure proper implementation of care and services to prevent any delay in treatment. The DON confirmed she was not notified of the fall till the next morning. During an interview on 3/27/25, at 2:55 p.m. with LN 2, LN 2 stated she assessed Resident 1 and stated Resident 1 had indicated she had soreness to left hip. LN 2 further stated there was also some bruising to Resident 1 ' s left hip. LN 2 explained she had monitored Resident 1 during her night shift but did not fully check on Resident 1 ' s leg. Review of the facility ' s Clinical Protocol titled, Acute Condition Changes, revised 3/18, indicated, .Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who collected and organized pertinent information, including the resident/patient ' s current symptoms and status .The nursing staff will contact the physician based on the urgency of the situation .The attending physician .will respond in a timely manner to notification of problems or changes in condition and status .The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Clean food service items were found put away wet (e.g. trays, steam table pans, scoops, and blender); 2) Can opener, food processor, and large saucepan were found dirty and/or rusted; 3) Raw chicken was prepared on a metal rack that had an uncovered container of dessert cups underneath; 4) Three bags in the freezer were open to the environment (sausage patties, biscuits, and mixed vegetables); 5) Staff were unable to demonstrate/explain the testing of sanitation concentration for the dish machine and red buckets/manual dish washing); and, 6) Resident refrigerator contained multiple food items with no name and/or date; and nursing staff were uncertain of how to label food brought in from outside, as well as where to reheat. These failures had the potential to lead to food borne illness for the 62 residents eating facility prepared meals. Findings: 1) During the initial kitchen tour on 12/3/24, beginning at 8:27 a.m. with the Dietary Director (DD), the blender was observed to be covered (indicating it was ready for use), but was found wet inside when the cover was removed. Two green scoops and one blue scoop were found in the scoop drawer stored wet. 17 out of 17 large steam table pans were found in the storage racks wet; and 7 out of 10 quarter sized steam table pans were stored wet. During a concurrent interview with the DD, she stated her expectation was that staff put away dishes after they were fully air dried. She went on to state that, wet nesting (placing wet items inside another item) could lead to contamination. Review of a facility provided policy titled, Ware washing (Healthcare Services Group, Inc., and its subsidiaries, revised 2/2023) stated in bullet 4, All dishware will be air dried and properly stored. Review of the United States (US) Food and Drug Administration (FDA) Food Code 2022, Section 4-901.11, indicated, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 2) During the initial kitchen tour/observation on 12/3/24, at 9:14 a.m. with the DD and the Regional Dietary Director (RDD) 1, the can opener, can opener sheath/base were found dirty with dark discoloration and rust. The food processor bowl, when opened, showed tan-colored crumbs inside. A large saucepan hanging in the ready to use area had food particles and rust inside. RDD 1 acknowledged the dirty and/or rusted items and moved them to the dish wash area for cleaning. During a concurrent interview with the DD, she stated her expectation was that staff properly wash cooking equipment and have it air dried after each use to avoid contamination. Review of a facility provided policy titled, Equipment (Healthcare Services Group, Inc., and its subsidiaries, Revised 9/2017) stated in bullet 3, All food contact equipment will be cleaned and sanitized after every use. In bullet 4 it further indicated, All non-food contact equipment will be clean and free of debris. A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 3) During the initial kitchen tour on 12/3/24 at 9:38 a.m., [NAME] (Ck) 1 was preparing raw chicken for the lunch meal by mixing it with seasonings in a large metal bowl. The bowl was placed on top of a metal cart where clean, uncovered dessert bowls were being stored. During an interview on 12/4/24 at 8:48 a.m., with the DD in the kitchen, Ck 1 was beginning to make meatloaf on this same metal cart. The DD stated that they had limited space in the kitchen and proceeded to move the dessert bowls to another area of the kitchen. A review of the US FDA Food Code 2022, 4-903.12 Prohibitions. Chapter 4. Titled, Equipment, Utensils, and Linens indicated that: (A) Except as specified in (B) of this section, cleaned and sanitized equipment . may not be stored: . 8) Under other sources of contamination. 4) During the initial kitchen tour on 12/3/24, at 9:54 a.m. with the DD and RDD 1, the walk-in freezer was observed. The freezer had three boxes (sausage patties, biscuits, and mixed vegetables) which contained plastic bags of these foods that had been left open to the environment. During a concurrent interview with RDD 1, he acknowledged the opened packages of frozen foods and stated they should be resealed and covered to prevent air exposure (potentially leading to cross contamination of the food) and freezer burn (which damages food). Review of a facility provided policy titled, Food Receiving and Storage-Refrigerated/Frozen Storage (Healthcare Services Group, Inc. and its subsidiaries, Revised 9/2017) indicated in bullet 1, All foods stored in the refrigerator or freezer are covered, labeled and dated. Review of the US FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines on section 3-302.11 Title Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation indicated, . Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants may be present on the outside of containers and may contaminate food if the packaging is inadequate or damaged, or when the packaging is opened. 5) During a concurrent observation and interview on 12/3/24 at 9:24 a.m., Dietary Aide (DA) 1 was washing the dishes from breakfast. She demonstrated how to check the sanitation concentration of the dish machine with a test strip into the rinse water via the initial dish machine drain. When asked to retest at the plate level, she was unable to get a reading which indicated the sanitation was effective. RDD 1 then attempted to test and noted sanitizer was not going through the tube to the machine. During a concurrent observation and interview on 12/3/24 at 4:02 p.m. DA 2 showed how he would check the dish machine sanitizer using a test strip. DA 2 placed the strip into the initial drain of the dishwashing machine instead of testing the plates that had been run through the machine to ensure that they were sanitized. The Department asked him to retest at the plate level which showed a concentration of 200 parts per million (ppm). When asked what the desired numbers were, DA 2 stated, any of the [four] levels would be OK. The DD corrected DA 2 and stated, the lightest color would not be concentrated enough, and the darkest color would be too concentrated. During this same kitchen visit on 12/3/24 at 4:11 p.m., DA 2 went on to show how he would wash dishes using the 3-compartment manual dishwashing process. He proceeded to show how to set up for washing, rinsing, and sanitizing but was unsure of the correct water temperature. He was shown the instructions posted over the sink but did not find the temperature on these instructions. RDD 1 stated he thought, it should be 110 F (Fahrenheit, a unit of measurement). DA 2 then demonstrated how he would test the sanitation concentration for the manual dish washing and red bucket sanitizing solution. The testing concentration showed 100 ppm which RDD 1 stated was OK even though it was the lowest of the 3 possible colors. A review of the test strip bottle on 12/3/24 at 4:17 p.m. did not show the desired concentration. RDD 1 was asked to provide instructions for the two sanitation strips (dish machine and red bucket/manual dish washing) the facility used. On 12/4/24 at 9:00 a.m., the DD was asked again to provide the dish machine and red bucket/manual dish washing instructions for test strips used in the facility. During a return visit to the kitchen on 12/4/24 at 9:12 a.m., DA 3 was asked to demonstrate sanitizing using the red buckets that are used to sanitize counters and fixed equipment. DA 3 stated they use the same sanitizer for the red buckets as they do to wash dishes by hand when the dishwasher is not working. DA 3 proceeded to describe the 3-compartment manual wash process. DA 3 was unable to state the temperature needed for effective cleaning and sanitizing. After checking with her supervisor, DA 3 stated, the temperature of the water in the sink should be 110 F. When asked about how long the dishes needed to remain in the sanitizer, she stated she would sanitize the dishes for 5-10seconds. Instructions over the sink stated to leave the dishes in the sanitizer for 10 minutes. During a demonstration of how to test the sanitizer solution the test strip concentration level result was 200 ppm. On 12/4/24 at 11:15 a.m., the DD brought the surveyors instructions for the red bucket/manual dish washing sanitizer solution, though nothing for the dishwashing machine. Review of given instructions showed that the red bucket instructions were not for the product that had been demonstrated (6 potential color options as opposed to the 3 on the bottle observed and had a 5 second wait time as opposed to 1 second on the bottle viewed). During a revisit to the kitchen on 12/4/24 at 11:46 a.m., the Department discussed with RDD 2 that these instructions were not same as the test strip bottle. RDD 2 concurred and said he would correct and get the instructions for dishwashing machine as well. No instructions were given prior to the end of survey. Review of the US FDA Food Code 2022, 4-501.116 titled, Warewashing Equipment, Determining Chemical Sanitizer Concentration indicated that Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The Food Code also indicated in Annex 3-174 . a sanitizing solution that is too weak would be a violation of section 4- 501.114. A solution that is too strong would be a violation of section 7-204.11. Review of the US FDA Food Code 2022, Annex 3. Public Health Reasons/Administrative Guidelines. 7-204.11 Titled, Sanitizers, Criteria indicated that Chemical sanitizers are included with poisonous or toxic materials because they may be toxic if not used in accordance with requirements listed in the Code of Federal Regulations (CFR). Large concentrations of sanitizer in excess of the CFR requirements can be harmful because residues of the materials remain . According to the US FDA Food Code 2022, Chapter 4, Equipment, Utensils, and Linens. 4-501.114 titled, Manual and Mechanical Ware washing Equipment, Chemical Sanitization - Temperature, pH (a measure of how acidic or basic a substance or solution is), Concentration, and Hardness indicated that A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 . shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and pH of the solution as listed in the following chart; as indicated .by the manufacturer's use directions included in the labeling. 6) During a visit to the resident dining room on 12/4/24 at 9:51 a.m. two refrigerators were observed in the area. Activities staff explained that the small refrigerator was used to stock snacks like sandwiches and pudding for residents who may want a snack after the kitchen closed. The second refrigerator contained resident food brought in from outside of the facility. When the large refrigerator was opened, it was filled with drinks and containers of food. Some items included names, room numbers, and dates. The refrigerator also contained the following items: -A fast food bag which listed an initial and last name, as well as a date of 11/3 (no year), but no room number, -A bag containing 5 string cheese with a room number, but no name or date, -A bottle of sports drink with a room number, but no name or date, -A package of noodle soup with a room number, but no name or date, and -A bag containing three plastic containers, which include a room number and date, but no name. During an interview on 12/5/24 at 9:55 a.m. Certified Nursing Assistant (CNA) 2 stated residents may receive food from outside sources. If the resident wanted it to be kept for later, the nurses would label it with the resident's name, room number and date by which it needed to be consumed. When asked how they would determine the date, she stated, it would depend, but was unable to give the criteria for figuring out the date. CNA 2 also stated that outside food would be heated for the resident in the microwaves in the employee break room. During an interview with CNA 3 on 12/5/24 at 10:13 a.m., she stated, the residents may bring store bought food or food prepared by family members to the facility. CNA 3 stated the food needs to be labelled with name or room number. When asked about the need for a date she was unsure. When prompted further about date labeling, she was unclear if the date would represent when the food was opened or brought in. CNA 3 further stated food would be discarded by common sense, such as it looks bad or is just sitting there or they can check the expiration date. CNA 3 went on to state that food would be reheated in the therapy microwave. During an interview on 12/5/24 at 10:25 a.m. the Rehabilitation Therapy Director (RTDr) stated the microwave in her department was only used for therapy purposes and it was not used for resident food heating. During an interview with the Director of Nursing (DON) on 12/5/24 at 1:40 p.m., the process for food brought from outside the facility was discussed. The DON was unfamiliar with the specifics of the policy but concurred that labeling with only a room number could lead to an inappropriate food being served to a resident. The DON further stated that the resident name is needed because sometimes residents are moved to another room. The DON went on to state, the staff knows where to reheat food and pointed to the staff breakroom. Review of facility provided policy titled, Safe Handling of Foods From Visitor dated 8/25/21 indicated in bullet 3 number 4, When food items are intended for later consumption, the responsible staff member will: a. Ensure that the food is stored separate or easily distinguishable from the facility food. b. Ensure that foods are in a sealed container to prevent cross contamination. c. Label foods with the resident's name and the current date and use by date (2 days from the date when the food was brought in) Example: day 1 is the date of food was brought in = 2/1/21. Use by date is = 2.2.21.